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Is it safe for a woman with ADHD to receive stimulant medication treatment when she is pregnant or breastfeeding?

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With more women being diagnosed and treated for ADHD, the question whether stimulant medications during pregnancy are safe for the developing fetus has become more critical to answer with good data. In general, stimulants (either the amphetamines like Adderall or methylphenidate like Concerta, Ritalin LA and Metadate CD) are all considered "Category C" teratogens. That means that they should only be used when the risk to the mother (by not receiving medication treatment) outweighs the risk to the fetus.

The safety of stimulant medication for the fetus is difficult to know because most of the research has been done in animals. Very few human studies have been done. In animals, birth defects and behavioral changes have been found in several different species treated with high doses of methylphenidate or amphetamines.

A 2005 U.S. government expert panel evaluating the safety of methylphenidate concluded there are insufficient data to draw conclusions on 1) an association between methylphenidate therapy in pregnant women and pregnancy loss and 2) possible reproductive effects of methylphenidate in humans.(Golub et al., 2005b) A related expert panel expressed more concern about the safety of amphetamines.(Golub et al., 2005a). They concluded "there is some concern for developmental effects, specifically for potential neurobehavioral alterations, from prenatal amphetamine exposure in humans both in therapeutic and nontherapeutic settings."

A reference book, Drugs in Pregnancy and Lactation, ninth edition, summarized the literature by categorizing methylphenidate as: "Limited human data, - Animal data suggest moderate risk." Breastfeeding- limited human data- potential toxicity."(Briggs et al., 2011)

This same text categorized amphetamines as "Human and animal data suggest risk." For Breastfeeding- the authors classified amphetamines as "Limited human data- potential toxicity."(Briggs et al., 2011) The American Academy of Pediatrics classifies Amphetamines as contraindicated during pregnancy because of potential irritability and poor sleeping patterns for the infant.(American Academy of Pediatrics Committee On, 2001)

Some important questions for a woman being treated for ADHD who is thinking about getting pregnant or who is pregnant are:

  • Should she discontinue stimulants prior to becoming pregnant?
  • Should she discontinue medication during the first trimester of pregnancy?
  • Should she discontinue medication during the entire pregnancy?
  • What are the risks both to the mother and the baby if her ADHD goes untreated?
  • Are there psychosocial treatments for ADHD that do not include medication treatment that might be helpful?
  • Each woman should consider all of the available information and discuss these issues with her physician and make her own decision about her treatment during her pregnancy.

Implications:

Although we have tried to answer whether it is safe to take stimulant medication during pregnancy, this information should not be considered a substitute for medical advice. We encourage each woman to discuss this information and any questions or concerns with her physician. We also provide, below, a brief description of non-medication treatments to consider.

Further Information on pregnancy and nursing:

Non-medication treatments to consider

Pregnant and nursing women with ADHD may want to consider non-medication treatments. An effective cognitive-behavioral treatment has been developed that aims to help people develop their executive skills, including time-management, organization, and planning, and can be provided in group (Solanto et al, 2010) or individual (Safren et al, 2010) therapy. Published manuals for each of these are available for treatment providers.

Coaching is another non-medical intervention that may hold promise for pregnant or nursing mothers. Coaching allows individuals to deliberately manage behavior in all areas of life while having accountability and support to enhance their follow through (Quinn, Ratey, & Maitland et al., 2000; Whitworth et al. 2007). Coaches use an inquiry approach to promote reflection and introspection while allowing individuals to set realistic, specific goals, develop action plans and reflect on what helps and gets in the way of goal attainment. There is a small but promising body of research using coaching with adults and college students with ADHD.

References:

American Academy of Pediatrics Committee On, D. (2001). Transfer of drugs and other chemicals into human milk. [Guideline Review]. Pediatrics, 108(3), 776-789.

Briggs, G. G., Freeman, R. K., & Yaffe, S. J. (2011). Drugs in pregnancy and lactation : a reference guide to fetal and neonatal risk (9th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Golub, M., Costa, L., Crofton, K., Frank, D., et al. 2005a. NTP-CERHR Expert Panel Report on the reproductive and developmental toxicity of amphetamine and methamphetamine. [Review]. Birth Defects Res B Dev Reprod Toxicol, 74(6), 471-584. doi: 10.1002/bdrb.20048

Golub, M., Costa, L., Crofton, K., Frank, D..et al. 2005b. NTP-CERHR Expert Panel Report on the reproductive and developmental toxicity of methylphenidate. [Review]. Birth Defects Res B Dev Reprod Toxicol, 74(4), 300-381. doi: 10.1002/bdrb.20049 (Safren et al, 2005) (Solanto, 2011 #2220). Research thus far indicates that these treatments can be helpful whether or not patients are concurrently receiving medication for ADHD.

Safren, S. A., S. Sprich, et al. (2005). Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program (TherapistWorkbook ). New York, Oxford University Press.

Safren, S. A., S. Sprich, et al. (2010). "Cognitive behavioral therapy vs. relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial." Journal of the American Medical Association 304(8): 875-880.

Solanto, M. V., D. J. Marks, et al. (2010). "Efficacy of meta-cognitive therapy (MCT) for adult ADHD." American Journal of Psychiatry 167(8): 958-968.

Solanto, M. V. (2011). Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction. New York, N.Y., Guilford Press.

Field, S., Parker, D., Sawilowsky, S., & Rolands, L. (2010). Quantifying the effectiveness of coaching for college students with Attention Deficit/Hyperactivity Disorder: Final report to the Edge Foundation. Retrieved from http://www.edgefoundation.org/wp-content/uploads/2011/01/Edge-Foundation-ADHD-Coaching-Research-Report.pdf.

Field, S., Parker, D., Sawilowsky, S., & Rowlands, L. (2013). Assessing the Impact of ADHD Coaching Services on University Students' Learning Skills, Self-Regulation, and Well-Being. Journal of Postsecondary Education and Disability, 26(1).67 - 61 67

Kubik, J. A. (2009). Efficacy of ADHD coaching for adults with ADHD. Journal of Attention Disorders, 13(5), 442-453.

Parker, D. R., & Boutelle, K. (2009). Executive function coaching for college students with learning disabilities and ADHD: A new approach for fostering self-determination. Learning Disabilities Research & Practice, 24(4), 204-215. doi:10.1111/j.1540-5826.2009.00294.x

Parker, D. R., Hoffman, S., Sawilowsky, S., & Rolands, L. (2011). An examination of the effects of ADHD coaching on university students' executive functioning. Journal of Postsecondary Education And Disability, 24(2), 115-132. Retrieved from http://www.ahead.org/publications/jped

Richman, E.L, Rademacher, K.N. & Maitland, T.L. (2014). Coaching and College Success. Journal of Postsecondary Education and Disability, 27 (1), 33-52.


Updated: July, 2014
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