Commentary

COVID-19: Optimizing therapeutic strategies for children, adolescents with ADHD


 

Recently, the Yakima Health District (YHD), in collaboration with the Washington State Department of Health, issued dramatic revisions to its educational curriculum, opting for exclusively remote learning as an important next step in COVID-19 containment measures.

Dr. Faisal Islam

Dr. Faisal Islam

The newly implemented “enhanced” distance-learning paradigm has garnered considerable national attention. Even more noteworthy is how YHD addressed those with language barriers and learning differences such as ADHD as a “priority group”; these individuals are exempt from the newly implemented measures, and small instructional groups of no more than five “at-risk” students will be directly supervised by specialized educators.1,2 To overcome these new unprecedented challenges from the coronavirus pandemic, especially from the perspective of distance education and mental health for susceptible groups such as those with ADHD, it is of utmost importance to explore various programs of interest, as well as the targeted therapies being considered during this crisis.

From a therapeutic standpoint, individuals with learning differences are more likely to play catch-up with their age-matched peers. This puts them at significant risk for developmental delays with symptoms manifesting as disruptive behavioral issues. This is why ongoing parental guidance, coupled with a paradoxically stimulating environment, is critical for children and adolescents with ADHD.3 Accumulating evidence, based on a myriad of studies, demonstrates that childhood treatment with ADHD stimulants reduces the incidence of future substance use, as well as that of other negative outcomes.4,5

Therapeutic strategies that work

“The new normal” has forced unique challenges on clinicians for mitigating distress by novel means of health care delivery. Given the paucity of research exploring the interactions of individuals with ADHD within the context of COVID-19, American clinicians may need to draw inspiration from international pandemic studies in accordance with evidence-based medicine. Take for example, the suggested guidelines from the European ADHD Guidelines Group (EAGG) – such as the following:

  • Telecommunications in general, and telepsychiatry in particular, should function as the primary mode of health care delivery to fulfill societal standards of physical distancing.
  • Children and adolescents with ADHD should be designated as a “priority group” with respect to monitoring initiatives by educators in a school setting, be it virtual or otherwise.
  • Implementation of behavioral strategies by parent or guardian to address psychological well-being and reduce the presence of comorbid behavioral conditions (such as oppositional defiant disorder).
Zaid Choudhry

Zaid Choudhry

In addition to the aforementioned guidance, EAGG maintains that individuals with ADHD may be initiated on medications after the completion of a baseline examination; if the patients in question are already on a treatment regimen, they should proceed with it as indicated. Interruptions to therapy are not ideal because patients are then subjected to health-related stressors of COVID-19. Reasonable regulations concerning access to medications, without unnecessary delays, undoubtedly will facilitate patient needs, allowing for a smooth transition in day-to-day activities. The family, as a cohesive unit, may benefit from reeducation because it contributes toward the therapeutic process. Neurofeedback, coping skills, and cognitive restructuring training are potential modalities that can augment medications.

Although it may seem counterintuitive, parents or caregivers should resist the urge to increase the medication dose during an outbreak with the intended goal of diminishing the psychosocial burden of ADHD symptomatology. Likewise, unless indicated by a specialist, antipsychotics and/or hypnotics should not be introduced for addressing behavioral dysregulation (such as agitation) during the confinement period.

Historically, numerous clinicians have suggested that patients undergo a routine cardiovascular examination and EKG before being prescribed psychostimulants (the rationale for this recommendation is that sympathomimetics unduly affect blood pressure and heart rate).6,7 However, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) eventually amended their previous stance by releasing a joint statement in which they deemed a baseline EKG necessary only in ADHD patients with preexisting cardiac risk. For all other patients, the use of EKGs was entirely contingent on physician discretion. However, given the nature of safety precautions for COVID-19, it is prudent to discourage or delay in-person cardiovascular examination/monitoring protocols altogether, especially in those patients without known heart conditions.

Another area of concern is sleep dysfunction, which might exist as an untoward effect of ADHD medication intake or because of the presence of COVID-19 psychosocial stressors. However, clinicians advise that unnecessary psychopharmacology (such as hypnotics or melatonin) be avoided. Instead, conservative lifestyle measures should be enacted, emphasizing the role of proper sleep hygiene in maintaining optimal behavioral health. Despite setbacks to in-person appointments, patients are expected to continue their pharmacotherapy with “parent-focused” ADHD interventions taking a primary role in facilitating compliance through remote monitoring.

ADMiRE, a tertiary-level, dedicated ADHD intervention program from South Dublin, Ireland, has identified several roadblocks with respect to streamlining health care for individuals with ADHD during the confinement period. The proposed resolution to these issues, some of which are derived from EAGG guidelines, might have universal applications elsewhere, thereby facilitating the development of therapeutic services of interest. ADMiRE has noted a correspondence between the guidelines established by EAGG and that of the Canadian ADHD Resource Alliance (CADDRA), including minimal in-person interactions (in favor of virtual teleconferencing) and a cardiovascular screen can be performed in lieu of baseline cardiac auscultation. Moreover, in the event that the patient is a low cardiac risk candidate for ADHD treatment, monitoring protocols may be continued from a home setting. However, if a physical examination is indicated, CADDRA recommends the use of precautionary PPE before commencing ADHD pharmacotherapy.

One of the most significant hurdles is that of school closures because teacher feedback for baseline behavior was traditionally instrumental in dictating patient medical management (for example, for titration schedule). It is expected that, for the time being, this role will be supplanted by parental reports. As well as disclosing information on behavioral dysregulation, family members should be trained to relay critical information about the development of stimulant-induced cardiovascular symptoms – namely, dyspnea, chest pain, and/or palpitations. Furthermore, as primary caregivers, parents should harbor a certain degree of emotional sensitivity because their mood state may influence the child’s overall behavioral course in terms of symptom exacerbation.8

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