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57
Primary Psychiatry © MBL Communications Inc.
Issues in the Diagnosis and Treatment of
Adult ADHD by Primary Care Physicians
Lenard Adler, MD, David Shaw, BA, David Sitt, PsyD, Erica Maya, BA,
and Melinda Ippolito Morrill, LMSW, MA
May 2009
ABSTRACT
Introduction: The objective of this article is to compare primary
care physicians’ (PCPs’) experiences with diagnosing and treating
adult attention-deficit/hyperactivity disorder (ADHD) versus other
mental health disorders.
Methods: Four hundred PCPs who have patients with ADHD, bipo-
lar disorder, depression, generalized anxiety disorder (GAD), or
obsessive-compulsive disorder completed a public release survey
assessing their experiences and attitudes on diagnosing and
treating these disorders.
Results: Forty-eight percent of PCPs felt uncomfortable diagnosing
adult ADHD and 44% reported that there were no clear diagnostic
criteria. Seventy-five percent rated the quality and accuracy of exist-
ing adult ADHD diagnostic tools as either poor or fair. Seventy-two
percent reported that ADHD is easier to diagnose in children than
adults. Sixty-five percent reported deferring to specialists to diag-
nose adult ADHD, compared to 2% for depression and 3% for GAD.
Eighty-five percent reported that they would be more comfortable
diagnosing and treating adult ADHD if thorough, straightforward
screening tools were validated and if there were effective medica-
tions that were neither stimulants nor controlled substances.
Discussion: While this survey indicated that adult ADHD is gener-
ally accepted by PCPs, the results also indicate that PCPs are sig-
nificantly less likely to diagnose and treat ADHD in adults without
deferring to a specialist, when compared to GAD and depression.
The recent development of new screening tools for adult ADHD as
well as non-stimulant and novel stimulant medications may reduce
PCPs’ reliance on specialist referrals.
Conclusion: This study highlights a potential need for PCPs for
increased education and training in adult ADHD. As the study was
conducted 6 years ago, follow-up investigations into the current
PCP awareness of adult ADHD are indicated.
Dr. Adler is professor and Mr. Shaw is a research assistant in the Department of Psychiatry, both at New York University (NYU) School of Medicine in New York City. Dr. Sitt is a psychologist at the
Hallowell Center in New York City. Ms. Maya is Clinical Trials Coordinator at the William and Sylvia Silberstein Institute for Aging and Dementia at NYU School of Medicine. Ms. Morrill is a graduate
research assistant at the Center for Couples and Family Research and a doctoral student in clinical psychology at Clark University in Worcester, Massachussetts.
Disclosure: Dr. Adler is consultant to Eli Lilly, McNeil/Johnson & Johnson, the National Institute on Drug Abuse (NIDA), Organon, Psychogenics, sanofi-aventis, and Shire; is on the speaker’s bureaus of
McNeil/Johnson & Johnson and Shire; and receives research support from Bristol-Myers Squibb, Eli Lilly, McNeil/Johnson & Johnson, the NIDA, and Shire. Mr. Shaw, Dr. Sitt, Ms. Maya, and Ms. Morrill report
no affiliation with or financial interest in any organization that may pose a conflict of interest.
Acknowledgments: This study was commissioned by the New York University School of Medicine in cooperation with Eli Lilly and was funded in part by a research grant from Eli Lilly.
Please direct all correspondence to: Lenard A. Adler, MD, Department of Psychiatry, NYU School of Medicine, 530 First Ave #7D, New York, NY 10016; Tel: 212-263-3580; Fax: 212-263-3581;
E-mail: lenard.adler@nyumc.org.
FOCUS POINTS
• This article explores new findings about issues with diag-
nosing and treating attention-deficit/hyperactivity disorder
(ADHD) in adults by primary care physicians (PCPs).
• Despite a high rate of prevalence and significant impair-
ments, most adults with ADHD have not been diagnosed
and remain untreated.
• PCPs had less training and had lower comfort levels treat-
ing adults with ADHD than with depression and anxiety
disorders.
• PCPs were more likely to refer adult patients with ADHD to
specialists for diagnosis and/or treatment than they were
for adult patients with major depressive disorder or gener-
alized anxiety disorder.
• PCPs would be more likely to diagnose adult ADHD if quick,
easy-to-use screening tools were developed and validated.
