Factors affecting extremity fracture risk in children with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is increasingly recognized not only for its behavioral and cognitive challenges but also for its potential implications in physical health, particularly injury risk. This study aimed to investigate the incidence of extremity fractures among children and adolescents diagnosed with ADHD, and to evaluate the influence of demographic, clinical, and pharmacological variables-including ADHD subtypes and medication types-on fracture risk.

This retrospective cross-sectional study included 754 children and adolescents aged 6-18 years old who were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders-5 criteria. Data were collected from electronic health records at a tertiary referral hospital. Variables analyzed included age, sex, ADHD subtype, intelligence quotient (IQ) level, pharmacological treatment status (methylphenidate or atomoxetine), comorbid psychiatric and medical conditions, and fracture history confirmed by clinical and radiological evidence. Binary logistic regression analysis was conducted to identify independent predictors of fracture risk.

The overall incidence of extremity fractures was 15%, with 69% occurring in the upper extremities. Children using ADHD medication had significantly lower fracture rates (9.7%) compared to untreated peers (32.6%, p < 0.001). Logistic regression showed that both methylphenidate (OR = 0.396) and atomoxetine (OR = 0.138) were associated with reduced fracture risk. The inattentive subtype also showed a protective effect. Other factors, such as age, sex, IQ, and comorbidities, were not significantly associated with fracture incidence.

This study highlights a notable reduction in extremity fracture risk among children with ADHD receiving pharmacological treatment, suggesting a possible protective role of stimulant and nonstimulant medications. Subtype-specific risk profiles further emphasize the importance of personalized approaches in ADHD management strategies.