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Impact of COVID-19 on lifestyle habits and mental health symptoms in children with attention-deficit/hyperactivity disorder in Canada

Abstract Objectives The COVID-19 pandemic created an environment of restricted access to health and recreation services. Lifestyle habits including sleep, eating, exercise, and screen use were modified, potentially exacerbating adverse mental health outcomes. This study investigates the impact of COVID-19 on lifestyle habits and mental health symptoms in paediatric attention-deficit/hyperactivity disorder (ADHD) in Canada. Methods An online survey was distributed across Canada to caregivers of children with ADHD (children aged 5 to 18 years) assessing depression (PHQ-9), anxiety (GAD-7), ADHD (SNAP-IV), and lifestyle behaviours. Data were analyzed by gender (male/female) and age category (5 to 8, 9 to 12, and 13 to 18 years). Spearman’s correlations between lifestyle habits and mental health outcomes were conducted. Results A total of 587 surveys were completed. Mean child age was 10.14 years (SD 3.06), including 166 females (28.3%). The PHQ-9 and GAD-7 indicated that 17.4% and 14.1% of children met criteria for moderately severe to severe depression and anxiety symptoms respectively. Children met SNAP-IV cut-off scores for inattention (73.7%), hyperactivity/impulsivity (66.8%), and oppositional defiant disorder (38.6%) behaviours. Caregivers reported changes in sleep (77.5%), eating (58.9%), exercise (83.7%), and screen use (92.9%) in their ADHD child, greatly impacting youth. Sleeping fewer hours/night, eating more processed foods, and watching TV/playing videogames >3.5 hours/day correlated with greater depression, anxiety and ADHD symptoms, and exercising <1 hour/day further correlated with depression symptoms (P<0.01). Conclusions The COVID-19 pandemic has resulted in less healthy lifestyle habits and increased mental health symptoms in Canadian children with ADHD. Longitudinal studies to better understand the relationship between these factors are recommended.

Attention-deficit/hyperactivity disorder (ADHD) is a childhood onset neurodevelopmental disorder characterized by inappropriate levels of inattention and/or hyperactivity and impulsivity (1). Prevalence estimates range from 5 to 9% with a recent meta-analysis reporting a pooled estimate of 7.2% in children up to 18 years old (2,3). Children with ADHD receive significantly more psychiatric diagnoses including anxiety and depression; approximately half have a learning disorder, and 50 to 70% experience difficulties with peer relationships leading to lower quality of life reports in children with ADHD compared to their typically developing peers (4)(5)(6)(7).
The World Health Organization (WHO) announced the COVID-19 pandemic on March 11, 2020, which led to provinces across Canada mandating school and business closures, encouraging children and adults to stay home (8,9). Recreation facilities including access to teams and clubs were suspended, and provincial and national parks were closed to public access. Previous research has suggested that such isolation procedures are particularly impactful in children and youth, leading to increased prevalence of anxiety and depression, and possible increases in suicide due to stress and loneliness (10,11). A recent parent survey in China (241 respondents) reported that the average behaviour of their child with ADHD, including the abilities to focus, manage anger and routines, was significantly worse during the COVID-19 pandemic (12). A Japanese study (15 children) showed increased hyperactivity/impulsivity and inattention scores during the pandemic (April/May 2020) compared to baseline (February/March 2020) (13). A study from France (533 respondents) found that 35% of ADHD children experienced worsening of wellbeing between days 20 and 30 of the country's lockdown, 34% showed no change, and 31% were doing better (14). Isolation impacts children differently with some struggling due to lack of peer support, and others showing improvement due to reduced anxiety, peer pressure, and exposure to bullying (15).
The COVID-19 pandemic is an unprecedented example of societal restrictions with mental and physical health implications. Restrictions have impacted regular routines, modifying factors including sleep, eating, exercise, and screen use, potentially exacerbating adverse mental health outcomes (16). Children with ADHD often require medical, therapeutic, and educational support to succeed in education and peer situations (17). Therefore, these children may be at high risk for adverse mental health and behavioural outcomes when access to services is restricted. The objective of this study was to understand the impact of the COVID-19 pandemic on lifestyle habits, mental health symptoms, and ADHD behaviours in children with ADHD in Canada.

