More Families Seeking ADHD Diagnosis: Advice for Clinicians

What’s happening – Clinicians are facing a growing number of parents seeking an ADHD diagnosis for their children, whether they are having trouble focusing on schoolwork or finding their grades slipping. In fact, a helpline set up by the nonprofit CHADD (Children and Adults with Attention Deficit Hyperactivity Disorder) has seen an increase in calls by 62% during the pandemic, and their website traffic has increased by 77%, illustrating growing concerns about attention issues over the past year.

Experts caution, however, that diagnosing and treating ADHD may not be the answer for many students who are losing focus right now. They point out that for some students, attending school online without their normal structure and activities may be contributing to attention and performance problems, rather than ADHD.

Clinicians are encouraged to obtain a detailed history of a child’s behavior before COVID-19 to determine if the difficulties may have existed in the past. If the symptoms have emerged during the pandemic, it’s less likely to be caused by ADHD and more likely to be related to present circumstances. Clinicians can also encourage parents to help children be more organized and have a more formal routine in place to help them improve functioning.  The American Academy of Pediatrics provides a toolkit for providers to guide them through the process of diagnosing, treating, and supporting children with ADHD. (More on assessment with Randy Bressler, PsyD, in our Psy-Q below.)

Why it’s complicated – Children and adults with ADHD can be at increased risk of contracting COVID-19, and of experiencing a more severe case of COVID infection, according to a study just published in the Journal of Attention Disorders. In fact, the scientists led by Eugene Merzon at York University, Toronto, point out that having ADHD puts someone at as much risk for COVID-19 as having diabetes and cardiovascular diseases – and may present an even higher risk than having asthma or being obese. They speculate that the risk for people with ADHD may be tied to failure to comply with various social distancing guidelines and other measures to reduce disease spread.

And ADHD is not the only factor involved. With so many everyday life changes that have come about during the COVID-19 pandemic, children’s mental health is suffering across the board. A study published in September 2020 in the International Journal of Disaster Risk Reduction by Margues de Miranda et al calls attention to the fact that children are at increased risk of experiencing anxiety, PTSD, and depression. Yet, there is a shortage of behavioral health providers to meet the needs that exist, putting even more stress on families and the medical community – including primary care and emergency care clinicians.

Conversation & Perspectives –

  • The Psychiatry & Behavioral Health Learning Network shares highlights of the American Professional Society of ADHD and Related Disorders (APSARD) 2021 Virtual Conference plenary session on how COVID-19 is having a strong impact on children with ADHD – and is disproportionately affecting children in lower socio-economic backgrounds.
  • An article on C and G News points out that for some people, the COVID-19 pandemic has shined a spotlight on ADHD problems that have not yet been diagnosed. The lack of structure involved with working or going to school from home can make behaviors associated with ADHD more difficult to ignore.
  • A study in the Journal of Psychiatric Research found that children with ADHD are experiencing an increase in their symptoms during the pandemic. The researchers noted that children with ADHD are particularly at risk for depression and dropping out of school due to factors such as social isolation, difficulty with online learning, lack of motivation, and boredom.
  • @MichaelleAtCCC (Clay Community Mental Health Counseling) tweets: “Many kids w/ADHD have been trying to learn through virtual school due to COVID-19 but are struggling due to deficits in focusing. You can help an ADHD child be successful w/virtual school by creating a study place free of distractions like toys and open windows…”
  • @DrJPriceTrustee (Associate Professor, UVIC Faculty of Ed. ) tweets: “Psychologist notes increase of ADHD referrals during COVID-19 pandemic via @theoaklandpress.”
  • @nilikm (family doctor @UCL @Yale) tweets: “Parent: Can I increase my child’s meds? We aren’t coping in #COVID with their #ADHD. Screen time’s out of control, behaviour is scary. Me (family doc): Let’s talk about your family’s physical and #mentalhealth – are you all safe? Vulnerable kids ….”

In practice –

Psy-Q Challenge

How should clinicians respond when a parent is seeking a new ADHD diagnosis for their child during COVID-19? Randy Bressler, PsyD, answers.

Get the Answer

Addiction and Obsessive-Compulsive-Related Disorders: A New Consensus Framework on Criteria

What’s happening – Understanding, classifying, and treating addiction and obsessive-compulsive-related disorders (OCRD) has challenged clinicians for decades. In recent years, some progress has been made in understanding the trajectory of these psychiatric disorders but more meaningful ways to proactively address the biological mechanisms behind OCRD and prevent onset are needed. Today, many addiction and OCRDs diagnoses are based on superficial clinical observation rather than biologically valid criteria.

This gap prompted 90 international experts across disciplines to come together under the guidance of the National Institute of Mental Health Research Domain Criteria to create a uniform framework to define some key characteristics of addiction and OCRD. The participants formed two panels to agree on features shared by people with addiction and compulsions. They discovered some key constructs for each diagnosis and determined much overlap between both conditions, including response inhibition, habit, and compulsivity.

Understanding the self-regulatory and reward-fear circuitries involved in these factors is essential to guide new treatments that target essential transdiagnostic mechanisms. The expert group’s findings, which appear in JAMA Psychiatry, include the suggestion of using the core factors identified in addiction and OCRD and then taking steps to modify them. For example, when treating someone with ORCD who uses alcohol as a reward, clinicians could train the person’s response over a period of time to replace the alcohol with a healthy food choice or exercise as a reward. Such an approach holds promise for future interventions.

