In reply: We believe the core symptoms of attention-deficit hyperactivity disorder (ADHD) in children reflect a behavioural "final common pathway" of developmental risk factors,1 which can include transgenerational associations of core symptoms, as Poulton notes. Current scientific evidence suggests both genetic and environmental contributions, such as verbal and visuospatial executive dysfunction2 and/or early patterns of attachment deficits.3 Increased levels of parental psychopathology, associated with (in the child) deficiencies in problem solving, affect regulation, emotional communication and secure attachment, may contribute to the child's symptoms. For this reason, we advocate that medical management be based on a thorough assessment, to ensure that appropriate psychological interventions (eg, parent and teacher management training) are offered alongside psychostimulant medication.

In a recent speech at a scientific meeting of the Faculty of Child and Adolescent Psychiatry, Dr A Mawdsley, a distinguished child psychiatrist, expressed his belief that "prescribing medication in the absence of a careful emotional state assessment is inferior medical practice". He went even further to state that "prescribing medication in the absence of a behavioural modification program should be considered medical negligence".