RESEARCH

 

Parenting experiences of parents of children with ADHD, in grades 1 to 3, during the COVID-19 lockdown in South Africa

 

 

M Szigethy^I; J K Bezuidenhout^II; J Potterton^III

^IBSc (Occ Ther), MSc (Med); Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand; Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand
^IIMB ChB, FCPaed (SA); Charlotte Maxeke Johannesburg Academic Hospital, Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
^IIIMSc (Physiotherapy), PhD; Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence

 

 

---

ABSTRACT

BACKGROUND: The experiences of parents of children with attention deficit hyperactivity (ADHD) disorder in grades 1 to 3 during the COVID-19 lockdowns in South Africa (SA) are explored in the context of school closures and prohibition of extramural activities, therapies and social gatherings. The psychosocial and mental health implications of COVID-19 lockdown are largely undocumented in SA families with children with ADHD
OBJECTIVES: To explore parenting experiences of and perspectives on the impact of the closure of schools, extramural activities, therapies and social gatherings on their child, and to determine strategies parents implemented to support their child during lockdown
METHODS: Qualitative research design of a cross-sectional study was done using an interpretivist paradigm. Data from 12 participants were collected through questionnaires and online/face-to-face interviews conducted between March and June 2022. Interviews were audio recorded, transcribed and analysed using an inductive thematic approach
RESULTS: Participants were parent couples from six households who were retrenched, employed, or essential workers. They described the familial, occupational and educational implications of lockdown, the physical and mental well-being of families, and effective coping strategies that they implemented during lockdown
CONCLUSION: Recommendations reiterate the education of parents in the management of ADHD symptoms from the point of diagnosis. Effective online teaching techniques and applications for children with ADHD in grades 1, 2 and 3 must be explored. The impact of restricted access to facilities and professionals for the diagnosis and treatment of ADHD, and for grief counselling for children and their families during COVID-19 lockdowns, requires further investigation

---

 

 

COVID-19 was recognised by the World Health Organization (WHO) in December 2019, and characterised as a pandemic on 11 March 2020.^[1] Social distancing measures that required the wearing of face masks, maintaining a social distance of 1.5 m between people, limiting large social gatherings and frequent washing of hands were recommended to limit its spread. The Risk Adjusted Strategy implemented in South Africa (SA) through lockdown measures closed educational centres and therapeutic services, and prohibited sporting events, travel and social gatherings.^[2] Quarantine is known to affect physical health,^[3] cause negative psychological responses^[4] and impact mental health.^[5] Research emerged that children in lockdown were less physically active,^[6] had increased screen time habits, showed irregular sleep patterns and had less appropriate diets.^[7] Children aged 6 - 18 years were more inattentive during lockdown. Factors that influenced their mental well-being included developmental age, isolation during lockdown and socioeconomic status.^[8]

Parents of children with attention deficit hyperactivity disorder (ADHD) experience greater stress than parents of children without ADHD.^[9] They experience more behavioural challenges with their children and increases in their own anxiety, stress, depression and burden of care.^[10] ADHD is linked to maternal stress,^[11] disturbed family dynamics and marital functioning.^[12] It is anticipated that the difficulties that these children have controlling behavioural responses would make make meaningful interactions with caregivers even more challenging.^[13] Closure of schools removed valuable support for children and parents as access to sport facilities, therapists, counsellors,^[14] protection services^[15] and school-feeding schemes^[16] were reduced.

Global studies found that children with ADHD in lockdown had increased depression, self-harming behaviours and anxiety as a result of school closures,^[17] exercised less and engaged more in social media and gaming.^[18] Their sleep, dietary habits and emotional tolerance levels were negatively affected, and parents reported a worsening of their own pre-existing mental health conditions when balancing work, child care and family responsibilities.^[19]

A study in France noted improvements in some children's anxiety due to less pressure at school, a change of teaching pace and flexible home schedules.^[20] Children's self-esteem improved as a result of less negative feedback related to their ADHD symptoms, more individualised assistance at home and more time available for play.^[20]

In many countries, schools adopted an online learning approach. Children with ADHD in China were more inattentive when learning online,^[21] and in SA online learning increased anxiety in children with ADHD as a result of the limited support from teachers and increased distractibility.The SA literature is limited in documenting lockdown experiences of parents of children with ADHD in grades 1 to 3. There are limited publications recording effective parenting strategies to support children during lockdowns when schools, extramural and therapeutic interventions were restricted.

