Washington Behavioral Medicine Associates

Jaclyn Halpern, PsyD 

Although we have all been challenged by the COVID-19 pandemic, those with underlying mental health and neurodevelopmental diagnoses have faced particular hardship. Individuals with attention-deficit/hyperactivity disorder (ADHD) especially seem to have struggled to effectively adapt to the pandemic, showing more vulnerability to its many challenges.

Individuals with ADHD have showed a higher level of mental health concerns, difficulty adhering to preventive measures, and less economic success during the pandemic, as well as negative impacts on behavioral, emotional, and perceptual skills.

 Other challenges reported by adults with ADHD and caregivers of children with ADHD during the pandemic included social isolation, motivation difficulties, managing boredom, and difficulty engaging with online learning. Individuals with ADHD also reported increased symptom severity with higher risk factors for both major depression and school dropout.

 As the pandemic eases, these individuals are likely to require a high level of support, including therapy, psychiatry, and school and workplace accommodations to attain optimal functioning.

The COVID-19 pandemic forced most students to engage in virtual learning. During that time, caregivers of children with ADHD reported significant changes in the children’s behaviors, suggesting a higher level of underlying emotional dysregulation.

 After returning to school, many children with ADHD have found it harder to adapt. They have required a higher level of support in reacclimating to a set schedule and have needed to rely on executive functioning skills that they may not have had support for during the period of virtual learning.

Due to the combination of online learning, increased access to devices, and, for many, increased hours spent on digital media, it is not surprising to see struggles increase among children with ADHD. It has been suggested that ADHD symptoms, behavioral concerns, executive functioning difficulties, and family struggles all increased as digital media use increased during the pandemic.

 For many, the combination of these challenges and the challenges faced by exhausted parents has caused ongoing conflict even as the pandemic has begun to calm. Families continue to require mental health support for children and coaching for parents to manage these concerns.

The routine changes caused by the COVID-19 pandemic also presented a particular challenge for adults with ADHD. These individuals tend to require a higher level of structure than neurotypical peers and colleagues and are more likely to struggle when changes to routine occur. Creating a new schedule requires the ability to plan, organize, and initiate independently, which can be particularly challenging for those with ADHD, many of whom reported experiencing decreases in motivation and increases in distractions during the pandemic.

The constant access to media and electronics created a difficult distraction for many. The stimuli of “in-person” work was lost, and the ability to “body double”—that is, to work beside another person while completing a nonpreferred task to support engagement and accountability—was diminished. Individuals with ADHD are easily distracted and prone to missing social and environmental cues. The impact of both masking guidelines and frequent changes to these guidelines and other rules have likely increased these challenges and related stress, as well. It is important to support individuals with ADHD as they continue to adapt to changing guidelines, including changes to masking requirements.

Accurate diagnosis of ADHD has also become more challenging because of the COVID-19 pandemic. Now more than ever, it is imperative to explore neurodevelopmental history to determine early signs and traits of ADHD. Even neurotypical individuals have found themselves more distracted and distressed during the COVID-19 pandemic, including those who have not struggled with attention, executive functioning, or related emotional or behavioral dysregulation in the past. As a result, more people sought care for potential ADHD as evidenced by increased inquires to CHADD.

 In some cases, caregivers began noticing their children’s attentional concerns for the first time while virtual learning was in effect. In other cases, caregivers found their child’s ADHD easier to manage without the restrictions of the pandemic. With increasing calls for diagnosis, practitioners have had to take great care to avoid misdiagnosis. It has been imperative to recognize that children may display ADHD symptoms when preferred distractions are nearby, when anxiety is high, when social opportunities are limited, when children are sitting on a screen and exercising infrequently, and when children are internalizing their caregivers’ anxiety.

A final concern related to ADHD during the COVID-19 pandemic has been the response to infection itself. Research shows that individuals with ADHD are at increased risk of acquiring COVID-19, experiencing greater severity of COVID-19 symptoms, and being hospitalized for COVID-19. The same study noted the need for more research on whether individuals with ADHD are at higher risk for long COVID or for neuropsychiatric symptoms resulting from COVID infection.

 Long COVID is an emerging challenge that is in need of additional study. For some, long COVID symptoms include cognitive impairment and memory loss, as well as disturbed sleep and increased anxiety.

 These symptoms mirror those of ADHD and will require accurate diagnosis and treatment.

is a licensed psychologist with Washington Behavioral Medicine Associates, LLC, and director/co-founder of The SOAR Program for Psychotherapy and Testing at WBMA.

is a psychiatrist and the director of Washington Behavioral Medicine Associates, LLC, and the co-founder of The SOAR Program.

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6. Merzon E, Weiss MD, Cortese S, et al. 

The association between ADHD and the severity of COVID-19 infection

7. Raveendran AV, Jayadevan R, Sashidharan S. 

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TikTok, the global sensation: is this app harmless fun or dangerous? Following the start of a nationwide investigation into the video platform’s negative impacts, 

 sat down with Jaclyn Halpern, PsyD, from Washington Behavioral Medicine Associates to talk all about it.

Psychiatric Times (PT): State attorneys general from several states have launched a nationwide investigation into TikTok and its possible harmful effects on young users’ mental health. What does the medical literature/research show about TikTok and its impact?

 Research specific to social media and TikTok is relatively new, and it continues to emerge. Some research shows that those with attentional difficulties may experience more struggles with social media. Other research has concluded that children with complex mental health and environmental stressors or trauma may see at least temporary increases in emotional symptoms after social media use.

