Costs and longer-term savings of parenting programmes for the prevention of persistent conduct disorder: a modelling study

Evidence for investing in parenting interventions aiming to improve child health: a systematic review of economic evaluations

A comprehensive review of the economic evidence on parenting interventions targeting different aspects of child health is lacking to support decision-making. The aim of this review is to provide an up to date synthesis of the available health economic evidence for parenting interventions aiming to improve child health. A systematic review was conducted with articles identified through Econlit, Medline, PsychINFO, and ERIC databases. Only full economic evaluations comparing two or more options, considering both costs and outcomes were included. We assessed the quality of the studies using the Drummond checklist. We identified 44 studies of varying quality that met inclusion criteria; 22 targeting externalizing behaviors, five targeting internalizing problems, and five targeting other mental health problems including autism and alcohol abuse. The remaining studies targeted child abuse (n = 5), obesity (n = 3), and general health (n = 4). Studies varied considerably and many suffered from methodological limitations, such as limited costing perspectives, challenges with outcome measurement and short-time horizons. Parenting interventions showed good value for money in particular for preventing child externalizing and internalizing behaviors. For the prevention of child abuse, some programs had the potential of being cost-saving over the longer-term. Interventions were not cost-effective for the treatment of autism and obesity. Future research should include a broader spectrum of societal costs and quality-of-life impacts on both children and their caregivers.

Evaluating childhood policy impacts on lifetime health, wellbeing and inequality: Lifecourse distributional economic evaluation

We introduce and illustrate a new framework for distributional economic evaluation of childhood policies that takes a broad and long view of the impacts on health, wellbeing and inequality from a cross-sectoral whole-lifetime perspective. Total lifetime benefits and public cost savings are estimated using lifecourse microsimulation of diverse health, social and economic outcomes for each individual in a general population birth cohort from birth to death. Cost-effectiveness analysis, policy targeting analysis and distributional analysis of inequality impacts are then conducted using an index of lifetime wellbeing that allow comparisons of both value-for-money (efficiency) and distributional impact (equity) from a cross-sectoral lifetime perspective. We illustrate how this framework can be applied in practice by re-evaluating a training programme in England for parents of children at risk of conduct disorder. Our illustration uses a simple index of lifetime wellbeing based on health-related quality of life and consumption, but other indices could be used based on other kinds of outcomes data such as life satisfaction or multidimensional quality of life. We create the detailed underpinning data needed to apply the framework by using a previously published meta-analysis of randomised controlled trials to estimate the short-term effects and a previously published lifecourse microsimulation model to extrapolate the long-term effects.

The Good Behaviour Game intervention to improve behavioural and other outcomes for children aged 7–8 years: a cluster RCT

Background

Universal, school-based behaviour management interventions can produce meaningful improvements in children’s behaviour and other outcomes. However, the UK evidence base for these remains limited.

Objective

The objective of this trial was to investigate the impact, value for money and longer-term outcomes of the Good Behaviour Game. Study hypotheses centred on immediate impact (hypothesis 1); subgroup effects (at-risk boys, hypothesis 2); implementation effects (dosage, hypothesis 3); maintenance/sleeper effects (12- and 24-month post-intervention follow-ups, hypothesis 4); the temporal association between mental health and academic attainment (hypothesis 5); and the health economic impact of the Good Behaviour Game (hypothesis 6).

Design

This was a two-group, parallel, cluster-randomised controlled trial. Primary schools (n = 77) were randomly assigned to implement the Good Behaviour Game for 2 years or continue their usual practice, after which there was a 2-year follow-up period.

Setting

The trial was set in primary schools across 23 local authorities in England.

Participants

Participants were children (n = 3084) aged 7–8 years attending participating schools.

Intervention

The Good Behaviour Game is a universal behaviour management intervention. Its core components are classroom rules, team membership, monitoring behaviour and positive reinforcement. It is played alongside a normal classroom activity for a set time, during which children work in teams to win the game to access the agreed rewards. The Good Behaviour Game is a manualised intervention delivered by teachers who receive initial training and ongoing coaching.

Main outcome measures

The measures were conduct problems (primary outcome; teacher-rated Strengths and Difficulties Questionnaire scores); emotional symptoms (teacher-rated Strengths and Difficulties Questionnaire scores); psychological well-being, peer and social support, bullying (i.e. social acceptance) and school environment (self-report Kidscreen survey results); and school absence and exclusion from school (measured using National Pupil Database records). Measures of academic attainment (reading, standardised tests), disruptive behaviour, concentration problems and prosocial behaviour (Teacher Observation of Child Adaptation Checklist scores) were also collected during the 2-year follow-up period.

Results

There was no evidence that the Good Behaviour Game improved any outcomes (hypothesis 1). The only significant subgroup moderator effect identified was contrary to expectations: at-risk boys in Good Behaviour Game schools reported higher rates of bullying (hypothesis 2). The moderating effect of the amount of time spent playing the Good Behaviour Game was unclear; in the context of both moderate (≥ 1030 minutes over 2 years) and high (≥ 1348 minutes over 2 years) intervention compliance, there were significant reductions in children’s psychological well-being, but also significant reductions in their school absence (hypothesis 3). The only medium-term intervention effect was for peer and social support at 24 months, but this was in a negative direction (hypothesis 4). After disaggregating within- and between-individual effects, we found no temporal within-individual associations between children’s mental health and their academic attainment (hypothesis 5). Last, our cost–consequences analysis indicated that the Good Behaviour Game does not provide value for money (hypothesis 6).

Limitations

Limitations included the post-test-only design for several secondary outcomes; suboptimal implementation dosage (mitigated by complier-average causal effect estimation); and moderate child-level attrition (18.5% for the primary outcome analysis), particularly in the post-trial follow-up period (mitigated by the use of full information maximum likelihood procedures).

Future work

Questions remain regarding programme differentiation (e.g. how distinct is the Good Behaviour Game from existing behaviour management practices, and does this makes a difference in terms of its impact?) and if the Good Behaviour Game is impactful when combined with a complementary preventative intervention (as has been the case in several earlier trials).

Conclusion

The Good Behaviour Game cannot be recommended based on the findings reported here.

Trial registration

This trial is registered as ISRCTN64152096.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 7. See the NIHR Journals Library website for further project information.

From the Cradle to the Web: The Growth of “Sharenting”—A Scientometric Perspective

“Sharenting” is an internet trend in which parents report detailed information or repeatedly post pictures, videos, and other content about their children on social media. Due to the duality of sharenting, which takes place online but has offline consequences, it is essential to understand the implications of sharenting for real-world parenting and child development. The present work analyzes references in the existing literature and links among published articles to better understand sharenting, evidence for it, and major topics associated with it and to uncover the gaps in the literature. Citation analysis of the current literature mainly focuses on risks and benefits related to sharenting practices, especially for the children, and on ethical and privacy concerns. Future studies should investigate the psychological mechanisms that drive sharenting-related behaviors in parents and multidisciplinary approaches to the phenomenon. With a broader perspective on these issues, practitioners and professionals in family studies will be able to delineate guidelines for informative interventions to increase awarenes about the causes and consequences of publicly sharing child content.

