ADHD Medication and Pregnancy
Physicians often struggle to inform patients about the safety of their ADHD medication during pregnancy. Until more research is available, physicians must weigh the advantages of medication use during pregnancy against the potential dangers for children in each unique circumstance.
A recent study on a population-based cohort monitored 898 babies born to women taking ADHD medications throughout pregnancy (stimulants such as amphetamine, methylphenidate, dexamphetamine; 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:
Doctors are concerned about the long-term effects that exposure to drugs in utero may result in, especially for centrally stimulating medications such as those used to treat ADHD. It is crucial that women receive appropriate medical advice from their doctors regarding the potential risks and benefits of using medications prior to conception and during pregnancy. In this CAP Smart Take, we look at the most current research in this area and how it can guide the practice of a physician.
Animal studies as well as research on illicit drugs suggest that stimulant drugs are passed to the fetus via the placenta, and could adversely affect the development of the fetus and growth. However, there are limited data regarding the way that the fetus reacts to the therapeutic doses of prescription stimulant medication during pregnancy, and the majority of this evidence is based on single-arm studies that are not sufficiently powered to detect possible significant associations.
The study conducted by Cohen and colleagues4 is unique because it is the most complete and well-controlled. The study comprised a sample of 364,012 births from the Danish Medical Registry, and information about the use of medications was obtained by analyzing prescriptions that were redeemed. Researchers excluded women who had taken SSRIs, clonidine or clonidine since these drugs could interact with the fetal NMDA and increase the risk for neurodevelopmental disorders such as autism and ADHD. The authors modified their analysis in order to account for the timing of exposure as well as make sure that they control for confounding factors.
The results of this study, along with the results of other limited studies, suggest that the majority of women who continue to take their prescribed stimulant medications for ADHD during pregnancy don't experience adverse effects on their foetuses. As a result, it is likely that a large number of women will continue to use their medications for ADHD during pregnancy. It is important for doctors to weigh the risks and benefits of these medications prior to advising their pregnant patients to stop taking the medications. It is important that pregnant women with ADHD inform their parents as well as extended families and employers of the decision they've taken. This is because the symptoms of hyperactivity, inattention and impulsivity are likely to return when the mother stops taking her medications.
Pregnancy Tests
Preconception counseling for women with ADHD who want to become pregnant should focus on a comprehensive plan of management that involves both behavioral and pharmacologic treatment and continuous monitoring throughout the perinatal period. The plan should include a discussion of the current treatment regimens, especially during the first trimester when the risks of harming the baby due to untreated ADHD are highest. This should be a collaborative effort between obstetrics, psychiatry and primary care.
The discussion of the risks and benefits should also cover how a woman will manage her ADHD symptoms during pregnancy, the effect of this on the family's functioning, and how she feels about discontinuing psychostimulant treatment in the initial stages. This should be informed by a thorough review of evidence available, including consideration of the specific patient's needs and concerns.
The authors of a large study that followed children who were exposed to ADHD medications during utero concluded that "continuation psychostimulant usage during early pregnancy did not cause adverse birth outcomes and if anything, was associated with reduced stress among mothers." However their conclusion isn't without limitations. The study didn't consider the significance of the dosage of stimulant medication, nor the long it was used in addition to other sociodemographic and clinical factors. There is no research controlled that studies the safety of continued use of psychostimulants by nursing mothers.
While there is a lack of clear scientific data on the safety of ADHD medications in pregnancy, the majority of doctors have a basic understanding of what the current research suggests and employ the best practices in consultation with the individual needs of each patient. It is known, for instance, that infants born to mothers taking methylphenidate in the first trimester are more likely to suffer from cardiac malformations (Cooper, et al. 2018). However this conclusion is based on a tiny study that didn't consider the differences in the demographics of patients and the underlying psychiatric conditions.
In a recent survey of ADDitude readers, they revealed that they are more likely than ever before to quit taking their ADHD medication during early pregnancy. However, women who stopped psychostimulants in the first trimester of their pregnancy experienced a clinically significant increase in depressive symptoms. They also felt less able to enjoy their pregnancy and rated their 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 aspect of the test in that it determines whether an individual is able to carry out their job. The test is designed for testing functional limitations. It includes a variety of graded material handling tasks (lifting at various levels, pulling and pushing) and positional tolerance exercises (sitting and standing as well as walking and balancing, stooping and kneeling), as well as specialized tests. The evaluator analyzes the results to formulate the return-to-work conclusions. ROC curves can be used to determine the point of minimal classification (MIC) in the general work capability physical work capability and the work-functioning issues score.
The MIC is calculated using the COnsensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. adhd medications divides scores for general physical work capabilities and work-functioning issues by answering an anchor question. This prevents a change in metrics from biasing the average.
Driving Test
Psychostimulant medication is a gold treatment for ADHD. It reduces symptoms and improves performance in other areas, such as driving safety. Impairment due to severe untreated ADHD can have profound psychosocial and financial consequences.
Psychotherapeutic treatments, like cognitive behavior therapy (CBT) or "coaching" techniques have been proven by research to reduce symptoms and improve function. These strategies can help women tailor their routines, and use their coping skills to minimize the impact of ADHD on their work and other areas.
All of these factors could be important considerations in the decision of whether to continue or discontinue psychostimulant therapy. As the most recent data available indicate, although there is some concern regarding pregnancy outcomes with in utero exposure to stimulant medication, the risks are minimal and the outcomes are influenced by other medication, health care utilization, maternal mental and physical health, and other comorbidities. Bang Madsen K, Bliddal M, Skoglund CB, Larsson H, Munk-Olsen T, Hove Thomsen P, Bergink V. In utero exposure to attention deficit hyperactivity disorder medication and long-term effects on offspring.