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Director's Report to the National Advisory Council on Drug Abuse - May, 2007

Research Findings - Prevention Research

Can Universal Prevention Reduce Substance Use Among Adolescent Substance Users?

Efforts to address youth substance use have focused on prevention among non-users and treatment among severe users with less attention given to youth occupying the middle ground who have used substances but not yet progressed to serious abuse or addiction. Using a sample from 35 middle schools of 1,364 youth who reported using substances, this study examined the effectiveness of a universal youth substance use prevention program, "Keepin' it REAL", in promoting reduced or recently discontinued alcohol, cigarette, and marijuana use. Discrete-time event history methods modeled the rates of reduced and recently discontinued use across four waves of data. Each substance (alcohol, cigarettes, and marijuana) was modeled separately. Beginning at the second wave, participants who reported use at wave 1 were considered in need of reducing or discontinuing use. Since the data sampled students in schools, multi-level models accounted for the nesting of data at the school level. Results indicated that prevention program participation influenced the rates of reduced and recently discontinued use only for alcohol, controlling for baseline use severity, age, grades, socioeconomic status, ethnicity and gender. Among youth who reported use of alcohol in wave 1 (N=1,028), the rate of reducing use for program participants was 72% higher than the rate for control students. The rate of discontinuing use was 66% higher than the rate for control students. Among youth who reported use of one or more of the three substances in wave 1 (N=1,364), the rate of discontinuing all use was 61% higher for program participants than for control students. Limitations and implications of these findings and plans for further research are discussed. Kulis, S., Nieri, T., Yabiku, S., Stromwall, L., and Marsiglia, F. Promoting Reduced and Discontinued Substance Use among Adolescent Substance Users: Effectiveness of a Universal Prevention Program. Prev Sci, 8(1), pp. 35-49, 2007.

Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions

Authors used nationally representative data to examine whether individuals' sexual and drug behavior patterns account for racial disparities in sexually transmitted disease (STD) and HIV prevalence. Data were derived from wave III of the National Longitudinal Study of Adolescent Health. Participants were aged 18 to 26 years old; analyses were limited to non-Hispanic Blacks and Whites. Theory and cluster analyses yielded 16 unique behavior patterns. Bivariate analyses compared STD and HIV prevalence for each behavior pattern, by race. Logistic regression analyses examined within-pattern race effects before and after control for covariates. Unadjusted odds of STD and HIV infection were significantly higher among Blacks than among Whites for 11 of the risk behavior patterns assessed. Across behavior patterns, covariates had little effect on reducing race odds ratios. White young adults in the United States are at elevated STD and HIV risk when they engage in high-risk behaviors. Black young adults, however, are at high risk even when their behaviors are normative. Factors other than individual risk behaviors and covariates appear to account for racial disparities, indicating the need for population-level interventions. Hallfors, D., Iritani, B., Miller, W., and Bauer, D. Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions. Am J Public Health, 97(1), pp. 125-132, 2007.

Preventive Effects Of Treatment Of Disruptive Behavior Disorder In Middle Childhood On Substance Abuse and Delinquent Behavior

Disruptive behavior disorder (DBD) is a well-known risk factor for substance abuse and delinquent behavior in adolescence. Therefore, the long-term preventive effects of treatment of DBD in middle childhood on beginning substance use and delinquency in early adolescence were investigated. Children with DBD (8-13 years old) had been randomly assigned to manualized behavior therapy (Utrecht Coping Power Program; UCPP) or to care as usual (CU) in the Netherlands. Five years (2003-2005) after the start of treatment (1996-1999), substance use and delinquency were monitored in 61 of the initial 77 adolescents and compared with a matched healthy control group by means of self-report questionnaires. One-factor analyses of variance and Pearson's chi2 analyses were performed. Differences in substance use were revealed in favor of the UCPP, with more adolescents in the CU group smoking cigarettes in the last month (UCPP 17%, CU 42%; chi2 = 4.7; p < .03) and more adolescents in the CU group having ever used marijuana (UCPP 13%, CU 35%; chi2 = 4.0; p < .045). Moreover, in this respect, the UCPP fit in the range of the matched healthy control group. Both treatment groups were comparable to the matched healthy control group in delinquent behavior. Manualized behavior therapy for DBD in middle childhood seems to be more powerful than CU in reducing substance use in early adolescence. Both treatment conditions show a beneficial long-term preventive effect on delinquency. Zonnevylle-Bender, M., Matthys, W., Van de Wiel, N., and Lochman, J. Preventive Effects of Treatment of Disruptive Behavior Disorder in Middle Childhood on Substance Use and Delinquent Behavior. J Am Acad Child Adolesc Psychiatry, 46(1), pp. 33-39, 2007.

