Dr Rosanna Breaux of the Virginia Polytechnic Institute and State University in the USA has been conducting research to evaluate the impact of the COVID-19 pandemic on the mental health of adolescents, including those at risk due to pre-existing mental health conditions, specifically ADHD. This research, undertaken with her colleagues, has highlighted the need for a mental health intervention, such as the RELAX (Regulating Emotions Like An eXpert) intervention for building resilience in adolescents by imparting coping and emotion regulation skills.
The COVID-19 pandemic has had wide-reaching impacts on societies and people around the world. Various public health measures introduced to contain the transmission of COVID-19 have demanded tremendous adjustments and adaptations by people. Changes linked to stay-at-home directives and transitions to virtual work and school have been rapid and significant, adding to the stress emanating from the health and economic impact of the pandemic.
From early on in the pandemic, scientists started documenting the mental health impact as people responded to the unfolding crisis and navigated the waves of ongoing stress and adaptation. States of anxiety and depression were noted to be high across wide sectors of the global population, as people struggled through the public health crisis. This has been the case for people with and without pre-existing mental health conditions, placing those already vulnerable, due to ongoing chronic life stress and pre-existing mental health conditions, at greater risk for more severe mental health distress. Changes to routine have impacted everyday activities and functioning, including work, leisure, exercise, social activity and relaxation and rest.
Stress and mental health both impact people’s sleep patterns which, in turn, affect their functioning and emotional states. This impact is likely to be even more profound for groups of individuals already vulnerable to disturbances of sleep patterns, such as adolescents and people living with ADHD (attention deficit hyperactivity disorder). Dr Rosanna Breaux and her colleagues have been at the forefront of research during the pandemic aimed not only at understanding the mental health burden of the pandemic for adolescents, with and without ADHD, but also exploring and documenting the effectiveness of mental health interventions aimed at alleviating this distress.
Pathway of adolescence
Dr Breaux has been involved in longitudinal research aimed at evaluating mental health interventions for adolescents with ADHD since before the pandemic. Adolescence is a time of tremendous change along the developmental pathway towards adulthood. During this time, young people have to adapt to neuro-physiological change, social and psychological change, and the reverberation of these changes on relationships with family and friends. Conflict with friends and parents can increase; this may be more so for youth with prior difficulties managing and regulating emotions. Dr Breaux says that research has previously documented the importance of supportive interactions with parents (such as validation, problem solving coaching, comforting) in facilitating effective coping by adolescents. This is likely to be particularly important for adolescents with a pre-existing mental health condition, such as ADHD.
Impact of COVID-19 on adolescent mental health
Drawing on an existing longitudinal group of adolescent research participants, Dr Breaux and her colleagues brought together a group of 283 adolescents in the Southeastern and Midwestern United States, to evaluate changes in and predictors of adolescent mental health during the COVID-19 pandemic. The research participants were of mixed gender, aged 15-17, and included 118 adolescents diagnosed with ADHD. Mental health ratings were obtained from parents and the adolescents using various assessment measures of anxiety, depression, ADHD, oppositionality/defiance, and emotional regulation. An analysis of the results indicated a number of indicators of mental health stress for the youth during the pandemic. These included an increase in symptoms of depression, anxiety, difficulties with cognitive focus and attention, and behavioural difficulties. The researchers noted that these symptoms (with the exception of inattention which remained high) increased and decreased as lockdowns were imposed and lifted respectively, requiring adolescents to stay at home and complete schooling online during periods of lockdown.
Dr Breaux says that adolescents with ADHD experienced more significant increases in difficulties with attention, regulation of activity and impulses, and behavioural difficulties that prompted conflict, compared to adolescents without ADHD. For adolescents who entered the COVID-19 pandemic with less effective emotion regulation abilities, there was an increased risk for all-round mental health symptoms. However, this risk was the highest for adolescents with ADHD and poor emotion regulation abilities, confirming the vulnerability of this group.
RELAX: Regulating Emotions Like an eXpert
Several years ago, Dr Breaux developed an intervention to support adolescents with ADHD in managing emotions that are intense and difficult to process. Emotions like anger, frustration and worry, if not effectively managed, regulated and controlled, can result in depression and anxiety, and potentially cause negative behavioural and interpersonal repercussions (such as family conflict and peer rejection). Young people with ADHD often show difficulties in managing frustration and anger and can be inclined to respond impulsively, which can in turn have negative impacts on schooling and relationships. Dr Breaux says there has been overwhelming evidence of the need to develop interventions appropriate for this group of young people, focused on helping them learn how to regulate their emotions.
