Response to the Clinical Practice Points draft document of the NHMRC. Dr Kim Pedlow MBBS(UWA), FRACGP, FACCRM, Dip Obs(Advanced)COG, Clinical Lecturer RCS (UWA) Thank you for the opportunity to respond to the latest document from the NHMRC trying to promulgate and disseminate credible ADHD guidelines to the Australian community. I sat on the original working group housed in the College of Physicians. I watched the assault by the Church of Scientology who influenced the MOH to remove Dr Darryl Efron as chair. He was ably replaced by Dr David Forbes from Western Australia. However we lost a number of our ranks at that time due to real or perceived pressure from the associated controversy. We eventually got underway and produced what I thought were reasonably accurate and conservative guidelines. My imperatives through this process were as follows # That we produce a set of guidelines which made diagnosis and management accessible to rural Australians. Similarly underprivileged Australians needed to be looked after. # We needed to ensure that children and adults seeking assistance in this area were attended to by health professionals trained in the area. To this end I engaged the other members of the committee in long conversations explaining that in rural Australia there are very few Fellows of the Royal Australian College of Physicians and that if diagnosis and medical management was restricted to members of this college then the following would occur. # Large numbers of rural and underprivileged people would be unable to access necessary services for geographical and financial reasons. # By giving blanket, one size fits all style credentialing to fellows of the Royal Australian College of Physicians regardless of whether the doctor has training in the area caused me great difficulty. I went on to explain that I am a rural generalist with special interests in obstetrics and paediatrics. In my town of Geraldton there is now a post at the local health service for GPpaediatricians. This is along the lines of GP obstetrician and anaesthetist. I look after 250 families affected by attention deficit hyperactivity disorder and for the last 20 years have been part of a strong network of teachers, psychologists, other allied health workers, doctors and community members. Our task is to care for members of the local community affected by attention deficit hyperactivity disorder and the common associations of learning difficulty and behavioural problems. I am therefore from a very different culture to the members of the current working group of the NHMRC. On reading your document I find myself agreeing with much of what you say. However the constant reference to specialist clinician for diagnosing and medical management will make it very difficult for the majority of my patients to access treatment in a timely and equitable manner. I can find no reference to shared prescribing. May I suggest that instead of specialist clinician that the working group substitutes clinician trained in the diagnosis and management of ADHD. I remind the working group that large numbers of psychiatrists and paediatricians have had little or no training in the area and to give them the unqualified blessing of your committee causes me difficulty. Scope of practice is the important thing here. My suggestions are more in tune with the current attitude in the United States of America. It is my understanding that the silo model taken up by the current committee is more along the English way of doing things. If this was widely applied to rural Australia our health system would fall apart. On a less important note I have concerns about the emphasis on direct observation of the affected child as mentioned several times. It’s true one can get some idea of hyperactivity, impulsivity and so on but I have found it more valuable to seek information particularly from trained observers such as teachers, reliable family and friends as to the unfettered behaviour of the affected child or adult. I thought also that the conclusions of the MTA trial were slanted in favour of diminishing the role of medication. Your paragraph gave the impression that there was not much to choose between pharmacological and non-pharmacological strategies. I suggest that you revisit this document. I sincerely hope and trust that these comments are taken in a constructive manner. I have nothing against the College of Physicians but my reality is that they play very little part in delivery of service in my area. Yours sincerely