Fractures account for 25% of all injuries in children and are the most common reason for hospitalization, but the rate is higher in children with ADHD.
5% of children and adolescents live with attention deficit / hyperactivity disorder (ADHD), a neurological developmental disorder that affects inattentiveness, motor hyperactivity and impulsivity. When we think of a child with ADHD, we tend to think of a fidgety, distracted child who reacts impulsively.
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It is believed that children with ADHD have higher rates of musculoskeletal injury due to their inattentiveness and impulsiveness, but we do not know exactly how much higher the incidence is.
Based on the work by Brehaut et al. It is estimated that children with behavioral disorders are 1.5 times more likely to be injured, but this is not specific to ADHD. Therefore a new systematic review aims to investigate the increased risk especially for children with ADHD.
Methods
This systematic review corresponded to the PRISMA guidelines and was pre-registered and followed at PROSPERO, both marks of a good systematic review.
Five databases were searched, which is more than sufficient to obtain adequate coverage of the published work, including CINAHL, EMBASE, PsycINFO, PubMed, and Scopus, all searches that took place in November 2018.
The search terms used were attention deficit hyperactivity disorder OR attention deficit disorder AND bone fracture * without restriction on language or publication period.
To be included in the review article, five essential criteria had to be met.
Participants under 18 years of age
Diagnosis of ADHD based on DSM or ICS classification
Participants had to be observed for a period of five or more years with a subgroup who suffered a fracture
Published in a peer-reviewed journal
The study population must be unique and is not covered by other articles
Articles were screened and rated for inclusion by two independent reviewers, with differences of opinion resolved by consensus. The quality of the study was assessed with the Critical Appraisal Tool of the Joanna Briggs Institute.
A meta-analysis was carried out with the Excel tool by Neyeloff, Fuchs and Moreeira. The prevalence of fractures was calculated using a random effects model and the degree of heterogeneity was assessed using the I2 method.
Results & implications
A total of five studies were included in the qualitative synthesis and five in the meta-analysis. The headline result is that children with ADHD are 2.55 times more likely to suffer a fracture than children without ADHD.
Brief summary of
Children with ADHD have a 2.55 times the risk of breaking a bone than children without ADHD
60% of these fractures occur in the upper extremity
We don't know how great an impact medication has on injury prevalence
Fractures are not only about half as likely to fracture, but they are also much more likely to occur in the arms. The studies that recorded the fracture localization were summarized and show that 70% of the fractures are carried in the upper extremities, 23% in the lower extremities and 8% in other skeletal regions.
This increased probability of fractures and distribution of the upper limbs is most likely to occur because children with ADHD show impulsive behavior and, although they can recognize danger, expect less serious consequences for their behavior.
The results of this study have some limitations, including the fact that ADHD comes in many forms and degrees of severity, which are often insufficiently considered in studies. The type of drug and dose were also not investigated, which could influence the results.
