BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is a complex condition where children find it difficult to concentrate or are hyperactive and impulsive. There are no studies on its prevalence in Sri Lanka¹, although one in 20 school children are affected by ADHD1. Young individuals with ADHD are particularly at risk due to their vulnerability to unpredictable and complex changes, exhibiting symptoms such as angry outbursts and deteriorated daily routine. In order to support the wellbeing of children during challenging times, it is essential to understand the family processes as well as the protective and risk factors in their home environment ².

Green Memorial Hospital, Manipay (GMH), was the first medical school established in Sri Lanka and has been rebuilt and reactivated after a prolonged period of civil war. The Gabriella Rasiah Memorial Paediatric Centre at GMH provides care to children with neurodevelopmental delays free of charge.

SARS-CoV-2 is a newly emerging human infectious coronavirus that causes COVID-19, resulting in the ongoing global pandemic4. The government of Sri Lanka had implemented stringent lockdown and a nationwide curfew as public health measures to control the spread of the COVID–19 during the early part of the epidemic.

This article aims to highlight the impact of the COVID-19 pandemic restrictions on a child with ADHD and the innovative methods adopted to manage the child at a pediatric centre with limited resources.

INTRODUCTION OF THE CASE

A nine year old female child who was initially identified by the team in a school-based special education unit was referred to GMH.  After the initial assessment, the team at the pediatric centre arranged the delivery of several interventions, including speech and occupational therapies, shallow teaching, and Art/Dance therapy. The child progressed well with the therapies and was able to bathe herself partially, wash after toilet, and eat on her own.

The effects and management of quarantine due to COVID- 19

The progress of this child was unfortunately interrupted by the restriction imposed during the lockdown period due to COVID- 19. Social restrictions that have been put in place to reduce the spread of the virus have been shown to impact on the mental health and well-being of the population⁵. The situation is further confounded in children with ADHD. The team adopted as far as possible the measures suggested for ADHD management during the COVID-19 pandemic by guidance from the European ADHD Guidelines Group⁵.

The mother of the child reported that the emotions of the child varied during lockdown from feeling angry, sad, worried, and frustrated. She was withdrawn and clingy, more emotionally reactive, and had more trouble with getting ready for the day, having sleep and eating regular meals. She did not enjoy spending time at home and found it very challenging to adapt to the new environment. At one-point, the mother was quite helpless, struggled to manage the child and pleaded with us to increase the doses of her medication or even to add new medications.

We made regular telephone calls to ensure the prescribed medications were given.  It was pleasing to note that the mother also played her part by setting a regular schedule to go to bed and wake up early to help the child. We also encouraged them to follow a structured daily living and also to ensure that she was getting a healthy diet with an adequate intake of fluid. We tried our best to intervene before any challenges arose, and to avoid punishing the child for any adverse behavior and to communicate with her in a straightforward language and listen to her concerns.

The children with ADHD may benefit from occupational therapy, and sensory integration therapy. The occupational therapist helped the child to improve certain skills, such as organization, physical coordination, ability to do everyday tasks, and control her energy levels, and hyperactivity at home.

Whenever the child seems to be bored, parents were asked to join with various activities such as artwork, imaginary play, jump rope, catching or kicking the ball, reading, dancing, listening to music and setting up activity stations (e.g., book area, drawing area, physical activity area), and also discouraged to watch television.

We also worked directly and closely with the parents, by ensuring that they received a sustainable service during the lockdown. We particularly carried out regular motivational interview with parents of the child to provide self awareness, goal setting, problem solving, and decision making. Our overall aim was to provide an integrated service to both the parents and the child

Lesson learnt:

The COVID-19 pandemic has threatened even the most developed healthcare systems of the world. However, some countries were able to respond to the threat in a positive way without burdening their own healthcare systems⁶. Covid 19 has created an unprecedented effect on society and its way of living and an even greater impact on children with neuro developmental delays. The management of these children has been hampered by the lack of face to face interactions. We used various alternative measures to manage the well-being of the child. During the Covid-19 restrictions, we had to stop face-to-face appointments, and it had been challenging to ensure adequate physical monitoring without face-to-face reviews even though we continued with telephone and video consultations through the use of mobile phones. The situation provided a good learning experience to minimize the effect of the pandemic on children with ADHD. This learning experience has made us to think about alternative solutions even in the post Covid environment. We started to train the mothers to operate real-time chatting methods to carry our supportive consultations effectively using available technologies to improve interactions This type of training also helps the patients to have a more frequent and regular interactions with their care providers. Another advantage for the mothers is to minimize the travel cost and improve their self-confidence in handling the children at their home. 

CONCLUSION AND RECOMMENDATION

This case study highlights that the successful way of providing care and support for the child and the family when the services for normal face to face services are disrupted for children with chronic disorders like ADHD.  It also emphasizes the practicality of applying these methods in poor resource settings. We also attempted to show that the mothers could be empowered to handle their children if they are guided remotely through the modern mobile and video conferencing technologies. Adopting this kind of techniques may reduce the cost of care, especially for the parents of children with chronic diseases and could also reach many children in  remote areas if the coverage of the network services could be attained.  Lessons learnt during the Covid 19 pandemic can enhance productivity and quality of care in the Post Covid world.

REFERENCES

1. Kariyawasam SH., Koralagama A, Jayawardane P, Karunathilake B, Perera V and Perera H. A descriptive study of attention deficit hyperactivity disorder (ADHD) at Lady Ridgeway Hospital for Children, Colombo, Sri Lanka Journal of Child Health.2002; 31: 109-114
2. Wang G, Zhang Y, Zhao J, Zhang J, and Jiang F. Mitigate the effects of home confinement on children during the COVID-19 outbreak. Lancet. 2020; 395: 945–947. doi: 10.1016/S0140-6736(20)30547-x
3. World Health Organization,Coronavirus disease, Covid-19 situation report 51. 2020
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5. Marasinghe RB. Telehealth - bringing healthcare to one’s doorstep:How ready is Sri Lanka?/ Sri Lanka Journal of Bio-Medical Informatics 2010;1(3):124-38
6. Ghanizadeh A. Sensory processing problems in children with ADHD, a systematic review. Psychiatry Investig. 2011;8(2):89-94. doi:10.4306/pi.2011.8.2.89