Creating a Supportive Network for Children With ADHD

(Part 2 of 2)

Heather Flint, Senior Managing Digital Editor, Psych Congress Network, Malvern, Pennsylvania, interviews Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry, University of South Carolina School of Medicine, Greenville, South Carolina, about the COVID-19 pandemic’s impact on different age groups of children with pediatric attention-deficit/hyperactivity disorder (ADHD) and how parents and schools can be better prepared to support children during the back to school transition.

In the previous part Part 1 of this video series, Dr Maletic, who is also a Psych Congress steering committee member, explains that increased screen time, diet changes, social impacts affects and other COVID-19 pandemic outcomes impact children with pediatric ADHD at varying levels depending on disorder severity.

Heather Flint:  I'm wondering when you were speaking about the differences between treating boys and girls, and you touched on 2-year-olds and socialization, do you find different age groups have different responses to the way they've been impacted with COVID-19 but also how clinicians are treating them?

Secondly, tips for providers and clinicians to assist in treatment, and would that be based on age group as well?

Dr Vladimir Maletic:  Absolutely. In terms of in general looking at age categories and looking at gender, there are differences. Younger children, in general, are more impacted than older children. In terms of coping, younger children also do not have very developed coping skills. They're more subject to influence of their environment.

Younger children are also not always capable of participating in remote therapies and telehealth. Cognitive-behavioral therapy is going to work much better in adolescents than in younger children. Girls are more likely to experience anxiety. Boys are more likely to experience depression. What can be done in those circumstances?

There are a couple of obvious answers. One is that schools can now rise to the occasion and start providing some maybe limited but therapeutic interventions. How teachers relate to children can be very therapeutic. Then there can be therapists that will work with school systems and try to address some of the issues that children have.

Of course, the greater burden when it comes to younger children will be on parents. What can parents do in that situation? Explain. Children will ask about what is going on. Children will have concern, oddly enough, not as much about their own health. COVID-19, at least the previous variants, mainly had mild to minimal manifestations in children.

They were worried about their parents. This is who they depend on. Will mom and dad get sick? Mom and dad are acting in unusual way. What is going on? Taking time and explaining to children in age-appropriate manner what is going on, reassuring them. Although parents are stressed out, not overreacting to some of their disruptive behaviors.

It's good to know that some of the temper tantrums, some of the defiant behaviors and even aggressive behaviors are indeed a response to feeling helpless, to feeling lost, to feeling distressed. That is how children cope with it. Not being overly punitive, engaging in so-called positive parenting.

Explanation, reassurance, disciplinary measures, definitely need to be age-appropriate and not overboard. If parents are acting because they're angry and frustrated, that's not necessarily the best way to parent. There are a lot of things that can be done. With adolescents, of course, there are different interventions that are available.

Initially, it was difficult to reach members of mental health community. Now, it is becoming easier. Paradoxically, with the expansion of telehealth, the access in some instances has increased, although we are still in a crisis mode. It's still hard to get appointments. You can have individuals, therapists who will work with the families remotely.

You will have the therapeutic community respond and provide psychotherapy, many times cognitive-behavioral or similar psychotherapeutic interventions that will help. Pediatricians, psychiatrists, developmental pediatricians have now found ways of remotely working with their patients.

Not only can one have a comprehensive evaluation, one can see a little bit more about what the living environment looks like. If necessary, medications can be prescribed. Basic medical monitoring can be also conducted via telehealth. There is help. Number one is parental interventions, reassurance, positive parenting, and explaining the circumstance.

Number two, therapeutic interventions that come in through schools. Number four, members of a therapeutic community involving a large spectrum of mental health providers. There are some other wellness strategies that can be utilized.

Especially children who have ADHD, probably would be a good idea for those children to sleep anywhere between 8 to 12 hours a day. Sleep has diminished in terms of quantity and sleep rhythms are often disturbed. Parents will work at odd hours. That will influence children's schedules. Two, let's organize some kind of appropriate peer activities.

Playgrounds are slowly opening. Parks are slowly opening. Even when that is not available, one can have so-called bubbles interacting with each other. Families, other related or close friendships, parents are vaccinated, proper precautions have taken place, is it possible to have smaller playgroups? That would help.

Children in these earlier stages of development need social interaction in order to develop social skills. Those are some of the interventions. Let's try as much as we can to have fresh foods, not to overload kids with sugar, simple carbohydrates, starches, and processed food. Let us try to have fresh vegetables and fruits to have a healthier diet.

Let's try to have more physical activity. Let's try for at least hour and a half, two hours of physical activity. Indeed, children do rely on screen time, but let's not lose control. Let's not have kids solely communicating with peers via social media, playing games. Their education is via electronic devices.

