The COVID-19 pandemic has presented challenges for almost everyone, but one group has been uniquely affected by shifting circumstances: children and adults with attention-deficit/hyperactivity disorder (ADHD).
“People with ADHD rely on structure. When that structure was removed, symptoms that were under control became much more impairing,” said Jeffrey S. Katz, PhD, a clinical psychologist based in Virginia Beach, Virginia, and a member of the board of directors of the national nonprofit Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
Surveys, research studies, and practitioner reports have documented an uptick in referrals for ADHD assessment as well as a worsening of symptoms and trouble adapting to preventive measures around COVID-19 among those with ADHD (ADDitudeopens in new window, March 31, 2021; Zhang, J., et al., Asian Journal of Psychiatryopens in new window, Vol. 51, 2020; Pollak, Y., et al., Journal of Attention Disordersopens in new window, online first publication, 2021). Phone-based and online queries to CHADD increased inopens in new window 2020 by 62% and 77%, respectively, compared with 2019.
The dramatic, immediate change in environment that occurred in March 2020 forced nearly everyone to create a new routine, but that task was particularly difficult for people who already struggle with planning, motivation, and attention, said clinical psychologist Margaret Sibley, PhD, an associate professor of psychiatry and behavioral medicine at the University of Washington and Seattle Children’s Hospital. Other pandemic-related factors—such as more distractions at home, fewer opportunities to exercise, and a nationwide increase in substance use—made it even harder to function well.
In response to the pandemic, psychologists were tasked with differentiating cases of ADHD from more situational ADHD-like symptoms. They also found new ways to help adults and children who needed support to work and learn effectively from home. When some patients benefited from the flexibility of remote conditions, including remote mental health care, psychologists took note. Now, clinicians and others are working to apply these insights to deliver much-needed ongoing support.
“We’re in this for the long haul,” said Thomas Power, PhD, ABPP, a professor of school psychology in pediatrics, psychiatry, and education and director of the Center for Management of ADHD at the Children’s Hospital of Philadelphia (CHOP). “This is not just a crisis that’s going to last for another year or so. There will be downstream effects for years that we need to address.”
The imperative for early intervention
In the United States, about 8% of children and 4% of adults have ADHD (“General Prevalence of ADHDopens in new window,” CHADD). People with ADHD face problems with inattention, such as trouble listening or staying organized, and/or hyperactivity and impulsivity, such as restlessness or interrupting others. To receive a diagnosis, these symptoms must impair functioning in at least two areas of life—for example, at home, at school, at work, or in relationships—and must affect an individual before age 12, according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).
Dopamine dysregulation, which influences motivation, is at the root of many of these issues, Sibley said. People with ADHD may find some tasks, like reading a novel for school, less rewarding than others do—while other activities, like playing video games, feel hyper-rewarding and hard to stop.
If left untreated, these problems with motivation set the stage for significant hardship down the line. Follow-up studies of children with ADHD have documented more unemployment, less educational attainment, and more problems with depression, anxiety, and substance use than in those without the condition (“ADHD and Long-Term Outcomesopens in new window,” CHADD; Schiavone, N., et al., Psychiatry Researchopens in new window, Vol. 281, 2019). Research suggests that early intervention can mitigate some of these outcomes, so experts say timely and ongoing treatment is crucial for long-term success (Katzman, M. A., et al., BMC Psychiatryopens in new window, Vol. 17, 2017).
Remote work and learning
Early intervention has become an imperative amid the COVID-19 pandemic, when remote work and school conditions have upended the lives of so many. Children with ADHD are disproportionately affected by the academic disruption, Power said, because it can be difficult for them to learn using virtual systems.
“With the return to in-person school, students with ADHD, generally speaking, have required more support with instruction, organization, time management, and planning,” he said, because of both shifts in routines and setbacks related to remote learning.
The loss of structure and limited opportunities to socialize with peers have also caused social and behavioral setbacks for kids and teens, said Katz, including social anxiety and trouble sustaining healthy peer relationships. Several studies have documented increased emotional dysregulation among children and adolescents with ADHD during the pandemic (Breaux, R., et al., The Journal of Child Psychology and Psychiatryopens in new window, Vol. 62, No. 9, 2021; Korpa, T., et al., Childrenopens in new window, Vol. 8, No. 11, 2021).
Working from home has also presented challenges for adults with ADHD, including dealing with the loss of boundaries—such as a dedicated workspace or an on-site supervisor—that help them avoid distractions and provide cues about when to stop and start tasks.
“You’ve also got one of the most addictive things in the world, your cell phone, and there’s less external pressure to put it down,” said Allyson G. Harrison, PhD, an associate professor of clinical psychology and clinical director of the Regional Assessment and Resource Centre at Queen’s University in Ontario, Canada.
On the other hand, some people with ADHD have reported upsides of working and learning from home, said Danielle M. Politi, PsyD, who manages a team of clinical and educational assessment consultants at Multi-Health Systems, Inc., a Toronto-based company that develops psychological and other scientific assessments. For example, the increased flexibility allowed people to take frequent breaks and work at their own pace, while recorded lectures enabled college and graduate students to review class materials without time pressure.
