The editorial on attention-deficit hyperactivity disorder and life-span development (Reference McArdleMcArdle, 2004) is timely. However, it highlights the issues from the perspective of clinicians who may be directly involved in treating the disorder.

In general adult psychiatry, however, it is not widely recognised that (adult) attention-deficit disorder (ADD) is not uncommon and that people presenting with diagnoses of psychotic disorders, mood disorders, anxiety disorders, etc., may also be suffering from unrecognised ADD. This has profound implications for both treatment and outcome. For example, if a person develops a hypomanic or manic episode superimposed on ADD, it is possible that the clinician unaware of ADD may end up overtreating the mood episode, as the baseline ADD may mislead the clinician into believing that the talkativeness and hyperactivity (of ADD) are an indication of elevated mood. The consequences include higher than necessary doses of medications, combination pharmacotherapy and increased length of stay in hospital. In patients with schizophrenia it is possible that the impairments in functioning caused by independent ADD may potentiate the poor functioning caused by schizophrenia. Again, if ADD is not recognised, it is possible that the poor outcome may be attributed to ‘resistant’ or ‘residual’ schizophrenia or perhaps to poor motivation. It is important to assess comorbidity such as ADD at the very first contact with mental health services, and early intervention service providers are ideally placed for this.

Regarding treatment, new strategies (other than stimulant medications) need to be developed, as stimulants may have destabilising effects on the baseline mental illness.