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9 Nov 2020

Becker SP et al. J Adol Health 2020; 67: 769-777

A previous study investigated the impact of COVID-19 on children with ADHD in China (n=241, mean age 9.43 years); it reported that parents thought their child with ADHD was less focused and that they saw an increased frequency in their anger (Zhang et al, 2020). However, the report did not include a comparison with children without ADHD, did not investigate remote learning specifically and only looked at school-age children. Therefore, this present study aimed to examine remote learning practices and difficulties amongst adolescents with and without ADHD and their parents during the COVID-19 pandemic in the US.

Data were collected between 16 May and 15 June 2020. The measures used for data collection included the Home Adjustment to COVID-19 Scale, which is a parent-report measure to assess remote learning practices, costs, learning difficulties and service-use changes. The Adolescent Routines Questionnaire was also used to allow parents and adolescents to rate how often the adolescent engaged in behaviours in a routine manner (Meyer, 2008). Finally, the COVID-19 Adolescent Symptom and Psychological Experience Questionnaire (adolescent-report measure to assess their experiences and exposures related to COVID-19) were used (Ladouceur, 2020).

Participants were 238 adolescents (n=132 male, n=106 female; aged 15.64–17.99 years), 118 adolescents had a diagnosis with Diagnostic and Statistical Manual (DSM-5™) ADHD and 120 adolescents did not have an ADHD diagnosis. It was determined that 59% of the participants within the study engaged in online class meetings and 53% watched recorded videos. However, 21% of the adolescents did not receive any remote or online learning during the US stay-at-home period (mid-March to mid-June 2020); low-income families possibly were significantly more likely to be part of the 21% compared with high-income families (χ2 = 6.28, p = 0.012) and significantly less likely to engage in class meetings (χ2 = 8.78, p = 0.003). There was no significant difference for remote learning methods between adolescents with ADHD and adolescents without ADHD (χ2 = 0–2.81, ps > 0.094). The majority (72%) of parents reported that their child spent less than 3 hours on schoolwork on an average school day during the COVID-19 pandemic.

Furthermore, 73% of families received materials from their school to support remote learning. Financial burden was undertaken by 22% of families to support remote learning, with mean cost $198 per family (range = $5–$1000 per family); low-income families were more likely than high-income families to incur financial burden (χ2 = 7.34, p = 0.007). Of note, 12% of families had to invest in a better internet plan to support remote learning (mean cost of $68 per month; range = $10–$150 per month).

Experience of remote learning in adolescents with and without ADHD

Significantly more difficulties with remote learning were experienced by adolescents with ADHD compared with adolescents without ADHD (d = 1.03, p < 0.001). Furthermore, parents of adolescents with ADHD had less confidence in managing remote learning compared with parents of adolescents without ADHD (d = 0.46, p = 0.001) and more difficulties supporting home learning and home-school communication (d = 0.60, p < 0.001). Fewer routines during the COVID-19 pandemic were reported by parents (d = 0.82, p < 0.001) and adolescents with ADHD (d = 0.49, p = 0.002). However, there was no difference between adolescents with and without ADHD in terms of their self-ratings of positive affect, negative affect or difficulties concentrating due to COVID-19 (ds = 0.07–0.19, ps > 0.1).

Correlates of adolescent difficulties

ADHD status moderated the association between parent confidence in managing remote learning and adolescent difficulties with remote learning (b = –0.33, standard error [SE] = 0.11, p = 0.026). Additionally, when parents had greater confidence there were fewer difficulties for both adolescents with and without ADHD; however, the association was stronger for adolescents with ADHD (b = –0.70, SE = 0.1, p < 0.001) compared with adolescents without ADHD (b = –0.37, SE = 0.11, p = 0.001). There was a significant association between parental learning support and home-school communication difficulties and adolescent remote learning difficulties (b = 0.30, SE = 0.06, p < 0.001), but this was not moderated by ADHD status (b = 0.13, SE = 0.09, p = 0.162).

The ADHD status of the adolescents significantly moderated the association between parent-reported and adolescent-reported routines (b = –0.13, SE = 0.06, p = 0.039) and adolescent remote learning difficulties (b = –0.14, SE = 0.06, p = 0.021). Furthermore, increased parent-reported routines were associated with fewer difficulties for adolescents with and without ADHD, although the relation was stronger for adolescents with ADHD (b = –0.25, SE = 0.04, p < 0.001) compared with adolescents without ADHD (b = –0.12, SE = 0.05, p = 0.011). Increased adolescent-reported routines were associated with fewer adolescent difficulties in adolescents with ADHD (b = –0.20, SE = 0.04, p < 0.001), but not in adolescents without ADHD (b = –0.06, SE = 0.04, p = 0.158). The ADHD status of the adolescents significantly moderated the associations between positive and negative effects (b = –0.39, SE = 0.19, p = 0.044) and adolescent remote learning difficulties (b = 0.14, p = 0.033). Finally, the ADHD status of the adolescents significantly moderated the association between their difficulties concentrating because of COVID-19 and their difficulties with remote learning (b = 0.26, SE = 0.11, p = 0.022). Problems concentrating were associated with more remote learning difficulties for adolescents with ADHD (b = 0.38, SE = 0.08, p < 0.001), but not for adolescents without ADHD (b = 0.12, SE = 0.08, p = 0.156).

There were several limitations to this study. First, due to the study being cross-sectional, no assumptions can be made about the directionality of the associations. Second, no teacher-ratings were collected due to the time-sensitive nature of the study and the transitional stress to remote learning that was placed on teachers during this time. Third, the authors did not have a robust measurement of medication use. Finally, the study provides no information about how much learning occurred via remote education and the actual uptake of knowledge.

In summary, this study provided the first evidence that there were more difficulties faced by adolescents with ADHD and their parents compared with adolescents without ADHD and their parents during the COVID-19 pandemic. Additionally, this was the first study to document remote learning practice rates and school services during the stay-at-home orders due to the COVID-19 pandemic in the US.

Read more about COVID-19 and remote learning difficulties associated with ADHD here

Becker SP, Breaux R, Cusick MS, et al. Remote learning during COVID-19: Examining school practices, service continuation, and difficulties for adolescents with and without attention-deficit/hyperactivity disorder. J Adolesc Health 2020; 67: 769-777.

Ladouceur CD. COVID-19 adolescent symptom and psychological experience questionnaire (CASPE). Pittsburgh, PA: Author; 2020.

Meyer K. Development and validation of the adolescent routines questionnaire: parent and self-report [doctoral dissertation]. Baton Rouge, LA: Louisiana State University; 2008. Available at: https://digitalcommons.lsu.edu/gradschool_dissertations/4052/. Accessed December 2020.

Zhang J, Shuai L, Yu H, et al. Acute stress, behavioural symptoms and mood states among school-age children with attention-deficit/hyperactive disorder during the COVID-19 outbreak. Asian J Psychiatr 2020; 51: 102077.

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