Untreated Attention Deficit Hyperactivity Disorder: A Risk Factor in Paediatric Injuries?

ADHD has been estimated to affect between 1 and 20% of children although most estimates range between 3% and 5%. Treatment of children with ADHD begins with making the correct diagnosis and this is based upon criteria delineated in the Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) in addition to other clinical factors that are assessed by the physician.9 When the diagnosis of ADHD is confirmed, a combination of behavioural therapy and pharmacological treatment with stimulants is commonly instituted. Some practitioners and many parents opt to withhold these stimulant medications during the summer months when children are out of school and not expected to perform academically. Traumatic injury is a major cause of death and disability in children. A recent report suggests that more than 50% of deaths in children between the ages of 1 and 19 are related to traumatic injury. Continued improvements in automobile safety, the widespread institution of injury prevention programs and the installation of smoke detectors and sprinklers appear to have decreased the rate of death due to accidental injury but as of 1997, trauma continues to be the leading killer of children in the United States. Compared to 21,727 childhood deaths due to injuries in 1979, 11,694 children died due to unintentional injuries in 1997, a reduction by nearly 50%. Despite these optimistic figures, many children still die or are seriously injured each year due to preventable causes. While automobile safety and injury prevention programs have clearly improved safety for children, there may be additional underappreciated factors that place many children at risk for injury and death. One of these factors may be the presence of attention-deficit/hyperactivity disorder (ADHD), which is now believed to be the most common neurobehavioral disorder in children. The purpose of this report is to describe the cases of two children with a diagnosis of ADHD who suffered severe, disabling lower extremity injuries and to highlight the possible importance of this co-morbidity and its treatment in the context of paediatric trauma. The two cases described in this report occurred during the same summer and are examples of the consequences of risk-taking behaviour on the part of two children with ADHD. While safety measures such as seatbelts, smoke detectors and bicycle helmets may be having a favourable impact upon the incidence and severity of paediatric trauma, children with psychological or behavioural disorders constitute a high-risk cohort that should not be ignored. Both of the children reported were on summer vacation and had been counselled to discontinue their ADHD medications while out of school. Since children with ADHD may be at increased risk for injury and even death, the following recommendations may be made for emergency department paediatricians, psychiatrists, primary care providers as well as parents. First, clinicians should encourage parents to be particularly watchful of their children during the summer while the child is not in school. Adequate parental supervision of children should be particularly stressed as lack of adequate supervision has been clearly linked to a significant percentage of paediatric injuries. Bicycle helmets and assistance to children in busy streets and neighbourhoods should be actively recommended as all children and especially those with ADHD appear to be in danger while on bicycles and while crossing or playing in streets. Second, health care providers should look for symptoms of ADHD when evaluating any injured child. A recent study suggests that a significant number of primary care paediatric office visits occur for evaluation and treatment of relatively minor injuries such as lacerations, sprains and contusions. Early recognition of symptoms of ADHD in this setting may allow for referral of a potentially injury prone child to a paediatric psychiatrist or primary care paediatrician for treatment of ADHD before a more serious or life-threatening injury occurs. Third, when providing care to children with ADHD, the clinician should attempt to educate the parents about the risks of trauma and the importance of preventive measures such as seatbelts and helmets. Finally, it would be our recommendation that consideration be given to continuation of medications prescribed for treatment of ADHD during the summer months when children are involved in outdoor activity and at increased risk for trauma.