ABSTRACT

OBJECTIVES: to describe behavioral changes related to mental health in children and adolescents with Attention Deficit Hyperactivity Disorder during social isolation due to the COVID-19 pandemic.
METHODS: this is a systematic review conducted under the PRISMA protocol (2020) in the PubMed, SciELO and VHL databases, with a period of 2019-2022.
RESULTS: 3,735 studies were screened and ten were selected, according to the eligibility criteria. The sample had 4,688 participants. There was evidence of a worsening of signs and symptoms regarding the mental health of this population, expressed mainly through changes in mood, with increased anxiety, sadness or depressed symptoms, in addition to increased hyperactivity. Behavioral changes also included reduced sleep quality and physical activity, and increased use of digital technologies and screen time.
CONCLUSIONS: it was described that children and youth groups, especially those with attention deficit hyperactivity disorder, had increased emotional symptoms and conduct problems when compared to before the pandemic, making it possible to recognize the negative repercussions of the changes imposed by it. These factors are important for planning more effective care strategies.

Keywords: Attention deficit hyperactivity disorder, Child, Social isolation, Mental health, COVID-19

RESUMO

OBJETIVOS: descrever mudanças comportamentais, relacionadas à saúde mental, em crianças e adolescentes com Transtorno de Déficit de Atenção e Hiperatividade durante o isolamento social devido à pandemia da COVID-19.
MÉTODOS: trata-se de uma revisão sistemática conduzida sob protocolo PRISMA (2020) nas bases de dados PubMed, SciELO e BVS, com período de 2019-2022.
RESULTADOS: foram triados 3.735 estudos e selecionados dez, de acordo com os critérios de elegibilidade. A amostra contou com 4.688 participantes. Evidenciou-se um agravamento de sinais e sintomas quanto à saúde mental dessa população expresso principalmente através de mudanças no estado de humor, com aumento da ansiedade, tristeza ou sintoma deprimido, além do aumento da hiperatividade. As mudanças comportamentais incluíram ainda redução da qualidade do sono e da prática de atividades físicas e aumento do uso de tecnologias digitais e tempo de tela.
CONCLUSÕES: foi descrito que os grupos infanto-juvenis, sobretudo com Transtorno de Déficit de Atenção e Hiperatividade, tinham sintomas emocionais e problemas de conduta aumentados quando comparados a antes da pandemia, sendo possível reconhecer as repercussões negativas das mudanças impostas por ela. Esses fatores são importantes para o planejamento de estratégias de cuidado mais efetivas.

Palavras-chave: Transtorno de déficit de atenção e hiperatividade, Crianças, Isolamento social, Saúde mental, COVID-19

Introduction

In March 2020, the World Health Organization (WHO) declared a Public Health Emergency due to COVID-19. ¹ The main containment measures were based on controlling the spread through isolation and social distancing. ^1,2 In this context, the psycho-socio-cultural dimensions of coping with a pandemic are highlighted, which can have psychological and psychiatric repercussions, such as depressed mood, irritability, fear and insomnia. ³

In children and teenagers, social restriction may imply a deterioration of mental health due to the reduction of physical activity, weakening of social relations, and dysregulation of the circadian rhythm, for example, especially during prolonged periods. ⁴ Children and teenagers with Attention Deficit HyperactivityDisorder (ADHD) arepotentially more vulnerable to the negative repercussions of the containment and coping measures of the pandemic. ⁵

There is still a scientific gap regarding the mental health of this population during the COVID-19 pandemic. There is evidence that children and teenagers with ADHD are more prone to increased symptoms of inattention, hyperactivity/impulsivity, and oppositional/defiant during the COVID-19 pandemic. ⁶ However, there was no systematic worsening of their symptoms during social isolation asthe external environmentcould be a source of conflict and stress. ⁷ Thus, social isolation could be relatedtoboth positive and negative impacts on the health of children and teenagers living with ADHD. ⁸

Given the conflicting literature and the scientific gap on this topic, the objective of this study is to describe behavioral changes, related to mental health, in children and teenagers with ADHD during social isolation due to the COVID-19 pandemic.


