Impact of COVID-19 for people living and working with ADHD: A brief review of the literature

Objective COVID-19 lockdowns have changed the social and environmental context. Those with ADHD are more vulnerable to experiencing difficulties than their non-ADHD peers. This paper attempts to provide a brief summary of the literature that has emerged during the COVID-19 pandemic. Method A literature search was completed using the following databases; Embase, Ovid Medline, APA PsycInfo. A total of 36 papers were identified as relevant to the topic. Results The pandemic has exacerbated the core symptoms of ADHD and co-occurring difficulties. Services have adapted their assessment and intervention protocols for tele-health working and findings suggest that tele-interventions present a viable alternative. However, much of this research utilises small sample sizes and a restricted number of population groups. Conclusions More research is required to determine the effectiveness of ADHD care during the pandemic and whether adaptations will be retained post-pandemic.


Introduction
In 2019, coronavirus 2 (SARS-CoV-2), a severe acute respiratory syndrome, was identified, originating in China [1]. It is known more commonly as COVID- 19. By March 2020 the World Health Organisation declared that COVID-19 was a "pandemic". However, from January 2020 countries began systematic lockdowns, restricting the movement of their citizens. These worldwide restrictions have placed significant stressors on young people and their families, with over three quarters of young people's behaviour and psychology being negatively affected [2][3][4]. At particular risk of the negative effects of COVID-19 social restrictions are those with pre-existing conditions such as Attention Deficit Hyperactivity Disorder (ADHD) [2,[5][6][7][8][9][10].
To determine the impact of COVID-19 lockdown on individuals, their families and professionals, a review of the literature was conducted. At the time of writing this review many parts of the world are still experiencing some degree of social restrictions and therefore the experiences of lockdown will be referred to in the present tense.

Methods
A literature search in Embase, Ovid Medline, APA PsycInfo was completed on 18 th March 2021. No restrictions on country of origin or language were enforced. All articles that reported information about young people and/or adults with a diagnosis of ADHD or ADHD symptoms were included. In addition, articles that explored the effect of COVID-19 on parents or caregivers of individuals with ADHD were included. This review was also interested in exploring adaptations to neurodevelopmental or mental health services and educational providers. The following terms were used to identify papers that included ADHD: "ADHD" or "Attention Deficit Hyperactivity Disorder" or "Hyperactivity Disorder" or "ADD" or "Attention Deficit Disorder" or "Hyperkinetic Disorder". This resulted in 364,658 results. Published papers relating to COVID-19 were identified using the following search terms: "COVID-19" and "coronavirus". This resulted in 262,069 results. When these search strings were combined, 886 papers were identified. 319 duplicates were removed leaving 567 papers. The titles and abstracts of these 567 papers were screened and a total of 36 papers were included. Papers were excluded if they did not explore the effect of COVID-19 on ADHD symptomology, the functioning of people with ADHD or service and/or other institutional provisions for people with ADHD. See Figure 1 for search strategy and Tables 1-2 for list of included papers. The bibliographies of these papers were reviewed to identify further relevant papers, but none were identified.  Table 1 for list of included papers and Table 2 for summary of paper outcomes.  The adults with ADHD surveyed had significant levels of emotional distress during the COVID-19 pandemic period. However, there was no evidence of significant deterioration to the mental health of the sample during the COVID-19 pandemic.
The COVID-19 pandemic could be a factor in inducing psychological distress in the participants who adjust relatively better at work/school but did not do well at home before the pandemic. The study indicates the need for special support for individuals with ADHD, especially those who originally had difficulties at home. This study provides initial findings of the nature and impact of remote learning during the COVID-19 pandemic. Adolescents, particularly those with mental health and/or learning difficulties require additional support from schools and communities. 5.
Becker Presents the European ADHD Guidelines Group (EAGG) perspective on starting ADHD medications (specifically psychostimulants and atomoxetine), during the pandemic, for patients who did not have a baseline, face-to-face cardiovascular assessment before the crisis began. Telepsychology "Bootcamp" for ADHD can be implemented with comparably high levels of content and process fidelity and treatment satisfaction to inperson groups; and it appears to be feasible and acceptable to caregivers. Caregiver and clinician qualitative feedback revealed themes of appreciating the convenience of telepsychology, while experiencing some challenges in relating to others and sharing over video. 14. Kavoor AR, Mitra S (2021).
Provides a brief summary of the current literature on the management of ADHD during COVID-19 and signposts areas for more research. 15. Laslo-Roth R, Bareket-Bojmel L, Margalit M (2020).
Students with ADHD reported higher levels of loneliness and more negative experiences with distance learning than their peers. Results demonstrated that ADHD and negative experiences with distance learning predicted higher levels of loneliness, while college support and peer support in addition to hopeful thinking mediated these relations. The ADHD group had one of the highest increases in negative semantic features for certain subreddits. Some parents in France of children and adolescents diagnosed with ADHD reported increased hyperactivity and inattention, while other parents reported symptomatic improvement. 17. Mallik CI, Radwan RB (2021).
Prevalence of emotional, conduct disorder and hyperactivity were also increased significantly during the lockdown period than before. Conduct disorder and hyperactivity were more prevalent among boys both before and within lockdown. 18. McGowan G, Conrad R, Potts H (2020).
The risk for worsening ADHD symptoms under quarantine highlighted the need for more home-based interventions and symptom monitoring by families and providers. Further research is needed to determine the efficacy of telehealth services during the pandemic.

