Preparing Children with ADHD for a Return to In-Person Learning

Ann Childress, MD, President of the Center for Psychiatry and Behavioral Medicine Inc in Las Vegas, Nevada and Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry, University of South Carolina School of Medicine, Grenville, South Carolina, continue their discussion about the pandemic’s effect on children with pediatric attention deficit/hyperactivity disorder (ADHD).

Children in lockdown saw differing rates of symptoms, including aggression, oppositional defiant behaviors, and restlessness, while isolating at home without in-person school. Dr Childress answers questions about preparing children with ADHD for a return to in-person education. 

In the previous part 1 and part 2, Dr Childress and Dr Maletic discussed the pandemic’s effects on relationships, daily lives, and nutrition for children with pediatric ADHD.

In the upcoming part 4, they converse about comorbid conditions and differing ADHD symptoms among patients. 

Read the Transcript:

Dr Maletic: There is something interesting, you have mentioned a transition to school. I know you're aware of the recent study that comes from Rome. This is a large study. It included about 990 patients, approximately 1,000 patients. They used an instrument to evaluate emotional impact of sequestration of lockdown related to COVID but also some aberrant behaviors. 

This is a twofold question. One is, what did they find in terms of emotions? What they noticed is that the levels of boredom have increased and also ability to enjoy life and interest have significantly decreased.

When it came to some of the behaviors, we all see these in children who have ADHD anyway, a more disruptive behavior, more oppositional defiant behaviors, more verbal but even physical aggression was observed in these individuals. Here is the part that is paradoxical. Individuals who have ADHD and who had more aggression, who had more oppositional, defiant behaviors, more restlessness, when in a COVID influenced lockdown actually did better. 

Paradoxically, kids who had milder manifestations of aggressive, restless, oppositional defiant behaviors, they did substantially worse in lockdown. 

Number one, I'd be interested in hearing your thoughts about this phenomenon. Number two, something that I'm sure is very important, both for our colleagues to hear and also for parents of children. You mentioned going back to face-to-face education. 

How does one transition, especially having in mind the complexity of the change that took place during COVID and change in education, peer relationships, and all that? How do you get your kids ready to go back to a live education? 

Dr Childress: I was a little bit surprised that the kids in the study that had severe symptoms, had fewer during the lockdown. I wasn't surprised at all that the kids that had mild to moderate symptoms had worsened emotional symptoms and more behavioral issues. 

I wasn't surprised at all that the emotional impact was worse for the little guys than it is for the older kids, than it was for the teen. I am very much looking forward to the kids going back to school. 

Although, it's always a little hard for me because it's still easier to get people in for research studies during the summertime because they have the days off. I turn into the Maytag repairman in the morning. After school, our clinics starts hopping as kids are coming out. But there are a number of things to do. 

I think trying to get kids excited about going back to school and I think my kids with ADHD have been cooped up long enough that they are actually excited about going back to school, but there can be a lot of trepidation, too because for a lot of our kids, it's been about 16 months since they've stepped into the classroom. 

There were a few hybrid classes going on here, and some of the charter schools were still going in person, but still, a lot of our kids have not been back in the school. So, getting them excited about it, getting new clothes because they have grown, buying school supplies. That's always fun to get your new box of crayons, your new Sharpies and all of those things. Making it an exciting thing to go back. 

One problem has been, and it's always a problem, is sleep hygiene. A lot of these kids are staying up late. School starts early in the morning. High school here starts at 7:00 AM. Working on right now, we've got a little bit less than a month. We've got three weeks until school starts. It starts the first week in August, I think the 10th or the 9th. 

Backing up those sleep times, I always say, go to bed at a time that's not “sexy,” by eight o'clock, nine o'clock. You need nine hours sleep if you're 16, and you need more than that if you're younger. Working on how are we going to back that up and make sure that they're getting good sleep hygiene. 

Planning on trips or things that they're going to do on their Thanksgiving break or the semester break, so looking towards the future.

Talking about anxiety and fears with their parents, that's important. I try to have the parents minimize the news on at home because the news isn't always good. A lot of the news focuses on bad things, and the number of COVID cases, and that sort of thing. 