Methods

This is a systematic review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, 2020). ⁹ Based on the PECOS strategy: P) Patient, E) Exposure, C) Comparison, O) Outcome (outcome), and S (type of study),¹⁰ we established the research question: "What are the behavioral changes, related to mental health (O), of children and teenagers with ADHD (P) during social isolation, due to the COVID-19 pandemic (E), compared to the pre-pandemic period (C)?". As it was a literature review, approval from the Research Ethics Committee was not required. There was no record of a research protocol.

The research and selection of studies were finalized on 07/20/2022, from the Health Science Descriptors (DeCS): "Child", "Attention deficit hyperactivity disorder", "Social Isolation", "Physical Distancing", "Quarantine", "Lockdown", "pandemics", "COVID-19", "Mental health", "Quality of Life", "Child Development" combined with the Boolean operators AND or OR the Scientific Electronic Library Online databases (SciELO), Regional Portal Virtual Health Library (VHL) and PubMED. Table 1 summarizes the six search strategies used. Each combined three topics related to the PECOS¹⁰ strategy with the Boolean operator AND.

 



To select the articles of the systematic review, the eligibility criteria were applied, according to the themes of the research question in Figure 1. Observationalstudies, published in English, Portuguese, Spanish or French, between the years 2019 and 2022 were included. Articles published outside the period of the COVID-19 pandemic, duplicates, reviews of any kind, as well as articles that were incomplete, or that did not address 1) children with ADHD were excluded; 2) social distancing during the COVID-19 pandemic; 3) mental health outcomes; 4) mental health impact assessment.

 



The findings were filtered by publication period (2019-2022), exported and inserted into the Rayyan¹¹ web application. The articles were screened by reading the titles and abstracts, followed by the full articles by two independent and anonymized evaluators (GGCL and DBR). The disagreements were resolved by consensus.

To prepare the analysis, the articles were systematized in a database using Microsoft Excel^® software, considering the variables: journal, author and year of publication, title, place of research, study design, characteristics of the participants, exposure and outcome variables analyzed, evaluation instrument, main results, biases/limitations of the study.

The quantitative data were presented based on Descriptive Statistics through graphs, in absolute numbers, percentages and/or means, according to the outcome and, the statistics were performed with the aid of the JAMOVI software. A table was elaborated presenting the quality information of the studies and their main results.

This stage was conducted by two reviewers (BRMT and ABC) independently. When the article did not explicitly present some information for Table 1, it was standardized to describe with "-".

Since this was a literature review, approval from the Research Ethics Committee was not required. No research protocol was registered.


Results

Selection of studies

Initially, the bibliographic research identified a total of 3,735 studies, and 10 studies were considered eligible. ^{7,8,12,13,14,15,16,17,18,19} We excluded studies that did not address the following topics:1) the target audience of children with ADHD (N = 130); 2) social distancing during the COVID-19 pandemic (N = 265); 3) mental health outcomes l (N = 12); 4) mental health impact assessment (N = 1).

Characteristics of the studies

In total, 4,688 participants were included, of who46 (1.09%) were fathers, 1,296 (32%) mothers and 3,133 (66.83%) children and teenagers. Among the children and teenagers analyzed, 2,412 (72.8%) were boys and 721 (27.2%) girls, with ages ranging from 3 to 20 years and a mean of 13.5 years. Of the ten articles analyzed, most were conducted in developed countries (8/10). Regarding the period of confinement, nine articles contained an average duration of 5 weeks in the year 2020. Only the study by Zhang et al. ¹³ did not provide information on the study time.

Of the 3,133 children and juveniles, 532 (16.98%) used ADHD medication.In four studies, the patients also had other comorbidities (N = 398)^8,13,14,17: 1) Autism Spectrum Disorder (28.14%); 2) Anxiety (27.14%); 3) Learning Disorders (17.34%); 4) Tics (10.05%); 5) Speech and Language Disorders (8.04%); 6) Obsessive-Compulsive Disorder (3.02%); 7) Depression (6.28%).

