Maternal substance use may increase risk of childhood Attention Deficit Hyperactivity Disorder

1. Substance use in the prenatal period may be associated with an increased risk of an Attention Deficit Hyperactivity Disorder (ADHD) diagnosis in children.

2. A statistical association between ADHD risk and opioid, cannabis or alcohol use in pregnancy was found.

Level of evidence rating: 2 (Good)

Study Rundown: Substance use during pregnancy is known to exert a number of adverse effects on fetal development, with conditions such as fetal alcohol syndrome well-established in the literature. However, the longitudinal consequences of maternal substance use on mental health outcomes of offspring remains poorly understood. The present study sought to describe the association between substance use and the risk of developing attention deficit hyperactivity disorder (ADHD) in childhood. A total of 3138 children were included in this cohort study, 348 of whom had a diagnosis of ADHD (15.5%). Mothers of children with ADHD were more likely to be single, divorced or widowed and less likely to have graduated from college than those whose children did not have an ADHD diagnosis. 24.2% of mothers reported using at least one substance (tobacco, alcohol, opioids, cannabis) during the last 3 months of their pregnancy; tobacco was the most common exposure. Opioid exposure had the strongest association with risk of ADHD diagnosis. The risk of ADHD was found to increase with the number of substances concurrently used as well. This study describes an increased risk of childhood ADHD diagnosis following maternal use of substances during the last three months of pregnancy; specifically, opioids were associated with a higher childhood ADHD risk, as was polysubstance use in general. This study further underscores the importance of screening pregnant patients for substance use and providing education about the longitudinal consequences of these behaviors on maternal and fetal health. Strengths of this work include the prospective data collection window and large sample size. A notable weakness of this study is the reliance on self-reported data to assess maternal substance use, leaving this work susceptible to underestimating the prevalence and consequence of maternal substance use. This study lays the groundwork for more specific research into the impacts of opioid use on childhood health outcomes.

Click here to read this study in JAMA Network Open

Click to read an accompanying editorial in JAMA Network Open

Relevant Reading: Maternal substance use during pregnancy and offspring conduct problems: a meta-analysis

In-Depth [prospective cohort study]: This prospective cohort study was conducted in Boston, MA. Data were derived from an ongoing repository of maternal-child data (Boston Birth Cohort) initiated in 1998. Children with missing information, multiple gestations, known chromosomal abnormalities or pregnancies resulting from in vitro fertilization were excluded. Participating individuals were recruited between the ages of 6 months and 21 years if they received healthcare within the Boston Medical Center network. ADHD diagnosis was defined on the basis of International Classification of Diseases codes; children in the control group did not have a diagnosis of ADHD or any other neurodevelopmental disorder (i.e., autism spectrum disorder, etc.). Data about maternal substance use was participant-reported through a questionnaire conducted within 24-72 hours following delivery. Mothers were asked about their use of the following substances during the last three months of their pregnancy: tobacco, opioids, cannabis, alcohol. The median follow-up period was 12 years. In total, 759 women reported substance use within 3 months of delivery; 580 (18.5%)  children were exposed to maternal use of tobacco products, 253 (18.1%) to alcohol, 123 (3.9%) to cannabis and 60 (1.9%) to opioids. The adjusted hazard ratio (HR) for ADHD risk in children exposed to opioids compared to those who were not was 2.19 (95% confidence interval 1.10-4.37). Neither cannabis (log HR 0.28, -0.15 to 0.58) nor alcohol exposure (log HR 0.28, -0.03 to .06) were associated significantly with ADHD risk. Each additional substance used in pregnancy was found to increase the risk of ADHD by 21%; specifically, the interaction of opioids and tobacco use was found to significantly increase ADHD risk (hazard ratio 1.17).

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