613- ADHD in Pregnancy: Navigating Risk, Evidence, and Clinical Decision-Making

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0:33Welcome to the Attention Deficit Disorder Expert Podcast Series by Attitude Magazine.

0:43Everyone, I'm Annie Rogers, and on behalf of the Attitude team, I am delighted to welcome you to today's ADHD Experts presentation titled, ADHD in Pregnancy, Navigating Risk, evidence, and clinical decision-making. Leading today's presentation is Dr. Allison Baker, who we are honored to welcome back to Attitude. Dr. Baker presented a free Attitude webinar in 2023 titled Pregnancy and Motherhood, a practical guide for hopeful parents that you can listen to later by searching attitudemag.com for podcast 454 or subscribing to the ADHD Experts podcast. Dr. Baker 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.

1:41She has expertise in pediatric obsessive compulsive disorder, ADHD, adolescent mood disorders, and perinatal psychiatry. Dr. Baker frequently lectures and leads workshops on a variety of topics in child and perinatal psychiatry. She received her medical degree from the University of Virginia, where she was elected to the Alpha Omega Alpha Honor Society for her excellence in scholarship and professionalism. She completed her residency in general psychiatry at Columbia University, serving as chief resident. Dr. Baker trained in child and adolescent psychiatry at the combined program of Columbia and Cornell Universities.

2:24She then served on the faculty at Columbia University Medical Center and was a senior pediatric psychopharmacologist at the Child Mind Institute before moving to Boston. We are extremely lucky to learn from Dr. Baker here today. And today, she will provide a clinically grounded, evidence-based framework for navigating ADHD in pregnancy, emphasizing that these decisions are not about risk versus no risk, but rather trade-offs between maternal functioning and fetal infant outcomes. Dr. Baker will review the latest observational data on stimulant exposure in pregnancy and examine the limitations of the evidence base.

3:10The truth is that ADHD is a disorder of executive functioning, safety, and daily life management. Untreated illness during pregnancy can carry meaningful consequences for maternal well-being, stability, and functioning. Indeed, in a 2024 survey of nearly 2 ,000 attitude readers who had experienced pregnancy, 99 % of respondents said they ceased treatment with medication during pregnancy. And 97 % said they ceased medication while breastfeeding as well. Like so many other areas in women's health, research is lagging. But today, we're going to learn about the very latest science to help our patients, our clients, our family members, and ourselves make the best decisions possible.

3:58Okay, without any further ado, I'm so pleased to welcome Dr. Allison Baker. Thank you so much for joining us today and leading this really critical discussion. Thank you, Annie. It's a pleasure to be here. and good afternoon to all tuning in. I'm thrilled to be back at the Attitude webinar series and especially thrilled to speak about ADHD and pregnancy, which as Annie mentioned, is a topic that is right at the intersection of several areas that are very near and dear to me in terms of women's mental health, reproductive psychiatry, child development, and the health and well-being of families, as well as the lifelong course of ADHD.

4:54As a child and adolescent psychiatrist, I fell into this work actually because of what Annie was describing in terms of the dearth of research at the Center for Women's Mental Health. I was one of the few child and adolescent psychiatrists embedded in a perinatal group. And so over time, the young girls and adolescents in my clinic actually grew up and entered their reproductive years appropriately asking questions about their ADHD medication, safety in pregnancy, the postpartum, breastfeeding, and the literature to guide us through all of those questions was surprisingly thin. And so I will offer today a framework that is helpful in thinking about ADHD in pregnancy and will, I think, sort of frame it as Annie said, that it's not reflexively, you know, stop all medications and alarmist, nor is it necessarily reflexively reassuring, but really a risk-risk framework where we are comparing potential risk with respect to treatment in terms of maternal, functional, psychiatric, and sort of parenting needs, as well as real risks of untreated or undertreated ADHD in pregnancy and in the early postpartum.

6:37And it's important to make the point that in adult women, ADHD is not just a cognitive disorder in in terms of challenges with executive functioning. It's also one in which I've really come to appreciate the way that emotional regulation, anxiety, mood symptoms, shame, and daily life demands are all inextricably and dynamically linked. And although girls are diagnosed at less often than boys, we know that prevalence approaches parity in adulthood, in large part because inattentive and internalizing presentations are so often missed in earlier development. So my hope today is that we can spend some time really reviewing how to recognize and treat ADHD when life demands, especially the enormous demands of pregnancy and new motherhood, exceed a woman's prior compensatory capacity.

