ADHD insights: COVID-19 pandemic, sleep patterns

Hi, we are the ADHD skills lab podcast. My name is Skye and my name is Sarah, and we will be your hosts chatting to you about practical ADHD strategies. You can use the research behind some of these strategies, as well as interviewing other professionals with ADHD about how they've developed skills and working through struggles in their lives.

You might know us from unconventional organization, where we talk about this kind of stuff all day long. So we're super excited to have you along and we're going to chat through it together.

Today we're going to be talking about two papers. We're talking about a paper that looks at the COVID 19 pandemic and particularly the experiences of adults with ADHD during that experience in 2021. And then we're also going to be looking at sleep and circadian preference. Are you a morning person? Are you an evening person?

And does that have an impact on your ADHD? So two very. And I know, Sarah, sleep is a big focus of yours. You did write the paper on it on our website. So I'm excited to hear what you have to say about that one.

Yes. Well, knowledge usually comes from seeking an answer. And so I've had a lot of questions about sleep.

Yeah. Yeah, yeah, totally. Totally.

The Experience of Adults With Attention-Deficit/Hyperactivity Disorder in 2021 During the COVID-19 Pandemic: The UNCOVER Study

So just to kind of start us off with the paper on. COVID 19. So this comes from the Primary Care Companion for CNS Disorders, obviously published this year. And basically what they were looking at was what effect did adults with ADHD say that the COVID 19 pandemic had on their ability to manage their health?

Their symptoms, their ability to achieve their treatment goals. So their executive functioning, their ability to manage that. And they particularly looked at people who were receiving medical support and people who weren't as well, which is quite interesting. 'cause often that's not something that people are looking at specifically.

So Sarah, do you wanna take us through a little bit of the methodology? Yeah, so they had a sample size of 93 adults with ADHD. The diagnosis was a self report and there was no independent verification. But they found these people on a platform called PatientsLikeMe. Which is basically like a little community for people to come together, who share a diagnosis and sort of just community support, you know, talk about their experience, look for different treatment options and things like that, but the platform also functions as a data collection resource.

So in this case, they sent out this massive survey to all these people, and we're able to gather this data from that. Of the 93 adults, there were 44 participants who were taking medication for ADHD, and then the rest were not. So that's sort of how they qualified medical intervention during COVID.

Yeah, it's interesting.

They said only 10 percent of the sample had no comorbidities, which I think is just a great example of how many different things can be involved with and affecting ADHD, particularly during the pandemic. I'm sure that, um, mental health struggles. Would have been in the background of this whole conversation, a hundred percent, essentially they found quality of life decreased overall.

And it's interesting because Sarah, you flagged that next time is going to be another paper that we're going to look at on COVID, which is going to be slightly different. So watch out for that. But this paper. They found that, you know, 36 percent of participants said, okay, my symptoms were pretty well managed, but 39 percent said no, they weren't well managed.

So that's quite a high number. And, and over half actually said that they had a change in insurance slash employment status. So they had some big executive functioning shift. That occurred during the pandemic. And it actually made me think, cause I remember like we moved, we shifted roles. Like there was a lot of things happening.

You sort of forget because at the time it was also heightened what was going on. But yeah, it was, it was a lot of transitions for a lot of

people. Yeah, they must have had a really long survey, because they found a lot of stuff, but that really is sort of the crux of it, is overall people experienced widespread disruption.

They go on to sort of talk more about medication changes and various symptoms experienced, but yeah, the root is that it disrupted a lot of people's lives in very different ways.

Yeah, so some of the examples here on the list are, um, lost job, but still employed, shifted to remote working, took a leave of absence for health or family reasons, lost a job, but now employed, changing insurance status.

Switched to Medicare, like there's just a lot of things going on as well as I think the numbers here were like 71 people struggling with depression, 69 people struggling with anxiety. It was a big time. There was lots of things going on. Um, it's funny. It's sort of putting me back now in that mental space of obviously it hit everybody very, very differently, but there can be a sense sometimes with ADHD where we're.

We're managing in a crisis, so it is strange to look back on it now. I did want to just reference as well, they did a survey where they had a bubble, large bubbles indicated what goals they had. So how many people felt that they didn't meet their ADHD management goals?

It was actually 37 out of the 38 people who had responded reported that the pandemic negatively impacted progress in those areas, and the larger the bubble, sort of the more prevalent that goal was.

Yeah. So for a lot of people, their biggest goal was mental health. Their second biggest goal was being organized, having a positive attitude, healthy living, managing their medication. Project compression. Project completion. This just looks like my mood boards and financial security, that kind of thing. So people had a lot of those kinds of goals.

