How COVID-19 Pandemic Affected ADHD Treatment

This is the 5th installment of our 6-part series on mental health issues exacerbated by the COVID-19 pandemic. In this installment, we will discuss identifying and treating ADHD disorders in children and adults in primary care.

A 35-year-old woman presents for a 3-month follow-up visit with her primary care provider. The patient was diagnosed with COVID-19 and was hospitalized 3 months earlier for 5 days because of shortness of breath, oxygen saturation of 92% on room air, and fever of 103 ⁰F. She was treated with intravenous remdesivir for 5 days. She required minimal supplemental oxygen during her hospitalization. Since her discharge from the hospital, she has had frequent headaches, fatigue, low-grade fever, and difficulty concentrating at work.

 At the visit, the patient is 15 minutes late, which is uncommon. She notes that her medication for attention-deficit/hyperactivity disorder (ADHD; lisdexamfetamine 40 mg/d) no longer has the same effect. She states, “I am just so tired all the time, can’t stay focused, and I’m getting behind at work. My brain just feels foggy and I cannot rest at night.” She reports having to resist napping when she gets home from work but then does not sleep well at night. She notes being late paying bills for the last 3 months.

The patient describes a lack of motivation to do things with her friends after work and having no energy to complete her housework. She sleeps an average of 4 hours a night and is not eating well; her weight, however, has not changed. She reports the 6 mg of melatonin she usually takes before bed is no longer helping her sleep.

Medical and Psychiatric History

In addition to ADHD and COVID-19, the patient has a history of hypertension and insomnia. She is compliant with her medications (amlodipine 5 mg/d, lisdexamfetamine 40 mg/d, and melatonin 6 mg at bedtime). Her body mass index falls into the normal category and her vital signs are as follows: blood pressure 128/78 mm Hg, heart rate 90 beats per min, respiratory rate 18 breaths per min, temperature 100 ⁰F, and oxygen saturation 99% on room air. Laboratory results are all within normal levels (Table 1).

Table 1. Laboratory Results

	Normal Limitsa	Patient Values
Complete blood cell count, cells/µL	White blood count: 4500-11,000	10,000
C-reactive protein, mg/L	0.1-10	4.1
Erythrocyte sedimentation, mm/h	0-20	19
Ferritin, ng/mL	40-200	150
Glucose, mg/dL	64-100	99
Hematocrit, %	36-48	40
Hemoglobin, g/dL	11.5-15.5	13
Liver function tests, U/L	ALT: 10-40 AST: 5-40 GGT: 8-55	30 25 12
SARS-CoV-2 PCR test	Negative	Negative
Thyrotropin, mU/L	0.4-4.0	2.0
Urinalysis	Color: yellow Clarity: clear pH 4.5-8 Specific gravity 1.0005-1.025 Glucose: negative Ketones: negative Nitrates: negative	Straw Cloudy 7 1.025   Negative Negative Negative
Urine toxicology	Negative	+ amphetamine
Vitamin B12, pg/mL	160-950	325
Vitamin D, pg/mL	20-40	30

Mental Status

The patient is appropriately dressed but has dark circles under her eyes. She is alert and oriented to person, place, time, and situation. However, she reports forgetting important dates and having brain fog. Twice during the assessment, the clinician has to repeat questions or wait an extended period before she responds to questions. She denies auditory or visual hallucinations and does not appear to be attending to internal stimuli. Her thoughts are logical but appear slow at times. She endorses no delusional thinking. She reports her mood is “okay, just tired.” Her speech has a normal rate and tone with no pressured speech.

She reports difficulty with focusing at work and paying her bills on time. The frequency of headaches has increased and her fatigue has prevented her from doing things with friends or family. She denies any history of hypomania or mania. She reports taking her medication as prescribed and does not use alcohol or recreational drugs. Her attention is slightly impaired but her judgment is intact. She has fair insight into her ADHD diagnosis and asks appropriate questions about long COVID symptoms. Her insight on depression is fair but she would benefit from additional education regarding the disease process. The patient scores 11 on the Patient Health Questionnaire (PHQ-9).

Diagnosis

The patient is diagnosed with mild depression, long COVID, insomnia, and ADHD. She is started on trazodone 50 mg nightly, the lisdexamfetamine dose is increased to 50 mg daily, and she was referred for cognitive behavioral therapy to improve her long COVID symptoms.