Social problems based in personal values and ethics impacted by social media use have also been found. However, data is limited, causation has yet to be clearly established, personal factors impacting positive and negative outcomes are unclear, and long-term impact has yet to be fully studied given that social media use and related research is relatively new. Additionally, studies on individual platforms like TikTok, as opposed to social media as a whole, are very limited. Given that research is mixed, not definitive, and in its very early stages and while there is clear cause for concern, there are likely both positive and negative outcomes resulting from social media use.

PT: Has research shown it’s more harmful to boys or girls?

 I have not encountered definitive research suggesting Tik Tok is more harmful based on gender.

PT: About 1 billion users are on TikTok. Do you think it’s become too large to control at this point? Is that part of the problem?

 TikTok is indeed a large platform. While there are parental controls available, not all parents have the knowledge to protect their children from inappropriate content. Though there is a restricted mode, the size of the site may well allow inappropriate content to slip through.

Additionally, not all subject matter can be properly filtered, and what families find appropriate for one child may be inappropriate for another. Given this, the size of TikTok makes it likely that any child using the platform will be exposed to inaccurate information, and something potentially upsetting, harmful, or traumatizing, even with parental monitoring and careful use.

PT: During the pandemic, TikTok became the forefront for trends: baking bread, whipped coffee, dances. Are there any potential positives you see in the app? Has it helped sort of bring us together?

 Absolutely. There are a range of benefits that can come from using TikTok and other social media platforms. This includes allowing people to interact over their interests; learn a new hobby; promote their businesses and creations; share content that is playful, fun, or educational; peacefully mobilize around social and political issues; establish a sense of identity; and even learn about other cultures. Positive TikTok content can be empowering and educational. Particularly during the pandemic, it became a source of both entertainment and connection for many. This was critical to the well-being of many during a time of isolation and fear.

PT: On the flipside, have things like the TikTok dances contributed to the oversexualization of young people’s bodies?

 It is reasonable to conclude that some of the content on TikTok, including some of the dances, may lead to oversexualization of young people’s bodies. Oversexualization of children by media in general is a long-standing concern, particularly for females. These concerns are based in standards of beauty and sexuality portrayed by the bodies and styles of models and performers, as well as song lyrics, dances, music videos, and portrayals of children and teens in videos, TV, and movies. Recent press and publicized anecdotes also suggest a potential negative impact on body image for all genders. To fully understand oversexualization caused by TikTok, specific research on the impact of dances and other potentially sexual content available on the platform is needed.

PT: Representative Cathy McMorris Rodgers of Washington, the senior Republican on the House Energy and Commerce Committee, has said that: “TikTok threatens the safety, mental health, and well-being of our kids.”

 Do you think this opinion is in any way related to adults’ lack of understanding and fear of this new method of engaging for their kids?

 Based on the research currently available, there is evidence that adults’ lack of understanding and fear are factors when making judgments about the negative impacts of TikTok and other social media platforms. However, there is also reason for concern given the content available on TikTok, differences in ethics and values surrounding TikTok’s content, the pressures children and teens may feel based on TikTok’s content, and the possibility of encountering an online predator when using the app. Ultimately, research has begun to show both risks and positives for youth using TikTok and other social media platforms.

PT: The focus is on TikTok here, but what about Instagram, Snapchat, and other forms of social media? What does the current medical literature say about their harmful effects, and are they not similar to TikTok in their promotion of things like eating disorder content?

 There is a critical need for research on the impact of individual platforms and content. Current research has shown a mix of both positive and negative outcomes resulting from social media use. As with TikTok, there is early research suggesting both positive (eating disorder recovery) and negative (pro-anorexia and pro-bulimia) impacts of eating disorder content on multiple social media platforms.

PT: One social media influencer in Germany may have contributed to what researchers are calling a “mass social media-induced illness,” in which patients were presenting with Tourette symptoms and tics closely resembling the social media influencer’s tics.

 Apps like TikTok may help spread awareness of mental illness, but do you think it also contributes to self-diagnosis?

 Yes, absolutely. That said, self-diagnosis can be both positive and negative. For some, self-diagnosis opens the door to better self-understanding and improved self-esteem, and may lead to seeking medical diagnosis and support. For others, self-diagnosis may be detrimental and even dangerous, particularly if the conclusions drawn are inaccurate or based in faulty information.

PT: Finally, what advice would you give to any mental health clinicians talking to children and adolescents and their parents about social media?

 Mental health clinicians should continue to monitor the research on social media use in order to make accurate recommendations when talking to children, adolescents, and their parents. They should consider individual factors, and help families weigh the pros and cons of social media use, including the pros and cons of different social media platforms. Additionally, mental health clinicians should encourage parents to explore parental controls that might be effective and appropriate for their families. They should also encourage families to discuss appropriate monitoring of their child’s social media use, based on the family’s values and individualized needs.

1. Associated Press. California among states launching probe into TikTok’s effect on kids’ health. KTLA. March 2, 2022. Accessed March 4, 2022. 

https://ktla.com/news/california/california-among-states-launching-probe-into-tiktoks-effect-on-kids-health/

2. Kuntz L. Tourette’s or mass sociogenic illness? You decide. 

https://www.psychiatrictimes.com/view/tourettes-or-mass-sociogenic-illness-you-decide

TikTok has over 1 billion users and dominates youth culture. But is it damaging their mental health?

Jaclyn Halpern, PsyD

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