McGrath J (2020).
There is a growing evidence base for telepsychiatry in assessing and treating young people with ADHD. This paper provides a practical approach that could be considered by CAMHS nationally. Young people with neurodevelopmental conditions, compared to neurotypical controls, had a higher prevalence of emotional symptoms and conduct problems and fewer prosocial behaviours. All groups had worse emotional symptoms than pre-COVID groups, and those with attention-deficit/hyperactivity disorder showed inflated conduct problems. A systematic review and meta-analysis revealed that children with pre-existing behavioural problems like autism and ADHD have a high probability for the worsening of their behavioural symptoms Video based teleneuropsychology benefits consumers through reduced wait times, decreased family financial burden (i.e. travel and parent time off work), expedites referrals for interventions and increases access for those whose access is limited by geography, language and culture. 27. Saline S (2021).
Interventions to help families of young people who are neurodiverse are most effective when they rely on the 5 C's method of successful ADHD parenting. Working together for effective solutions based on meaningful incentives reduces family conflict, improves young people's participation and fosters parentchild cooperation. Compared to pre-pandemic, children with ADHD had less exercise, less outdoor time, and less enjoyment in activities, while television, social media, gaming, sad/depressed mood, and loneliness were increased. Child stress about COVID-19 restrictions was associated with poorer functioning across most domains. Most parents reported positive changes for their child including more family time. 29. Shah AC, Badawy SM (2021).
The evidence from this review suggests that telemedicine services for the general public and paediatric care are comparable to or better than in-person services. This service evaluation indicated that the program provided by a neurodevelopmental clinic was well received, the virtual format and technology ran smoothly, and the recommendations were generally perceived as helpful. 33 Children's ADHD behaviours were significantly worsened during the pandemic in comparison to their normal state. Children's overall mood, parents' overall mood state, and children's study time, significantly predicted children's ADHD behaviours.

ADHD symptoms, co-occurring difficulties and impairment
Adults with ADHD are identified to have experienced significant levels of emotional and behavioural difficulties during the pandemic but the degree of deterioration is uncertain [19,20]. However, the pandemic is reported to have exacerbated difficulties for many young people with ADHD and their families [5] and rates of ADHD have been reported to have increased during the pandemic compared with pre-pandemic rates [21]. Shah and colleagues [22] found that during lockdown young people with ADHD experienced an increase in activity, disruptive behaviour and irritability. Symptoms of inattention and oppositionality have also been found to increase for young people with ADHD compared with their non-ADHD counterparts [23].
Regarding mental health, low mood and isolation have been found to increase for young people with ADHD as a result of COVID-19 restrictions [24]. In addition, a decrease in general well-being, demonstrated by an increase in oppositionality and emotional outbursts have been reported by parents [7,25]. The presence of both ADHD and emotional dysregulation are found to increase the risk of negative mental health functioning [23].
Young people with Obsessive Compulsive Disorder (OCD) and a family history of ADHD are also reported to have experienced an increase of OCD symptoms during lockdown [26]. Furthermore, young people with ADHD, experience a reduction in outdoor activities and an increase in indoor activities, such as social media use, watching television and video game play [24] which can be detrimental to well-being and functioning for some young people [27].
Young people are reported to be experiencing sleep difficulties during lockdown due to symptoms of COVID-19, sedentary behaviours, isolation, limited exposure to sunlight, poor sleep hygiene and increased exposure to "blue light" [28][29][30]. However, young people with ADHD may be at a higher risk of sleep difficulties due to medication use and co-occurring conditions [31] which may in turn increase or mediate other difficulties such as inattention, emotional difficulties and conduct problems [32,33].

