Susan McLaughlin's 12-year-old daughter, Isabela, was a straight-A student before the pandemic. Isabela, who lives in a suburb of Columbus, Ohio, excelled at science and math and was already getting high school credit for algebra.
But when her school shut down in March and classes shifted to Zoom, Isabela's grades took a nosedive. She signed on for her virtual class from a desk piled high with books, papers and stuffed animals and then spent hours trying to clean her room instead of focusing on schoolwork. She found herself "paralyzed" by assignments, McLaughlin said, but she wouldn't tell the teacher over email that she was struggling, as she would have done in person.
"It was meltdown after meltdown after meltdown," said McLaughlin, 53, a mother of three from Delaware, Ohio, who works in a high school with chronically truant children.
McLaughlin recalls one time in April when Isabela, who was already diagnosed with severe anxiety, was given a language arts assignment and "fell to pieces."
"She was crying and screaming and hyperventilating and started to get some tics, moving her head and flapping her arms. She had never had them before. That's when we started to consider that it might be ADHD."
McLaughlin spent months trying to bring more structure to Isabela's day by writing lists, schedules, timelines and checkboxes. But as someone who was diagnosed with attention deficit hyperactivity disorder herself a decade ago, McLaughlin realized that she was seeing the same behaviors in Isabela. She thought, "I've got to nip this in the bud."
Isabela is being evaluated by a psychiatrist, a process that takes several hours and requires her teachers to fill out questionnaires about her behavior. McLaughlin hopes that with an ADHD diagnosis, Isabela will be able to get a prescription for a stimulant medication — such as Ritalin, Adderall or Vyvanse — to alleviate her symptoms.
"I know it's super controversial sometimes. But I've been medicated for a long time, and I can't function without taking it," McLaughlin said. "If I don't take my medication, I see an immediate difference in my ability to manage complex tasks, clean the house, get up and cook dinner. So I'm hoping it will have the same effect on her."
McLaughlin isn't alone in seeking an ADHD assessment for her child during the pandemic. Two dozen children, pediatricians, psychiatrists, psychologists and researchers all described a crisis among children suffering from inattention and tanking school performance.
Data from specialists involved with diagnosing and treating ADHD show just how much parents are struggling to get help: They are flooding an ADHD support line with questions, and ADHD diagnoses and prescriptions for related medications have soared.
"Covid has been a tipping point that has pushed some families to get help," said Dr. Melvin Oatis of the American Academy of Child and Adolescent Psychiatry, who said the stress of the pandemic, the shift to remote learning and social isolation have created "anxiety-provoking" conditions that affect students' attention.
Experts warn that children who appear to have symptoms of ADHD should have thorough evaluations to rule out other conditions or stresses related to the pandemic before they seek medication.
"Our concern is that pediatricians and families be very careful to not simply list the symptoms of ADHD, but to look at the child's history and use differential diagnosis to make sure we have the best possible explanation for the symptoms," said Dr. Arthur Lavin, a Cleveland-based pediatrician who has served on several national committees of the American Academy of Pediatrics.
In the meantime, parents are seeking any help they can find. The number of parents calling a help line set up by CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), a nonprofit that supports people with ADHD, rose by 62 percent since the pandemic started, the organization said. Traffic to its website last year grew by 77 percent compared to 2019.
"We're getting a lot of calls from caregivers who are working at home alongside their children and starting to see more issues with their behavior than they did before," said April Gower-Getz, CHADD's chief operating officer.
They're certainly trying to get their children evaluated more frequently. The Child Mind Institute, a New York-based nonprofit that helps children with mental health disorders and their families, recorded a 20 percent increase in the number of appointments to discuss medication last year compared to 2019. The "lion's share" of the appointments were to discuss medication for ADHD, said Dr. Harold Koplewicz, the institute's founder.
And more parents are getting their children diagnosed and treated with medication for ADHD.
Athenahealth, a technology company that creates practice management software for health care providers, published research in May, drawing on data from its customers, that showed an increase in patients ages 13 to 17 who received new diagnoses of ADHD. From the week of March 9 to the week of March 30, the proportion of visits by teenagers that involved first-time ADHD diagnoses rose by 67 percent. There was a similar spike among teenagers — particularly boys — who received prescriptions for ADHD medicines for the first time.
The cases also seem to have picked up in recent months, said psychologist Keith Sutton, director of the Bay Area Center for ADD/ADHD. He said he had a "sharp increase" in inquiries during the fall.
"Before the summer, everyone was just trying to get through those months," Sutton said. "Then, in October, when grades were coming back, parents were thinking we're in it for the long run, something is going on here and we need help."
Experts attribute the increase in inquiries to a variety of factors, including the loss of structure and accommodations in the classroom setting.
Parents are also seeing their children's troubles during school hours firsthand. Dr. Devang Patel, a family medicine physician in Illinois who specializes in ADHD, is one of several clinicians who said he is fielding more requests from parents for medication for their children.
