Comparative Cost Analysis of Sequential, Adaptive, Behavioral, Pharmacological, and Combined Treatments for Childhood ADHD.

We conducted a cost analysis of the behavioral, pharmacological, and combined interventions employed in a sequential, multiple assignment, randomized, and adaptive trial investigating the sequencing and enhancement of treatment for children with attention deficit hyperactivity disorder (ADHD; Pelham et al., 201X; N = 146, 76% male, 80% Caucasian). The quantity of resources expended on each child's treatment was determined from records that listed the type, date, location, persons present, and duration of all services provided. The inputs considered were the amount of physician time, clinician time, paraprofessional time, teacher time, parent time, medication, and gasoline. Quantities of these inputs were converted into costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics, the prices of 30-day supplies of prescription drugs from the national Express Scripts service, and mean fuel prices from the Energy Information Administration. Beginning treatment with a low-dose/intensity regimen of behavior modification (large-group parent training) was less costly for a school year of treatment ($961) than beginning treatment with a low dose of stimulant medication ($1,669), regardless of whether the initial treatment was intensified with a higher "dose" or if the other modality was added. Outcome data from the parent study (Pelham et al., 201X) found equivalent or superior outcomes for treatments beginning with low-intensity behavior modification compared to intervention beginning with medication. Combined with the present analyses, these findings suggest that initiating treatment with behavior modification rather than medication is the more cost-effective option for children with ADHD.

The impact of the State Children's Health Insurance Program's unborn child ruling expansions on foreign-born Latina prenatal care and birth outcomes, 2000-2007.

The 2002 "unborn child ruling" resulted in State Children's Health Insurance Program (SCHIP) expansion for states to cover prenatal care for low-income women without health insurance. Foreign-born Latinas who do not qualify for Medicaid coverage theoretically should have benefited most from the policy ruling given their documented low rates of prenatal care utilization. This study compares prenatal care utilization and subsequent birth outcomes among foreign-born Latinas in six states that used the unborn child ruling to expand coverage to those in ten states that did not implement the expansion. This policy analysis examines cross-sectional pooled US natality data from the pre-enactment years (2000-2003) versus post-enactment years (2004-2007) to estimate the effect of the UCR on prenatal care utilization and birth outcome measures for foreign-born Latinas. Then using a difference-in-difference estimator, we assessed these differences across time for states that did or did not enact the unborn child ruling. Analyses were then replicated on a high-risk subset of the population (single foreign-born Latinas with lower levels of education). The SCHIP unborn child ruling policy expansion increased PNCU over time in the six enacting states. Foreign-born Latinas in expansion enacting states experienced increases in prenatal care utilization though only the high-risk subset were statistically significant. Birth outcomes did not change. The SCHIP unborn child ruling policy was associated with enhanced PNC for a subset of high-risk foreign-born Latinas.

Mediation, identification, and plausibility: an illustration using children's mental health services.

OBJECTIVE: Analyses of mediation are important for understanding the effects of mental health services and treatments. The most common approach is to add potential mediators as regressors and to estimate the direct and indirect effects of the treatment of interest. This practice makes the strong assumption that the mediator itself does not suffer from unobserved confounding--that it is as if randomly assigned. In many instances, this assumption seems rather implausible. The objective of this article is to describe the identification problem that represents the fundamental challenge of causal inference. It outlines how mediation complicates identification and considers several identification strategies. The goal of this article is not to propose a new method for handling mediation or to identify a best method for doing so. The latter, in fact, is impossible. The contribution of the article is to illustrate how one can think about possible approaches to mediation in the context of a specific empirical study. METHOD: Using data from a large evaluation of a demonstration project in children's mental health services (n = 763), the article illustrates identification strategies. That demonstration improved service delivery in several ways but primarily by offering services "intermediate" between inpatient and outpatient. These analyses focus on the impact of these intermediate services on 6-month improvement in a behavior checklist commonly used to measure psychopathology and competence among children and youths. RESULTS: The results highlight how different identification strategies produce different answers to key questions. These alternative findings have to be assessed in light of substantive knowledge of the program involved. CONCLUSIONS: The analyses generally support the notion that children and youths treated at the demonstration site who received intermediate services benefited from them.

