Assessment of health state utilities for attention-deficit/hyperactivity disorder in children using parent proxy report

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This study used standard gamble (SG) utility interviews to assess parent preferences for health states of childhood attention-deficit/hyperactivity disorder (ADHD). Health state utilities are needed to calculate quality-adjusted life years (QALYs), a
  Assessment of health state utilities for attention-deficit/hyperactivity disorderin children using parent proxy report Louis S. Matza 1 , Kristina Secnik 2 , Anne M. Rentz 1 , Sally Mannix 1 , F. Randy Sallee 3 , Donald Gilbert 3 &Dennis A. Revicki 11 MEDTAP International, Inc., Bethesda, MD (E-mail:;  2 Eli Lilly & Company,Indianapolis, IN;  3 Cincinnati Children’s Hospital, Cincinnati, OH  Accepted in revised form 15 April 2004 Abstract This study used standard gamble (SG) utility interviews to assess parent preferences for health states of childhood attention-deficit/hyperactivity disorder (ADHD). Health state utilities are needed to calculatequality-adjusted life years (QALYs), a critical outcome measure in cost-effectiveness studies of newtreatments. Parents (n ¼ 43) of children diagnosed with ADHD completed SG utility interviews, ratingtheir child’s current health and 11 hypothetical health states describing untreated ADHD and ADHDtreated with a stimulant or non-stimulant. Parents completed questionnaires on their children’s symptomsand health-related quality of life (HRQL). Parents’ SG rating of their child’s current health state (mean of 0.74 on a utility scale ranging from 0 to 1) was significantly correlated with inattentive, hyperactive, andoverall ADHD symptoms ( r ¼ 0.37, 0.36, and 0.40 respectively;  p  < 0.05) and psychosocial HRQL do-mains. Hypothetical health state utilities ranged from 0.48 (severe untreated ADHD) to 0.88 (effective andtolerable non-stimulant treatment). Comparisons between health states found expected differences betweenuntreated mild, moderate, and severe ADHD health states. When both treatments were effective andtolerable, parents preferred the non-stimulant health state over the stimulant health state (  p  < 0.03).Results suggest that parent SG interviews are a feasible and useful method for obtaining utility scores thatcan be used in cost-effectiveness models of ADHD treatment. Key words:  ADHD, Health-related quality of life, Non-stimulant, Stimulant, Utility Introduction Attention-deficit/hyperactivity disorder (ADHD)is characterized by a persistent and developmen-tally inappropriate pattern of inattention, hyper-activity, and/or impulsivity [1]. The symptoms of ADHD are associated with impairment in chil-dren’s academic performance, social functioning,and health-related quality of life (HRQL) [2–6]. Asnew treatments for this disorder are introduced, itis important to evaluate their cost-effectiveness toprovide an indication of their potential value toclinicians, patients, families, and third-party pay-ers. Health state utilities are needed to calculatequality-adjusted life years (QALYs), a criticalmeasure of outcomes in cost-utility studies, whichare a type of cost-effectiveness analysis that incor-porates the preferences of individuals for differenttreatment-relatedoutcomes[7,8].Utilitieshavenotfrequently been evaluated for ADHD-relatedhealth states, and no previous studies were locatedthat have assessed utilities based on the preferencesof individuals affected by ADHD. Thus, the pur-pose of this study was to use standard gamble (SG)utilitymethodologytoassessparentpreferencesforchildhood ADHD health states.Health state utilities are values between 0 and 1that can be conceptualized as a single summary Quality of Life Research (2005) 14: 735–747    Springer 2005  measure of HRQL [9, 10], a broad construct thatencompasses the impact of health status, includingdisease and treatment, on physical, psychological,and social functioning [11, 12]. In most studies,utility scores are used to rate chronic health states,with a score of 0 representing death and 1 repre-senting perfect health. For disease states such asADHD that do not involve mortality, however, itis conceptually appropriate to use temporaryhealth states framed in terms of a specific duration,with the lower anchor of 0 corresponding to a‘worst’ health state instead of death [7]. If it isnecessary to compare temporary health states tochronic health states, these temporary health stateutilities can be