Six studies used validated instruments to measure the difficulties experienced by the sampleduring the pandemic period: 1) Swanson, Nolan, and Pelham 26-question scale (SNAP-IV)^13,15; 2) Strengths and Difficulties Questionnaire (SDQ)^12,18 and 3) Attention-Deficit Hyperactivity Disorder Rating Scale (ADHD-RS). ¹⁹ According to the main theme and objective of each article, the number of instruments used varied, with some cases involving the use of two or more types. Table 2 describes the characteristics of the studies, the variables that were analyzed, the evaluation instruments used and the main findings of the sample database.

 



Summary of evidence

Regarding COVID-19, two studies showed that children were concerned about the pandemic period^8,18 and 52% (N = 226) were apprehensive about their health status and/or their family and loved ones. ¹⁸ Additionally, on average, 46.60% (N = 302) of the children and teenagers were distressed by the repercussions of the pandemic. ^8,18

Four studies analyzed the mood state of the participants (N = 1,158) and showed worsening of the mood. ^8,14,15,16 The children and juveniles felt more anxious (33.07%), sad or depressed (25.56%), distracted (18.05%), restless (8.55%), lonely (7.60%), worried (4.49%) and/or aggressive (2.68%).

The behavior evaluated by the parents of 840 children showed that 40.95% had worsened, 25.83% showed improvement, and in 33.21% no alterations were perceived. ^7,18 When analyzing the hyperactivity variable in 301 juveniles, it was found that 47.18% had worsened, 20.60% improvement and in 32.23% no alterations were evidenced. ¹⁸

In comparison to the other studies, three evaluated variables of changes related to sleep and physical activity, quantified from the perspective of the parents. ^8,15,16 Then analyzing the total sample with results related to sleep (N = 651) and physical activity (N = 503), respectively, 22.12% (N = 144) and 25.84% (N = 130) of the sample showed improvement, while 77.88% (N = 503) and 74.16% (N = 373) worsened. ^8,15,16

Regarding the studies that evaluated the use of technologies,^8,16 the parents or guardians reported that 31.21% (N = 142) of the children spent more time playing; 28.57% (N = 130) watching TV; and 40.22% (N = 183) making use of social media. In terms of health care, 39.19% (N = 58) of the juveniles (N = 148) were assisted by pediatricians, 36.49% (N = 54) by psychologists, 11.49% (N = 17) by psychiatrists and 12.84% (N = 19) by occupational therapists. In studies conducted in Australia and Italy, an increase in the use of digital technologies was observed, and only this study identified the need for children to consult with specialists. ^8,16

Main limitations of the studies

Some studies did not specify whether the results referred to the sample composed of children and/or teenagers. Samples with child and teenager populations were used,^7,12,14 as well as joint analysis of children and teenagers,^{8,13,16,17,19} and a fixed parameter was not used to classify individuals as children or teenager.

Four studies did not present a representative sample due to the small sample size^14,16,18,19, while others had restrictions related to internet access^12,13 or the need for fluency in languages. ¹² It is important to emphasize that eight studies pointed out the limitation of not capturing the perspective of the child but relying solely on their parents perspective. ^7,8,12-17

One study pointed out that the methodological design does not allow formulating causal relationships between confinement and the evolution of the state of children with ADHD⁷ and three others reported as a relevant limitation the non-comparison of the behavior of children with attention deficit hyperactivity disorder with those of the general population. ^12,13,18

Regarding the assessment instruments, six studies did not use standardized tools for the diagnosis of ADHD and comorbid conditions. ^{7,8,13,14,16,17} The methodological heterogeneity between the studies may cause biases among the evidence and lead to challenges in the interpretation of the clinical relevance of the impacts on mental health, in the differentiation of adaptive symptoms and mental illness, and possible geographical and cultural influences. ^8,14-17


Discussion

The data obtained show several impacts on the mental health of children and teenagers with ADHD during the COVID-19 pandemic social isolation. Among the studies that analyzed mood,^8,14,15,16 they showed an increased in stress, depression and anxiety. These findings show the urgency for social policies and strategies that minimize the impacts of short- and long-term isolation on children and teenagers, especially those with ADHD. ^20,21,22