The effects of breastfeeding exclusivity on early childhood outcomes.

OBJECTIVES: We examined the relationship between breastfeeding exclusivity and duration and children's health and cognitive outcomes at ages 2 and 4 years. METHODS: We used the Early Childhood Longitudinal Study-Birth Cohort, a nationally representative sample of 10,700 children born in the United States in 2001. Parent interviews and child assessments were conducted in measurement waves at 9 months, 2 years, 4 years, and in kindergarten, with the focus on ages 2 and 4 years. We employed propensity scores as a means of adjusting for confounding involving observed characteristics. RESULTS: Outcome analyses using propensity scores showed some small effects of breastfeeding on key outcomes at age 4 years but not at age 2 years. Effects appeared to be concentrated in reading and cognitive outcomes. Overall, we found no consistent evidence for dosage effects of breastfeeding exclusivity. Our sensitivity analyses revealed that a small amount of unobserved confounding could be responsible for the resulting benefits. CONCLUSIONS: Our study revealed little or no effect of breastfeeding exclusivity and duration on key child outcomes.

Multiple Forensic Interviews During Investigations of Child Sexual Abuse: A Cost-Effectiveness Analysis.

In cases of suspected child sexual abuse (CSA) some professionals routinely recommend multiple interviews by the same interviewer because any additional details provided might improve decision-making and increase perpetrator convictions. We analyzed alternative policies about child interviewing to estimate the probability that a policy of all children receiving multiple interviews will increase criminal convictions and better protect children. Using decision analysis, we prepared a decision tree reflecting the structure through which a case of possible CSA passes through the health care, welfare, and legal systems with an estimated probability of conviction of the offender. We reviewed the CSA disclosure, criminal justice, and child welfare literature to obtain estimates for the median and range of rates for the steps of disclosure, substantiation, criminal charges, and conviction. Using the R statistical package, our decision analysis model was populated using literature-based estimates. Once the model was populated, we simulated the experiences of 1,000 cases at 250 sets of plausible parameter values representing different hypothetical communities. Multiple interviews increase the likelihood that an offender will be convicted by 6.1% in the average community. Simulations indicate that a policy in which all children seen for a CSA medical evaluation receive multiple interviews would cost an additional $100,000 for each additional conviction. We estimate that approximately 17 additional children would need to be interviewed on more than one occasion to yield one additional conviction. A policy of multiple interviews has implications for the children, for the costs of care, for protecting other children, and for the risk of false prosecution.

A Person-Centered Examination of Adolescent Religiosity Using Latent Class Analysis.

Empirical studies of religion's role in society, especially those focused on individuals and analyzing survey data, conceptualize and measure religiosity on a single measure or a summary index of multiple measures. Other concepts, such as "lived religion," "believing without belonging," or "fuzzy fidelity," emphasize what scholars have noted for decades: humans are rarely consistently low, medium, or high across dimensions of religiosity including institutional involvement, private practice, salience, or belief. A method with great promise for identifying population patterns in how individuals combine types and levels of belief, practice, and personal religious salience is latent class analysis. In this paper, we use data from the first wave of the National Study of Youth and Religion's telephone survey to discuss how to select indicators of religiosity in an informed manner, as well as the implications of the number and types of indicators used for model fit. We identify five latent classes of religiosity among adolescents in the United States and their socio-demographic correlates. Our findings highlight the value of a person-centered approach to understanding how religion is lived by American adolescents.

Cost analysis of maternal disease associated with suboptimal breastfeeding.

OBJECTIVE: To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs. METHODS: Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars. RESULTS: If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38-24.68 billion), $733.7 million in direct costs (95% CI $612.9-859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00-153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI -810-7,918). CONCLUSIONS: Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.

Systems science and childhood obesity: a systematic review and new directions.

