To watch a replay of this webinar, go to https://event.webinarjam.com/go/replay/330/m26v2u2ock4t64fg  

Dr Wendy Duncan presented an informative and comprehensive presentation on the ADHD child and Covid. This webinar was hosted by Medical Chronicle, made possible by Dr Reddy’s.  

Her talk examined the challenges of attention deficit hyperactivity disorder (ADHD), the impact of Covid, managing ADHD in the Covid era, and the long way back to normality after the pandemic. The following article is based on her presentation.  

Attention-deficit hyperactivity disorder is a neurodevelopmental disorder characterised by developmentally inappropriate levels of inattention and/or hyperactivity and impulsivity. It is well-recognised as a childhood-onset condition, and it is increasingly recognised as persisting into adulthood, with enduring impact.  

It is a highly prevalent condition in both the developed and the developing world, with a recent pooled estimate of 7.2% in children up to 18 years of age.  

Most children with ADHD have one or more comorbid conditions such as anxiety disorder, mood disorder, learning disorders, disruptive behaviour disorder, oppositional defiant disorder, conduct disorder, autism spectrum disorder sensory processing difficulties and tic disorders.  

The condition is characterised by frequent difficulties with social integration and managing friendships, poorer educational achievement, notoriously poor sleep patterns, emotional (and behavioural) regulation, outcomes of injudicious choices, executive functioning difficulties that provide everyday obstacles for these children and adolescents.  

ADHD in lockdown  

The impact of Covid-19 on mental health was recognised early, in lockdowns. This had a disproportionate impact on children and adolescents, of particular concern in those who are disadvantaged, marginalised or have pre-existing psychiatric morbidity.  

Lockdown created a profound change in the psychosocial and educational environment. A child’s developmental stage will determine the potential impact and the presentation of distress. Lockdown created a disruption to routine, changes in circadian rhythms, more indoor time, fewer opportunities for exercise, isolation, boredom and loneliness. Parental stress and financial pressure add to this ‘perfect storm’.  

Children with ADHD are relatively more challenged by the impact of Covid-19, than their neurotypical peers. They are more vulnerable to the disruption in routine and the frustrations of restricted movement. This resulted in the deterioration of core ADHD symptoms. Several domains of concern include: 

• Education
• Behaviour and family functioning
• Sleep
• Screen usage
• Emotional regulation.

Distance/ online learning often requires self-guidance, organisation and motivation to complete assignments. Inattention was core to the worsening of symptoms. Increases in hyperactivity and impulsivity were also documented. There were reports of slowed cognitive tempo, especially in adolescents. This is made worse by limitations to available support from educators.  

There are high rates of learning disorders in these children as it is, so they are at a particular disadvantage. ADHD children and adolescents show higher rates of anxiety around online learning.  

The ‘unseen value’ of being in a classroom includes routine, setting a physiological and behavioural rhythm, structure and regulation, requirement of prosocial behaviour and responsibility taking.   

Physically, sitting at a desk, carrying a book bag, walking to the playground, standing in the sunlight and snacking at limited intervals also have a benefit.  

However, there is a cohort of ADHD children who fared better during lockdown as a result of the experience of reduced stress and demand.  

Worsening behaviour such as reduced ability to focus, manage anger and routines increases inattention and hyperactive/impulsive symptoms. These children had higher levels of frustration and aggression. Boys showed more behavioural problems while girls experienced higher anxiety. There was a notable increase in oppositional behaviour, which leads to increased caregiver stress (taking into account parents’ mental state) and a deterioration in the quality of family relationships. Remember that ADHD is highly heritable.  

Sleep  

Bedtimes and wake-times were noted to be later during Covid lockdown. In the formal studies of sleep, there were mixed results with some reports of improvement in sleep duration (not necessarily quality). ADHD youth have higher rates of sleep problems and are less likely to obtain requisite “school night” sleep. This leads to greater inattention, greater oppositional behaviours and more depressive symptoms.  

Poor sleep is associated with reduced physical activity, increased screen time, worsening focus, emerging mood and anxiety disorders and higher consumption of processed foods. All of these elements impact negatively core ADHD symptoms.  

Problematic use of the internet  

Lockdowns and stay at home orders have directly influenced the escalation in screen media usage. Generally, this is understood to be potentially harmful. There are multiple added layers of potential risk in excessive screen usage for children and adolescents with ADHD.  

Problematic use of the internet (PUI) is an inability to control one’s usage of the internet resulting in dysfunctional patterns. This has major negative consequences on interpersonal relationships, academic performance and emotional well-being.  

There is a well-documented association between ADHD and PUI. It is consistently associated with impulsivity, internet gaming disorder, elevated social media use associated with poorer ADHD symptom control (especially in girls), cyberbullying, and increased risk as perpetrators and victims.  

Emotional regulation  

Emotional (dys)regulation (ER) is linked to comorbidity in ADHD. While ADHD adolescents display high levels of emotional dysregulation, not all ADHD adolescents struggle to regulate. It is a potential indicator of risk for both internalising and externalising disorders in youth with ADHD.  

Managing ADHD in the Covid era   

Treatment should be commenced without unnecessary delay. Untreated ADHD presents a risk to mental health and family well-being and may increase the risk for Covid infection.  

There are suggestions that when untreated, the demands of physical distancing and mask-wearing are harder to manage. Access to controlled medication presented an obstacle, worldwide. This created an escalated administrative burden for pharmacists and medical practices.  

Multiple formulations of methylphenidate may need to be adjusting to accommodate altered routine/school schedule. ‘Drug holidays’ over weekends are not necessarily advisable. Atomoxetine remains a highly useful alternative for ADHD management, but practitioners need to monitor liver function tests.  

Management of comorbidities is important. Melatonin is useful, provided adequate attention is paid to sleep hygiene and screen time. Be aware of growth monitoring and cardiovascular monitoring when pharmacology is prescribed.  

Other therapeutic interventions include: 

•  Behavioural management strategies
• Parental training/counselling
• Individual cognitive behavioural therapy
• Individual supportive psychotherapy
• Occupational therapy
• Speech and language therapy
• Educational support.

ADHD is a risk factor for Covid   

The condition itself confers potential risk. Data collected on Covid tests between Feb and April 2020 from Leumit Health Services; subject N = 14 022, 10% were Covid positive. Having a Covid-positive test was significantly associated with having ADHD (among other factors). ADHD patients on treatment (92% stimulants) had a similar risk of Covid to non-ADHD patients. Adherence to treatment should be encouraged as a means of reducing the risk of infection.  

Identification of risk factors is critical for priority testing, vaccination, early treatment, and hospitalisation. There is some suggestion that psychiatric diagnosis is associated with a 1.5-fold increase in Covid-related death. Data from Leumit Health Services shows the severity of illness is also associated with ADHD. In fact, ADHD was as strong a predictor for Covid illnesses like diabetes and cardiovascular disease.   

The long way back  

The pandemic and lockdown have had a disproportionate effect on the mental health of children. There is a particular impact on neurodiverse and disadvantaged populations of children, such as those with disabilities and intellectual disabilities, those with ER issues, high levels of anxiety and externalising disorders.  

There will be a ‘developmental debt’. Blended learning (multiple modes and platforms of learning) is to be expected. Caregivers will need to ‘tune in’ to which platform might be optimal for a particular child. ADHD children will need support in frameshifting and working across platforms, and support in the development of executive functioning – planning, timetabling and scheduling. Parents and teachers will need to adapt to feedback for online learning and show a consistency of boundaries and expectations. 

Please note webinars are only CPD accredited for a calendar year. This webinar has unfortunately expired, but can still be watched for information purposes.