7:53So with that, I'll just share that neither I nor my partner has a relevant financial relationship with a commercial interest to disclose, and we're off to the races. So ADHD in women, in terms of a new lens on this neurodevelopmental condition that is lifelong, we know that it affects about 1 in 30 adults and is a lifelong neurodevelopmental condition with, as I mentioned before, a really significant impact on functional and emotional well-being. And while there's no formal diagnosis of perinatal ADHD, clinically, we see this present in those years very often because of how challenging it becomes to manage during pregnancy and the postpartum.

8:47These are windows of particular vulnerability in terms of major hormonal shifts taking place, escalating cognitive and emotional demands. There is often acute on chronic sleep disruption, sensory overload, often a tremendous amount of appointments in terms of obstetrics and gynecology, new responsibilities, of course, when the baby arrives, and then often a sudden collapse of structures that had previously helped a woman function. Many women have described that when their environment is scaffolded, they can do well, and pregnancy and new motherhood often removes those scaffolds in an instant, overnight.

9:44So one of the things we're often evaluating in the perinatal consultation room is not whether all of a sudden ADHD has arisen de novo, but whether actually pregnancy has exposed the degree to which, for example, a woman's functioning had previously depended on enormous compensatory effort that she's just no longer able to sustain.

10:15and we know that um adhd is linked to elevated risk of poor general and mental health increased risk for substance use disorders challenges with work performance and financial distress so um by way of background women with pre-existing diagnosis of adhd are likely to be more vulnerable to worsening cognition during pregnancy, as well as roughening vulnerability factors across the board.

10:48I created this visual representation of ADHD in women really to illustrate the interplay and complexity of the disorder. And my goal here is to help clinicians, family members, individuals themselves recognize and pick up ADHD more accurately in women, particularly when the presentation is not the stereotypical childhood picture a la sort of DSM-5, where we can see if we consider these considerations why diagnostic accuracy can be challenging in women, largely because our criteria and clinical instincts historically have been shaped by male predominant samples, both in terms of any research that then informed any diagnostic rating scales, and also by externalizing presentations that we know are often not as often the case in women.

11:55because in women, ADHD often is hiding behind perhaps more commonly given diagnoses like anxiety or depression, perfectionism, dysregulation with eating or emotions, chronically overwhelmed that often gets lumped under anxiety, or just the general sense that I should be able to do this and I don't understand why I cannot, which I think leads to a tremendous amount of shame, a higher motivation to mask symptoms, a lower motivation to sort of raise your hand and ask for some help or support. So the clinical pearl from this slide is really to drive home the point that ADHD in women often lives at the intersection of executive dysfunction and self-blame.

12:50So to keep it in mind when seeing women presenting with these refrains, but thinking about, you know, and teasing apart this complex presentation, is there a component of ADHD that has just never been diagnosed previously and was highly compensated for previously? So in terms of this slide, I'll pause and just read it just to say that we know ADHD in adulthood for women, as I said before, largely based on research by the late Joe Biederman at MGH, is associated with depression, anxiety, substance use, and occupational, social, and overall impairment domains. We also know that adult women with ADHD can experience difficulties at work and at home related to their ADHD symptoms.

13:42And so because treatment of ADHD improves functioning and quality of life tremendously, women who are on psychostimulant treatment for the disorder may very well wish to continue their medicines during pregnancy. so they will come in often and say as per the attitude um poll where something like 99 percent of women discontinued medication um they'll come into clinic saying i not like i have attention problems but i am drowning i cannot keep up i feel like everyone else got the manual i'm exhausted from trying to appear competent. And that has become an important refrain to stay sort of attuned to when evaluating women at this developmental stage.

14:40We know that ADHD in women will present, often present differently. So it's important to think about this is predominantly an inattentive presentation with a core pattern where symptoms are often internalized, subtle, under-recognized, and that women will commonly present with clinical features such as chronic disorganization, tremendous challenges with initiation and completion of tasks, feeling mentally restless. The hyperactive domain is often hyperverbal in women. So having a lot of hyperverbal outputs or actually sort of hyper sort of ruminative in their thinking patterns rather than like physical hyperactivity or driven by a motor.

