Roe v. Wade Ruling May Disproportionately Impact Girls with ADHD
“By limiting a woman’s right to choose, the Supreme Court decision is likely to have chilling effects on the health and mental health of women with ADHD, not just immediately but over the long term.” — Stephen Hinshaw, Ph.D.
Young women with ADHD are roughly four times more likely than their neurotypical peers to experience an unwanted pregnancy before age 30,1 according to research conducted, in part, by Stephen Hinshaw, Ph.D. This elevated risk, combined with a higher likelihood of engaging in unprotected sex and experiencing intimate partner violence, means that females with attention deficit hyperactivity disorder (ADHD) will almost certainly feel a disproportionate impact from today’s U.S. Supreme Court ruling overturning Roe v. Wade, Hinshaw said.
“We know, from the Berkeley Girls with ADHD Longitudinal Study (BGALS), that girls with ADHD — as they progress into adolescence and adulthood — are truly at high risk for unplanned pregnancies, the experience of intimate partner violence, and engagement in self-harm (both ‘cutting’ and attempted suicide),” said Hinshaw, author of Straight Talk About Girls with ADHD. “By limiting a woman’s right to choose, the Supreme Court decision is likely to have chilling effects on the health and mental health of women with ADHD, not just immediately but over the long term.”
The BGALS study has tracked the behavioral, emotional, and academic development of 140 ethnically and socioeconomically diverse girls with “rigorously diagnosed ADHD” from childhood to adulthood since 1997. It has found, among other things, that about 43% of the participants with ADHD had one or more unplanned pregnancies by their mid to late 20s, compared to about 10% of women in the comparison group.2
These results echo the findings of a 2019 Swedish study that found girls with ADHD are 6.2 times more likely to become mothers during their teenage years than are their non-ADHD counterparts.3
Similarly, a 2017 Danish study found that girls with ADHD were almost four times as likely as their peers to become pregnant between the ages of 12 and 15, while boys in the same age group were two and half times as likely as their peers to impregnate a partner. Teens of all genders with ADHD between the ages of 16 and 19 were about twice as likely to become pregnant or contribute to a pregnancy. Young adults with ADHD often had more children overall than their peers by age 25.4
These studies and several others have named ADHD as an independent risk factor for early pregnancy. ADHD symptoms may encourage risky behaviors that could lead to unplanned pregnancies in middle and high school, when the BGALS study shows that the learning gap between girls with ADHD and their non-ADHD peers often widens — and eating disorders, risky sexual behaviors, and substance use issues begin to surface.
Further, more than one-fifth of the BGALS study participants with ADHD had attempted suicide, compared to only 6% of the girls without a history of ADHD. And more than half of the participants with a history of inattention and impulsivity reported that they’d engaged in moderate to severe self-harm, including cutting, burning, or other forms of self-mutilation, compared to 19% of typically developing young women.
“Girls with ADHD feel different, marginalized, and criticized. They crave approval and acceptance but are haunted by shame and stigma,” said Ellen B. Littman, Ph.D., a clinical psychologist who specializes in identifying and treating complex presentations of ADHD and issues affecting women and girls. “The SCOTUS decision creates yet another minefield for these girls to navigate, hounded by messages of condemnation and threat when they feel most vulnerable and alone. It is daunting to consider where their desperation and despair might lead them, and we must all be vigilant, supportive, and compassionate.”
Why Girls with ADHD Face Increased Risk for Early Pregnancy
The increased risk for early and unwanted pregnancies among girls with ADHD may be attributed to several factors, such as trouble remembering to take a daily pill, impulsivity that leads to unprotected sex, lack of sexual education, and limited or no access to contraceptives such as condoms or birth control.
“Underlying difficulties associated with ADHD such as executive problems, impulsivity, and risk-taking behaviors are probably part of the explanation of why girls and young women with ADHD are at such high risk for becoming mothers at such a young age,” said Charlotte Borg Skoglund, M.D., Ph.D., lead author of the Swedish study.
Girls with ADHD are also more likely to engage in risky sexual behaviors compared to girls without ADHD.
“Females discover, very early, that sexuality is a shortcut to social acceptance,” Littman said in a 2020 ADDitude webinar. “It’s common to find a history of early initiation of sexual activity, early intercourse, more sexual partners, more casual sex, less protected sex, more sexually transmitted infections, and more unplanned pregnancies in women with ADHD.”
Premenstrual Syndrome (PMS) also may exacerbate ADHD symptoms, according to Littman. During this time, girls with ADHD may self-medicate with drugs, alcohol, food, and/or sex, complicating the picture.
“For many girls, internalizing symptoms like anxiety and depression blossom around puberty, as estrogen levels increase,” she said. “As hormone levels fluctuate throughout the month, medications may vary in effectiveness. Even with a prescriber knowledgeable about the hormonal effects on girls with ADHD, finding the optimal regimen can take time and patience.”
Littman advises parents to stay vigilant. “Be watchful for small changes in behavior that can be subtle but rapid,” she said. “A girl might be doing great when she’s 13 and a half, but at age 14, a change in her peer group can trigger emotions that can derail her.”
Treatment for Girls with ADHD
Using ADHD medication for 180 days or longer decreases the likelihood of early pregnancy and any pregnancy among teens with ADHD by 34% and 30%, respectively.5 This finding comes researchers at Taipei Veterans General Hospital and National Yang-Ming University who studied pregnancies in women with and without ADHD before the age of 30.
