Prenatal Use of Antidepressant Medication

Concern continues regarding whether pregnancy health can affect offspring risk for neurodevelopmental conditions like autism spectrum disorder (ASD) and ADHD. One “hot topic” in recent years has been maternal use of antidepressant medication during pregnancy. Several studies have suggested that if you take your antidepressant medication during pregnancy, chances increase that your child will have autism or ADHD. However, a careful review this month calls this association into question.

In a Recent Report…

The investigators isolated studies that have been controlled for confounding variables, such as studies of siblings in which the mother used medication in one pregnancy but not the other. While the overall association of antidepressant use with ASD and ADHD was seen, this was not confirmed in sibling studies or when using other controls. For instance, paternal use of antidepressants had an even stronger association with child ADHD, suggesting whatever is driving the association may not be maternal medication use.

Caution is warranted, but the final conclusion regarding the use of antidepressant medication during pregnancy is still unclear.

Source:

Antidepressant use during pregnancy and risk of autism spectrum disorder and attention deficit hyperactivity disorder: systematic review of observational studies and methodological considerations.

Morales DR, Slattery J, Evans S, Kurz X.

BMC Med. 2018 Jan 15;16(1):6. doi: 10.1186/s12916-017-0993-3.

ADHD and Nutrient Adequacy

When we reflect on the often-controversial evidence regarding nutrition and ADHD, one of the key questions is this: Do individuals with ADHD simply not eat the right food (perhaps causing nutritional inadequacies), or do individuals with ADHD somehow metabolize food differently, leading to altered nutrient benefit? The jury is out, but a new study this month is interesting.

In a Recent Report…

Investigators looked at different forms of iron (ferritin, iron) in children with ADHD using blood samples. They concluded that ADHD was associated with either reduced ferritin or iron deficiency. Most physicians will consider iron deficiency if a child has particular symptoms, but ADHD is not usually a trigger for such an evaluation. Still, it may make sense to ask your pediatrician if it seems likely, or possible, that some aspect of iron metabolism is disrupted by testing ferritin, iron, or other indicators medically indicated. If a child has ADHD and iron deficiency, it is possible based on these data that iron supplementation will also help ADHD symptoms. However, too much iron can cause problems, so coordinate with your physician. Also, consider vitamin C supplements—vitamin C assists iron absorption. Overall, this study is a reminder that nutritional status remains an area of active investigation for ADHD.

Source:

Peripheral iron levels in children with attentiondeficit hyperactivity disorder: a systematic review and meta-analysis.

Tseng PT, Cheng YS, Yen CF, Chen YW, Stubbs B, Whiteley P, Carvalho AF, Li DJ, Chen TY, Yang WC, Tang CH, Chu CS, Yang WC, Liang HY, Wu CK, Lin PY.

Sci Rep. 2018 Jan 15;8(1):788.

Safety and ADHD

A paramount concern for all parents is the physical safety of their child; this is an extra significant worry for parents if their child has ADHD. Kids with ADHD are are about twice as likely as other kids to have suicidal ideation and attempt suicide—although serious attempts mainly in kids with ADHD who are also depressed and/or engaged in antisocial behavior. They are also more likely to be in accidents that require medical attention. An analysis presented last week (January 2018) at APSARD (a national ADHD meeting) by Russell Barkley concluded that ADHD is associated with shorter life span– doubtless due to these two major contributors to early death.

What are the most important steps to keep your young teen safe?

Here are the key steps for suicide prevention:
1) Listen to warning signs: 80% of teens who attempt suicide give warning signs first, according to the Centers for Disease Control. If your child is feeling hopeless or thinking more than occasionally about suicide, or has suicidal ideas that are potentially deadly, consult a counselor about how to create a safety plan (not just a safety contract).

2) Lock up the medicine cabinet:

A common way teens injure or kill themselves is through taking pills from parents’ cabinets including Tylenol (acetaminophen) (an overdose of acetaminophen can be lethal especially if not  treated within a few hours—acute liver failure is extremely dangerous). Lock up your medicines, including all over  the-counter drugs. At my University, health care providers have begun providing families of at-risk teens free emergency lock bags; you can purchase the same lockable and tough medication pouch for $20, or a larger lock box for the same purpose, at www.lockmed.com.

3) Firearms: Review and double down on your firearm safety plans. The literature suggests that we as parents are not accurate at knowing our children’s or teens’ knowledge or behavior when they are around guns without our supervision. Don’t kid yourself about the risks. If you have a child with ADHD, be extra thorough in educating or training your children in gun use and safety, and triple check and regularly review your gun storage and safety procedures.

4) Medication treatment: Talk to your doctor about the pros and cons of stimulant treatment for your teen. Stimulants (methylphenidate) reduce the risk of physical injury for kids with ADHD, but they come with a warning that suicidality is a contraindication. However, last month a national population study from Taiwan reported reduced suicide attempt in youth who had been treated at least 3 months with stimulants. (Caution, suicide rates differ in Taiwan and U.S.)

For accidents and injuries:

Follow ADHD treatment recommendations and then remember these basics:

1) Make your child wear a bicycle helmet and seat belt.

2) If your teen drives: monitor your teen’s driving behavior and ensure they understand the extra risks for teen drivers from friends in the car, use of cell phone, and speeding. Almost half of high schoolers who drive either text or email while driving; a lesser percent drink or let friends who drink be in the car.

3) Get to the bottom of it if: you find out your teen has been in a fight, carried a weapon (knife for fighting or gun), or is afraid or feels unsafe going to, or at, school.

Communicate:

Whether we are talking suicide, violence or bullying, antisocial behavior, risky sex, accidents, or internet safety, the overall principle from scientific studies of teen safety: the teens at most risk is those with whom parent-child communication has broken down. Keep those lines of communication open. Stay interested. Be a little nosy. Take some time to listen non-judgmentally. Share your perspective. If you know what is going on with your teen and what they are thinking about, and if your teen understands your viewpoint as well, then you have already taken a major step in keeping them safe. The fact that you took the time to read this shows you care, and you are on your way. Despite how worrisome some of these concerns can be, with some basic precautions your chances are good that your teen will be okay. Hang in there, and stay positive!

 

 

Key studies:
This correlational study released this month from a large population cohort in Taiwan associated stimulant medication treatment with reduction in suicide attempts:

Liang SH, Yang YH, Kuo TY, Liao YT, Lin TC, Lee Y, McIntyre RS, Kelsen BA, Wang TN, Chen VC. Suicide risk reduction in youths with attention-deficit/hyperactivity disorder prescribed methylphenidate: A Taiwan nationwide population-based cohort study. Res Dev Disabil. 2018 Jan;72:96-105. doi: 10.1016/j.ridd.2017.10.023.

Previous work in 2015 associated stimulant treatment with reduced risk of injury:

S. Dalsgaard, J.F. Leckman, P.B. Mortensen, H.S. Nielsen, M. Simonsen. Effect of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: A prospective cohort study. The Lancet Psychiatry, 2 (8) (2015), pp. 702-709

N. Savill, C.J. Bushe. A systematic review of the safety information contained within the Summaries of Product Characteristics of medications licensed in the United Kingdom for Attention Deficit Hyperactivity Disorder. how does the safety prescribing advice compare with national guidance? Child and Adolescent Psychiatry and Mental Health, 6 (2) (2012)

Parental and child discordance of gun report:

May 2006 Parental Misperceptions About Children and Firearms. Frances Baxley, MD; Matthew Miller, MD, ScD. Arch Pediatr Adolesc Med. 2006;160(5):542-547. doi:10.1001/archpedi.160.5.542