15:41There can be components of emotional dysregulation and challenges with frustration tolerance. And then, as I've mentioned before, paired with really high rates of masking and compensatory overfunctioning, especially in high-achieving women, which often delays an accurate diagnosis and is a barrier to accessing treatment because of the ways in which it has become internalized as a personal failure rather than a treatable neurodevelopmental condition.

16:18Across the female lifespan, we know ADHD symptoms will often fluctuate in intensity alongside hormonal transitions. A lot of this is based on clinical observation and anecdotal data because of the dearth of research still in this domain. But it makes great sense if we consider puberty and pregnancy and the postpartum period and the perimenopausal transition all as windows where women will clinically report incredible amplification of their challenges with executive functioning, their emotional reactivity, sleep sensitivity, and general cognitive overload. So I've put together this visual slide really to represent that ADHD is not this static entity, but really this dynamically shaped experience influenced by neurobiology and hormones and context in the course of a woman's life.

17:27And for some women, estrogen sensitive changes in cognition and mood can make their ADHD symptoms feel suddenly very worse. So that can look like patients who report that almost like clockwork, the sort of three to five days before their period in the sort of late luteal phase of their menstrual cycle, they feel like they forgot to take their stimulant. They go to check their pill minder. Indeed, they did take it, but it feels completely ineffective. And at the beginning of their menstrual cycle in the follicular phase, they haven't had a problem. They haven't switched to generic manufacturer.

18:09They're just feeling like it's not working the same as it did at the beginning of their menstrual cycle. And so that hormone sensitivity in terms of fluctuating estrogen and progesterone and related hormones can feel like the stimulant treatment is less impactful. For other women, it's less about hormones alone and also about the mismatch between sort of prior coping capacity and new demands or a combination of all of the above. And if we think about pregnancy in the postpartum period, that mismatch can then become enormous. Because if you think about tasks that multiply, like sleep is now fragmented, routines are unpredictable, especially with a newborn, and emotional stakes really feel a lot higher.

19:05and for a woman whose ADHD has always been managed, let's say through, for example, a looming deadline or urgency, adrenaline, perfectionism, or the external structure of, for example, work, the perinatal period can be really destabilizing. In terms of treatment for ADHD, just like in pediatrics, it should always be multimodal. Um, so this, uh, table has been taken from a terrific, um, review by colleagues in Canada, um, and is available in the American Journal of Obstetrics and Gynecology, but looking at sort of mild to moderate symptom severity, um, treatment modalities like psychoeducation, self-management strategies, good coaching, um, environmental supports, skills-based psychotherapies, and sleep protection, exercise, and relational scaffolding can be extremely helpful, frankly, for everybody with ADHD and especially for women in the perinatal period.

20:15And then that may be sufficient for women with mild ADHD, but for moderate to severe ADHD, pharmacotherapy is often required. And I think that distinction is very important in pregnancy because sometimes medication, as my patients have shared with me over the years, is discussed as something that's optional or even like a nice to have or a cosmetic, as if stimulants simply help someone perform at a higher level. But for many women, it is the thing that allows them to, for example, drive safely, attend their prenatal care, regulate their emotions, perform at work, eat consistently, avoid substance use, manage the older children in the home, for example, and just generally function in daily life.

21:11And so when we talk about stopping medication, I often share with patients and trainees that we need to ask, what exactly are we asking this person to give up and what supports are we using to replace it? so this slide and the next slide is taken from the ADHD medication guide that is a freely available downloadable resource that I find very helpful clinically especially in consultation with patients who might be providing a history of treatment but they couldn't remember what was the name of the stimulant or non-stimulant they took but they do remember that it was a yellow and white capsule. And so this is a very nice clinical tool that you can use when treating patients and taking histories and also guiding next steps.

22:06But when we think about ADHD medications in pregnancy, we're still really most commonly talking about stimulants. So for example, methylphenidate and amphetamine-based preparations, including list-xamphetamine, as well as all the methylphenidate derivatives. There are also non-stimulant options like adamoxetine, guanfacine, clonidine, and bupropion or Welbutrin, though the reproductive safety literature really does vary substantially by agent. And so we'll get to that shortly. A key point I want to make in thinking about medication is that ADHD medication is not one exposure because different medicines have different pharmacology, different degrees of impact on blood pressure, appetite.