Discussion

Attention-deficit/hyperactivity disorder is a neurodevelopmental disorder that is usually diagnosed in childhood but can continue into adulthood.¹ The prevalence of ADHD among children aged 4 to 17 years increased by 42% between 2003 and 2011 (from 7.8% to 11.0%).¹ Boys had a higher prevalence of ADHD than girls with prevalence rates of 15.1% and 6.7%, respectively, in 2011.¹ The prevalence of ADHD among adults aged 18 to 44 years is 4.4% with a lifetime prevalence of 8.1%.¹ Nearly 10 million adults in the US are diagnosed with ADHD.²

Attention-deficit/hyperactivity disorder is diagnosed using structured interviews, Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5) criteria, rating scales/screening tools, and performance tests (Table 2).^3-5 Rating/screening tools alone should not be used to diagnose ADHD. In 2013, the DSM-5 updated the diagnosis of ADHD to reflect that the disorder can continue through adulthood. By adapting criteria for adults, DSM-5 aimed to ensure that children with ADHD can continue to get care throughout their lives if needed.⁶

Table 2. Sample of Rating Scales and Screening Tools for ADHD ^3-5

Tool	Method	Scoring	Interpretations
Rating Scales
National Institute for Children’s Health Quality (NICHQ) Vanderbilt Assessment Scale	Parent and teacher questionnaire	55 Symptom Questions Based on frequency 0-3 scale (never, occasionally, often, very often) Performance Questions Based on the problem severity 0-5 scale (excellent, above average, average, somewhat of a problem, problematic)	Positive if a specific number of symptoms rate as 2 or 3 and if one performance question rates a 4 or 5
Conners Rating Scale	Parent, teacher, and adolescent questionnaire	Based on how true the question is for the child on a scale of 0-3 (not true at all, just a little true, pretty much true, very much true).	Higher scores indicate further investigation is needed Interpretation guidelines indicate that scores ≥60 are above average
SNAP-IV (Swanson, Nolan, and Pelham revision)	Parent and teacher questionnaire	Based on frequency on a scale of 0-3 (not at all, just a little, quite a bit, very much)	Higher scores indicate more symptoms
Performance Tests
Conners CPT (Continuous Performance Test)	Computerized test	Response to target and nontarget questions	Standardized scores are calculated using an algorithm T scores and percentiles are calculated. The higher the score, the worse the problem
IVA CPT (Integrated Visual and Continuous Performance Test)	Computerized test	Response to target and nontarget questions	Auditory and Visual domain scores are calculated for a total of 12 quotients.
TOVA (Test of Variables of Attention)	Computerized test	Response to target and nontarget questions	Omission and commission errors are calculated
CANTAB (Cambridge Neuropsychological Test Automated Battery)	Computerized test	Scored by different domains	Interpretation varies on outcome measures

The DSM-5 diagnostic criteria for children/adolescents is greater than 6 symptoms of inattention and/or more than 6 symptoms of hyperactivity/impulsivity that last longer than 6 months and impact social and academic/professional activities.⁴ In adults, greater than 5 symptoms must be present in either group for greater than 6 months. Evidence suggests that ADHD is overdiagnosed in children with mild symptoms for whom cognitive therapy could have been beneficial.⁷ The patient, in this case, has already been diagnosed with ADHD and no additional screening tools were used to assess her ADHD symptoms.

Treatment for ADHD includes psychoeducation, behavioral modification, and/or pharmacotherapy (Table 3).⁸ Psychoeducation is a primary treatment for ADHD and helps patients learn about the diagnosis, treatment options, and behavioral modification strategies for home, school, and work. People with ADHD have higher rates of emotional dysregulation that can adversely affect aspects of daily living. Behavioral therapy can include encouraging calming techniques to de-escalate conflict, setting clear goals, and using positive incentives and consequences. Cognitive behavioral therapy for ADHD targets issues like time management and organizational skills. Pharmacotherapy for ADHD in adolescents and adults targets the symptoms that cause impairment and includes psychostimulants (amphetamines and methylphenidates).⁸  

Table 3. Treatments for ADHD⁸

Type	Description
Psychoeducation	Educate people with ADHD about their diagnosis and treatment options
Behavioral	⦁ Home: give clear instructions and have instructions repeated. Be positive and calm. Use de-escalating techniques, praise, positive incentives, and set attainable goals and limits. ⦁ School: have immediate positive feedback, use visual cues, break down steps, set clear expectations, and reduce the amount of work. ⦁ Work: identify accommodation needs, have regular and frequent meetings with the manager, set goals, prioritize, identify time management techniques, and declutter.
Medication	⦁ First-line: amphetamine/dextroamphetamine salts (Adderall XR), methylphenidate (Concerta), or lisdexamfetamine (Vyvanse) ⦁ Second-line: methylphenidate (Ritalin, Ritalin SR); guanfacine (nonstimulant Intuniv XR), atomoxetine (Strattera) ⦁ Third-line: bupropion, clonidine, modafinil, imipramine, and atypical antipsychotics