As a public health problem, childhood obesity operates at multiple levels, ranging from individual health behaviors to school and community characteristics to public policies. Examining obesity, particularly childhood obesity, from any single perspective is likely to fail, and systems science methods offer a possible solution. We systematically reviewed studies that examined the causes and/or consequences of obesity from a systems science perspective. The 21 included studies addressed four general areas of systems science in obesity: (1) translating interventions to a large scale, (2) the effect of obesity on other health or economic outcomes, (3) the effect of geography on obesity, and (4) the effect of social networks on obesity. In general, little research addresses obesity from a true, integrated systems science perspective, and the available research infrequently focuses on children. This shortcoming limits the ability of that research to inform public policy. However, we believe that the largely incremental approaches used in current systems science lay a foundation for future work and present a model demonstrating the system of childhood obesity. Systems science perspective and related methods are particularly promising in understanding the link between childhood obesity and adult outcomes. Systems models emphasize the evolution of agents and their interactions; such evolution is particularly salient in the context of a developing child.

Myths, presumptions, and facts about obesity.

BACKGROUND: Many beliefs about obesity persist in the absence of supporting scientific evidence (presumptions); some persist despite contradicting evidence (myths). The promulgation of unsupported beliefs may yield poorly informed policy decisions, inaccurate clinical and public health recommendations, and an unproductive allocation of research resources and may divert attention away from useful, evidence-based information. METHODS: Using Internet searches of popular media and scientific literature, we identified, reviewed, and classified obesity-related myths and presumptions. We also examined facts that are well supported by evidence, with an emphasis on those that have practical implications for public health, policy, or clinical recommendations. RESULTS: We identified seven obesity-related myths concerning the effects of small sustained increases in energy intake or expenditure, establishment of realistic goals for weight loss, rapid weight loss, weight-loss readiness, physical-education classes, breast-feeding, and energy expended during sexual activity. We also identified six presumptions about the purported effects of regularly eating breakfast, early childhood experiences, eating fruits and vegetables, weight cycling, snacking, and the built (i.e., human-made) environment. Finally, we identified nine evidence-supported facts that are relevant for the formulation of sound public health, policy, or clinical recommendations. CONCLUSIONS: False and scientifically unsupported beliefs about obesity are pervasive in both scientific literature and the popular press. (Funded by the National Institutes of Health.).

Economic analysis of a multi-site prevention program: assessment of program costs and characterizing site-level variability.

Programmatic cost analyses of preventive interventions commonly have a number of methodological difficulties. To determine the mean total costs and properly characterize variability, one often has to deal with small sample sizes, skewed distributions, and especially missing data. Standard approaches for dealing with missing data such as multiple imputation may suffer from a small sample size, a lack of appropriate covariates, or too few details around the method used to handle the missing data. In this study, we estimate total programmatic costs for a prevention trial evaluating the Strong African American Families-Teen program. This intervention focuses on the prevention of substance abuse and risky sexual behavior. To account for missing data in the assessment of programmatic costs we compare multiple imputation to probabilistic sensitivity analysis. The latter approach uses collected cost data to create a distribution around each input parameter. We found that with the multiple imputation approach, the mean (95 % confidence interval) incremental difference was $2,149 ($397, $3,901). With the probabilistic sensitivity analysis approach, the incremental difference was $2,583 ($778, $4,346). Although the true cost of the program is unknown, probabilistic sensitivity analysis may be a more viable alternative for capturing variability in estimates of programmatic costs when dealing with missing data, particularly with small sample sizes and the lack of strong predictor variables. Further, the larger standard errors produced by the probabilistic sensitivity analysis method may signal its ability to capture more of the variability in the data, thus better informing policymakers on the potentially true cost of the intervention.

Duration of breastfeeding and childhood obesity: a generalized propensity score approach.