transformed onto a scale with deathas the lower anchor [7]. Temporary health stateshave been used in previous studies examining arange of medical and psychiatric conditions [13– 17]. The ADHD health states used in the currentstudy are temporary health states of 1-monthduration. The 1-month time frame was chosenbecause it was short enough to be consistent withthe dynamic nature of ADHD and child develop-ment, while also being long enough to ensure thatparents would be sufficiently invested in theirchoices between health states.The current study uses the standard gambleapproach, which is considered the classic methodfor obtaining utilities [7, 9, 10, 18, 19]. This meth-odology is directly derived from the fundamentalaxioms of utility theory, which involves decision-making under conditions of uncertainty. Only oneprevious study was located that assessed ADHD-relatedutilities,andutilityscoreswereestimatedbythe investigators based on a literature review ratherthan by eliciting individuals’ preferences [20].Because of the complexity of the SG task, thepresent study was conducted with a sample of parents of children with ADHD rather than thechildren themselves. Parents evaluated 11 hypo-thetical health states that incorporated ADHDsymptoms, behavior in school, impact on familyfunctioning, and medication side effects. Four of these health states were designed based on thepossible outcomes of treatment with a long-actingstimulant, such as Concerta  (i.e., extended-re-lease methylphenidate HCL). Although stimulantshave well-established efficacy for the treatment of childhood ADHD [21–23], there is interest in newmedications because stimulants are not effectiveand tolerable for all children, and also becausestimulants are classified as controlled substances[24].Four additional health states described possibleoutcomes of treatment with a non-stimulantmedication. These health states were designedbased on currently available data and physicians’impressions regarding atomoxetine (brand name:Strattera  ), a new non-stimulant that has dem-onstrated efficacy for the treatment of ADHD [24– 26]. For some children, a non-stimulant may bepreferable to stimulants because of the differentside effect profile and the potential for all-dayefficacy, without the therapeutic variabilitythroughout the day that is characteristic of stim-ulant treatment. For example, a recent clinical trialfound that atomoxetine was superior to placebo inthe morning and late afternoon/evening [27],which are times when stimulants taken once ortwice per day are typically not effective [21].Parents also rated health states describing mild,moderate, and severe untreated ADHD to providebenchmarks for the treatment-related healthstates. In addition, parents rated their own child’scurrent health state, which was compared to healthstatus questionnaires to validate the standardgamble procedure among this population. In sum,this study aimed to demonstrate the feasibility andvalidity of the SG method for assessing parentpreferences for ADHD health states. Methods Participants Participants were recruited at the CincinnatiChildren’s Hospital Medical Center. All parents inthis sample of convenience were in the PsychiatryDepartment’s database because their children re-ceived treatment for ADHD at the hospital, at-tended a hospital-administered camp for childrenwith ADHD, or participated in a clinical trial of ADHD medication at the hospital. Hospital staff provided a list of 53 parents who expressed interestin participating in the study. Data were collectedwith 43 of these parents (81%). The other 10parents did not participate for the following rea-sons: (a) One parent could not participate becauseof medical reasons, (b) three parents stated that736  they were no longer interested in participating, (c)four parents were not reachable (e.g., phonenumbers were no longer in service), and (d) twoparents did not attend the interviews that theyscheduled. Health utility measureInformation in ADHD health states Eleven hypothetical ADHD-related health stateswere created for use in the current study’s SGutility interviews. Prior to composing the first draftof these health states, literature was reviewed toidentify the symptom profile of ADHD [1, 2]; theimpact of ADHD on HRQL [6, 24, 28]; academicperformance, classroom behavior, and familyfunctioning associated with ADHD [2–4]; andefficacy and side effects of atomoxetine and stim-ulants [2, 24, 25]. Furthermore, clinical trial resultson atomoxetine were