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Follow Up on ADD/ADHD

Graham, I agree with your comments in many respects, but would ask you to
look at those kids with A's and ADHD. Why did they end up in your office?
If they are succeeding socially and academically, what is it that you are
managing/treating? I have yet to experience such a case. The IQ is not
tested to declare a person to be ADHD free, but rather to identify those
kids whose primary problem may lie elsewhere, in particular MR. I worked
exclusively with Bill Seman (Child Psychology) in New Bern, and our team
approach met with gret success.

I should add I didn't usually see these kids until their parents or the
school saw behavior or academic problems... Most of these kids are well in
other respects and don't see us routinely, and school issues don't get
"straight" answers at other visits, but that may be an experience limited to
my military kids. I doubt it. There is no inference that I wait until the
are having problems, they just aren't presenting until a crisis has

While we are not using Methotrexate, we are making a diagnosis... or at east
trying to! I try to do this to the best of my limited abilities.

Kevin, the danger in laying on medications without strong information (this
is where experience comes in, limited by the haze of patient history,
smothered with a sense of desperation) is that the childs behavior may
improve, and he stops being a serious behavior problem, but his other issues
don't get dealt with: "so what if he gets C's and D's"? There is also the
issue of the integrity of the diagnosis: just becasue the shoe fits doesn't
make it appropriate. I do agree that those kids with comorbid issues, and
my experience has been nearly all have them, stimulant medications will
often allow a better evalaution of those other problems, but it cannot stop
with the med and the evaluation must not be set aside. We owe that to the
kids and the family. Meds are an adjunct.

IRT the use of counseling for ADHD, I would offer that these children's self
esteem and the familial dysfunction that always is a part of this "syndrome"
have no equal management tool. This is a dynamic process that changes as
the child and the family changes, the challenges academically and socially
to a six year old are not those of a pre-adolescent or a teenager, and these
issues are amenable to counseling. Providing the child and the family tools
to succeed can come from few more effective places. I would no more provide
stimulant meds without counseling to a child with this psych diagnosis than
I would any other psych diagnosis. The medication provides a means for the
child to succeed, only if he knows what to do with this new ability to
attend and complete tasks, to inteeract effectively socially, and the family
must know how to deal with their own feelings and perceptions, and how to
help their child with this special need to adapt and grow. (IMHO this is why
Prozac got a bad rap: effective med with no counseling allow a depressed
person to find the energy and concentration to now carry out their
suicidal/homicidal plans, but no tools or support to address those issues,
but I digress).

The problem with the stigma of ADD/ADHD is not the meds, it's the same
stigma we attach to anyone with any mental health issue. That's why we have
so many problems getting families and administrations to help their kids,
and why we have so much trouble getting mental health resources.

[Graham, it is wonderful to have received your e-mail. I hope you are well
and in good spirits. I regret not having met you personally while I was at
MCAS Cherry Point! I look forward to your sage advice on so many issues,
and hope you keep offering it for some time to come.]

Ken Schroeter, DO, FAAP

Professional Website:

The one thing that does not abide by majority rule is a person's
cience. -Harper Lee


As I said before managing ADHD is an ongoing process and doesn't stop with a
prescription. So if the child is continuing to fail then the further
academic eval is necessary. The fact is that there are lots of kids who
don't need that further eval however. The suggestion that all or most kids
with ADHD have comorbidity of another condition to me indicates a high
likelihood of underdiagnosis, because that certainly isn't suggested by the
studies I've seen of the demographics of ADHD. Also, I 've seen dozens of
kids with ADHD go from academic failure to success with medication alone.
It is paramount to follow these kids because they are at risk for
comorbidity but I haven't found it necessary to have the full academic eval
done upfront for all kids.

Regarding the students' perceptions. As I said I don't doubt that some kids
are put on meds without any eval. I was merely pointing out that just
because the student goes into the room with the MD that the student may not
have the experience and knowledge about the child and family as the MD does.


"The suggestion that all or most kids
with ADHD have comorbidity of another condition to me indicates a high
likelihood of underdiagnosis, because that certainly isn't suggested by the
studies I've seen of the demographics of ADHD. "

Which studies??? I am always looking for more data.

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Actually Kevin, the student goes in the room takes a history and does the exam,
then presents to the MD and they decide on the treatment plan together.
Follow-up may or may not be adequate.