Take a look at these eight short animations, by "Families Under Pressure", giving tips for parents struggling with their children's challenging behavior during the COVID-19 lock down. They are designed by some of the UK's top young creative talent and voiced by well known UK celebrities who are parents.
During the covid-19 era, APSARD has been able to connect and lean on our partnerships with other ADHD organizations. CADDRA, the Canadian ADHD Resource Alliance, has partnered with APSARD in the past and present to share information in the ADHD field. APSARD is proud to work alongside CADDRA and encourages its members to utilize the resources highlighted in the CADDRA submitted blog below.
Treating ADHD in a Time of COVID-19
COVID-19 has created a range of challenges for clinicians, including those treating patients with ADHD.
At the end of March, CADDRA – Canadian ADHD Resource Alliance – surveyed its members regarding the impact the continued spread of the virus and subsequent public health measures had on their practices. We heard about their concerns for patients, the impact on practices, and how they are making patient care work during this time.
Not surprisingly, Canadian practices were morphing into virtual care centres and figuring out ways to adapt to a new work environment while the survey also revealed a substantial financial impact on practices.
Respondents to the CADDRA member survey were representative of different disciplines, practice settings and locations.
Rate the extent to which you agree with the following statement: “My ADHD practice has been impacted by COVID-19
The majority (85%) reported their practice was impacted or very impacted by the pandemic. Additionally, 80% reported a financial impact on their practice.
Has the COVID-19 outbreak had a financial impact on your practice?
Several respondents indicated that the biggest difficulty they were facing was the ability to properly assess patients, some citing an inability collect biometrics virtually.
Are you continuing to see patients with ADHD?
New patient consultations have generally reduced, with roughly half (45%) reporting that they were no longer able to see new patients, and 17% seeing existing patients only.
Most respondents (80%) - have switched to virtual care only, while 8.5% continue to provide some in-person with virtual care.
What type of virtual care are you providing?
Switching to virtual care was achieved through a combination of phone, video and email support for just over a third of respondents (35%); just under a third were using phone only (30%) and the same number were using video only; a small number were using email only.
Of those using video, almost half (46%) were using alternative video-conferencing platforms (e.g. Zoom, Skype); 19% were using provincial telemedicine platforms and the same percentage were using private virtual care solutions; other videoconferencing options (FaceTime, WhatsApp) were used by 16%.
More than half reported that the care they are providing patients with ADHD had changed.
Challenges facing practices & patients
Assessments were the biggest problem area identified. However, respondents also discussed issues with accessibility of the virtual tools for patients, and difficulties faced when patients had to conduct an interview in a more distracting home environment.
Asked about what they perceived to be the biggest challenges facing their patients with ADHD, many respondents discussed how anxiety was generally high among patients and families now facing new challenges and increased stress.
Additionally, many patients are dealing with a loss of their routine and now face a much more unstructured schedule. Dealing with boredom and managing to stay productive or active was a common comment – not just for patients, but also for the healthcare professionals surveyed.
How are healthcare professionals staying healthy?
Asked about their personal strategies for navigating this situation, many respondents stressed the importance of staying connected – talking with friends or colleagues, spending time with family (or simply walking the dog more).
Others are taking the time to do yoga or practice mindfulness. A common theme was the importance of maintaining some form of routine.
Strategies for navigating COVID-19
The survey respondents also told us what resources better support patient care during this time would. In response, CADDRA has compiled the following evidence-based information and resources for clinicians and their patients:
- A Frequently Asked Questions (FAQ) document with answers to commonly asked questions regarding assessing and treating ADHD in a virtual care model during this pandemic
- Respondents told us that a huge challenge for their patients is adapting to the new work/school from home environment. We developed practice handouts on scheduling with printable schedule templates for:
- A series of webpages with resources and information for health providers and patients:
In the last few weeks, many of our members sent in ADHD resources, and wellness tips or provided general feedback and we will continue to update our resource pages in the coming weeks based on this information. We invite APSARD members to utilize our resources.
Keep safe, keep healthy.
CADDRA – Canadian ADHD Resource Alliance
ADHD and Race in the School Setting
Catherine L. Montgomery & Kevin Antshel, Ph.D.