Costing of a Multiple Family Group Strengthening Intervention (SMART Africa) to Improve Child and Adolescent Behavioral Health in Uganda

Reliable cost estimates are key to assessing the feasibility, affordability, and cost-effectiveness of interventions. We estimated the economic costs of a multiple family group (MFG) intervention-child and adolescent mental health evidence-based practices (CAMH-EBP) implemented under the SMART Africa study, seeking to improve family functioning and reduce child and adolescent behavior problems-delivered through task-shifting by community health workers (CHWs) or parent peers (PPs) in school settings in Uganda. This prospective microcosting analysis was conducted from a provider perspective as part of a three-armed randomized controlled trial of the MFG intervention involving 2,391 participants aged 8-13 years and their caregivers in 26 primary schools. Activity-specific costs were estimated and summed, and divided by actual participant numbers in each study arm to conservatively calculate total per-child costs by arm. Total per-child costs of the MFG-PP and MFG-CHW arms were estimated at US$346 and US$328, respectively. The higher per-child cost of the MFG-PP arm was driven by lower than anticipated attendance by participants recruited to this arm. Personnel costs were the key cost driver, accounting for approximately 70% of total costs because of intensive supervision and support provided to MFG facilitators and intervention quality assurance efforts. This is the first study estimating the economic costs of an evidence-based MFG intervention provided through task-shifting strategies in a low-resource setting. Compared with the costs of other family-based interventions ranging between US$500 and US$900 in similar settings, the MFG intervention had a lower per-participant cost; however, few comparisons are available in the literature. More costing studies on CAMH-EBPs in low-resource settings are needed.

Childhood adversity and approach/avoidance-related behaviour in boys

Childhood adversity has been suggested to affect the vulnerability for developmental psychopathology, including both externalizing and internalizing symptoms. This study examines spontaneous attention biases for negative and positive emotional facial expressions as potential intermediate phenotypes. In detail, typically developing boys (6-13 years) underwent an eye-tracking paradigm displaying happy, angry, sad and fearful faces. An approach bias towards positive emotional facial expressions with increasing childhood adversity levels was found. In addition, an attention bias away from negative facial expressions was observed with increasing childhood adversity levels, especially for sad facial expressions. The results might be interpreted in terms of emotional regulation strategies in boys at risk for reactive aggression and depressive behaviour.

A video-feedback parenting intervention to prevent enduring behaviour problems in at-risk children aged 12-36 months: the Healthy Start, Happy Start RCT

BACKGROUND

Behaviour problems emerge early in childhood and place children at risk for later psychopathology.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of a parenting intervention to prevent enduring behaviour problems in young children.

DESIGN

A pragmatic, assessor-blinded, multisite, two-arm, parallel-group randomised controlled trial.

SETTING

Health visiting services in six NHS trusts in England.

PARTICIPANTS

A total of 300 at-risk children aged 12-36 months and their parents/caregivers.

INTERVENTIONS

Families were allocated in a 1 : 1 ratio to six sessions of Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) plus usual care or usual care alone.

MAIN OUTCOME MEASURES

The primary outcome was the Preschool Parental Account of Children's Symptoms, which is a structured interview of behaviour symptoms. Secondary outcomes included caregiver-reported total problems on the Child Behaviour Checklist and the Strengths and Difficulties Questionnaire. The intervention effect was estimated using linear regression. Health and social care service use was recorded using the Child and Adolescent Service Use Schedule and cost-effectiveness was explored using the Preschool Parental Account of Children's Symptoms.

RESULTS

In total, 300 families were randomised: 151 to VIPP-SD plus usual care and 149 to usual care alone. Follow-up data were available for 286 (VIPP-SD, n = 140; usual care, n = 146) participants and 282 (VIPP-SD, n = 140; usual care, n = 142) participants at 5 and 24 months, respectively. At the post-treatment (primary outcome) follow-up, a group difference of 2.03 on Preschool Parental Account of Children's Symptoms (95% confidence interval 0.06 to 4.01; p = 0.04) indicated a positive treatment effect on behaviour problems (Cohen's d = 0.20, 95% confidence interval 0.01 to 0.40). The effect was strongest for children's conduct [1.61, 95% confidence interval 0.44 to 2.78; p = 0.007 (d = 0.30, 95% confidence interval 0.08 to 0.51)] versus attention deficit hyperactivity disorder symptoms [0.29, 95% confidence interval -1.06 to 1.65; p = 0.67 (d = 0.05, 95% confidence interval -0.17 to 0.27)]. The Child Behaviour Checklist [3.24, 95% confidence interval -0.06 to 6.54; p = 0.05 (d = 0.15, 95% confidence interval 0.00 to 0.31)] and the Strengths and Difficulties Questionnaire [0.93, 95% confidence interval -0.03 to 1.9; p = 0.06 (d = 0.18, 95% confidence interval -0.01 to 0.36)] demonstrated similar positive treatment effects to those found for the Preschool Parental Account of Children's Symptoms. At 24 months, the group difference on the Preschool Parental Account of Children's Symptoms was 1.73 [95% confidence interval -0.24 to 3.71; p = 0.08 (d = 0.17, 95% confidence interval -0.02 to 0.37)]; the effect remained strongest for conduct [1.07, 95% confidence interval -0.06 to 2.20; p = 0.06 (d = 0.20, 95% confidence interval -0.01 to 0.42)] versus attention deficit hyperactivity disorder symptoms [0.62, 95% confidence interval -0.60 to 1.84; p = 0.32 (d = 0.10, 95% confidence interval -0.10 to 0.30)], with little evidence of an effect on the Child Behaviour Checklist and the Strengths and Difficulties Questionnaire. The primary economic analysis showed better outcomes in the VIPP-SD group at 24 months, but also higher costs than the usual-care group (adjusted mean difference £1450, 95% confidence interval £619 to £2281). No treatment- or trial-related adverse events were reported. The probability of VIPP-SD being cost-effective compared with usual care at the 24-month follow-up increased as willingness to pay for improvements on the Preschool Parental Account of Children's Symptoms increased, with VIPP-SD having the higher probability of being cost-effective at willingness-to-pay values above £800 per 1-point improvement on the Preschool Parental Account of Children's Symptoms.

LIMITATIONS

The proportion of participants with graduate-level qualifications was higher than among the general public.

CONCLUSIONS

VIPP-SD is effective in reducing behaviour problems in young children when delivered by health visiting teams. Most of the effect of VIPP-SD appears to be retained over 24 months. However, we can be less certain about its value for money.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN58327365.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 29. See the NIHR Journals Library website for further project information.

Economic Return on Investment of Parent Training Programmes for the Prevention of Child Externalising Behaviour Problems

Economic models to inform decision-making are gaining popularity, especially for preventive interventions. However, there are few estimates of the long-term returns to parenting interventions used to prevent mental health problems in children. Using data from a randomised controlled trial evaluating five indicated parenting interventions for parents of children aged 5-12, we modeled the economic returns resulting from reduced costs in the health care and education sector, and increased long-term productivity in a Swedish setting. Analyses done on the original trial population, and on various sized local community populations indicated positive benefit-cost ratios. Even smaller local authorities would financially break-even, thus interventions were of good value-for-money. Benefit-cost analyses of such interventions may improve the basis for resource allocation within local decision-making.

