We continue to see an increasing number of women with attention-deficit/hyperactivity disorder (ADHD) who are either pregnant or planning to conceive.  While we have considerable data to indicate that women with mood and anxiety disorders are at increased risk for relapse during pregnancy, we have very limited information on the course of ADHD during pregnancy.  

In a recent study for the MGH Center for Women’s Mental Health, Dr. Alison Baker and colleagues recruited pregnant women with ADHD in order to better characterize the course of ADHD during pregnancy. Pregnant women (less than 20 weeks of gestation) between the ages of 18 and 45 were followed prospectively across pregnancy.  In this observational study, all of the women were taking ADHD medications prior to conception and elected to discontinue (n=5), maintain (n=12), or adjust their ADHD medications during pregnancy (n=8). 

Assessments were completed at baseline, 24 weeks, and 36 weeks pregnant.  At each visit, participants completed the Adult ADHD Investigator Symptom Rating Scale (AISRS), an 18-item questionnaire which evaluates the severity of both hyperactivity and inattentive ADHD symptoms over the previous two weeks.  In addition, they completed self-rated assessments including the Edinburgh Postnatal Depression Scale (EPDS) and the Weiss Functional Impairment Rating Scale Self-Report (WFIRS-S).

A total of 25 women with ADHD were eligible for analysis. Looking at AISRIS scores alone, which indicate the severity of ADHD symptoms, women in all three groups did not experience any significant changes in the severity of their symptoms as they progressed through the pregnancy.  

Although ADHD symptoms remained relatively stable across pregnancy for women who discontinued psychostimulants, this group of women experienced a clinically significant increase in depressive symptoms (as measured using the EPDS) despite making no changes in their antidepressant medications.  In contrast, women who either maintained or adjusted ADHD medications experience no significant change in depressive symptoms.

In addition, women who discontinued psychostimulant treatment during pregnancy experienced significant impairment in family functioning. Specifically, they were more likely to experience conflict within the family, had greater difficulty in having fun as a family, rated parenting as more difficult, and described being more isolated from their family.

Clinical Implications

To date, there have been no systematic studies examining the course of ADHD during pregnancy. Given this dearth of information, it has been difficult to advise women regarding the treatment of ADHD during pregnancy.  Further complicating the decision-making process is the significant heterogeneity of this population, with some women having more severe illness and psychiatric comorbidity, and others who may use stimulants only as needed.  

Despite reassuring data on the reproductive safety of stimulants, we often recommend discontinuing psychostimulant  treatment when a woman has milder symptoms, and if it seems that she has been able to function fairly well without stimulants.  While this approach makes sense in terms of limiting unnecessary exposures in women with what appears to be milder illness, we have often been surprised by the clinical outcomes in this population, specifically  when women who were previously high functioning experience significant psychiatric morbidity during the course of pregnancy and the postpartum period after discontinuation of stimulants.  

This preliminary study gives us important information regarding the course of ADHD during pregnancy, highlighting the risks of stimulant discontinuation in this population.  The authors note, “These data mirror the clinical phenomenon of an expectant woman with ADHD who describes feeling more ‘together,’ centered, and generally competent when she has the ability to take her stimulant medication as she deems appropriate.”  Furthermore, they note that in this clinical population, half of the participants met criteria for Generalized Anxiety Disorder, and a third had Major Depressive Disorder. Given the prevalence of psychiatric comorbidity in women with ADHD, it is essential that clinicians consider the whole clinical picture in terms of making decisions about the treatment of ADHD.  The current study indicates that discontinuing treatment with a stimulant can have significant consequences, increasing risk for depressive symptoms and worse family functioning.  

Ruta Nonacs, MD PhD

Baker AS, Wales R, Noe O, Gaccione P, Freeman MP, Cohen LS.   The Course of ADHD during Pregnancy. J Affect Disord (in press).