Pandemic’s Impacts on Pediatric ADHD Varies Depending on Disorder Severity

(Part 1 of 2)

Increased screen time, diet changes, social impacts affects and other COVID-19 pandemic outcomes impact children with pediatric attention-deficit/hyperactivity disorder (ADHD) at varying levels depending on ADHD severity, says Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry, University of South Carolina School of Medicine, Greenville, South Carolina.

In Part 1 of this video series, Heather Flint, Senior Managing Digital Editor, Psych Congress Network, Malvern, Pennsylvania, interviews Dr Maletic about the pandemic’s impact on children with ADHD who are going back to school and tips for clinicians and caretakers to support the transition.

Read the transcript:

Heather Flint: Hello. Today, we're talking with Dr. Vladimir Maletic. We will discuss COVID-19 and its impact on children, especially ADHD children going back to school, and how providers and clinicians can help their patients move into this new back-to-school, non-virtual world. Dr. Maletic, if you'd like to introduce yourself?

Dr Vladimir Maletic:  Gladly. My name is Vladimir Maletic, and I'm a clinical professor of Psychiatry and Behavioral Science at the University of South Carolina School of Medicine in Greenville, South Carolina.

Flint:  Thank you. If you'd like to begin and talk in general about the impact that COVID-19 has had on children, and going from a virtual learning experience into a real-world classroom again, please?

Dr Maletic:  There has been a tremendous impact of the COVID-19 pandemic, and some significant changes have taken place in the lives of these children. The impact based on the studies that are available, and there are some studies that compile data regarding about 23,000 children.

These are large database researchers who have found that impact has been much more significant in younger children than in adolescence, and that indeed is worrisome. Where do these differences stem from? Children unfortunately, are independent possession. They don't have nearly the sense of agency that adults have.

The other thing is especially if they're young, they've had no opportunity to develop coping skills in order to handle similar scenarios that has never happened in their life. Now, what all has changed? Many times, playgrounds are closed. The parks are closed. They have no opportunity to play with their friends. Parents are stressed out.

Mom and dad are working from home, needing to have a role in their education. Their education is no longer live, now they're at home. The rules have changed. They're totally upside down. In the past, parents would despise media.

Your time on your computer, on tablet, on the phone is limited. It is only doled out in small quantities as a reward, and all of the sudden, entertainment is via the same electronic devices. School is via the same electronic devices. Staying in touch with their peers and friends and little relatives, same devices. Very unusual.

The other thing is children as young as 2 years old are aware of changes in their social environment, and social environment impacts them. If parents are anxious and stressed out and depressed, it will have a significant impact on children. The little sponges, they soak all of that in. That will have a significant impact.

Now, there are some other possibly preventable alterations. Children's sleep time has shortened. There has been some data generated suggesting that if sleep is shortened one to three hours, that may have significant impact on mood and anxiety levels. Exercise time is diminished to less than one hour in many children. That also has an impact on depression.

Diets have changed. Unfortunately, not for the better. Much more emphasis on processed foods that has negative impact on children. According to some of the studies, increased screen time, and increased screen time is more than three and a half hours a day, 90 percent of the kids. Many, many changes. What are some of the consequences that we are seeing from these changes?

Let's look at emotional and then let's look at behavioral consequences. In terms of emotional consequences, based on some of the studies, significant increase in depressive symptomatology. As many as 30 percent of the children who have ADHD are now manifesting prominent depressive symptoms. We're also seeing quite a bit of inattentiveness, again, in excess of 30 percent.

We're seeing more irritability. We're seeing more anxiety that would be in excess of 20 percent. Specifically, in ADHD that looked at severe anxiety, that number is about 15 percent. They've looked at moderate and severe depression, that's about 17 percent. Significant impact on children, in general, and quite a bit more pronounced in children who have ADHD.

There are multiple reasons for that. One has to do with all these changes that we have outlined related to COVID-19 pandemic, relative social isolation, increased level of stress in the household, as well as a relative limitation in resources.

Talking about limitation in resources, about 30 percent of the parents of children who have ADHD have reported decline in ability to reach mental health professionals who are assisting them in this situation. Looking at all these, what do we see?

In terms of emotional symptoms, some of the ones that I already mentioned, more depression, more anxiety, more irritability, more boredom, decreased motivation, disturbances in sleep. What are we seeing behaviorally? More irritability, more verbal and physical aggression in the worst cases, more oppositional and defiant behaviors, more temper tantrums, a lot of the negative consequences.

The question is, what can we do about it? I mentioned that there's limitation in terms of resources. There are some other concerns. For example, not only are mental health professionals, and to a significant degree especially in early months, became unavailable. There were noted differences in terms of how girls and boys received help.

When it comes to girls, they were more likely to be prescribed therapy and to have some kind of telemedicine engagement focusing on anxiety and depressive disorders, therapeutic CBT interventions. When it came to little boys, they received medicine, much less psychotherapy. [laughs] There are some important differences.

In terms of manifestations of COVID-19 pandemic, there are also some significant differences there. If children had mostly mild ADHD symptomatology, counterintuitively, they had worse outcomes. These are children who are by and large better socialized and, therefore, relied more on their peers, did better while in schools. That has been removed.

Now they're having remote education. This strains their ability to focus. They're having harder times. On the other hand, children who have more prominent ADHD, more severe ADHD symptoms, by and large, they have had issues with socialization as it is. Many times, they were being bullied. They felt that they did not fit in the school environment.

Now that they are participating in virtual and remote learning, all of a sudden, they're doing better. Some of the adversity has been removed from their life. It's also good to take into account some of the genetic factors. There are large genome-wide association studies that have looked into genetic makeup in children who have ADHD and children who are typically developing.

There's some really interesting findings from those. That is, there is no single gene or even half a dozen genes that are responsible for ADHD. We're talking about multiple, dozens of genes that have a role in propagating vulnerability towards ADHD. Here's the part that is maybe surprising to some.

We can in some ways measure vulnerability towards ADHD by looking at so-called polygenic risk score. This is the sum of all the risk genes. We're finding out that the higher the polygenic risk score, the greater severity of ADHD symptoms. Not surprising. On the other hand, these genes carry the greatest risk for obesity. That, we did not see coming. They're also associated with risk for anxiety, risk for mood disorders, and risk for temper instability, emotional instability, reactivity, irritability.

The big question is, these responses seen in typically developing children may be amplified in children with ADHD. Is this a predictable process in children who have biological and genetic vulnerability towards emotional dysregulation to start with? Unfortunately, this is in some ways, sadly enough, a living lab. We don't have all the answers in terms of what can be done.