Helping the Noncompliant Child: An Updated Assessment of Program Costs and Cost-Effectiveness

Behavior disorders (BD) in children can lead to delinquency, antisocial behavior, and mental disorders in adulthood. Evidence-based behavioral parent training (BPT) programs have been developed to treat early-onset BDs, yet cost analyses of BPT are deficient. We provide updated estimates of cost and cost-effectiveness of Helping the Noncompliant Child (HNC), a mastery-based BPT, delivered to low-income families. The cost of research-specific activities was $1,152 per family. HNC program delivery costs were $293 per family from a payer perspective, including the cost of therapist time ($275 per family) and non-labor resources, such as supplies and toys ($18 per family). It costs an average of $6 to improve the Eyberg Child Behavior Inventory intensity score by each additional point or $171 to improve it by one standard deviation. The cost of delivering the HNC program appears to compare favorably with the costs of similar BPT programs.

Supporting public health practice in healthy growth and development in the Province of Ontario, Canada

BACKGROUND

As public health services are modernized in Ontario, Canada, there is a need to inform the system-level roles and responsibilities of government agencies. The aim of this study was to identify how Public Health Ontario (PHO) can optimally support evidence-based planning and programming in Healthy Growth and Development (HGD) across Ontario.

METHODS AND DESIGN

A situational assessment was conducted with key informants from public health and other HGD fields.

SAMPLE

Key informants were identified using purposeful snowball sampling and included public health nurses, health promoters, and medical officers of health. Analytic strategy: Twenty telephone interviews and seven focus groups were used to collect data. A thematic analysis was conducted concurrently with data collection.

RESULTS

Five themes were identified: (a) Transition to the new Ontario Public Health Standards (OPHS) included experiences of adopting the new OPHS within local public health units (PHUs). (b) Collaborating and networking referred to the ability to work with community partners. (c) Data, evidence, and research described the presence of data, evidence, and research to support practice. (d) Decision making, planning, and priority setting described resources available that influenced decision making. (e) Current and emerging issues in HGD included high-priority topics.

CONCLUSION

Public health practice in HGD is complex with many challenges in data and evidence, and making programming decisions without adequate or measurable indicators. A specialized position at PHO is an opportunity to support some of these system-wide needs.

An intervention for parents with severe personality difficulties whose children have mental health problems: a feasibility RCT

BACKGROUND

The children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs.

OBJECTIVES

To develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial.

DESIGN

A pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation.

SETTING

Two NHS mental health trusts and concomitant children's social care services.

PARTICIPANTS

Parents who met the following criteria: (1) the primary caregiver of the index child, (2) aged 18-65 years, (3) have severe personality difficulties, (4) proficient in English and (5) capable of providing informed consent. Index children who met the following criteria: (1) aged 3-11 years, (2) living with index parent and (3) have significant emotional/behavioural difficulties. Exclusion criteria were (1) having coexisting psychosis, (2) participating in another parenting intervention, (3) receiving inpatient care, (4) having insufficient language/cognitive abilities, (5) having child developmental disorder, (6) care proceedings and (7) index child not residing with index parent.

INTERVENTION

The Helping Families Programme-Modified - a 16-session intervention using structured, goal-orientated strategies and collaborative therapeutic methods to improve parenting, and child and parent functioning. Usual care - standard care augmented by a single psychoeducational session.

MAIN OUTCOME MEASURES

Trial feasibility - rates of recruitment, eligibility, allocation, retention, data completion and experience. Intervention acceptability - rates of acceptance, completion, alliance (Working Alliance Inventory-Short Revised) and experience. Outcomes - child (assessed via Concerns About My Child, Eyberg Child Behaviour Inventory, Child Behaviour Checklist-Internalising Scale), parenting (assessed via the Arnold-O'Leary Parenting Scale, Kansas Parental Satisfaction Scale), parent (assessed via the Symptom Checklist-27), and health economics (assessed via the Client Service Receipt Inventory, EuroQol-5 Dimensions).

RESULTS

The findings broadly supported trial feasibility using non-diagnostic screening criteria. Parents were mainly referred from one site (75.0%). Site and participant factors delayed recruitment. An estimate of eligible parents was not obtained. Of the 86 parents referred, 60 (69.7%) completed screening and 48 of these (80.0%) were recruited. Participants experienced significant disadvantage and multiple morbidity. The Helping Families Programme-Modified uptake (87.5%) was higher than usual-care uptake (62.5%). Trial retention (66.7%, 95% confidence interval 51.6% to 79.6%) exceeded the a priori rate. Process findings highlighted the impact of random allocation and the negative effects on retention. The Helping Families Programme-Modified was acceptable, with duration of delivery longer than planned, whereas the usual-care condition was less acceptable. At initial follow-up, effects on child and parenting outcomes were detected across both arms, with a potential outcome advantage for the Helping Families Programme-Modified (effect size range 0.0-1.3). For parental quality-adjusted life-years, the Helping Families Programme-Modified dominated usual care, and child quality-adjusted life-years resulted in higher costs and more quality-adjusted life-years. At second follow-up, the Helping Families Programme-Modified was associated with higher costs and more quality-adjusted life-years than usual care. For child quality-adjusted life-years, when controlled for baseline EuroQol-5 Dimensions, three-level version, usual care dominated the Helping Families Programme-Modified. No serious adverse events were reported.

CONCLUSION

The Helping Families Programme-Modified is an acceptable specialised parenting intervention. Trial methods using non-diagnostic criteria were largely supported. For future work, a definitive efficacy trial should consider site selection, recruitment methods, intervention efficiency and revised comparator condition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14573230.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 14. See the NIHR Journals Library website for further project information.

Cost-effectiveness analysis of parenting interventions for the prevention of behaviour problems in children

BACKGROUND

Behavior problems are common among children and place a high disease and financial burden on individuals and society. Parenting interventions are commonly used to prevent such problems, but little is known about their possible longer-term economic benefits. This study modelled the longer-term cost-effectiveness of five parenting interventions delivered in a Swedish context: Comet, Connect, the Incredible Years (IY), COPE, bibliotherapy, and a waitlist control, for the prevention of persistent behavior problems.

METHODS

A decision analytic model was developed and used to forecast the cost per averted disability-adjusted life-year (DALY) by each parenting intervention and the waitlist control, for children aged 5-12 years. Age-specific cohorts were modelled until the age of 18. Educational and health care sector costs related to behavior problems were included. Active interventions were compared to the waitlist control as well as to each other.

RESULTS

Intervention costs ranged between US$ 14 (bibliotherapy) to US$ 1,300 (IY) per child, with effects of up to 0.23 averted DALYs per child (IY). All parenting interventions were cost-effective at a threshold of US$ 15,000 per DALY in relation to the waitlist control. COPE and bibliotherapy strongly dominated the other options, and an additional US$ 2,629 would have to be invested in COPE to avert one extra DALY, in comparison to bibliotherapy.

CONCLUSIONS

Parenting interventions are cost-effective in the longer run in comparison to a waitlist control. Bibliotherapy or COPE are the most efficient options when comparing interventions to one another. Optimal decision for investment should to be based on budget considerations and priority settings.

