Cost-effectiveness of preventing child internalising problems: Results from the translational trial of Cool Little Kids at school entry
Introduction
Internalising (anxious/depressive) problems are among the most common difficulties of childhood, affecting approximately 10–20 % of those at school age (Carter, Wagmiller, & Gray, 2010; Lawrence, Hafekost, & Johnson, 2016). By the time internalising disorders are treated (typically in adolescence), problems are often severe and entrenched, and treatment effectiveness can be limited (Kapornai & Vetro, 2008). Given that early internalising problems often have longer-term consequences and persist into adulthood, prevention and early intervention are key to producing a positive impact (Bayer, Rapee, & Hiscock, 2011). In recent years, a number of effective universal (targeting the general population); selective (targeting high-risk groups); and indicated (targeting groups already displaying symptoms of illness but not meeting full diagnostic criteria) interventions (Mrazek & Haggerty, 1994) have been developed and shown to be effective in the prevention of internalising problems in young people (Stockings, Degenhardt, & Dobbins, 2016). Additional evidence supports the cost-effectiveness of these programs (Lee, Barendregt, & Stockings, 2017; Mihalopoulos, Vos, & Pirkis, 2012; Simon, Dirksen, & Bogels, 2012; Simon, Dirksen, & Bögels, 2013).
However, the majority of economic evaluations for the prevention of internalising disorders in children have utilised economic modelling. These studies have generally extrapolated costs and outcomes over a longer period as well as assessing both costs and impacts when implemented in a broader population beyond the original randomised controlled trials upon which efficacy/effectiveness was established (Lee et al., 2017; Mihalopoulos et al., 2015). This is important in the case of preventing internalising disorders, since the greatest benefits of effective interventions would be seen years in the future while the costs of the preventive interventions are incurred up-front. Economic models require efficacy (or ideally effectiveness) data and a variety of assumptions around the likely changes in costs and benefits with a sustained effect of the intervention. Trial‐based economic evaluations consider the costs and outcomes within the randomised controlled trial's observation time. These provide useful information typically on the more immediate cost‐effectiveness of interventions (one or two years after implementation) (Lynch et al., 2005; Simon et al., 2012; Simon et al., 2013). Longer-term follow up of trial cohorts can provide invaluable information within the context of a trial design, including stability of intervention effect and any other impacts that might be a consequence of the intervention.
Cool Little Kids is the only early intervention program designed to prevent anxiety and depression from preschool age (Bayer et al., 2011). Randomised trials demonstrated the efficacy of this targeted approach (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005) and additional economic modelling has estimated that the intervention is likely to be very cost-effective using the trial efficacy results and projecting future benefits if implemented across all preschools in Australia (Mihalopoulos et al., 2015; Mihalopoulos, Vos, Pirkis, & Carter, 2011). While Cool Little Kids represents a preventive intervention with the potential for significant public health effects, the previous trial results are limited due to the nature of the randomised trial design (i.e. strict inclusion criteria and conducted at one single centre). The economic evaluation is also subject to limitations due to the use of trial based efficacy data and assumptions concerning intervention implementation. Therefore, a translational trial of Cool Little Kids was conducted that aimed to provide real-world effectiveness and cost-effectiveness evidence if implemented via a universal screening paradigm (Bayer et al., 2011; Bayer, Beatson, & Bretherton, 2018). This paper reports on the planned economic evaluation using resource use and outcome data collected from trial participants. The research question was whether Cool Little Kids, a population-based screening for an early precursor of internalising problems in pre-schoolers followed by a preventive parenting program, is cost-effective compared to usual care over a one-year follow-up period (at primary school entry) from both societal and health sector perspectives.
Section snippets
Methods
This study was conducted within 307 metropolitan preschools in Melbourne, Victoria, offering government-funded programs for 4 year olds. A screening questionnaire was distributed to all parents of children enrolled in their year before school in 2011 and 2012 which included 17,661 enrolled children. Of the 6346 screening questionnaires received, 703 children were identified as inhibited by scoring above 30 on the Australian Temperament Project’s approach/inhibition scale, a validated 7-item
Results
Of the 545 families who were recruited into the trial, 265 were randomised to the intervention and 280 to the control group. The characteristics of the study participants in Table 1 show that the groups were well matched at baseline.
Tables S2 and S3 in the supplementary materials provide the components and unit costs included in the screening and intervention costing. The total cost of screening the 17,661 children from the health sector perspective was estimated at $140,497 or $200 per
Discussion
This study reports results from the first economic analysis alongside an implementation study of a population-based screening and parenting intervention to prevent child internalising problems starting from preschool age. It represents an important step demonstrating the value of early intervention for the prevention of internalising disorders in very young children.
The current analysis found that the children of parents in the group receiving the Cool Little Kids program had a similar total
Conclusions
Despite the limitations, the results indicate that the intervention is possibly cost saving from a societal perspective and likely to be cost-effective from a health sector perspective. Hence, offering Cool Little Kids across the population of inhibited pre-schoolers may be a cost-effective strategy based on data after one year at entry into primary school. As the current study was the first trial-based economic analysis to evaluate the prevention of internalising disorders in preschool
Trial registration
ISRCTN30996662; www.isrctn.com/ISRCTN30996662.
Availability of data and material
The datasets generated and/or analysed during the current study are not publicly available due to issues of participant confidentiality.
Declaration of Competing Interest
Rapee developed and distributes the Cool Little Kids program, but receives no financial benefit. There are no other conflicts of interest.
Acknowledgements
The authors thank the preschool services and families in the Victorian cities of Banyule, Boroondara, Frankston, Kingston, Knox, Maroondah, Whitehorse and Wyndham who took part in this research. They thank Joyce Cleary (Victorian Department of Education and Early Child Development) for her support in contacting preschool services. We also acknowledge and thank Alexandra Perry, Megan Mathers, Kate Beasley, Cassima Beechey, Timothy Grant-Taylor and Chelsea Cornell who were research assistants
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