22:56And frankly, at this point, the best studied medications actually in pregnancy are stimulants, especially with the methylphenidate and amphetamine-based medications. And overall, the reproductive safety data are mostly reassuring, particularly for congenital malformations or birth defects and long-term diagnosed neurodevelopmental outcomes. So how do those children do who were exposed to stimulants in pregnancy? There are some signals that we need to discuss when we are doing the risk-risk analysis in terms of placental and vascular outcomes. So for example, gestational preeclampsia or hypertensive disorders of pregnancy.

23:46But zooming out the clinical sort of maneuvers, not like safe versus unsafe in a global way, but sort of which medication, what dose, during which period of time, for which patient, with what other baseline risks or comorbidities, and also with what consequences if we stop, which is why it's a lengthy process to walk through these discussions with our patients. The GLP-1 pills you've been hearing about are on row. Yep, they're here. With clinically proven ingredients for weight loss, now in a pill, and now on row. Two FDA-approved GLP-1 pill options, both at the lowest cash pay price available.

24:36Get real results from a daily GLP-1 pill. Now on Rho. To see if you qualify, go to Rho.co slash choices. Rx only. Go to Rho.co slash safety for serious side effects and boxed warning associated with GLP-1s. So here's the second part of that medication guide that is a handy resource. And so we will get into interpreting data with respect to medication safety. And I also think it's helpful to think about different aspects of risk in terms of first, second, third trimester risks, and then also neurodevelopmental outcomes is another sort of variable of interest with respect to the course of treatment.

25:28So in terms of pregnancy considerations, I've already stated this, but given that medication use is increasing among women with ADHD and there is consensus about the safety of ADHD medication historically lacking, it's important to consider all of this in the context of nearly half of United States pregnancies being unintended, early pregnancy being a critical period of fetal development. This is why this is an important topic clinically and in this group here at Attitude. So we set out to investigate what are the risks with respect to ADHD during pregnancy. And this was a study that was done at our center following women longitudinally throughout their pregnancy.

26:25And these were women who were making decisions with respect to their treatment course independently of their participation in our study. So we were not having a role in advising, rather we were following them longitudinally in sort of a natural observational study where women and their doctors based on their clinical scenario made decisions to continue treatment, modify treatment, or discontinued treatment. And then we had various outcome measures that we followed as we walked alongside these women during their pregnancies. So here's an outline just briefly of the study and how we interviewed our participants and sort of what other outcomes of interest we measured.

27:17So anxiety, depression, stress, and functional impairment were also monitored alongside of burden of ADHD symptoms. It worked out that participants essentially self-sorted into roughly three different groups with the majority of participants maintaining medication as is. About a third of participants adjusted medicine. And so what that meant practically was either went to a as-needed or going from, for example, from an extended release to an immediate release, and then another third discontinued altogether.

28:02We know that our sample was representative of real patients in that we know that there's tremendous comorbidity in ADHD. So, for example, 50 % of our small but still statistically significant patient population had a co-morbid diagnosis of generalized anxiety disorder, with about a third also having mood disorders. So this is very representative of what we see in the general population. And as I said, we looked at ADHD symptoms along with functional impairment and mood stress and other outcome variables. And so what we found was that the main sort of finding of our study was that women who made changes, whether that's modifying or discontinuing medication, were more at risk for impairment in family functioning versus those who continued their medications as they were prescribed prenatally.

29:13And we also found that those who discontinued medication were at higher risk for roughening of co-occurring mood disorder or a bump in their Edinburgh Postnatal Depression Scale score. So that might feel intuitive in terms of even if the burden of ADHD symptoms doesn't change per se in terms of how you might score on a rating scale of ADHD symptoms, what did change with medication discontinuation was vulnerability or risk for mood declining, mood symptoms roughening, as well as impairment in family functioning. So again, small study, but the first study really to look at the other side of this risk-risk analysis in terms of like what are the risks with respect to medication discontinuation and maternal well-being.

30:12So back to sort of the broader review of clinical implications. Despite generally reassuring reproductive safety data, we still know that stimulant discontinuation is often recommended for women with ADHD symptoms who appear able to function without medication. And our study suggested that this approach confers some risk because stimulant discontinuation during pregnancy may worsen family functioning and also may put women risk for roughening of comorbid mood symptoms. And in this study, as I mentioned earlier, the AJOG review, it does a really nice job summarizing how this informs the clinical approach.

