American Psychological Association 2014 Convention Presentation

Comparative Costs of Treatment for ADHD With Behavioral

Consultation and As-Needed Medication
Timothy F. Page William E. Pelham, Jr.
Florida International University Florida International University
tpage@fiu.edu
Elizabeth M. Gnagy Gregory A. Fabiano
Florida International University University At Buffalo--State University Of New York

Erika K. Coles William E. Pelham Iii

Florida International University Dartmouth College

Brian T. Wymbs Anil Chacko

Ohio University City University Of New York Queens College
wymbs@ohio.edu
Kathryn S. Walker Frances Arnold
Hospital For Sick Children Ohio University

Jessica Robb Lisa Burrows-Maclean

Florida International University University At Buffalo--State University Of New York

Martin T. Hoffman James G. Waxmonsky

University At Buffalo--State University Of New York Pennsylvania State University College Of Medicine

Daniel A. Waschbusch Greta M. Massetti

Pennsylvania State University College Of Medicine Centers For Disease Control

Topic: 10.4 evidence-based practice

 Objective: We conduct a cost analysis of an ADHD treatment protocol that included either no, low-, or high-intensity
behavioral interventions and subsequently provided adjunctive medication treatment as needed. Methods: 127 unmedicated
children with ADHD were randomly assigned to either no, low-, or high-intensity behavioral consultation procedures in their
regular school and home settings. In the low-intensity condition, a clinician met with the child’s teacher three times to help
establish a daily report card (DRC) with home-based rewards (the teacher had a “bank” of three additional consultation visits
to be used if needed). In the high-intensity condition, the child’s teacher again received three visits helping to implement a
DRC, but also additional as-needed consultation on implementing school-based rewards, response-cost systems, point
systems, escalating-deescalating time outs, and the individualizing of treatment components (the teacher had a “bank” of nine
additional visits). Parents in both behavioral treatment conditions had access to monthly group booster parent training
sessions. Those in the low-intensity condition had a “bank” of three individual parent training sessions to be used as needed,
while those in the high-intensity condition had a “bank” of nine sessions. The children were assessed weekly to determine if
they required adjunctive medication treatment with a CNS stimulant. In order to analyze the costs of this treatment protocol,
the quantity of resources expended on each child’s treatment was determined from records of the frequencies of the behavioral
interventions employed and type and dosage of all medication taken. The inputs considered were the amount of clinician time,
doctor time, paraprofessional time, teacher time, parent time, and medication. Quantities of these inputs were converted into
costs in 2013 USD using national wage estimates from the Bureau of Labor Statistics and the New York State Medicaid
reimbursement rates for prescription drugs. Costs were calculated assuming first the prices of immediate-release formulations
taken in the study, and second the prices of the equivalent extended-release formulations that would be taken today. Results:
Using the prices of the generic IR methylphenidate that was taken in the study, the average cost of treatment in the conditions
that included behavior modification was only $160 more over the course of the school year than that in the condition that had
no behavior modification. However, using the prices of the equivalent extended-release formulations that would be taken
today, this difference disappeared. This was likely because children who were assigned to a behavioral consultation condition
initiated medication treatment later in the school year, as the parent treatment study showed. Thus, the inclusion of less
expensive behavioral treatment components averted more expensive potential medication costs.