OBJECTIVE: To estimate the effect of breastfeeding duration on childhood obesity. DATA SOURCE: The Child Development Supplement (CDS) of the Panel Study of Income Dynamics (PSID). The PSID provides extensive data on the income and well-being of a representative sample of U.S. families from 1968 to the present. The CDS collects information on the children in PSID families ranging from cognitive, behavioral, and health status to their family and neighborhood environment. The first two waves of the CDS were conducted in 1997 and 2002, respectively. The data provide information on 3,271 children and their mothers. STUDY DESIGN: We use the generalized propensity score to adjust for confounding based on continuous treatment, and the general additive model to analyze the adjusted association between treatment and the outcome conditional on the propensity score. The main outcome is the body mass index (BMI) directly assessed during the in-person interview in 2002. Covariates include family, maternal, and child characteristics, many of which were measured in the year the child was born. PRINCIPAL FINDINGS: After using propensity scores to adjust for confounding, the relationship between breastfeeding duration and childhood BMI is trivially small across a range of model specifications, and none of them is statistically significant except the unadjusted model. CONCLUSIONS: The causal link between duration of breastfeeding and childhood obesity has not been established. Any recommendation of promoting breastfeeding to reduce childhood obesity is premature.

Is inclusivity an indicator of quality of care for children with autism in special education?

OBJECTIVE: To determine whether the proportion of time spent in an inclusive educational setting, a process indicator of the quality of schooling for children with autism, improves key outcomes. METHODS: Patients were 484 children and youth educated in special education with a primary diagnosis of autism in the National Longitudinal Transition Study-2. These individuals were ages 20 to 23 in 2007. We used propensity-score inverse probability of treatment weights to eliminate the effect of multiple confounders. A causal interpretation of the effect of inclusivity on key educational and functional outcomes still depends on a critical assumption, that inclusivity is not confounded by remaining, omitted confounders. RESULTS: Compared with children with autism who were not educated in an inclusive setting (n = 215), children with autism who spent 75% to 100% of their time in a general education classroom (n = 82) were no more likely to attend college (P = .40), not drop out of high school (P = .24), or have an improved functional cognitive score (P = .99) after controlling for key confounders. CONCLUSIONS: We find no systematic indication that the level of inclusivity improves key future outcomes. Research on educational and functional outcomes for children with autism can benefit from data on large samples of children educated in real-world settings, such as the National Longitudinal Transition Study-2, but more nuanced indicators should be developed to measure the quality of special education for children with autism.

Duration of lactation and incidence of maternal hypertension: a longitudinal cohort study.

Never or curtailed lactation has been associated with an increased risk for incident hypertension, but the effect of exclusive breastfeeding is unknown. The authors conducted an observational cohort study of 55,636 parous women in the US Nurses' Health Study II. From 1991 to 2005, participants reported 8,861 cases of incident hypertension during 660,880 person-years of follow-up. Never or curtailed lactation was associated with an increased risk of incident hypertension. Compared with women who breastfed their first child for ≥12 months, women who did not breastfeed were more likely to develop hypertension (hazard ratio (HR) = 1.27, 95% confidence interval (CI): 1.18, 1.36), adjusting for family history and lifestyle covariates. Women who never breastfed were more likely to develop hypertension than women who exclusively breastfed their first child for ≥6 months (HR = 1.29, 95% CI: 1.20, 1.40). The authors found similar results for women who had never breastfed compared with those who had breastfed each child for an average of ≥12 months (HR = 1.22, 95% CI: 1.13, 1.32). In conclusion, never or curtailed lactation was associated with an increased risk of incident maternal hypertension, compared with the recommended ≥6 months of exclusive or ≥12 months of total lactation per child, in a large cohort of parous women.

Deployment and the citizen soldier: need and resilience.

