Download The Cost of Oppositional Defiant Disorder and Disruptive Behavior

The Cost of Oppositional Defiant Disorder
and Disruptive Behavior: A Review of the
Literature
Jacob D. Christenson, D. Russell Crane,
Julie Malloy & Shannon Parker
Journal of Child and Family Studies
ISSN 1062-1024
J Child Fam Stud
DOI 10.1007/s10826-016-0430-9
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DOI 10.1007/s10826-016-0430-9
ORIGINAL PAPER
The Cost of Oppositional Defiant Disorder and Disruptive
Behavior: A Review of the Literature
Jacob D. Christenson1 • D. Russell Crane2 • Julie Malloy2 • Shannon Parker1
Ó Springer Science+Business Media New York 2016
Abstract This purpose of this paper is to review the literature on the treatment of Oppositional Defiant Disorder,
with a specific focus on cost analyses. In general the literature shows that while there has been substantial research
on Oppositional Defiant Disorder there has been little focus
on the costs involved. A search of the major databases in
psychology and the social sciences yielded only seven
articles even marginally appropriate for a review of costs
associated with Oppositional Defiant Disorder and related
disruptive behavior. Interestingly, only two of these studies
investigated treatment costs specifically associated with
Oppositional Defiant Disorder. These studies showed that
the treatment of Oppositional Defiant Disorder is much less
expensive than the treatment of Conduct Disorder and
family therapy is the most cost effective approach. Overall,
the review showed that there is a dearth of literature related
to treatment costs, which leads to the conclusion that much
more research is needed on the cost of treating Oppositional Defiant Disorder.
Keywords Oppositional defiant disorder Costeffectiveness Cost analysis Disruptive behavior
& Jacob D. Christenson
[email protected]
1
Marriage and Family Therapy, Mount Mercy University,
1330 Elmhurst Dr. NE, Cedar Rapids, IA 52402, USA
2
Marriage and Family Therapy, Brigham Young University,
234 TLRB, Provo, UT 84602, USA
Introduction
Behavioral disorders place considerable strain on the
individual, family, and society (Charles et al. 2011). These
childhood disorders are becoming increasingly recognized
as an area of major public health concern, with numerous
studies reporting an alarmingly high prevalence in the
childhood population (Maughan and Rowe 2004; Loeber
et al. 2000). One of the most common of these childhood
psychiatric disorders is Oppositional Defiant Disorder
(ODD). The Diagnostic and Statistical Manual of Mental
Disorders [(DSM-V), American Psychiatric Association
(APA) 2013] defines ODD as a pattern of angry/irritable mood, argumentative/deviant behavior and vindictiveness that is severe enough to impair the child’s functioning
for at least 6 months.
Studies on the point prevalence of this disorder estimate
the occurrence to be between 2 and 16 %; the numbers
varying depending on the population, ascertainment
methods, and diagnostic measures used (Loeber et al.
2000). Studies demonstrate that the presence of ODD is
associated with lifelong mental health disorders in 50 % of
children affected (Boylan et al. 2007). This childhood
disorder is of great interest to the mental health professions
not only because of the disruption it causes, but also
because it is highly predictive of delinquency, criminality,
and substance abuse in later adolescence and adulthood
(Cohen 1998).
Although it is clear treatment of ODD should be a priority, the current health care market dictates treatment must
not only reduce symptoms, but also be cost effective as well.
Accordingly, the purpose of this article is to outline the
current research on the cost of ODD and disruptive behavior. Furthermore, this article will make the argument that the
current body of literature is deficient and more research is
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needed because of the lack of ODD specific findings. First,
the paper will provide some background concerning the
state of knowledge as it relates to ODD and its treatment, as
well as the implications this has for costs. Second the paper
will cover in depth the cost literature. Finally, the paper will
focus on the strengths and weaknesses in the literature, as
well as what future research is needed.
Before delving into the research relating to the cost of
ODD and its treatment, it should first be established that a
significant amount of research has been conducted on ODD
already and relevant findings have implications for costs.
Accordingly, this section of the paper is included to briefly
touch on information gathered from studies of ODD
focusing on age of diagnosis, developmental sequence, and
the impact on parents. As is common in this field, articles
referenced in this paper generally divide childhood mental
illness into two categories, behavioral disorders and emotional disorders. Behavioral disorders are those disorders
that include externalized behavior, such as ODD and
Attention Deficit Hyperactivity Disorder (ADHD). Emotional disorders parallel internalizing disorders such as
depression and anxiety.
