As one of the most prevalent adult psychiatric disorders, ADHD poses unique challenges for clinicians, who must navigate a lack of formal diagnostic guidelines to properly evaluate and treat patients.

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Dr. Jake Behrens, a psychiatrist specializing in adult ADHD, shares his framework for conducting thorough assessments, tailoring treatment plans, navigating stimulant shortages, and busting common myths that perpetuate stigma and hinder access to care.

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Read on or listen to learn:

• Dr. Behrens' comprehensive approach to ADHD evaluations that ensures diagnostic accuracy
• Strategies for medication management amidst an unprecedented stimulant shortage
• The potential of digital health tools to revolutionize ADHD assessment and treatment
• Why underdiagnosis and undertreatment of adult ADHD pose significant dangers
• Practical resources to enhance patient education and empower self-management

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A Framework for Thorough ADHD Assessments

Central to Dr. Behrens' approach is gathering detailed patient history across various settings, from childhood experiences to current functioning at work and in relationships. "I always think of gathering the stories, that's the richness of it," he explains. "Give me the specifics - everything that we try and paraphrase when we document ourselves, I want caught verbatim by patients."

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Collateral information from family, friends, and prior clinicians is key, as are validated rating scales like the Adult ADHD Symptom Scale (ASRS). Dr. Behrens also incorporates objective cognitive testing to assess executive function. "To me, a diagnosis is if there's at least overlap amongst all of those things - the history, collateral information, rating scales, and objective measures."

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ADHD Psychoeducation: Empowering Patients from the Start

Dr. Behrens dedicates significant time in initial evaluations to diving deep into psychoeducation. "It's not like we're going to jump right into treatment - I want it to be educational," he emphasizes. "I lay out a whole menu of options, from medications to therapy, coaching, lifestyle changes, and more."

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By helping patients understand the neurobiology of ADHD and the full spectrum of evidence-based treatments, Dr. Behrens sets the stage for a collaborative treatment process grounded in patient empowerment.

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Navigating the Stimulant Medication Shortage

The current stimulant medication shortage has made mainsream headlines at this point. "I can say the shortage has been the most trying time of my entire time in private practice," Dr. Behrens shares candidly. To ensure his patients maintain access to appropriate treatments, he has had to employ creative strategies and challenge long-held assumptions about working with the pharmaceutical industry.

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"I had to do a lot of processing. In med school, you're taught that if you even talk to people in industry, you grow your own horns and tail," Dr. Behrens explains. "I had to get over that. Cause I'm not doing this because I want to do name brand or anything like that. But if it's the thing that's available and especially if it's actually less expensive to the patient..." By establishing relationships with pharmaceutical reps and having their direct contact information, Dr. Behrens has been able to quickly resolve issues with pharmacy stock and insurance coverage. "What's been a godsend for me is getting to know the reps and having their direct contact info," he shares. "If I'm having an issue at a pharmacy or with insurance coverage, I can reach out and they'll get it resolved incredibly quickly - it's the best form of patient advocacy I've seen."

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Dr. Behrens also strategically identifies alternative medications with comparable active ingredients and release profiles to maintain continuity of care. He works closely with his patients to find the most effective and affordable options, often starting with smaller supplies to allow for dosage adjustments as needed.

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By proactively partnering with pharmaceutical representatives and thinking creatively about alternative medication options, Dr. Behrens has been able to weather the stimulant shortage and ensure his patients maintain access to the treatments they need. His experience underscores the importance of challenging assumptions and embracing unconventional strategies to advocate for patients in the face of systemic challenges.

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The Potential of Digital Health Tools and Measurement-Based Care (MBC)

Dr. Behrens is excited about the future of digital health tools and measurement-based care to enhance ADHD assessment and treatment. From smartphones passively tracking behavioral patterns to wearables capturing biometric data, he envisions a future where objective measures can be paired with patient self-reports to precisely guide treatment.

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"What I would love is to partner the patient's subjective report with something more objective in the background," he explains. "We're going to have to see if we can identify some signal in all the noise, but I'm very excited for that - ADHD is ripe for this kind of innovation."

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Dr. Behrens emphasizes the power of involving patients in the measurement-based care process. "People love their own data. They love seeing it. Anytime you can use it, even in treatment, I don't care if it's visualizing rating scales with them or showing someone their own labs, there's something about personally showing people their own data and using that as almost like a motivational interviewing tool - it makes it so easy."

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By presenting data to patients and asking for their insights, Dr. Behrens finds that they naturally come to their own conclusions. "If you just show data, you ask people what they think, they'll tell you. They come to their own conclusions, and I'm there more to support people in their own conclusions than I am to dictate to tell them what to do. In many ways, I find it makes my job so much easier."

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Some clinicians may worry that measurement-based care feels impersonal, but Dr. Behrens argues the opposite. "I can't imagine practicing without measurement-based care and without involving the patient in that, because I think it's just - some people think, oh, it's a little cold or impersonal, but on the contrary, I feel like it grounds the conversation and it starts the conversation."