Department of Psychology
ADHD Lifespan Treatment, Education, and Research (ALTER) Program
The prevalence rate of ADHD in the United States varies by race/ethnicity; notably, rates of ADHD diagnoses in Black children are estimated to be 65% to 75% of rates of diagnosis in White children of similar SES and symptom severity. (See (Miller, Nigg, & Miller, 2009) for a review of this literature.) ADHD diagnostic practices rely on collecting multiple informant (i.e., parent, teacher, and child) ratings of symptoms. These ratings may be impacted by the actual ADHD symptoms, the context (school v. home) or characteristics about the informant (Kraemer et al., 2003). Over 80% of primary and secondary school teachers are White (U.S. Department of Education, 2017). Thus, one potential contributor to the identified ADHD racial discrepancy rates may be differences in how Black parents and White teachers consider a child’s behaviors.
To investigate this hypothesis, Kang and Harvey (Kang & Harvey, 2019) recently compared ADHD ratings of 71 Black parents (92% female) to those of 60 White teachers (68% female) and 65 White parents (75% female) recruited through Amazon’s Mechanical Turk (MTurk). Participants watched ten 1-minute video clips of children in actual preschool, Kindergarten, 2nd grade and 3rd grade classrooms which were posted publicly on YouTube. Within each classroom, one child served as the target child for participants to rate. Two Black boys, two Black girls, two White boys, two White girls, one Asian boy and one Latina girl served as targets with the order of the children counterbalanced between participants. All participants watched the same 10, 1-minute video clips. Following each video, participants completed Vanderbilt ADHD symptom checklists and rated the likelihood of the target child having ADHD (1 = Very Unlikely – 6 = Very Likely). Only 11 items were used from the Vanderbilt. These 11 items were chosen based off of what could be readily observed from a video. Importantly, the parent and teacher ratings were compared against each other and not an external “gold standard”. Thus, conclusions about the accuracy of a reporter’s ratings could not be reached. Finally, the authors’ also examined beliefs about ADHD stigma, verve (movement expressiveness), experiences with racial discrimination, and racial attitudes as potential explanations for racial differences.
- White teachers rated Black boys’ ADHD behaviors (d = .33) and ADHD likelihood (d = .44) higher than Black parents. No differences emerged between White teachers and White parents for Black boys’ ADHD behaviors and ADHD likelihood.
- No group differences emerged for Black girls, White boys or White girls.
- Black and White parents aligned well in their ratings of all children except for Black boys.
- White teachers with more negative racial attitudes gave significantly higher ADHD behavior (r = -.30) and likelihood (r = -.45) ratings to Black boys than those with less negative racial attitudes. Teacher’s racial attitudes were not related to any other child’s ADHD ratings or likelihood.
- There was a positive relationship between Black parents’ experiences with racial discrimination and ratings of all children’s ADHD behaviors.
- No group differences emerged for ADHD stigma beliefs.
- Neither ADHD stigma beliefs nor verve were related to any group’s ratings.
Kang and Harvey reported significant racial differences in ratings of Black boys’ ADHD behaviors and likelihood, a finding which other studies have similarly reported (Harvey, Fischer, Weieneth, Hurwitz, & Sayer, 2013; Lawson, Nissley-Tsiopinis, Nahmias, McConaughy, & Eiraldi, 2017). Kang and Harvey held the context constant (all actual classrooms) and suggest that these differences are due, at least in part, to racial differences in adult perception as opposed to contextual differences present in different settings (e.g., home versus school). Kang and Harvey concluded that it remains unclear if these discrepancies are due to Black parents underestimating Black boys’ symptoms or White teachers overestimating Black boys’ symptoms.
These findings may help to explain the lower rates of ADHD diagnosis in Black children. The DSM-5 criteria emphasize the importance cross-situational symptoms when diagnosing ADHD. If parents and teachers are not reporting the same symptoms at the same severity, then a diagnosis is less likely. Kang and Harvey offered several clinical and practical implications such as the implementation of teacher interventions to reduce the role of racial biases, the provision of more explicit instructions for completing ADHD rating scales, and bringing awareness of these racial discrepancies to clinicians. Additional research on this topic is necessary to further explain the variation in the rates of diagnosis. For example, Black teachers were not recruited for the current study, and including Black teachers may reveal more about the discrepancy. Future research could also consider additional mechanisms that might explain the observed racial differences in adults’ perceptions of ADHD behaviors in Black boys. Finally, a design which includes more than 1-minute of child behavior may enhance the ecological validity of the ratings.