Diagnosis by Age
ODD is described in the DSM-V (APA 2013) as typically
being first noticeable during the preschool years and not
usually developing after early adolescence. The typicallydeveloping child likewise starts to display oppositional
behavior at an early age; however, this normal oppositional
behavior tends to diminish as they mature (Mireault et al.
2008). While some children might demonstrate this type of
typical oppositionality, other children present with more
severe oppositional and defiant behavior. When these
behavior problems persist over time they can ultimately
become severe enough to warrant clinical attention (Borrego and Burrell 2010).
Some young children with ODD ‘‘grow out of it,’’ yet a
substantial portion do not. Many children continue to have
ODD as a single diagnosis, while others later develop
anxiety or depression as a comorbid disorder (Lavigne
et al. 2001). The presence of other disorders with ODD can
complicate treatment, increasing the number of sessions
needed and therefore the total cost of treatment. For these
reasons it is important that children with this disorder be
treated early before symptoms become more severe. Add to
this the fact that externalizing behavior has been found to
show considerable stability throughout childhood and
adolescence (Webster-Stratton and Taylor 2001; Farris
et al. 2011) and it becomes clear that cost-effective treatment methods are needed.
As noted above, preschool children showing signs of
ODD are likely to continue to exhibit the disorder, and such
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children often have ADHD as a comorbid concern (Lavigne
et al. 2001). ODD in early childhood is predictive of earlyonset conduct disorder (Burke et al. 2010). This is important
because early-onset antisocial behavior is linked to serious
maladaptive social and health functioning when compared to
later-onset antisocial behavior (Odgers et al. 2007). Some
researchers have noted that youth showing the childhoodonset subtype of Conduct Disorder (CD) may have had ODD
during early childhood (Maughan and Rowe 2004). As such,
the onset of ODD represents an important window of
opportunity for prevention efforts (Greene and Doyle 1999).
Should this window be missed there is a greater likelihood
the child’s behavioral problems and emotional problems will
become more severe, and severe mental illness is known to
burden the health care system and increase costs in the long
term (e.g., Insel 2008).
Developmental Sequence of Psychopathology
Children with oppositional and conduct problems comprise
a diverse group who engage in a broad array of problem
behaviors ranging from relatively minor defiance and
temper tantrums to more serious violations such as physical
aggression, destructiveness, and stealing (Cunningham and
Ollendick 2010). ODD is generally considered a milder
disorder than other more severe behavior disorders such as
CD or Antisocial Personality Disorder (APD), but it is far
from benign (Frick and Nigg 2012). It has been argued that
ODD forms an early stage in CD development and constitutes a developmental antecedent to CD in a significant
number of cases (APA 2013). Research on predictive
validity shows that a substantial proportion of children with
ODD later develop CD, and a proportion of those with CD
later meet criteria for APD. Loeber et al. (2002) conducted
a study tracking the development of disruptive behaviors
and showed that ODD is a strong predictor of CD, and that
CD is a strong predictor of APD. This same study found a
correlation between individuals with CD and APD in terms
of callous/unemotional behavior. When callous/unemotional behavior is present at an early age it may be more
likely that the child’s behavior will develop into CD or
APD. This is in contrast to those who may develop the
disorder in response to poor parenting or inadvertent
reinforcement of negative behaviors (Frick et al. 1992).
Studies suggest that ODD and CD are different disorders
but are developmentally related (Greene and Doyle 1999).
Although longitudinal studies have consistently found that
ODD symptoms are associated with increases in CD symptoms over time, it is clear that not all children with ODD will
go on to develop CD (Loeber et al. 2009). However,
according to researchers, if left untreated, about 52 % of
children with ODD will continue to meet the criteria up to
3 years later and about half of those will later progress into
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CD. The costs associated with CD and APD are significant.
Foster and Jones (2005) reported that over a 7 year period the
additional public costs associated with CD was $70,000.
Cohen and Miller (1998) estimated that the cost of psychotherapy for victims of crime, which is often committed by
individuals with APD, was more than $5.8 billion in a year.
Such findings again support the notion that early treatment of
ODD should be associated with overall cost savings since
there is an opportunity for prevention of more serious conditions that have a much greater impact on costs.
