Frankie is an 8-year-old boy seen in consultation because of school difficulties in second grade and "odd behavior." His family has been concerned about him for the past 2 years, and he has had psychological testing at school. His parents are seeking another evaluation now because they are concerned that his school performance is declining and his self-confidence is decreasing.Frankie was born at term weighing 7 lb, 3 oz. Delivery was complicated by the "cord around the neck," but Apgar scores were 8 and 9, and he had no difficulties in the neonatal period. He went home with his mother. As an infant he was easily soothed and liked to be held. He sat at 6 months, crawled at 8 months, and walked alone at 14 months. He spoke three intelligible words at 1 year and was speaking in sentences by 2 years. He was fully toilet trained by 2 years, 9 months. He had no significant medical illnesses.His parents began to be concerned about Frankie when his preschool teacher noted a concern about his fine motor skills. She remarked also that, although he had no problems socially, he seemed happy to play alone. From a very early age, he liked ropes and often carried around a length of rope as some children carry a blanket. He was never a difficult child or disruptive at home or in his preschool. The only problem his parents have had is that he tends to get extremely involved in a particular activity (watching TV, building with LEGO blocks), and it is very difficult to turn his attention away from that activity to a family task. At the same time, he is also noted to be easily distracted from tasks in which he has less investment.Frankie's father is said to have attention-deficit hyperactivity disorder (ADHD) and learning disabilities, and he is being treated with a selective serotonin reuptake inhibitor (SSRI) for depression. He works as a successful carpenter and builder. A maternal uncle had Down syndrome and died at the age of 17 years as a result of heart disease. There is no other contributory family history. A 12-year-old sister is successful academically and socially. Frankie's mother is a librarian. The grandparents live nearby and share the parents' concerns about Frankie.He was evaluated a year earlier by his pediatrician and thought to have attention deficit disorder, primarily because of distractibility and easy frustration. He is not oppositional but does have emotional outbursts and cries easily when frustrated. He was noted to carry with him a piece of rope and to play with it repetitively. A trial of methylphenidate was considered unsuccessful. An occupational therapy evaluation revealed low muscle tone and difficulty with visual-motor skills and handwriting. He was said to have "sensory integration problems," and twice-weekly occupational therapy interventions were recommended. His parents requested our opinion about this recommendation.Frankie's academic work was considered average by his teacher in all areas, though weakest in spelling and reading. He was particularly strong in oral expression and noted to have excellent vocabulary and knowledge. He hesitated to participate in group activities and frequently needed considerable encouragement. On the other hand, he was noted to be liked by his peers and was not disruptive. His main weaknesses were considered to be in organization and attentional skills. Handwriting is difficult and slow, and thus written work is a particular challenge.His parents noted that Frankie remembers "everything" in detail. He is very talkative and has a great sense of humor. He loves to speak in groups and is "a ham" when given a microphone. He enjoys crafts of all sorts and playing with LEGO blocks. He likes music. His favorite TV programs are educational ones, from which he seems to learn a lot of information easily. He has made several extensive presentations to his class based on what he has learned from such programs. Relationships among all members of the family are said to be excellent. Frankie continues to enjoy playing with ropes and similar objects, and his parents have made some rules to keep this from interfering in family activities. He participates in family and classroom activities.The Behavioral Assessment System for Children (BASC) checklist was completed by both his teacher and his mother. The teacher's responses suggested concerns in the subscales of Anxiety/Depression, Attention, Adaptability, and Atypicality. Social Skills were a notable strength. The mother's responses suggested concerns in Attention, Adaptability, and Social Withdrawal.Frankie's parents and teacher completed a checklist based on the DSM-IV criteria for ADHD. Both parents noted three items among the hyperactivity cluster and five among the inattentive cluster to be "often or very true" for Frankie. His teacher noted four inattentive items and two hyperactivity items to be true.The Woodcock-Johnson Battery revealed a standard score of 100, with particular strength in Short Term Retrieval and relative weaknesses in Auditory Processing and Processing Speed. Math skills, reading, and written language were average, whereas knowledge in all areas was in the superior range. On the WISC-III, Frankie's Verbal IQ was 104 and Performance was 97. The highest subscales were Vocabulary (13) and Similarities (12); the lowest were Coding (6) and Symbol Search (6).On evaluation, Frankie was a pleasant and cooperative young man who participated in all tasks and related appropriately. His neurological examination was normal. He held a pencil or crayon tensely and wrote slowly and laboriously with tremendous pressure. He did not appear to be anxious during the evaluation. He kept a short piece of rope with him at all times and occasionally fiddled with it. He complied with all requests passively and did not initiate conversation or activities. He had no difficulty making transitions from one activity to another even when specifically challenged.There are several discrete conditions that may be applied in this case. Is it in the child's best interest to define which diagnosis fits him best? Is it acceptable to provide the parents and teachers with some guidelines for helping Frankie to succeed in school and at home, and to "wait and see" how he develops over time? Would some practitioners initiate a trial of a pharmacological intervention?