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Preliminary Evidence of an Association Between ADHD Medications and Diminished Bone Health in Children and Adolescents

Howard, Jeffrey T. PhD*; Walick, Kristina S. MD; Rivera, Jessica C. MD*,‡

Journal of Pediatric Orthopaedics: July/August 2017 - Volume 37 - Issue 5 - p 348–354
doi: 10.1097/BPO.0000000000000651
Selected Topics

Background: The US Centers for Disease Control and Prevention estimate that 3.5 million children use psychotropic drugs for attention-deficit hyperactivity disorder (ADHD). With an increase in use of these types of drugs, thorough understanding of their potential side effects on the growing skeleton is needed. The purpose of this study was to determine whether there is an association between use of ADHD medication and diminished bone health.

Methods: Three waves of the National Health and Nutrition Examination Survey public-use data set, collected from 2005 through 2010, were compiled for this study (N=5315). Bone health was measured using dual-energy x-ray absorptiometry scans, which were performed for participants aged 8 to 17 years to determine bone mineral density (BMD) for 3 regions: (1) total femur; (2) femoral neck; and (3) lumbar. Use of ADHD medications was determined by self-reported responses to questions regarding prescription drug use, which were answered by either the respondent or the respondent’s parent or guardian. Multiple statistical techniques were used to produce estimates of association between ADHD medication use and z score age and sex standardized BMD measures, including survey adjusted univariate, survey adjusted multiple linear regression, and generalized estimating equations with a propensity-matched subsample (N=1967). Multivariate models adjusted for covariates including time period, age, sex, race/ethnicity, family income to poverty ratio, and total number of prescription medications.

Results: Conservative estimates of the difference in standardized BMD measures between the ADHD medication group and the nonmedicated group range from −0.4855 (±0.27; P<0.001) for total femoral, −0.4671 (±0.27; P<0.001) for femoral neck, and −0.3947 (±0.29; P<0.01) for lumbar. Significantly more children on ADHD medications versus match subjects on no medication had BMDs with in osteopenic range (38.3% vs. 21.6%, P<0.01).

Discussion: The findings suggest that there are real and nontrivial differences in BMD for children and adolescents taking ADHD medications, as compared with similar children not taking any prescription medications. Prescribing physicians and parents should be aware of potential bone health risks associated with these medications.

Level of Evidence: Level III—case-control study.

Supplemental Digital Content is available in the text.

*US Army Institute of Surgical Research, San Antonio

Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX

Evans Army Community Hospital, Department of Orthopaedics, Fort Carson, CO

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Supported by a postdoctoral fellowship from the Oak Ridge Institute of Science and Education (ORISE).

The authors declare no conflicts of interest.

Reprints: Jessica C. Rivera, MD, Department of Orthopaedics and Rehabilitation, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA, Fort Sam Houston, TX 78234. E-mail:

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