Impact on Parents
Consistent with previous literature, one study by Evans,
Sibley, and Serpell (2009) affirms that defiance and
delinquency are very wearing on parents. Childhood
oppositional and defiant behaviors are one of the greatest
contributors to parent stress (Angold et al. 1999; Evans
et al. 2009; Pfiffner et al. 2005; Seipp and Johnston 2005).
Stress has long been understood to be a significant contributor to health care costs and some estimate that up to
90 % of all doctor visits are due to stress and stress related
symptoms (e.g., Gibson 1993). A decrease in stress related
doctor visits by parents of children with ODD could result
in a significant cost savings.
This diagnosis is particularly detrimental to parental
mental health (Burke et al. 2002). In one study, a diagnosis of
ODD emerged as the most significant predictor of caregiver
strain (Bussing et al. 2003). Several other studies have
established that parents of children with externalizing disorders show significantly elevated levels of caregiver distress related to their child’s disorder (Kashdan et al. 2004).
Parental stress has been shown to lead to other mental health
disorders such as depression (Sim and England 2009). The
potential negative effects of ODD on parental mental health
is another factor that could be associated with increased
costs. Due to the relationship between parent and child
mental health, it is possible that treating ODD might also
result in cost savings associated with improved parental
functioning (e.g., increased work productivity).
Therapeutic Interventions
Over the last several years, interest in the economic analysis
of interventions and services to prevent or treat behavioral
problems among children has grown (Foster and Murrihy
2011). Treatment for ODD and CD is most often not specific
to either disorder, but to conduct problems or antisocial
behavior in general. There are various empirically supported
treatments (ESTs) that can help to reduce symptoms of
childhood behavioral disorders. Most methods of treatment
for these problems fall under either an individual or family
modality and both forms have proved successful and positively impact treatment outcomes (e.g., Crane and Payne
2011). The treatment strategies that have been found to be
most effective employ cognitive behavioral strategies while
targeting multiple levels, most commonly child and parent,
but also may include family, peers, and the school (Loeber
et al. 2009). One interesting study found that the use of
dialectic behavioral therapy may also be useful in reducing
symptoms of ODD as well (Nelson-Gray et al. 2006).
Psychological interventions specifically for the family
such as parenting skills training and behavior therapy have
been found to reduce conflict behaviors in children with
ODD (Kelsberg and St. Anna 2006). Therapy can serve as a
preventative intervention for children with behavioral
problems by supporting parents in the acquisition of strategies to promote positive behaviors (Charles et al. 2011).
There is evidence from randomized trials that suggests parent management training strategies are effective in the
treatment of disruptive behavior disorders as well (Burke
et al. 2002)
Medication management is another option for treatment,
though at this point it is usually seen as an adjunct to
behavioral interventions. Most often medication is used to
primarily treat another comorbid disorder such as ADHD,
and the benefits of this primary intervention is seen as then
extending to symptoms of ODD (Newcorn et al. 2005;
Steiner and Remsing 2007). Nevertheless, in at least one
study, treatment with divalproex sodium resulted in better
management of symptoms when CD was the primary diagnosis (Steiner et al. 2003). Although this study was conducted on those with CD, the results lend support to the idea
that medication can be helpful. However, Steiner and Remsing (2007) recommend that medications only be used for the
management of ODD after a strong therapeutic alliance has
been establish and assent has been obtained from the client.
Inclusion of Family Component
Considering the family’s important role in the initiation
and escalation of childhood behavior problems, familybased interventions have been of great interest to treatment
researchers and community **practitioners (e.g., Sexton
et al. 2004). It should be noted that while the child’s
behavior can be very distressing for the parents, parental
factors (e.g., APD tendencies in the parents) can also have
a significant effect on the development and course of ODD
in their children (Frick et al. 1992). Therefore, it is not
surprising that several reviews have found family-based
systemic treatments to be model approaches for youth with
conduct problems (Henggeler and Sheidow 2003; Kazdin
and Weisz 1998). Family-focused therapy addresses several aspects of a child’s environment including individual
internal processes, family relations, caregiver functioning,
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peer relations, and the school environment among others
(Crane et al. 2005).
Previous studies have shown that family therapy is
effective at reducing symptoms of ODD (Carr 2009).
