Attention Magazine February 2021

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The COVID-19 pandemic has presented numerous challenges to children’s lives. These challenges may be more pronounced among children with ADHD given wide disruptions to routine and structure. The same procedures that were introduced to protect us from COVID-19 and contain its spread, could adversely impact the emotional wellness of children with ADHD by limiting social interactions, outlets for education, physical activities, and opportunities for socialization. The good news is that resilience, the ability to adapt well to challenging circumstances, can be fostered among children.

International research has been conducted on the effects of the pandemic among children diagnosed with ADHD. Parents in China reported that their children’s ADHD-related behaviors worsened and their overall mood suffered relative to pre-pandemic times.¹  Parents in France reported more oppositional/defiant attitudes, emotional outbursts, sleep problems, and anxiety.²

Notably, the adverse impact of COVID-19 on mental health is not universal across all children with ADHD. Some parents explained that the pandemic had increased their awareness of the role of inattention and ADHD symptoms in their children’s schooling and made adaptations.² In some ways, distance learning can be helpful, because there is less school-related strain and more academic flexibility.

A logical question follows: why are some children/families more affected than others in a time of serious disruption to their lives? We turn to resilience.

Six broad areas of protective factors

Resilience consists of dynamic processes that foster an individual’s positive adaptation to difficult circumstances and challenges. An exemplar of human resilience in the face of COVID-19 involves individuals, families, communities, schools, and governments working together to mobilize capabilities, connect in new and creative ways, and discover new strengths. Stay-at-home orders, for example, may afford children with more time to discover new hobbies and redefine meaning.

Where one sees challenges, a resilient perspective views opportunities. This is also supported by research; Chinese adolescents who reported a more optimistic outlook for the COVID-19 crisis had lower levels of anxiety and depression than their peers.³ For example, spending more time at home can offer greater flexibility with leisure time, more sleep, and increased time with family members.

In order to isolate what promotes healthy coping in response to life’s challenges, Alvord and Grados (2005) suggested that resilience can be comprised of six broad areas of protective factors. Importantly, resilience can be enhanced by strengthening each of these protective factors as children cope with the variety of struggles brought on by the current crisis.

A proactive orientation

First, one’s tendency to take a proactive orientation towards problems, through setting goals, brainstorming solutions, taking action, and maintaining an optimistic outlook, can reduce feelings of helplessness and help achieve a sense of control.  Parents can guide their children to become more proactive by identifying problems faced by the pandemic and asking them, What can we control about this problem? How can we come up with a plan to improve what we can control?  A child whose basketball season was cancelled can use the opportunity to hone her skills by shooting baskets each day in the driveway.

Importantly, parents can model their own proactive stance by acknowledging when to use problem-focused coping (when we can take meaningful action to address a challenge) and when to use emotion-focused coping (when we cannot change our circumstances but can change how we react). In other words: what can’t we control, and how can we accept these circumstances with an optimistic outlook?

When we think optimistically, we remind ourselves that the problem is specific rather than general, temporary rather than permanent, and not an indication of personal failure. Imagine a teenager is upset to learn that school will shift to distance learning. A parent can remind him: “I understand how you feel. We find it more difficult to learn/work at home, so you aren’t the only one. Even though you can’t see your friends in school, you can still meet up with them online. Let’s remember that this pandemic won’t last forever and you will return to in-person school.”

Self-regulation

Self-regulation is an equally important protective factor that encompasses our ability to control our attention, behaviors, and emotions, and is a common area of difficulty among youth with ADHD. The ability to self-regulate through challenging circumstances can help children succeed in school, activities, and friendships. Parents can teach children to self-regulate by helping them label their emotions and common triggers. Giving a name to a feeling helps it seem more manageable and familiar.

We encourage families to practice relaxation and mindfulness strategies with their children regularly. Fortunately, numerous resources exist, including YouTube and other video channels (GoNoodle and Cosmic Kids Yoga are some of our favorites), apps (such as Mindshift or Calm), or digital recordings (Relaxation and Self-regulation Techniques for Children and Teens; Alvord, Zucker, & Alvord, 2011). Children can also identify a number of calming activities, such as thinking of a pleasant situation in their mind, using positive self-talk, going for a walk, arts and crafts, texting a friend, or watching a funny television show.

Connections and attachments

Social isolation is a well-documented risk factor for mental health difficulties among youth and an area of particular importance among youth with ADHD. As such, the term “social distancing” is troubling because it implies that we must separate from important people in our lives, contributing to social isolation and decreasing our resilience in a time of crisis. The World Health Organization promotes the term “physical distancing,” because it encourages creative ways for us to continue to connect with others in a responsible, careful manner. In this way, we can maintain our connections and attachments through the COVID-19 pandemic, another crucial protective factor.

