In Ireland, ADHD is the most common presentation to child and adolescent mental health services (CAMHS). Established in September 2018, ADMiRE is a tertiary-level specialist ADHD service in South Dublin, Ireland. ADMiRE provides early access to evidence-based assessment, diagnosis and intervention for >200 children who are referred with primary presenting difficulties suggestive of ADHD. ADMiRE has implemented an evidence-based standardised model of care that involves structured assessment and observation, and interventions offered include psychoeducation, pharmacotherapy and ADHD-specific groups, including a parenting programme.
As confirmed cases of COVID-19 began to rise in Ireland, there were very few in-person consultations in ADMiRE during late March and early April 2020, and it was difficult to provide an adequate ADHD service. However, innovative and alternative approaches for service delivery have since been developed, affirmed by guidelines on managing ADHD during the COVID-19 pandemic from the European ADHD Guidelines Group (EAGG) (Cortese et al, 2020a; Cortese et al, 2020b) and the Canadian ADHD Resource Alliance (CADDRA) (CADDRA 2020).
Impact of the COVID-19 pandemic on ADHD service provision
Specific difficulties experienced by ADMiRE during the COVID-19 pandemic include the postponement of new patient assessments prior to the availability of videoconferencing facilities, and delays in the initiation, titration and optimisation of medication. The issue of how to initiate medication in newly diagnosed patients was addressed by newly issued guidance from EAGG and CADDRA, advising on risk factors and means of obtaining baseline cardiovascular assessments.
Regarding medication titration, it became difficult for clinicians at ADMiRE to arrange adequate physical monitoring, as families were anxious to remain at home. In addition, due to school closures, there was also a lack of teacher input on the response to medication during titration. As a result, titrations were paused for many young people at a time when an optimised dose of ADHD medication may have been particularly beneficial. A variety of options were considered and trialled by ADMiRE. For example, if families have a sphygmomanometer, smartphone and weighing scales, home physical monitoring is possible. However, GPs are now offering more face-to-face appointments and some families have now opted to attend for cardiovascular monitoring; additionally, ADMiRE has set up a dedicated physical monitoring clinic so that young people may attend the service at set times, similar to the current practices in GP surgeries.
When COVID-19 restrictions were first introduced, ADMiRE clinicians received a surge of requests for prescriptions for stimulant medication (a Schedule 2 controlled drug in Ireland) because families were concerned about future supply and accessibility. However, this involved an excessive number of journeys between the CAMHS, the GP and then the pharmacy, therefore GPs began accepting e-mail prescriptions from ADMiRE clinicians, and emailing these directly to the patients’ pharmacy, requiring only one journey for the family to collect medication.
Unsurprisingly, the referral rate for ADHD has dropped by approximately 80% since the emergence of COVID-19 in Ireland, and when restrictions ease it is probable that there will be a surge of referrals for a variety of mental health concerns, including ADHD.
Difficulties reported by families
A number of themes emerged during telephone consultations in ADMiRE during the first 4 weeks following the implementation of COVID-19 restrictions. In almost all cases, parents/caregivers reported an improvement in the behaviour and mood of the young person since schools had closed. This included a number of adolescents with ADHD and conduct disorder who were reported to have improved behaviourally and were respecting restrictions; this was attributed to their concern over vulnerable family members. In contrast, young people with ADHD and comorbid autism spectrum disorder were reported to be struggling with the lack of structure and routine, as reflected in an increase in irritability, oppositionality and challenging behaviours. In the majority of families, sleep patterns deteriorated, with sleep-onset times pushed forward by approximately 3 hours.
Evidence base for the use of telepsychiatry in ADHD
Amid the COVID-19 pandemic, CAMHS need to find new ways to provide a sustainable service to young people in Ireland, including the use of technology such as videoconferencing to deliver mental health care remotely, known as telepsychiatry. This approach may be particularly suited to the assessment and management of ADHD, permitting sustainable, effective assessment and intervention.
Factors that should be considered when developing a telepsychiatry service for children and adolescents with ADHD include the security of the application, the quality and angle of the camera, and the suitability and privacy of the location – all to permit effective observation and engagement between the physician and the individual with ADHD.
Going forward, it may also be possible to use technology to enable physical monitoring of young people on ADHD medication without face-to-face interviews. For example, heart-rate monitors have been included as standard in smartphones and fitness watches for a number of years. Technology to facilitate home blood-pressure monitoring requires further validation but may also be available in the near future.
In summary, the COVID-19 pandemic has had a significant impact on the provision of mental health services for children and adolescents with ADHD in Ireland, and there has been an urgent need to find effective new ways of working. There is a growing evidence base for the use of telepsychiatry in assessing and treating young people with ADHD; this is a practical approach that could be considered by CAMHS nationally.
CADDRA. ADHD and COVID-19: frequently asked questions. 2020. Available at: https://www.caddra.ca/wp-content/uploads/CADDRA-ADHD-and-Virtual-Care-FAQ.pdf. Accessed June 2020.
Cortese S, Asherson P, Sonuga-Barke E, et al. ADHD management during the COVID-19 pandemic: guidance from the European ADHD Guidelines Group. Lancet Child Adolesc Health 2020; 4: 412-414.
Cortese S, Coghill D, Santosh P, et al. Starting ADHD medications during the COVID-19 pandemic: recommendations from the European ADHD Guidelines Group. Lancet Child Adolesc Health 2020; 4: e15.
McGrath J. ADHD and Covid-19: current roadblocks and future opportunities. Ir J Psychol Med 2020; Epub ahead of print.