ADHD Medication and Pregnancy
Physicians often struggle to counsel patients on the safety of their ADHD medication during pregnancy. As long as research is not available, physicians must weigh the benefits of medication use during pregnancy against the potential dangers for children in each individual situation.
A recent cohort study of the population followed 898 babies born to women who were taking ADHD medications throughout their pregnancy (stimulants amphetamine, methylphenidate dexamphetamine, methylphenidate; non-stimulants: modafinil, atomoxetine, clonidine) until they were diagnosed with a developmental disorder, or died or left the country.
Risk/Benefit Discussion
CAP Smart Take
Physicians are concerned about the long-term consequences of drug exposure in the uterus, specifically to centrally stimulating drugs like those prescribed for ADHD. It is therefore critical that women receive appropriate counseling from their physicians about the potential risks and benefits of using medications prior to conception and during pregnancy. In this Smart Take on CAP, we look at the most current research in this field and how it could inform the clinical practice.
Animal studies as well as studies on illicit drug use suggest that stimulant drugs are passed to the fetus via the placenta, and could negatively affect fetal development and growth. There is however, a limited amount of information on the response of the fetus to dosages of prescribed stimulant medication during pregnancy, and most of this evidence is based on single-arm studies that have been underpowered to detect possible significant associations.
The recent study by Cohen and co. stands out from the others, as it is the largest and most carefully controlled. The study covered 364,012 pregnancies collected from the Danish Medical Registry. Information on medication use was gathered by analyzing redeemed medications. Researchers excluded women who had taken SSRIs, clonidine or clonidine since these drugs can interact with the fetal NMDA and increase the risk for neurodevelopmental disorders like autism and ADHD. The authors also modified their analyses to control for potential confounding factors as well as to account for the timing of the in utero exposure.
The results of this study, along with the results of other limited studies, show that the majority of women who continue to take their prescribed stimulant medication for ADHD throughout pregnancy do not experience adverse effects on their fetuses. As a result, it is likely that a lot of women will continue to use their medication for ADHD during pregnancy. However, it is important that doctors carefully evaluate the advantages and risks of these medications for their pregnant patients, as well as take into consideration the individual circumstances of each patient prior to suggesting they stop their medication. It is crucial that women who are pregnant with ADHD inform their parents as well as extended families and employers of the decision they've taken. This is because signs of inattention, hyperactivity, and impulsivity could return when the mother stops taking her medication.
Pregnancy Tests
Preconception counseling should include an extensive management plan that includes both behavioural and pharmaceutical treatment and continuous monitoring during the perinatal stage. The plan should include a discussion on the current treatment regimens, especially during the first trimester when the risks of harming the baby because of untreated ADHD are the highest. This should be a collaborative effort with psychiatry, obstetrics, and primary care.
The discussion of the risks and benefits should also include how a woman intends to manage her ADHD symptoms during pregnancy, the impact of this on the family's functioning, and how she feels about discontinuing psychostimulant treatment in the initial stages. This should be based on a thorough evaluation of the evidence available and consider the individual needs and concerns.
In a recent study that followed children exposed to ADHD medications during utero and concluded that "continuation of psychostimulant use during the early stages of pregnancy did not increase the risk of adverse birth outcomes, and, if anything, was associated with reduced maternal stress." However, this conclusion is not without its limitations. The study did consider other factors such as the duration for which stimulant medication was used, the dose and the sociodemographics. There is also no research controlled that studies the safety of continued psychostimulant usage in nursing mothers.
Although there is a dearth of scientifically substantiated evidence regarding the safety of ADHD medications in pregnancy, most physicians have a basic understanding of what the current research suggests and employ the best practices, in consultation with each patient's unique needs. For example, it is recognized that there is a higher rate of cardiac malformations in infants born to mothers who have taken methylphenidate during the first trimester of pregnancy (Cooper and co., 2018), while it is important to note that this finding was based on a single study that did not take into account variations in the demographics of patients or underlying psychiatric comorbidity.
In the full report of ADDitude readers, they reported that they are more likely than ever before to stop taking their ADHD medication in the early stages of pregnancy. Women who stopped psychostimulants during the first trimester showed a clinically significant rise in depressive symptoms. They also reported feeling less able to enjoy their pregnancy and rated their family functioning as more difficult than those who continued to take their dose of ADHD medication or increased it.
Work Functioning Test
The work function test is an important part of the examination, as it determines if the candidate is able to perform their job. The test is designed for the evaluation of functional limitations. It includes a variety of graded material handling tasks (lifting at various levels pulling and pushing) and tests for positional tolerance (sitting and standing while walking, balancing and walking in a stoop, kneeling and stoop) and specific tests. The examiner will analyse the results and formulate an appropriate return to a conclusion of the work. ROC curves are used to show the point of minimal misclassification (MIC) for both physical and general working ability as well as the functional score for a particular problem.
The MIC is calculated by using the COnsensus Standards for the Selection of Health Measurement Instruments Checklist (COSMIN). This method divides the scores of physical and general ability and work-functioning issues based on an answering an anchor question, to avoid changes in the metric from biasing the overall average.
Driving Test
Psychostimulant medication is a gold standard treatment for ADHD. It helps reduce symptoms and improves performance in other areas, including driving safety. The effects of severe, untreated ADHD can have significant psychosocial and financial consequences.
Psychotherapeutic treatments such as cognitive behavioral therapy (CBT) and "coaching" strategies have also been shown to reduce symptoms and improve functioning. These strategies may assist women in tailoring their routines and use their coping skills to minimize the effects of their ADHD on their work and other domains.
All of these factors could be crucial considerations when making the decision to continue or end psychostimulant therapy. The most recent data available indicate that, despite concerns regarding the outcome of pregnancy when in utero stimulant medications are used, the relative risks of this are small. The results are muddled by other medication, the use of maternal healthcare, maternal mental and physically health, and 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.