Unfortunately, little research has been done on treatment
outcomes and cost of this specific behavioral disorder,
let alone how treatment might reduce health care costs for
ODD patients and their families. Given the research
demonstrating that a significant amount of a child’s noncompliant and inappropriate behavior is shaped and
maintained through maladaptive patterns of family interaction, treating the problem as a family modality is likely
to be more effective than other forms of treatment.
One of the tenants of a family systems approach is that a
change in one area of the system will results in a change in
other parts of the system. This would lead to the conclusion
that improvement in the identified patient may result in
improvement in parents and siblings as well. As an example,
Law and Crane (2000) demonstrated that when the identified
patient (i.e., the child) was treated, family members reduced
their own health care use by 30.5 %. This type of reduction in
health care use could result in significant cost savings that
extend beyond the treatment of the child.
Unfortunately, the literature on ODD as highlighted
above, while rich in content is extremely short on information related to costs. This is in contrast to other childhood behavioral disorders that have received significant
attention in the cost literature. For example, Matza, Paramore, and Prasad (2005) conducted an extensive review on
the costs associated with ADHD and were able to find 22
relevant articles. In terms of actual costs, the Centers for
Disease Control and Prevention (CDC) (2016) cite a
number of studies that demonstrate costs associated with
ADHD are well known. Among the statistics they cite are
that the annual cost of ADHD is between $12,005 and
$17,458 per individual and the total societal cost of ADHD
in 2000 exceeded $31.6 billion. The CDC also indicated
that at least one study has shown that annual costs for an
adult with ADHD are approximately three times higher
than for an individual without ADHD. As will be evident
below, the literature on ODD is not as well developed.
Review of Costs
In order to find articles related to costs associated with ODD,
major databases from psychology and the social sciences
were searched using EBSCOhost. Articles from all years
available in the databases were included. The databases used
for this study included Academic Search Complete, Academic Search Elite, PsycARTICLES, PsycINFO, SocINDEX, eBook Collection (EBSCOhost), Newswires, and
eBook Academic Collection (EBSCOhost). Broad search
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terms were used to find studies on ODD because of the
paucity of research specifically focused on costs associated
with this disorder. The search terms used were cost effectiveness, cost, cost analysis, budget, financial, health care
cost and Oppositional Defiant Disorder. This search resulted
in a total of 109 articles, but of these only seven articles
specifically mentioned costs associated with the treatment of
ODD. Given the few studies found, all studies that included
specific data generated by the researchers were included in
the review. Of these seven articles, only one article reported
numerical data appropriate for this review.
Because of the few studies found using ODD as the key
term, the search was expanded to include studies on costs
associated with ‘‘disruptive behavior.’’ This second search
was conducted to delve deeper into the literature, and
because of the tendency of researchers to lump ODD in
with other disorders when evaluating costs. As can be seen
below, a number of the studies found in this second search
actually contained specific information on costs associated
with ODD. For the second search, only cost analysis and
cost effectiveness were used as secondary terms in order to
generate more applicable results. In the search using disruptive behavior as the key term, 248 articles were found in
the initial search, with 11 articles specifically highlighting
costs related to disruptive behavior. Of these 11 articles,
only 5 reported specific numerical data related to costs.
Finally, an unpublished thesis that also reported on specific
costs associated with the treatment of ODD was included.
The total number of papers found, selected, and reviewed
was seven (Table 1).
Public Costs
The public costs of behavior problems among children and
youth are enormous (Foster and Jones 2005). This disorder
is associated with substantial emotional and financial burdens to individuals, families, schools, agencies, and society
at large (Farris et al. 2011). One estimate is that $1.7 to
$2.3 million can be saved from successful intervention for
each high-risk youth by avoiding a lifetime of negative
impacts from disruptive and/or delinquent behavior (Cohen
1998). Studies demonstrate that in general there is a small
subset of offenders who commit a large share of criminal
offenses (Cohen and Piquero 2009). It would seem plausible that if these offenders can be accurately identified
early and provided with preventative treatment criminal
activity may be curtailed. While not specific to ODD, such
information about offenders highlights the potential value
of targeting high-risk youth presenting with ODD or CD
(Cohen and Piquero 2009).
