Abstract
Many youth with attention deficit hyperactivity disorder (ADHD) and disruptive behavior disorder (DBD) are treated with antipsychotic (AP) drugs. Among youth in foster care, a vulnerable group with high behavioral health service needs and utilization, the rate of AP prescribing is high, and is particularly so for youth with DBD. What is not clear is the specific role of DBD, and the timing of this diagnosis, in this prescribing pattern. In this study, we apply Cox proportional hazards regression models to 2011–2018 Medicaid claims data from a southeastern state to estimate the incidence of AP prescribing in a population of youth in foster care, and estimate the hazard rate of AP prescribing among youth in foster diagnosed with DBD following an ADHD diagnosis. DBD diagnosis was entered as a time-varying covariate. In this population, about 16% of youth were prescribed an AP, and 35% were diagnosed with DBD. Youth diagnosed with DBD have, on average, 4 times the rate of being prescribed an AP relative to those youth with ADHD who are not subsequently diagnosed with DBD. In light of the goal that youth with behavioral health needs be treated in the community, these trends are not surprising. Nevertheless, off-label prescribing of APs does come with health risks. Efforts should be made to improve access to alternative forms of care, and to support foster parents’ efforts to provide effective care. Additional research is needed to understand the complex processes by which foster youth with ADHD and DBD are prescribed APs.
Highlights
-
Existing research underscores the risks associated with prescribing APs to youth in foster care.
-
Although youth in foster care with ADHD and DBD are prescribed APs at a high rate, the role of DBD accounting for timing is not clear.
-
We used event history analysis to estimate the rate of prescribing APs to these youth, comparing those with and without DBD.
-
Youth with ADHD who are later diagnosed with DBD were prescribed APs at 4 times the rate of youth without DBD.
-
This rate is more than twice the magnitude when the timing of the DBD diagnosis is not accounted for.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
American Academy of Child and Adolescent Psychiatry (2011). Practice parameter on the use of atypical antipsychotic medications in children and adolescents. Available at: https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed Aug. 28 2021.
American Academy of Child and Adolescent Psychiatry (2009). Practice parameter for the assessment and treatment of children and adolescents with Oppositional Defiant Disorder. Available at: https://www.aacap.org/App_Themes/AACAP/docs/practice_parameters/Atypical_Antipsychotic_Medications_Web.pdf. Accessed Aug. 28 2021.
Aitken, M., Waxman, J. A., MacDonald, K., & Andrade, B. F. (2018). Effect of comorbid psychopathology and conduct problem severity on response to a multi-component intervention for childhood disruptive behavior. Child Psychiatry & Human Development, 49(6), 853–864. https://doi.org/10.1007/s10578-018-0800-1.
Allison, P. (1995). Survival analysis using the SAS System: A practical guide. The SAS Institute.
Bandou, N., Koike, K., & Matuura, H. (2010). Predictive familial risk factors and pharmacological responses in ADHD with comorbid disruptive behavior disorders: Pediatrics International, 52(3), 415–419. https://doi.org/10.1111/j.1442-200X.2009.03003.x.
Barnett, E. R., Butcher, R. L., Neubacher, K., Jankowski, M. K., Daviss, W. B., Carluzzo, K. L., Ungarelli, E. G., & Yackley, C. R. (2016). Psychotropic medications in child welfare: From federal mandate to direct care. Children and Youth Services Review, 66, 9–17. https://doi.org/10.1016/j.childyouth.2016.04.015.
Brown, J. D., Hamilton, M., Natzke, B., Ireys, H. T., & Gillingham, M. (2011). Use of out-of-home care among a statewide population of children and youth enrolled in medicaid. Journal of Child and Family Studies, 20(1), 48–56. https://doi.org/10.1007/s10826-010-9376-5.
Crystal, S., Mackie, T., Fenton, M. C., Amin, S., Neese-Todd, S., Olfson, M., & Bilder, S. (2016). Rapid growth of antipsychotic prescriptions for children who are publicly insured has ceased, but concerns remain. Health Affairs, 35(6), 974–982. https://doi.org/10.1377/hlthaff.2016.0064.
