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

The use of telehealth in attention-deficit/hyperactivity disorder: a survey of parents and caregivers

The use of telehealth became widespread during the COVID-19 pandemic, including in child and adolescent attention-deficit/hyperactivity disorder (ADHD) services. Telehealth is defined as live, synchronous phone and video appointments between a healthcare provider and a parent and/or child with ADHD. There is a dearth of research on the use of telehealth within this population. The aim of this study was to examine parents' and caregivers' perceptions of telehealth for children and adolescents with ADHD. A cross-sectional survey design was employed. Recruitment of parents and caregivers of children and adolescents with ADHD was conducted online. The survey asked participants about their views of telehealth, previous experience, and willingness to use telehealth. Quantitative data were analysed using STATA. Qualitative data were analysed using content analysis. One hundred and twelve respondents participated in the survey. Participants were mostly female (n = 97, 86.6%) and aged between 45 and 54 (n = 64, 57.1%). Of the 61 (54.5%) participants with experience of telehealth, the majority reported that that they were at least satisfied with telehealth visits (n = 36, 59%), whilst approximately half rated their quality more poorly than in-person visits (n = 31, 50.8%). The majority of respondents (n = 91, 81.3%) reported that they would be willing to use telehealth for their child's future appointments. Most common reasons selected for wanting to use telehealth included saving time, improvements to the family routine, and reducing costs. Reasons selected for not wanting to use telehealth included not being able to receive hands-on care, belief that the quality of care is poorer than in-person consultations, and distraction of the child during telehealth visits. The study demonstrates that parents recognise deficits and benefits of telehealth, suggesting a need to build their trust and confidence in remote ADHD care.

The adult ADHD assessment quality assurance standard

Background

Attention Deficit Hyperactivity Disorder (ADHD) frequently persists into adulthood. There are practice guidelines that outline the requirements for the assessment and treatment of adults. Nevertheless, guidelines specifying what constitutes a good quality diagnostic assessment and report and the competencies required to be a specialist assessor are lacking. This can lead to variation in the quality and reliability of adult ADHD assessments. Poor quality assessments may not be accepted as valid indicators of the presence of ADHD by other clinicians or services, resulting in wasteful re-assessments and delays in providing treatment. To address this issue the UK Adult ADHD Network (UKAAN) proposes a quality framework for adult ADHD assessments - the Adult ADHD Assessment Quality Assurance Standard (AQAS).

Methods

The co-authors agreed on five questions or themes that then guided the development of a set of consensus statements. An initial draft was reviewed and amended in an iterative process to reach a final consensus.

Results

What constitutes a high-quality diagnostic assessment and report was agreed by consensus of the co-authors. The resulting guideline emphasises the need to evaluate impairment, describes core competencies required by the assessor and highlights the importance of linking the diagnosis to an appropriate post-diagnostic discussion. Assessments should be completed in the context of a full psychiatric and neurodevelopmental review, and need good interview skills, using a semi-structured interview with open questioning and probing to elicit real life examples of symptoms and impairments. It is recommended that 2 hours or more is required for an adequate assessment including both the diagnostic assessment and initial post-assessment discussions.

Conclusion

The AQAS has been developed as a practical resource to support reliable and valid diagnostic assessments of adult ADHD. It is intended to complement formal training. A secondary objective is to empower patients by providing them with evidence-based information on what to expect from an assessment and assessment report.

Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021

OBJECTIVE

To characterize provider types delivering outpatient care overall and through telehealth to U.S. adults with ADHD.

METHOD

Using employer-sponsored insurance (ESI) and Medicaid claims, we identified enrollees aged 18 to 64 years who received outpatient care for ADHD in 2021. Billing provider codes were used to tabulate the percentage of enrollees receiving ADHD care from 10 provider types overall and through telehealth.

