Behavior changes in children/adolescents with attention deficit hyperactivity disorder during the COVID-19 pandemic: a systematic review

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.


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. 1,2In 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. 3n 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. 4Children and teenagers with Attention Deficit HyperactivityDisorder (ADHD) arepotentially more vulnerable to the negative repercussions of the containment and coping measures of the pandemic. 5here 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. 6However, there was no systematic worsening of their symptoms during social isolation asthe external environmentcould be a source of conflict and stress. 7Thus, social isolation could be relatedtoboth positive and negative impacts on the health of children and teenagers living with ADHD. 8iven 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). 9Based 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 PECOS 10 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 Rayyan 11 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.

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.
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). 19According 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.
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. 7,18When 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. 18n comparison to the other studies, three evaluated variables of changes related to sleep and physical activity, quantified from the perspective of the parents. 8,15,16Then 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. 8,15,16egarding 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. 8,16in 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][14][15][16][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 ADHD 7 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. 12,13,18egarding the assessment instruments, six studies did not use standardized tools for the diagnosis of ADHD and comorbid conditions. 7,8,13,14,16,17[16][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. 20,21,22tudies have described an association between ADHD and poor emotional regulation as a risk factor for

QCD, TABS, ADHD-RS, ODBI, DSRS e SCAS
In elementary school students, there were no significant differences in the TABS, ADHD-RS, ODBI, DSRS and SCAS scores between the two groups.In high school students, there were no significant differences in TABS, ODBI, DSRS and SCAS scores between the two groups.The "ADHD-RS" scores indicating ADHD symptoms were 16.78 ± 12.69 in the case group and 11.80 ± 10.40 in the control group.In elementary school students, the QCD scores indicating functionality or disability during school hours were 3.31 ± 2.52 in the case group and 4.52 ± 2.33 in the control group.For high school, there were no significant differences in QCD scores between the two groups.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. 6,8The children's groups, especially those with ADHD, had emotional symptoms and conduct problems, presenting behavioral changes associated with social isolation measures. 23her indicators of decreased in mental health were reduced sleep quality and physical activity, 8,15,16 as well as increased use of digital technologies. 8,16There is also greater vulnerability to develop sleep disorders in children and teenagers with ADHD due to the pandemic period. 24n addition, physical activity promotes improvements in ADHD symptoms in children, such as attention to domains of executive functions. 25However, 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. 23t 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. 26n 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. 23,25,26egarding 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 questionnaire 7 and analysis instruments 19 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. 7It 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.

Table 1
Synthesis of search strategies.
• (Child and Attention deficit hyperactivity disorder) • (Social Isolation or Physical Distancing or Quarentine or Lockdown) • (pandemics or COVID-19) • Mental health • Quality of Life • Child Development

Table 2
Characteristics and main findings of the selected studies.