Attention-deficit/hyperactivity disorder (ADHD), once predominantly thought to be a disorder of childhood, is now recognized as commonly persisting into adulthood and the prime reproductive years. The author presents a case of a woman with a history of ADHD who is stable on stimulant therapy and presents for preconception counseling. The patient’s history is presented, and preconception counseling is provided. The author considers how clinicians should provide preconception counseling to women with ADHD by reviewing functional impairment caused by ADHD, in addition to the risks of ADHD treatment on the developing fetus.
Attention-deficit/hyperactivity disorder (ADHD) is common disorder among US adults, with a prevalence of approximately 4.4%.1 Although there is a lack of data on the impact of ADHD on pregnancy, information from the general population has shown that ADHD can cause significant functional impairment. There are very effective pharmacologic treatment options for ADHD. However, knowledge about the impact of these medications on the developing fetus is limited. These two factors make preconception counseling for ADHD challenging. Here, the author presents a case of a woman seeking preconception counseling and the means by which a clinician should determine how to provide such counseling.
Mrs. L. is a 38-year-old, married white woman with a history of ADHD. She presented to a reproductive psychiatry program for preconception counseling regarding treatment of her ADHD during a future pregnancy. Her symptoms were well controlled on a regimen of methylphenidate extended-release, 20 mg twice daily and methylphenidate immediate-release, 5 mg nightly. She had a history of the attentional subtype of ADHD, which was first diagnosed when she was in her early 20s; in retrospect, however, she admitted awareness of her symptoms from an early age.
Prior to stimulant treatment, she had had significant difficulty sustaining attention. When practicing the piano, she found herself “looking at the sky,” and when working, she became teary-eyed and overwhelmed by simple tasks such as having to answer the phone. These symptoms caused significant functional impairment, including an inability to finish her undergraduate degree at an Ivy League institution and to sustain full-time work. Results of neuropsychologic testing 14 years prior were consistent with attentional deficits and she had been started on stimulant treatment 9 years prior with significant improvement. With treatment, she was able to finish her undergraduate degree and had started a master’s degree program.
She has been on stimulants continuously for the past 9 years. She was uncertain if she wished to have children, but was concerned about the effects of her medication on a possible pregnancy and sought guidance prior to conception. She was counseled about the limited data on the effects of stimulant medication on the developing fetus. Given the paucity of data, it was recommended that, prior to conception, she attempt a slow taper off her stimulants. However, should she have a significant decline in functioning, she should consider remaining on stimulants during pregnancy. After the consultation, she decided not to conceive, but indicated that this decision was not based on the recommendation to attempt a taper off her stimulants.
ADHD is a common neuropsychologic disorder diagnosed by a careful clinical history. It is characterized by symptoms of inattention and/or hyperactivity and impulsivity. According to the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the symptoms must be present before age 7 years and occur in two or more settings. They must cause significant social, academic, or occupational impairment, and cannot be better accounted for by another mental disorder.2 Once thought to be a disorder of childhood, it is now well recognized that the majority of cases persist into adulthood, during the prime reproductive-bearing age for women.