METHODS
A survey with 113 questions related to family demographics, mental health, quality of life, and lifestyle habits was created in Qualtrics XM . Inclusion criteria were 1) caregiver of a child with ADHD, 2) child aged 5 to 18 years, 3) ability to read and write English, and 4) lives in Canada. The survey was advertised through social media (Facebook, Twitter), University of Calgary affiliated websites, and direct email messages to ADHD families in Alberta (permission to contact database) and ADHD clinics across Canada. Mental health questionnaires included the Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and the Swanson, Nolan, and Pelham (SNAP-IV) 26-question scale (18)(19)(20). Lifestyle questions were created by the study leaders to capture changes in sleep, eating, exercise, and screen use behaviours based on experience working with ADHD children. A daily activities table with the same activity categories as the United Kingdom Co-SPACE study was included (21). The survey was available over a period of five weeks (May 11 to June 15, 2020), and responses at least 90% complete were included in analyses (587 of 663 submissions retained). A response of 587 exceeded the minimum sample size (n=384) required to represent the paediatric ADHD population of Canada (430,000 children), based on a sample size calculation (95% confidence interval, 5% margin of error) (3,22,23).
The Statistical Package for the Social Sciences (SPSS) version 26.0 was used to conduct all the data analyses. The data were inspected for missing values and outliers prior to running any statistical analyses. The data were also evaluated for normality, linearity, and homogeneity of variance to meet the assumptions of parametric analysis. Chi-square tests were conducted between gender (male and female) and age categories (5 to 8, 9 to 12, and 13 to 18 years) for categorical variables. Spearman's correlations were conducted between lifestyle variables and mental health symptoms. Summary data are presented in this article (the complete dataset is available upon request to the corresponding author). The study was approved by the University of Calgary Conjoint Health Research Ethics Board (REB20-0672).
Sleeping fewer hours/night, eating more often and more processed foods were each positively correlated with the PHQ-9 and GAD-7 total scores (P<0.01). Reduced sleep was further correlated with greater hyperactive/impulsive and ODD scores, and caregiver reports of increased depression, anxiety and ADHD symptoms during the pandemic (P<0.01). Eating more processed food correlated with higher inattention and ODD total scores, and caregiver reports of increased ADHD behaviours (P<0.01). Exercising <1 hour/day correlated positively with the PHQ-9 (P<0.01) but negatively with the hyperactive/impulsive (P<0.05) score. Finally, watching TV/ playing videogames >3.5 hours/day correlated positively with the PHQ-9, GAD-7, inattention and ODD total scores, and parent reports of increased depression symptoms during the pandemic (P<0.05 to 0.01).

DISCUSSION
This study indicates that the COVID-19 pandemic impacted lifestyle habits and mental health symptoms in Canadian children with ADHD. Approximately one-fifth of children met criteria for moderately severe to severe depression and/or anxiety symptoms, with a significant number of caregivers reporting an increase in their child's symptoms during the pandemic. Correlations were observed between less healthy lifestyle habits and adverse mental health outcomes, which is an important consideration because lifestyle behaviours are modifiable. Therefore, resources to support healthy lifestyle choices in paediatric ADHD may prevent adverse mental health outcomes in times of stress, such as during a pandemic.
Approximately one-third of caregivers reported changes in access to therapy and medication dosage during the pandemic. Upon lockdown measures due to COVID-19, health clinics across Canada halted preventative services, hospitals restructured to provide only emergency services, and pharmacists restricted medication refills for fear of viral spread and/or inability to obtain medical supplies (24)(25)(26). These restrictions increased caregiver stress and burden to manage their child's wellbeing. European guidelines for ADHD management during the pandemic recommended virtual technologies for initial assessments, psychoeducation and follow up, e202 and encouraged parents to plan ahead to acquire prescriptions (27). However, planning during a pandemic is difficult, and one-tenth of caregivers reported difficulty filling their child's prescription, which may have contributed to medication changes. In addition, some children were doing well at home, such as those with social anxiety, while others were exhibiting increased ADHD behaviours, and these symptom changes likely contributed to medication modifications. Gender and age differences in symptom profiles, including more males exhibiting increased ADHD behaviours and more young females showing increased anxiety symptoms, may have been a result of, or contributed to treatment changes, but additional inquiry is needed. Previous research has suggested that child health outcomes are worse for children of highly distressed caregivers (28). Recognizing that supportive, responsive parenting can play important protective roles against adverse mental health outcomes in children with ADHD, the Canadian Paediatric Society published guidelines for parent self-care and managing child ADHD during the pandemic (29,30). These guidelines emphasize the importance of routines, sleep hygiene, physical activity, and social connection, as an increase in ADHD behaviours due to pandemic restrictions can adversely impact social distancing requirements and family functioning (27).
