Understanding ADHD in Women: Pregnancy, Medication, and Postnatal Considerations
As the number of women presenting for ADHD assessment and treatment increases, I am seeing a growing number of young women who are asking about what happens to their ADHD treatment if and when they become pregnant. As with most decisions about medical treatments in pregnancy, the question comes down to the risk posed by ADHD treatments versus the risks posed by stopping treatment. Risks for both the fetus and the mother must be considered. The risks of stopping or reducing ADHD medication will be weighted differently for each person based on their unique circumstances, and this requires a discussion with a person's doctor. The response should not be a blanket ban or free-for-all on stimulant medication.
**Most of the studies I refer to below are not cited in this blog post, rather, further information can be found in an authoritative presentation listed at the bottom of the blog post.**
Perinatal and Postnatal Risks
Women with ADHD face additional challenges during the perinatal (pregnancy) and postnatal stages. Studies have indicated that women with ADHD are at a higher risk of experiencing postnatal depression, anxiety, and emotional dysregulation. Many women with ADHD will already have experienced depression and/or anxiety in their lives, which is an indicator of increased peri and postnatal risk for recurrence.
Furthermore, the demands of caring for a newborn can intensify ADHD symptoms. Lack of sleep, a common issue for new mothers, can exacerbate problems with attention, memory, and mood regulation, which can be particularly challenging for women with ADHD.
Stimulant Medication: Risks in Pregnancy and Breastfeeding
Stimulant medications, such as methylphenidate and amphetamines, are used as first-line treatments for ADHD. However, when it comes to pregnancy and breastfeeding, the use of these medications can be a complex topic.
Research in this area is limited, and there is a lack of definitive, long-term studies assessing the safety of stimulant medications during pregnancy. As with all studies of medications used in pregnancy, randomised controlled trials do not exist due to ethical considerations. Some research has suggested that there may be an increased risk of certain heart defects, preterm birth, and low birth weight with stimulant use during pregnancy. However, these studies often do not account for other factors that could contribute to these outcomes, such as smoking or alcohol use, which are higher in samples of women with ADHD than without.
One naturalistic study with a moderately large sample size and multi-year follow-up was performed in Denmark and published in early 2023. All women in the sample had taken stimulant medication pre-pregnancy, with 893 continuing to fill a prescription during pregnancy, and 1,270 ceasing medication. This study is important as the control group were also women with ADHD, so the increased risk factors that ADHD brings with it were present in both groups. The average follow-up time of those unborn children was five years, with the maximum being 20 years. The study found no increase in rates of ADHD, ASD, cerebral visual or auditory impairments, seizure disorders, or growth restriction in the children whose mothers continued to take stimulant medication compared to those who ceased. The authors note "These findings provide reassurance for women with ADHD who depend on ADHD medication for daily functioning and who consider continuing medication in pregnancy."
While the full text of this article is not freely accessible, you can read the abstract here: In utero exposure to ADHD medication and long-term offspring outcomes
Breastfeeding while on stimulant medication also needs consideration. These medications can pass into breast milk. However, again, research is limited, and the impact is not entirely understood, but it shows that around 1% of methylphenidate and 5% of amphetamine preparations can make it into breast milk.
Risks of ceasing stimulant medication
People with ADHD take stimulant medication for a reason. It can produce significant improvements in ADHD symptoms and can reduce functional impairment at home, work, and other settings. Discontinuation of medication will lead to symptom exacerbation and can impact on people's functioning in a number of life areas. I have met women who have avoided yet another drop-out at university or another impulsive quitting of a job because they are now on stimulant medication. The risks of negative outcomes happening due to stimulant cessation is a real risk to the mother, family, and the unborn child.
So what does research say about the increased risks of stimulant cessation for a mother at these times? Not surprisingly, there isn't much research on this topic. But what there is has found increased rates of peri-natal and post-natal depression (even when continuing antidepressant medication), and lower self-esteem and self-confidence in the post-natal period. For a woman with a history of significant emotional dysregulation that can include depressive episodes and suicidal ideation or attempts; the risks to the woman, her family, and her unborn child of coming off a stimulant medication perinatally really should be weighed carefully against the small risks of a few known birth abnormalities.
If you are a woman with ADHD contemplating pregnancy, have a conversation with your healthcare provider about their and your understanding of the risks of both continuing, reducing, or ceasing stimulant medication.
It's essential to remember that every woman's experience is unique, and what works best will depend on individual circumstances. Balancing the benefits of ADHD management with the potential risks to both the mother and the baby is a decision made through careful deliberation, with the health and wellbeing of both mother and baby at the forefront.
An authoritative one-hour presentation of known risks and benefits of stimulant medications peri and post-natally is presented by psychiatrist Dr Allison Baker, who is a clinician, researcher, and educator with the Perinatal and Reproductive Psychiatry Clinical Research Program at Massachusetts General Hospital, with an appointment at Harvard Medical School: ADHD, Pregnancy, and Motherhood: A Practical Guide for Hopeful Parents
Treating for Two: ADHD Meds in Pregnancy on ADDitude