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ADHD & lockdown: How to manage the end of the day if agitation and impulsivity are at their peak

Dr E Khoury, Dr A Cohen, Dr E Acquaviva (Psychiatrists), Ms J. Chagneau (Psychomotrician) - Specialized Unit for the Diagnosis and Treatment of ADHD - Centre of Excellence for Neurodevelopmental Disorders of Ile de France

As in all families, the end of the day is always a challenge for parents, especially for those with a child with ADHD. Agitation and impulsivity are increasingly intense. Conflicts emerge even more so when we parents are tired from our day, divided between managing the children, homework, cooking, shopping and work. In short, the end of the day can be a nightmare and we find ourselves counting the hours until bedtime. So to avoid too much tension at home or leaving your child in front of the television or video games for hours on end, here are a few tools.

1 - Plan in advance the activities for the 4 p.m. - bedtime period:

In the form of a visual timetable, your child will be able to check off the activities that will be carried out as you go along.

# Favor physical activities to allow him to exercise. Be careful not to do them too close to bedtime, as they may delay falling asleep. Here are a few suggestions for motor activities:

o With your child, make a trail that you create with equipment or furniture from home: chairs, cushions, books... (equipment that does not break). The course must be built so that the child can crawl, jump on one foot/two feet/on the spot, slalom... Your child must do it in one direction than the other, this will help him work on his memory skills. Ask your child to do it again after a while singing or telling a story.

o Take the same material and ask your child to create a new route, as different as possible from the first one. This will help your child work on his imagination and mental flexibility.

o Play mime games: write actions to mime on paper and place them inside a container and take turns to pick an action to mime and make the other participants guess it.

o Play statue games: put on music to get your child dancing and let off as much steam as possible, and they should freeze in place as soon as the music stops.

o For more motor activity ideas, see our age-specific motor activity sheets:

▪ MIDDLE SCHOOL/HIGH SCHOOL : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-middle-school-high-school

▪ ELEMENTARY SCHOOL : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-elementary-school

▪ EARLY CHILDHOOD/KINDERGARTEN : https://www.debrechildpsychiatry.org/post/psychomotor-therapy-during-home-lockdown-preschool-kindergarten

# Assign missions after 4:00 p.m.: your child will channel his or her energy into completing the mission and will feel valued by these new responsibilities. For example:

o Appoint him as a chef: involve him in the kitchen in the preparation of a cake, or dinner, or master of ceremonies or a game to be played with the family.

o Involve him in the management of his little brothers and sisters.

# Set up a schedule of things to do after 4pm: especially for the bedtime rituals: washing, brushing teeth, pajamas, reading... Encourage your child for the efforts he makes to reach these goals, without systematically criticizing him for not achieving them. These are goals to be achieved, not prerequisites.

# Organize your schedule so that you are also more available for your child after 4pm. If possible, try to put your important telephone meetings at the beginning of the day, when your child is calmer. Or when you know that he is able to be calm, for example just after breakfast or just after lunch. Or when they have a chance to let off steam in the courtyard of your building or your house.

# Establish a calm environment & keep a steady pace of life:

o Put in place conditions to promote relaxation: soothing, orderly environment, soft light, soft music... avoid overestimation at the end of the day.

o Pay attention to the group effect: separate the children in different rooms if necessary.

o Serene family environment, appropriate parental attitude: do not raise your voice, speak in a neutral tone.

# Encourage behavioral change by reinforcing positive behaviors. Set up a special 'after 4pm' board if necessary, click here for more information: https://www.debrechildpsychiatry.org/post/how-to-keep-my-child-motivated-during-the-lockdown-token-chart-or-token-economy-system

# Dealing with rage and opposition. The whole family is under a lot of stress. So your child may face frustrating situations that are triggers for tantrums or rage, especially. They will therefore have to be managed in the best possible way, in order to preserve family harmony during lockdown. The key message is not to "escalate" during the crisis, i.e. react like a mirror to your child. Click here for more information: https://www.debrechildpsychiatry.org/post/how-to-deal-with-oppositional-behavior-and-rage-attacks-during-confinement

# Manage screen use. Excessive screen use can lead to a direct aggravation of agitation, but also indirectly by disrupting sleep if this activity is practiced unreasonably in the evening. Anticipate stopping screens 1 to 2 hours before bedtime. Click here for more information: https://www.debrechildpsychiatry.org/post/how-to-manage-the-digital-activities-of-my-child-during-the-lockdown-period

# Assess the possibility of other causes of agitation at the end of the day, including anxiety about going to bed, fear of the dark, fear of being separated from you, or even fear of dying from Covid19. Click here for more information: https://www.debrechildpsychiatry.org/post/how-to-help-your-child-anxious-about-coronavirus

2 – The special case of children with methylphenidate treatment:

For parents who have a child treated with methylphenidate, you already know that the treatment has a relatively short action and that the effects usually wear off around 4pm. This is a time when all children, and especially those with ADHD, are restless and impulsive.

# Did you know? There can be rebound effects at the end of the dose.

Sometimes when the treatment is no longer active, there can be rebound effects. This means that the agitation and impulsivity are even stronger than if your child wasn't taking medication. He or she may be overwhelmed, or even a little sad. Be careful, this rebound effect is not very frequent. It is therefore important to compare your child's behaviour at 4 or 5 p.m. on a day when he did take his treatment and on a day when he did not take it. Most often, it is only a return to your child's usual level of agitation.

# Are there ways to increase the duration of the treatment's effectiveness without preventing your child from sleeping?

1. Suggest a change in treatment to a longer lasting formulation, providing longer coverage over 24 hours.

2. Add a small dose of immediate-release treatment in the afternoon, just before the morning treatment wears off.

3. Shift the time of intake of treatment in the morning by delaying it a little. In fact, it is possible that during the confinement period, your child will sleep a little longer in the morning and that the treatment can be given, for example, an hour later than during the regular school period. But be careful! It is strongly advised not to completely delay waking time (and consequently bedtime) and to disturb your child's sleep/wake cycle. Sleeping late in the morning should be avoided at all costs. Your child should continue to get up early and start his day. However, a little flexibility (30-60 minutes maximum) is not impossible.

4. There is a risk that switching to a longer-lasting formulation, or adding an extra dose in the afternoon, may lead to sleep disturbance. Therefore, keep a close eye on your child's sleep, and insist on good sleep hygiene measures (relaxation time before bed, avoid exciting activities in the evening, light but consistent dinner, regular sleeping hours, quiet room with adequate temperature, dark +/- small night light, access to daylight in the morning...).

5. In general, watch out for potential side effects or signs of overdose if the total daily dose of the treatment is increased: insomnia, loss of appetite, palpitations, sadness or irritability during the duration of action the treatment.

Contact your doctor (psychiatrist, pediatrician or general practitioner) by email (or any other means they will have suggested during this period of confinement), to discuss this with him. Do not make any treatment changes without the advice of a specialist.

Translated by Dr Elie Khoury (psychiatrist)

48 Boulevard Serurier, 75019  Paris France

©2020 by Dr. Benjamin Landman. Child Psychiatry, Robert Debre Hospital - Paris