And those are the things that they specifically said were a bit of a struggle. And interestingly, there was a difference in people who were unmedicated and people who were medicated in whether they struggled particularly. So Sarah, do you want to take us through a little bit of what that looked like?

Yeah, so there were 47 medicated participants out of 93. I can't do math, but that's about half. Um, so of those 47 medicated patients, a quarter of them had at least one med type switch. So either they had like a new med that they were trying out. Or they switched entirely. Like a quarter of people have that experience.

47 percent of them had some kind of dosage switch as well. And 53 percent had like a new medication, like an additional medication prescribed. And I think that that really paints a picture of how. Desperately, we were trying to maintain control throughout that whole process. Yeah, definitely how many people were reaching out, how many people needed that support.

It is interesting because we talked about this idea that 50 percent of unmedicated patients struggled with symptoms, but only 26 percent of medicated patients struggled and why that might be. And one of the things that we were talking about was the concept that With ADHD executive functioning strategies, often they're focused around supporting you in your ADHD environment.

So at work, for example, and when the pandemic happened and everyone moves home, or now you have to look for another job and you're, you're in a totally different executive functioning space all of a sudden. And so this would have been particularly tricky for people who were. More reliant potentially on those executive functioning strategies for a certain kind of environment.

Yeah, definitely. That just goes back to the scaffolding conversation that we had a couple of weeks ago, and it reminds me too, when I'm talking about transitioning between tasks with clients, a physical change of space is really effective. And so being unable to access that physical space that was working, I can't even imagine.

Yeah, well, we sort of can.

Well, I didn't have that experience actually. When COVID sort of hit, I was working in an elementary school as a special ed sort of assistant. So yeah, I was there when they decided to close them. I'll never forget.

Yeah, yeah, definitely. Well, it definitely was a big switch and it is interesting though, because we do have to flag one of the limitations was that the study is funded by several pharmaceutical companies.

I think given the fact that medication is considered to be so, so much of a support over other kinds of supports, it is worth mentioning that that is where the funding for this actual study comes from. They do a really wonderful job of disclosing where everything comes from. I mean, the watermark on this paper, it says psychiatrist.com. So I would be surprised if they didn't have pharmaceutical ties, but yeah. Important consideration.

Yeah, definitely one to keep in mind. They also didn't control for confounding variables. You know, it is interesting, a lot of the changing meds, given how many different other factors were involved in terms of anxiety and mental health, the changes in meds could have had a lot to do with that specifically, and maybe the benefits as well could have had a lot to do with that.

It's a very complex conversation to have. They also had self report bias because it was a retrospective survey, which a lot of them are. So people had to remember how they felt during the pandemic, which, which is tricky, especially retrospectively. I feel like I can definitely say that having read this paper, then having to think back.

Into like, what was it like in 2021 it was it was a tricky thing to get my mind around and I was just reading the paper, not filling out the survey

because the medicated patients were obviously having prescriptions they were having to meet with telehealth providers on a regular basis throughout the pandemic, so 42 percent of medicated participants met with at least one telehealth provider during the period of time in which they were the pandemic.

surveying people, but only 19 percent of the unmedicated participants did have that kind of a provider visit. And so I'm just thinking that's also another social support that was gone suddenly.

Yeah, that's a really good point, actually. You know, and also there's a sort of level of stability to Getting those connections, definitely.

Well, in terms of the practical implications, you know, it was good to get some insight into the experiences of ADHD during COVID 19. Understanding what happened. The thing that I took away from it was just a reminder of how much has changed and how much changed during that year. Because I think it can be easy to just get used to the new normal and forget.

Yeah, that's so important. Reflection is good. I think for me, the takeaway was just accepting that any massive transition in life is going to cause some kind of disruption, especially if it relates to like your employment status and in the United States, access to your health insurance and things like that are also disrupted.

And so I was actually thinking about this more in terms of like job loss and like big life transitions, stressful periods of time. Just that those are the times where people need more support.

Yeah, and it's a good reminder as well, you know, because maybe you are going through that time right now. You know, we're talking about a retrospective experience that we all had, but now you might find that you're in that huge time of flux and transition.

And so you do need that support and you do need that extra scaffolding. So if that is you. Then, um, yeah, everybody experienced that you're in COVID, but it's still important now as well. Yeah,

absolutely. Before we move on, I just wanted to say it was funny hearing you talk about COVID in the 2021 lens, because for us here, it was like fully like March 2020 and everything changed.

Just like the ball was dropped and it took a bit to get to New Zealand.