Three dimensional convolutional neural network-based classification of conduct disorder with structural MRI

Conduct disorder (CD) is a common child and adolescent psychiatric disorder with various representative symptoms, and may cause long-term burden to patients and society. Recently, an increasing number of studies have used deep learning-based approaches, such as convolutional neural network (CNN), to analyze neuroimaging data and to identify biomarkers. In this study, we applied an optimized 3D AlexNet CNN model to automatically extract multi-layer high dimensional features of structural magnetic resonance imaging (sMRI), and to classify CD from healthy controls (HCs). We acquired high-resolution sMRI from 60 CD and 60 age- and gender-matched HCs. All subjects were male, and the age (mean ± std. dev) of participants in the CD and HC groups was 15.3 ± 1.0 and 15.5 ± 0.7, respectively. Five-fold cross validation (CV) was used to train and test this model. The receiver operating characteristic (ROC) curve for this model and that for support vector machine (SVM) model were compared. Feature visualization was performed to obtain intuition about the sMRI features learned by our AlexNet model. Our proposed AlexNet model achieved high classification performance with accuracy of 0.85, specificity of 0.82 and sensitivity of 0.87. The area under the ROC curve (AUC) of AlexNet was 0.86, significantly higher than that of SVM (AUC = 0.78; p = 0.046). The saliency maps for each convolutional layer highlighted the different brain regions in sMRI of CD, mainly including the frontal lobe, superior temporal gyrus, parietal lobe and occipital lobe. The classification results indicated that deep learning-based method is able to explore the hidden features from the sMRI of CD and might assist clinicians in the diagnosis of CD.

Cost and cost-effectiveness of a parenting programme to prevent violence against adolescents in South Africa

INTRODUCTION

This paper presents the costs and cost-effectiveness of 'Parenting for Lifelong Health: Sinovuyo Teen', a non-commercialised parenting programme aimed at preventing violence against adolescents in low-income and middle-income countries.

METHODS

The effectiveness of Sinovuyo Teen was evaluated with a cluster randomised controlled trial in 40 villages and peri-urban townships in the Eastern Cape of South Africa from 2015 to 2016. The costs of implementation were calculated retrospectively and models of costs at scale estimated, from the perspective of the programme provider. Cost-effectiveness analysis considers both the cost per incident of abuse averted, and cost per disability-adjusted life year averted. Potential economic benefits from the societal perspective were estimated by developing a framework of possible savings.

RESULTS

The total implementation cost for Sinovuyo Teen over the duration of the trial was US$135 954, or US$504 per family enrolled. Among the 270 families in the treatment group, an estimated 73 incidents of physical and emotional abuse were averted (95% CI 29 to 118 incidents averted). During the trial, the total cost per incident of physical or emotional abuse averted was US$1837, which is likely to decrease to approximately US$972 if implemented at scale. By comparison, the economic benefits of averting abuse in South Africa are large with an estimated lifetime saving of US$2724 minimum per case.

CONCLUSION

Parenting programmes are a cost-effective intervention to prevent the abuse of adolescents by their caregivers in South Africa, when compared with existing violence prevention programmes and cost-effectiveness thresholds based on GDP per capita.

Differences in healthcare costs in youths with conduct disorders in rural vs. urban regions: an analysis of German health insurance data

Background

For children and adolescents with mental health problems, there is a lack of data as to whether the type of residential area (urban vs. rural) influences healthcare costs for affected individuals. The aim of this study was therefore to explore potential urban vs. rural healthcare cost differences in children and adolescents with conduct disorder (CD), one of the most frequent and cost-intensive child and adolescent psychiatric disorders. Additionally, we aimed to compare healthcare costs of youths with CD, and of youths without this diagnosis.

Methods

We analysed data from a German health insurance company, extracting all youths with a CD diagnosis in 2011 (CD group; N = 6337), and an age- and sex-matched group without this diagnosis (control group). For both groups, annual costs per person for outpatient and inpatient healthcare were aggregated, stratified by area of residence (urban vs. rural).

Results

While mean annual overall costs in the CD group did not differ significantly between urban and rural areas of residence (2785 EUR vs. 3557 EUR, p = 0.253), inpatient treatment costs were significantly higher in rural areas (2166 EUR (60.9% of overall costs) vs. 1199 EUR (43.1% of overall costs), p < 0.0005). For outpatient healthcare costs, the reverse effect was found, with significantly higher costs in individuals from urban areas of residence (901 EUR (32.3% of overall costs) vs. 581 EUR (16.3% of overall costs), p < 0.0005).

In the control group, no significant rural vs. urban difference was found for either overall health costs, inpatient or outpatient costs. Mean overall costs in the CD group were four times higher than in the control group (3162 (±5934) EUR vs. 795 (±4425) EUR).

Conclusions

This study is the first to demonstrate urban vs. rural differences in healthcare costs among youths with CD. The higher costs of inpatient treatment in rural regions may indicate a need for alternative forms of service provision and delivery in rural settings.

Population cost-effectiveness of the Triple P parenting programme for the treatment of conduct disorder: an economic modelling study

Parenting programmes are the recommended treatments of conduct disorders (CD) in children, but little is known about their longer term cost-effectiveness. This study aimed to evaluate the population cost-effectiveness of one of the most researched evidence-based parenting programmes, the Triple P-Positive Parenting Programme, delivered in a group and individual format, for the treatment of CD in children. A population-based multiple cohort decision analytic model was developed to estimate the cost per disability-adjusted life year (DALY) averted of Triple P compared with a 'no intervention' scenario, using a health sector perspective. The model targeted a cohort of 5-9-year-old children with CD in Australia currently seeking treatment, and followed them until they reached adulthood (i.e., 18 years). Multivariate probabilistic and univariate sensitivity analyses were conducted to incorporate uncertainty in the model parameters. Triple P was cost-effective compared to no intervention at a threshold of AU$50,000 per DALY averted when delivered in a group format [incremental cost-effectiveness ratio (ICER) = $1013 per DALY averted; 95% uncertainty interval (UI) 471-1956] and in an individual format (ICER = $20,498 per DALY averted; 95% UI 11,146-39,470). Evidence-based parenting programmes, such as the Triple P, for the treatment of CD among children appear to represent good value for money, when delivered in a group or an individual face-to-face format, with the group format being the most cost-effective option. The current model can be used for economic evaluations of other interventions targeting CD and in other settings.

The high societal costs of childhood conduct problems: evidence from administrative records up to age 38 in a longitudinal birth cohort

BACKGROUND

Children with conduct problems that persist into adulthood are at increased risk for future behavioral, health, and social problems. However, the longer term public service usage among these children has not been fully documented. To aid public health and intervention planning, adult service usage across criminal justice, health care, and social welfare domains is compared among all individuals from a representative cohort who followed different conduct problem trajectories from childhood into adulthood.

METHODS

Participants are from the Dunedin Multidisciplinary Health and Development Study, a prospective, representative cohort of consecutive births (N = 1,037) from April 1972 to March 1973 in Dunedin, New Zealand. Regression analyses were used to compare levels of public service usage up to age 38, gathered via administrative and electronic medical records, between participants who displayed distinct subtypes of childhood conduct problems (low, childhood-limited, adolescent-onset, and life-course persistent).

