To the Editor: Halasz and Vance1 are correct to point out that there is a diversity of causes that can contribute to a child exhibiting symptoms of attention-deficit hyperactivity disorder (ADHD), as defined in the Diagnostic and statistical manual of mental disorders (DSM-IV).2 In their article, they describe a child who meets the DSM-IV criteria for diagnosis of ADHD and in addition has been affected by environmental factors including poor bonding (due to maternal depression), domestic violence and parental separation. The child also exhibits developmental disability, as exemplified by delayed language development. The message is that, by explaining his symptoms in terms of his early experiences and his developmental disability, a diagnosis of ADHD can be excluded.

Children with ADHD frequently come from families with disharmonious parental relationships. This may be associated with ADHD in one of the parents, perhaps the violent father in the case described.

As clinicians our aim is to ameliorate symptoms as promptly and effectively as possible, and I am frequently impressed by the dramatic improvement that stimulant medication can make to a child's functioning both at school and within the family, with follow-on improvements in mood and self-esteem. Behavioural interventions and family therapy are important adjuncts to medication, but families such as the one described can be difficult to work with and this can limit the effectiveness of such interventions.

A carefully monitored one-month trial of stimulant medication, with behavioural rating scales completed by the class teacher, may be appropriate in cases such as the one described. On the other hand, to deny a child a trial of stimulant medication on the basis of adverse early experiences and developmental disability may be to keep from the child the treatment that would help most.