Washington State Institute for Public Policy
Multimodal Therapy (MMT) for children with ADHD
Children's Mental Health: Attention Deficit Hyperactivity Disorder
Benefit-cost estimates updated December 2016.  Literature review updated April 2012.
These treatments target more than one dimension with psychosocial interventions. For instance, many therapies provide behavioral training to parents, school consultations with teachers, and self-control training with children. In this analysis, all studies utilized either behavioral or cognitive-behavioral orientations.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2015). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $1,835 Benefits minus costs ($6,177)
Participants $769 Benefit to cost ratio $0.30
Others $3,738 Chance the program will produce
Indirect ($3,720) benefits greater than the costs 33 %
Total benefits $2,623
Net program cost ($8,800)
Benefits minus cost ($6,177)
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $1,493 $0 $3,320 $749 $5,561
Labor market earnings associated with test scores $472 $1,040 $461 $0 $1,973
K-12 grade repetition $2 $0 $0 $1 $3
K-12 special education $20 $0 $0 $10 $29
Health care associated with disruptive behavior disorder $36 $12 $44 $18 $109
Costs of higher education ($187) ($282) ($87) ($94) ($650)
Adjustment for deadweight cost of program $0 $0 $0 ($4,403) ($4,403)
Totals $1,835 $769 $3,738 ($3,720) $2,623
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $9,120 2010 Present value of net program costs (in 2015 dollars) ($8,800)
Comparison costs $950 2010 Cost range (+ or -) 20 %
Per-participant costs are based on the average cost of intensive behavioral treatment reported in Jensen et al., (2005). Cost-effectiveness of ADHD treatments: findings from the Multimodal Treatment Study of children with ADHD. American Journal of Psychiatry 162, 1628–1636. Comparison costs are based on the average DSHS reimbursement for treatment of child ADHD.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Crime 1 81 -0.430 0.230 16 -0.430 0.230 26 -0.190 0.062
Disruptive behavior disorder symptoms 7 362 -0.229 0.096 9 -0.109 0.068 12 -0.341 0.007
Attention deficit hyperactivity disorder symptoms 9 453 -0.079 0.079 9 0.000 0.005 10 -0.186 0.125
Global functioning 1 30 0.141 0.256 9 0.000 0.011 10 0.151 0.582
Test scores 5 324 0.023 0.079 9 0.014 0.087 17 0.023 0.774
Citations Used in the Meta-Analysis

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

Chacko, A., Wymbs, B.T., Wymbs, F.A., Pelham, W.E., Swanger-Gagne, M.S., Girio, E., . . . O'Connor, B. (2009). Enhancing traditional behavioral parent training for single mothers of children with ADHD. Journal of Clinical Child and Adolescent Psychology, 38(2), 206- 218.

Hechtman, L., Abikoff, H., Klein, R.G., Weiss, G., Respitz, C., Kouri, J., . . . Pollack, S. (2004). Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 43(7), 812-819.

Hechtman, L., Etcovitch, J., Platt, R., Arnold, L.E., Abikoff, H.B., Newcorn, J.H., . . . Wigal, T. (2005). Does multimodal treatment of ADHD decrease other diagnoses? Clinical Neuroscience Research, 5(5-6), 273-282.

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

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

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

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

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

For more information on the methods
used please see our Technical Documentation.
360.664.9800
institute@wsipp.wa.gov