RESULTS

Children exhibiting life-course persistent conduct problems used significantly more services as adults than those with low levels of childhood conduct problems. Although this group comprised only 9.0% of the population, they accounted for 53.3% of all convictions, 15.7% of emergency department visits, 20.5% of prescription fills, 13.1% of injury claims, and 24.7% of welfare benefit months. Half of this group (50.0%) also accrued high service use across all three domains of criminal justice, health, and social welfare services, as compared to only 11.3% of those with low conduct problems (OR = 7.27, 95% CI = 4.42-12.0).

CONCLUSIONS

Conduct problems in childhood signal high future costs in terms of service utilization across multiple sectors. Future evaluations of interventions aimed at conduct problems should also track potential reductions in health burden and service usage that stretch into midlife.

Distinguishing Adolescents With Conduct Disorder From Typically Developing Youngsters Based on Pattern Classification of Brain Structural MRI

Background: Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents antisocial behaviors, and is associated with structural alterations in brain. However, whether these structural alterations can distinguish CD from healthy controls (HCs) remains unknown. Here, we quantified these structural differences and explored the classification ability of these quantitative features based on machine learning (ML).

Materials and Methods: High-resolution 3D structural magnetic resonance imaging (sMRI) was acquired from 60 CD subjects and 60 age-matched HCs. Voxel-based morphometry (VBM) was used to assess the regional gray matter (GM) volume difference. The significantly different regional GM volumes were then extracted as features, and input into three ML classifiers: logistic regression, random forest and support vector machine (SVM). We trained and tested these ML models for classifying CD from HCs by using fivefold cross-validation (CV).

Results: Eight brain regions with abnormal GM volumes were detected, which mainly distributed in the frontal lobe, parietal lobe, anterior cingulate, cerebellum posterior lobe, lingual gyrus, and insula areas. We found that these ML models achieved comparable classification performance, with accuracy of 77.9 ∼ 80.4%, specificity of 73.3 ∼ 80.4%, sensitivity of 75.4 ∼ 87.5%, and area under the receiver operating characteristic curve (AUC) of 0.76 ∼ 0.80.

Conclusion: Based on sMRI and ML, the regional GM volumes may be used as potential imaging biomarkers for stable and accurate classification of CD.

Protocol for the economic evaluation of a complex intervention to improve the mental health of maltreated infants and children in foster care in the UK (The BeST? services trial)

INTRODUCTION

Children who have experienced abuse and neglect are at increased risk of mental and physical health problems throughout life. This places an enormous burden on individuals, families and society in terms of health services, education, social care and judiciary sectors. Evidence suggests that early intervention can mitigate the negative consequences of child maltreatment, exerting long-term positive effects on the health of maltreated children entering foster care. However, evidence on cost-effectiveness of such complex interventions is limited. This protocol describes the first economic evaluation of its kind in the UK.

METHODS AND ANALYSIS

An economic evaluation alongside the Best Services Trial (BeST?) has been prospectively designed to identify, measure and value key resource and outcome impacts arising from the New Orleans intervention model (NIM) (an infant mental health service) compared with case management (CM) (enhanced social work services as usual). A within-trial economic evaluation and long-term model from a National Health Service/Personal Social Service and a broader societal perspective will be undertaken alongside the National Institute for Health Research (NIHR)-Public Health Research Unit (PHRU)-funded randomised multicentre BeST?. BeST? aims to evaluate NIM compared with CM for maltreated children entering foster care in a UK context. Collection of Paediatric Quality of Life Inventory (PedsQL) and the recent mapping of PedsQL to EuroQol-5-Dimensions (EQ-5D) will facilitate the estimation of quality-adjusted life years specific to the infant population for a cost-utility analysis. Other effectiveness outcomes will be incorporated into a cost-effectiveness analysis (CEA) and cost-consequences analysis (CCA). A long-term economic model and multiple economic evaluation frameworks will provide decision-makers with a comprehensive, multiperspective guide regarding cost-effectiveness of NIM. The long-term population health economic model will be developed to synthesise trial data with routine linked data and key government sector parameters informed by literature. Methods guidance for population health economic evaluation will be adopted (lifetime horizon, 1.5% discount rate for costs and benefits, CCA framework, multisector perspective).

ETHICS AND DISSEMINATION

Ethics approval was obtained by the West of Scotland Ethics Committee. Results of the main trial and economic evaluation will be submitted for publication in a peer-reviewed journal as well as published in the peer-reviewed NIHR journals library (Public Health Research Programme).

TRIAL REGISTRATION NUMBER

NCT02653716; Pre-results.

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Background

Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years®(IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects.

Objectives

To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings.

Design

Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention.

Settings

UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal.

Participants

Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys).

Interventions

IY Basic parenting programme.

Main outcome measures

Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms.

Results

There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximumn = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention.

Limitations

Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention.

Conclusions

There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions.

Funding

The National Institute for Health Research Public Health Research programme.

Preventing enduring behavioural problems in young children through early psychological intervention (Healthy Start, Happy Start): study protocol for a randomized controlled trial

BACKGROUND

Behavioural problems are common in early childhood, and can result in enduring costs to the individual and society, including an increased risk of mental and physical illness, criminality, educational failure and drug and alcohol misuse. Most previous research has examined the impact of interventions targeting older children when difficulties are more established and harder to change, and have rarely included fathers. We are conducting a trial of a psychological intervention delivered to families with very young children, engaging both parents where possible.

METHODS

This study is a two-arm, parallel group, researcher-blind, randomized controlled trial, to test the clinical effectiveness and cost-effectiveness of a parenting intervention, Video Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD) for parents of young children (12-36 months) at risk of behavioural difficulties. VIPP-SD is an evidence-based parenting intervention developed at Leiden University in the Netherlands which uses a video-feedback approach to support parents, particularly by enhancing parental sensitivity and sensitive discipline in caring for children. The trial will involve 300 families, who will be randomly allocated into either an intervention group, who will receive the video-feedback intervention (n = 150), or a control group, who will receive treatment as usual (n = 150). The trial will evaluate whether VIPP-SD, compared to treatment as usual, leads to lower levels of behavioural problems in young children who are at high risk of developing these difficulties. Assessments will be conducted at baseline, and 5 and 24 months post-randomization. The primary outcome measure is a modified version of the Preschool Parental Account of Child Symptoms (Pre-PACS), a structured clinical interview of behavioural symptoms. Secondary outcomes include caregiver-reported behavioural difficulties, parenting behaviours, parental sensitivity, parental mood and anxiety and parental relationship adjustment. An economic evaluation will also be carried out to assess the cost-effectiveness of the intervention compared to treatment as usual.

DISCUSSION

If shown to be effective, the intervention could be delivered widely to parents and caregivers of young children at risk of behavioural problems as part of community based services.

TRIAL REGISTRATION

ISRCTN Registry: ISRCTN58327365 . Registered 19 March 2015.

Costs and savings of parenting interventions: results of a systematic review

BACKGROUND

This systematic review of economic evaluations of universal preventative or targeted treatment parenting interventions that aim to enhance parent-infant interaction is primarily intended to inform decision makers who have to make difficult spending decisions, especially at a time of reduced spending allocations. A synthesis of available costs and savings about parenting interventions that set out to enhance parent-infant interaction is presented. This topic is important specifically in view of the UK Governments' emphasis on the equalities agenda and the early years. The benefits of positive early life experiences, which include good parent-infant interaction, are far reaching and may be positively correlated with improved educational, health and well-being outcomes and reduced criminality.

