Treating ADHD in Expectant Mothers

Heather M. Joseph, DO, associate professor of psychiatry and pediatrics, Department of Psychiatry, University of Pittsburgh School of Medicine, studies the earliest detectable signs of attention-deficit/hyperactivity disorder (ADHD) and the family factors that influence how the condition develops over time. Much of that work began with a simple question: could children at elevated risk for ADHD be identified early enough to intervene before behavioral difficulties became established?

As her research followed infants and families through the first years of life, another pattern emerged. Although the studies focused on children, the initial research findings came from the parents. Families in which a parent had ADHD experienced greater parenting stress, poorer sleep quality, higher rates of depression and anxiety during the postpartum period, and early differences in parent-child interactions.

The Moms Managing ADHD (MomMA) study, developed in collaboration with Dr. Andrea Chronis-Tuscano at Maryland University and Dr. Nicole Lorenzo at American University, evaluates a behavioral intervention developed specifically for expectant mothers with ADHD. The program has progressed from community input and intervention development through a single-group pilot study and is now being evaluated in a randomized controlled trial delivered by behavioral health therapists at the Magee Behavioral Health Clinic.

Why Start With the Parent?

ADHD is among the most heritable psychiatric conditions. Prior research suggest that approximately 80% of parents with ADHD have at least one child who also develops the condition. Genetics contribute to the risk, but family environment also plays a role in shaping early development.

Dr. Joseph's earlier work through the Pittsburgh ADHD Risk in Infancy Study (PARIS) and its follow-up cohorts sought to identify behavioral and developmental markers that might signal elevated ADHD risk during infancy and early childhood.

"Parents in families with parental ADHD report greater parenting stress. They have worse sleep, even if it's the other person who has ADHD," Dr. Joseph says. "Both of them are more stressed and both of them have poor sleep." During the first year after childbirth, mothers and fathers in those families also experienced depression and anxiety at rates three to five times higher than parents in families without ADHD. The research also identified differences in early mother-infant attachment.

Many of the most effective behavioral treatments for young children with ADHD, including parent management training and parent-child interaction therapy, depend on parents learning and consistently applying new behavioral strategies. If a parent is also struggling with untreated ADHD symptoms, implementing those interventions may become more difficult.

Building an Intervention for Pregnancy

The MomMA study grew directly from those earlier observations. Rather than waiting until children began exhibiting behavioral symptoms, Dr. Joseph and colleagues asked if pregnancy and the transition to parenthood might provide an opportunity to intervene even earlier, before many of the challenges associated with parental ADHD begin to affect family functioning. The intervention also builds on work from collaborator Andrea Chronis-Tuscano, PhD, at the University of Maryland, whose research demonstrated that effectively treating maternal ADHD can improve parenting behaviors and child outcomes.

The intervention combines cognitive behavioral therapy with organizational skills training designed for the needs of expectant mothers with ADHD in pregnancy and the postpartum transition to parenthood. The program is designed to reduce maternal ADHD symptoms, lower the risk of postpartum depression, and strengthen early parent-child relationships during the first months after birth.

MomMA is delivered by behavioral health therapists at Magee Behavioral Health Clinic, allowing patients to receive care in the same setting where they already receive prenatal services.

Expectant and new mothers first participated in focus groups to review the proposed intervention and identify practical considerations for pregnancy and early parenthood. Their feedback and input from obstetric and behavioral health clinicians guided the structure, content, and number of treatment sessions.

Dr. Joseph and colleagues then conducted a single-group pilot study to determine whether the intervention could be successfully integrated into routine prenatal care and if participants found it acceptable, appropriate, and feasible.

"If you're trying to teach the parents how to work with their children to improve positive behavior and reduce negative behaviors, the parent has to be able to participate and then implement the skills. And if they have ADHD, that can be challenging."

Testing the MomMA Intervention

The current phase of the project is evaluating both the clinical effects of the intervention and whether it can be successfully integrated into routine obstetric practice.

The pilot randomized controlled trial plans to enroll 40 pregnant women with ADHD, who are randomly assigned to receive either the six-session MomMA intervention or treatment as usual. Sessions are offered either in person at UPMC Magee-Womens Hospital or through telehealth, with optional booster sessions available after delivery.

Participants complete assessments before beginning the intervention, immediately afterward, and again four months postpartum, with a subset returning for an additional evaluation at 12 months.

In addition to measuring changes in ADHD symptoms and maternal mental health, the study is also evaluating implementation. Dr. Joseph and colleagues are examining if behavioral health therapists embedded within obstetric practices can deliver the intervention with fidelity, and how clinicians and participants view its acceptability and feasibility.

Moving ADHD Intervention Earlier

The MomMA study is one part of Dr. Joseph's broader research program, which seeks to identify opportunities for intervention long before ADHD-related difficulties become firmly established.

Her earliest studies focused on identifying infants and toddlers at elevated risk for ADHD. Those investigations highlighted the challenges experienced by parents, leading to the development of an intervention during pregnancy. At the same time, Dr. Joseph’s ongoing AtHENS study is examining how attention networks develop during the preschool years in hopes of identifying biological markers that may eventually guide even earlier intervention.

"If we can intervene earlier and reduce the negative consequences of ADHD, we may also be able to prevent depression and anxiety for these individuals," Dr. Joseph says.

Although the current trial is focused on expectant mothers with ADHD, its goal goes beyond maternal symptoms. Strengthening parental functioning during pregnancy and the transition to parenthood may help improve early parent-child interactions and change the developmental trajectories for families affected by ADHD.

Further Reading and Contact Information

The MomMA study is currently enrolling. To learn more you can reach the study team by phone or text at 412-420-8309, or by email at MomMAstudy@upmc.edu.