Objective

To determine the effect of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on birth outcomes.

Data Source

The Child Development Supplement (CDS) of the Panel Study of Income Dynamics (PSID). The PSID provides extensive data on the income and well-being of a representative sample of U.S. families from 1968 to present. The CDS collects information on the children in PSID families ranging from cognitive, behavioral, and health status to their family and neighborhood environment. The first two waves of the CDS were conducted in 1997 and 2002, respectively. We use information on 3,181 children and their mothers.

Study Design

We use propensity score matching with multiple imputations to examine whether WIC program influences birth outcomes: birth weight, prematurity, maternal report of the infant's health, small for gestational age, and placement in the neonatal intensive care unit. Furthermore, we use a fixed-effects model to examine the above outcomes controlling for mother-specific unobservables.

Principal Findings

After using propensity scores to adjust for confounding factors, WIC shows no statistically significant effects for any of six outcomes. Fixed-effects models, however, reveal some effects that are statistically significant and fairly substantial in size. These involve preterm birth and birth weight.

Conclusions

Overall, the WIC program had moderate effects, but findings were sensitive to the estimation method used.

Service use patterns and costs of youth diagnosed with attention-deficit/hyperactivity disorder (ADHD) and comorbid conduct disorder (CD) were assessed across adolescence (ages 12 through 17). Featured service sectors include mental health, school services, and the juvenile justice system. Data are provided by three cohorts from the Fast Track evaluation and are based on parent report. Diagnostic groups are identified through a structured assessment. Results show that public costs for youth with ADHD exceed $40,000 per child on average over a 6-year period, more than doubling service expenditures for a non-ADHD group. Public costs for children with comorbid ADHD and CD double the costs of those with ADHD alone. Varying patterns by service sector, diagnosis, and across time indicate different needs for youth with different conditions and at different ages and can provide important information for prevention and treatment researchers.

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

Objective

Accurate assessment of racial disparities in attention-deficit/hyperactivity disorder (ADHD) depends on measurement that is equally valid for all groups. This study examines differences among African American and white children in ADHD measurement with a widely used parental report instrument, the Diagnostic Interview Schedule for Children (DISC).

Methods

Data come from 1070 children in the Fast Track Project, a longitudinal study of predominantly low-income children at risk of emotional and/or behavioral problems. Item Response Theory (IRT) methodology is used to determine whether ADHD screening items provide comparable information for African American and white children or whether differential item function (DIF) exists. IRT scores and race/ethnicity are entered in logistic regression models predicting use of ADHD medication.

Results

Seven of 39 DISC items performed differently among African Americans and whites. In most cases, parents of white children were more likely to endorse these items than were parents of African American children at comparable underlying levels of children’s hyperactivity. When items exhibiting differential functioning were deleted, race disparities predicting underlying need as indicated by ADHD medication use decreased and were no longer statistically significant.

Conclusions

Perceptions of ADHD-related symptoms among parents of African American children appear to differ in important ways from those of parents of white children, and screening instruments relying on parent report may yield different results for African American and white children with similar underlying treatment needs. Gathering information from additional sources including teachers and school counselors can provide a more complete picture of the behavioral functioning and therapeutic needs of children in all race/ethnic groups.

Economic analysis plays an increasingly important role in prevention research. In this article, we describe one form of economic analysis, a cost analysis. Such an analysis captures not only the direct costs of an intervention but also its impact on the broader social costs of the illness or problem targeted. The key question is whether the direct costs are offset by reductions in the other, morbidity-related costs, such as the use of expensive services. We begin by describing how economists think about costs. We then outline the steps involved in calculating the costs of delivering an intervention, including both implicit and explicit costs. Next we examine methods for estimating the morbidity-related costs of the illness or problem targeted by the intervention. Finally, we identify the challenges one faces when conducting such an analysis. Throughout the article, we illustrate key points using our experiences with evaluating the Fast Track intervention, a multiyear, multicomponent intervention targeted to children at risk of emotional and behavioral problems.

Using data from the evaluation of the Fast Track intervention, this article illustrates three methods for handling attrition. Multiple imputation and ignorable maximum likelihood estimation produce estimates that are similar to those based on listwise-deleted data. A panel selection model that allows for selective dropout reveals that highly aggressive boys accumulate in the treatment group over time and produces a larger estimate of treatment effect. In contrast, this model produces a smaller treatment effect for girls. The article's conclusion discusses the strengths and weaknesses of the alternative approaches and outlines ways in which researchers might improve their handling of attrition.