METHODS

A literature search was undertaken using on-line indexing databases between 2004 and 2014 that included the search terms 'parent', 'infant', 'interaction', 'cost benefit analysis' and their synonyms.

RESULTS

Despite existing economic studies generally focusing upon targeted short-run outcomes, significant savings were observed in the included studies. Parenting interventions could save the health service around £2.5k per family over 25 years and could save the criminal justice system over £145k per person over the life course. In light of the escalating costs of remedial services, these potential savings may provide the UK and other governments with a robust incentive to invest in early years parenting interventions.

CONCLUSIONS

Parenting interventions can be economically efficient and return savings on investment. Moreover, and one might argue as a moral imperative of democratic societies, population health can be improved and health inequalities reduced. An important debate is needed about early years policy, to include acknowledgement of the differences between UK and international healthcare systems and the potential savings from the synergistic and spin-off effects of early years interventions to inform decision-making to fund and implement appropriate action.

The effectiveness of universal parenting programmes: the CANparent trial

BACKGROUND

There is substantial evidence for the efficacy and effectiveness of targeted parenting programmes but much less evidence regarding universal parenting programmes. The aim of the present study was to evaluate the effectiveness of the CANparent Trial of 12 universal parenting programmes, which were made available to parents of all children aged 0-6 years in three local authorities in England. To the best of our knowledge, this is the first study of universal parenting programmes on this scale.

METHODS

Parents accessed a voucher, value £100, to attend an accredited programme of parenting classes. Parents completed measures of their mental well-being, parenting efficacy, parenting satisfaction, and parenting stress, at pre- and post-course. Comparative data were derived from a sample of non-participant parents in 16 local authorities not providing CANparent programmes. A quasi-experimental design was adopted following estimation of propensity scores to balance the two groups on socio-demographic variables.

RESULTS

Following their programme, changes in parenting stress were small and nonsignificant (Cohen's d frequency 0.07; intensity, 0.17). Participating parents showed significantly greater improvements than the comparison group for parenting efficacy (0.89) but not parenting satisfaction (-0.01). Mental well-being improved from 0.29 SD below the national norm to the national norm after the course. Parents were overwhelmingly positive about their course (88-94%) but this was lower for improvement in their relationship with their child (74%) and being a better parent (76%).

CONCLUSIONS

The CANparent Trial demonstrated that universal parenting programmes can be effective in improving parents' sense of parenting efficacy and mental well-being when delivered to the full range of parents in community settings. However, there was no evidence of a reduction in levels of parenting stress; nor was there a significant improvement in satisfaction with being a parent. This is the first study of its kind in the UK; although the results point to a population benefit, more research is needed to determine whether benefits can be maintained in the longer term and whether they will translate into better parenting practices.

TIGA-CUB - manualised psychoanalytic child psychotherapy versus treatment as usual for children aged 5-11 years with treatment-resistant conduct disorders and their primary carers: study protocol for a randomised controlled feasibility trial

BACKGROUND

The National Institute for Health and Care Excellence (NICE) recommends evidence-based parenting programmes as a first-line intervention for conduct disorders (CD) in children aged 5-11 years. As these are not effective in 25-33% of cases, NICE has requested research into second-line interventions. Child and Adolescent Psychotherapists (CAPTs) address highly complex problems where first-line treatments have failed and there have been small-scale studies of Psychoanalytic Child Psychotherapy (PCP) for CD. A feasibility trial is needed to determine whether a confirmatory trial of manualised PCP (mPCP) versus Treatment as Usual (TaU) for CD is practicable or needs refinement. The aim of this paper is to publish the abridged protocol of this feasibility trial.

METHODS AND DESIGN

TIGA-CUB (Trial on improving Inter-Generational Attachment for Children Undergoing Behaviour problems) is a two-arm, pragmatic, parallel-group, multicentre, individually randomised (1:1) controlled feasibility trial (target n = 60) with blinded outcome assessment (at 4 and 8 months), which aims to develop an optimum practicable protocol for a confirmatory, pragmatic, randomised controlled trial (RCT) (primary outcome: child's behaviour; secondary outcomes: parental reflective functioning and mental health, child and parent quality of life), comparing mPCP and TaU as second-line treatments for children aged 5-11 years with treatment-resistant CD and inter-generational attachment difficulties, and for their primary carers. Child-primary carer dyads will be recruited following a referral to, or re-referral within, National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) after an unsuccessful first-line parenting intervention. PCP will be delivered by qualified CAPTs working in routine NHS clinical practice, using a trial-specific PCP manual (a brief version of established PCP clinical practice). Outcomes are: (1) feasibility of recruitment methods, (2) uptake and follow-up rates, (3) therapeutic delivery, treatment retention and attendance, intervention adherence rates, (4) follow-up data collection, and (5) statistical, health economics, process evaluation, and qualitative outcomes.

DISCUSSION

TIGA-CUB will provide important information on the feasibility and potential challenges of undertaking a confirmatory RCT to evaluate the effectiveness and cost-effectiveness of mPCP.

TRIAL REGISTRATION

Current Controlled Trials, ID: ISRCTN86725795 . Registered on 31 May 2016.

Return on investment of public health interventions: a systematic review

BACKGROUND

Public sector austerity measures in many high-income countries mean that public health budgets are reducing year on year. To help inform the potential impact of these proposed disinvestments in public health, we set out to determine the return on investment (ROI) from a range of existing public health interventions.

METHODS

We conducted systematic searches on all relevant databases (including MEDLINE; EMBASE; CINAHL; AMED; PubMed, Cochrane and Scopus) to identify studies that calculated a ROI or cost-benefit ratio (CBR) for public health interventions in high-income countries.

RESULTS

We identified 2957 titles, and included 52 studies. The median ROI for public health interventions was 14.3 to 1, and median CBR was 8.3. The median ROI for all 29 local public health interventions was 4.1 to 1, and median CBR was 10.3. Even larger benefits were reported in 28 studies analysing nationwide public health interventions; the median ROI was 27.2, and median CBR was 17.5.

CONCLUSIONS

This systematic review suggests that local and national public health interventions are highly cost-saving. Cuts to public health budgets in high income countries therefore represent a false economy, and are likely to generate billions of pounds of additional costs to health services and the wider economy.

No evidence of whole population mental health impact of the Triple P parenting programme: findings from a routine dataset

BACKGROUND

The Triple P parenting programme has been reported to improve child mental health at population level, but it consumes substantial resources. Previous published work has suggested improvements in whole population scores in the Strengths and Difficulties Questionnaire (SDQ) Total Difficulties Scale among samples of children following introduction of the programme. This paper aims to explore whether Triple P had an impact on child mental health problems using routinely collected data over 6 years before and during the implementation of the multilevel Triple P programme in Glasgow City.

METHODS

Annual monitoring of teacher-rated SDQ Total Difficulties Scale scores among children in their pre-school year in Glasgow City.

RESULTS

No significant or consistent changes in SDQ Total Difficulties Scale scores were seen during or after the implementation of Triple P programme on a whole population level.

CONCLUSION

Triple P in Glasgow City appears to have had no impact on early child mental health problems over a 6 year period. The Triple P programme, implemented on a whole population level, is unlikely to produce measurable benefits in terms of child mental health.

