Fractures account for 25% of all injuries in children and is the most common reason for hospital admission, but the rate is higher in children with ADHD.
5% of children and adolescents live with attention-deficit/hyperactivity disorder (ADHD) a neurodevelopment disorder impairing inattention, motor hyperactivity and impulsivity. When we think of a child with ADHD we tend to think of a fidgety distracted child reacting on impulse.
It’s assumed that children with ADHD have higher rates of musculoskeletal injury because of their inattention and impulsivity however we don’t know exactly how much higher the incidence is.
Based on work by Brehaut et al it’s estimated that children with behavioural disorders have 1.5x increase in risk of injury however this is not specific to ADHD. Therefore a new systematic review aims to investigate the risk increase specifically for children with ADHD.
This systematic review adhered to PRISMA guidance and was pre registered on PROSPERO and adhered to, both hallmarks of good systematic review.
Five databases were searched, which is more than adequate to gain suitable coverage of published work, and included CINAHL, EMBASE, PsycINFO, PubMed and Scopus all searches taking place in November 2018.
The search terms used were attention deficit hyperactivity disorder OR attention deficit disorder AND bone fracture* with no restriction set on language or publication period.
To be included within the review articles had to meet five essential criteria.
- Participants under 18 years old
- Diagnosis of ADHD based on DSM or ICS classification
- Participants had to be followed over a five or more year period with a subset that experienced a fracture
- Published in peer-reviewed journal
- The study population has to be unique not covered by any other articles
Articles were screened and assessed for inclusion by two independent reviewers with disagreement resolved via consensus. Study quality was assessed using the Joanna Briggs Institute critical appraisal tool.
A meta-analysis was completed using Neyeloff, Fuchs and Moreeira Excel tool. A random effects model was used to calculate the prevalence of fractures and the level of heterogeneity was assessed using the I2 method.
Results & Implications
In total five studies were included within the qualitative synthesis and five were included within the meta-analysis. The headline outcome is that children living with ADHD are 2.55x more likely to sustain a fracture than children without ADHD.
As well as being toward half times more likely to sustain a fracture the fractures are far more likely to occur in the arms. The studies which recorded location of the fracture were pooled together and show that 70% of the fractures are sustained in the upper limbs, 23% in the lower limbs and 8% in other skeletal regions.
This increased likelihood of fracture and upper limb distribution is most likely to occur because children with ADHD display impulsive behaviours and, although they can identify hazards, anticipate less severe consequences to their behaviours.
There are some limitations to the results of this study including the fact that ADHD comes in many forms and severity which is often poorly considered within studies. Medication type and dose was also not investigated which could influence the results.