COVID-19: Special Topics | The Impact of COVID-19: A Nine Year Old Boy with ADHD
Brett Nelson, MD
Project TEACH Child and Adolescent Psychiatrist, Region 2/Saratoga, and Medical Director at Four Winds Saratoga
The Coronavirus pandemic has stressed the entire nation and interrupted daily routines. Stress is a well-known contributor to worsening mental health, especially for those already coping with mental health challenges. One change that often follows treatment disruption is that patients return to their Pediatric Primary Care Provider (PCP) to rebuild the care team and create an effective treatment plan. The following is a case example of how the COVID-19 pandemic affected a child with ADHD.
John is a 9-year-old boy with a history of ADHD that was extremely impairing. He struggled at home and school with his behaviors, which included extreme hyperactivity, impulsivity, and an inability to focus on areas that were “boring”. This led to significant problems at school where John struggled to achieve modest academic progress. At home he was argumentative and defiant to his parents, and never seemed to listen. He couldn’t sit still during meals, and had problems falling and staying asleep at night. John’s parents initially consulted their PCP, who was able to start treatment for ADHD. However, when treatment of John’s ADHD became increasingly complicated and symptoms returned, John’s PCP called Project TEACH for a phone consultation with a Project TEACH Child and Adolescent Psychiatrist to get the best guidance on what treatment would be required, including what medication regimen to initiate and/or resume. On advice from Project TEACH, a medication regimen was started to treat John’s core symptoms.. In addition, on advice from Project TEACH a behavioral therapist was also recommended. The behavioral therapist worked with the family on improving John’s coping skills, organizational strategies, and social skills. His parents requested an Individual Education Program from his school counselor, and John was provided with extra time to complete his assignments and an aide to assist with keeping him on task and organized. Through this team approach, John’s parents learned to manage John’s behaviors and educational needs which allowed John to be successful at school and happy at home.
This team approach was disrupted with the arrival of COVID-19 and a subsequent shelter-at-home order. John initially seemed to enjoy the change in his routines; however, once his school established a virtual educational plan to keep their students progressing forward things became much more challenging. John was assigned an intensive virtual learning program with multiple layers of homework packets and instructional videos to watch. Without the structure of being in school, and the special educators working with him throughout the day, it was difficult for John to keep up with his school work. His parents, who worked full-time at home, found it extremely challenging to give John the time and attention he needed to complete assignments. John’s previous routines began to shift significantly as he much preferred staying up late at night to play video games and sleeping late in the morning. He received his medications at different times than previously scheduled as his parents didn’t want to wake him up at the usual earlier hour. John began having more behavioral outbursts and seemed to become depressed out of frustration. He was unable to meet with his mental health providers due to the stay-at-home order, and the family suddenly felt alone in their efforts to care for John. The breakdown in the routines and support previously relied upon to treat John’s ADHD led to a dramatic decrease in quality of life for everyone in the family.
John’s parents again asked his PCP to get involved with John’s care, but she felt ill-equipped to manage his complicated medication regimen and social situation by herself. The PCP once again called Project TEACH for a phone consultation with a Project TEACH Child and Adolescent Psychiatrist to determine the most appropriate management strategies. On advice from Project TEACH, a telehealth consultation was set up for John and his parents to virtually meet with the patient under the new conditions to further adjust John’s medication regimen. As a result, John’s medications were able to better target the new presentation of symptoms which were causing John difficulty with his focus, mood and sleep. His parents were encouraged to give John his medications at a structured time each day to prevent a further slide in his behavior. On advice from Project TEACH, John’s parents were also encouraged to re-engage in routine behavioral therapy via telehealth with his therapist, which they weren’t aware was available to meet in this way.
Following re-engagement with John’s team virtually through telehealth methods, John began to succeed under difficult circumstances. He began to learn new coping skills to manage the unique stressors related to the isolation and change in his daily routine as a result of COVID-19. His parents, in turn, received guidance on how better to provide structure in John’s day. His school became more involved with John, implementing a more tailored virtual education program for him that included giving John more time on assignments and establishing routine meetings with a virtual special education teacher and other school support staff who all knew John well. Management of his ADHD with medication, therapy, and educational accommodations adapted for virtual circumstances had a dramatic effect on the family unit as a whole– their stress levels were reduced, family arguments became minimal, and John’s acting out decreased while his mood improved.
John’s case illustrates how an otherwise stable nine-year old boy with ADHD rapidly developed increased symptoms secondary to several environmental stressors. Also illustrated is the importance of sustained medication adherence. Most of all the quick action of his PCP with consultation from Project TEACH enabled rapid re-stabilization.
Pediatric Primary Care Providers in New York State have long enjoyed free access to phone consultation, referral for services, and one-time psychiatric assessments available through Project TEACH. Flexible, creative, collaborative approaches like telemedicine and psychiatric phone consultation to primary care providers are lifesavers for specific vulnerable groups during unusual adverse conditions such as during a pandemic. They also offer lessons to help us provide more effective modes of service when the pandemic eventually ends.