Outcomes of a Comparison Study into a Group-Based Infant Parenting Programme

This paper reports on a quantitative evaluation of a group-based programme designed to promote parent-infant attachment and child development. Whilst group-based parenting programmes are recommended for treating and preventing conduct disorder in older children, there is, as yet, little evidence as to whether they have a positive effect on very young children and their carers'. Recent UK Government initiatives to support families and improve parenting skills in the first 2 years of children's lives have increased the demand for the delivery and evaluation of community-based programmes. Eighty mother-child dyads were recruited from nine areas to intervention (n = 54) and control condition (n = 26). Baseline measures were collected in the children's home when the infants were on average 3-months-old, and follow-up measures were collected 6 months post-baseline (N = 63). Mothers' positive play behaviours were independently coded from video recordings taken in the home. Other measures included self-reported maternal confidence and mental well-being, assessed infant development and home environment. Socio-demographic data was collected once at baseline. After controlling for baseline scores, control mothers were observed to be significantly less sensitive during play with their baby at the 6 months follow-up with a significant increase in confidence. No differences were found between the groups on the other measures. This paper provides limited evidence for the effectiveness of the Incredible Years Parents and Babies group-based programme delivered in the first year of life. Further evaluation, particularly with parents at increased risk of poorer outcomes is needed to confirm and extend these results.

Cost-benefit analysis of a preventive intervention for divorced families: reduction in mental health and justice system service use costs 15 years later

This cost-benefit analysis compared the costs of implementing the New Beginnings Program (NBP), a preventive intervention for divorced families to monetary benefits saved in mental healthcare service use and criminal justice system costs. NBP was delivered when the offspring were 9-12 years old. Benefits were assessed 15 years later when the offspring were young adults (ages 24-27). This study estimated the costs of delivering two versions of NBP, a single-component parenting-after-divorce program (Mother Program, MP) and a two-component parenting-after-divorce and child-coping program (Mother-Plus-Child Program, MPCP), to costs of a literature control (LC). Long-term monetary benefits were determined from actual expenditures from past-year mental healthcare service use for mothers and their young adult (YA) offspring and criminal justice system involvement for YAs. Data were gathered from 202 YAs and 194 mothers (75.4 % of families randomly assigned to condition). The benefits, as assessed in the 15th year after program completion, were $1630/family (discounted benefits $1077/family). These 1-year benefits, based on conservative assumptions, more than paid for the cost of MP and covered the majority of the cost of MPCP. Because the effects of MP versus MPCP on mental health and substance use problems have not been significantly different at short-term or long-term follow-up assessments, program managers would likely choose the lower-cost option. Given that this evaluation only calculated economic benefit at year 15 and not the previous 14 (nor future years), these findings suggest that, from a societal perspective, NBP more than pays for itself in future benefits.

A Cost-Effectiveness Analysis of the Swedish Universal Parenting Program All Children in Focus

OBJECTIVE

There are few health economic evaluations of parenting programs with quality-adjusted life-years (QALYs) as the outcome measure. The objective of this study was, therefore, to conduct a cost-effectiveness analysis of the universal parenting program All Children in Focus (ABC). The goals were to estimate the costs of program implementation, investigate the health effects of the program, and examine its cost-effectiveness.

METHODS

A cost-effectiveness analysis was conducted. Costs included setup costs and operating costs. A parent proxy Visual Analog Scale was used to measure QALYs in children, whereas the General Health Questionnaire-12 was used for parents. A societal perspective was adopted, and the incremental cost-effectiveness ratio was calculated. To account for uncertainty in the estimate, the probability of cost-effectiveness was investigated, and sensitivity analyses were used to account for the uncertainty in cost data.

RESULTS

The cost was € 326.3 per parent, of which € 53.7 represented setup costs under the assumption that group leaders on average run 10 groups, and € 272.6 was the operating costs. For health effects, the QALY gain was 0.0042 per child and 0.0027 per parent. These gains resulted in an incremental cost-effectiveness ratio for the base case of € 47 290 per gained QALY. The sensitivity analyses resulted in ratios from € 41 739 to € 55 072. With the common Swedish threshold value of € 55 000 per QALY, the probability of the ABC program being cost-effective was 50.8 percent.

CONCLUSION

Our analysis of the ABC program demonstrates cost-effectiveness ratios below or just above the QALY threshold in Sweden. However, due to great uncertainty about the data, the health economic rationale for implementation should be further studied considering a longer time perspective, effects on siblings, and validated measuring techniques, before full scale implementation.

Psychosocial Interventions for Child Disruptive Behaviors: A Meta-analysis

BACKGROUND

Disruptive behavior disorders are among the most common child and adolescent psychiatric disorders and associated with significant impairment.

OBJECTIVE

Systematically review studies of psychosocial interventions for children with disruptive behavior disorders.

METHODS

We searched Medline (via PubMed), Embase, and PsycINFO. Two reviewers assessed studies against predetermined inclusion criteria. Data were extracted by 1 team member and reviewed by a second. We categorized interventions as having only a child component, only a parent component, or as multicomponent interventions.

RESULTS

Sixty-six studies were included. Twenty-eight met criteria for inclusion in our meta-analysis. The effect size for the multicomponent interventions and interventions with only a parent component had the same estimated value, with a median of -1.2 SD reduction in outcome score (95% credible interval, -1.6 to -0.9). The estimate for interventions with only a child component was -1.0 SD (95% credible interval, -1.6 to -0.4).

LIMITATIONS

Methodologic limitations of the available evidence (eg, inconsistent or incomplete outcome reporting, inadequate blinding or allocation concealment) may compromise the strength of the evidence. Population and intervention inclusion criteria and selected outcome measures eligible for inclusion in the meta-analysis may limit applicability of the results.

CONCLUSIONS

The 3 intervention categories were more effective than the control conditions. Interventions with a parent component, either alone or in combination with other components, were likely to have the largest effect. Although additional research is needed in the community setting, our findings suggest that the parent component is critical to successful intervention.

[Cognitive and affective perspective-taking in girls with conduct problems as a function of the callous-unemotional personality feature]

OBJECTIVE

Do girls with conduct problems (CP) and callous-unemotional (CU) traits show specific deficits in perspective-taking (PT) compared to healthy girls?

METHOD

We examined cognitive and affective PT in girls with CP and high CU scores (SVP-CU+), girls with CP and low CU-scores (SVP-CU-), and a healthy control group (KG) using a video sequence task and the animated shapes task. The sample consisted of 59 girls aged 8;6 to 16; 11 years.

RESULTS

The groups did not differ in affective or in cognitive PT.

CONCLUSION

The results emphasize the necessity of studies of PT in girls with CP and CU traits that account for differences in age ,and gender.

Perinatal depression and child development: exploring the economic consequences from a South London cohort

BACKGROUND

Depression in mothers during pregnancy and in the postnatal period has been recognized to have wide-ranging adverse impacts on offspring. Our study examines some of the outcomes and long-term economic implications experienced by offspring who have been exposed to perinatal depression.

METHOD

We analysed the effects of perinatal depression on child development outcomes of children at ages 11 and 16 years from the community-based South London Child Development Study. Economic consequences were attached to those outcomes through simple decision-analytic techniques, building on evidence from studies of epidemiology, health-related quality of life, public sector costs and employment. The economic analysis takes a life-course perspective from the viewpoints of the public sector, individual and society.