For further reading on this topic, please consider DuPaul’s excellent commentary on this study (DuPaul, 2020).
DuPaul, G. J. (2020). Adult Ratings of Child ADHD Symptoms: Importance of Race, Role, and Context. J Abnorm Child Psychol. doi:10.1007/s10802-019-00615-5
Harvey, E. A., Fischer, C., Weieneth, J. L., Hurwitz, S. D., & Sayer, A. G. (2013). Predictors of discrepancies between informants' ratings of preschool-aged children's behavior: An examination of ethnicity, child characteristics, and family functioning. Early Child Res Q, 28(4), 668-682. doi:10.1016/j.ecresq.2013.05.002
Kang, S., & Harvey, E. A. (2019). Racial Differences Between Black Parents' and White Teachers' Perceptions of Attention-Deficit/Hyperactivity Disorder Behavior. J Abnorm Child Psychol. doi:10.1007/s10802-019-00600-y
Kraemer, H. C., Measelle, J. R., Ablow, J. C., Essex, M. J., Boyce, W. T., & Kupfer, D. J. (2003). A new approach to integrating data from multiple informants in psychiatric assessment and research: mixing and matching contexts and perspectives. Am J Psychiatry, 160(9), 1566-1577. doi:10.1176/appi.ajp.160.9.1566
Lawson, G. M., Nissley-Tsiopinis, J., Nahmias, A., McConaughy, S., & Eiraldi, R. (2017). Do parent and teacher report of ADHD symptoms in children differ by SES and racial status? Journal of Psychopathology and Behavior Assessment, 39, 426-440.
Miller, T. W., Nigg, J. T., & Miller, R. L. (2009). Attention deficit hyperactivity disorder in African American children: what can be concluded from the past ten years? Clin Psychol Rev, 29(1), 77-86. doi:10.1016/j.cpr.2008.10.001
U.S. Department of Education, National Center for Education Statistics, Schools and Staffing Survey (SASS), “Public School Teacher Data File,” 2003–04; and National Teacher and Principal Survey (NTPS), “Public School Teacher Data File,” 2015–16. (2017). Public School Teacher Data File, 2003–04 and National Teacher and Principal Survey (NTPS), Public School Teacher Data File, 2015–16. Washington, DC.
Managing ADHD in College Students During COVID-19
Afton Kapuscinski, Ph.D. & Kevin Antshel, Ph.D.
The dynamic and rapidly developing COVID-19 pandemic has affected us all. Rather than focusing on the totality of the impact, we are electing to focus on what we know best: college students with ADHD. Below, we outline ideas to help college students with ADHD cope and function well despite the substantial disruptions caused by COVID-19. Managing ADHD during a global pandemic is, to our knowledge, not a topic that has been previously investigated. Thus, when developing these considerations, we relied upon our knowledge of the science of clinical psychology as well as our combined near 30-years of clinical experience working with college students with ADHD.
College students, especially those who were living away from home, are likely to be experiencing significant disruption to their daily lives. Not only has their primary residence suddenly changed, but they have also lost social supports, as well as the structure provided by academic and extracurricular obligations. Before COVID-19, many studies reported that college students with ADHD were already at increased risk for depression and anxiety. The jarring changes to daily life and uncertainty about when normal life will resume may well increase prevalence rates of depression and anxiety in students with ADHD. While some feelings of fear and loss are normative (COVID-19 is a legitimate threat), those with pre-existing anxiety and depression may have a more difficult time managing the intensification of these emotions.
