Debate is needed over who provides drug treatment in attention deficit hyperactivity disorder

EDITOR—Levy's editorial on attention deficit hyperactivity disorder focuses on treatment issues in Australia and the United States, which only partially generalise to the current situation in Britain.1 Although the diagnostic criteria given in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders for attention deficit hyperactivity disorder and in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems for hyperkinetic disorder are much more comparable than their predecessors were, they are not “almost identical.” Hyperkinetic disorder has a much more stringent definition than attention deficit hyperactivity disorder: it is characterised by persistent traits of severe and pervasive inattentiveness, overactivity, and impulsiveness, beginning in the first five years of life.2 The prevalence varies according to the diagnostic system used, and this influences prescription rates.

Information on prescribing of stimulant drugs in Britain is fairly sparse. A recent survey of experts in child and adolescent psychiatry, however, showed considerable agreement that methylphenidate is useful in those with hyperkinetic disorder and helpful for some children with attention deficit hyperactivity disorder who do not meet criteria for hyperkinetic disorder.3 These views are likely to become more widespread in clinical practice, with a resultant increase in prescription rates.

Levy expresses concern about paediatricians and general practitioners initiating prescribing. These issues were also examined in the above survey. Opinion was divided on whether methylphenidate should be initiated only by child psychiatrists or whether paediatricians should do this too. Some respondents emphasised that prescribers should also be able to address psychological, educational, and family issues if necessary. The role of general practitioners in initiating prescribing was not examined, but there was a majority view that they should be able to continue prescribing and monitoring until the next specialist review.

Since parental demand for treatment exceeds mental health services' resources, it is important to obtain interested paediatricians' views about initiating treatment and developing consensus guidelines for clinical practice. Currently specialists are more likely to be working in parallel rather than jointly, and services may be duplicated in some regions, with general practitioners being uncertain whether to refer patients to psychiatrists or paediatricians. It may be that child psychiatrists, paediatricians, and general practitioners have complementary roles in the management of attention deficit hyperactivity disorder, but this requires debate among the disciplines involved.