RESULTS

Additional risks that children exposed to perinatal depression develop emotional, behavioural or cognitive problems ranged from 5% to 21%. In addition, there was a high risk (24%) that children would have special educational needs. We present results in the form of cost consequences attached to adverse child outcomes. For each child exposed to perinatal depression, public sector costs exceeded £3030, costs due to reduced earnings were £1400 and health-related quality of life loss was valued at £3760.

CONCLUSIONS

Action to prevent or treat mothers' depression during pregnancy and after birth is likely to reduce public sector costs, increase earnings and improve quality of life for children who were exposed to the condition.

Efficacy of a multimodal treatment for disruptive behavior disorders in children and adolescents: focus on internalizing problems

Disruptive Behavior Disorders (DBDs) are among the most common reasons for youth referrals to mental health clinics. Aim of this study is to compare short and medium term efficacy of a multimodal treatment program (MTP), compared to community care (treatment-as-usual, TAU). The sample included 135 youths with DBDs (113 males, age range 9-15 years, mean age 12±2.5 years) were assigned either to a MTP (n=64), or addressed to community care for a TAU (n=71). Outcome measures were the Child Behaviour Checklist (CBCL) and the Children's Global Assessment Scale (C-GAS). All subjects were assessed at the baseline (T0), after 1-year treatment (T1) and after a 2-year follow-up (T2). Compared with patients receiving TAU, youths in the MTP showed, both at T1 and T2, significantly lower scores on CBCL Externalizing Scale, Internalizing Scale, Anxious/Depressed, Social Problems, and Aggressive Behavior, and higher scores at the C-GAS. Improvement in Internalizing Scales was particularly evident, with a shift from the clinical to the non-clinical range. Rate of use of mental health services and scholastic failure were reduced in the MTP. It is suggested that the improvement of the Internalizing symptoms is a crucial component of the therapeutic process in this MTP.

Effects of a preventive parenting intervention for divorced families on the intergenerational transmission of parenting attitudes in young adult offspring

This study evaluates whether the New Beginnings Program (NBP), a parenting intervention for divorced mothers, led to positive parenting attitudes in young adult offspring. Data were collected from 240 mothers (G1) and offspring (G2) at ages 9-12 and again in adolescence and young adulthood. Alternative theoretical models were tested to examine mediators of NBP effects on G2 parenting attitudes. Significant interactions between condition and baseline G1 parenting indicated that NBP improved G2's parenting attitudes for those exposed to poorer G1 parenting at program entry. Effects on G2 warm attitudes were partially mediated through program effects on G1 warm parenting. The implications of improving parenting attitudes in offspring who experience parental divorce on well-being in the next generation are discussed.

Investigating changes in use of services by high-need families following the Helping Families Programme, an innovative parenting intervention for children with severe and persistent conduct problems

BACKGROUND

Interventions aimed at high-need families have difficulty demonstrating short-term impact on child behaviour. Measuring impact on use of services could provide short-term indication of longer term benefits.

METHOD

During a feasibility pilot study we collected data on service use and attitudes to services from a small sample of parents from high-need families, before and after receiving the Helping Families Programme.

RESULTS

Respondents provided a range of opinions on a variety of social and community services received.

CONCLUSIONS

The study demonstrates the potential of short-term changes in enhanced service use data for building hypotheses of longer term change.

Highlighting the evidence gap: how cost-effective are interventions to improve early childhood nutrition and development?

There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.

Annual research review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders

BACKGROUND

Resources for supporting children and adolescents with psychiatric disorders continue to be scarce. Economics research can identify current patterns of expenditure, and help inform allocation of treatment and support resources between competing needs or uses.

SCOPE AND METHODS

The aim was to identify the costs of supporting children and adolescents, the economic impacts of childhood psychiatric disorders in adulthood and any new evidence on the cost-effectiveness of interventions. An electronic search of databases (including PubMed, Medline and Psychinfo) identified peer-reviewed journal articles published between 2005 and 2012.

FINDINGS

Sixty-seven papers provided data on support and treatment costs now or in the future, or cost-effectiveness analyses of services. Half the articles came from the United States. Most articles focussed on autism spectrum disorder (ASD; 23 articles), attention deficit hyperactivity disorder (ADHD; n = 15), conduct disorder (CD; n = 7), and anxiety or depression (n = 8).

CONCLUSION

Only 14 studies used a cost perspective wider than health care; most included education costs (n = 11), but only five included costs to the justice system. The number of studies estimating costs to the family has increased, particularly for children with autism spectrum disorder (ASD). In the United Kingdom, support costs for children and adolescents with conduct disorder (CD) appear to be lower than for those with attention deficit hyperactivity disorder (ADHD), although for the United States, the opposite may be true. Support costs for children and adolescents with ASD may be higher than both CD and ADHD. However, there were many differences between the samples and the methods employed making comparisons between studies difficult. Outcomes in adulthood include negative impacts on (mental) health, quality of life, public sector services, employment status and income. The evidence base is improving for child and adolescent psychiatric disorders, although only one full cost-effectiveness analysis was identified since the previous review published in 2012. However, we still do not know enough about the economic implications of support and treatment for specific disorders.

Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data

BACKGROUND

Approximately one in ten children aged 5-15 in Britain has a conduct, hyperactivity or emotional disorder.

METHODS

The British Child and Adolescent Mental Health Surveys (BCAMHS) identified children aged 5-15 with a psychiatric disorder, and their use of health, education and social care services. Service costs were estimated for each child and weighted to estimate the overall economic impact at national level.

RESULTS

Additional health, social care and education costs associated with child psychiatric disorders totalled £1.47bn in 2008. The lion's share of the costs falls to frontline education and special education services.

CONCLUSIONS

There are huge costs to the public sector associated with child psychiatric disorder, particularly the education system. There is a pressing need to explore ways to reduce these costs while improving health and well-being.

Economic evaluation of multisystemic therapy for young people at risk for continuing criminal activity in the UK

OBJECTIVE

To evaluate whether multisystemic therapy (MST) is more cost-effective than statutory interventions that are currently available for young offenders in England.

METHOD

A cost-offset evaluation of MST based on data from a randomised controlled trial conducted in North London, England, comparing MST with usual services provided by two youth offending teams (YOT). Service costs were compared to cost savings in terms of rates of criminal re-offending.

RESULTS

108 adolescents, aged 11-17 years, were randomly allocated to MST+YOT (n = 56) or YOT alone (n = 52). Reductions in offending were evident in both groups, but were higher in the MST+YOT group. At 18-month follow-up, the MST+YOT group cost less in terms of criminal activity (£9,425 versus £11,715, p = 0.456). The MST+YOT group were significantly cheaper in terms of YOT services than the YOT group (£3,402 versus £4,619, p = 0.006), but more expensive including the cost of MST, although not significantly so (£5,687 versus £4,619, p = 0.195). The net benefit per young person for the 18-month follow-up was estimated to be £1,222 (95% CI -£5,838 to £8,283).

CONCLUSIONS

The results reported in this study support the finding that MST+YOT has scope for cost-savings when compared to YOT alone. However, the limitations of the study in terms of method of economic evaluation, outcome measures used and data quality support the need for further research.