When channeled appropriately (e.g., not at panic levels), fear and anxiety can be quite adaptive and help us follow CDC guidelines cautiously to “flatten the curve”. However, very high levels of anxiety often lead to difficulty with concentration and completing tasks. Additionally, a larger, more long-term concern is the potential for depression to set in as weeks of social distancing and restriction of activities likely turns into months. In an effort to help with both proximal anxiety as well as the greater distal threat (depression) in an already vulnerable population, several of the following may be beneficial to consider for college students with ADHD:
- Be mindful of media consumption levels. Media headlines, news alerts and social media are likely to be rife with the most tragic and dramatic stories (e.g., celebrities who have died from COVID-19). Consuming excess media (probably defined by the extent to which catastrophizing occurs) likely leads to a loss of balanced perspective (Jenness et al., 2016) and the adoption of irrational beliefs (e.g., I won’t be able to graduate college). Consider silencing news alerts or using screen time limits to moderate media exposure.
- Establish routines. Everyone’s daily routines have been impacted. Rather than getting lost in a cycle of Netflix and gaming, it is important to re-establish routines. If uncertainty is the poison, routines are the antidote. In our experience, the importance of sleep-wake cycles as the first routine to re-establish cannot be overstressed (Lyall et al., 2018). Routines related to medication adherence, physical activity and coursework should be the next ones added to the daily schedules.
- Establish physical boundaries. Being at home 24/7 increases the risk for a blurring of boundaries between work and recreation. Develop specific places to do school work that are separate from recreation spots. If this is not possible, develop some rules (e.g., I won’t browse YouTube until after 3 PM).
- Maintain social supports. Stay connected in real time with sources of social support from college through phone calls, Facetime, and Zoom (e.g., virtual throwback dance parties!). It is unfortunate that the public health officials labeled it “social distancing”. In our opinion, “physical distancing” is a better term and belies the importance of not isolating.
- Maintain sources of reinforcement. COVID-19 has disrupted many of our existing sources of reinforcement (e.g., engaging in Greek life, attending a NCAA basketball game with friends, earning money working at a campus coffee shop). Find creative ways to derive pleasure, especially through activities that bring a sense of meaning and purpose. For example, developing new hobbies (e.g., biking, photography) might serve to reduce the reinforcement void.
- Limit use of substances. College students with ADHD are at increased risk for substance use problems. The distress caused by the pandemic in combination with reduced opportunities for rewarding activities may make substance use (alcohol and cannabis in particular) more enticing for those who are particularly vulnerable. We recommend being mindful that despite liquor stores being classified as essential services, heavy use can actually impair mood and academic functioning (Meda et al., 2017).
- Increase physical activity, especially outside. A significant body of research indicates that physical activity is beneficial for reducing inattention and anxiety and improving mood (Neudecker, Mewes, Reimers, & Woll, 2019). A sedentary lifestyle is therefore particularly problematic for college students with ADHD. Aiming for 7000 steps per day is a reasonable place to start. The old maxim, “What gets measured, gets done” suggests smartphone apps to track and plan physical activity may improve adherence.
- Reduce procrastination. Rather than saying, “I will do that later”, attach a specific time/date target to each important task, and use a planner to indicate when you will work on each task. Divide larger tasks into smaller tasks and connect each task to a specific time/date in your planner. Be mindful of how you “advertise” the task to yourself. A script, “What is in it for me to do this now?” can be useful for framing tasks in a way which increases engagement.
The above represents only a few of many possibilities. Please consider replying to this blog with your own ideas about what might be beneficial to consider for college students with ADHD during the COVID-19 pandemic!