“Some individuals with ADHD actually seem to function better at home, so how do we continue to create that type of environment as people return to school and work?” Politi said.
Diagnosing ADHD during the pandemic
With the pandemic-driven uptick in referrals for ADHD, many providers face a conundrum. Are people feeling bored, restless, and distractable purely due to circumstance—or are they living with an underlying condition?
“One thing we know about ADHD is that its severity is environmentally dependent to some degree,” said Sibley. A loss of structure, in other words, could lead to a worsening of symptoms among individuals with milder, undiagnosed ADHD. For that reason, clinicians should focus primarily on impairment when making a diagnosis, she said.
Is the patient experiencing meaningful difficulties in their life? If so, environmental modifications can make a big difference, and providers have used a mix of old and new strategies to help people with ADHD function well during the pandemic, many of which are still being applied as work and school conditions continue to shift. For adults working from home, a clear workspace that contains only work-related items helps to limit distractions, Politi said. She also recommends scheduling frequent breaks and using the last 15 to 30 minutes of each workday to reset: Clear your inbox and office space and make a plan for the following day.
Standard pre-pandemic advice is also more important now than ever, said Harrison. People with ADHD can improve their functioning by seeking out optimal work times and settings, for example during the late morning in a quiet area without internet access. They can also build in rewards for completing onerous tasks, such as 10 minutes of browsing social media after 50 minutes of studying. Setting external limits on electronic device use, for example through apps that block access to certain websites, can also help.
Supporting students with ADHD
Supporting children and adolescents with ADHD has been somewhat trickier (Rosenthal, E., et al., Journal of Attention Disordersopens in new window, online first publication, 2021).
“It’s tough because at a time when these students need the most support, the people we rely on to provide that support—teachers and parents—are very stressed, fatigued, and burdened,” Power said.
Teachers can make accommodations for students with ADHD, for instance by providing extra time to complete assignments or by allowing them to deliver a presentation in a different format. Katz also recommends that teachers meet one-on-one with these students each week to monitor their progress and performance. For classes that meet remotely, a teacher might schedule a short weekly video meeting to help students get a head start on assignments that feel daunting.
But teachers are concurrently attempting to accommodate students with special needs, address gaps in learning, obey and enforce rules related to masking, monitor potential symptoms of COVID-19, and make up for increased absenteeism.
In light of those competing demands, Power and his colleagues at CHOP, who design school-based interventions for children with ADHD, are working to simplify programs as much as possible to ease the burden on the teachers who deliver them. For example, many teachers use daily report cards to evaluate students several times throughout the day on various behaviors, such as working on assigned tasks or raising their hand to ask for help, and then they inform parents of the results. Power’s team works to streamline these reports by having teachers track just one behavior per child and evaluate them just twice each day.
CHOP also holds parent training sessions where groups of five to six families learn strategies for supporting their children and teens with ADHD. During the pandemic, the meetings have been adapted to include coping tools for overwhelmed parents, such as tips for staying organized, regulating their own emotions, engaging in self-care, and strengthening their support networks with other caregivers. Power has also worked with parents on how best to communicate with teachers about a child’s needs during this stressful period.
On the legal side, CHADD advocates for policies that address the needs of kids and adults with ADHD. For example, the United States Department of Education announced in 2020 that school districts must continue to provide special accommodations for students with ADHD and learning disabilities. Katz works with parents and helps create public messaging campaigns that spread awareness about such policies.
Other insights from the past 2 years include reaching new patient communities in new ways. “If there’s a silver lining to the pandemic, it’s that people got creative in connecting with others,” said Ellen Littman, PhD, a clinical psychologist based in Mount Kisco, New York, who studies women and girls with ADHD. “YouTube, Twitter, and TikTok are helping us cross an abyss and talk about ADHD with groups we haven’t been able to reach before.”
Sources like Jessica McCabe’s How to ADHDopens in new window YouTube series provide evidence-based explanations and advice to hundreds of thousands of viewers—including women of color, transgender people, and other underrepresented groups—and have become a crucial support network for many, Littman said.
Like many other patients, people with ADHD have also enjoyed opportunities for remote care. In particular, weekly check-ins with a health care provider can help those with ADHD keep up with time management and organization goals. These appointments are well suited to telehealth, which enables patients to more easily access specialized care regardless of their location.
“The real winners in this, patient-wise, are people who benefited from telehealth being an option and accessed care more because of it,” Sibley said.
Ongoing challenges
Though many schools and workplaces have resumed meeting in-person, the pandemic is not over. Many adults and children who contract or are exposed to COVID-19 may still be required to quarantine and intermittently return to remote work or learning, said Michael Suess, a licensed school psychologist and an assessment consultant at Multi-Health Systems, Inc. Even for children who do not get sick, periodic at-home learning may be common whenever classmates test positive. People with ADHD may require additional supports for navigating these changing circumstances for an extended period of time, even once life has largely returned to “normal.”
“We’re all still functioning in an uncertain environment,” said Politi. “That’s scary for everyone, but especially for kids and adults with ADHD.”