reviewed to identify the po-tential for morning and evening effects of non-stimulant medication [27]. This thorough review of currently available data ensured that there wouldbe empirical support for each statement includedin the health states.After conducting the literature review, fourphysicians were consulted regarding presentationof ADHD symptoms, impact, and treatment. Allfour had extensive experience treating childhoodADHD with both atomoxetine and stimulants.During these interviews, the physicians were que-ried about their observations of the efficacy andside effects of the medications. Physicians werealso asked to recall typical phrases that parents useto describe ADHD symptoms and medication sideeffects so that this language could be incorporatedinto the health states. The final step prior todrafting the health states was to conduct inter-views with two parents who had children diag-nosed with ADHD. Each parent was asked abouttheir family’s experience with ADHD and phar-maceutical treatments. ADHD health states After completing the literature review and inter-views with physicians and parents, hypotheticalhealth states were drafted. Each health state wasframed in terms of one month duration and de-signed to capture five domains related to ADHD.The first domain was a typical symptom profile of ADHD. Key symptoms were selected from theDSM-IV to represent a range of inattention,hyperactivity, and impulsivity [1]. The second do-main consisted of typical ADHD behaviors in theevening and morning. The language of this seconddomain corresponded to items from a parent-report instrument which reflected significantatomoxetine-related improvements in a placebo-controlled clinical trial (Daily Parent Rating of Evening and Morning Behavior – Revised) [27].The third and fourth domains represented theimpact of ADHD on school and family function-ing, respectively. The fifth domain captured thecommon side effects of atomoxetine or stimulantsas indicated by clinical trials. Side effects wereclassified as either tolerable or intolerable. Forexample, the tolerable side effects of atomoxetinewere mildly upset stomach, somnolence, and de-creased appetite. The tolerable side effects of stimulants were minor sleep difficulties, appetitedecrease, and occasionally feeling ‘wired’.Variations of these five domains were combinedto form 11 hypothetical health states of ADHD(see Table 1 for examples of statements fromhealth states; see Table 2 for a list of all healthstates). Health states A through H describehypothetical examples of a child with moderateADHD treated with either a stimulant or non-stimulant. For each of the two possible treatments,there are four health states corresponding to allcombinations of either adequate or inadequateresponse and either tolerable or intolerable sideeffects. The three other hypothetical health statescorrespond to three severity levels of untreatedADHD: (I) mild, (J) moderate, (K) severe.Four additional health states were created foruse in the SG interview. ‘Perfect health’ and ‘worsthealth’ included statements corresponding to eachof the five domains of the eleven hypotheticalhealth states. Each statement in ‘perfect health’indicated that the child had no problems in anyareas relevant to ADHD, whereas ‘worst health’described a child with extreme ADHD-relatedproblems necessitating hospitalization. ‘Child’sown current health’ required parents to evaluateand rate their child’s current health state onthe same scale as the hypothetical health states.Finally, there was a ‘death’ health state that wasused as a lower anchor.737        T    a      b      l    e      1  .     E   x   a   m   p    l   e   s   o    f    t    h   r   e   e    h   y   p   o    t    h   e    t    i   c   a    l    A    D    H    D  -   r   e    l   a    t   e    d    h   e   a    l    t    h   s    t   a    t   e   s    H   e   a    l    t    h   s    t   a    t   e    S   y   m   p    t   o   m   s    E   v   e   n    i   n   g    /    M   o   r   n    i   n   g   e    ff   e   c    t   s    S   c    h   o   o    l    /    F   a   m    i    l   y    f   u   n   c    t    i   o   n    i   n   g    M   e    d    i   c   a    t    i   o   n  -   r   e    l   a    t   e    d   s    t   a    t   e   m   e   n    t   s    H   e   a    l    t    h   s    t   a    t   e    A        •     N   o   n  -   s    t    i   m   u    l   a   n    t    t   r   e   a    t   m   e   n    t        •     A    d   e   q   u   a    t   e   r   e   s   p   o   n   s   e        •     T   o    l   e   r   a    b    l   e   s    i    d   e   e    ff   e   c    t   s        •     C   a   n   s    t   a   y    f   o   c   u   s   e    d   o   n   m   o   s    t    t   a   s    k   s ,   s   e   e   m   s    t   o    l    i   s    t   e   n ,   a   n    d    i   s   n   o    t   e   a   s    i    l   y    d    i   s    t   r   a   c    t   e    d    d   u   r    i   n   g    t    h   e    d   a   y .        •     D   o   e   s   n   o    t   s   e   e   m    t   o    fi    d   g   e    t   o   r    h   a   v   e    d    i    ffi   c   u    l    t   y   s    i    t    t    i   n   g   s    t    i    l    l   m   o   s    t   o    f    t    h   e    t    i   m   e .        •     D   o   e   s   n   o    t   u   s   u   a    l    l   y    t   a    l    k    t   o   o   m   u   c    h ,   a   n    d   s    /    h   e   c   a   n   p    l   a   y   q   u    i   e    t    l   y .        •     C   a   n   w   a    i    t    f   o   r    h    i   s    /    h   e   r    t   u   r   n   w    i    t    h   o   u    t    i   n    t   e   r   r   u   p    t    i   n   g   o    t    h   e   r   s .        •     U   s   u   a    l    l   y   w   a    i    t   s   u   n    t    i    l   q   u   e   s    t    i   o   n   s    h   a   v   e    b   e   e   n   c   o   m   p    l   e    t   e    d    b   e    f   o   r   e   a   n   s   w   e   r    i   n   g .        •     I   s   u   s   u   a    l    l   y   a    b    l   e    t   o   c   o   m   p    l   e    t   e    h   o   m   e   w   o   r    k   a    f    t   e   r    d    i   n   n   e   r   a   n    d   s   e    t    t    l   e    d   o   w   n    f   o   r    b   e    d   w    i    t    h    l    i    t    t    l   e    d    i    ffi   c   u    l    t   y    i   n    t    h   e   e   v   e   n    i   n   g .        •     G   e    t   s   r   e   a    d   y   w    i    t    h   o   u    t   m   u    l    t    i   p    l   e   r   e   m    i   n    d   e   r   s    i   n    t    h   e   m   o   r   n    i   n   g .        •     C   a   n    f   o   c   u   s   o   n   s   c    h   o   o    l   w   o   r    k   m   o   s    t   o    f    t    h   e    t    i   m   e ,   a   n    d   s    /    h   e    i   s   p   e   r    f   o   r   m    i   n   g   w   e    l    l   a   c   a    d   e   m    i   c   a    l    l   y .        •     I   s   n   o    t    d    i   s   r   u   p    t    i   v   e    i   n    t    h   e   c    l   a   s   s   r   o   o   m .        •     D   o   e   s   n   o    t   u   s   u   a    l    l   y    i   n    t   e   r    f   e   r   e   w    i    t    h    f   a   m    i    l   y   a   c    t    i   v    i    t    i   e   s   o   r    l    i   m    i    t    t    h   e   a   c    t    i   v    i    t    i   e   s   y   o   u   c   a   n    d   o   a   s   a    f   a   m    i    l   y .        •     D   o   e   s   n   o    t   c   a   u   s   e    t   e   n   s    i   o   n    i   n   y   o   u   r    h   o   m   e ,   a   n    d   y   o   u   o   n    l   y    h   a   v   e   o   c   c   a   s    i   o   n   a    l   a   r   g   u   m   e   n    t   s   a   n    d    d    i   s   c    i   p    l    i   n   e   p   r   o    b    l   e   m   s   w    i    t    h   y   o   u   r   c    h    i    l    d .        •     R   e   c   e    i   v   e   s   m   e    d    i   c   a    t    i   o   n    f   o   r    A    D    H    D   o   n   c   e   p   e   r    d   a   y .        •     S   o   m   e    t    i   m   e   s    h   a   s   a   m    i    l    d    l   y   u   p   s   e    t   s    t   o   m   a   c    h   o   r   n   a   u   s   e   a    t    h   a    t    d   o   e   s   n    ’    t    l   a   s    t    l   o   n   g .        •     F   e   e    l   s   a    l    i    t    t    l   e    t    i   r   e    d   o   n   s   o   m   e    d   a   y   s .        •     A   p   p   e    t    i    t   e    h   a   s    d   e   c   r   e   a   s   e    d   a    l    i    t    t    l   e .    H   e   a    l    t    h   s    t   a    t   e    E        •     S    t    i   m   u    l   a   n    t    t   r   e   a    t   m   e   n    t        •     A    d   e   q   u   a    t   e   r   e   s   p   o   n   s   e        •     T   o    l   e   r   a    b    l   e   s    i    d   e   e    ff   e   c    t   s        •     S   a   m   e   a   s    h   e   a    l    t    h   s    t   a    t   e    A   a    b   o   v   e .        •     O    f    t   e   n    h   a   s    d    i    ffi   c   u    l    t   y   c   o   m   p    l   e    t    i   n   g    h   o   m   e   w   o   r    k   a    f    t   e   r    d    i   n   n   e   r   a   n    d   s   e    t    t    l    i   n   g    d   o   w   n    f   o   r    b   e    d    i   n    t    h   e   e   v   e   n    i   n   g .        •     F   r   e   q   u   e   n    t    l   y   n   e   e    d   s   e   x    t   r   a   r   e   m    i   n    d   e   r   s    t   o   g   e    t   r   e   a    d   y    i   n    t    h   e   m   o   r   n    i   n   g .        •     S   a   m   e   a   s    h   e   a    l    t    h   s    t   a    t   e    A   a    b   o   v   e .        •     R   e   c   e    i   v   e   s   m   e    d    i   c   a    t    i   o   n    f   o   r    A    D    H    D   o   n   c   e   p   e   r    d   a   y .        •     H   a   s   a    l    i    t    t    l   e    d    i    ffi   c   u    l    t   y    f   a    l    l    i   n   g   a   s    l   e   e   p ,    b   u    t   g   e   n   e   r   a    l    l   y   s   e   e   m   s   w   e    l    l  -   r   e   s    t   e    d .        •     A   p   p   e    t    i    t   e    h   a   s    d   e   c   r   e   a   s   e    d   a    l    i    t    t    l   e .        •     O   c   c   a   s    i   o   n   a    l    l   y    f   e   e    l   s   a    l    i    t    t    l   e    ‘    ‘   w    i   r   e    d    ’    ’   o   r    ‘    ‘   n   e   r   v   o   u   s .    ’    ’    H   e   a    l    t    h   s    t   a    t   e    J        •     U   n    t   r   e   a    t   e    d    A    D    H    D        •     M   o    d   e   r   a    t   e   s   y   m   p    t   o   m   s   e   v   e   r    i    t   y        •     H   a   s    d    i    ffi   c   u    l    t   y   s   u   s    t   a    i   n    i   n   g   a    t    t   e   n    t    i   o   n    t   o   m   o   s    t    t   a   s    k   s ,    i   s   e   a   s    i    l   y    d    i   s    t   r   a   c    t   e    d ,   a   n    d    f   r   e   q   u   e   n    t    l   y    d   o   e   s   n    ’    t   s   e   e   m    t   o    l    i   s    t   e   n    d   u   r    i   n   g    t    h   e    d   a   y .        •     O    f    t   e   n    fi    d   g   e    t   s   a   n    d   o    f    t   e   n    h   a   s    d    i    ffi   c   u    l    t   y   s    i    t    t    i   n   g   s    t    i    l    l .        •     F   r   e   q   u   e   n    t    l   y    t   a    l    k   s    t   o   o   m   u   c    h ,    h   a   s    d    i    ffi   c   u    l    t   y   p    l   a   y    i   n   g   q   u    i   e    t    l   y ,   a   n    d   r   u   n   s   a   r   o   u   n    d    i   n   s    i    t   u   a    t    i   o   n   s   w    h   e   n    i    t    i   s    i   n   a   p   p   r   o   p   r    i   a    t   e .        •     F   r   e   q   u   e   n    t    l   y    h   a   s    d    i    ffi   c   u    l    t   y   w   a    i    t    i   n   g    h    i   s    /    h   e   r    t   u   r   n ,   a   n    d   m   a   y    i   n    t   e   r   r   u   p    t   o    t    h   e   r   s .        •     O    f    t   e   n    b    l   u   r    t   s   o   u    t   a   n   s   w   e   r   s    b   e    f   o   r   e    t    h   e   q   u   e   s    t    i   o   n   s    h   a   v   e    b   e   e   n   c   o   m   p    l   e    t   e    d .        •     O    f    t   e   n    h   a   s    d    i    ffi   c   u    l    t   y   c   o   m   p    l   e    t    i   n   g    h   o   m   e   w   o   r    k   a    f    t   e   r    d    i   n   n   e   r   a   n    d   s   e    t    t    l    i   n   g    d   o   w   n    f   o   r    b   e    d    i   n    t    h   e   e   v   e   n    i   n   g .        •     F   r   e   q   u   e   n    t    l   y   n   e   e    d   s   e   x    t   r   a   r   e   m    i   n    d   e   r   s    t   o   g   e    t   r   e   a    d   y    i   n    t    h   e   m   o   r   n    i   n   g .        •     H   a   s    d    i    ffi   c   u    l    t   y    f   o   c   u   s    i   n   g   o   n   s   c    h   o   o    l   w   o   r    k ,   w    h    i   c    h    i   n    t   e   r    f   e   r   e   s   w    i    t    h    h    i   s    /    h   e   r   a   c   a    d   e   m    i   c   p   e   r    f   o   r   m   a   n   c   e .        •     I   s    f   r   e   q   u   e   n    t    l   y    d    i   s   r   u   p    t    i   v   e    i   n    t    h   e   c    l   a   s   s   r   o   o   m .        •     O    f    t   e   n    i   n    t   e   r    f   e   r   e   s   w    i    t    h    f   a   m    i    l   y   a   c    t    i   v    i    t    i   e   s   a   n    d    l    i   m    i    t   s    t    h   e   a   c    t    i   v    i    t    i   e   s   y   o   u   c   a   n    d   o   a   s   a    f   a   m    i    l   y .        •     F   r   e   q   u   e   n    t    l   y   c   a   u   s   e   s    t   e   n   s    i   o   n    i   n   y   o   u   r    h   o   m   e ,   a   n    d   y   o   u    f   r   e   q   u   e   n    t    l   y    h   a   v   e   a   r   g   u   m   e   n    t   s   a   n    d    d    i   s   c    i   p    l    i   n   e   p   r   o    b    l   e   m   s   w    i    t    h   y   o   u   r   c    h    i    l    d .        •     I   s   n   o    t   r   e   c   e    i   v    i   n   g   m   e    d    i   c   a    t    i   o   n . 738  The first drafts of the health states were thenpresented to the four physicians during a secondset of interviews. All physicians agreed that thehealth states accurately reflected the typical pro-files with children diagnosed with ADHD as wellas their experience with children treated with eitheratomoxetine or stimulants. Although none of thephysicians suggested changing the content of anyhealth state, each physician suggested at least oneminor edit to the language. These changes weremade, and the final edited versions of the healthstates were used in the parent utility interviews. Utility interview procedure The utility interview followed procedures thathave been established in previous studies that as-sessed patient preferences relating to other medicaland psychiatric conditions [17]. The first step,called the ‘feeling thermometer’ (FT), was a visualanalog scale exercise to familiarize the parents withthe health states. Parents were given a series of laminated cards, each with a description of onehealth state, and they were asked to rate the 11hypothetical health states and their child’s owncurrent health on a 100-point scale ranging fromperfect health (100) to death (0).Next, parents were administered a structuredSG interview in which the hypothetical health statecards were presented to parents one-by-one inrandom order [18, 19]. For each health state,parents were given the choice between having theirchild live in the hypothetical health state for onemonth or accepting a gamble between the perfecthealth state and the worst health state. Probabili-ties of the perfect vs. worst health state gamblewere varied sequentially until the parent wasindifferent about the two options. High probabil-ities of perfect and worst health were alternated toavoid anchoring bias and framing effects. Whenparents completed rating all the hypotheticalhealth states, they rated their child’s own currenthealth using the same procedures.The final step in the SG interview procedure wasto assign a score to the worst health state. Parentswere asked to choose between having the child livein the worst health state or accepting a gamblebetween the perfect health state and death. Duringdata analysis, the raw SG scores were recalibrated Table 2.  ADHD health state utility scores*Standard Gamble – raw Standard Gamble – adjusted Feeling thermometerMean SD Mean SD Mean SDDrug treatment health states(Treatment, Response, Side effects)A: Non-Stimulant, Adequate, Tolerable 0.88 0.10 0.98 0.06 85.4 12.3B: Non-Stimulant, Adequate, Intolerable 0.72 0.19 0.94 0.12 63.9 22.1C: Non-Stimulant, Inadequate, Tolerable 0.59 0.24 0.92 0.13 40.1 20.7D: Non-Stimulant, Inadequate, Intolerable 0.50 0.29 0.90 0.20 32.1 15.4E: Stimulant, Adequate, Tolerable 0.81 0.16 0.96 0.09 77.0 13.3F: Stimulant, Adequate, Intolerable 0.66 0.24 0.92 0.16 50.2 25.4G: Stimulant, Inadequate, Tolerable 0.63 0.23 0.93 0.11 40.1 18.1H: Stimulant, Inadequate, Intolerable 0.52 0.27 0.92 0.14 27.3 16.2Untreated health statesI: Mild ADHD 0.71 0.25 0.95 0.10 62.1 24.7J: Moderate ADHD 0.58 0.27 0.91 0.19 37.7 21.4K: Severe ADHD 0.48 0.28 0.90 0.18 26.1 17.4Child’s own current health state 0.74 0.20 0.96 0.10 60.8 21.0Worst health state 0.83 0.26 – – 12.6 10.8*SG raw scores on a scale ranging from 0 (worst health) to 1 (perfect health), except for the worst health state which is on a scaleranging from 0 (death) to 1 (perfect health). SG adjusted scores and the feeling thermometer scores on a scale ranging from 0 (death) to1 (perfect health). Adjusted scores were derived through a linear transformation of raw scores using the following formula: SG adjustedscore=[SG raw score  ·  (1 ) worst health state score)] + worst health state score. 739
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