The results of the literature search returned only one
article that reported public costs specifically associated
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Table 1 Studies considered regarding costs associated with Oppositional Defiant Disorder
Study
Foster and
Jones (2005)
N
664
Ages
Gender
Ethnicity/race
Behavioral
issues
Method
Data available
Key results
11–18
M/F
AA, 49 %
At risk youth
with CD or
ODD
diagnosis
Longitudinal
Public costs and
treatment costs
7-Year public cost,
[$23,000
Emotional/
behavioral
disorders
Retrospective
survey
Medical
expenditures
Annual ODD
expenditure,
$2196
NR
Normal/
abnormal
SDQ
scores
Cross sectional
Medical
expenditures
Average cost
difference,
€1237
NR
NR
Cost
effectiveness
Treatment costs
and startup
costs
Per child, $1025
C, 48 %
L/A, 3 %
Guevara et al.
(2003)
3955
Kohlboeck
et al. (2014)
3579
Goldfine et al.
(2008)
17 Studies
2–18
M, 65 % F,
35 %
C, 80 %
AA, 12 %
L, 8 %
M, 51 %
F, 49 %
Thompson
et al. (1996)
66
Robinson et al.
(1996)
Malloy (2014)
10
2–8
NR
treatment cost,
[$13,000
startup, $14,063
2–17
M, 64 %
C 97 %
Conduct
problems
Nonequivalent
control group
Treatment costs
Per family, $70
45
5–12
F, 36 %
M/F
NR
Behavioral
problems
Program
description
Treatment costs
Per day, $41
9904
3–16
M, 65 %
NR
ODD
Cost
effectiveness
Medical claims
First episode of
care, $390
F, 35 %
NR not reported, AA African American, A Asian, L Hispanic/Latino, C Caucasian, M male, F female
with ODD. Foster and Jones (2005) reported findings from
the Fast Track Project, which included 664 children at risk
for behavioral problems, tracked over 7 years. The focus of
the article was on the cost of CD, but the authors reported
specific comparison information from a subsample with
ODD. Costs resulted from the youths’ involvement in a
variety of child-serving sectors; namely, juvenile justice,
child welfare, and special education (Foster and Jones
2005). The figures they reported show that the overall
public cost was almost twice as much for those diagnosed
with CD compared to those diagnosed with ODD. Over the
7 year period the total public cost of CD was more than
$41,000 and the total public cost of ODD was more than
$23,000. At risk youth in an undiagnosed comparison
group had much lower public costs, which for this group
was more than $11,000. Public costs generally increased
over the course of the study. In the first year the total public
cost was $2929 for CD, $2072 for ODD, and $1009 for the
comparison group. By the seventh year of the study these
costs had risen to $6178 for CD, $3271 for ODD, and
$1704 for the comparison group. Over the course of the
7 years, the average annual public cost was $6735 for CD,
$4033 for ODD, and $3830 for the comparison group.
Those in the 90th percentile for costs accounted for roughly
half of all expenditures. For those in this percentile, the
average yearly expenditures were $25,985 for CD, $12,848
for ODD, and $8212 for the comparison group. The
strengths and weaknesses of the Foster and Jones article
will be discussed in the section on ODD specific studies
below.
‘‘Disruptive Behavior’’ Studies
As noted above, five studies were found that included cost
data when the primary search term was disruptive behavior.
Although these studies do not provide substantive information about ODD, they do provide information about
costs associated with ODD behaviors and treatments.
Guevara et al. (2003) conducted a study using data from
the 1996 Medical Expenditure Panel Survey with the intent
of determining if children with behavioral disorders had
similar health care expenses to children with physical
conditions. The authors included a number of ICD-9 codes
representing a wide range of emotional and behavioral
disorders (including ODD, CD, and ADHD) when deriving
their sample of 3955 children.
Guevara et al.’s (2003) study showed that children with
behavioral disorders had significantly higher expenditures
($1468) than control children with no conditions ($710).
However, when compared to children with physical disorders ($1071) the costs were not significantly higher.
When looking at subtypes of services, children with
behavioral disorders were also found to have significantly
higher expenditures for office visits ($425 vs $236), prescription medications ($235 vs $156), and emergency room
visits ($155 vs $61) when compared to children with
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physical disorders. When the authors adjusted costs based
on demographics and physical comorbidities they also
found that those with emotional disorders had total
expenditures that were twice what was found for behavioral disorders. Interestingly, these authors also compared
sub-groups and actually found that expenditures for those
with ODD ($2196) were significantly higher than for those
with CD ($1172) or ADHD ($1093); however, these
authors argue that caution should be exercised in interpreting this result since it was based on a small subset of
the sample and they did not adjust for other factors that
would have affected this finding.
