Attention Magazine April 2021

COVID-19 literally turned our lives upside down. Take me, for example: I have worked from home since March 2020. That’s nine months of not seeing colleagues and having to use all of my energy to regulate myself to get my work done at home and keep up with online meetings, all while trying to balance this work with a toddler, getting some exercise, and having a bit of “me” time. On the other hand, there have been parts of the pandemic that I have welcomed with outstretched arms, such as not having commute to work and the slower pace of life. My emotions associated with COVID-19 are very much like a rollercoaster with many ups and downs. If we have experienced such impacts as adults, surely children may be feeling similar things? How might we expect the experience to affect children with ADHD?

There may be many positives for children with ADHD during this time. Getting to spend more time at home may be great for strengthening family bonds. Remote learning could potentially take away some stressful things related to school, such as comparisons with other students, social difficulties, or even peer victimization. However, there are also things that may be challenging, such as dealing with the uncertainty and managing changes in usual routines and social contact. It is likely quite demanding for parents to manage working from home while also trying to manage their child’s learning from home.

We have conducted a study of about 200 children with ADHD in Australia to understand the impacts of COVID-19, both positive and negative, from the perspective of parents. The results from this research were published in the Journal of Attention Disorders.¹ We conducted our first survey in May 2020, when families in Australia were experiencing restrictions such as needing to work from home and having their children learn from home.

Who participated, and what did we learn?

The results summarised below are from 213 families that participated in the first wave of the ADHD COVID-19 study. Parents of children with ADHD completed an online survey and were eligible to participate if they had a child with ADHD with aged between 5 and 17 years. Most of the children in our study were boys and were taking medication to manage their ADHD symptoms.

We learned that:

• Just over one quarter of parents reported that their child with ADHD was moderately/very/extremely worried about either themselves or family members being infected with COVID-19.
• Close to half of parents said that restrictions on leaving home had been moderately/very/extremely stressful for their child.
• Most parents (64%) reported that there were many positive parts of the COVID-19 pandemic, such as more time with family, being able to learn at home, being less busy and more relaxed, fewer stressors related to going to school.
• Parents told us that some areas of their child’s functioning had worsened during COVID-19, while positively there were no changes in other areas (see Table 1 for a summary).

Stress associated with COVID-19 restrictions was associated with negative changes in mental health for children with ADHD and also increased social media use.

Worries about contracting COVID-19 were not associated with negative changes in functioning.

Table 1. Average changes in physical health, media use, and mental health

	Was there a change?
Physical health
Sleep	No change ?
Exercise
Outdoor time
Media use
TV
Social media
Gaming
Mental health
General worry, feeling anxious/nervous	No change ?
Feeling sad/depressed/unhappy
Enjoying activities
Fidgety behaviour	No change ?
Feeling fatigued
Unfocused/distracted	No change ?
Irritable	No change ?
Loneliness

How can parents support children with ADHD during the pandemic?²

1. Establish routines.
   Try to establish some consistent routines even if spending more time at home. For example, getting up and going to bed at the same time, having set meal times, and establishing set times for home learning and breaks. In a connected research study, we asked over 600 parents of children with and without ADHD what were the most helpful strategies they found for supporting their child’s learning at home. Over half of parents reported that the most helpful strategy was using routines and schedules.³
2. Consider the role of medication.
   Best practice clinical guidance suggests that children with ADHD should continue to take their medication during the pandemic even if learning from home.^4,5 In our study, most families continued with their child’s usual medication during the pandemic. Continuing with usual medications, as prescribed, may help children adapt to new circumstances, including learning from home. Preliminary, unpublished data from the ADHD COVID-19 study suggests that ADHD symptom severity was the strongest predictor of home learning difficulties in children with ADHD, emphasizing the importance of strategies to manage ADHD symptoms in the home learning environment.
3. Look for the reasons behind challenging behaviors.
   If your child is engaging in challenging behaviors, try to understand what the triggers might be and be there to help before triggers arise. Our research showed that children’s experience of stress related to restrictions and lockdowns was associated with negative changes in functioning. Therefore, helping children to cope with these challenges is important. One part of helping with coping is to validate the emotions they feel about lockdown, as it really is tough. It is still important to promote positive and respectful behaviors, however. You could consider involving your child in setting rules and also try to role-model expectations. Additionally, you can aim for quality one-on-one time where you can do something fun together that doesn’t involve home learning.
   Boredom can sometimes be a trigger of challenging behaviors. Getting in early before boredom kicks in can be helpful. Come up with a list together of fun activities for your child to select from depending on their interests; for example, art, reading, dancing, construction, cooking, board games, and imaginary play.
4. Consider rules for screen time and aim for outdoor time with exercise.
   Unsurprisingly, we found that children had higher levels of screen time during lockdown. This is understandable given all the extra time we now have inside, especially given that many parents need to manage their own work with their children at home. It’s important that we don’t beat ourselves up as parents for letting our children have more screen time than usual. However, it can still be helpful to consider making some rules about screen time, including where, when, and how your child can use screens. Try to aim for shorter sessions of screen time (perhaps 30 minutes) and avoid screen time before bed.⁶
   Again, it is no surprise that children were reported to get less exercise during lockdown. Try to still aim for outdoor time with exercise each day (if lockdown rules permit) such as going for a walk, a run, a bike ride, or a scoot around the neighbourhood.
5. Stay connected with others.
   We found an increase in children’s experiences of loneliness during the lockdown. We are lucky to have a range of technologies at our disposal to enable connections with others. If possible, aim for at least one social connection per day with friends and/or extended family members. You could consider organizing for your child to watch a virtual movie with friends, eat lunch with a friend virtually, along with other virtual activities.
6. Look after yourself.
   One of the most important things that we can do as parents is to look after ourselves. Give yourself permission to rest, do things you enjoy, and maintain social connections. Exercise self-compassion; we are all doing the best that we can.

How do our results compare to other studies?

So far there have been very few research studies published about ADHD in the context of COVID-19. One study of 241 parents of children with ADHD from Shanghai found that some behaviors had worsened, including the child’s ability to focus, increased anger, and poorer daily routines.⁷ However, many parents reported that some things had improved, such as their child’s sleep and eating.

Another study of children experiencing lockdown in France also pointed to varied outcomes for children with ADHD.⁸ About one-third were reported by their parents to have worse wellbeing, while another third were reported to be functioning better during lockdown. Another study focused specifically on the home learning experiences of adolescents with ADHD during the pandemic in the United States and found that remote learning was more challenging for adolescents with ADHD compared to adolescents without ADHD.⁹

The ADHD COVID-19 survey has surveyed families four times now, at monthly intervals to see how they are going during the pandemic. We are now working on understanding more about the impacts over time for children with ADHD and their families. We plan to follow up with them in May 2021, one year after they were enrolled in the study.

COVID-19 has been extremely challenging for parents and children around the world. It is important to discuss with health practitioners any difficulties you and your child might be experiencing. If further support is needed, consider obtaining a referral to a psychologist or another mental health professional.

Emma Sciberras, DPsych, is an associate professor and clinical psychologist in the school of psychology at Deakin University in Australia. She is also an honorary research fellow and team leader in health services research at the Murdoch Children’s Research Institute. Dr. Sciberras holds a career development fellowship funded by the Australian National Health and Medical Research Council, which focuses on developing evidence-based interventions for children with ADHD. She has published over 120 peer-reviewed papers, largely in the area of ADHD.

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