CASE.Steven is a 9 year old who was brought to his pediatrician 1 year ago when his parents were concerned that “he never pays attention and is always forgetting to do his chores.” Attention-deficit disorder (ADD) was diagnosed. Steven responded to a stimulant medication and behavior modification moderately well for several months. Then, the original problems reappeared, and, despite trials of different doses and different medications, things worsened. Although Steven's school performance was good, the teacher and parents felt his self-esteem was declining. This worried his parents, who were also experiencing increased disagreement and conflicts about managing “Steven's ADD.” Furthermore, his younger brother was starting to “act up like Steven.” Phone calls and visits became more frequent and urgent. The pediatrician suggested the family join the local CHADD (Children and Adults with ADD) support group and loaned the parents some books on ADD. He met individually with Steven (who did little talking) and with the mother (who ventilated her worries and frustrations). He even met with the family to review Steven's situation, offer reassurance, check on compliance (which was good), and to offer more advice concerning the growing number and complexity of the problems. Things continued to worsen, and, at the latest visit, everyone seemed discouraged, angry, and tired. Although the pediatrician felt he had run out of answers, he also felt that a referral (for either Steven or the family) was not appropriate at this time, that he was uncertain to whom he would refer, that the family would not accept a referral, and that his managed care practice would not approve a referral in the present situation.