“Long-term ADHD treatment reduces the risk of any pregnancy and [early pregnancy] both directly by reducing impulsivity and risky sexual behaviors and indirectly by lowering risk and severity of the associated comorbidities, such as disruptive behavior and substance use disorders,” the study said.
Sexual education, including information about risky sexual behaviors, use of contraceptives, and pregnancy, may also decrease unplanned pregnancies in teens with ADHD.
“Parents should take a proactive approach to educate their children about sex — whether or not they have ADHD,” said Andrea Chronis-Tuscano, Ph.D., of the University of Maryland at College Park.
Roe v. Wade: What’s Next for Care Providers?
The U.S. Supreme Court’s decision to overturn Roe v. Wade is expected to ban or restrict abortions for more than 40 million women of child-bearing age in the United States.
In the hours following the ruling, the American Academy of Pediatrics (AAP) expressed concern with the ruling and reaffirmed its support for adolescents’ rights to reproductive healthcare services, including abortion.
AAP President Moira Szilagyi, M.D., Ph.D., FAAP issued the following statement:
“Today’s Supreme Court decision to overturn Roe v. Wade means that the once Constitutionally protected right to access an abortion is no longer guaranteed nationwide. This decision carries grave consequences for our adolescent patients, who already face many more barriers than adults in accessing comprehensive reproductive healthcare services and abortion care.
“The American Academy of Pediatrics (AAP) this morning reaffirmed our longstanding policy supporting adolescents’ right to access comprehensive, evidence-based reproductive healthcare services, including abortion. Today’s ruling means that in many places in the United States, this evidence-based care will be difficult or impossible to access, threatening the health and safety of our patients and jeopardizing the patient-physician relationship.”
“AAP is concerned that attempts to limit abortion care will not only interfere with the adolescents’ trusting, confidential relationship with their physician, but could result in real psychological and physical harm. Any delays in healthcare can increase volatility within a family, limit pregnancy options, or cause someone to seek an unsafe abortion,” said Elise D. Berlan, M.D., MPH, FAAP, who co-authored two policy updates in support of reproductive healthcare services, including abortion, written by the AAP Committee on Adolescence.
In two updated policy statements, the AAP advises physicians to study laws and policies in their state that impact access to abortion care, especially for minor adolescents. They urge physicians to examine their own beliefs and values to determine if they can provide nonjudgmental, factual pregnancy options counseling.
“Laws that restrict access to reproductive health care have a disproportionate impact on young people of color and those in rural and medically underserved areas, as well as other populations,” said Elizabeth Alderman, M.D., FAAP, FSAHM, chair of the AAP Committee on Adolescence. “People with resources, money, and transportation have the ability to travel to another state to receive the safe and legal care they need. For those who do not have those resources, including most adolescents, access to the health care they need is out of their reach. This reinforces the health disparities that exist across our country.”
Young people who identify as LGBTQ+ and young people involved in the juvenile justice and child welfare systems also have experienced added barriers when accessing comprehensive sex education, contraception, and abortion care, according to AAP.
“Everyone – including teenagers — deserves the right to confidential medical care that best supports their own needs and is informed by their physician’s expertise,” says Elise D. Berlan, M.D., MPH, FAAP, co-author of both policy statements, written by the AAP Committee on Adolescence. “Teenagers need accurate information about their reproductive health options, as well as other vital services like comprehensive sex education and contraception.”
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1Hinshaw, S. P., Owens, E. B., Zalecki, C., Huggins, S. P., Montenegro-Nevado, A. J., Schrodek, E., & Swanson, E. N. (2012). Prospective follow-up of girls with attention-deficit/hyperactivity disorder into early adulthood: continuing impairment includes elevated risk for suicide attempts and self-injury. Journal of Consulting and Clinical Psychology, 80(6), 1041–1051. https://doi.org/10.1037/a0029451
2 Owens, E. B., Zalecki, C., Gillette, P., & Hinshaw, S. P. (2017). Girls with childhood ADHD as adults: Cross-domain outcomes by diagnostic persistence. Journal of Consulting and Clinical Psychology, 85(7), 723–736. https://doi.org/10.1037/ccp0000217
3Skoglund C, Kopp Kallner H, Skalkidou A, et al. (2019). Association of Attention-Deficit/Hyperactivity Disorder With Teenage Birth Among Women and Girls in Sweden. JAMA Netw Open, 2(10):e1912463. doi:10.1001/jamanetworkopen.2019.12463
4 Østergaard, Søren D., Dalsgaard, Søren, Faraone, Stephen V., Munk-Olsen, Trine, Laursen, Thomas M. (2017) Teenage Parenthood and Birth Rates for Individuals with and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study. Journal of the American Academy of Child & Adolescent Psychiatry. doi:https://doi.org/10.1016/j.jaac.2017.05.003
5 Hua, M.-H., Huang, K.-L., Hsu, J.-W., Bai, Y.-M., Su, T.-P., Tsai, S.-J., … Chen, M.-H. (2020). Early Pregnancy Risk Among Adolescents With ADHD: A Nationwide Longitudinal Study. Journal of Attention Disorders. https://doi.org/10.1177/1087054719900232