Antipsychotic use among youth in foster care with comorbid ADHD and disruptive behavior disorder

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.