Sir.—The recent article by Varga (Am J Dis Child 133:413-418, 1979) is commendable for raising serious questions regarding any simplistic approach to the evaluation and management of the hyperactive child. However, the article glosses over certain important developments in the field, fails to note others, and continues to leave the impression that the use of medication remains the mainstay of therapy.
In describing the behavior of hyperactive children, Dr Varga noted, "In common with all children, they manifest swings in behavior that are closely related to environmental changes, ie, they are stimulus bound." The primary focus for environmentally determined hyperactive behavior should be psychosocial, ie, environmental manipulation and behavior modification, rather than pharmacological. A recent study1 showed that the behavior of hyperactive children could be controlled as efficaciously with behavior modification as with medication.
The article fails to note some highly pertinent information regarding the use of medication.