Although it is positive that a national sample was used,
one significant weakness of Guevara et al.’s (2003) study was
that the data was limited to medical expenditures and the
authors were unable to distinguish mental health treatment
from regular medical use. Accordingly, the authors really
have nothing to offer regarding the cost of mental health
treatment. It is possible that treatment would actually reduce
the costs for those with a particular disorder if they engaged
in treatment. Conversely, engaging in treatment might also
result in increased costs if treatment costs were added on top
of the regular medical expenditures. However, without data
on treatment it is only possible to say that one group had
higher costs, not why they had higher costs. This lack of a
focus on treatment was a weakness in almost all studies that
were found. Finally, Guevara et al. relied on parent’s reports
of symptoms for making a diagnosis, which makes their
categorizations potentially unreliable.
Kohlboeck et al. (2014) used data from a 10-year follow-up of the German Infant Nutritional Intervention study
to determine health care cost for children with elevated
scores on the Strengths and Difficulties Questionnaire
(SDQ). According to Kohlboeck et al. the SDQ is designed
to aid in identify children who are at risk of a psychiatric
disorder. Based on normative data, the authors were able to
categorize participants as ‘‘normal,’’ ‘‘at risk,’’ ‘‘borderline,’’ and ‘‘abnormal.’’ Costs among the participants in
these groups were then analyzed. They compared children
with these higher levels of difficulties to children with
normal difficulties across a 12-month period. This survey
provided information on the type of difficulties (i.e.,
attention, emotional, conduct, etc.) and types of health care
used (e.g., psychotherapy). These authors found there was a
highly significant cost difference (p \ .001) for children in
the abnormal range, which was on average €1237 ($1340)
more than for children with normal difficulties. Much of
this cost difference was attributable to higher hospitalization costs for those with abnormal difficulties. When the
subtypes of difficulties were investigated, these authors
found the average medical expenditures for those with
conduct problems (€190; $215) was significantly lower
than the costs for either those with emotional symptoms
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(€603; $682) or hyperactivity/inattention (€391; $442).
Psychotherapy costs were similar for all three groups, and
those with emotional symptoms on average had significantly higher inpatient rehabilitation costs than those with
conduct problems (€83; $94 vs €0; $0).
The questions on the SDQ conduct problem subscale are
more closely aligned with ODD than CD (e.g., questions
related to temper tantrums and disobedience). Kohlboeck
et al.’s (2014) findings, therefore, support the narrative that
treatment for ODD is similar to, or lower, than treatment for
other disorders. However, this study also had a significant
issue with dropout among those with behavioral disorders.
These types of disorders are typically associated with
increased use of health care services, which means their calculations may have underestimated the costs for those with
behavioral issues. Also, similar to Guevara et al. (2003), this
study relied on a screening measure instead of a diagnostic
assessment to determine the presence of disordered behavior.
Goldfine et al. (2008) conducted a cost-effectiveness
study on Parent–Child Interaction Therapy (PCIT).
Although PCIT is used for more than the treatment of disruptive behaviors, this study was included because the
authors specifically focused on disruptive behaviors in their
paper. The authors used 17 studies to determine effectiveness, while estimating costs associated with starting up and
running the program. The total cost per child that participates
in the program was found to be $1025, and the startup cost
was $14,063. When cost ratios were calculated, Goldfine
et al. found that a one point decrease on the Eyberg Child
Behavior Inventory cost between $22 and $87, on the Child
Behavior Checklist it was $101, and on the Parenting Stress
Index it was $26. Before detailing the next study, it should
also be noted that Aos et al. (2004) reported on PCIT in their
study of delinquency as well and found that the benefits
outweighed the costs by $3427. Aos et al. is not reviewed in
detail here because of its specific focus on delinquency.
Of the articles reviewed thus far, Goldfine et al. (2008)
stand out as an exemplar in terms of cost study methodology. These authors use multiple sources of data to
determine costs and include both direct and indirect costs
in their calculations. Additionally, they used accepted
formulas for calculating cost-effectiveness and reported
evidence of the treatment’s effectiveness, unlike the other
studies reviewed in this paper. The only significant weakness of the study is that the authors used secondary data to
make their calculations, which required that the authors
make estimations of costs in some areas (e.g., cost of office
space), as opposed to using actual incurred costs from a
specific program.
