In the review above, we discussed the effectiveness of First Step Next. Based on the available evidence, it is an effective intervention for preschool through third grade students. The next question for school leaders is how cost-effective it is? In other words, how much do they pay for the obtained outcomes? School financial resources are limited, so educators must be cost-conscious. The next evolution in the evidence-based practice movement in education is conducting cost-effectiveness analysis. Regardless of effectiveness, if an intervention has a poor cost-benefit ratio, then it is not likely to be adopted. The authors of this study evaluated the cost-effectiveness of an efficacy study of First Step Next. Cost-effectiveness was calculated for the combined intervention of First Step Next and homeBase, First Step Next alone, and homeBase alone. Cost-effectiveness was evaluated for classified as ADHD, students classified Conduct Disorder, and those students with comorbid ADHD and Conduct Disorder. Treatment effectiveness was defined as movement from the clinical range into the borderline or normative range or from the borderline to the normative range post-intervention.
The combined intervention of First Step Next and homeBase was the most cost-effective. The combined package cost more to implement but produced a greater return on the investment than First Step Next alone or homeBase alone. First Step Next alone was the next most cost-effective, and homeBase was the least cost-effective. In terms of treating the clinical syndromes addressed in this study, it was most expensive to produce improvement in the comorbid condition of ADHD and Conduct Disorder, followed by Conduct Disorder, and then ADHD.
This study highlights the complexity of decision-making for school leaders. The combined package of First Step Next and homeBase is the most expensive intervention but produces the greatest return on investment. It is not always possible for school leaders to offer the multi-component intervention because parents may refuse to participate or district policies may prohibit home-based services. The school leaders will still achieve a reasonable return on their investment by offering First Step Next alone. Adding to the complexity of decision-making is the differential cost-effectiveness of the different clinical populations. School leaders will get the greatest return on investment for addressing ADHD. Providing First Step Next to address problems associated with the comorbid condition of ADHD and Conduct Disorder is more expensive, thus reducing the cost-benefit ratio. It may be that First Step Next is still more cost-effective than some other interventions developed to address this population. Comparisons with different treatments were not conducted in this analysis.
These data should be taken with a “grain of salt.” The data were derived from a large-scale efficacy study. These tend to be more expensive since researchers are so closely involved in the implementation of the intervention. Efficacy studies usually produce greater effects than when usual school resources implement an intervention. The outcomes would not be as strong, but the costs may be less, so the cost-benefit ratio may be approximately the same. These analyses are a welcome addition to the evidence base for specific interventions. It would be beneficial to have cost-effectiveness data for an intervention across different contexts and populations.
Kuklinski, M. R., Small, J. W., Frey, A. J., Bills, K., & Forness, S. R. (2022). Cost Effectiveness of School and Home Interventions for Students with Disruptive Behavior Problems. Journal of Emotional and Behavioral Disorders, 10634266221120521.
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