This study aimed to explore the experiences and coping mechanisms of SA parents of children with ADHD through consideration of the implications that COVID-19 lockdown had on family relations, occupational and educational performance, and overall family well-being. Access to treatment and educational support was equally restricted in 2020 and 2021 by the Risk Adjusted Strategy.

 

Methods

The study was conducted at a school for learners with special educational needs, including ADHD, that provides interventions and accommodations for grade 1 to 12 learners. The school's low learner numbers per class, low teacher-learner ratio, group therapy sessions four times per week for each learner, assessment accommodations like extra time, daily medication regimen provided by qualified nurses and monthly on-site paediatrician consultations are ADHD intervention strategies provided at the school. Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee (ref. no. M211015) and permission was obtained from the school's headmaster, the Department of Occupational Therapy and the Gauteng Department of Education. A cross-sectional study design was used with a convenience sampling method on the basis of the availability of children with ADHD at school. Forty-four parents were invited to participate in the study if they met the eligibility criteria of having children with ADHD who were in grades 1, 2 or 3 in 2020/21 and had lived with their children during lockdown. Twelve participants, from six households, volunteered. This unintended response resulted in a small study sample. Written consent to be interviewed and audio recorded was obtained from participants before each interview, and confidentiality and anonymity measures were clarified. Participants completed a demographic questionnaire detailing their children's diagnoses, medication regimen, therapy and extramural involvement at the time of lockdown. Participants were given the choice of online or face-to-face interviews, adhering to social distancing measures implemented at the time.

Interviews were conducted between March and June 2022 in English. Semistructured questions, and associated probes, were prepared in an interview schedule. Participants were asked: (i) to describe positive and negative parenting experiences during lockdown; (ii) how isolation from school, friends, extramural activities and therapies affected their children positively or negatively; (iii) how they supported their children's development and mental well-being during lockdown; and (iv) how participants would have liked to receive additional support and from whom.

Of the 44 parents invited to participate, 14 met the eligibility criteria. Twelve agreed to be interviewed individually and consented to their preferred interview method: online via Zoom, or face-to-face. Over 4 months, four interviews were face-to-face at the school, with social distancing measures in place. Eight interviews were conducted on Zoom. Consent included that videos remain on to facilitate non-verbal communication while recording audio data only. Data saturation was reached when no new information or themes emerged. Thereafter, no further participants were invited to the study.

Interviews were anonymised using a data management code recording the gender of the parent, date of the interview, child's grade in 2020 and child's gender. Interviews were transcribed by the researcher and analysed using an inductive thematic approach with an interpretivist paradigm to interpret participants' experiences during lockdown. Interview transcriptions were read by a second coder for peer reviewing and institutional checking. ^[23] Trustworthiness was established by aligning the interpretation process according to data triangulation and external checking of transcripts. Researcher bias was limited because lockdown restrictions were never experienced before 2020. The researcher's professional and personal experience of children with ADHD was of pre-COVID-19 parental experiences, strategies and presentation of ADHD. Trustworthiness was attained through the detailed capturing and quoting of participants, and by recording the features of ADHD and the specific context of COVID-19 in SA through literature referencing.

 

Results

Twelve parents from six households were interviewed separately, allowing for separate perspectives to be documented. Table 1 contains participant data during lockdown, recording the children's grades in 2020 as reference points relating to the study. Two children repeated a grade in 2021, one of whom received a diagnosis in 2021 owing to diagnostic delays caused by lockdown. Two fathers disclosed their own ADHD diagnoses during the interviews.

 

 

Table 2 contains data on household descriptors (N=6). Oppositional defiance disorder, epilepsy, anxiety, dyslexia and sensory processing disorder were comorbid diagnoses. All households had internet access and only one child did not take ADHD medication during lockdown.