To shield them from that if they can, and to not overschedule. A lot of our kids are overscheduled. Some of my kids that are doing club ball and club dance were able to continue doing that, but not to get right back into school and then schedule every day after school. Dip your toe in the water so to speak, and gradually increase activities if they haven't been doing outside activities. 

Dr Maletic:  It's a great idea. Some of the pearls that you have shared with us, one is do not overschedule, do not make it a dramatic change between the lower activity level during lockdown. In contrast, not only have the usual school activities, but add a lot on top. I guess the magnitude of change could be adverse.

Then, shield them. Not everything that shows up in the media and in the chat rooms, number one, is a fact or verifiable, and misinformation sometimes can also do some harm. The last thing I heard you say is build up enthusiasm. Present this transition as something that is positive. This links to this, I mentioned, to the Italian study and the paradox that they noticed. 

This is just the authors' discussion. I'd be curious to hear your thoughts because it is relevant to our topic. What they were suggesting is that kids who have less disruptive behaviors were, in general, more socialized, and better fit in the school environment. The structure of school was actually helpful. 

In the lockdown, some of the structure was eliminated or minimized, and therefore we see more disruptive behaviors. On the others hand, some of the kids who had more disruptive behaviors, it may have been associated with bullying and victimization in school. They were not good fits in school. Therefore, removing them from that environment, for them, may have been a relief. 

I'm sure that, to a degree, both you and I will have patients who are in these categories. Do you have some differential strategies? You've already mentioned something; be more in touch with your peers. If you have schoolmates who have been in touch, intensify it. In some ways, it will provide for a smoother transition. 

What about kids who didn't fit well at school, who had lot of problems with bullying, who had a lot of disruptive behaviors in school? Any thoughts and ideas on how to facilitate their transition back to face-to-face education? 

Dr Childress:  I think one of the things that is really important is, a lot of these kids get bullied because their ADHD symptoms aren't under good control. They may be more impulsive, they're calling out, they're getting in trouble. May be the class clown, but may not necessarily be the class clown, so the teacher doesn't like them. 

Making sure that their ADHD symptoms are under good control. It's just like getting a new backpack for school. We want to make sure that you are optimized on your medication and your ADHD treatment. 

Working with them, talking about, "This is a new opportunity, people haven't seen you in a year and a half. You're in a different grade, you're going to be with different peers, so this is a nice opportunity for a fresh start." 

Many of the elementary school kids are now going to be in middle school, and the middle schoolers will be in high school. Everybody is going to be in a different boat. Really, working with those kids, trying to help them fit in a little bit better. 

Dr Maletic:  I really like your response, because something that you're mentioning, maybe the reason they're not fitting in their environment is because they have greater severity of symptoms. Therefore, let's again revise what has been done up to now, and see if there is more that we can do. 

Ann C. Childress, MD, is in private practice in Las Vegas, Nevada. She has adjunct faculty appointments at the University of Nevada Las Vegas, School of Medicine and Touro University Nevada College of Osteopathic Medicine. She is board certified in psychiatry, with a subspecialty in child and adolescent psychiatry. Her current research focuses on the treatment of children, adolescents, and adults with ADHD. Dr. Childress is a Distinguished Fellow of the American Psychiatric Association, President-elect of The American Professional Society of ADHD and Related Disorders, a member of the American Academy of Child and Adolescent Psychiatry and is Education Director for the Nevada Psychiatric Association.

Vladimir Maletic, MD, MS, is a clinical professor of psychiatry and behavioral science at the University of South Carolina School of Medicine in Greenville, and a consulting associate in the Division of Child and Adolescent Psychiatry, Department of Psychiatry, at Duke University in Durham, North Carolina. Dr. Maletic received his medical degree in 1981 and his master’s degree in neurobiology in 1985, both from the University of Belgrade in Yugoslavia. He went on to complete a residency in psychiatry at the Medical College of Wisconsin in Milwaukee, followed by a residency in child and adolescent psychiatry at Duke University.