Current recommendations are that medication should be initiated by child and adolescent psychiatrists or paediatricians or learning disability specialists with particular expertise [4
]. Once the condition is stabilised children can then be followed up in primary care [4
] and NICE guidance recommends health authorities should draw up shared care protocols [4
] . Is primary care in this country ready to follow these recommendations? Follow up of ADHD is often undertaken by primary care in the Unites States [8
]. Moreover adult ADHD is becoming increasingly recognised and some of the cohort of children and adolescents who are currently on stimulant medication will graduate to adult mental health services. These factors together with statements in the NICE guidance on the use of methylphenidate are likely to increase pressure on primary care to become more involved in the management of ADHD.
However there is a great need for caution and careful planning before implementing shared care protocols for ADHD and sharing follow up with primary care. Primary care teams are already having to assume responsibility for follow up of an increasing number of chronic conditions and although for some (such as diabetes) there is evidence this is successful [11
], the monitoring of children on treatment for ADHD may pose different problems. Most general practitioners and nurses will have undergone no or very little training in child and adolescent psychiatry. Many general practitioners do not feel confident about their skills in recognising and undertaking follow-up management of ADHD and feel that education is essential [12
]. Attitudes amongst members of the primary care team members may also represent a problem. The media represents an important source of knowledge of ADHD for many general practitioners [12
]. Given that recent media features have highlighted problems with over diagnosis and over treatment this is likely to affect attitudes within the primary care team to the use of stimulant medication and heighten anxieties about management. Although there is some evidence that most general practitioners are willing to take on physical monitoring of children on medication for ADHD (e.g. height, weight and blood tests if necessary) the only available data suggest general practitioners feel clinical monitoring of these children is a specialist responsibility [12
]. Therefore shared care protocols for ADHD may have limited impact in reducing specialist workload and will need to incorporate effective mechanisms for close integration and good communication between services to ensure that patients and their families receive appropriate care.
It is therefore important that a clear strategy for the follow up care of children with ADHD is devised. Planners need to ensure that roles and responsibilities of different healthcare sectors in monitoring children with ADHD on medication are clearly demarcated and acceptable to the professionals concerned. When these clear roles have been identified, it is then important to ensure that professionals possess the appropriate skills and knowledge to effectively undertake the assigned role. The resource implications of carrying out this monitoring also need to be addressed so that this can be done successfully (as has been achieved for monitoring of anticoagulant therapy). It is essential that patient needs are met in a coordinated and supported manner to avoid a situation of placing children and families into a "no mans land" of uncertain responsibility and inadequate skills,