Attention deficit hyperactivity disorder is a pervasive and crippling disorder that affects multiple areas of life, including academic, social, and family relationships. Compared to the general population, children with ADHD are more likely to have parents with major interpersonal conflicts, family strife, and parental psychiatric conditions . The complications linked to ADHD are further intensified by comorbid problems in more than 50% of the patients, including significant behavioral and emotional symptoms .
Coronavirus disease 2019 (COVID-19) pandemic resulted in a total shutdown in many countries, including Egypt. Subsequently, the schools were closed as a part of the lockout. Children are supposed to stay all the time inside their homes. It is understood that ADHD children can be particularly difficult to keep within the house in a condition like a lockout. They could be a continuous cause of disruption for family members, and families can also have difficulty managing them . The study of Coghill et al.  and Yousefia et al.  believed that raising a child with ADHD is a great stress for parents. In normal circumstances, what about the frustrating situation associated with the COVID-19? We aimed in our study to assess symptoms of anxiety, depression, and stress symptoms among the mothers of ADHD children and adolescents during COVID-19 outbreaks and determine the relationship between these symptoms and the changed circumstances that occurred by the COVID-19 pandemic, also with the behavioral problem of their children that may deteriorate by their mothers’ psychological state. We conducted our study on 54 participants of the mothers of ADHD patients. Our research identified that (22%) of the participating mothers lost their work because of COVID-19, while 14.8% of the fathers lost their job because of COVID-19. Also, we found that the COVID-19 pandemic has a big financial drawback on the family of our participants by a percentage of 31.5%.
According to research carried by the Social Policy Institute at Washington University on 5500 participants in 2020, 24% lost their jobs or incomes as a result of COVID-19, and 46% of low-income individuals recorded trouble paying their mortgage after the epidemic started, with roughly 32% saying it was hard for them to support their families. Around 20% of middle-income individuals had to deal with these issues .
Our findings showed that 46.3% of our sample documented the presence of domestic violence toward them compared to before COVID-19. This was in line with the UN’s global alert about the rise in domestic violence toward females. In France, they recorded that abuse against women is said to have risen by 30% during the first episode of lockdown . We showed a statistically significant association between the symptoms of depression and stress of our participating mothers and the domestic violence toward them, which was increased compared to before COVID-19. There is an epidemiological relationship between anxiety, depression, mental illness, adverse life experiences, and a bad relationship with a partner .
Our results showed that the mothers of ADHD children have bigger challenges in the management of the child’s meals, structured activities, and sleep as compared to before COVID-19, according to Owens JA, who recorded that sleep problems, especially in the beginning and sustaining sleep, are generally found in children and adolescents with ADHD . Pagoto et al.  demonstrated that ADHD patients had difficulties monitoring their diet. Davis et al. reported that ADHD is positively correlated with “unhealthy” food consumption that is hard to handle .
We found that mothers of ADHD children have increased levels of depression, anxiety, and stress symptoms, which were associated with lost family members and the presence of significant financial drawbacks due to COVID-19, domestic violence toward the mother compared to before COVID-19, and the mother’s assessment of the period of change and restrictions as being very demanding.
Since the start of the COVID-19 pandemics, 45% of parents have reported increased caregiver burden, according to a study published in pediatrics. The percentage of parents who said they were in a bad mood part of the time increased from 10 to 33% of the time, and the number of parents who said they were in a bad mood all day increased from 9 to 29% of the time .
Moreover, the mother’s depressive, anxiety, and stress symptoms were associated with the non-compliance of the ADHD children on treatment compared to before the epidemic. Subsequently, we found an association between these symptoms and the increased conduct, learning, psychosomatic, impulsive hyperactive, anxiety problems in their children compared to before COVID-19, which was expected as many studies showed that internalizing and externalizing problems of the children increased in depressed mothers. Also, maternal depression affected the development of both conduct and depressive symptoms in ADHD children [37, 42].
A study showed that depression of the mothers unenabled them to respond correctly to the non-compliant behavior of their ADHD children result in more behavioral problems in those children with deterioration of their condition .