Objectives

To examine the cost-effectiveness of the Fast Track intervention, a multi-year, multi-component intervention designed to reduce violence among at-risk children. A previous report documented the favorable effect of intervention on the highest-risk group of ninth-graders diagnosed with conduct disorder, as well as self-reported delinquency. The current report addressed the cost-effectiveness of the intervention for these measures of program impact.

Design

Costs of the intervention were estimated using program budgets. Incremental cost-effectiveness ratios were computed to determine the cost per unit of improvement in the 3 outcomes measured in the 10th year of the study.

Results

Examination of the total sample showed that the intervention was not cost-effective at likely levels of policymakers' willingness to pay for the key outcomes. Subsequent analysis of those most at risk, however, showed that the intervention likely was cost-effective given specified willingness-to-pay criteria.

Conclusions

Results indicate that the intervention is cost-effective for the children at highest risk. From a policy standpoint, this finding is encouraging because such children are likely to generate higher costs for society over their lifetimes. However, substantial barriers to cost-effectiveness remain, such as the ability to effectively identify and recruit such higher-risk children in future implementations.

Objective

To determine the cost-effectiveness of three alternative high-quality treatments for attention deficit hyperactivity disorder (ADHD) relative to community care (CC) and to determine whether cost-effectiveness varies with the presence of comorbid disorders.

Data Sources/Collection

The study included 579 children ages 7–9.9 with diagnosed ADHD at six sites. Data for the study were distilled from administrative data and from interviews with parents, including estimates of the child's functional impairment. These analyses focus on changes in functional impairment over 14 months.

Study Design

The study involved a large clinical trial that randomized participants to one of four arms: routine CC, intensive medication management (MedMgt), multicomponent behavioral treatment, and a combination of behavioral treatment and medication.

Principal Findings

We assessed the cost-effectiveness of the alternatives using costs measured from a payer perspective. The preferred cost-effective treatment varies as a function of the child's comorbidity and of the policy maker's willingness to pay. For pure (no comorbidity) ADHD, high-quality MedMgt appears likely to be cost-effective at all levels of willingness to pay. In contrast, for some comorbid conditions, willingness to pay is critical: the policy maker with low willingness to pay likely will judge MedMgt most cost-effective. On the other hand, a policy maker willing to pay more now in expectation of future costs savings (involving, for example, juvenile justice), will recognize that the most cost-effective choice for comorbid conditions likely involves behavior therapy, with or without medication.

Conclusions

Analyses of costs and effectiveness of treatment for ADHD must consider the role of comorbidities.

Objectives

A recent joint report from the Institute of Medicine and the National Academy of Engineering, highlights the benefits of--indeed, the need for--mathematical analysis of healthcare delivery. Tools for such analysis have been developed over decades by researchers in Operations Research (OR). An OR perspective typically frames a complex problem in terms of its essential mathematical structure. This article illustrates the use and value of the tools of operations research in healthcare. It reviews one OR tool, queueing theory, and provides an illustration involving a hypothetical drug treatment facility.

Method

Queueing Theory (QT) is the study of waiting lines. The theory is useful in that it provides solutions to problems of waiting and its relationship to key characteristics of healthcare systems. More generally, it illustrates the strengths of modeling in healthcare and service delivery.

Queueing theory offers insights that initially may be hidden. For example, a queueing model allows one to incorporate randomness, which is inherent in the actual system, into the mathematical analysis. As a result of this randomness, these systems often perform much worse than one might have guessed based on deterministic conditions. Poor performance is reflected in longer lines, longer waits, and lower levels of server utilization.

As an illustration, we specify a queueing model of a representative drug treatment facility. The analysis of this model provides mathematical expressions for some of the key performance measures, such as average waiting time for admission.

Results

We calculate average occupancy in the facility and its relationship to system characteristics. For example, when the facility has 28 beds, the average wait for admission is 4 days. We also explore the relationship between arrival rate at the facility, the capacity of the facility, and waiting times.

Conclusions

One key aspect of the healthcare system is its complexity, and policy makers want to design and reform the system in a way that affects competing goals. OR methodologies, particularly queueing theory, can be very useful in gaining deeper understanding of this complexity and exploring the potential effects of proposed changes on the system without making any actual changes.