Video calls, playing video games online with friends, virtual movie nights, and, when appropriate, biking or other outdoor get-togethers with appropriate distance, are just a few options for children and teens to remain connected to friends. If school has shifted to distance learning, parents can encourage children to socialize by having a virtual lunch with a group of friends or starting an online study group.

Community

Furthermore, connection with one’s community outside of friendships and family members is another important protective factor that may otherwise be lost during the COVID-19 pandemic. Parents can help children continue and cultivate meaningful relationship with teachers, youth leaders, extended family members, and recreational club leaders despite limitations to in-person meetings.

Achievements and areas of competence

Resilient children and teens also engage in and identify achievements and areas of competence. Prior to the pandemic, this included participation in extracurricular activities such as sports, theater, or art classes. During the pandemic, families can find creative ways to develop and strengthen children’s areas of enjoyment and competence. This may include participating in known activities in new ways (for example, creating a “dance studio” in one’s basement for virtual ballet classes) or learning and nurturing new talents (such as painting, baking, teaching the family dog new tricks).

Proactive parenting

The final protective factor may be the most meaningful during the COVID-19 pandemic, as children often turn to parents during difficult times. Proactive parenting characterizes caregivers who are consistent, loving, and supportive. It is preferable to be a “coping model,” rather than “mastery model.” For example, a parent can say: “I know you miss your friends. I miss my friends, too. Maybe we can try to do an outdoor get-together?”

Parents can maintain structure, routines, and behavioral standards during the pandemic, with compassion and flexibility. For instance, where screen time is concerned, parents can set limits on non-social activities such as gaming, surfing the internet, or watching television, but allow reasonable time to chat with friends. Of course, caregivers are encouraged to pay attention to their own self-care and seek support when needed, which may otherwise be neglected to the increasing demands of childcare, work, and other obligations.

What would indicate more serious problems?

The current COVID-19 pandemic places many people at risk for mental health concerns. Children and teens, particularly those with pre-existing concerns such as ADHD, may be at increased risk. It is essential that families and professionals promote resilience among youth during difficult times.

There may be some indications of a more serious problem if any of the following occur:

• a child or teen continues to struggle with uncontrollable, unpleasant emotions such as sadness, irritability, or anxiety despite parental involvement;
• significant changes to sleep, eating, or other behavioral routines;
• persistent distress following a trauma such as loss of a loved one to COVID-19;
• signs of dangerous behaviors including substance use, self-injury, or suicidal ideation.

If a parent has any of these concerns or anything else that simply doesn’t feel right about a child or teen, a prompt consultation with a mental health professional is recommended.

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Colleen Cummings, PhD, is a psychologist at Alvord, Baker & Associates, LLC. She has training and experience in the cognitive-behavioral treatment of youth with anxiety, depression, obsessive-compulsive, and attention disorders.

Anahi Collado, PhD, is a clinical psychologist at Alvord, Baker & Associates, LLC, and an assistant research professor at the Cofrin Logan Center for Addition Research and Treatment at the University of Kansas.

Mary K. Alvord, PhD, is a psychologist and is director of Alvord, Baker & Associates, LLC. She is coauthor of Conquer Negative Thinking for Teens and Resilience-Builder Program for Children and Adolescents.

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FOOTNOTES

1. Zhang, J., Shuai, L., Yu, H., Wang, Z., Qiu, M., Lu, L., & Chen, R. (2020). Acute stress, behavioural symptoms and mood states among school-age children with attention-deficit/hyperactive disorder during the COVID-19 outbreak. Asian Journal of Psychiatry, 51, 102077.

2. Bobo, E., L. Lin, E. Acquaviva, H. Caci, N. Franc, L. Gamon, M-C. Picot et al. “Comment les enfants et adolescents avec le trouble déficit d’attention/hyperactivité (TDAH) vivent-ils le confinement durant la pandémie COVID-19?.” L’encephale(2020).

3. Zhai Y., Du X. Mental health care for international Chinese students affected by the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e22. doi: 10.1016/S2215-0366(20)30089-4.

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REFERENCES

Alvord, M.K., & Grados, J. J. (2005). Enhancing resilience in children: A proactive approach. Professional Psychology: Research and Practice, 36(3), 238-245.

Bobo, E., L. Lin, E. Acquaviva, H. Caci, N. Franc, L. Gamon, M-C. Picot et al. “Comment les enfants et adolescents avec le trouble déficit d’attention/hyperactivité (TDAH) vivent-ils le confinement durant la pandémie COVID-19?.” L’encephale (2020).

Cortese, S., Asherson, P., Sonuga-Barke, E., Banaschewski, T., Brandeis, D., Buitelaar, J., … & Doepfner, M. (2020). ADHD management during the COVID-19 pandemic: guidance from the European ADHD Guidelines Group. The Lancet Child & Adolescent Health.