ADHD in Lockdown

Mental health, specifically in children and adolescents, has been affected by the COVID-19 Pandemic and lockdown. This had a disproportionate impact on children and adolescents, of particular concern in those who are disadvantaged, marginalised, or have a pre-existing psychiatric morbidity.

Children with ADHD are relatively more challenged by the impact of Covid-19, than their neurotypical peers.

Several domains of concern include:

• Education
• Behaviour and family functioning
• Sleep
• Screen usage
• Emotional regulation
• Profound change to the psychosocial and educational environment
• Disruption to routine
• Changes in circadian rhythms
• More indoor time
• Fewer opportunities for exercise
• Isolation
• Boredom
• Loneliness

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

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.

Comorbid conditions are found in most children with ADHD:

• Anxiety disorder
• Mood disorder
• Learning disorders
• Disruptive behaviour disorder
• Oppositional defiant disorder
• Conduct disorder
• Autism spectrum disorder sensory processing difficulties
• Tic disorders.

Frequent difficulties include:

• Social integration and managing friendships
• Poorer educational achievement
• Notoriously poor sleep patterns
• Emotional (and behavioural) regulation
• Outcomes of injudicious choices
• Executive functioning difficulties

Slowed cognitive tempo, especially in adolescents have been reported. Limitations to available support from educators has made this worse, particularly in children with learning disorders.

ADHD children and adolescents show higher rates of anxiety around online learning.

Sleep

Higher rates of sleep problems and being less likely to obtain requisite ‘school night’ sleep.

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
• Higher consumption of processed foods

Use of internet

Problematic use of the internet (PUI) is an inability to control one’s usage of the internet resulting in dysfunctional patterns.

An escalation in screen media usage is understood to be potentially harmful.

The major negative consequences include:

• Interpersonal relationships
• Academic performance
• Emotional well-being

Well-documented association between ADHD and PUI is consistently associated with:

• Impulsivity
• Internet gaming disorder
• Elevated social media use associated with poorer ADHD symptom control (especially in girls)
• Cyberbullying
• Increased risk as perpetrators and victims.

Emotional regulations

Emotional (dys) regulation (ER) is linked to co-morbidity in ADHD.

ADHD adolescents display high levels of emotional dysregulation. 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 risk to mental health and family well-being and may increase risk for Covid infection
• Demands of physical distancing and mask-wearing are harder to manage
• 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 highly useful alternative for ADHD management
• Practitioners need to monitor liver function tests

Management of comorbidities

Melatonin is useful, provided adequate attention is paid to sleep hygiene and screen time.

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 a risk factor for COVID

Covid-positive test are significantly associated with having ADHD (among other factors). ADHD patients on treatment (92% stimulants) had similar risk of Covid to non-ADHD patients.

• Identification of risk factors is critical for priority testing
• Psychiatric diagnosis is associated with a 1.5-fold increase in Covid-related death
• ADHD is as strong a predictor for Covid illness as diabetes and cardiovascular disease

Sources:

Medical Chronical, November 2021

The ADHA Child and COVID – Dr Wendy Duncan