31:03So this review makes the point that aligns very closely with how we think about the risk-risk consultation model sitting with patients at the Center for Women's Mental Health at MGH. It is common for care providers to advise patients to stop ADHD medication if they are considering pregnancy or are already pregnant. This is something we hear all the time. We encourage patients and providers to slow down and really think about discontinuing ADHD medication during pregnancy as potentially leading to the possibility of worsening mental health outcomes, significant functional impairment, difficulty maintaining prenatal care.

31:57certainly increased risk for motor vehicle accidents and worsening eating or sleeping patterns as well as potentially downstream effects on for example pregnancy risks like miscarriage or preterm birth through pathways that are related to maternal destabilization. On the other hand, while weighing these risk risks, reproductive safety data are mostly reassuring. For major malformations, particularly with amphetamine-based medications, we do not see a strong signal. For methylphenidate, we might see a small cardiac malformation signal, but the absolute risk in terms of the absolute increase in any kind of cardiovascular malformation outcome is modest.

32:54We know for neurodevelopmental risks in terms of how do these babies do in terms of their learning growth and behavior and general development after exposure to these medicines in pregnancy. We have newer Danish and Swedish studies that are reassuring for breastfeeding we know that methylphenidate exposure through milk appears very low. And so where we are in 2026 is that not every woman should continue medication, but also not every woman should stop. Rather, treatment with medication should absolutely not be reflexively stopped or panic stopped. And it is, especially if it is required for daily function of the pregnant and breastfeeding person, it is reasonable to continue.

33:50And we will often say the biggest avoidable risk is not the medication exposure itself, but the abrupt unplanned stop with no monitoring, no supports, and no perinatal plan. Because that typically roughens things across the board and then really makes the clinical scenario that much more precarious. precarious. So again, in terms of the summary of medication safety and pregnancy, big picture themes, when we look across the perinatal safety literature, the overall story is mostly reassuring. When we break it down into the trimester risks, as I previewed before, we talk about congenital malformations and the largest data sets including U.S.

34:49claims and Nordic registry data are broadly reassuring. Amphetamine-based medicines have not shown a clear increase in major or cardiac malformations. I mentioned earlier that methylphenidate may have a small signal for cardiac malformations, but again, the absolute risk appears very modest. So roughly a few additional cases per 1 ,000 births. So this is not a large teratogenic signal. Clinically, the reason this matters is because many patients will present after an early exposure that has already occurred and feel very nervous that what do we do? Should we reflexively stop? But fortunately, the data on early exposures generally reassuring.

35:42We also think about second and third trimester exposure and placental and vascular outcomes. So if we think about things like blood pressure, gestational, hypertension, preeclampsia, and downstream preterm birth, this is where the absolute increase in risk may be something to consider, but why we monitor blood pressure and collaborate with OBGYNs to, again, not discontinue or reflexively stop medication, but just consider baseline risk, dose, timing, and then monitoring are the things that matter the most. In terms of long-term neurodevelopment, the news is really reassuring. The outcomes actually that I have found clinically families worry about the most.

36:51And as I said, the newer Danish and Swedish studies are reassuring because when those studies have accounted for things like familial or genetic liability and done some adjusting for those, you know, confounds by, for example, using like sibling or paternal medication comparisons, there is not a clear signal of any increased risk of being diagnosed with long-term neurodevelopmental conditions. So that's very reassuring to a lot of families. And really the bottom line is that the pregnancy safety literature is not a story of major teratogenic risk. It is not a story of major congenital malformation risk.

37:39It is a story of mostly reassuring data with the main area for monitoring and closer follow-up with respect to blood pressure, growth, and any kind of vascular and placental outcomes with respect to gestational hypertension or preeclampsia. So what about the transition to motherhood? So now that the baby has arrived, and this is where functional implications of ADHD become incredibly vivid because perinatal women, in my experience, have reported just, well, all perinatal women face uniquely demanding and vulnerable period of time with rising responsibilities, now incredible challenges getting enough sleep, managing the hormonal shifts, the sensory overload, the feeding demands, the fragmented time, medical appointments, and then of course, very high societal expectations.

38:50So what often shows up in clinic are women who are neglecting self-care, masking symptoms, feeling incredibly overwhelmed, but struggling in silence and feeling tremendous shame, low self-esteem, and having challenges with executive functioning that in turn really informs mood and anxiety symptoms. And we now have converging evidence from several countries that show that women with ADHD are at markedly higher risk for postpartum mood and anxiety symptoms. So that's something important to underscore. Back to Danish data, in a Danish registry, it shows that approximately 15 % of women with ADHD had elevated depressive symptoms on the EPDS around eight weeks postpartum.