To meet this need, Dr Breaux developed the RELAX intervention which she and her colleagues have evaluated in groups of adolescents with ADHD prior to the pandemic. The RELAX intervention is a social-emotional intervention which has been shown to increase adolescents’ ability to regulate their emotions and reduce family conflict. Interestingly, this improvement extended to the parents, who reported enhanced ability to manage their own emotions, and who were also observed to have a better ability to adopt more supportive responses to conflict with their children. The intervention aims not only to teach adolescents more effective skills for regulating their emotions but also to impart skills to parents which enhance adaptive emotional socialisation of their adolescent children during times of intense emotions. The intervention is unique in that it first teaches the parents, and then a week later, teaches the adolescents the skills. This approach allows parents to reinforce the skills for their adolescents, as the adolescents start to learn and apply these skills. The RELAX skills include psychoeducation, setting realistic goals and expectations, practicing coping skills and discussing the management of thoughts and behaviours (cognitive-behavioural management). The intervention comprises 8 group sessions of 90 minutes duration, split into 60-minute parent and adolescent only skills-building sessions/discussions, followed by a joint 30-minute discussion and problem-solving activity including the adolescents and parents.
Dr Breaux is currently evaluating the RELAX intervention delivered in online telehealth formats during the COVID-19 pandemic, even though it was originally developed as an in-person intervention. This includes both a group-based intervention delivered by clinicians and using a self-administered, interactive website.
Building adolescent resilience
Given the uncertainty of a clear end to the COVID-19 pandemic and the documented mental health impact of the pandemic, the research conducted by Dr Breaux and her colleagues offers an important pathway of hope for those at risk of increased psychological vulnerabilities due to the chronic stress of the pandemic and unique individual circumstances and characteristics. This has implications not only for alleviating mental health distress but also for potentially impacting academic outcomes during the pandemic for at-risk youth. Dr Breaux explains that high emotionality and poor emotional coping skills have been linked to greater difficulties with remote learning during the pandemic for adolescents with ADHD. Empowering adolescents with skills to manage and regulate their emotions benefits not only the socio-emotional wellbeing of adolescents but also their family relationships and academic performance, thereby building resilience for the longer-term outcomes that might be skewed by the pandemic.
- Becker, S. P., Breaux, R., Cusick, C. N. et al. (2020). Remote learning during COVID-19: examining school practices, service continuation, and difficulties for adolescents with and without attention-deficit/hyperactivity disorder. Journal of Adolescent Health, 67(6), 769-777. Available at: https://doi.org/10.1016/j.jadohealth.2020.09.002
- Becker, S.P., Dvorsky, M.R., Breaux, R., Cusick, C.N., Taylor, K.P. & Langberg, J.M. (2021). Prospective examination of adolescent sleep patterns and behaviours before and during COVID 19. Sleep. Available at https://academic.oup.com/sleep/advance-article/doi/10.1093/sleep/zsab054/6149938
- Breaux, R., Becker, S. P., & Dvorsky, M. R. (2021). ADHD in COVID-19: Risk, resilience, and the rapid transition to telehealth. The ADHD Report, 29(2). ISSN 1065-8025. Available at: https://doi.org/10.1521/adhd.2021.29.2.1
- Breaux, R., Dvorsky, M.R., Marsh, N.P. et al. (2021). Prospective impact of COVID-19 on mental health functioning in adolescents with and without ADHD: protective role of emotion regulation abilities. The Journal of Child Psychology and Psychiatry. Available at: https://doi.org/10.1111/jcpp.13382
- Breaux, R. & Langberg, J.M. (2020). Development and Refinement of the RELAX Intervention, an Intervention Targeting Emotion Dysregulation and Interpersonal Conflict in Adolescents with ADHD: Results from a Pilot Study. Evidence-Based Practice in Child and Adolescent Mental Health. Available at: https://doi.org/10.1080/23794925.2020.1759468
- McFayden, T. C., Breaux, R., Bertollo, J. R., et al. (2021). COVID-19 remote learning experiences of youth with neurodevelopmental disorders in rural Appalachia. Journal of Rural Mental Health. Available at: www.researchgate.net/publication/346965833_COVID-19_Remote_Learning_Experiences_of_Youth_with_Neurodevelopmental_Disorders_in_Rural_Appalachia
Dr Breaux developed the RELAX intervention to improve emotion regulation/coping abilities in adolescents with ADHD, exploring the utility during COVID-19.
The COVID-19 research was supported by the Institute of Education Science (IES), U.S. Department of Education (grant R305A160126), Cincinnati Children’s Research Foundation, and a Virginia Tech COVID-19 Rapid Response Seed Grant. The RELAX Intervention research was supported by the Clark-Hill Institute for Positive Youth Development at Virginia Commonwealth University.
Stephen Becker, Melissa Dvorsky, Joshua Langberg, Tyler McFayden, Thomas Ollendick, Emma Sciberras
Dr Breaux’s research focuses on the emotional, academic, and social functioning of children and adolescents, particularly those with ADHD, with a focus on emotion regulation. She is also interested in understanding the role parents play in shaping youth’s social-emotional development. Dr Breaux is working to evaluate and disseminate the RELAX intervention, which targets emotion dysregulation and interpersonal conflict.
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