Jenness, J. L., Jager-Hyman, S., Heleniak, C., Beck, A. T., Sheridan, M. A., & McLaughlin, K. A. (2016). Catastrophizing, rumination, and reappraisal prospectively predict adolescent PTSD symptom onset following a terrorist attack. Depress Anxiety, 33(11), 1039-1047. doi:10.1002/da.22548
Lyall, L. M., Wyse, C. A., Graham, N., Ferguson, A., Lyall, D. M., Cullen, B., . . . Smith, D. J. (2018). Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91 105 participants from the UK Biobank. Lancet Psychiatry, 5(6), 507-514. doi:10.1016/S2215-0366(18)30139-1
Meda, S. A., Gueorguieva, R. V., Pittman, B., Rosen, R. R., Aslanzadeh, F., Tennen, H., . . . Pearlson, G. D. (2017). Longitudinal influence of alcohol and marijuana use on academic performance in college students. PLoS One, 12(3), e0172213. doi:10.1371/journal.pone.0172213
Neudecker, C., Mewes, N., Reimers, A. K., & Woll, A. (2019). Exercise Interventions in Children and Adolescents With ADHD: A Systematic Review. J Atten Disord, 23(4), 307-324. doi:10.1177/1087054715584053
ADHD Among Seniors: APSARD Members in the News
APSARD members David Goodman, Kathleen Nadeau, Lenard Adler, and Sandra Kooij recently discussed with the Wall Street Journal’s Sumathi Reddy the importance of properly diagnosing and treating ADHD among older adults. The article, ‘An Unexpected New Diagnosis in Older Adults: ADHD’, juxtaposes patient perspectives with those of expert care providers in this underserved demographic and highlight the need for better provider education. Read the article here:
For years, ADHD has been considered a disorder of kids and younger adults. Now, doctors are realizing older people have it too—and it’s sometimes mistaken for dementia.
Many seniors get diagnosed with conditions like dementia or heart disease.
Not Timothy McMichael. At the age of 60, he was diagnosed with a condition most often associated with school children: attention-deficit hyperactivity disorder. He started taking a low dose of a stimulant about a year-and-a-half ago and says his attentiveness and concentration at work have never been better.
“I’ve been fairly successful in my life and career, and did not think of ADHD as an adult thing,” says Mr. McMichael, a 61-year-old Leonardtown, Md., resident and engineer for the Department of Defense. “But I had spent the last 40 years coming up with coping mechanisms.”
Like many older people diagnosed with ADHD for the first time, Mr. McMichael didn’t consider the condition until his then-11-year-old son went through the diagnosis and treatment process about five years ago. He recognized many of the symptoms and struggles of his son and raised the issue with his son’s psychiatrist, David Goodman.
Dr. Goodman, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, sees patients between the ages of 15 and 85. He has a particular interest in ADHD patients who are over 50 and have never been diagnosed.
Until just a few years ago, older adults were hardly ever diagnosed with ADHD. But as awareness of the condition among younger people has surged, doctors are beginning to make the diagnosis more often in seniors as well.
Doctors don’t believe the actual prevalence of the condition among seniors has increased, or that they are developing the condition as they age. Instead, doctors suspect many seniors have lived their whole lives with ADHD, and only now are getting diagnosed. Many found ways to manage their symptoms in earlier stages of life, but hit a new hurdle as they aged that prompted a flare-up—or simply recognized the symptoms after a younger relative’s diagnosis.
People with ADHD experience symptoms of inattention, disorganization and hyperactivity. Often hyperactivity diminishes with age, but challenges with attention and organization don’t.
Research on ADHD in seniors is nascent, but one study estimated the prevalence rate in people over 50 at 3%. That compares with about 8% in U.S. children and about 4.5% in adults under age 45. Some studies have found that about half of the children diagnosed with ADHD no longer meet diagnostic criteria by the time they reach adulthood.
One challenge to diagnosing ADHD in seniors is that symptoms look similar to age-related ailments. Cognitive difficulties in older people are often attributed to memory impairments or early signs of dementia, says Dr. Goodman. For women in their early 50s, such complaints are often attributed to perimenopause, the time before a woman reaches menopause.
Treatment presents another hurdle. The most common ADHD treatment among younger people is stimulants. But those are riskier in older adults because they can raise heart rate and blood pressure, so they need to be monitored closely.
Kathleen Nadeau, founder and clinical director of the Chesapeake Center, an ADHD, learning and behavioral health clinic based in Bethesda, Md., says she has seen three typical patterns for a diagnosis in seniors. Some patients were in treatment for another condition, like depression, and their psychiatrist suggested they get evaluated for ADHD. Another group had a relative or friend diagnosed. A third had a change in their life that increased the demands on them and they couldn’t cope.
She says ADHD symptoms rise and fall in people depending on how stressful their circumstances are. “If you don’t have to work or raise children anymore, it may look like you have less ADHD, but you actually have less demands,” says Dr. Nadeau. “If you’re put back in a situation you may have similar difficulties. This doesn’t go away and people still need help” at older ages.
