Dr Cribb's comments are welcomed. Our discussion (Reference Sayal, Taylor and BeechamSayal et al, 2002) also highlights the potential role of both parents and teachers in making referrals to child and adolescent mental health services (CAMHS). The paper is developing new methodology and we deliberately posed it on a simplified system, selecting an area where most referrals come from general practitioners (GPs). GPs are also the main referrers to CAMHS nationally and their role in primary care trusts will be of great importance in shaping specialist services. Nevertheless, this is only one component of tier 1 services and 48% of CAMHS referrals come from other sources (Audit Commission, 1999). We plan to widen our programme to examine the role of other sources of referral.

Restricting referrals to particular agencies imposes barriers to access, and the resulting delay in referrals might exacerbate severity or chronicity of problems. Kurtz et al (Reference Kurtz, Thornes and Wolkind1996) described a service that only accepted GP referrals. It failed to reduce the number of referrals and generated resentment from other agencies. Comparisons of CAMHS with different referral systems will improve knowledge in quantifying the barriers to access to services. This could contribute to assisting the successful implementation of the National Service Framework for Children.

The role of teachers in the pathway to care merits particular comment. Relationship difficulties with teachers are a predictor of referral of hyperactive children to CAMHS (Reference Woodward, Dowdney and TaylorWoodward et al, 1997). Our study has demonstrated that selective targeting can lead to particularly high rates (98%) of teacher participation in research. This is likely to reflect their concern about behavioural and emotional difficulties in children. Teachers are a rich potential source of child mental health information for parents. However, in considering referrals from schools, it is imperative that teachers fully discuss their concerns with parents. Parents need to agree to any referral. For hyperactivity, in particular, it needs to be ascertained that the problems are pervasive. Unless this happens, there is a risk that learning difficulties are wrongly identified as hyperactivity. This also highlights the importance of adequately resourced educational psychology services to support schools, and health service input in the training of teachers.