These young people with CFS were at high risk of psychiatric disorder. They were substantially disabled when compared to individuals with a known chronic illness. Also, as a group, they were characterised by a preference for rest rather than exercise.

Clinicians have been describing individuals with chronic fatigue states for over 100 years, although chronic fatigue syndrome is often regarded as a modern disease. The aetiology of chronic fatigue syndrome is uncertain. For young individuals with chronic fatigue syndrome there are neither reliable prevalence figures nor scientific evidence concerning the effectiveness of treatments. Information obtained from research into adult individuals with chronic fatigue syndrome may be helpful but is not necessarily directly applicable to children and adolescents. Developmental factors and the influence of other family members on the course of the disorder in young sufferers should be considered. The uncertainties surrounding chronic fatigue syndrome should not deter child and adolescent mental health workers from becoming involved in the assessment and management of individual patients. The mainstay of treatment is rehabilitation with an emphasis on gradually increasing activities. Considerable attention will need to be given to engaging the young people and their families and working effectively with a multidisciplinary team. If mental health workers do not become involved in treating young people with chronic fatigue syndrome there is a risk that psychological factors will not be addressed and that chronic functional impairment will ensue.

General practitioners in a south London health authority were sent a questionnaire about their experience and views concerning the treatment of childhood chronic fatigue syndrome. Most thought childhood chronic fatigue syndrome had a significant psychological component, but opinion was divided over referral to a psychiatrist. The involvement of self-help organisations was supported but the place of rest and exercise unclear. The optimum primary care management of childhood chronic fatigue syndrome needs to be established.

Like other NLS patients studied in the United Kingdom and Ireland, this group had significant handicaps secondary to psychiatric illness, concomitant physical illness and disability and behaviour unacceptable in community settings. They were also characterised by significant social isolation. These factors may be important determinants of rehabilitation failure and need to be addressed in the process of de-institutionalisation as well as in longitudinal studies examining these and other factors predicting NLS status.

Few clinical decisions are more difficult than whether or not to withhold treatment from patients who are unable to make this choice for themselves. This is because they bring into conflict a number of principles central to clinical practice, such as the duty to save life, the duty to relieve suffering, and the duty to heed patients' wishes. In North America, advance directives (‘living wills’) from patients, made when they are fully competent, have achieved considerable popularity in recent years as a possible way out of these dilemmas (La Puma et al, 1991; Molloy et al, 1991); unfortunately, it is by no means clear whether these can in fact provide a workable solution to the problem of treating incompetent patients (Hope, 1992). For the time being, decisions about withholding treatment will continue to be made by the health professionals immediately involved at the time, often junior staff with little experience or training, and there is a need for a professional consensus as to the factors that should be properly taken into consideration. This study investigates the current attitudes and approaches of psychiatrists and psychiatric nurses in one health district to this problem. It examines the criteria used, and the conditions under which decisions about administering or withholding treatments are being made.