Service provision
National lockdowns and restrictions on face-to-face contact have had a dramatic impact on the services that are provided by institutions and the mode by which these services are provided. Given the high transmission rates of COVID-19 [34] and the fact that the majority of young people are asymptomatic [35], face-to-face contact was significantly reduced and, in many cases, stopped altogether and a number of adaptations were developed for both young people and adult services.

Assessments
Referral rates for ADHD assessments have reduced by as much as 80% in Ireland [36] and this has been attributed to the reduction in school referrals and families minimising non-emergency contact with health care services.
Tele-assessments have been identified as effective in the diagnosing and management of neurodevelopmental disorders, including ADHD [37,38], but less is known about the accuracy of these assessments for adults compared with face-to-face assessments [37].
Diagnostic assessments that require liaison with schools has been impaired or delayed by the closure of many schools and the capacity of educators. Whilst screening measures can be facilitated remotely either by post or email it has not been possible to undertake behavioural observations when required or monitor the effect of medication within the school environment [36].

Pharmacological interventions
The National Institute for Health and Care Excellence [39] recommends a baseline physical health examination prior to starting ADHD medications which has not been possible as many services are limited to remote appointments.
Due to concerns over the potential increase in health risks for individuals with ADHD if medication is not initiated or they fail to access their existing prescriptions, the European ADHD Guidelines Group (EAGG) recommended that it is appropriate to start ADHD medication remotely, with specific stipulations [40].
As a result of lockdown restrictions, additional responsibility has been placed on families to ensure that their dependants attend clinical examinations when required, are compliant with their medication and engage in appropriate home-based monitoring. For some families this may increase financial pressures, such as having to purchase blood pressure machines.

Psycho-social interventions
Given the restrictions around face-to-face interventions, adapted remote psycho-social interventions present a promising alternative to the traditional models for a range of conditions [41][42][43][44][45][46][47], and this is also true for ADHD [48]. Examples of successful ADHD psychosocial interventions that have been delivered remotely include a parent training group [49], a programme for college students [50] and a brief intervention programme [51]. Overall, tele-interventions have been identified to have a number of possible benefits including, reduced wait times, providing access to more geographically remote populations, and reduced financial stressors, such as travel or taking time off work [52]. However, it should be noted that these studies include relatively small sample sizes and far more research is required to determine the effectiveness of remote tele-interventions across the full range of therapies and programmes.
As a result of the restricted access to face-to-face interventions for young people with ADHD, parents are taking on more of the responsibility for psycho-social interventions. For example, using behavioural parenting strategies and self-help versions of evidenced based interventions [53].

Educational provision
The transition to remote study has posed challenges for learning institutions worldwide [54]. However, for students with ADHD, this medium of learning is particularly problematic [9,[55][56][57][58]. For example, Laslo-Roth and colleagues [59] found that students with ADHD reported higher levels of loneliness and more negative experiences with distance learning than non-ADHD peers, including fewer routines [60]. However, peer and college support along with hopeful thinking mediated feelings of loneliness and negative experiences [59]. Families of young people with ADHD are also reported to have experienced difficulties managing remote learning due to a reduction in school support and additional financial costs, such as improving their internet plans [60]. The hereditary nature of ADHD may mean that parents and carers who are taking responsibility for their children's learning may also be struggling with their own experiences of inattention, hyperactivity and impulsivity. In some cases, children have continued to attend school due to individual or family necessity. It is not known to what extent smaller class sizes may have positively or negatively affected children with ADHD.