Studies have described an association between ADHD and poor emotional regulation as a risk factor for maintaining mental health in the context of the pandemic. A higher risk of chronic stressors is present when compared to typical controls, which can affect behavioral, psychological and social domains. ^6,8 The children's groups, especially those with ADHD, had emotional symptoms and conduct problems, presenting behavioral changes associated with social isolation measures. ²³

Other indicators of decreased in mental health were reduced sleep quality and physical activity,^8,15,16 as well as increased use of digital technologies. ^8,16 There is also greater vulnerability to develop sleep disorders in children and teenagers with ADHD due to the pandemic period. ²⁴ In addition, physical activity promotes improvements in ADHD symptoms in children, such as attention to domains of executive functions. ²⁵ However, there was a decrease in pleasure and time spent in outdoor activities, concomitantly with an increase in exposure to screens and solitude, when compared to the routine before the pandemic. ²³

It should be noted that, although social media is able to promote greater social connection by maintaining affective ties with people outside the family nucleus, increased internet use and screen exposure may be associated with symptoms of depression and anxiety. In addition, the individual may present sleep alterations. ²⁶

In several countries, there was a prioritization of remote services of health care, via telehealth, to the detriment of face-to-face care. Although, the optimization of these services for a digital approach is a continuous process, with logistical, technological and financial implications, prioritizing the quality of care,^27,28 especially in children and teenagers with ADHD.

Some evidence can be applied to the current context, such as the importance of social contact, as it directly impacts the mental health of children and teenagers with ADHD. Changes in emotion and mood were associated with decreased activities that promote quality of life. Thus, it was demonstrated the importance of sleep quality, physical activity and regular use of digital technologies. ^23,25,26

Regarding the limitations of the studies analyzed, three articles did not report whether there were exclusion criteria in the sample selection;^13,14,17 two did not clearly present how the results of the open questionnaire⁷ and analysis instruments¹⁹ applied were measured and/or evaluated; one, when establishing criteria for the analysis of their results, did not inform how they were analyzed,⁸ and one did not use a validated analysis instrument. ⁷ It is also noteworthy the predominance of studies conducted in developed countries and the heterogeneity of the studies in relation to the methodological design and age group considered.

Therefore, in order to develop more robust scientific evidence, it is necessary that samples be probabilistically representative of the population analyzed, carefully defining the population of interest and selecting the characteristics to be researched. Studies should also have methodological designs with greater homogeneity and should be carried out in developing and underdeveloped countries to understand the specificities of these locations. Such questions are able to reduce the chances of deviations from the analysis and interpretation of the data, for the success of the investigation. ^29,30

Conclusion

This review showed a worsening of signs and symptoms related to the mental health of children and teenagers with ADHD, mainly due to changes in mood; increased anxiety, sadness or depressed symptom and increased hyperactivity. Behavioral changes also included reduced sleep quality and physical activity and increased use of digital technologies and screen time. Despite the limitations of the studies and the incipient literature on the subject, recognizing the negative repercussions of the abrupt change in routine, structure, and social contact, as well as the restrictions imposed by the pandemic, is important for planning more effective care strategies for children and teenagers with ADHD.

More robust and methodologically structured research is needed to describe the impacts that pandemics may have on the mental health of individuals with ADHD, as well as its long-term consequences. This review provides a foundation for future research in the area and can help ensure that supports can meet the specific mental health needs of this population.


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Received on October 11, 2020
Final version presented on April 14, 2023
Approved on May 12, 2023

Associated Editor: Pricila Mullachery

Author's contribution: Laguna GGC and Ribeiro DB: data collection; Laguna GGC, Tavares BRM and Cazé AB: data analysis and interpretation; Laguna GGC, Santos ACS and Borges GF: critical intellectual review. All authors contributed substantially in the planning, preparation of the study, approved the final version of the article and declared no conflict of the interest.