Daviss, W. B., Barnett, E., Neubacher, K., & Drake, R. E. (2016). Use of antipsychotic medications for nonpsychotic children: risks and implications for mental health services. Psychiatric Services, 67(3), 339–341. https://doi.org/10.1176/appi.ps.201500272.
dosReis, S., Yoon, Y., Rubin, D. M., Riddle, M. A., Noll, E., & Rothbard, A. (2011). Antipsychotic Treatment Among Youth in Foster Care. Pediatrics, 128(6), e1459–e1466. https://doi.org/10.1542/peds.2010-2970.
Farmer, E. M. Z., Wagner, H. R., Burns, B. J., & Richards, J. T. (2003). Treatment foster care in a system of care: sequences and correlates of residential placements. Journal of Child and Family Studies, 12(1), 11–15.
Finnerty, M., Neese-Todd, S., Pritam, R., Leckman-Westin, E., Bilder, S., Byron, S. C., Hudson Scholle, S., Crystal, S., & Olfson, M. (2016). Access to psychosocial services prior to starting antipsychotic treatment among medicaid-insured youth. Journal of the American Academy of Child & Adolescent Psychiatry, 55(1), 69–76.e3. https://doi.org/10.1016/j.jaac.2015.09.020.
Fong, H. F., Alegria, M., Bair-Merritt, M. H., & Beardslee, W. (2018). Factors associated with mental health services referrals for children investigated by child welfare. Child Abuse & Neglect, 79, 401–412. https://doi.org/10.1016/j.chiabu.2018.01.020.
Fraser, M. W., Galinsky, M. J., Smokowski, P. R., Day, S. H., Terzian, M. A., Rose, R. A., & Guo, S. (2005). Social Information-Processing Skills Training to Promote Social Competence and Prevent Aggressive Behavior in the Third Grades. Journal of Consulting and Clinical Psychology, 73(6), 1045–1055. https://doi.org/10.1037/0022-006X.73.6.1045.
Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: Current insight. Psychology Research and Behavior Management, ume 10, 353–367. https://doi.org/10.2147/PRBM.S120582.
Huefner, J. C., Griffith, A. K., Smith, G. L., Vollmer, D. G., & Leslie, L. K. (2014). Reducing psychotropic medications in an intensive residential treatment center. Journal of Child and Family Studies, 23(4), 675–685. https://doi.org/10.1007/s10826-012-9628-7.
Hulvershorn, L., Parkhurst, S., Jones, S., Dauss, K., & Adams, C. (2017). Improved metabolic and psychiatric outcomes with discontinuation of atypical antipsychotics in youth hospitalized in a state psychiatric facility. Journal of Child and Adolescent Psychopharmacology, 27(10), 897–907. https://doi.org/10.1089/cap.2017.0040.
Lanier, P., Jensen, T., Bryant, K., Chung, G., Rose, R., Smith, Q., & Lackmann, L. (2020). A systematic review of the effectiveness of children’s behavioral health interventions in psychiatric residential treatment facilities. Children and Youth Services Review, 113, 104951 https://doi.org/10.1016/j.childyouth.2020.104951.
Leathers, S. J., Vande Voort, B. L., & Melka-Kaffer, C. (2021). Mental health services and psychotropic medications provided to children at risk for placement instability in foster care. Developmental Child Welfare, 3(3), 256–281. https://doi.org/10.1177/25161032211034255.
Lee, E. S., Vidal, C., & Findling, R. L. (2018). A focused review on the treatment of pediatric patients with atypical antipsychotics. Journal of Child and Adolescent Psychopharmacology, 28(9), 582–605. https://doi.org/10.1089/cap.2018.0037.
Levesque, L. E., Hanley, J. A., Kezouh, A., & Suissa, S. (2010). Problem of immortal time bias in cohort studies: Example using statins for preventing progression of diabetes. BMJ, 340(mar12 1), b5087–b5087. https://doi.org/10.1136/bmj.b5087.
