Problematic cost-utility analysis of interventions for behavior problems in children and adolescents

Cost-utility analyses are slowly becoming part of randomized control trials evaluating physical and mental health treatments and (preventive) interventions in child and adolescent development. The British National Institute of Health and Care Excellence, for example, insists on the use of gains in Quality Adjusted Life Years (QALYs) to compute the "value for money" of interventions. But what counts as a gain in quality of life? For one of the most widely used instruments, the EuroQol 5 Dimensions scale (EQ-5D), QALYs are estimated by healthy individuals who provide utility scores for specific health states, assuming that the best life is a life without self-experienced problems in five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The worst imaginable outcome is defined as "a lot of problems" in each of these five domains. The impact of the individual's problems on the social network is not weighted, and important social-developmental domains (externalizing problems, social competence) are missing. Current cost-utility computations based on EQ-5D favor physical health over mental health, and they rely on adult weights for child and adolescent quality of life. Thus, a level playing field is absent, and developmental expertise is sorely missing.