Yeah, we had an interesting one. It took a bit to get to us. We shut down basically a. Like in 2020, and then we sort of didn't shut down. We were a little bit behind, I think, compared to what was happening. And so then, yeah, by the time everyone else was sort of like slowly opening up, we were in a position where we were like still very much shut down cause we only just gotten all the COVID.

So, yeah, it was, um, it was an interesting experience. You spend a lot more time reading the news, um, and like just checking things out. Yeah. It was a huge transition. And I think that's the basic thing is like, if it felt like a huge transition to you, it was, they're now doing studies on it. Yes.

Watch out for the next one in two weeks.

Yeah.

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ADHD, chronotype, and circadian preference in a multi-site sample of college students

So the next paper we have is actually looking at sleep on a sample of college students. So the paper is the Journal of Sleep Research.

They're looking at ADHD Chronotype, which Sarah's gonna talk about, and I'm really excited to hear more actually. And, um, circadian preference in a very, very large study of different college students. They wanted to particularly look at, is there an association between essentially being a morning person versus an evening person and ADHD?

Which is a really good question, something that I've thought about before and they wanted to find out. So yeah, Sarah, how did they do it? Yeah, 

and we hear about that all the time, too, that sleep is just disrupted, so I love when we look at studies specifically with ADHD and sleep, because there wasn't a ton.

So, the sample size is 4, 751 university students. Wow. 

It's probably the biggest to date that we've had in terms of sample size that we've looked at. 

Yeah, 

maybe with the example of like a literature review in which we didn't know the total sample size, but yeah, for sure, like a single study. This was incredible.

And so actually, that was one of the main questions that I wanted answered. Like, how did they get such a large sample size? And they told us. Yes, they did. Given that they were university students, they pretty much offered these kids some undergrad. credits to participate in a study of their choice. So they did get to choose this one.

Yeah, I will say the alternative was doing a lab report. They very much got people with ADHD as well because I definitely would have done this rather than do another lab report back in university days. Absolutely. 

Like filling out a survey. Yes, please. Um, because that's all it was. Um, and we'll get into, we'll get into those surveys in a second, but I wanted to flag also.

being an adult 18 and over was the only inclusion and exclusion criteria. Like they didn't care anything else. That was it. So of that gigantic sample, 656 participants met the criteria for ADHD. They measured that with a self rating scale, which again, it was tricky. They said they met the criteria for an ADHD diagnosis.

What they mean is that they did a self rating scale, you know, it's a Barclay ADHD adult rating scale. Chances are, if you were in a psychiatrist's office and you were being diagnosed, you might do this scale, but it would be part of a larger conversation. And it was really weird reading this paper. Having just a couple of episodes ago, talked about another paper where they also looked at, um, the rating scale of ADHD in, um, in students in the medical community.

And they found that a lot of people were diagnosing themselves with ADHD using these scales because they were so stressed out. So this is not a be all and end all diagnosis of ADHD, but we also have a lot of controversy around that. So we're going to flag that and then we're going to 

leave it. Yeah, that's fair.

The paper does sort of say that that was a limitation. They did wish that they could have done interviews, but obviously with a almost 5, 000 person sample, they were never going to be able to do that. Maybe in the future with something different, but definitely a good flag. 

So tell us what chronotypes are.

So a chronotype is basically just like your preference. Are you a morning person or are you an evening person? Sometimes in the literature it's actually called morningness and eveningness, which You know what, that was really, it was really grating to me when I first discovered that like, I'm out here trying to take myself seriously, and um, researchers are just making things up like morningness, just to say that you prefer to be awake in the morning, like, it's so simple, and I guess I prefer it to the genetics.

Yeah, 

yeah, you sort of got chronotype, which sounds quite intimidating, or you've got morningness, which is sort of the opposite thing, you know, so, but yeah, this is a, this is a research focus. They do do this. I think Sarah, you said you actually took this scale because you were curious. Yeah, 

absolutely.

This is a very, this is a very well respected and well researched rating scale. It's the MEQ, literally, Morningness Eveningness Questionnaire. I was able to find this rating scale online, and I took it, and I got intermediate. So we can talk about what that means in a second. So they measured chronotype with that self report questionnaire, the same one that I just mentioned.

They assessed ADHD with the Barclay scale, and then they also were looking at depression and anxiety scores, which were also measured by self report. In terms of what they found, a lot. I mean, so they, so they looked at all of the subtypes of ADHD individually. 

Yeah. So based on the Barclays scale, they were able to go, okay, this is what we think of based on your self reporting.

We think that you have a diagnosis of inattentive or primarily hyperactive or whatever it is. 

Right. So what they found was that evening type. Occurred in 30 to 50 percent of people with ADHD, but only 28 and a half percent of those without. None of the groups were associated with morning type. 