ORIGINAL RESEARCH
Primary Psychiatry. 2009;16(5 ):57-63
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
58
Primary Psychiatry © MBL Communications Inc. May 2009
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
INTRODUCTION
Attention-deficit/hyperactivity disorder (ADHD) is a
chronic and commonly occurring neuropsychiatric disorder
that is usually first diagnosed in childhood and is associated
with an inability to sustain attention and/or an inability
to regulate motor behavior.1 Research has shown ADHD
to negatively impact attention,2,3 behavioral inhibition,2,3
memory,2,3 and functional outcomes2,4-8 in many settings of
daily life including home,2,9 school,2,5 work,2,5 driving,5,10 and
interpersonal relationships.5,10
The prevalence of ADHD in children is approximately 6%
to 8% world wide11 and it is estimated that 66% continue to
meet full criteria or partial criteria with significant impair-
ment as adults, indicating that as many as 8 million adults
in the United States have the disorder.4,12-15 The National
Comorbidity Survey Replication (NCS-R), a nationally rep-
resentative survey conducted in the US between 2001–2003
of ~10,000 English-speaking household residents ≥18 years
of age, demonstrated that the prevalence of ADHD in adults
in the US is ~4.4%.16
While recognition of adult ADHD has grown recently in
the medical community and general population, the disorder
remains under-recognized and under-treated when compared
to other commonly occurring mental health disorders such
as mood, anxiety, or substance use disorders.17 Results from
a 2005 survey found that ~1.5 million adults in the US were
diagnosed with and receiving treatment for ADHD, indicating
that only 1 in 4 adults with the disorder have been diagnosed
and are receiving adequate medical attention.18 The NCS-R
found that >40% of respondents who met the criteria for
ADHD reported that they had not been previously diagnosed
with the disorder despite seeing a healthcare professional in the
previous year.16,19 In fact, only 10% of the sample with ADHD
had received treatment for the disorder within the year prior to
the interview.16 Furthermore, only 25% of respondents with
ADHD who had received treatment within the previous year
for a mental health or substance use disorder reported also
receiving treatment for ADHD.16
The principal goal of this study was to examine the
experiences and attitudes of primary care physicians (PCPs)
regarding the diagnosis and treatment of ADHD in adults
through a public release survey. For some portions of the
survey, PCPs were asked to also rate their experiences and
attitudes regarding other disorders such as major depressive
disorder (MDD), generalized anxiety disorder (GAD), bipo-
lar disorder, and obsessive-compulsive disorder (OCD).
METHODS
The survey was approved by the New York University
School of Medicine Institutional Board of Research Associates.
Participants in the survey included 400 PCPs recruited ran-
domly from the master directory of the American Medical
Association. Physicians were selected using the following cri-
teria. First, they were currently practicing as part of a family,
general, or internal medicine practice Second, they had been
practicing for at least 2 years. Last, they were currently treat-
ing at least 30 adult patients per week with any combination
of the target disorders, which were ADHD, bipolar disorder,
MDD, GAD, or OCD. These disorders were chosen because
they are commonly occurring, impairing disorders character-
ized by low rates of diagnosis and adequate treatment among
patients in treatment.20-22
Potential participants were mailed an invitation to partici-
pate in an online survey. Each invitation explained the purpose
of the research in general terms and contained a unique pass-
word and URL to access the survey. Passwords were provided
for security purposes and to prevent duplicate responding. The
survey was made available online from May 14—May 28,
2003 by Harris Interactive. Physicians completing the survey
received a $40 honorarium. Fewer than 40% of physicians who
received the invitation completed the survey. Demographic
information of the physicians can be found in Table 1.
The survey asked the physicians to rate the following
items on a five-point scale from lowest (ie, poor) to highest
(ie, extremely knowledgeable/thorough): their knowledge
of the target disorders; the quality of their education and/or
training received regarding the target disorders; their per-
ceptions regarding specific aspects relating to the diagnosis
and treatment of adult ADHD (ie, adult ADHD is more
difficult to diagnose than childhood ADHD); their per-
TABLE 1
PHYSICIAN DEMOGRAPHICS
Mean number of patients in practice >18
years of age 2,407.1
Mean number of years since residency 13.4
Medical Specialty %
Family Practice 53
Internal Medicine 40
General Practice 7
Practice Setting %
Single-specialty group 33
Solo practice 27
Multi-specialty group 20
Outpatient clinic 11
Hospital-based practice 9
Other 1
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
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Primary Psychiatry © MBL Communications Inc. May 2009
Issues in the Diagnosis and Treatment of Adult ADHD by Primary Care Physicians
ception regarding the quality of diagnostic tools available
for the target disorders; and their perception regarding the
importance of specific qualities/parameters necessary for an
effective screening tool for adult ADHD. Lastly, physicians
were asked to rate the frequency that they refer patients to
a specialist for the treatment of each of the target disorders
and the reasons why they collaborate with or defer to a spe-
cialist when diagnosing adult ADHD.