Implementation Fidelity and Effectiveness of the Reconnecting Youth Program

This paper reports the results of an implementation fidelity study of the Reconnecting Youth (RY) prevention program. The research questions were (i) was the program implemented with fidelity? and (ii) did better fidelity predict better outcomes? RY is an indicated drug abuse prevention program for high school students that seeks to 'reconnect' high risk youth to school before they drop out. The results reported here were part of a randomized controlled effectiveness trial of the RY prevention program conducted in two urban school districts in which 15 teachers taught 41 RY classes. Overall, implementation fidelity was high with an average 90% of core lessons being taught. In a previous study (Cho et al., 2005) researchers reported unexpected negative outcomes of the intervention condition compared to the control condition. In the current study, aspects of implementation quality--program fidelity, adherence to the curriculum and exposure to the program also predicted negative outcomes (e.g., increased alcohol use and anger, bonding to high risk peers). Thus, the negative outcomes were predicted by high implementation fidelity. Results were discussed in terms of group contagion, and several research limitations were discussed. The authors conclude by reiterating the need to study programs within real world contexts to assess whether positive program effects are replicated, and to assess the potential for unintended consequences to occur when programs are adopted. Sanchez, V., Steckler, A., Nitirat, P., Hallfors, D., Cho, H., and Brodish, P. Fidelity of Implementation in a Treatment Effectiveness Trial of Reconnecting Youth. Health Education and Research, 22 (1), pp. 95-107, 2007.

Implementation Fidelity Impacts Prevention Program Outcomes

Implementation fidelity is increasingly recognized as a key component of effective prevention programming. The present study examined the association between implementation fidelity and youth substance use outcomes among students in 11 New York City middle schools receiving a drug abuse prevention program. Trained observers monitored the implementation of a research-based prevention program by classroom teachers (N = 38), and participating students (N = 1,857) completed surveys assessing smoking and alcohol use over a 15-month period. Findings indicated that teachers who relied more on lecturing when teaching the program were less likely to use discussion and demonstration as teaching methods. Teachers who relied on lecturing were rated by observers as being less ready to teach and having poorer classroom management skills. Findings indicated that factors related to the quality of implementation significantly predicted change in student substance use outcomes. Students who were taught by the most skilled providers reported significantly lower increases in smoking and drinking at the follow-up assessments compared to students taught by other providers. Griffin, K.W., Mahadeo, M., Weinstein, J., and Botvin, G.J. Program Implementation Fidelity and Substance Use Outcomes among Middle School Students in a Drug Abuse Prevention Program. Saludy Drogas, 6(1), pp. 9-28, 2006.

The Fast Track Prevention Program is Cost-Effective for Highest Risk Children

This study examined the cost-effectiveness of the Fast Track intervention, a multi-year, multi-component intervention designed to reduce violence among at-risk children. A previous report documented the favorable effect of intervention on the highest-risk group of ninth-graders diagnosed with conduct disorder, as well as self-reported delinquency. The current report addressed the cost-effectiveness of the intervention for these measures of program impact. Costs of the intervention were estimated using program budgets. Incremental cost-effectiveness ratios were computed to determine the cost per unit of improvement in the 3 outcomes measured in the 10th year of the study. Examination of the total sample showed that the intervention was not cost-effective at likely levels of policymakers "willingness to pay" for the key outcomes. Subsequent analysis of those most at risk, however, showed that the intervention likely was cost-effective given specified willingness-to-pay criteria. Results indicate that the intervention is cost-effective for the children at highest risk. From a policy standpoint, this finding is encouraging because such children are likely to generate higher costs for society over their lifetimes. However, substantial barriers to cost-effectiveness remain, such as the ability to effectively identify and recruit such higher-risk children in future implementations. Foster, E., and Jones, D. Can a Costly Intervention Be Cost-Effective? An Analysis of Violence Prevention. Arch Gen Psychiatry, 63(11), pp. 1284-1291, 2006.