39:53So that's translating to more than a twofold increased risk of depression. And similarly, Swedish data show elevated psychiatric service contact for both depression and anxiety. We have data from Canada showing a similar story in terms of twofold increased risk of postpartum depression among women with ADHD symptoms. So I really emphasize that this is a group that is high risk in terms of perinatal mental health outcomes.

40:32so what about expectations of parenting and prenatal care in a study of first-time pregnant women we know that there are high levels of maternal adhd symptoms that are associated with a less positive parenting experience feeling less in control and having less attendance at prenatal examinations. So this is, again, important to underscore clinically that it's not just interfering with how a woman is feeling, but also with how she's able to prepare, plan, attend appointments, track recommendations, organize supplies, and imagine herself as competent in the role of parent. And this, I'm certain you can appreciate, can become a very painful loop for women where the more overwhelmed she feels, the more she's likely to avoid.

41:31And the more she avoids, the more behind she gets. And the more behind she gets, the more ashamed she feels. And shame is that gasoline on the fire of perinatal mood and anxiety vulnerability. So prenatal care, like how do we turn this around? I would say prenatal care for women with ADHD is not just like, are you taking a stimulant, but also proactive scaffolding. Have you ever had CBT for ADHD? Would you benefit from an executive function coach? Let me provide reminders. Let's get into your phone and schedule that now. Let's have written plans and partner involvement when appropriate. Let's make a big deal about sleep and nutrition and a lot of anticipatory guidance about postpartum executive load.

42:27In this first meta-analysis on parenting, parental ADHD and parenting behaviors, parental ADHD was associated with more harsh and lax parenting, less positive parenting, greater over-reactivity with kids, and lower parental control and satisfaction. And so this just really drives home the point that the cognitive overload really can be impactful in terms of the parent-child relationship. And in this study, we really see the point about how the executive aspects of parenting, like planning, organization, routines, supervision, flexibility, transitions, follow through, all of these are so linked to the inattentive symptoms and poor executive functioning and really can contribute to increased home chaos.

43:30So in terms of ADHD in the acute postpartum, we followed that cohort, and I'll just fly through this super quickly so we'll have plenty of time for questions. But we found that the ADHD symptoms frequently worsened in the postpartum and that medication dose adjustments and the addition of other treatment modalities were often the rule more than the exception. um family functioning was also really vulnerable in the postpartum period particularly around negative self-concept of mom and so I really think this is one of the most clinically tender pieces because many women with ADHD enter motherhood already carrying a long history of feeling like they don't have their stuff together and um they're too much or they're not enough or they're inconsistent and they feel ashamed and so then the postpartum culture of saying motherhood should be natural and intuitive and blissful and the happiest time of your life.

44:31But really, they're having sleep deprivation and executive overload. It just makes everything harder. So as I underscored earlier, this is a population at elevated risk and one that benefits from a good plan in anticipation of the pregnancy. So here, I'm just summarizing what we found in our study. And again, driving home the clinical reality that we have seen these symptoms often intensify after the baby arrives because of that sort of contribution with respect to more demands, increased inattentiveness and emotional dysregulation while sleep deprived, and overall greater functional impairment, including decline in sense of self and confidence during early motherhood.

45:19So this is a high stress, low control period, which makes family and role functioning a key vulnerability for women with ADHD. So going back to our study right before we jump into a quick case sample and then hop into questions. These are the general principles regarding meds management for women as they anticipate pregnancy. So preconception-wise, if taking a stimulant and you've never had a trial off of it, it's not a bad idea to see where the baseline is. And if you're unable to discontinue the medication because it interferes with functioning, then continue with the current medicine or reduce it to the lowest effective clinical dose or consider intermittent use or switching to a non-stimulant.

46:10but always engaging in a risk-risk discussion regarding the choice. And then with respect to pregnancy and at birth and during breastfeeding, again, monitoring is the word. So fetal growth, blood pressure, and appropriate weight gain, and monitoring infant and early development with respect to feeding as well as mom in terms of her well-being. so um this is a case of miss c who's a 32 year old attorney this is a sort of a fictional case based on a composite of a bunch of different common presentations but this is lifelong history of combined type adhd has tried several stimulants and non-stimulants has done beautifully on a long acting methylphenidate as well as weekly cbt and elects to stay on our stimulant until conception And then she thinks maybe move to an as-needed fashion.