RESULTS

Family practice physicians, psychiatrists, and nurse practitioners/psychiatric nurses were the most common providers for adults with ESI, although the distribution of provider types varied across states. Lower percentages of adults with Medicaid received ADHD care from physicians. Approximately half of adults receiving outpatient ADHD care received ADHD care by telehealth.

CONCLUSION

Results may inform the development of clinical guidelines for adult ADHD and identify audiences for guideline dissemination and education planning.

Mental health during the COVID-19 pandemic in children and adolescents with ADHD: A systematic review of controlled longitudinal cohort studies

Prior studies reported mixed effects of the COVID-19 pandemic on the mental health of children and adolescents with ADHD, but they were mainly cross-sectional and without controls. To clarify the impact, we searched Web of Science, EMBASE, Medline, and PsychINFO until 18/11/2023 and conducted a systematic review of controlled longitudinal cohort studies (Prospero: CRD42022308166). The Newcastle-Ottawa scale was used to assess quality. We identified 6 studies. Worsening of mental health symptoms was more evident in ADHD or control group according to symptom considered and context. However, those with ADHD had more persistent elevated symptoms and remained an at-risk population. Sleep problems deteriorated more significantly in those with ADHD. Lower pre-COVID emotion regulation skills and greater rumination were associated with worse mental health outcomes, and longer screen time with poorer sleep. Quality was rated as low in most studies, mainly due to self-report outcome measures and no information on attrition rates. Despite these limitations, results suggest a predominantly negative impact on youths with ADHD and may guide clinical practice and policy.

Female sex and burden of depressive symptoms predict insufficient response to telemedical treatment in adult attention-deficit/hyperactivity disorder: results from a naturalistic patient cohort during the COVID-19 pandemic

Background

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neuropsychiatric disorder, that typically manifests itself during childhood and persists in a majority of the affected individuals into adulthood, negatively affecting physical and mental health. Previous studies have shown detrimental effects of the COVID-19 pandemic on mental health in individuals with ADHD. Thus, telemedicine could be a useful tool for optimizing treatment-outcomes in adult ADHD by improving treatment adherence and persistence. However, data on telemedical treatment outcomes in adult patients with ADHD is scarce.

Methods

We report here the sub-cohort analysis of a naturalistic cohort of adult patients (N = 254) recruited between April 2020-April 2021, comparing the effects of telemedical treatment on participants either clinically diagnosed with depression (N = 54) or ADHD (N = 67). Participants were asked to fill out the WHO-5 repetitively during >12 weeks of telemedical treatment. Furthermore scores of WHO-5, SCL-90R and BDI-II, psychopathology, psychosocial functioning, sociodemographic data, medical records and a feedback survey were analyzed for both groups and compared. Participants with ADHD were further stratified according to the development of well-being during the study period in order to identify factors associated with a satisfactory treatment outcome.

Results

Participants with depression reported a significant improvement of well-being during the course of the study, while no such effect could be seen in participants with ADHD on a group level. Despite the good outcome, participants with depression were more severely affected at baseline, with significantly worse psychopathology and a more precarious labor and financial situation. A detailed analysis of ADHD participants without clinical improvement revealed significantly higher BDI-II scores than for ADHD participants with a satisfactory outcome (p = 0.03, Mann-Whitney-U-Test), suggesting successful treatment was hampered by the combination of ADHD and depressive symptoms. Furthermore, female sex among ADHD patients was correlated with an unfavorable treatment outcome during the course of the study (p = 0.001, Spearman correlation) as well as living with children (p = 0.02, Spearman correlation).

Conclusion

Besides screening for depressive symptoms before telemedical treatment, future research should address the specific needs of female ADHD patients as these patients may be at a particularly high risk of being overburdened with family work.

Functional Impairments and Related Factors in Adolescents with Attention Deficit Hyperactivity Disorder During the COVID-19 Normalization Stage

Background

Attention deficit hyperactivity disorder is a disorder associated with significant functional impairments that can have important consequences for the individual and the society. Those with attention deficit hyperactivity disorder were reported to be more vulnerable in the face of difficulties and experience more psychological problems during the coronavirus disease 2019 pandemic. It was shown that the psychological problems experienced during the pandemic could persist during the normalization stage. We aimed to assess functional impairment in adolescents with attention deficit hyperactivity disorder and the related factors during the normalization stage which involved the initiation of fully face-to-face schooling practices.