The Gap Between Self-Reported STIs and Test-Identified STIs

Many studies rely on respondent reports of prior diagnosed sexually transmissible infections (STIs), but these self reports are likely to under-estimate infection prevalence. The extent of bias from using self-reported STI data, and whether bias varies by sex and race, is largely unknown. This gap is addressed through a cross-sectional analysis of Wave III of the National Longitudinal Study of Adolescent Health. Participants were 18-26 years old (n = 12,359). Estimates of the prevalence of Chlamydia infection based on self-reported diagnoses in the past year were compared with actual prevalence based on nucleic acid amplification testing (NAAT) at the time of data collection. Ratios of test-identified prevalence to self-reported diagnosis prevalence were calculated by sex and race/ethnicity groups. Larger ratios indicate greater extent of self reports under-estimating infection prevalence. About 4.2% of the sample had a current NAAT-identified Chlamydia infection, but only 3.0% reported having been diagnosed with Chlamydia in the past year, yielding a ratio of 1.43. The ratio of test-identified infection prevalence to prevalence identified from self-reported diagnoses was larger among men than women (2.07 versus 1.14, P < 0.05). Among men, the ratio was larger among non-Hispanic blacks (2.40) compared with non-Hispanic whites (1.07, P < 0.05). The authors conclude that the use of self-reported diagnoses underestimates Chlamydia infection prevalence, particularly among men, and among non-Hispanic black men. Reliance on self-reported STIs may consequently lead to biased conclusions, particularly for these groups. Use of biological testing for STIs in research studies is recommended. Iritani, B., Ford, C., Miller, W., Hallfors, D., and Halpern, C. Comparison of Self-Reported and Test-Identified Chlamydia Infections Among Young Adults in The United States of America. Sex Health, 3(4), pp. 245-251, 2006.

Developmental Trajectories and the Analysis of Adolescent Substance Use Data

This study of 498 adolescents examined the covariates of early onset substance use from Grade 6 through Grade 9. The youth were randomly assigned to a family-centered Adolescent Transitions Program condition or a control condition. Variable-centered (i.e., zero-inflated Poisson growth model) and person-centered (latent growth mixture model) approaches were taken to examine treatment effects on patterns of substance use development across early adolescence. Variable-centered analysis revealed treatment effects of the intervention both on decreasing the likelihood of initiating substance use and on the rate of growth of substance use among those who initiated use. Person-centered analyses revealed the following five trajectories of early substance use (1) no use, (2) low/rare use, (3) early accelerating use, (4) late accelerating use, and (5) early high but decreasing use. Of note, random assignment to the ATP intervention was strongly predictive of following the decreasing-use trajectory. In addition, the early high but decreasing group was most likely to engage in the Family Check-Up and linked intervention services. These findings suggest that covariates of early adolescent substance use, as well as the effectiveness of prevention strategies, vary as a function of the developmental pattern underlying early adolescent risk. Connell, A.M., Dishion, T.J., and Deater-Deckard, K. Variable- and Person- Centered Approaches to the Analysis of Early Adolescent Substance Use: Linking Peer, Family, and Intervention Effects with Developmental Trajectories. Merrill-Palmer Quarterly, 52(3), pp. 421-448, 2006.

Planned Missing Data Designs in Psychological Research

The authors describe 2 efficiency (planned missing data) designs for measurement: the 3-form design and the 2-method measurement design. The 3-form design, a kind of matrix sampling, allows researchers to leverage limited resources to collect data for 33% more survey questions than can be answered by any 1 respondent. Power tables for estimating correlation effects illustrate the benefit of this design. The 2-method measurement design involves a relatively cheap, less valid measure of a construct and an expensive, more valid measure of the same construct. The cost effectiveness of this design stems from the fact that few cases have both measures, and many cases have just the cheap measure. With 3 brief simulations involving structural equation models, the authors show that compared with the same-cost complete cases design, a 2-method measurement design yields lower standard errors and a higher effective sample size for testing important study parameters. With a large cost differential between cheap and expensive measures and small effect sizes, the benefits of the design can be enormous. Strategies for using these 2 designs are suggested. Graham, J., Taylor, B., Olchowski, A., and Cumsille, P. Planned Missing Data Designs in Psychological Research. Psychol Methods, 11(4), pp. 323-343, 2006.