47:12So I've included this as almost a script to help guide your conversations in the consultation room with patients. And this is taken from colleagues who put this in a journal article, and I've cited it down below. But it's an excellent way to just sort of give you an option in terms of how do you answer these questions. So thinking about, you know, the patient saying, what are some of those risks? And you say, well, some studies have suggested there might be associations between methylphenidate and some cardiac malformations, particularly ventral septal defects. But the absolute risk is low, like a few full two to three in a thousand.

47:53And there were a lot of confounding variables. So we should really talk more about, you know, what would be the alternative and also, you know, what is our plan to round out supports before we make any decisions. So in this case, our patient conceived. She felt her symptoms were well controlled by moving to an as needed model of taking her medicine. And then she had stopped work at 36 weeks of gestation. and asked about breastfeeding. Could she breastfeed on methylphenidate? And we do have data that show that methylphenidate levels in milk are very low and not detectable in infant serum. So again, restating that with the appropriate references there.

48:47In the postpartum, our patient resumed her stimulant medication, as I said, the rule, not the exception, needed to actually optimize her dose. She also started executive functioning coaching, and she found the return to work and motherhood, generally speaking, overwhelming. So we folded in mindfulness-based stress reduction, as well as fluoxetine and some couple support, and she's doing well. So with that, I'll skip our summary, but you've heard it all over and we'll have time for questions. And I really thank you for your attention. Dr. Baker, thank you so much for that thorough and informative and little discussed information.

49:36It was really so important. And so thank you. And I also want to give a shout out to we have a number of people listening today who are in support roles, a certified yoga instructor, perinatal mental health therapist, midwife, all here looking to support their patients, their clients, their loved ones who are facing these, you know, hard, hard choices and looking for the best information they can. So thank you to everyone. And I will get right into it because we have some great questions. Someone wondering, does the data tell any difference or nuanced stories regarding the risk considerations for amphetamine versus methylphenidate and also for non-stimulants versus stimulants?

50:36Is there anything we should know about, like, would it be worth a woman investigating her response to a non-stimulant prior to pregnancy? That's a great question. And so I would say, like, the sort of simple surface answer is there is no one globally, like, safer medication. This is something that comes up a lot when people learn of, you know, maybe methylphenidate has a slightly increased risk for cardiac malformations. But again, the absolute risk is really low. And let's say real world, that patient is an exquisite methylphenidate responder. We would maintain her methylphenidate because that is the medicine that has gotten her well and kept her well.

51:26And in fact, it also has strong lactation data, very low milk transfer. Um, and, um, so it, it, there's no single, I guess, best, um, ADHD medication for every reproductive situation. Um, the answer really changes depending on, um, individual history, prior response, um, clinical severity and things like that. Um, you know, in terms of the clinical severity, I didn't really talk a lot about the non-stimulants, Um, but you know, that is a question that we get, like are non-stimulants safer? And, um, that does not, um, non-stimulant does not automatically mean safer in pregnancy. Um, we do have data, um, on adamoxetine as looking relatively free of any indication of risk.

52:20Um, the numbers are lower than what we have for the two main stimulant, um, categories, but we do have enough data to say atomoxetine. If you happen to be an atomoxetine or that Stratera responder, that is a nice option. We have a lot of reproductive safety data about bupropion or Wellbutrin because it has more sort of pregnancy experience, if you will, because of its other indications. So for example, for the treatment of depression or even the treatment of smoking cessation. So we know it can help ADHD for some people, But in my experience, and I would say that's probably, you know, expert consensus that it's usually less robust than stimulants for core ADHD symptoms.

53:07So I hope that answers that question. Yes, very helpful. And sort of piggybacking on that, a number of women here are asking, are there non-medication treatments that are shown to have near the same efficacy in symptom control for ADHD that they should consider?

53:33So, great. Yeah, yeah, yeah. So going back to sort of my point about like treatment should be multimodal, just like in sort of, you know, DMTA studying kids and thinking about how can we optimize across the board. Um, so for example, um, there, we have data about cognitive behavioral therapy for the treatment of ADHD. So that is certainly something I'm often asking about and recommending or prescribing if that has not been tried before, because we have, um, very good data to support its efficacy in the treatment of ADHD and any, it's also protective against, um, co-occurring vulnerability for mood or anxiety disorders.

