Attention-deficit hyperactivity disorder (ADHD) is a commonly diagnosed childhood psychiatric disorder. Debate over its diagnostic validity, aetiology, presentation and treatment has extended from the clinical to the public domain. As children with ADHD diagnoses reach adulthood there is increasing interest in ‘adult ADHD’. Cohorts followed up show poorer outcomes as adults than do controls. Self-referred adults, sometimes relatives of children with ADHD, are also of interest regarding adult ADHD. Innovative work is being done examining issues of aetiology, treatment, outcomes and comorbidity in these groups, but heterogeneity among those diagnosed with ADHD and changes in classification systems and diagnostic criteria over time complicate comparison of research findings. The diagnostic validity of adult ADHD remains uncertain and needs further study.

Most child and adolescent mental health services recognise the existence of, and need for treatment in, attention-deficit hyperactivity disorder (ADHD). Many specialist multidisciplinary ADHD clinics have been developed in recent years, and many paediatricians have included the treatment of ADHD as an important part of their clinical activity. A good deal of the justification for this increase in therapeutic activity has been the demonstration that ADHD is indeed a predictor of adult mental health problems. General adult psychiatry, however, has not followed suit in identifying and treating substantial numbers of affected people. It is likely none the less that an increasing load in adult psychiatry will develop. A rising number of young people will enter adult life still receiving stimulant medication or other treatment for ADHD, and adult psychiatrists are likely to be consulted. Furthermore, an increasing number of adults are likely to recognise themselves as having been disabled by ADHD and therefore to seek assistance. In many cases, individuals with adult ADHD who require specific treatment for the condition will have been treated unsuccessfully for disorders with overlapping symptom profiles such as anxiety, depression, bipolar disorder and antisocial personality disorder.

Advance statements, originally designed for situations of terminal illness, are becoming increasingly relevant in psychiatry. This article examines their background, rationale and use in old age psychiatry. The difference between advance statements and advance directives is highlighted, and different roles are suggested for each. We discuss the advantages, and the possible limitations, of advance statements, including the unique issue of the Mental Health Act 1983.

Risk assessment is notoriously difficult and offers a particular challenge to mental health workers. There are two main conceptual approaches to the consideration of risk assessment and management: the actuarial and the clinical methods. I use case material to examine the clinical, and in particular the psychodynamic, approach in order to illustrate that violent behaviour has meaning. Understanding its meaning and learning from it can substantially reduce the risks of further violent behaviour. Managing risk with the aid of psychodynamic psychotherapy enables the patient to become aware of his or her own mind and its function. Although this process may initially be distressing to the patient, in the longer term the aim is to enable the development of a healthier, more stable internal reality. This should, in turn, reduce the risk of dangerous acting out.

The rise of the risk industry in psychiatry in England and Wales can be given a precise date: 17 December 1992. That was the day that Christopher Clunis, a man who had been in contact with psychiatric services for some 6 years, murdered Jonathan Zito in an unprovoked attack. This tragedy received enormous publicity and resulted in a flurry of activity within the Department of Health. As a result of the moral panic surrounding Clunis, which crystallised long-term trends, the assessment and management of risk became a central focus of mental health policy and practice (Holloway, 1996). Risk remains a core issue, and indeed mental health services have come to be seen as a key element in a strategy for public protection that aims to keep people who are identified as a potential risk to others off the streets. (We await, with some professional trepidation, the legislation that will provide a sufficiently broad definition of mental illness to fully legitimate this social role.) Mental health staff are now required by government policy and their employers to assess an ever-expanding range of risks – most recently, following the Victoria Climbié Inquiry (House of Commons Health Committee, 2003), risks to dependent children, generally with the aid of unvalidated risk assessment tools. Increasingly, mainstream mental health services are being expected to provide interventions for people whose presenting problems are risky behaviours (or even risky feelings) rather than to offer treatment for mental illness.

Doctor (2004, this issue) raises the important question of how to assess and manage violent behaviour. He claims that actuarial models of risk assessment based on epidemiology have failed, and that indeed the most reliable risk assessment is one based on clinical methods. He proposes that psychodynamic psychotherapy be used for this purpose, to uncover the meaning of the violent behaviour. Such therapy will, Doctor argues, help the violent person be aware of and understand the function of their behaviour. This understanding in turn will reduce the need in the patient to act out violently.

In this article on getting on with colleagues in the workplace we explore how the nurse–doctor relationship in psychiatry has evolved and discuss its current status in both the in-patient ward and community mental health teams. In particular, we outline the changed roles and expanding responsibilities of nurses in the UK today. We suggest ways in which doctors can improve the relationship and give areas of possible future collaboration between doctors and nurses.

Mental health professionals in Western societies are generally less religious than their patients and receive little training in religious issues. Using case studies, the author discusses issues involved in working with patients who hold religious beliefs: problems of engagement; countertransference; religious and spiritual issues not attributable to mental disorder; problems of differential diagnosis; religious delusions; religion and psychotherapy; psychosexual problems; and religiously oriented treatments. The article ends with a discussion of the various ways in which religious themes can be incorporated into mental health work, especially the need to involve religious professionals and develop collaborative patterns of working together with mental health professionals.

Even to have a paper on working with patients with religious beliefs in a psychiatric journal is a liberating experience, and Dr Dein (2004, this issue) has dealt with his subject with thoroughness and fair-mindedness. We have come a long way since the standard British textbook of psychiatry in the 1960s (Mayer-Gross et al, 1960) could state that religion is for ‘the hesitant, the guilt-ridden, the excessively timid, those lacking clear convictions with which to face life’. At that time religious belief in patients was equated with neurosis, and in trainees in psychiatry it was regarded as being seriously unscientific and was strongly discouraged.

The use of plant essential oils in aromatherapy has been recorded for thousands of years, but until recently there was very little formal evidence regarding the use of these treatments in people with dementia. Over the past few years a number of clinical trials have compared aromatherapy, principally using either lavender (Lavandula angustifolia or Lavandula officinalis) or lemon balm (Melissa officinalis), with inactive treatment. All of these studies demonstrated a significant impact on behavioural problems in patients with dementia, with negligible side-effects. However, there is still not sufficient evidence to recommend widespread use in clinical practice and the key question of whether these treatments can provide a viable alternative to existing pharmacological agents needs to be addressed.

Children and young people are usually referred to specialist child and adolescent mental health services (CAMHS) by adults because of concerns raised by other adults. Most CAMHS consider them from a developmental perspective and as individuals in the context of their families and other relationships/systems. In this article I discuss ethical and legal challenges posed by making decisions with and about children and young people within CAMHS, with particular reference to duty of care; the rights of minors' and parents'; capacity and consent; and disagreement between decision-makers. It is important to involve children and young people in decision-making, and I suggest ways of acheiving this.

In psychiatric and psychotherapeutic practice, ‘boundaries' delineate the personal and the professional roles and the differences that should characterise the interpersonal encounters between the patient/client and the professional. Boundaries are essential to keep both parties safe. The author outlines the various types of boundary violation that can arise in clinical practice, their consequences (both clinical and legal), how professionals can avoid them and how health care institutions might respond, should they occur. He concentrates on sexual boundary violations, because these have been the subject of most empirical study.