"When the problem was in front of the teachers, it wasn't really the parents' concern," Patel said. "But now they are at home trying to make their kid sit still for just half an hour and seeing how difficult that is."
Children also miss the school environment, which helped ameliorate such issues. Dr. Jenny Radesky, a Michigan-based developmental behavioral pediatrician, said she has started prescribing stimulants for children as young as 5 and 6 this year. Their ADHD symptoms were manageable in supportive classrooms with flexible teachers, sensory tools and clear routines. But when those structures went away in March, their symptoms flared up.
"I'm watching kids who used to love school become unenthused and unmotivated," said Radesky, who said she was worried about the long-term impact of virtual learning. "They need the social environment at school to learn how to regulate themselves. Without that, they are really struggling."
Sasha Harris-Cronin's 8-year-old son, Z (he chose his own name when he was 6), who is in the third grade, was diagnosed with ADHD in 2019 but didn't start medication until last August.
Before the pandemic, Z's school provided accommodations, like seating him directly in front of the teacher, where he wouldn't be distracted, and making sure he ran around outside during recess.
Harris-Cronin said the shift to Zoom for Z was "awful."
"It was so difficult. There were so many tears," she said. Z missed the structure of school and couldn't focus on Zoom classes. He would take an hour to write four words of a writing assignment. Days would go by when he got "absolutely nothing" done.
When she and Z realized that they were "looking down the barrel of another year like this," they visited a psychiatrist, who prescribed Ritalin and Metadate.
"It was mind-blowing," Harris-Cronin said. "He wrote a poem the first day. It's not a miracle cure. But boy, is it an effective tool."
Jahkim Hendrix, 18, of Atherton, California, suspected that he had ADHD for many years. But he didn't get formally evaluated until late last year, during his senior year of high school. He had been falling behind academically the previous year, and when the schools closed in March, it didn't take long for him to "give up completely."
"The teacher would be speaking and I'd go blank," he said, adding that students objected to putting their cameras on for their teachers, which made them — and him — even less accountable. "I would mute my teacher and go on TikTok and stay there for hours. That's what sustained my attention."
He barely passed his junior year of high school, and his grades slid from Ds to Fs as he started his senior year last fall. He and his mom, who was also diagnosed with ADHD as a child, decided it was time to seek help. It took two months to get an appointment with a psychiatrist, who evaluated him for over five hours in mid-December.
In late January, he was diagnosed with ADHD.
"I cried with relief," he said. "I have always been told I have high potential but low performance, and I didn't know why. Now I have a name to the thing that I'm facing, as well as tools and resources to help me."
Many experts said parents and clinicians need to be extra cautious about diagnosing ADHD during a pandemic because a child might show more signs that meet the criteria for the disorder. A diagnosis simply needs six or more symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, the book of mental disorders recognized by the American Psychiatric Association. They include making careless mistakes, struggling to stay focused on tasks, having trouble organizing activities, not following through on instructions, avoiding schoolwork, losing items and being easily distracted.
"The pandemic has substantially disrupted the routines of every family, and that is going to make a good number of children feel like they can't pay attention so well," said Lavin, the Cleveland pediatrician. "ADHD might be one of the explanations, but only one. But the stress of a pandemic may also cause inattention."
Medical experts say someone with ADHD was very likely to show signs before the pandemic began. Both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry recommend lengthy evaluations that take in children's full developmental histories, surveys parents and teachers and compares symptoms to peers their own ages and genders.
A 15-minute office visit with a pediatrician isn't long enough to rule out other causes of inattention, such as anxiety, depression and problems at home, said Sutton of the Bay Area Center for ADD/ADHD.
As many schools remain closed, some experts said they were concerned about the long-term impact of remote learning for young people with ADHD, particularly teenagers.
Maggie Sibley, a psychologist and researcher at the University of Washington and Seattle Children's Hospital, has written a research paper, accepted by the Journal of Psychiatric Research, showing that symptoms are worsening and stress levels are skyrocketing among adolescents and young adults with ADHD during the pandemic. That has prompted numerous problems, including social isolation and disengagement from class.
"A person with ADHD typically has fewer friends and less social activities in their calendar," she said. "A lot are getting their only social interactions at school."
Students with ADHD were at particular risk of depression and dropping out of school, the study concluded.
"If you are in a situation where you are experiencing chronic boredom, getting poor grades in school, socially isolated and stuck in a house, it's a recipe for depression," Sibley said. While suicide isn't an inevitable result, "we have to be vigilant down the road, especially since we know from research that when people with ADHD get depressed, they are more likely to make suicidal gestures because of their impulsivity."
Susan McLaughlin will find out whether Isabela has ADHD at a follow-up appointment with the psychiatrist on Tuesday. While they wait, Isabela continues to battle with her assignments, particularly on Thursdays and Fridays, when class is entirely self-directed.
"I just want her to be everything she can be, a happy, well-adjusted 12-year-old — or as well-adjusted as anyone can be at this point."