All reported significance refers to 95% confidence, using
unweighted data. Descriptive results are reported for all
analyses. For the purposes of explanation, a data reduction
was performed when presenting results for items rated on a
five-point scale and results are hereafter presented only for
the two highest-rated items.
RESULTS
Knowledge Differential
Respondents reported that they saw significantly more
patients in an average week with depression and GAD than
any of the other three target disorders (Table 2). This corre-
lated with the finding that respondents consider themselves
significantly more knowledgeable about both MDD and
GAD than they are about bipolar disorder, OCD, or ADHD
(Figure 1). Only 34% of respondents answered that they
were either very or extremely knowledgeable about adult
ADHD (Figure 1). Furthermore, only 13% of respondents
reported that they had received very or extremely thorough
clinical training in adult ADHD which was significantly
less than all of the other target disorders except for OCD
(Figure 2). Seventy-seven percent of physicians reported
that they believe that adult ADHD is not well understood
by the medical community (Figure 3).
Knowledge and Understanding of Adult ADHD
in Primary Care
Somewhat contrary to the reported lack of knowledge
and understanding of adult ADHD, only 26% of respon-
dents concurred that ADHD is a condition that the vast
majority of children outgrow (Figure 3). However, 72%
reported that it is more difficult to diagnose ADHD in
adulthood than in childhood (Figure 3). Nearly half of
respondents reported that they were not confident in
TABLE 2
PATIENT ROSTER
Target Conditions
Mean Number of
Patients
Mean Number of
Patients per Week
Depression 215.7 29.8
GAD 150.0 22.0
Bipolar disorder 26.8 6.5
ADHD 23.7 5.9
OCD 22.3 4.8
GAD=generalized anxiety disorder; ADHD=attention-deficit hyperactivity disorder;
OCD=obsessive-compulsive disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
FIGURE 1
PERCEIVED KNOWLEDGE OF THE TARGET DISORDERS
GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; ADHD=attention-
deficit/hyperactivity disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
100%
80%
60%
40%
20%
0%
% Very/Extremely Knowledgeable (top 2 box)
Depression GAD Bipolar disorder OCD ADHD
(n=336) (n=331) (n=144) (n=134) (n=137)
92%
83%
36% 34% 34%
FIGURE 2
PERCEIVED EDUCATION IN TARGET DISORDERS
GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; ADHD=attention-
deficit/hyperactivity disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
60%
40%
20%
0%
% Very/Extremely Thorough (top 2 box)
Depression GAD Bipolar disorder OCD ADHD
(n=227) (n=159) (n=78) (n=58) (n=53)
57%
40%
20%
15% 13%
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
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Primary Psychiatry © MBL Communications Inc. May 2009
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
their ability to diagnose ADHD in adults (48%) and
believe that there are no clear criteria for diagnosing
adults with the disorder (44%; Figure 3). Seventy-three
percent of respondents reported that the underlying
symptoms of ADHD are similar in children and adults
but the manifestations of these symptoms differ through-
out the life course (Figure 3).