 

 

Ten categories emerged from the data which were grouped into four themes (Fig. 1).

Family implications

Participants reported frustration due to confinement with family, compounded by work and school demands and employment changes. One third (33%) reported family fights, emotional outbursts and strained parent-child relationships.

Ί thought I was going to have the breakdown, with him; it really put a big strain on my relationship with [son], even at 7 years old because I would get so cross and frustrated with him" (mother: grade 1 boy).

Seven participants (58%) reported negative behaviours of screaming, fighting and crying in their children, while a quarter (25%) saw destructive behaviours, destroying toys and property. They were unsure how to cope with negative ADHD symptoms without support from schools or healthcare professionals. Seventy-five percent (n=9) of participants reported their children had missed teachers and friends, and participants recognised the importance of peer interactions for their children. Their children did not have opportunities to develop skills through sporting activities in lockdown.

Fifty percent of participants (n=6) reported that interactions and family activities improved parent-child and sibling relationships. One-quarter (25%) of participants reported no negative impact of lockdown on their children and a further three participants (25%) reported positive effects and a reduction in anxiety in their children without school pressures of bullying, time restraints and reduced schoolwork demands.

Ά positive of being home with [son] was that we got to see almost like a different side of him because it wasn't the stress of school; you know, we grew closer as a family' (mother: grade 3 boy).

Two participants of one household reported different perspectives on their son's behaviour.

'He was just happy to be at home, to have his toys around... then watch TV. ... he was fine with it' (mother: grade 3 boy, only child); 'the fighting with us over stupid things because the smallest thing would just set him off' (father: same grade 3 boy).

Occupational and educational implications

Participants developed respect for teachers when navigating the challenges of children's schoolwork and their own work. Only three participants (25%) had experience with online interventions for ADHD. They observed greater concentration difficulties in their children, and face-to-face therapy was preferred.

'He works better with that face-to-face interaction - not necessarily one-on-one but being able to have somebody in front of him and less distractions; because of the ADHD he gets very easily distracted' (retrenched father: grade 3 boy).

One father was unable to find parental support for ADHD online and felt poorly equipped for teaching and managing his son with ADHD.

'We didnt really have anyone that can actually guide us to what to do because of [son] that [has] ADHD; we don't know, nobody knows how or what to do (father: grade 2 boy).

More interactive support from the teachers and therapists was desired but participants were happy with the school's online presentations for return-to-school preparations when the time came. A quarter (25%) had difficulty limiting screen time for entertainment purposes in their children.

Physical and mental health implications

This study found that the COVID-19 pandemic and lockdown measures impacted participants' mental health through the deaths of loved ones due to COVID-19, fear of the virus and of going into the community, daily exposure to negative news reports and financial challenges due to retrenchments.

Mental health was impacted when access to public medical facilities and grief counselling for those who lost loved ones and for the diagnosing and treating of ADHD was restricted. Parents were concerned about the possible effects of social distancing on their children's social development when schools reopened.

Ί was so concerned that he doesn't social[ise] any more, because it was for so long that he doesn't have friends' (mother: grade 2 boy).

Participants desired greater spiritual, emotional and physical support, more information for a holistic approach to ADHD, and greater teacher and therapist interventions in lockdown.

'If there was maybe from the therapists that has done the physical and speech therapy and so on, if they'd maybe sent something what we could do as well, like what you guys do at school that we could have done also at home, I think that might have helped a bit as well, for his mental well-being' (father: grade 2 boy).

Effective techniques

Participants gained insight into ADHD symptoms. Three (25%) recognised the importance of home routines in ADHD management and discovered new methods to support their children's learning styles and address difficult behaviours.

'We got to understand him better and understand what works for him and what doesn't work for him. There are certain ways that he does things, and we have to learn to be okay with that' (mother: grade 3 boy).