Why it’s complicated – There are few diagnostic tests that can capture an accurate picture of functional deviations at the earliest stage and map their developmental trajectory to guide clinical decisions and lead to treatments that can promote optimal outcomes. Developing and implementing such testing can be expensive and time-consuming, making it out of reach for most clinicians and patients. But the consensus framework authors point out that it’s important to begin moving in the direction of making such testing more accessible. They stress that the first step is recognizing the need to create a bridge between neuroscience and practice.

Conversation & Perspectives –

  • The International OCD Foundation shares a case study on a patient with co-occurring OCD and SUD and explores the current difficulties, and need, to treat both disorders at the same time.
  • An earlier study that appeared in Australian & New Zealand Journal of Psychiatry identified four constructs within the RDoC framework that cut across both addiction and OCRD.
  • The National Institute of Mental Health shares an important update to its Research Domain Criteria (RDoC) used as a framework to study mental disorders.
  • @NIMH_RDoC ( NIMH Research Domain Criteria) tweets about the framework paper: “What #transdiagnostic dimensions are relevant to understanding addictions & #OCD? @ProfYucel, @dr_ricolee, & field experts form a unifying consensus framework of biologically validated initiators of both, guided by the #RDoC framework…”
  • @Cemhri (Center for Mental Health Research & Initiative) shared the paper as well: “Consensus Framework for Treatment in Addiction and Obsessive-Compulsive-Related Disorders ….”
  • @StefanKertesz (physician/researcher) tweets: “Choosing is a part of the story we radically overlook in typical reiterations of the medical/brain disease addiction framework — I don’t mean ‘choose’ as judgmental either. Just that there is a human agency and a process that involves a person reasoning about their options.”

In practice – Drs. Ryan Vidrine and Owen Muir discuss the benefits of using deep transcranial magnetic stimulation for people with refractory OCD.

Behavioral Inhibition and Activation in Women with SUD and Depression

What’s happening – Substance use disorders (SUD) have been on the rise in recent years, and women with SUD are twice as likely as males to experience co-occurring psychiatric disorders, including depression. This statistic recently prompted researchers in China to try to better understand the relationship using the National Institute of Mental Health’s (NIMH) Research Domain Criteria (RDoC) framework. Their findings were published in Frontiers in Psychiatry (Xie J et al).

Looking at 300-plus women in a compulsory substance abuse detention center using several methods, the researchers determined that the subjects’ behavioral inhibition system (BIS) had a positive correlation with intolerance of uncertainty (IU) and a negative correlation with anhedonia (the inability to experience pleasure in daily life). Their behavioral activation system (BAS) also had a negative association with both anhedonia and depression. In addition, IU and anhedonia had a positive relationship with depression. These insights provide an important understanding of depression in women who have SUD and may help clinicians to better identify and treat the disorder.

The team further suggested that BIS and BAS may be strong indicators of different mechanisms related to depressive symptoms in women with SUD. For instance, BIS intensifies a person’s reaction to a threat and can lead to a more negative interpretation of ambiguous information. This can result in high IU, which increases depression. At the same time, BAS is related to reward-seeking. Thus, women with SUD and low BAS levels may have less motivation to seek out positive experiences and instead become stuck in anhedonia, which furthers depression.

Why it’s noteworthy –  Dr. Xie’s team efforts mark the first comprehensive empirical study using the NIMH RDoC framework to look specifically at the roles of the BIS, BAS, IU, and anhedonia on women with depression and SUD.

Conversation & Perspectives –

  • An article in Middle East Current Psychiatry calls attention to the fact that SUD is related to severe depression and anxiety and the severity of the drug-related problems seems directly related to the levels of anxiety and depression.
  • NIDA looked at common comorbidities with SUDs and pointed out that multiple studies have captured the fact that approximately half of all people with a mental illness diagnosis will also experience SUD.
  • A study exploring BIS and BAS in college students found a strong correlation between these factors and substance use. Specifically, the scientists discovered a relationship between BAS Fun Seeking and the extent of illegal substances used, the number of alcoholic drinks consumed, and the frequency of binge drinking.
  • NIDA also shared a research report exploring sex and gender differences in SUD treatment and finds that the progression of SUD varies by gender. In fact, the authors point out that women who enter substance abuse treatment are already experiencing more severe effects, including physical, behavioral, psychological, and social problems. This is because females progress from using a substance for the first time to becoming dependent more quickly than males.
  • @AHappierMe2 (community engagement effort) tweets: “When it comes to mental illnesses, gender has its specific role. Women are more likely to be diagnosed with mental illness like anxiety and depression, while men tend to lean toward substance abuse and antisocial disorders…”
  • @mawsmanitoba (network supporting women and children who experience violence) says: “Women who have experienced domestic violence or abuse are at a significantly higher risk of experiencing a range of mental health conditions including post-traumatic stress disorder (PTSD), depression, anxiety, substance abuse, and thoughts of suicide.”
  • @Solutionsofcha1 (nonprofit counseling organization) says: “WHO reports that ‘Depression, anxiety, psychological distress, sexual violence and escalating rates of substance use affect women to a greater extent than men across different countries and different settings….”

In practice – Gender is not the only risk factor for substance abuse. Age also makes a difference. See highlights from the most recent Psych Congress on the role age plays in vulnerability.

Last Updated: Apr 27, 2021