ADHD Medication and Pregnancy
Physicians are unable to provide accurate information on the security of ADHD medications during pregnancy. In the absence research, physicians must weigh the benefits and risks of using medications during pregnancy.
A recent population-based cohort study tracked 898 infants born to women taking ADHD medications throughout pregnancy (stimulants such as amphetamine, methylphenidate dexamphetamine, methylphenidate; and non-stimulants such modafinil, atomoxetine and clonidine) until they were diagnosed with a developmental disorder or passed away or left the country.
Risk/Benefit Discussion
CAP Smart Take:
Doctors are concerned with the long-term effects that exposure to drugs in utero can be a source of harm, particularly for centrally stimulating drugs such as those used to treat ADHD. It is important that women receive appropriate guidance from their physicians about the dangers and benefits of taking medications during pregnancy and prior to conception. In this Smart Take on CAP, we examine the latest data in this area and how it can inform the practice of a physician.
Animal studies as well as research on illicit drugs suggest that stimulant medications pass to the fetus through the placenta and may adversely affect the development of the fetus and growth. However, there are limited information regarding the way that the fetus reacts to dosages of prescribed stimulant medication during pregnancy and the majority of this data is based on single-arm studies that have not been sufficiently powered to determine if there are significant connections.
The study conducted by Cohen et al4 stands out from the rest, as it is the largest and most carefully controlled. The study covered 364,012 pregnancies that were retrieved from the Danish Medical Registry. Information about the use of medications was gathered by analyzing the redeemed medication. The researchers specifically excluded women who had reported taking SSRI drugs or clonidine because these medications can interfere with the fetal NMDA receptor and increase the risk of developing neurodevelopmental disorders such as autism and ADHD. The authors modified their analysis to take into account the timing of exposure and to make sure that they control for confounding factors.
The results of this study and other limited trials indicate that the majority of women who continue to take their stimulant medication prescribed for ADHD during pregnancy are not experiencing adverse effects on their fetuses. As a result, it is likely that a large number of women will continue to take their medications for ADHD during pregnancy. However, it is crucial that doctors carefully weigh the risks and benefits of these medications for their pregnant patients, and be aware of the unique circumstances of each patient, before suggesting that they stop taking their medications. Whatever decision they make, it is crucial that pregnant women with ADHD educate their spouses or their partners, extended family members as well as their employers about the decision they have made. This is because the signs of hyperactivity, inattention and impulsivity are likely to return when the mother stops taking her medication.
Pregnancy Tests
Preconception counseling for women suffering from ADHD who want to become pregnant should focus on a comprehensive management plan that involves both pharmacologic and behavioral treatment and continuous monitoring throughout the perinatal period. The plan should include a discussion about the current treatment regimens, especially during the first trimester when the chances of harming the baby due to untreated ADHD are the highest. This should be a collaborative effort between psychiatry and primary care, as well as obstetrics.
The discussion of the risks and benefits should also include how a woman intends to manage her ADHD symptoms during pregnancy, the effect of this on family functioning, and how she feels about discontinuing psychostimulant treatment in the early stages. This should be based on an in-depth analysis of the evidence available and consider the individual needs and concerns.
The authors of a massive study that followed children who were exposed ADHD medication during pregnancy concluded that "continuation psychostimulant usage during early pregnancy did not cause adverse birth outcomes and, if anything, it was associated with less stress among mothers." However the conclusion they reached is not without limitations. The study did not take into account the importance of the dose of stimulant medication and how long it was used for, in addition to other sociodemographic and clinical factors. Furthermore, there is no controlled research examining the safety of continuing psychostimulant use among nursing mothers.
Although there is a dearth of clear scientific data on the safety of ADHD medications in pregnancy, the majority of doctors have a general understanding of what the current research suggests and employ the best practices while collaborating with the individual needs of each patient. For example, it is known that there is a higher rate of cardiac malformations among infants born to mothers who have taken methylphenidate within the first trimester of pregnancy (Cooper et al., 2018) It is important to remember that this conclusion was based on one small study that did not account for variations in patient demographics or underlying psychiatric co-morbidity.
In adhd medication ritalin of ADDitude readers, they reported that they are more likely than ever to stop taking their ADHD medication during the first trimester of pregnancy. However, women who stopped psychostimulants in the first trimester of their pregnancy experienced an increase in depressive symptoms. They also found themselves less able enjoy pregnancy and described family functioning as more challenging than those who remained on their dose of ADHD medication or increased it.
Work Functioning Test
The test of work function is a vital component of the examination as it will determine if the patient is able to carry out their tasks. The test is intended for the evaluation of functional limitations. It includes graded material handling exercises (lifting at various heights pulling and pushing), positional tolerance exercises (sitting and standing as well as walking and balancing or stooping, kneeling and stooping), as well as tests that are specialized. The test evaluator analyses the results to formulate an appropriate return-to-work conclusion. ROC curves are used to show the point of minimum misclassification (MIC) for both physical and general work capability as well as the work-functioning problem score.
The MIC is calculated using the COnsensus Standards for the Selection of Health Measurement Instruments Checklist (COSMIN). This method differentiates scores for general physical work capabilities and work-functioning issues, by answering an anchor question. This will prevent a change in metrics from biasing the average.
Driving Test
The most effective treatment for ADHD is psychostimulant medications. It improves driving safety and decreases symptoms. If not treated, severe ADHD can have significant psychosocial and financial implications.
Psychotherapeutic treatments, like cognitive behavior therapy (CBT) or "coaching" techniques have also been shown by research to improve symptoms and enhance performance. These strategies can assist women in tailoring their schedules and utilize their strategies to cope to minimize the effects of their ADHD on work and other areas.
All of these factors could be important considerations in the decision whether to continue or stop psychostimulant treatment. As the most recent data available suggest, even though there is some concern about pregnancy outcomes with in utero exposure to stimulant medications the relative risks are small and the results are confounded by other treatments, maternal health treatment, maternal mental and physical health and the comorbidities. Bang Madsen K, Bliddal M, Skoglund CB, Larsson H, Munk-Olsen TL, Hove Thomsen P, Bergink V. In utero exposure to attention-deficit hyperactivity disorder medication and long-term outcomes for offspring.