One-quarter (25%) learned to be patient after observing their children's concentration and behavioural difficulties firsthand. Parenting strategies were adapted. Participants reported that having open discussions with their children about the virus and lockdown measures, being actively involved in games, physical outdoor activities and academic tasks with their children, and sharing parental roles supported the family's well-being.

'I've noticed, the more time I spend with [son], the better our relationship obviously becomes, but the more I understand what he's going through' (father: grade 3 boy).

Maintaining regular contact with loved ones via social media and having the support of their own parents were effective coping mechanisms. Fifty percent of participants lived with an elderly parent during lockdown, who supported the learning, day-to-day care and some emotional needs of children with ADHD. Participants made use of online educational resources. Formal counselling programmes were utilised by 25% of participants for guidance with ADHD and grief management.

 

Discussion

This study aimed to explore the experiences and coping strategies of SA parents of children with ADHD during COVID-19 lockdowns, without access to educational, therapeutic or community support during the pandemic. Balancing work, chores and children's schoolwork, recorded by Bobo et al.,^[20] gave parents insight into ADHD behaviours and learning styles. Children's emotional regulation difficulties and some destructive behaviours became apparent for some participants living in closely restricted lockdown conditions with altered family routines. The importance of physical activity, exercise and routine was reported by participants. Sciberras et al.^[18] reported that isolation from friends, teachers, school and extramural activities affected the functioning of children with ADHD. Parents in this study also reported that reduced sport participation and therapy impacted their children. The need for face-to-face teaching, same-age interactions, equipping parents with skills for effective management of ADHD behaviours, improving accessibility to information on ADHD, and a holistic approach in the management of ADHD was highlighted by parents whose children were already in a school that provides accommodations for barriers to learning. The improvements reported in some children's behaviour and anxiety, credited to reduced school demands, flexible time for learning and play, and the removal of bullying, give credence to implementing these factors in ADHD treatment approaches. The pandemic highlighted the significant learning barriers faced by children with ADHD and their caregivers, which challenged the education system to allow for adaptable presentation of academic content and greater support of children and their families in education.^[10]'

The differing perspectives from father and mother within the same household suggest that parents may experience the child's symptoms differently, which should be acknowledged and addressed. Perspectives may have been influenced by time spent with their children at home, changed roles resulting from job losses and lockdown measures, parental stress and parental pre-existing conditions such as ADHD. Improvements that participants noted in their children are attributed to time that they invested in their children. Consistent parental presence and shared parent-child experiences, as described by Sciberras et al.^[18] regarding familial well-being, bears strong consideration in building parent-child relationships. Children's increased screen use in lockdown suggests there was insufficient support and monitoring from parents, and participation in positive activities as alternatives are recommended by Chen et al.^[4] to mitigate psychological distress.

Living with elderly family members influenced participants' mental health positively, owing to their added support in the care of children, but also negatively, because of concerns for their parents' health. Extended family members may play a role in developing relationships within the ADHD family structure and should be considered within a holistic approach.

Parents' reports of the greater benefit of face-to-face teaching and therapy over online learning highlighted the effectiveness of face-to-face interactions for children in their learning environment. Participants echoed the findings of Bobo et al.^[20] in their desire for greater teacher involvement when teaching online. Effective online teaching methods for children with ADHD beg further investigation and adaptation.

Delays in diagnosis and treatment of ADHD described by Currie et al.^[17] increased parent stressors and highlighted a lack of parental understanding of ADHD symptoms and management thereof without professional guidance. Uninterrupted access to ADHD support is essential for educating and supporting families of children with ADHD using up-to-date and holistic treatment approaches to ensure that parents are continually equipped to manage their children optimally.

Limitations of the study were that there were no single-parent participants and all participants were from one school. Interviews conducted online had some connectivity issues which impeded the flow of the interview. Face-to-face interviews may have been impeded by social distancing measures, particularly the use of face masks.