Methods

This is a cross-sectional study including attention deficit hyperactivity disorder (n = 52) and a healthy control group (n = 52). Functional impairment was assessed using the Weiss functional impairment rating scale self and parent forms. We also examined the factors associated with functional impairment (internalizing-externalizing problems, parenting strategies, and perceived expressed emotion).

Results

Adolescents with attention deficit hyperactivity disorder had higher functional impairment scores on Weiss functional impairment rating scale self and parent in all sub-domains and total. Weiss functional impairment rating scale self and parent total mean score had a positive correlation with negative parenting and externalizing-internalizing scores and a negative correlation with the positive parenting score. Weiss functional impairment rating scale-self total mean score was positively correlated with negative parenting and externalizing-internalizing scores and perceived expressed emotion scores.

Conclusion

Our results suggest that the effects of the pandemic on children's functioning may persist in the normalization stage. For a comprehensive evaluation and effective intervention, it is important that comorbid symptoms, parenting strategies, and the perceived family climate are evaluated from the perspectives of both the parent and the adolescent.

Benefits of Working from Home During the COVID-19 Pandemic for Undiagnosed Workers with Attention-Deficit/Hyperactivity Disorder Symptoms

Purpose

Our previous study suggested that working conditions might impact work productivity amid the COVID-19 pandemic. This study aimed to investigate the association between working from home (WFH) and depressive symptoms, work productivity, and quality of life (QOL), in undiagnosed workers with attention-deficit/hyperactivity disorder (ADHD) symptoms during the COVID-19 pandemic.

Methods

During the pandemic, the survey was conducted among eligible workers with (N = 904) and without (N = 900) ADHD symptoms based on the Adult ADHD Self-Report Scale [ASRS]. Each group was further stratified by working conditions (full working on-site [FWOS], hybrid, full WFH [FWFH]). Two-way ANOVA was performed to investigate the impact of WFH on depressive symptoms (Patient Health Questionnaire [PHQ-9] score), work productivity (Work Productivity and Activity Impairment scale [WPAI] scores), and QOL (EuroQol 5-Dimensions 5-Levels [EQ-5D-5L] score). The Tukey-Kramer test was used to assess differences between the stratified subgroups. Poisson and multiple regression analyses were also performed to assess the factors associated with these outcomes.

Results

Other than PHQ-9 score between FWOS and hybrid work in workers with ADHD symptoms (p < 0.05), no significant differences were observed in outcomes among the working condition subgroups in both workers with and without ADHD symptoms. In workers with ADHD symptoms, hybrid work and FWFH were significantly associated with a lower PHQ-9 score (hybrid, p < 0.001; FWFH, p < 0.05) but neither were significantly associated with WPAI score nor EQ-5D-5L. Annual income and discretionary work were significantly associated with a lower PHQ-9 score and a higher EQ-5D-5L score in workers with ADHD symptoms. Job type (manufacture/construction) was significantly associated with a lower presenteeism score.

Conclusion

WFH (hybrid and FWFH) may be associated with lower depressive symptoms compared with FWOS in undiagnosed workers with ADHD symptoms. The findings may be useful when considering suitable working environments for workers especially with ADHD symptoms.

Disability coaching in a pandemic

Purpose

An applied study using convenience data was conducted to compare the experiences of neurodivergent adults undergoing workplace coaching before and during the pandemic.

Design/methodology/approach

The naturally occurring opportunity permitted a comparison of face-to-face and remote coaching in three cohorts, pre-pandemic (100% face-to-face), forced-remote (100% remote) and choice (remote or face-to-face; 85% selected remote). A total of 409 participants self-reported performance before and 12 weeks after completing an average of 11 h coaching.