The study of Sanders identified that the mother’s psychological state affects her role and, subsequently, her children’s behavior. In one study, they found that anxious mothers were associated with hyperactivity and aggression among their children .
According to Yusefi’s research, some symptoms of ADHD were correlated with an increase in parent/child conflicts. Additionally, ADHD has been linked to maternal stress .
Costin discovered a strong correlation between hyperactivity in children and maternal anxiety, stress, and depression .
This study revealed that the period of change and restriction related to COVID-19 was associated with worsening of ADHD symptoms in the form of increased conduct, learning, impulsive hyperactive, and particularly the psychosomatic and anxiety problems in these patients during the pandemic as compared to before it. Furthermore, the problems remained in a large number of children. Just a few children showed any improvement in their behavioral difficulties over the lockdown time. ADHD patients have poor tolerance for ambiguity, making it difficult for them to follow instructions and comprehend the complexities of the pandemic scenario. According to Cortese et al., the imposed situation at home and the hostile setting, which alters their usual pattern, may raise the likelihood of more severe hyperactivity and impulsive behaviors. Also, this worsening of symptoms is consistent with the disorder’s nature and the constraints enforced as part of the shutdown .
In line of our results, Zhang and colleagues’ study found that children’s ADHD symptoms significantly deteriorated during the COVID-19 pandemic compared to their normal state . Also, inconsistent with the study of Shah, R. and colleague, who found that the lockout caused by the COVID-19 pandemic was related to deteriorating the symptoms of ADHD in half of their study participants, which was in the form of a rise in the level of activity (slight or significant), irritability, or disruptive conduct behavior .
While the study of Bobo et al. found improvements in restlessness and duration of study time in connection with the relief of stress caused by the forced regularity of scholarly activities, although some parents identified worsening of the oppositional/defiant behavior and emotional outbursts. Parents also documented sleep disturbance and anxiety symptoms in their ADHD children. The authors attributed this improvement to the decreased school-related stress and schedules that accommodated their children’s rhythms. Improved self-esteem was another factor as their children were receiving less negative feedback .
In our opinion, the COVID-19 pandemic increased the presentation of depression, anxiety, and stress symptoms of the mothers of ADHD children by the changing that occurred in the surrounding circumstances like the financial impact, the increased domestic violence, and the burden of having confirmed COVID-19 cases or loses among family members. These psychiatric symptoms may affect the mother’s ability to care for their children, including the compliance of their children with their medication which was also affected by the financial drawbacks of the epidemic. These factors may deteriorate the ADHD symptoms of these children and adolescents that were already and directly affected by the stressful condition of the pandemic. So, as a psychiatrist, we should carefully observe the psychological state of the mothers of ADHD children, especially in a distressful situation like the pandemic, to give them appropriate psychiatric care and avoid the impact of their symptoms on their children’s condition.
Limitation of the study
Although this study was the first one in Egypt to determine the psychological impact of the COVID-19 pandemic on a vulnerable group like the mothers of ADHD children, unfortunately, our research had some limitations, one of them is we did not have an assessment for depression, anxiety, and stress symptoms of the mothers of ADHD children before the COVID-19 epidemic to compare it with their evaluation after the pandemic, which in turn could determine the exact impact of it on our sample. Also, the cross-sectional design of this study failed to analyze the direction of the effect of the psychological state of the mothers on the behavioral symptoms of their children. Another limitation was the small sample size which is still less than expected according to previous studies. We were constrained by the available number of records in our clinic as the lockdown measures unenabled us to increase our sample size. Also, the lockdown measures prevented us from performing a structured psychiatric interview to diagnose the psychiatric disorders that may present in our participants or apply specific questionnaires instead of the subjective questions for assessment of certain points like the financial impacts and the domestic violence as this study was done through an electronic Google form questionnaire not face to face interview, so we were not able to use multiple questionnaires as many of our participants may find difficulty in completing it. So, we tried to make it as concise as possible and at the same time give us accurate data regarding our sample and what we try to assess in our study.