Let's keep it reasonable. Let's monitor. Let's have an idea of what is going on. Indeed, there are multiple interventions at our disposal that can help children in general, but also more specifically, children who suffer from ADHD.

Flint:  As we look at getting more socialization and going back into the school setting, a lot of schools have already gone back in person last year, but now, we're looking at things like mask mandates being lifted, like you said, the playgrounds being opened up again.

There's going to be more sports and interaction that way. Do you feel that both clinicians and the schools are equipped to handle the impact that this is going to have on the children, especially children with ADHD moving forward?

Dr Maletic:  Advances have been made. Some of the strategies that we have discussed are now being deployed. Something that is a hanging question, we can't anticipate what will happen with the Delta variant. We're already seeing some communities change their plans.

Majority of the children under the age of 12 are not vaccinated. We don't know if vaccines will be and when will be approved for those ages. When it will be seven and up, that will influence what's going to be happening in school.

I'm hearing from many communities that children, if they are attending live education, and live education is now recommended in most of the communities, they will have to mask. That is obviously easier said than done. Trying to influence children to continue wearing their masks during the breaks, during lunchtime, even during class is going to be a challenge on teaching staff.

There are good news. Good news is, we do know what to expect. We do understand pitfalls. We're in much better shape than we were a year ago. On the other hand, I wouldn't consider COVID-19 epidemic over. This is not the time to declare victory. This is the time to be calm, not to panic. To be prepared and have this whole menu of therapeutic and wellness interventions ready to deploy if necessary.

Flint:  Do you have any tips or general information for clinicians and other providers who are trying to get these kids ready to go back to school in some capacity? Also, how to deal with generalized anxiety or things to look out for as they go back to school that could potentially be triggers that could set them back instead of moving them forward?

Dr Maletic:  Indeed, it would be good for clinicians to keep up with the literature. Again, this is not a life as usual. To understand it if we're seeing more anxiety, more depression, a low motivation, boredom, more inattentiveness, again, a spectrum of disruptive behaviors, not to overreact, not pathologize, but to put it into context.

To understand that developmentally, children are not very well equipped to deal with this. That not only are they afraid for themselves, they're afraid for their parents. Stress in the household is building up. Education has changed. Peer relationships have changed. Let's be more understanding. Let us be more positive.

Let us not punish, but rather have conversation, contextualize, and understand that although these behaviors and emotions may seem out of the ordinary, they are not an unnatural response given the context. To contextualize it, and to do the best we can. Doing play therapy via telepsychiatry is not easy to do, but we can counsel parents what to do.

Schools can counsel parents how to handle these situations. Then again, therapeutic community will rise to occasion and provide resources for children and families. Finally, in some instances, if medicines are necessary, there are ways to both prescribed and safely monitor medications if necessary in those instances.

Flint:  To follow up on schools being able to help guide parents, do you think that schools and the counselors at the schools, they are dealing with a numerable amount of stressors for their children, do you think or feel that at some point some of the children with ADHD could get lost in the mix?

If so, what would you suggest for clinicians, but also for clinicians to suggest to parents in order for parents to identify that and be able to help address these things with both the school and with their children in general?

Dr Maletic:  The key question that you're bringing up in these unusual circumstance is, what is expected behavior in typically developing children, and when is it a time to diagnose a psychiatric disorder in a child? That is pretty tough because to make that differentiation, you need very experienced clinicians.

I would say that it's a good idea for parents to be on the lookout. It is a good idea for teachers to notice changes in behaviors. If they do have concerns that this is something that is different, then expected response of a typically developing child in very unusual circumstances. We're suspecting that there is ADHD. We're suspecting that there is an anxiety disorder, or a mood disorder.

In that case, let us do something about it. Talk to the parents and make sure that appropriate referrals are made because you do need professionals making that call.

Flint:  Excellent. Are there any final thoughts or topics you want to address as we move into the final month of preparation, going back to school and getting these children prepared?

Dr Maletic:  Again, I would have an optimistic message. Although challenges remain, adversities will continue. Now, it is not new. We have, I hope, gone through the worst of it. We have developed the means of coping. We know what wellness practices to institute if there is suspicion, be it parents or teachers. There may be a psychiatric condition involved.

There is more opportunity. Mental health system is still strained, but we have adapted. We know how to handle this situation. There will be more access, hopefully, than there was last year at this time.

Flint:  I want to thank you so much for discussing this with me today. Your insights are always extraordinarily helpful for our community. Until next time, we wish you the best and thank you again for all of your time and your support today.

Dr Maletic:  Thank you very much. Again, I appreciate this opportunity. I hope that our colleagues and parents will find some little pearls and something that can help them that stems from our conversation. Again, thank you very much.

Flint:  Thank you.