Positives
There is emerging evidence that lockdown has not had a negative impact and in some cases, it has actually been helpful for young people with ADHD [25,61]. Bobo and colleagues [25] found that approximately a third of young people were not reported to have experienced any change in their wellbeing since lockdown and around a third reported improvements in their well-being. Parents attributed this to less stress associated with school attendance and structure. In addition, parents thought that their children were subject to less criticism or punishment at school which had fostered more positive views about the self. Parents of young people with ADHD have also reported an increase in family time as a positive impact of lockdown [24].
ADHD has been found to be a risk factor for contracting COVID-19 [62], particularly for females [63], partially attributed to the non-adherence of government instructions such as social distancing or wearing masks [64]. However, in a US study, recovery rates (recovery-population ratio) have been found to rise with the prevalence of ADHD [65] suggesting that ADHD may present as a possible protective factor against severe COVID-19 symptoms.

Discussion
Individuals, families and services have had to respond quickly and adapt to familial, social and educational changes. Individuals with ADHD are more likely to be at risk of contracting COVID-19 and are more likely to experience difficulties due to lockdown with both the core features of ADHD and co-occurring mental health difficulties. These difficulties also appear to be more severe than their non-ADHD counterparts. However, it should be noted that some benefits have been observed for young people with ADHD.
Services have made attempts to adapt their assessment and intervention provisions with partial success. As might be expected, referrals for assessments and the completion of assessments have reduced during the pandemic. As a result, it is likely that services will need to be prepared for a spike in ADHD referrals following the end of the pandemic and extended waitlists will need to be addressed in a timely fashion. Adapted tele-interventions are reported to have had some success with accompanying benefits. However, to adhere to best practice, the prescription and monitoring of ADHD medication requires regular physical health checks which will need to be completed via face-to-face clinical assessments. The evidence for the efficacy of parent or adult psycho-social tele-interventions is limited. Currently, there is not an evidence base for the effectiveness of remote psycho-social teleinterventions compared with face-to-face interventions for children with ADHD. Due to the nature of this clinical work, it is likely that this will need to be conducted face-to-face. It is also likely that some interventions are more appropriate for tele-health administration than others and post-pandemic interventions may utilise a combination of tele-health and face-to-face interventions.
In addition, many adaptations have been made by educational institutions and young people and their families have experienced a number of difficulties managing remote learning. However, advances in these methods of teaching may provide some future flexibility in learning modalities. Further research is warranted in this area.

Future research
To date, the majority of the research has attempted to identify the difficulties for people living and working with ADHD during this pandemic. However, a few papers have identified possible benefits of this situation. Further research should explore the benefit of remote learning and assessments and interventions conducted via tele-health compared with face-to-face interventions to determine whether they present feasible alternatives for some individuals moving forward. Specifically, research should explore the exact adaptations or mechanisms of intervention that result in beneficial outcomes [66].
There are a number of groups that ADHD research has neglected during this pandemic. For example, adults, older adults, females, black and ethnic minority groups and the LGBTQ+ community. So less is known about how the pandemic has impacted on these groups and what recommendations could be made to better support them. Certain domains are also lacking from the research base, such as how the pandemic has impacted on employment, sexual health, substance use and criminality for those with ADHD.
In addition, thousands of different variants of COVID-19 have been identified throughout the world. Some are reported to have higher transmission, infection and hospital rates [67,68], such as B.1.617.2, otherwise known as the Delta variant. Although Arbel [65] identified higher recovery rates for people with ADHD in 2020, these findings may not be consistent with the emergence of the Delta variant or other future variants. At the present time, there is little published research into the shortterm effects of the Delta variant for young people, adults and older adults and there has not been enough time to determine the long-term consequences of this variant for both ADHD and non-ADHD individuals. Further research should explore the impact of different COVID-19 variants on outcomes for individuals with ADHD.

Conclusions
The COVID-19 pandemic and worldwide lockdown restrictions have created a number of challenges for all those living and working with ADHD. We are yet to see how service provision will change post-pandemic but it is possible that some adaptations may prove more effective for those with ADHD than previous models of support.

Conflict of interest
The authors declare no conflict of interest.