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2 Jun 2020

Cortese S et al. Lancet Child Adolesc Health 2020; 4(6): 412-414

The COVID-19 pandemic and physical distancing measures may cause distress to individuals with ADHD and pose questions for clinicians on how best to deliver care within the new restrictions. The European ADHD Guidelines Group has developed guidance on the assessment and management of ADHD during the COVID-19 pandemic as outlined below.

Diagnosis and follow-up assessments

All relevant service provision should continue via telephone or appropriate online video technology in line with current guidelines for the use of telepsychiatry (American Academy of Psychiatry; Royal College of Psychiatrists).

The importance of behavioural management strategies

The appropriate use of behavioural parent training strategies is important during the COVID-19 pandemic, especially as families are confined together for long periods where tensions may escalate out of control. When face-to-face support is not available, under the current circumstances, parents may have to rely on self-help versions of evidence-based systems. Six essential tips are provided for parents of children with ADHD: (1) keep positive and motivated; (2) make sure all family members know what is expected of them; (3) build your child’s self-confidence and trust in you; (4) help your child to follow instructions; (5) promote better behaviour; (6) limit conflicts.

It is also important for parents to understand how difficult these times are for adolescents with ADHD as the loss of daily school and homework structure, hobbies and friends can be stressful, in addition to being with their parents and siblings much of the time. Parents must stay connected with their adolescent, ask about their feelings and discuss their daily schedule if needed. Schools and teachers should also try to monitor their students with ADHD (e.g. participation in online classes, submission of tasks, worries about social and emotional wellbeing) and should actively reach out to parents and adolescents for individual tailoring of schoolwork and care. If individuals with ADHD are using neurofeedback or cognitive training then they should be encouraged to continue practising transfer exercises during homework and new challenges.

Pharmacological management

If clinically indicated and as recommended in standard national guidelines, individuals with ADHD should be offered the opportunity to initiate pharmacological treatment, or if already on medication, continue with this as usual. Prevention of pharmacological treatment may increase health risks associated with COVID-19 as behaviour related to ADHD could become disorganised and poorly controlled, which could adversely impact the ability to comply with physical distancing measures and have an impact on family dynamics.

Due to physical distancing and self-isolation, the initial assessments (including psychoeducation on ADHD and the available treatments) and follow-up assessments to monitor medication effectiveness and tolerability can continue via telephone or appropriate online video technology.

Pharmacies may experience delays in sourcing medication during the COVID-19 pandemic and parents and individuals with ADHD will need to ensure that they plan well in advance before medications are running low so that new prescriptions are ordered and medications are delivered on time.

Increasing the dose of ADHD medication or adding doses beyond those that are prescribed to manage a crisis or stress due to COVID-19-related confinement should be avoided. Medications to manage disruptive behaviour, such as antipsychotics, or the use of sedatives when not clinically indicated are not recommended.

Prescribers may want to discuss the possibility of changes in the type of formulation (i.e. short, intermediate, long duration) with individuals with ADHD and their families considering the change in routine and schedule due to COVID-19. As family confinement and physical distancing may exacerbate ADHD-related risk, there is no strong rationale for the introduction of weekend drug holidays during this time.

Monitoring of possible adverse events

For individuals with ADHD without any cardiovascular risk, routine cardiovascular clinical examinations and face-to-face monitoring should be postponed until these visits can be reinstated. Monitoring of blood pressure and heart rate using home blood pressure machines, if possible, is recommended.* If measured at home, blood pressure and heart rate values should be measured at approximately the same time on three separate days and the readings should be sent to and averaged by the prescriber, who should assess this value against expected age-adjusted norms. Individuals with ADHD should be encouraged to contact their prescriber if they experience any cardiovascular symptoms (e.g. chest pain, prolonged palpitations and breathing difficulties) or any other concerning symptoms.

Under the current constraints, weight and height measurements may need to be performed at home rather than in the clinic. Although ADHD medication may affect weight, it should also be noted that weight may be affected by factors related to self-isolation such as reduced physical activity and increased caloric intake.

Similarly, although psychostimulants may delay sleep-onset, sleep disruption during this time may be due to other factors such as stress and disruption of daily routines. It is recommended that sleep hygiene norms should be implemented or reinforced rather than inappropriate increases in the dose of melatonin beyond the therapeutic range.

If adults with ADHD or parents of children/adolescents with ADHD think that their child has COVID-19 symptoms they must notify their prescriber/clinician and discuss whether it is advisable to continue ADHD treatment.

To summarise, physical distancing measures due to the COVID-19 pandemic may affect those with ADHD; therefore, it is critical that strategies regularly recommended in parent-focused ADHD interventions and mental wellbeing interventions for children and adolescents with ADHD are drawn upon. The risks and benefits of initiating or maintaining ADHD medication under the COVID-19 restrictions should be carefully considered by clinicians and if the use of medication is necessary, strategies for remote monitoring should be applied.

Read more about the management of ADHD during the COVID-19 pandemic here

 

*Recommendations for home blood pressure monitoring: (1) use an age-adapted cuff size; (2) take the blood pressure at least 2 hours after taking a dose; (3) sit down for 10‒15 min before taking the reading; (4) take the reading on the left arm; (5) take the lowest of three readings, approximately the same time on three separate days and send the readings, alongside the pulse values, to the prescriber

American Association of Psychiatry. Telepsychiatry. Available at: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry. Accessed June 2020.

Cortese S, Asherson P, Sonuga-Barke E, et al. ADHD management during the COVID-19 pandemic: guidance from the European ADHD Guidelines Group. Lancet Child Adolesc Health 2020; 4(6):412-414.

Royal College of Psychiatrists. PIPSIG Guidelines for the use of telepsychiatry. Available at: https://www.rcpsych.ac.uk/docs/default-source/members/sigs/private-and-independent-practice-pipsig/pipsig-telepsychiatry-guidelines-revised-mar16.pdf. Accessed June 2020.

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