 

Conclusion

COVID-19 lockdown measures in SA isolated parents and their children with ADHD, restricting face-to-face teaching, therapies, extramural and social opportunities used as some ADHD support interventions. Participants in this study reported on their experiences, the strategies they implemented and their children's needs during lockdowns. They expressed their desires to better understand the symptoms of ADHD from professionals, and to be equipped with effective parenting strategies to address their children's emotional regulation and learning challenges. During lockdown, families' open interactions, parent-child activity participation, maintained routines, family play and exercise times had positive impacts on family relationships and mental well-being. This study recommends that access to diagnosis and treatment should be unhindered where parents can be equipped with accurate ADHD symptomatology and updated treatments at every stage of their child's development. A holistic approach, beyond a medication-only approach, can guide the management of symptoms and emotional regulation difficulties. Face-to-face interactions and active participation in activities with significant adults and same-age peers are recommended. Maintaining routines, reducing school stressors, giving more time for play and exercise, and sustaining open discussions support the well-being of children with ADHD and their parents. Investigating and adapting online teaching techniques and screen time management for learners with ADHD may support children's effective engagement on digital platforms. A follow-up study of the short- and long-term effects of delayed ADHD diagnosis during lockdown may direct relevant interventions for those who lacked these during the COVID-19 pandemic.

Declaration. This research is in partial fulfilment of the requirements of MS's degree of Master of Science in Medicine (Child Life and Paediatric Psychosocial Care) at the University of the Witwatersrand. It has not been submitted before for any other degree or to any other journal for publication.

Acknowledgements. Every parent who willingly volunteered their experiences in the interviews as contributions towards ADHD research. Soli Deo gloria (J S Bach).

Author contributions. MS: Preparing information document for research, demographic questionnaire, research consent document, interview questions and interview guide, conducting interviews, recording and transcribing interviews, researching literature and writing up report article.

JP: Supervising preparation of interview questions, reading transcriptions as second coder for peer review and institutional checking, proof reading and contributing to article. JB: Proof reading and contributing to article, provision of guidance and professional expertise on ADHD and COVID-19.

Funding. None.

Conflicts of interest. None.

 

References

1. World Health Organization. Interactive Timeline: WHO's COVID-19 response. 2021. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline# (accessed 17 February 2025).         [ Links ]

2. Department of Health. COVID-19 Online Resource and News Portal, COVID-19 Risk Adjusted Strategy. 2021. https://sacoronavirus.co.za/covid-19-risk-adjusted-strategy/ (accessed 25 July 2022).         [ Links ]

3. Meireles ALF, de Meireles LCF. Impact of social isolation due to the COVID-19 pandemic in patients with pediatric disorders: Rehabilitation perspectives from a developing country. Phys Ther 2020;100(11):1910-1912. https://doi.org/10.1093/ptj/pzaa152        [ Links ]

4. Chen CY, Chen IH, Pakpour AH, Lin CY, Griffiths M. Internet-related behaviors and psychological distress among schoolchildren during the COVID-19 school hiatus. Cyberpsychol Behav Soc Netw 2021;24(10):654-663. https://doi.org/10.1089/cyber.2020.0497        [ Links ]

5. Guessoum SB, Lachal J, Radjack R, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry Res 2020;291:113264. https://doi.org/10.1016/j.psychres.2020.113264        [ Links ]

6. Kim SJ, Lee S, Han H, Jung J, Yang SJ, Shin Y. Parental mental health and children's behaviors and media usage during COVID-19-related school closures. J Korean Med Sci 2021;36(25):e184. https://doi.org/10.3346/jkms.2021.36.e184        [ Links ]

7. Wang G, Zhang Y, Zhao J, Zhang J, Jiang F. Mitigate the effects ofhome confinement on children during the COVID-19 outbreak. Lancet 2020;395(10228):945-947. https://doi.org/10.1016/S0140-6736(20)30547-X        [ Links ]

8. Singh S, Roy D, Sinha K, Parveen S, Sharma G, Joshi G. Impact of COVID-19 and lockdown on mental health of children and adolescents: A narrative review with recommendations. Psychiatry Res 2020;293:113429. https://doi.org/10.1016/j.psychres.2020.113429        [ Links ]