54:16It's obviously not an exposure in terms of a medication. Other non-medication strategies that can help during pregnancy, if we sort of think about globally, like goal is to reduce executive load, that's where executive function coaching or org skills training can be so helpful. Sort of getting things sort of externalized, like off the brain and down on written checklists or one calendar. you know, all the good recommendations that I know you have in your publication, thinking about really trying to sort of operationalize and like automatize a lot of things. For example, you know, grocery delivery, meal repetition, sleep protection, um, reducing commitments, um, and, uh, also sort of partner or body doubling support.

55:19Um, these are all ways in which we can reduce executive load, um, and really build systems, um, that remember, um, and support, um, for the mom. And then I'll also say we have great data about in general with respect to stress reduction for exercise and even, for example, mindfulness based stress reduction, which is a eight session course that you can take that has a robust evidence base in terms of reducing mood and anxiety symptoms, which are often, as we saw from our study and other studies, almost the signal that emerges more so than, for example, more attention problems. Yeah. And it all kind of goes back to what you were saying at the beginning of the talk about you're really looking at what the scaffolding and the supports are, and that all of that factors into treatment decisions.

56:22So it is, in fact, very multimodal and holistic when treatment is approached well. Okay. Here's a question that I'm sure will sound familiar to many of our listeners. This person wrote in to say that their psychiatrist says, ask your OBGYN about ADHD medication related questions. And the OB says, refer back to your psychiatrist. It seems, it feels like nobody wants to be the one to, to give advice. Do women need to seek out OBGYNs who specialize in ADHD? Is that a thing? And if not, you know, do you have advice for how to help them navigate this maze? Yeah, no, it is such a maze. And at a time when you don't need more complexity, you need less, which is why I was so grateful for the very clear, crisp review that was published by Scotan and colleagues in the Journal of Obstetrics and Gynecology, interestingly enough, where it was like just in very clear language for mild ADHD, where a woman can optimize non-pharmacologic treatment, she can leverage executive function coaching, exercise, mindfulness-based stress reduction, CBT, all that, and do well, then it's appropriate to discontinue her stimulant medication, let's say.

58:02For moderate to severe symptoms where the medication is required for daily function, and that's how they defined it or operationalized it, it is reasonable to continue medication. And I think the reason it was published in that journal is because the goal is to familiarize and also increase the comfort level of all providers who will touch the lives of women across the perinatal experience. And it can be incredibly challenging for a patient to feel they're the most expert person in the room with respect to their knowledge and research that they've done, and then sort of meeting faces that might be blank or anxious.

58:47So I don't know of a specialty OBGYN per se that specializes in ADHD. As I said there's also no sort of diagnosis of perinatal ADHD. But I think about sort of this audience that you described in terms of therapists and midwives and doulas and yoga therapists and support professionals, you know, we're all, it's an opportunity for all of us to be screening for ADHD symptoms, reducing shame, helping patients identify functional risks, encouraging them to have shared decision-making. So for example, if a doctor says, go see the psychiatrist, the psychiatrist says, ask the OB, advocating for, can we have a treatment team meeting, please?

59:37Trying to simplify care plans, trying to coordinate with prescribers. And I often feel that the support people in the lives of our patients can really help translate like this medical advice or lack of clear medical guidance into a more executable game plan or routine. Well, that's wonderful advice. And I would also suggest that everyone listening, you are free and welcome to share today's webinar replay, including all the resources associated with it. Find this on AttitudeMag.com by searching for podcast 613. So please, like, let this be the conversation starter and help your care team get on the same page.

1:00:34Dr. Baker, thank you so much for bringing your expertise and the comfort of your knowledge to the Attitude community today. We so appreciate it. It's truly my pleasure and privilege to do so. and thank you for having me. And thank you to everyone again who joined us with the best interests of women with ADHD at heart. We hope that you will check out our full library of attitude webinars. It is available as a podcast called the ADHD Experts Podcast. And we also hope that you will take that survey that we mentioned at the outset of the webinar, the ADHD Rising Stars survey, you can feel free to nominate Dr.

1:01:20Baker among the providers who you think are really leading the field. And thank you again for joining us today. For more Attitude podcast and information on living well with attention deficit, visit AttitudeMag.com. That's A-D-D-I-T-U-D-E-M-A-G.com. you