Lifestyle factors were significantly impacted during the pandemic with less healthy behaviours correlating with higher depression, anxiety, and ADHD symptom scores. Eating processed foods and high screen use correlated positively with inattention and ODD behaviours, and reduced sleep correlated positively with hyperactive/impulsive and ODD behaviours. A recent systematic review found that junk food consumption exacerbated ADHD symptoms, and a review of screen use in children reported associations between ADHD behaviours and screen time, showing increased attention problems with increased TV viewing/ videogame playing (31,32). Screen use has been linked to sleep problems in children including shorter sleep duration and delayed sleep timing, which has been associated with increased ADHD behaviours (32)(33)(34). Therefore, the increased likelihood of adverse mental health outcomes with high junk food consumption, screen use and disturbed sleep supports Canadian food and activity guidelines of minimal processed food consumption, ≤2 hours of daily recreational screen time, and 8 to 12 hours of nightly sleep to prevent increases of ADHD behaviours and mental health symptoms (35,36). Physical activity was greatly modified during the pandemic, with half of caregivers reporting decreased athletic activity in their ADHD child. Low physical activity correlated positively with depression symptoms, a result also reported in a Chinese study that showed higher physical activity was significantly related to higher positive mood in youth during the pandemic (37). A recent meta-analysis of physical activity in paediatric ADHD reported significant improvements in depression, anxiety and aggressive behaviours due to physical activity intervention, and nonsignificant improvements in hyperactive/impulsive and inattention symptoms (38). Recognizing the importance of physical activity (i.e., to reduce symptoms of depression and anxiety, enhance learning, and prevent/manage noncommunicable disease), the WHO recently published guidelines that children and youth (≥3 years) should average 60 minutes of moderate to vigorous physical activity each day (39). A recent editorial recommended monitored playground access, street closures, trainer-led outdoor exercise, and  at-home guided exercise through video platforms to encourage physical activity (40). In addition, active-play video games have been shown to improve physical activity in adolescents, which may be an effective approach to increase physical activity in children during a pandemic (41). A recent Canadian study found that children who met seven to nine of nine lifestyle recommendations (e.g., food intake, physical activity, and screen use guidelines) at ages 10 to 11 years had a 62% lower incidence of ADHD diagnosis by age 14 than children who met one to three recommendations, suggesting correlation between lifestyle factors and development of ADHD behaviours (42). Research has shown lower physical activity and reduced fruit and vegetable intake in winter months (43,44), highlighting a need ѱ ѱ ѱ Figure 1. Average daily time ADHD children were spending on screens (A-D) and doing physical activity (E,F) during the pandemic. Youth aged 13 to 18 years (N=127) spent the most time on *audio/video calls (χ 2 (4)=62.731, P<0.001), **email/text messaging (χ 2 (4)=92.278, P<0.001), and ***playing video/computer games (χ 2 (4)=29.1000, P<0.001). In contrast, children aged 5 to 8 years (N=197) spent the most time doing ѱgentle (χ 2 (4)=48.378, P<0.001) and ѱ ѱ moderate to intense physical activity (χ 2 (4)=39.231, P<0.001).
Paediatrics & Child Health, 2021, Vol. 26,No. 5 e205 to support healthy movement, food, screen use, and sleep behaviours through Canadian winters. In summary, caregiver education, community supports (e.g., respite, coaches), access to recreational spaces and healthy, affordable foods might prevent and potentially alleviate adverse mental health outcomes in paediatric ADHD. The strengths of this study include sample size (highlighting an interest in ADHD research in Canada), a representative ADHD population (e.g., ethnicity, household income, gender) and the ability to reach remote communities. The limitations of the study included the following: 1) the self-selecting nature of recruitment, 2) families who were struggling less were likely more able to complete a 30 to 45-minute survey than families in crisis, 3) Alberta and Ontario represented the majority of survey responses, and 4) the child's perspective was not captured.
In conclusion, the COVID-19 pandemic has resulted in less healthy lifestyle habits and increased mental health symptoms in Canadian children with ADHD. Longitudinal studies to better understand the relationships between these factors are recommended, including possible protective effects of healthy lifestyle interventions.