According to my psychiatrist, I am the “textbook example of how ADHD gets missed in high-achieving girls,” and over the years, I’d become so adept at masking my symptoms that no one but me ever suspected there was a problem. My diagnosis at age 35 was an enormous relief, and I hoped that medication would give me a shot at finally feeling normal.
But if I wanted to keep nursing my 6-month-old baby, “normal” might have to wait.
There are no controlled studies of stimulants during pregnancy and lactation, my psychiatrist explained, so while there’s no evidence that they’re harmful, there’s no proof that they’re safe, either. Thomas Hale, head of the InfantRisk Center at Texas Tech University, places stimulants in the category of drugs that should be taken “only if the potential benefit justifies the potential risk to the infant.”
As I understood it, I had two options: I could quit breastfeeding and take medication, or continue breastfeeding and delay treatment. Neither was ideal. On one hand, I’d made it this far without meds, so what was another six months? On the other, hadn’t I suffered enough?
Later that day, after my Google searches for “breastfeeding adderall baby side effects terrible mother?” came up empty, I did what any responsible millennial parent would do: I emailed Emily Oster for help. Oster is a professor of economics at Brown University, and her books offer a data-driven approach to pregnancy and parenting that I find both liberating and deeply reassuring. If there was more evidence to consider, hopefully she could help me find it.
She wrote back, directing me to a 2015 paper on the use of methylphenidate (a.k.a. Ritalin) in breastfeeding patients with narcolepsy. The researchers found that the relative infant dose, which estimates drug exposure in breast milk relative to the parent’s dose, was less than 1 percent, with no adverse reactions reported in the babies. (A relative infant dose of under 10 percent is generally considered acceptable.) While that wasn’t much to go on, Oster said, “There’s no reason to think there’s a problem.”
With the green light from my son’s pediatrician, my psychiatrist prescribed an immediate-release stimulant I could try on an “as-needed” basis. I would nurse and pump beforehand, and bottle feed while the meds were in my system. She also recommended I “pump and dump” after each dose to further minimize exposure. This is what pediatrician Ann Kellams would call “creative problem solving.” Kellams is the president of the Board of the Academy of Breastfeeding Medicine and a professor of pediatrics at the University of Virginia. “You take the information you have, and then you figure out what will work best, and minimize the risk as much as possible for you to get to the place you feel comfortable.”
A few days later, I stood in my kitchen, staring down at a small blue pill in the palm of my hand. A wave of guilt washed over me. Was I doing the right thing? Would it even make a difference?
Turns out, the difference was enormous. When the meds kicked in, it felt like someone had slipped a pair of noise-canceling headphones onto my brain. I had no idea how loud it was in there until suddenly it was quiet. I knew I couldn’t go back to the way things were before. I also knew that spending most of those clearheaded hours attached to a pump was a waste of time — and milk.
I managed to keep up the routine for a few more weeks, until I found myself on vacation in Palm Springs, Calif., stuck inside pumping five to six times a day only to produce about as many ounces of “clean” milk, and missing out on all the fun with my kids. As my supply and my resolve dwindled in equal measure, I was ready to be done. So I hung up my nursing bras for good, and I’ve never once regretted it.
Rethinking the risk-benefit analysis
In situations like mine, the “risk-benefit analysis” paradigm is fundamentally flawed. By presuming that the needs of parent and child are in opposition, it fails to account for the risks of untreated ADHD, or the needs of other children in the family unit, or the benefits of formula feeding (which, I discovered, are many). “I don’t think of it as a risk-benefit analysis,” says Vivien Burt, a clinical psychiatrist in Los Angeles who specializes in maternal mental health. “I think of it more as a risk-risk evaluation.” Instead of asking only about the risks to an infant, she says, we should be asking, “What are the risks if a mother is not on her medication?”
Untreated postpartum anxiety and depression can lead to a variety of behavioral issues in their children, so it stands to reason that ADHD in parents, if not well managed, might have negative consequences for kids, as well. “Babies’ development depends on having parents who can tune in to them,” says Kellams. A distracted, disorganized or easily overwhelmed parent can find it difficult to connect with and care for young children, she says.
Further complicating the issue is that some people — including some doctors — still don’t see ADHD as a real diagnosis, even though it’s one that affects millions of people. “It’s only been for about 25 or 30 years that people have admitted that ADHD even occurs in adults,” explains James McGough, co-director of the ADHD Clinic at the University of California at Los Angeles, and a professor of clinical psychiatry at the David Geffen School of Medicine. Many ADHD symptoms may not seem like a big deal, which makes the disorder hard to diagnose and easy to dismiss.
For example, I can be absent-minded and easily distracted, which sounds cute when I’m telling a story about the time I lost my house keys and later found them in the refrigerator. Less cute? The times (yes, plural) I forgot to buckle my newborn into his car seat before backing out of the driveway. Surely that’s a much more serious risk than trace amounts of medication in my breast milk.
Treatment for ADHD can be life-changing, says McGough, but he stressed that medication is not the only effective option: “Cognitive behavioral therapy is a skill-based, time-limited intervention of 10 to 15 weeks that really has dramatic benefits.” For many people, therapy and lifestyle adjustments may be enough, but I was quarantined with two young children, and I was unraveling. I needed relief, and I needed it now, not in 10 to 15 weeks.
Gathering data and making decisions
When I spoke to Oster again recently, she explained that making good decisions depends a lot on asking the right question. Rather than asking how “committed” to breastfeeding I was, she said, a better question to ask myself would have been “What are my actual options?” With all the options on the table, you then go about gathering data. “When I talk about fact-finding,” she explained, “particularly in these places where it’s a data-poor environment, you want to collect all of the information.” That includes what we know about breastfeeding in general, my experiences with and without medication, my priorities and my personal risk tolerance.
In the absence of clinical trial data, Kellams urges doctors to consult resources like LactMed, the drugs and lactation database, and the reference manual “Hale’s Medications & Mothers’ Milk,” both of which compile the most recent anecdotal and case-based published reports on medication safety and lactation. “Everyone deserves to get all of that information,” Kellams says, “so they can arrive at the plan that’s best for them.”
So did I have to give up breastfeeding? Maybe not. But I can unequivocally say that taking medication for my ADHD has helped me be a better partner to my husband and a better mother to my children. Switching to formula gave me and my doctor the flexibility to find the right medication without worrying about putting my baby at risk. It also gave me more freedom to choose how I spent my time — including with my pandemic-scarred 5-year-old, who was gearing up for a year in Zoom kindergarten.
In the end, prioritizing my own mental health wasn’t selfish — it was the best parenting decision I’ve ever made. Not because it was the “right” thing to do, or even the only thing to do, but because it was absolutely the right choice for my family.
Rebecca Phillips Epstein is a screenwriter and essayist based in Los Angeles. Follow her on Twitter @thephillistein.