Adults with ADHD usually function well on medication. Off medication is another story. Hyperactivity, distractibility, and impulsivity can lead to marital strife, poor job performance, and friends backing off. And let's not forget problems with organization of thoughts, activities, and time, the nexus at which life can fall apart. This dilemma almost always occurs with women who are pregnant or nursing.
Clinicians once believed that the placenta served as a barrier that protected the fetus from adverse effects of medications and toxins taken by the mother. We now know that medication can pass through the placenta to the fetus. The Food and Drug Administration has established a classification system for judging the safety of medications taken during pregnancy. However, this system is considered by doctors to be informational only.
All of the medications used to treat ADHD are in the FDA's Class C. They are not definitely safe and they are not definitely harmful. "Best practices" means making decisions based on the physician's best knowledge of what other physicians do, what the outcomes have been when these medications have been used, and his or her best judgment for each patient. Each physician must educate the patient, make reasonable recommendations, and act based on a collaborative decision. Treatment must strike a balance between assumed safety and the needs of the adult. This decision should be one that both the woman with ADHD and her partner agree on.
The decision to continue ADHD medications is ideally made when the patient informs her physician that she plans to become pregnant. There is time to learn and to make the best decision. But life does not always go as planned. Frequently, the decision is first discussed after the woman learns that she is pregnant, often four or more weeks into the pregnancy, after the fetus has already been exposed to medications.
There is no definitive evidence in humans that ADHD medications have a negative impact on the fetus, and there is no published clinical data based on women who continued their medications during pregnancy. Thus, the course of treatment should be based on a balance between the mother's need for medication and her desire not to expose her baby to drugs about which very little is known.
A recent review of the literature found that there were no controlled studies on the safety of psychiatric medications of all types in nursing mothers. Thus, as with pregnancy, whether or not to nurse is another decision pregnant women need to make.
The Food and Drug Administration classification system is used in this situation too. The physician has even less data on the impact of ADHD medications during nursing than with their use during pregnancy. Each mother must discuss these issues with her physician and make her own decision.
If ADHD medications are used, it is recommended that the mother work closely with the pediatrician. She must learn what reactions in the baby might suggest a negative effect from the medication. For stimulant medications, these behaviors include irritability and poor sleeping patterns. If you notice these behaviors, the medication should be decreased in dose or stopped entirely.
So, What To Do?
One must weigh the effect on the mother of going off medication, considering what little is known about the impact of such medications on the fetus and, later, the baby.Your obstetrician will be able to provide you with literature on medications taken during pregnancy.
Your pediatrician will be able to provide you with literature on medications taken while breast feeding. Read this literature. Then think through how seriously you might need the ADHD medication during the nine months of pregnancy and, if chosen, 20+ months of breast-feeding.
Remember, too, that there are other non-invasive treatments and strategies for ADHD that don't involve such painful decisions. One is to get an ADHD coach to help you plan your day and follow through on your plans. Coaches can't take away the symptoms of ADHD but can certainly help you deal with them. Most coaching is done by phone.