BACKGROUND: The wars in Iraq and Afghanistan have made unprecedented demands on the nation's citizen soldiers, the National Guard and Reserve. A major concern involves the repeated deployment of these forces overseas. OBJECTIVES: Using data from the Department of Defense Survey of Health Related Behaviors among the Guard and Reserve Force, we examined the effects of deployment on 6 health outcomes. SUBJECTS: The Department of Defense Survey of Health Related Behaviors among the Guard and Reserve Force is a sample (n = 17,754) of all Reserve component personnel (including full time and/or activated Guard and Reservists) serving in all pay grades throughout the world. RESEARCH DESIGN: We relied on inverse probability of treatment weights to adjust for observed confounders and used sensitivity analyses to examine the sensitivity of our findings to potential unobserved confounding. RESULTS: Observed confounders explain much of the apparent effect of deployment. For men, the adjusted relationships could very well reflect further confounding involving unobserved factors. However, for women, effects of deployment on marijuana use, symptoms of post-traumatic stress disorder, and suicidal ideation are robust to adjustments for multiple testing and possible unobserved confounding. CONCLUSIONS: These effects are large in practical terms and troubling but suggest that media reports of the harm caused by deployment may be overstated. Such exaggerations run the risk of stigmatizing those who serve.

Breastfeeding and the child cognitive outcomes: a propensity score matching approach.

To estimate the effect of breastfeeding initiation and duration on child development outcomes. 3,271 children and their mothers participating in the Child Development Supplement of the Panel Study of Income Dynamics provide data for these analyses. Main outcomes include Woodcock Johnson Psycho-Educational Battery-Revised (WJ-R) test score (letter word, passage comprehension, applied problem, and broad reading), and Wechsler Intelligence Scale for Children-Revised (WISC-R) test score at the 2002 survey. Controlled variables include family, maternal, and child characteristics, many of which can be traced back to the year the child was born. The analytic technique is propensity score matching with multiple imputations. After using propensity scores to adjust for confounding factors, breastfeeding initiation showed statistically significant effects but the practical scale remains small. Breastfeeding duration showed a non-linear effect on those outcomes and most of the effects are not significant. The effects of breastfeeding on child's cognitive outcomes are modest in practical terms. The non-linear effects suggest that selection into breastfeeding may account for the increased score of children who are breastfed.

The Estimated Annual Cost of ADHD to the U.S. Education System.

The purpose of this study was to examine and monetize the educational outcomes of students with ADHD. Data were examined from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of children diagnosed with ADHD in childhood and recontacted for follow-up in adolescence and young adulthood. A comprehensive educational history was obtained for all participants from Kindergarten through 12th grade. Annual economic impact was derived from costs incurred through special education placement, grade retention, and disciplinary incidents. Results indicated that, as compared to students without ADHD, students with ADHD incurred a higher annual cost to the U.S. Education system. Specifically, a student with ADHD incurred an average annual incremental cost to society of $5,007, as compared to $318 for students in the comparison group. These results suggest that prevention and intervention strategies are greatly needed to offset the large financial impact of educating youth with ADHD.

Indicators of acculturation related to Somali refugee women's birth outcomes in Minnesota.

We investigated the effect of indicators of acculturation among Somali refugee women's birth outcomes. Data were extracted from medical records of 584 Somali women delivering infants at a Midwestern hospital between 1993 and 2006. Bivariate analyses measured relationships between independent factors and the dependent variables of gestational age and birthweight. Structural equation modeling (SEM) determined the fit between factors hypothesized to reflect acculturation and the data. Significant increases noted over time were substance use/exposure, interpreter use, body mass index, hemoglobin levels, gestational diabetes and preterm birth. Bivariate analyses showed significance between prenatal care utilization and both preterm birth and gestational age. SEM results indicated a moderate to good fit between the hypothesized model and available data. Factors hypothesized to reflect acculturation and effect birth outcomes among Somali women are increasing but did not account for increased preterm birth. Further investigation is warranted to identify and truncate further disparate birth outcomes.

Costs and effectiveness of the fast track intervention for antisocial behavior.