Findings

Significant differences between before and after scores for performance, with large effect sizes, were reported for all three cohorts across six dependent variables: memory, time management, organisational skills, stress management, understanding neurodiversity and concentration. There was no significant difference between the cohorts in terms of the magnitude of the effect. There were significant differences between the cohorts in terms of which topics were chosen as foci for the coaching, with executive functions related topics becoming less popular in the choice cohort.

Research limitations/implications

The authors abductively reasoned the results to suggest a positive relationship between personalised environments and cognitive demands for this client group. They call for further, theoretically grounded research exploring the role of coaching and environment in understanding the work performance of neurodivergent adults at work.

Originality/value

The study contributes to the emerging knowledge on the different experiences of in-person and video-mediated coaching. The focus on neurodivergent employees, which are heretofore less well researched within the workplace, provides essential data to support practitioners in maximising opportunity for a marginalised group.

Impact of COVID-19 on Youth With ADHD: Predictors and Moderators of Response to Pandemic Restrictions on Daily Life

We examined COVID-19 symptoms and infection rates, disruptions to functioning, and moderators of pandemic response for 620 youth with ADHD and 614 individually matched controls (70% male; M_age = 12.4) participating in the Adolescent Brain and Cognitive Development study. There were no group differences in COVID-19 infection rate; however, youth with ADHD were more likely to exhibit COVID-19 symptoms (d = 0.25), greater sleep problems (d = -0.52), fear and negative emotions to infection risk (d = -0.56), trouble with remote learning (d = -0.54), rule-breaking behavior related to COVID-19 restrictions (d = -0.23), family conflict (d = -0.13), and were less prepared for the next school year (d = 0.38). Youth with ADHD were less responsive to protective environmental variables (e.g., parental monitoring, school engagement) during the pandemic and may need more specialized support with return to in-person schooling and daily activities.

Working Conditions, Work Productivity, Quality of Life, and Depressive Symptoms in Undiagnosed Adults with and without Attention-Deficit/Hyperactivity Disorder (ADHD) Symptoms During the COVID-19 Pandemic

PURPOSE

This study aims to evaluate the impact of the COVID-19 pandemic on employment status, work productivity, quality of life (QOL), and depressive symptoms in undiagnosed adults with and without attention-deficit/hyperactivity disorder (ADHD) symptoms in Japan.

METHODS

An observational study used baseline data from a Japanese Medilead Healthcare Panel before the COVID-19 pandemic (October-December 2019). Eligible panel participants were then surveyed during the pandemic (March 2021). ADHD symptoms were screened using the Adult ADHD Self-Report Scale. Changes in QOL (EuroQol 5-Dimensions 5-Levels; EQ-5D-5L) and productivity impairment (Work Productivity and Activity Impairment scale; WPAI) from before to during the pandemic were analyzed in undiagnosed adults with and without ADHD symptoms. Unemployment rate and depressive symptoms (Patient Health Questionnaire; PHQ-9) during the pandemic were compared between groups.

RESULTS

Participants with (N=949) and without (N=942) ADHD symptoms completed the survey. The unemployment rate was not significantly different between participants with and without ADHD symptoms. Participants with ADHD symptoms were more likely to change jobs or employers during the pandemic. PHQ-9 scores in participants with ADHD symptoms were significantly higher than in those without ADHD symptoms (8.96 vs 3.57, respectively) during the pandemic. Before the pandemic, WPAI scores were significantly higher and EQ-5D-5L scores lower in participants with ADHD symptoms than in those without. Productivity improved and QOL was not altered during the pandemic in both groups, but productivity and QOL remained poorer among participants with ADHD symptoms than in those without.

CONCLUSION

Productivity was improved among all participants during the COVID-19 pandemic, contrary to expectations. However, adults with ADHD symptoms consistently had lower productivity, poorer QOL, and more depressive symptoms than those without ADHD symptoms.