Discussion

The COVID-19 pandemic has had a significant impact on children and adults with ADHD.^9-12 Restrictions put in place because of the pandemic, such as school and workplace shutdowns, social distancing, hand washing, and wearing a mask, have disrupted the social, educational, and work environment of patients with ADHD.^10,11 For children, services and accommodations through the Individuals with Disability Education Act (IDEA) and Section 504 under the Rehabilitation Act of 1973 have been disrupted.^2,13 Parents have had to take on a more active role in their children’s education, including hiring teachers and/or special education teachers to work virtually when possible.²

Maintaining treatment and receiving an accurate diagnosis of ADHD without in-person evaluations and performance testing is challenging.¹² Telemedicine and less restrictive prescribing guidelines for controlled substances have helped to ensure that patients could continue receiving care and be started on new medication if needed.¹² Pharmacotherapies for ADHD also may have a protective effect against severe COVID-19 infections. Findings from a study by Tuan et al showed that adults with ADHD who were taking stimulants had lower mortality rates from COVID-19, suggesting that stimulant treatment for ADHD may reduce the risk of COVID-19 complications.¹⁴

Concern regarding the effects of long COVID on children and adults is growing.¹⁵ Long COVID symptoms can be physical, psychological, and social and can affect an individual’s ability to attend school and perform daily activities (Table 4). According to the Kaiser Family Foundation, 15% of adults in the US report having had long COVID symptoms at some point, including 6% who have current symptoms.¹⁶ The definition of long COVID includes signs, symptoms, and conditions that continue or develop after initial COVID-19 or SARS-CoV-2 infection that last longer than 3 months.¹⁵ Although no test for long COVID exists, patients who present with symptoms should have a complete physical examination including vitals and blood work. When a patient presents with long-term fatigue after COVID-19, a walking pulse oximetry test should be performed.¹⁵ If cognitive impairment is noted, orthostatic vitals should be taken and referral to cognitive behavioral therapy is warranted.^15,17

Symptoms of long COVID should be treated using a comprehensive rehabilitation program.¹⁵ Although children and adolescents are less likely than adults to have long COVID symptoms, symptoms can affect an individual’s ability to attend school, complete schoolwork, and perform activities of daily living. Parents should be encouraged to discuss their concerns with the school to make further accommodations to their child’s Individualized Education Program (IEP) as needed.¹³

Table 4. Symptoms of Long COVID^15-17a

Abdominal pain Anosmia Arthralgia Chest pain Cognitive impairment (brain fog) Cough Diarrhea Disordered sleep Dyspnea Fatigue Fever Headache

Impaired daily functioning and mobility Lightheadedness, dizziness, vertigo Memory loss Menstrual cycle irregulars Mood changes Myalgia Pain Palpitations Paresthesia Postexertional malaise Rash Tinnitus

Conclusion    

The COVID-19 pandemic brought about many challenges for people with ADHD — from modifications in school/work environments to altered social norms. Limited access to health care providers created additional challenges and long COVID symptoms, which mimic many of the ADHD symptoms, have made diagnosing ADHD more difficult.

Shirley Griffey, DNP, PMHNP, is a psychiatric nurse practitioner at Baton Rouge General Medical Center and an instructor at Southeastern Louisiana University School of Nursing in Baton Rouge, Louisiana.

Jennifer Allain, DNP, MSN, APRN, FNP-C, is the NP program coordinator and master teacher of mental health psychiatric nursing at The LHC Group, Myers School of Nursing of the University of Louisiana at Lafayette College of Nursing and Health Sciences.

Christy Cook-Perry, DNP, PMHNP, ANP, is an assistant professor at Southeastern Louisiana University College of Nursing and Health Sciences.

Previous articles include:

Anxiety in Children and Adults Ballooned in US at Start of COVID-19 Pandemic
Depression After COVID-19: Identification and Treatment in Primary Care
Suicide Awareness During the COVID-19 Pandemic
Substance Use Disorders During the COVID-19 Pandemic: Case Study             

This article originally appeared on Clinical Advisor