Lenard Adler, director of the adult ADHD program at NYU Langone Health, says more people over the age of 60 are coming in with ADHD symptoms. Of the older patients he’s treated, some found him after other psychiatrists were unwilling to treat them, he says. One patient had a history of hypertension and cardiac problems. He was able to successfully treat the patient with a long-acting amphetamine.
Dr. Adler says it’s important to distinguish between memory and ADHD issues in seniors. “We’re dealing with a population that may have some age-related memory decline,” he says.
In some cases, patients may mistakenly be diagnosed with mild cognitive impairment, often a precursor to dementia. But other times families may be looking for any diagnosis besides cognitive decline. One family brought in their loved one hoping it was ADHD and not dementia. The patient, says Dr. Adler, was “having a substantial cognitive decline and it obviously was dementia. So it can go both ways. It’s important to get the diagnosis right.”
Doctors say that age-related memory impairments come on later in life and are primarily memory deficits, while ADHD symptoms start in childhood or early adolescence and revolve around inattention. While neuropsychological tests can’t distinguish between the two, certain cognitive impairments are associated with pre-dementia, such as difficulty remembering a word or getting lost while driving a familiar route.
Treatment of ADHD in older adults is similar to that of younger patients. Treatment can combine prescription stimulants with non-medication approaches such as cognitive behavioral therapy and organizational skill work. A study published last year showed that CBT was an effective treatment for older ADHD patients.
Dr. Goodman says most ADHD studies of stimulants don’t include seniors because of greater risks with heart rate and blood pressure. There is also a risk of developing insomnia, agitation and psychosis.
Dr. Goodman’s experience in treating some 800 seniors over the past three decades has shown few side effects, he says. He says diagnostic accuracy is crucial in seniors before prescribing any medications. “Dosing is thoughtfully slow while monitoring improving cognitive symptoms, side effects and blood pressure,” he says.
Sandra Kooij, an associate professor of psychiatry at Amsterdam University Medical Center, studies ADHD in seniors in the Netherlands. At her clinic they have treated about 150 seniors age 55 and older with stimulants, in addition to psychoeducation and cognitive behavioral therapy, for ADHD.
Dr. Kooij says they are analyzing the treatment and side effects for a study they hope to publish later this year. Overall efficacy has been similar to younger adults, and the medications were well tolerated with appropriate management of cardiovascular risks, she says. Patients were also treated for conditions like anxiety and depression that often present in ADHD patients, and sometimes occur as side effects of stimulants.
Seniors that have lived with ADHD all their lives and don’t feel impaired shouldn’t be treated, she notes. “Only people who feel impaired by their symptoms should be treated,” she says.
Joan Friess, a 76-year-old who lives in a senior community in Coconut Creek, Fla., was diagnosed with a precursor to Alzheimer’s disease about five years ago and started taking medication for it, says her son, Steve Friess, a freelance writer who lives in Ann Arbor, Mich.
But Ms. Friess never believed the neurologist who diagnosed her, both mother and son say. She is an advanced bridge and mahjong player and sings with an elite choir with no problem.
After her husband died and she moved to a different part of Florida, she decided to see a different neurologist.
Mr. Friess talked to the neurologist, who asked him if his mother’s behavior was different than most of her life. “I said, ‘No, not really,’ ” he recalls. “She was always losing things and a bit forgetful.”
The neurologist did some brain scans. Comparing them with previous scans, she said she saw nothing to indicate Alzheimer’s disease or dementia. Instead, she diagnosed Ms. Friess with ADHD.
Ms. Friess says she was relieved to confirm what she knew all along. “My husband thought I was forgetting things, but I knew there was nothing wrong with me,” she says.
Mr. Michael, the Department of Defense engineer, says even though he’s had a successful career, he can’t help but wonder how earlier treatment might have helped him. He says even his colleagues noticed his improved performance at work. “I’m much more focused on individual tasks,” he says. “I’m more efficient in how I use my day. I think my life absolutely would have been a lot easier had I known.”
Read the Article on the WSJ site:
Write to Sumathi Reddy at email@example.com