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Even when there's a discrepancy between objective measures and patient self-reports, Dr. Behrens sees it as a valuable opportunity for exploration and dialogue.

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Busting Myths and Misconceptions About Adult ADHD

Dr. Behrens is on a mission to bust the pervasive myths and misconceptions that perpetuate stigma and hinder access to care for adults with ADHD.

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Myth #1: ADHD is simply about hyperactivity and the inability to sit still.

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Fact: ADHD is fundamentally about variable executive function.

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"We just think it's about work or school because it's like, what the heck do attention and hyperactivity have to do with them now? It doesn't make any intuitive sense," Dr. Behrens explains. In reality, ADHD impacts all areas of life, from relationships to driving to simply relaxing with family. It's about how people function in the most boring, mundane moments when there's no immediate stimulation or pressure.

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Myth #2: Stimulant medications work like typical stimulants, such as caffeine, to simply 'jack people up'.

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Fact: Stimulant medications for ADHD work by increasing dopamine and norepinephrine in the prefrontal cortex, which enhances executive function. "

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You have to ask yourself, what is it "stimulating"? If it's stimulating dopamine and norepinephrine to the prefrontal cortex, we're "stimulating" the brakes or executive function. That's very different," Dr. Behrens clarifies. Unlike more general "stimulants" (caffeine included) that create a global sense of stimulation, ADHD medications more specifically target the brain's self-management system."  

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Myth #3: Overdiagnosis of ADHD is the biggest risk

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Fact: There are well studied and equally as major risks of underdiagnosis and undertreatment.  While concerns about overdiagnosis of ADHD abound, Dr. Behrens argues the dangers of underdiagnosis and undertreatment are equally as profound. "I understand overdiagnosis and overtreatment are real issues, but what no one talks about is, what are the dangers of underdiagnosis and undertreatment where there is a great deal of data of the real affects on not only affected individuals but also their families, employers, and society in general?

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He points out that ADHD is one of the few conditions that is highly treatable and can potentially prevent a host of negative outcomes. "How many other conditions do we have that we're actually good at treating that can potentially prevent crime, car accidents, obesity, comorbid psych disorders, job loss, divorce? Even from a libertarian standpoint, if other people want help, and them getting help potentially prevents my family from getting in car accidents or these other issues, I'd would hope that there be access to further evaluation and for it to be taken seriously and without the level of current bias and stigma."

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Recent large studies have shown that starting a stimulant when you have an ADHD diagnosis is associated with lower all-cause mortality, suicidality, and hospitalizations two years later. "There's so much we don't talk about in terms of the risks of undertreating and underdiagnosing ADHD - that's the biggest area under the curve that's missed," Dr. Behrens stresses.

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Recommended ADHD Tools and Resources

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Dr. Behrens aims to equip clinicians with the tools to navigate the complexities of adult ADHD with confidence. You can find his favorites curated in one place here.
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ADHD Assessment Tools:

• Adult ADHD Symptom Scale (ASRS): Clinicians should use the ASRS to gather a standardized self-report of current ADHD symptoms, which can be tracked over time to gauge treatment response. This scale, alongside 40+ other measures are included in Osmind’s psychiatry-tailored EHR.

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ADHD Medication References:

• Cohen Children's Medical Center stimulant medication comparison chart: This chart is a helpful reference for understanding the different formulations and dosage equivalencies of stimulant medications. Clinicians can use it to guide medication selection and to help patients understand their treatment options.

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ADHD Patient Education Resources:

• ADDitude website: Dr. Behrens suggests directing patients to this website, which offers a wealth of articles, webinars, and tools to help adults with ADHD understand and manage their condition. By empowering patients with reliable information, clinicians can foster greater treatment engagement and self-management skills.

Find links to all of Dr. Behren's favorite ADHD resources here.

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Conclusion:

Armed with these resources, along with a comprehensive framework for assessment, a multimodal treatment approach, and an awareness of common pitfalls, psychiatrists and psych NP’s can dramatically improve outcomes for this underserved population. As Dr. Behrens powerfully puts it, "ADHD is a core blocker to other treatments and positive changes - it's low-hanging fruit that we can treat. If we address it properly, we open up profound possibilities for our patients' lives."

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About Dr. Jake Behrens, M.D.

Jake Behrens is a board certified psychiatrist and the founder of the Envision ADHD Clinic where he specializes in the evaluation and treatment of ADHD in busy professionals. He serves on the APSARD Board and Membership Committee.

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He received his undergraduate and medical degree from the University of Wisconsin-Madison where he stayed for residency and then clinical faculty before venturing into lean model clinic startup with Envision ADHD where technology and workflow advancements could more rapidly be implemented in clinical practice. He is the co-founder of Healthtech MKE which works to connect, support and "put healthtech startups in Milwaukee, WI on the map".

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His interests include: ADHD, telemedicine, technology in clinical practice, exploring each and every function and feature of the software he uses and tests, getting into the "nitty gritty, nuts and bolts" workflows of clinical practice, smiling at dogs and spending time with wild minded individuals sharing/dreaming/designing/whiteboarding new ideas and ways to streamline seemingly mundane tasks.