Dependence on Referrals
Only 35% of respondents reported that they would diag-
nose adult ADHD without referring patients to a specialist,
whereas the vast majority reported that they would diagnose
major depression (98%) and GAD (97%) themselves (Figure
4). Respondents reported that they were most likely to refer
FIGURE 3
PERCEPTIONS OF ADULT ADHD
ADHD=attention-deficit/hyperactivity disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
I would take a more active role in diagnosing and treating adult
ADHD if there were an easy-to-use, validated screening tool
developed by physicians or institutions I respect
Adult ADHD is not very well researched or understood by the
medical community
I would take a more active role in diagnosing and treating adult
ADHD if there were effective prescription medicines that were not
stimulants or controlled substances
The underlying symptoms of ADHD are similar in children and
adults but the manifestation of the symptoms differs between
groups
It is more difficult to diagnose an adult with ADHD than it is to
diagnose a child with ADHD
I am not confident in my ability to diagnose adult ADHD
There are no clear criteria for diagnosising adults with ADHD
ADHD is a condition that the vast majority of children outgrow
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
85%
77%
75%
73%
72%
48%
44%
26%
% Answering Somewhat/Completely Agree
FIGURE 4
PERCENTAGE OF PCPS WHO DIAGNOSE THEMSELVES OR
REFER TO SPECIALISTS FOR DIAGNOSIS
PCPs=primary care physicians; OCD=obsessive-compulsive disorder; ADHD=attention-
deficit/hyperactivity disorder; GAD=generalized anxiety disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
54% 47%
65%
35%
98%
2%
3%
97%
33%
68%
ADHD
OCD
GAD
Depression
Bipolar Disorder
Diagnose myself
Refer to a specialist for diagnosis
FIGURE 5
TYPES OF PHYSICIANS/SPECIALISTS THAT PCPS ARE LIKE-
LY TO COLLABORATE WITH OR DEFER TO WHEN DIAGNOSING
ADULT PATIENTS WITH ADHD
PCPs=primary care physicians; ADHD=attention-deficit/hyperactivity disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
General Psychiatrists
Psychologists
Neurologists
Other PCP
Other
86%
55%
16%
3%
2%
0% 20% 40% 60% 80% 100%
% Answering Somewhat/Completely Agree
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
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Primary Psychiatry © MBL Communications Inc. May 2009
Issues in the Diagnosis and Treatment of Adult ADHD by Primary Care Physicians
adult patients seeking a diagnosis of ADHD to either a psy-
chiatrist (86%) or psychologist (55%; Figure 5). Fifty-two
percent of respondents attributed inexperience or lack of
confidence as the primary reason for collaborating with or
deferring to specialists when diagnosing adult ADHD, and
22% reported that they believed adult ADHD to have no
clear diagnostic criteria (Figure 6). Furthermore, only 5% of
respondents reported that they make the final decision regard-
ing medication when treating adult ADHD with 42% report-
ing that they collaborate with specialists and 53% reporting
that they refer their adult ADHD patients to specialists.
Need for an Adult ADHD Screening Tool
Ratings of the quality of adult ADHD screening tools were
significantly worse compared to screening tools for the other
FIGURE 6
PCPS’ REASONS FOR COLLABORATING WITH OR DEFERING
TO SPECIALISTS WHEN DIAGNOSING ADULT ADHD
PCPs=primary care physicians.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
Inexperience/lack of
confidence
Difficult to diagnose and
treat/no clear diagnostic
Second opinion/confirm diagnosis
Many treatment medications are
controlled substances
Other
Time constraints
0% 10% 20% 30% 40% 50% 60%
Percent Answering
52%
22%
20%
13%
11%
4%
FIGURE 7
PERCEIVED QUALITY AND ACCURACY OF DIAGNOSTIC TOOLS
OF TARGET DISORDERS
GAD=generalized anxiety disorder; OCD=obsessive-compulsive disorder; ADHD=attention-
deficit hyperactivity disorder.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
80%
60%
40%
20%
0%
75%
48%
46%
16%
7%
% Fair or Poor (bottom 2 box)
Depression GAD Bipolar disorder OCD ADHD
FIGURE 8
PCPS’ PERCEPTION OF THE IMPORTANT QUALITIES OF A SCREENING TOOL FOR ADULT ADHD
PCPs=primary care physicians; ADHD=attention-deficit/hyperactivity disorder; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
Adler L, Shaw D, Sitt D, Maya E, Morrill MI. Primary Psychiatry. Vol 16, No 5. 2009.
