Cynics who believe that attention-deficit hyperactivity disorder (ADHD) is not so much a medical diagnosis, but more of a euphemism for bad behaviour by children whose parents fail to discipline them adequately will nod sagely.

Cynics who believe that attention-deficit hyperactivity disorder (ADHD) is not so much a medical diagnosis, but more of a euphemism for bad behaviour by children whose parents fail to discipline them adequately will nod sagely. The new health guidelines for England by the National Institute for Health and Clinical Excellence (Nice) suggest that Ritalin, the drug most commonly used to treat hyperactivity in children, should be prescribed only after other options, including training programmes for parents.

In Scotland, it is up to doctors to decide when the drug should be prescribed, but the guidelines are currently being revised. The cross-border difference, however, reflects a much deeper divison over the diagnosis and treatment of attention-deficit disorders in both children and adults, with concern about under-diagnosis as well as over-medication. Earlier this year, Quality Improvement Scotland (QIS), the advisory body for health standards, reported that the condition is under-recognised in Scotland, where only 0.6% of children are diagnosed with ADHD compared with 5% in other similar countries (the Nice report puts the figure at 3%). The QIS report suggested that up to 34,000 children and young people could be suffering from undiagnosed ADHD while they and their families struggle to cope with the impulsive behaviour, failure to concentrate and the frustration and anger which result from always being in trouble. The latest guidelines from Nice are right, however, to say that Ritalin and similar drugs should be the last, rather than the first, resort. They boost concentration by raising the level of the brain chemical noradrenaline, but the side-effects can include sleeplessness, loss of appetite and, more rarely, hallucinations. In a few cases, they have also been linked with suicide by young people.

The considerable body of research on ADHD links it with both genetic and environmental factors, although no single cause has been identified. Parenting programmes, as recommended by Nice, will help some children, but the established link with poor diet should also result in an emphasis on nutrition and, where necessary, professional psychological intervention should be available. Together, these treatments could spare children not only many years on medication whose long-term effects are not fully known, but the disadvantages which too often result from being labelled with a mental illness. A recent phenomenon is that young adults discover that a childhood diagnosis of ADHD prevents them getting jobs and ask doctors to "undiagnose" them. Those who genuinely suffer from ADHD, however, can find their lives transformed by appropriate drug treatment and that should not be denied them. What is indisputable is that children and young people with behavioural problems need an expert diagnosis based on their individual symptoms and needs rather than a catch-all label and an automatic prescription.