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Multimodal therapy (MMT) 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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Multimodal therapies (MMT) combine child-focused psychosocial therapies (such as cognitive-behavioral therapy (CBT) or academic skills training) with a behavioral parent training component (involving psychoeducation and training in child behavior management techniques). Therapies frequently include a school component or involve regular teacher consultation. Therapies that occur exclusively in a school setting, such as after-school programs, were not included in this review. Often, interventions include a medication component; all such studies had a comparison group that also received medication. Interventions were provided in a variety of modalities, including individual, group, and family. Programs typically lasted three months with an average total of five sessions per month; two evaluations in this review were for treatments lasting approximately 12 months. All children in the included studies were diagnosed with attention-deficit hyperactivity disorder (ADHD) or met clinical levels of ADHD symptoms.
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 $2,370 Benefits minus costs $1,178
Participants $3,668 Benefit to cost ratio $1.30
Others $663 Chance the program will produce
Indirect ($1,595) benefits greater than the costs 53 %
Total benefits $5,104
Net program cost ($3,926)
Benefits minus cost $1,178
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 $64 $0 $149 $32 $245
K-12 grade repetition $6 $0 $0 $3 $9
K-12 special education $201 $0 $0 $101 $302
Labor market earnings associated with anxiety disorder $1,602 $3,527 $0 $0 $5,129
Health care associated with externalizing behavior symptoms $498 $141 $514 $250 $1,403
Adjustment for deadweight cost of program $0 $0 $0 ($1,981) ($1,983)
Totals $2,370 $3,668 $663 ($1,595) $5,104
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $3,676 2000 Present value of net program costs (in 2017 dollars) ($3,926)
Comparison costs $956 2010 Cost range (+ or -) 40 %
Per-participant costs are based on the average cost of intensive behavioral treatment reported in Jensen et al., (2005). Cost-effectiveness of ADHD treatments: Findings from the Multimodal Treatment study of children with ADHD. American Journal of Psychiatry, 162, 1628–1636. We use this analysis to calculate a monthly treatment cost and applied this to the average duration of multimodal programs included in this study. 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.

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 Primary or secondary participant 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
Anxiety disorder 9 Primary 2 264 -0.190 0.196 9 -0.075 0.108 10 -0.190 0.332
Attention-deficit/hyperactivity disorder symptoms 9 Primary 13 741 -0.165 0.064 9 0.000 0.141 10 -0.323 0.001
Disruptive behavior disorder symptoms 9 Primary 9 489 -0.247 0.089 9 -0.136 0.079 12 -0.387 0.001
Externalizing behavior symptoms 9 Primary 1 45 -0.288 0.214 9 -0.158 0.145 12 -0.288 0.177
Global functioning^ 9 Primary 2 103 0.414 0.171 9 n/a n/a n/a 0.613 0.114
Grade point average^ 9 Primary 1 67 0.161 0.193 9 n/a n/a n/a 0.315 0.104
Internalizing symptoms 9 Primary 2 93 -0.133 0.155 9 -0.133 0.155 11 -0.219 0.157
Test scores 9 Primary 6 353 0.038 0.085 9 0.023 0.094 17 0.038 0.659
Parental stress^ 43 Secondary 1 67 -0.293 0.194 43 n/a n/a n/a -0.574 0.003

Citations Used in the Meta-Analysis

Abikoff, H., Hechtman, L., Klein, R.G., Weiss, G., Fleiss, K., Etcovitch, J., . . . Pollack, S. (2004). Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 43(7), 802-811.

Horn, W.F., Ialongo, N.S., Pascoe, J.M., Greenberg, G., Packard, T., Lopez, M., . . . Puttler, L. (1991). Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children. Journal of the American Academy of Child & Adolescent Psychiatry, 30(2), 233-240.

Huang, Y.H., Chung, C.Y., Ou, H.Y., Tzang, R.F., Huang, K.Y., Liu, H.C., . . . Liu, S.I. (2015). Treatment effects of combining social skill training and parent training in Taiwanese children with attention deficit hyperactivity disorder. Journal of the Formosan Medical Association, 114(3), 260-267.

Klein, R.G., & Abikoff, H. (1997). Behavior therapy and methylphenidate in the treatment of children with ADHD. Journal of Attention Disorders, 2(2), 89-114.

MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder. Archives of General Psychiatry, 56(12), 1073-1086.

Pfiffner, L.J., Yee Mikami, A., Huang-Pollock, C., Easterlin, B., Zalecki, C., & McBurnett, K. (2007). A randomized, controlled trial of integrated home-school behavioral treatment for ADHD, predominantly inattentive type. Journal of the American Academy of Child & Adolescent Psychiatry, 46(8), 1041-1050.

Pfiffner, L.J., Zalecki, C., Kaiser, N.M., Villodas, M., McBurnett, K., Hinshaw, S.P., . . . Zalecki, C. (2014). A two-site randomized clinical trial of integrated psychosocial treatment for ADHD-inattentive type. Journal of Consulting and Clinical Psychology, 82(6), 1115-1127.

Power, T.J., Mautone, J.A., Soffer, S.L., Clarke, A.T., Marshall, S.A., Sharman, J., . . . Jawad, A.F. (2012). A family-school intervention for children with ADHD: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 80(4), 611-623.

Sibley, M.H., Graziano, P.A., Kuriyan, A.B., Coxe, S., Pelham, W.E., Rodriguez, L., . . . Ward, A. (2016). Parent–teen behavior therapy + motivational interviewing for adolescents with ADHD. Journal of Consulting and Clinical Psychology, 84(8), 699-712.

Sibley, M.H., Pelham, W.E., Derefinko, K.J., Kuriyan, A.B., Sanchez, F., & Graziano, P.A. (2013). A pilot trial of Supporting Teens’ Academic Needs Daily (STAND): A parent-adolescent collaborative intervention for ADHD. Journal of Psychopathology and Behavioral Assessment, 35(4), 436-449.

van der Oord, S., Prins, P.J.M., Oosterlaan, J., & Emmelkamp, P.M.G. (2007). Does brief, clinically based, intensive multimodal behavior therapy enhance the effects of methylphenidate in children with ADHD? European Child & Adolescent Psychiatry, 16(1), 48-57.

Webster-Stratton, C., Reid, M.J., & Beauchaine, T.P. (2011). Combining parent and child training for young children with ADHD. Journal of Clinical Child and Adolescent Psychology, 40(2), 191-203.