Multidimensional Treatment Foster Care For Girls in the Juvenile Justice System: Two Year Follow-Up of a Randomized Clinical Trial

This study is a 2-year follow-up of girls with serious and chronic delinquency who were enrolled in a randomized clinical trial conducted from 1997 to 2002 comparing multidimensional treatment foster care (MTFC) and group care (N = 81). Girls were referred by juvenile court judges and had an average of over 11 criminal referrals when they entered the study. A latent variable analysis of covariance model controlling for initial status demonstrated maintenance of effects for MTFC in preventing delinquency at the 2-year assessment, as measured by days in locked settings, number of criminal referrals, and self-reported delinquency. A latent variable growth model focusing on variance in individual trajectories across the course of the study also demonstrated the efficacy of MTFC. Older girls exhibited less delinquency over time relative to younger girls in both conditions. Implications for gender-sensitive programming for youths referred from juvenile justice are discussed. Chamberlain, P., Leve, L., and Degarmo, D. Multidimensional Treatment Foster Care for Girls in the Juvenile Justice System: 2-Year Follow-up of a Randomized Clinical Trial. J Consult Clin Psychol, 75(1), pp. 187-193, 2007.

Feasibility of Motivational Interviewing for Addressing Drug Use Among High-Risk Teens

Prevention of substance abuse among adolescents may require multiple strategies. Universal prevention programs administered in school classrooms are effective for many students, but those adolescents who use moderate to heavy amount of drugs may benefit from other approaches. Heavy and problem drinkers, for example, have been shown to be less interested in traditional school-based programs and many appear to have limited motivation to change their behavior. A brief, one-to-one intervention based upon motivational interviewing may provide an additional intervention tool that could be used to address the needs of such high-risk students. The aim of the current study was to evaluate the feasibility and preliminary effects of an MI approach at continuation high school sites. Participants were recruited from three morning classes at two continuation high schools in the greater Los Angeles area. Continuation high schools enroll students who are unable to attend regular high schools for various reasons including conduct problems and drug use. A total of 18 students (6 female; 12 males) participated in this pilot study. Eleven students were randomly assigned to the intervention group and 7 were randomly assigned to the control group. Those assigned to the intervention group met with one of two motivational interviewers. All participants assigned to the treatment group were willing to discuss their personal drug use. Five participants chose to discuss marijuana, four chose alcohol, one chose ecstasy, and one chose methamphetamine. This pilot study demonstrated that it is feasible to administer brief individualized interventions on alternative high school campuses to students who are at risk of substance abuse. Students actively participated in brief motivational interviews and showed some improvement in five of nine outcomes at three-month follow-ups. Grenard, J., Ames, S., Wiers, R., Thush, C., Stacy, A., and Sussman, S. Brief Intervention for Substance use Among At-Risk Adolescents: A Pilot Study. J Adolesc Health, 40(2), pp. 188-191, 2007.

Neighborhood Effects on Prevention Program Efficacy

This study examines how neighborhood characteristics affect program efficacy through an analysis of data from a randomized prevention trial. The prevention program, called "Keepin' it REAL", was administered to a predominantly Mexican American sample of 4,622 middle school students in Phoenix, Arizona, beginning in 1998. The program was designed to extend evidence-based resistance and life-skills prevention approaches to incorporate ethnically appropriate traditional values and practices that promote protection against drug use. Thirty-five middle schools were randomized to one of two culturally grounded prevention conditions or a control condition. Prior research supports the overall efficacy of the prevention program. However, among less linguistically accultured Latinos, living in poorer neighborhoods and in single-mother families decreased program effectiveness in reducing alcohol use. High neighborhood immigrant composition increased program effectiveness. Unexpectedly, the program was also more effective in neighborhoods with higher rates of crime. Yabiku, S., Kulis, S., Marsiglia, F.F., Lewin, B., Nieri, T., and Hussaini, S. Neighborhood Effects on the Efficacy of a Program to Prevent Youth Alcohol Use. Subst Use Misuse, 42 pp. 65-87, 2007.

