How to Counsel Pregnant Patients With ADHD on Stimulant Use
How should clinicians structure counseling for pregnant patients with attention-deficit/hyperactivity disorder who are using stimulant medication before conception or during pregnancy?
Pregnant patients with attention-deficit/hyperactivity disorder increasingly present to care while taking stimulant medication, and treatment decisions commonly cluster around conception and the first trimester. This guide applies to perinatal clinicians counseling patients with a known maternal ADHD diagnosis about whether stimulant treatment is being continued, stopped, or restarted during pregnancy.
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Confirm maternal ADHD and recent stimulant exposure
Establish whether the patient has a recorded maternal attention-deficit/hyperactivity disorder diagnosis and whether she has used stimulant medication in the year before conception or during pregnancy. In the study, stimulant use was defined by at least 1 filled prescription overlapping the 365 days before conception or the period from conception to childbirth, and the stimulant medications captured were amphetamine, dexamphetamine, methylphenidate, and lisdexamfetamine.
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Identify the specific stimulant medication
Document which stimulant the patient is using rather than treating all ADHD medications as interchangeable. Methylphenidate and lisdexamfetamine were the most frequently used stimulants across the study period, and the overall rise in prescribing was largely driven by lisdexamfetamine, which became the most prevalent ADHD medication in pregnancy by the end of the study period.
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Prioritize counseling before conception or in the first trimester
Address the medication decision as early as possible, because stimulant use was highest in the first trimester and discontinuation was concentrated before conception and in T1. In 2023, among those with stimulant use in the preconception year, 50.5% discontinued before conception and 24.6% discontinued in the first trimester, while only 3.6% discontinued in the second trimester.
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Discuss the main treatment paths patients actually follow
Frame counseling around the observed real-world patterns of stopping, continuing, and restarting treatment during pregnancy. In 2023, among patients with stimulant use in the preconception year, 15.9% continued throughout pregnancy and 5.5% discontinued before or during pregnancy but later reinitiated treatment in a subsequent trimester.
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Set expectations about the scale of stimulant use in pregnancy
Explain that stimulant use during pregnancy is no longer rare among pregnant patients with maternal attention-deficit/hyperactivity disorder. In the any-ADHD group, the proportion with a stimulant prescription overlapping pregnancy increased from 10.1% in 2014 to 20.9% in 2023, and preconception stimulant use increased from 21.8% to 39.8% over the same period.
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Review psychiatric complexity and support needs
Assess whether the patient has co-occurring psychiatric, substance use, or alcohol use disorders, because this population had substantially higher psychiatric comorbidity than pregnant patients without ADHD. In the cohort, 86.8% of pregnant patients with maternal ADHD had psychiatric history versus 42.9% of those without ADHD, supporting a need for broader perinatal support during medication decision-making.
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Discuss nonpharmacologic options when medication is stopped
If the patient plans to discontinue stimulant treatment, discuss nonpharmacologic ADHD management approaches that current guidelines recommend for the perinatal period. The article specifically notes self-management and coaching, psychoeducation, and psychotherapies such as cognitive behavioral therapies, while also emphasizing that perinatal-specific supporting data are limited.
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Be explicit about evidence gaps in medication safety
Counsel patients that reproductive safety data remain limited overall and are especially sparse for lisdexamfetamine despite its rising use. The article notes that most existing pregnancy safety data concern methylphenidate, which has not been associated with major increased risk of miscarriages, congenital anomalies, or long-term neurodevelopmental disorders, although it may carry a small risk of cardiac malformations and preterm birth.
Clinical Considerations
- The study was descriptive and did not test a counseling intervention or determine whether continuing or discontinuing stimulants improved maternal or fetal outcomes.
- Medication use was based on filled prescriptions overlapping pregnancy, which may underestimate exposure when prescriptions were filled before conception.
- The analysis included only obstetrical deliveries over 20 weeks gestation, so findings may not generalize to pregnancies ending in miscarriage or abortion.
- Nonstimulant ADHD medications such as atomoxetine were not captured, so total ADHD medication use around pregnancy may be underestimated.
Bottom Line
For pregnant patients with attention-deficit/hyperactivity disorder, stimulant counseling should happen before conception or in the first trimester, explicitly address whether treatment will be stopped, continued, or later restarted, and pay special attention to lisdexamfetamine because its use is rising fastest despite limited pregnancy safety data.