Easy to use
Validated with a large patient population
Relatively quick to administer
Physician administered
Patient self-administered
Created by a leading university with expertise in
neuroscience
Endorsed by leading health organization such as the
World Health Organization
Based on current DSM-IV criteria used for
diagnosing ADHD in children
Created by a team of physicians who specialize in
the treatment and diagnosis of ADHD
93%
90%
84%
81%
52%
50%
47%
44%
35%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
% Answering Very/Extremely Important
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
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Primary Psychiatry © MBL Communications Inc. May 2009
L. Adler, D. Shaw, D. Sitt, E. Maya, M.I. Morrill
target disorders. Seventy-five percent of respondents reported
that they thought the quality and accuracy of diagnostic tools
for adult ADHD was either poor or fair (Figure 7). Eighty-
five percent of respondents indicated that they would take a
more active role in diagnosing and treating adult ADHD if
an easy-to-use, relatively quick to administer screening tool
was developed and validated by physicians or institutions
they respect (Figure 8). However, only ~50% of respondents
indicated that screening tools for adult ADHD should be
based on the current Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition23 criteria for diagnosing
ADHD in children (Figure 8).
Need for Alternative Treatments
A significant number of respondents (13%) reported that
they refer adult ADHD patients to specialists for treatment
because many of the pharmacologic treatments, such as
methylphenidate and amphetamines, are psychostimulants
and controlled substances (Figure 6). Seventy-five percent of
respondents indicated that they would take a more active role
in diagnosing and treating adult ADHD if effective, non-
stimulant medications that were not controlled substances
were available (Figure 3).
DISCUSSION
While the results of this survey indicate that adult ADHD
is generally accepted by PCPs, it also highlighted a need
within the primary care community for more education and
training in diagnosing and treating adults with the disorder.
Although the majority of respondents reported that they
thought the underlying symptoms of ADHD are the same for
children and adults, they indicated that they thought adults
manifest these symptoms differently than children and that
the disorder is more difficult to diagnose in adulthood than
in childhood. This difficulty may be partially attributed to
the DSM-IV criteria for ADHD, which often reflect behavior
in school or playground settings, being the same for both
children and adults.6,24-27
Although the willingness of PCPs to diagnose and treat
adult ADHD without deferring to a specialist was strikingly
low when compared with MDD and GAD, the majority of
respondents reported that they would be more active in diag-
nosing and treating adult ADHD if they had an easy-to-use,
validated screening tool. It should be noted that since this
survey was conducted, the Adult ADHD Self-Report (ASRS)
v1.1 Screener has been developed and validated. The ASRS
v.1. Screener uses adult-specific, context-based language
to identify adults at risk for ADHD.28,29 The ASRS v1.1
Screener is self-administered and contains the six symptoms
of ADHD psychometrically determined to be most predictive
of the disorder.19,29 The ASRS v1.1 Screener has shown good
sensitivity and specificity and has a positive predictive value
between 57% and 93%.29,30 The ASRS is also available in an
18-item format (ASRS v1.1 Symptom Checklist), which con-
tains the 18 items corresponding to the adult presentation of
ADHD symptoms in the DSM-IV. The ASRS v1.1 Screener
and Symptom Checklist are copyrighted by the World Health
Organization and are available at no cost on the Internet.31,32
The majority of respondents also reported that they would
be more active in treating adult ADHD if non-stimulant med-
ications that were not controlled substances were available.
Around the same time that this survey was conducted, the
first non-stimulant medication, atomoxetine, was approved
and released for the treatment of adult ADHD. Additionally,
the first pro-drug stimulant, lisdexamfetamine dimesylate,
with a reduced overdose toxicity and drug tampering, was
recently approved for the treatment of pediatric and adult
ADHD.33-37 Together with the availability of novel extended-
release formulations of traditional psychostimulants and the
advent of non-stimulant and safer stimulant medications as
viable treatment options, the reluctance to treat adult ADHD
amongst the primary care community may be reduced.
There were several limitations to the current investigation.
First, <40% of the selected PCPs completed the survey, which
may indicate a selection bias. Second, the survey was conducted
in 2003 and there has likely been an increase in the awareness
and familiarity of adult ADHD amongst PCPs as well as the
general population. Third, advances made in the understand-
ing of adult ADHD in the scientific community as well as the
development of new diagnostic/symptom assessment scales and
medications may have had a positive impact on the willingness
of PCPs to diagnose and treat the disorder in adults.
CONCLUSION
Although the prevalence of adult ADHD is comparable to
that of MDD and GAD, this survey highlighted a potential
need amongst PCPs for more education and training in adult
ADHD. However, follow-up investigations into the current
PCP awareness of adult ADHD are needed as new, easy-to-
use screening tools for adult ADHD and non-stimulant and
novel stimulant medications have been developed in the 6
years since the survey was conducted. PP
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