The last two studies found using disruptive behavior as a
search term both has serious issues in terms of methods or
data available. The study by Thompson et al. (1996) indicated in the title that the article reported on a cost-
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effectiveness evaluation of a parent training program.
However, the authors failed to consider anything beyond
staff costs in their estimates and did not report any cost
ratios. Because of the lack of a thorough assessment of
costs any calculations with this data would result in significant underestimation. The authors only reported that by
shortening the program they were able to reduce the cost
from $160 per family to $70 per family. While it is noteworthy that costs were reported at all, the study had the
potential to make a much larger contribution to the literature than what was realized. Robinson et al. (1996)
reported on a partial day program serving youth with
behavioral disorders. These authors did not purport to be
conducting a cost-effectiveness study, though they did
report on the cost of the program. They noted that the cost
per day per child was $41, which was much less than the
$300–$500 rate for hospitalizations per day. However,
without data about the outcomes of the program it is
impossible to determine if one was more cost-effective
than the other.
ODD Specific Studies
Two studies were found that had substantive information
concerning the cost of treating ODD specifically. The first
of these, Foster and Jones (2005), has already been cited
above with regard to public costs. These authors also
reported on treatment costs for CD, ODD, and a comparison group. Treatment costs were more than three times as
much for those diagnosed with CD compared to ODD.
Over the 7 year study period the total treatment cost was
more than $43,000 for CD and $13,000 for ODD. The
undiagnosed comparison had much lower treatment costs
(just over $7000), and this amount was closer to the figures for ODD. As was the case for public costs, treatment
costs generally increased over the course of the study. In
the first year the treatment costs were $2648 for CD, $652
for ODD, and $450 for the comparison group. By the
seventh year these costs were $12,504 for CD, $1830 for
ODD, and $1517 for the comparison group. By far, the
greatest cost for any of the groups was because of inpatient
mental health care. The total spent on this type of treatment
over the course of the study was $24,089 for CD, $5988 for
ODD, and $3115 for the comparison group, on average.
The study by Foster and Jones (2005) had a number of
strengths and weaknesses. One of the primary strengths of
the study was the use of multiple sources of data to
determine costs. The researchers looked at school and court
records, and conducted interviews with the children and
their families. Additionally, they looked at numerous types
of service use, including general health care, inpatient
hospitalization, emergency room visits, residential treatment, etc. Using multiple sources of data strengthens cost
analysis (Christenson and Crane 2014). The authors also
used actual diagnostic measures to categorize the participants, as opposed to symptom checklists. In terms of
weaknesses, Foster and Jones used the same per-unit cost
for residential settings, even though the settings where CD
is treated may be much more expensive. This means that
they may have underestimated the relative cost of treating
CD. The also authors relied on self-report for health care
utilization, which may have led to underreporting and
underestimating costs. In terms of cost-analysis methodology, the greatest weakness of their study is that they did
not consider the benefits of treatment, which makes it
impossible to estimate costs versus benefits.
The second study concerned the cost effectiveness of
services for ODD delivered by different provider types and
using different treatment modalities (Malloy 2014). This
study looked at discrete episodes of care (i.e., sequence of
services provided without a 90 day break) and found that
that first episode of care cost on average $390 dollars.
Counselors had the lowest average cost ($340) and medical
doctors had the highest average cost ($450) per episode of
care. The study also looked at which modality was the most
cost effective (i.e., individual, family, or mixed) and found
that family therapy was the most cost effective, though this
was also the least used. The author also tested whether
treatment costs would differ according to age or gender and
found no significant differences.
Malloy’s (2014) study had a large, national sample of
individuals diagnosed with ODD, which is a significant
strength. The study is also the only one that looked at the
costs associated with different modalities and provider
types. The most glaring weakness of this study is the lack
of established methodology to calculate cost-effectiveness.
The cost-effectiveness formula used by the author is not
recognized in the cost-effectiveness literature, though it
does provided a common denominator with which different
providers and modalities can be compared. Accordingly,
one can’t conclude that a typical episode of care costs $390
since the episode didn’t end until they didn’t have a session
for over 90 days, which means in some cases this episode
extended over multiple years, which cannot be considered a
typical length of treatment.