Children and adolescents with serious and persistent conduct problems often require large public expenditures. Successfully diverting one high risk child from unfortunate outcomes may result in a net savings to society of nearly $2 million, not to mention improving the life of that child and his or her family. This figure highlights the potential of prevention, which often rests on the ability to identify these children at a young age. This study examined the ability of a short conduct-problems screening procedure to predict future need for mental health assistance, special education services, and the juvenile justice system during elementary school ages. The screen was based on teacher and parent report of child behavioral habits in kindergarten, and was used to identify children as either at risk or not at risk for behavioral problems. Service outcomes were derived from a service-use assessment administered to parents at the end of the sixth grade, while special education information was gathered through a survey of school records. Study participants (463 kindergarten children; 54% male, 44% African American) were from economically disadvantaged neighborhoods in four diverse communities across the United States. Results indicated that, while controlling for demographic background variables, the risk indicator strongly predicted which children would require services related to conduct disorder or behavioral/emotional problems. Additional analyses revealed that the dichotomous high risk indicator was nearly as strong as the continuous screening variable in predicting the service-use outcomes, and that the screening of both parents and teachers may not be necessary for determining risk status.

Children with early-starting conduct Problems have a very poor prognosis and exact a high cost to society. The Fast Track project is a multisite, collaborative research project investigating the efficacy of a comprehensive, long-term, multicomponent intervention designed to prevent the development of serious conduct problems in high-risk children. In this article, we (a) provide an overview of the development model that serves as the conceptual foundation for the Fast Track intervention and describe its integration into the intervention model; (b) outline the research design and intervention model, with an emphasis on the elementary school phase of the intervention; and (c) summarize findings to dale concerning intervention outcomes. We then provide a case illustration, and conclude with a discussion of guidelines for practitioners who work with children with conduct problems.

This prospective longitudinal study examined the unique and combined effects of neighborhood characteristics on parental behaviors in the context of more distal and more proximal influences. With a sample of 368 mothers from high-risk communities in 4 parts of the United States, this study examined relations between race (African American or European American), locality (urban or rural), neighborhood characteristics, family context, and child problem behaviors, and parental warmth, appropriate and consistent discipline, and harsh interactions. Analyses testing increasingly proximal influences on parenting revealed that initial race differences in warmth and consistent discipline disappeared when neighborhood influences were considered. Although generally culture and context did not moderate other relations found between neighborhood characteristics, family context, and child behaviors, the few interactions found highlight the complex influences on parenting.

Confirmatory factor analysis of 25 items on the Child and Adolescent Disruptive Behavior Inventory (CADBI v.2.3) was conducted on teacher ratings of 824 kindergarten children and replicated on 534 children. Model fit was improved when correcting for two method effects: (a) adjacent items, and (b) identical behaviors (e.g., argues with adults, argues with peers). The results showed that the 25 items load on three distinct but correlated factors: Hyperactivity, Oppositional to Adults, and Oppositional to Peers. These more refined constructs from the CADBI may be useful for practitioners in identifying children who are at risk and for helping define appropriate contexts in which to intervene. The CADBI and analytic procedures also may contribute to future psychoeducational research on the development of problem behavior.

School discipline referrals (SDRs) may be useful in the early detection and monitoring of disruptive behavior problems to inform prevention efforts in the school setting, yet little is known about the nature and validity of SDRs in the early grades. For this descriptive study, SDR data were collected on a sample of first grade students who were at risk for developing disruptive behavior problems (n = 186) and a universal sample (n = 531) from 20 schools. Most SDRs were given for physical aggression and the predominant consequence was time out. As expected, boys and at-risk students were more likely to receive an SDR and to have more SDRs than were girls and the universal sample. A large difference between schools regarding the delivery of SDRs was found. A zero-inflated Poisson model clustered by school tested the prediction of school-level variables. Students in schools that had a systematic way of tracking SDRs were more likely to receive one. Also, schools with more low-income students and larger class sizes gave fewer SDRs. SDRs predicted teacher ratings, and to a lesser extent, parent ratings of disruptive behavior at the end of first grade. Practitioners and researchers must examine school-level influences whenever first grade discipline referrals are used to measure problem behavior for the purpose of planning and evaluating interventions.

The economic evaluation of psychosocial interventions is a growing area of research. Though time costs are central to the economist’s understanding of social costs, these costs generally have been ignored by prevention scientists. This article highlights the need to measure such costs and then reviews the principles economists use in valuing time. It then considers the specific time costs that often arise in interventions designed to reduce behavior problems among children and youth. These include classroom time devoted to program activities, the time of parents or other caregivers, the time of teachers (outside of the classroom), and the time of volunteers. We consider the economic principles that govern how economists value these inputs and then apply these principles to data from an evaluation of a prominent intervention in the field, the Incredible Years Program. We find that the time costs are potentially rather large and consider the implications for public policy of ignoring them.