Yeah, yeah, that's really interesting.

And most people were intermediate type, so you were very much in the majority 

there. Yeah, I mean, most people were intermediate type, and when you look at the actual questionnaire, it kind of makes sense why, yeah, 65 percent of, like, the control, the neurotypicals scored intermediate, and then ADHD was a very similar 50 to 58 percent intermediate type, and basically what that means is, if you were left to your own devices, had nothing to do, What time would you wake up in the morning?

What time would you be ready for mental tasks, physical tasks? When do you start feeling tired during the day? Which I was kind of like, wait, why is the earliest time? Like 8 p. m. I get tired at 4 p. m. Um, let's talk about 

that. That is a really good point. Um, 

I mean, they did get these kids from university, so that was actually mentioned as a limitation because it limits the amount you're able to generalize about these 

stats.

Although I will say if that's a limitation of this paper, it's a limitation of almost every paper because our entire system of research is built on students at universities taking research papers, basically. A lot of people associated with ADHD were having that evening preference, specifically. But how much different was that to the controls, to the people who didn't have ADHD?

Really not that much. So, 28. 5 percent of the neurotypical sample had evening preference. 

It was interesting. It, it, it is a lot when you compare people who identified using the self-report as inattentive. Yes. So 40% of people who were considered inattentive had an evening preference, but when it came to predominantly hyperactive, it was only 30%.

So it was like a 2% difference. Mm-hmm. . And then when it was combined, it went up again to 41%. So interestingly, people who considered themselves. based on the self report to be hyperactive ADHD. Almost had results that were similar to neurotypicals in terms of that, um, evening preference and actually had higher morning preference, quite a lot higher 

than any sample.

Yeah. They were like up and ready to go in the morning, which makes sense when you consider what they were looking for, hyperactivity, action focused, you know, movement, that kind of thing. So in terms of practical takeaways from this study, it really is something that they wanted to have a big enough sample that they could look at people who were hyperactive or inattentive or had combined type ADHD to see if there was a difference in whether they were morning people or evening people.

And a lot of this is really just about having the conversation that that is an option. Because, you know, sometimes it can be hard to acknowledge that or understand that. And if that is you, if you prefer, if you had different energy levels at different kinds of times of the day, it might be worth considering how you're going to use that to your advantage when it comes to studying or working.

Yeah, absolutely. Like if you know that your brain is not going to be turned on enough to study for the day until 11am, Then you're going to sort of schedule your day around that knowledge if you have the option to. 

Yeah, which we might not, although life is more flexible than it used to be, which is ironically connected to the COVID pandemic, which we just talked about.

So, yeah, definitely, um, the idea of. That evening preference and morning preference, and I will say they didn't really talk about it, but you referenced it and it's kind of important is, are you a person who really doesn't like the afternoon because I work with a lot of clients and anecdotally, this is only anecdotal.

People tend to work better in the morning and the evening, but not very well in the afternoon. Occasionally I have clients who work really well in the afternoon, which is pretty amazing to me, but like for a lot of people, there is a definite dip there. And the research backs this up, you know, it's a post lunch dip, but it can be particularly pronounced for some people, at least anecdotally with ADHD.

So definitely worth considering your energy levels throughout the day. And this paper really. 

Yeah, this paper doesn't go into anything about like melatonin onset, adenosine or anything like that, which are all also part of the conversation, especially around hating the afternoons. But this is a really nice summary of the fact that a lot of people have a strong evening preference.

They feel like they do their best. Work when the rest of the world sleeps. And basically no one has morning preference. I mean, if you do, if you're out there and you're listening, like bless you. Um,

I actually have morning preference, so I'm going to just put my hand up there. But I don't know if it's inbuilt. And I think this is something that a lot of people have said is like, you know, it's the one time of the day when the family is asleep. So, ironically, that might be more of it. And this is kind of actually what they do reference here is they said, one of the reasons people might be evening people is not because they're evening people, but because they're procrastinating during the day and ending up doing it in the evening.

One of the reasons people might be morning people is because their families are awake every other hour of the day, which is very much my, my, um, situation. So. There's a lot of things that go into that as well. 

Yes, sleep is not a simple issue. 

No, no, which is why it is, it is so endlessly fascinating.

Awesome. So that is everything for today. Is there anything else you wanted to add, Sarah? No, that about covers 

it. 

Great. So next time we will talk more about COVID as part of a future study. We also have been able to connect with someone very special that we know, um, who has an understanding of genetics.

So we will be talking with her in hopefully the coming sessions as well. So keep an eye out for all of those things and we will see you again in another two weeks.

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