Lohr, W. D., & Honaker, J. (2013). Atypical antipsychotics for the treatment of disruptive behavior. Pediatric Annals, 42(2), 72–77. https://doi.org/10.3928/00904481-20130128-11.
Linares, L. O., Martinez-Martin, N., & Castellanos, F. X. (2013). Stimulant and atypical antipsychotic medications for children placed in foster homes. PLoS ONE, 8(1), e54152 https://doi.org/10.1371/journal.pone.0054152.
Linton, D., Barr, A. M., Honer, W. G., & Procyshyn, R. M. (2013). Antipsychotic and psychostimulant drug combination therapy in attention deficit/hyperactivity and disruptive behavior disorders: A systematic review of efficacy and tolerability. Current Psychiatry Reports, 15(5). https://doi.org/10.1007/s11920-013-0355-6.
Minjon, L., van den Ban, E., de Jong, E., Souverein, P. C., Egberts, T. C. G., & Heerdink, E. R. (2019). Reported adverse drug reactions in children and adolescents treated with antipsychotics. Journal of Child and Adolescent Psychopharmacology, 29(2), 124–132. https://doi.org/10.1089/cap.2018.0139.
Moran, L. V., Ongur, D., Hsu, J., Castro, V. M., Perlis, R. H., & Schneeweiss, S. (2019). Psychosis with methylphenidate or amphetamine in patients with ADHD. New England Journal of Medicine, 380(12), 1128–1138. https://doi.org/10.1056/NEJMoa1813751.
Olfson, M., Blanco, C., Liu, S.-M., Wang, S., & Correll, C. U. (2012). National trends in the office-based treatment of children, adolescents, and adults with antipsychotics. Archives of General Psychiatry, 69(12), 1247 https://doi.org/10.1001/archgenpsychiatry.2012.647.
Rose, R., A., Lanier, P., & dosReis, S. (2022) Antipsychotic medications and admission to psychiatric residential treatment facilities among youth in foster care diagnosed with disruptive behavior disorders. American Journal of Orthopsychiatry. https://doi.org/10.1037/ort0000624.
Rose, R. & Lanier, P. (2017). A Longitudinal Study of Child Maltreatment and Mental Health Predictors of Admission to Psychiatric Residential Treatment Facilities. International Journal of Environmental Research and Public Health, 14(10), 1141. https://doi.org/10.3390/ijerph14101141.
Rose, R. A., Chung, G., & Lanier, P. J. (2020b). Effectiveness of Intensive Alternative Family Treatment on Reducing Re-Admissions to Psychiatric Residential Treatment Facilities. Journal of Emotional and Behavioral Disorders, Online First. https://doi.org/10.1177/1063426620980700.
Seibert, P. J., Feinberg, R., Ayub, A., Helburn, A., & Gibbs, D. (2018). State Practices in Treatment/Therapeutic Foster Care. Research Triangle Park, NC: RTI International.
Stroul, B. A., Blau, G. M., & Friedman, R. M. (2010). Updating the system of Care Concept and Philosophy. Washington, D.C.: National Technical Assistance Center for Children’s Mental Health.
Vanderwerker, L., Akincigil, A., Olfson, M., Gerhard, T., Neese-Todd, S., & Crystal, S. (2014). Foster care, externalizing disorders, and antipsychotic use among medicaid-enrolled youths. Psychiatric Services, 65(10), 1281–1284. https://doi.org/10.1176/appi.ps.201300455.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no competing interests.
Informed Consent
Study protocols were reviewed by a university Institutional Review Board and declared exempt from informed consent.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Support for this research was provided from an internal grant from the University of Maryland, School of Social Work.
Rights and permissions
Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Rose, R.A., Lanier, P., dosReis, S. et al. Antipsychotic use among youth in foster care with comorbid ADHD and disruptive behavior disorder. J Child Fam Stud 32, 2026–2035 (2023). https://doi.org/10.1007/s10826-022-02375-1
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10826-022-02375-1