Hasan SA, Murugappan M, Westberg S, et al. Prescription Stimulant Continuation in Pregnancy and Birth Outcomes. Journal of Attention Disorders. 2026;30(3):315–328. doi:10.1177/10870547251397034.
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- “exposure definitions were based on prescription fills, which may not equate to actual consumption or adherence.” — p. 325
- “it is equally important to consider ConfoundingWhat it is: When another factor influences both the exposure and outcome, creating a misleading association.Does not mean legally: An observed association cannot be assumed causal when confounding has not been adequately addressed.Glossary › by indication.” — p. 323
Article primary conclusion
This retrospective Cohort StudyDefinition: A cohort study follows groups of people over time to compare outcomes between those exposed to a factor and those who are not.Evidence quality: Cohort studies occupy the middle of the evidence pyramid and provide strong evidence of association but not definitive causation.Court use: Courts may infer increased or decreased risk, but should not conclude that the exposure directly caused the outcome in an individual case.Glossary › used MarketScan commercial insurance claims data from 2013 through 2021 to examine whether the timing and duration of prescription stimulant dispensing during pregnancy were associated with maternal and fetal outcomes. Among 1,514,018 eligible pregnancy episodes, 24,200 had at least one prescription stimulant claim from the 90 days before pregnancy through pregnancy; 18,087 had a claim during pregnancy of these 10,266 had prescription claims limited to the first trimester and 7,821 had claims continuing into the second and/or third trimesters. Prescription stimulant exposure was defined from pharmacy claims for amphetamine- or methylphenidate-containing medications. The study compared exposed pregnancies with propensity-score-matched pregnancies without stimulant prescription claims and, in a separate analysis, compared pregnancies with continued prescription claims with those in which claims ended after the first trimester.
The authors found that first-trimester-only prescription stimulant exposure, meaning prescription stimulant use during the first trimester or pregnancy, was associated with a lower risk of spontaneous abortion (RR 0.69, 95% CI 0.64–0.76) and preterm birth (RR 0.75, 95% CI 0.62–0.90) compared with no stimulant exposure. Continued exposure into the second or third trimester was associated with higher risks of placental abruption (RR 1.63, 95% CI 1.03–2.57), preeclampsia (RR 1.42, 95% CI 1.19–1.69), gestational hypertension (RR 1.37, 95% CI 1.16–1.61), and preterm birth (RR 1.34, 95% CI 1.12–1.62). Compared directly with first-trimester-only exposure, continued exposure was associated with higher risks of stillbirth (RR 3.54, 95% CI 1.48–8.44), spontaneous abortion (RR 1.53, 95% CI 1.38–1.68), placental abruption (RR 1.78, 95% CI 1.11–2.84), preeclampsia (RR 1.33, 95% CI 1.12–1.59), preterm birth (RR 1.86, 95% CI 1.51–2.28), and small-for-gestational-age birth (RR 1.47, 95% CI 1.12–1.92).
The authors concluded that the timing and duration of prescription stimulant exposure during pregnancy may be important considerations when assessing maternal and fetal risks. Continued stimulant exposure into the second or third trimester was associated with several adverse pregnancy outcomes, and the authors suggested that these findings may be relevant to clinical decision-making regarding continuation of stimulant treatment during pregnancy.
Article context
This study is strengthened by its large sample, propensity-score matching, and its effort to distinguish first-trimester-only prescribing from continuation into later pregnancy. The central limitation is ConfoundingWhat it is: When another factor influences both the exposure and outcome, creating a misleading association.Does not mean legally: An observed association cannot be assumed causal when confounding has not been adequately addressed.Glossary › by indication and treatment continuation: people who continue stimulants later in pregnancy may differ from those who discontinue them in ADHD severity, psychiatric comorbidity, functional impairment, and other characteristics not fully captured in claims data. The authors acknowledge residual confounding by ADHD severity, stimulant dose, and unmeasured behavioral factors, and note that separating medication effects from the effects of the underlying conditions remains difficult.
Exposure was defined by prescription claims, which indicate that a medication was dispensed but do not establish that it was taken, at what dose, or with what adherence. First-trimester exposure required only one or more claims and therefore may not represent continuous use throughout the trimester.
Overall, the study supports an AssociationWhat it is: A statistical relationship between two variables.Does not mean legally: Association alone does not establish causation.Glossary › between continued prescription stimulant dispensing and several adverse pregnancy outcomes, but it does not establish that continuing the medication itself caused those outcomes or that discontinuation would have prevented them.
Editor's note
The study’s comparison of continued versus discontinued stimulant prescribing may appear to show that stopping medication reduces pregnancy risk, but treatment continuation was not randomly assigned: people who continued stimulants may have differed in ADHD severity, psychiatric comorbidity, functional needs, and other characteristics that also influence pregnancy outcomes. The authors themselves acknowledge that distinguishing the effects of stimulant medication from those of the underlying conditions remains a key challenge. Accordingly, the study should not be interpreted as evidence that discontinuing a prescribed stimulant during pregnancy would prevent the adverse outcomes associated with continued prescribing.