9. Babinski DE, Mazzant JR, Merrill BM, et al. Lifetime caregiver strain among mothers of adolescents and young adults with attention-deficit/hyperactivity disorder. J Fam Psychol 2020;34(3):342-352. https://doi.org/10.1037/fam0000609        [ Links ]

10. Chafouleas SM, Iovino EA. Comparing the initial impact of COVID-19 on burden and psychological distress among family caregivers of children with and without developmental disabilities. Sch Psychol 2021;36(5):358-366. https://doi.org/10.1037/spq0000426        [ Links ]

11. Yousef AM, Sehlo MG, Mohamed AE. The negative psychological impact of COVID-19 pandemic on mothers of children with attention deficit hyperactivity disorder (ADHD): A cross-section study. Middle East Curr Psychiatry 2021;28(1):57. https://doi.org/10.1186/s43045-021-00139-z        [ Links ]

12. Wehmeier PM, Schacht A, Barkley RA. Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. J Adolesc Health 2010;46(3):209-217.https://doi.org/10.1016/j.jadohealth.2009.09.009        [ Links ]

13. Cortese S, Asherson P, Sonuga-Barke E, et al. ADHD management during the COVID-19 pandemic: Guidance from the European ADHD Guidelines Group. Lancet Child Adolesc Health 2020;4(6):412-414. https://doi.org/10.1016/S2352-4642(20)30110-3        [ Links ]

14. Lee J. Mental health effects of school closures during COVID-19. Lancet Child Adolesc Health 2020;4(6):421. https://doi.org/10.1016/S2352-4642(20)30109-7        [ Links ]

15. Fore HH. Violence against children in the time of COVID-19: What we have learned, what remains unknown and the opportunities that lie ahead. Child Abuse Negl 2021;116:104776. https://doi.org/10.1016/j.chiabu.2020.104776        [ Links ]

16. Department of Basic Education. Curriculum Assessment Policy Statements: what is a National Curriculum and Assessment Policy Statement? 2021. https://www.education.gov.za/Curriculum/CurriculumAssessmentPolicyStatements(CAPS) (accessed 1 May 2022).         [ Links ]

17. Currie G, Finlay B, Seth A, et al. Mental health challenges during COVID-19: Perspectives from parents with children with neurodevelopmental disabilities. Int J Qual Stud Health Well-being 2022;17(1):2136090. https://doi.org/10.1080/17482631.2022.2136090        [ Links ]

18. Sciberras E, Patel P, Stokes M, et al. Physical health, media use, and mental health in children and adolescents with ADHD during the COVID-19 pandemic in Australia. J Atten Disord 2022;26(4):549-652. https://doi.org/10.1177/1087054720978549        [ Links ]

19. Masi A, Mendoza Diaz A, Tully L, et al. Impact of the COVID-19 pandemic on the well-being of children with neurodevelopmental disabilities and their parents. J Paediatr Child Health 2021;57(5):631-636. https://doi.org/10.1111/jpc.15285        [ Links ]

20. Bobo E, Lin L, Acquaviva E, et al. How do children and adolescents with attention deficit hyperactivity disorder (ADHD) experience lockdown during the COVID-19 outbreak? L'Encephale 2020;46(3S):S85-92. https://doi.org/10.1016/j.encep.2020.05.011        [ Links ]

21. He S, Shuai L, Wang Z, et al. Online learning performances of children and adolescents with attention deficit hyperactivity disorder during the COVID-19 pandemic. Inquiry 2021;58:469580211049065. https://doi.org/10.1177/00469580211049065        [ Links ]

22. Duncan W. ADHD Child and COVID [Webinar]. Dr Reddy's; 2021. Available from: https://event.webinarjam.com/go/replay/330/m26v2u2ock4t64fg (accessed 12 October 2021).         [ Links ]

23. Stahl NA, King JR. Expanding approaches for research: Understanding and using trustworthiness in qualitative research. J Dev Educ 2020;44(1):26-28. https://doi.org/10.4135/9781483329574        [ Links ]

 

 

Correspondence:
M Szigethy
michelleszigethy@gmail.com

Received 7 March 2024
Accepted 21 January 2025