BACKGROUND: Antisocial behavior is enormously costly to the youth involved, their families, victims, taxpayers and other members of society. These costs are generated by school failure, delinquency and involvement in the juvenile justice system, drug use, health services and other services. For prevention programs to be cost effective, they must reduce these costly behaviors and outcomes. AIM: The Fast Track intervention is a 10-year, multi-component prevention program targeting antisocial behavior. The intervention identified children at school entry and provided intervention services over a 10-year period. This study examined the intervention's impact on outcomes affecting societal costs using data through late adolescence. METHODOLOGY: The intervention is being evaluated through a multi-cohort, multi-site, multi-year randomized control trial of program participants and comparable children and youth in similar schools, and that study provides the data for these analyses. Schools within four sites (Durham, NC; Nashville, TN; Seattle, WA; and rural central Pennsylvania) were selected as high-risk based on crime and poverty statistics of the neighborhoods they served. Within each site, schools were divided into multiple sets matched for demographics (size, percentage free/reduced lunch, ethnic composition); one set within each pair was randomly assigned to the intervention and one to the control condition. Within participating schools, high-risk children were identified using a multiple-gating procedure. For each of three annual cohorts, all kindergarteners (9,594 total) in 54 schools were screened for classroom conduct problems by teachers. Those children scoring in the top 40% within cohort and site were then solicited for the next stage of screening for home behavior problems by the parents, and 91% agreed (n = 3,274). The teacher and parent screening scores were then standardized within site and combined into a sum score. These summed scores represented a total severity-of-risk screen score. Children were selected for inclusion into the study based on this screen score, moving from the highest score downward until desired sample sizes were reached within sites, cohorts, and conditions. RESULTS AND DISCUSSION: The intervention lacked both the breadth and depth of effects on costly outcomes to demonstrate cost-effectiveness or even effectiveness. LIMITATIONS: The outcomes examined here reflect effects observed during measurement windows that are not complete for every outcome. Data are lacking on some potential outcomes, such as the use of mental health services before year 7. CONCLUSION AND IMPLICATIONS: The most intensive psychosocial intervention ever fielded did not produce meaningful and consistent effects on costly outcomes. The lack of effects through high school suggests that the intervention will not become cost-effective as participants progress through adulthood. FUTURE RESEARCH: Future research should consider alternative approaches to prevention youth violence.

The U-shaped relationship between complexity and usefulness: a commentary.

The relationship between complexity and usefulness can be captured by a U-shaped curve. This comment explores that relationship. Complexity may be useful for one of the main aims of developmental psychology (causal inference) but not for another (description of developmental phenomena). Currently, developmentalists conduct complex analyses that are not useful in pursuing either aim: The analyses are too complex to produce good description, and the complexity is not employed in a manner that facilitates causal inference. Further complicating matters is that the complexity is often not made explicit, as the model specification is not mathematical. In many cases the analyses involve data that are not representative of a recognizable population and/or were sampled in ways that involve the processes of interest. Complex analyses of such data often plumb the depths of usefulness. The key to better analyses is to align the complexity of analyses with the research questions of interest. In some cases, doing so will mean simplifying the analyses to produce better description. In others, it will mean reducing some forms of complexity (e.g., involving measurement) and better aligning analytical complexity with the complexity of the underlying processes. This comment concludes with 6 questions authors can ask themselves in planning their analyses to maximize the usefulness of the results.

The value of reanalysis and replication: introduction to special section.

In their 2007 article in this journal, Duncan et al. examined 6 longitudinal data sets to gauge the links between 3 key elements of readiness at school entry (academic, attention, and socioemotional skills) and later achievement. Across all 6 data sets, the strongest predictors of later achievement were school-entry math, reading, and attention skills. Social skills and internalizing and externalizing behavior did not predict subsequent achievement, even among children with relatively high levels of problem behavior. Patterns of association were similar for boys and girls and were not moderated by socioeconomic status. The 5 articles in this section reconsider the original findings and reanalyze the data involved. Overall, the thrust of these articles confirms the original article. The articles in this section, however, do offer some new insights. In general, the articles find somewhat more support for socioemotional factors, especially for prosocial skills, but the relationships involved are very small. Perhaps the most striking new finding is the added emphasis on fine motor skills, which is the focus of 2 articles. Taken together, the articles reveal the value of reanalysis and replication in developmental psychology.