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Cognitive behavioral therapy (CBT) for children with ADHD

Children's Mental Health: Attention Deficit Hyperactivity Disorder
Benefit-cost methods last updated December 2018.  Literature review updated April 2018.
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Cognitive behavioral therapy (CBT) for children with attention-deficit hyperactivity disorder (ADHD) aims to teach children strategies for altering thinking patterns and behavior. Examples of CBT methods used with an ADHD population include relaxation training, self-verbalization, a self-control game, or social problem-solving activities. CBT generally also includes a homework component intended to support generalizing skills learned in therapy to everyday life. Programs in this review may have included modules for parents either alone or in combination with their child, but children were the focus of interventions. All children in the included studies were diagnosed with ADHD or met clinical levels of ADHD symptoms. Programs were delivered in individual or group format and lasted on average four months, with an average of 4.5 total sessions per month.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2017). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers ($432) Benefits minus costs ($3,540)
Participants ($1,227) Benefit to cost ratio ($2.52)
Others ($443) Chance the program will produce
Indirect ($432) benefits greater than the costs 47 %
Total benefits ($2,535)
Net program cost ($1,006)
Benefits minus cost ($3,540)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $10 $0 $26 $5 $41
Labor market earnings associated with test scores ($559) ($1,232) ($572) $0 ($2,363)
K-12 grade repetition $2 $0 $0 $1 $3
K-12 special education $27 $0 $0 $14 $40
Labor market earnings associated with major depression ($11) ($23) $0 $0 ($34)
Health care associated with disruptive behavior disorder $99 $28 $102 $50 $278
Mortality associated with depression $0 $0 $0 $0 $0
Adjustment for deadweight cost of program $0 $0 $0 ($501) ($501)
Totals ($432) ($1,227) ($443) ($432) ($2,535)
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $2,008 2015 Present value of net program costs (in 2017 dollars) ($1,006)
Comparison costs $956 2010 Cost range (+ or -) 20 %
This program is typically delivered over a three- or four- month period, with sessions delivered on a weekly basis. Per-participant cost estimates are based on weighted average therapist time, as reported in the treatment studies. Hourly therapist cost is based on the actuarial estimates of reimbursement by modality (Mercer. (2016). Behavioral health data nook for the state of Washington for rates effective January 1, 2017). For comparison group costs, we used 2010 Washington State DSHS data to estimate the average reimbursement rate for treatment of child and adolescent attention-deficit hyperactivity disorder (ADHD).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Attention-deficit/hyperactivity disorder symptoms 13 8 173 -0.081 0.111 13 0.000 0.141 14 -0.232 0.224
Disruptive behavior disorder symptoms 13 2 51 -0.100 0.220 13 -0.055 0.134 16 -0.196 0.375
Global functioning^ 13 1 59 0.192 0.195 13 n/a n/a n/a 0.942 0.001
Internalizing symptoms^^ 13 1 30 -0.019 0.258 13 n/a n/a n/a -0.038 0.884
Major depressive disorder 13 1 59 -0.034 0.204 13 0.000 0.310 15 -0.165 0.421
Test scores 13 4 52 -0.017 0.214 13 -0.014 0.235 17 -0.038 0.868

Citations Used in the Meta-Analysis

Abikoff, H., Ganeles, D., Reiter, G., Blum, C., Foley, C., & Klein, R.G. (1988). Cognitive training in academically deficient ADDH boys receiving stimulant medication. Journal of Abnormal Child Psychology, 16(4), 411-432.

Abikoff, H. & Gittelman, R. (1985). Hyperactive children treated with stimulants: Is cognitive training a useful adjunct? Archives of General Psychiatry, 42(10), 953-961.

Brown, R.T., Wynne, M.E., Borden, K.A., Clingerman, S.R., Geniesse, R., & Spunt, A.L. (1986). Methylphenidate and cognitive therapy in children with attention deficit disorder: A double-blind trial. Journal of Developmental and Behavioral Pediatrics, 7(3), 163-174.

Coelho, L.F., Barbosa, D.L.F., Rizzutti, S., Bueno, O.F.A., & Miranda, M.C. (2018). Group cognitive behavioral therapy for children and adolescents with ADHD. Psicologia: ReflexaÞo E Criìtica, 30(1), 11.

Fehlings, D.L., Roberts, W., Humphries, T., & Dawe, G. (1991). Attention deficit hyperactivity disorder: Does cognitive behavioral therapy improve home behavior? Journal of Developmental and Behavioral Pediatrics, 12(4), 223-228.

Sprich, S.E., Safren, S.A., Finkelstein, D., Remmert, J.E., & Hammerness, P. (2016). A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 57(11), 1218-1226.

Vidal, R., Castells, J., Richarte, V., Palomar, G., Garcia, M., Nicolau, R., . . . Ramos-Quiroga, J.A. (2015). Group therapy for adolescents with attention-deficit/hyperactivity disorder: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 54(4), 275-282.