Treatment for ADHD: Is More Complex Treatment Cost-Effective for More Complex Cases?

Attention problems are among the most common of mental/emotional/behavioral disorders among children and youth (U.S. Department of Health and Human Services 1999). Youth with attention deficit hyperactivity disorder (ADHD) are more likely to be involved in a variety of costly behaviors including substance use and abuse (Daley 2004) and delinquency (Richardson 2002) as well as to receive costly services. These children also are likely to receive additional school services, including (but not limited to) special education (Jones, Foster, and Gottschall 2005). Jones et al. (2005) estimate that the costs of such services can exceed $10,000 per year. These costs represent only some of the costs that appear on public budgets. These behaviors generate even larger costs to society, such as the costs to victims of violence or the broader costs of school failure (Haveman and Wolfe 1984). These figures suggest that a policy maker's willingness to pay for effective treatments should be quite high. As discussed below, this willingness to pay is a key determinant of a program's cost-effectiveness. Fortunately, effective treatments exist, notably behavioral treatment and psycho-stimulants. A key issue in the field involves the degree to which each of these treatments is more (or less) effective and cost-effective when combined with the other (Jensen 2000). Assessment of treatment effectiveness is complicated by comorbidities, including conduct disorder and anxiety. These conditions amplify the link between ADHD and service use (Vostanis et al. 2003) and raise the risk for poor long-term outcomes, such as violence and substance abuse (Arseneault et al. 2000). In contrast to efficacy and effectiveness, little is known about the cost-effectiveness of alternative treatments, either separately or in combination. To address this issue, we use data from one of the largest and most influential studies in the field, the Multimodal Treatment Study of Children with ADHD (MTA) (The MTA Cooperative Group 1999). The MTA was designed to compare the effectiveness of psychosocial (behavioral) treatment versus medication, and determine whether the two modalities are more effective when delivered together. An earlier cost-effectiveness analysis of MTA data focused on core attention and related symptoms in the whole sample (Jensen et al. 2005). The analyses presented here extend that earlier work in three ways. First, we examine a broader measure of functional impairment, the Columbia Impairment Scale (CIS). Second, we examine how cost-effectiveness varies with comorbidities. Third, we use new methodology for examining cost-effectiveness of treatments, the cost-effectiveness acceptability curve (CEAC) (Hoch, Briggs, and Willan 2002).