Summary and Future Research
This review clearly shows that little research has been done
on the cost-effectiveness of ODD treatment, and that when
ODD is isolated from CD the cost of treatment may be
much lower, though of course this may be impractical
given such high comorbidity with other disorders. The
review also shows that costs associated with conduct
problems in general may be significantly lower than those
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associated with emotional concerns, and are actually similar to what would be expected for youth suffering from
physical disorders. In all cases, inpatient mental health care
is much more expensive than other forms of treatment, and
it is plausible that those with emotional problems or CD
would be much more likely than those with ODD to be
treated in such settings, which lends support to the idea that
the treatment of ODD should be much lower overall.
Unfortunately, although the sample sizes were generally
large and fairly representative, the available data makes
firm conclusions about costs impossible given the paucity
of available data. As indicated in the introduction one of
the purposes in conducting this review was to demonstrate
the need for more research in this area by shining a light on
the dearth of relevant findings.
There are a number of weaknesses in the studies review in
this paper. Globally, the most pressing of these is that with
the exception of Goldfine et al. (2008) none of the studies
actually focused on a treatment for ODD or disruptive
behavior. Instead the studies looked at the costs individuals
with these concerns incur, which is not the same as costbenefit analysis, as will be described more fully below. It is
also possible the cost of treating the behavioral problems
identified in the studies may actually be underestimated. This
is especially true for those studies that only considered
general costs, since it is impossible to know what portion was
attributable to treatment (or lack thereof) of a psychiatric
disorder. In at least one study those with behavioral issues
were more likely to drop out (Kohlboeck et al. 2014), which
may have led to greater costs associated with this group being
excluded in the analysis. Another weakness across studies
was the lack of rigorous assessments to determine if the
participants actually met the criteria for a specific diagnosis.
Furthermore, with the exception of Foster and Jones
(2005) none of the studies were longitudinal and mostly
relied on retrospective analyses. In general, the studies also
lacked rigor in their determination of costs. For example,
Thompson et al. (1996) only took into account staffing
costs and entirely ignored other direct and indirect costs
that are commonly measured in economic evaluations.
Finally, none of the studies reviewed deliberately included
benefits in their evaluations. As was true for Aos et al.
(2004), it is likely that if benefits were included there
would be a net savings associated with treatment. More
rigorous research is certainly needed to address some of
these limitations in the cost literature.
As noted, with the exception of Goldfine et al. (2008),
none of the studies described above used accepted costbenefit methodology. In order to strengthen the cost literature
concerning ODD, researchers need to consider all three core
components of this type of research outlined by Christenson
and Crane (2014). These authors outline the need for data
regarding costs, benefits, and effectiveness (i.e., treatment
123
outcomes). In the current review, effectiveness was the most
glaring omission in almost all of the studies. This is unfortunate given there are a number of ESTs for ODD related
behaviors. Without an effective treatment to evaluate, true
cost-benefit analysis is meaningless, as was the case with the
Robinson et al. (1996) article. When referring to costs,
Christenson and Crane describe this as the costs of delivering
a particular treatment, both direct and indirect. Benefits on
the other hand, typically refers to cost savings associated
with the treatment. Foster and Jones (2005) provided information that could be used in this type of benefit analysis.
They calculated a number of costs that could be prevented if
effective treatment were delivered, which could then be
considered a benefit if a particular treatment led to a reduction in these types of costs. Costs and benefits once monetized can then be used to calculate the value of a particular
program. Often, the monetized benefits far outweigh the
costs associated with delivering the program. This type of
analysis is what is needed to fill the gap in the literature.
Additionally, despite the increasing prevalence and
significant costs of behavioral disorders, very little research
has assessed cost-effectiveness of family interventions for
this population. Little research has also been done on
recidivism or dropout rates for children and adolescents
with Oppositional Defiant Disorder. There is a need for
additional research to help understand variables that may
influence a client returning for additional treatment.
Effective treatments are critical to help minimize these
costs and to help provide adequate support to all who are
impacted by the disorder.
Further research is required in order to answer questions
related to the costs associated with treatment, and as noted
above there exists a need to include the benefits beyond just
decreased symptoms, such as improving family process
and/or quality of life for significant others. Researchers
should include these with the costs that arise from things
such as school evaluations, juvenile justice involvement,
hospital stays, criminal activity, and court costs. These
should all then be monetized and included in cost evaluations. A complete cost-benefit analysis could assist in
creating a clearer picture of the impact of treatment.
Finally, further research is also needed to assess potential
differences in cost by age at the time of treatment.
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