Training Active Drug Users as Peer Health Advocates

Efforts have expanded to create AIDS prevention programs for drug users that consider the social context and interpersonal relationships within which risky practices take place. The Risk Avoidance Partnership (RAP) project is designed to train active drug users as peer/public health advocates (PHAs) to bring a structured, peer-led intervention into the sites where they and their drug-using social networks use illicit drugs. The RAP peer health advocacy training curriculum and peer-led intervention promote harm reduction among drug users and support drug-user organization to reduce infectious disease and other harm in the context of injection drug use, crack cocaine use, and sexual activity. Initial findings suggest that RAP PHAs perceive a significant positive role change in themselves while conducting health advocacy work and willingly and successfully carry the peer-led intervention into locations of high-risk drug activity to deliver it to their peers even in the absence of project staff support. Weeks, M.R., Dickson-Gomez, J., Mosack, K.E., Convey, M., and Martinez, M. The Risk Avoidance Partnership: Training Active Drug Users as Peer Health Advocates. Journal of Drug Issues, Summer, pp. 541-554, 2006.

Suicidality, School Dropout, and Reading Problems Among Adolescents

The purpose of this study was to examine the risk of suicidal ideation and suicide attempts and school dropout among youth with poor reading in comparison to youth with typical reading (n = 188) recruited from public schools at the age of 15. In a prospective naturalistic study, youth and parents participated in repeated research assessments to obtain information about suicide ideation and attempts, psychiatric and sociodemographic variables, and school dropout. Youth with poor reading ability were more likely to experience suicidal ideation or attempts and more likely to drop out of school than youth with typical reading, even after controlling for sociodemographic and psychiatric variables. Suicidality and school dropout were strongly associated with each other. Prevention efforts should focus on better understanding the relationship between these outcomes, as well as on the developmental paths leading up to these behaviors among youth with reading difficulties. Daniel, S., Walsh, A., Goldston, D., Arnold, E., Reboussin, B., and Wood, F. Suicidality, School Dropout, and Reading Problems Among Adolescents Journal of Learning Disabilities, 39(6), pp. 507-514, 2006.

Adolescent Predictors of Emerging Adult Sexual Patterns

This study estimates the percentages of young adults who fall into three groups based on the context of sexual transition: (1) those who had vaginal intercourse before marriage (Premaritals), (2) those who postponed sex until after marriage (Postponers), and (3) those who have never had vaginal intercourse (Virgins). The second purpose was to determine adolescent biopsychosocial factors that predict membership in these adult groups. Analyses are based on 11,407 respondents ages 18-27 years who participated in Waves I and III of the National Longitudinal Study of Adolescent Health. Adolescent indicators reflecting sociodemographic, biosocial, experiential, and contextual factors were used to predict young adult sexual status using multinomial logistic regression models. About 8% of the sample were virgins and 2% were virgins until marriage. Almost 90% had sex before marriage (Premaritals--referent group). Most predictors of status were similar for males and females. Compared with Premaritals, Virgins were younger, non-Black, not advanced in physical maturity relative to peers in adolescence, had higher body mass indexes, were more religious, and perceived parental disapproval of sex during adolescence. Postponers were also more religious than Premaritals but were older. Female Postponers were non-Black and perceived parental disapproval of sex during adolescence. Male Postponers were less likely to have same-gender attractions or no sexual attractions. Findings document premarital sexual activity as the almost universal sexual trajectory into young adulthood for these cohorts and underscore the roles of biosocial factors and conventional institutions in emerging sexual patterns. Halpern, C., Waller, M., Spriggs, A., and Hallfors, D. Adolescent Predictors of Emerging Adult Sexual Patterns. J Adolesc Health, 39(6), pp. e1-e10, 2006.

Drug Abuse Risk and Protective Factors among Black Urban Adolescent Girls: A Group-randomized Trial of Computer-delivered Mother-daughter Intervention

A group-randomized design tested a mother-daughter intervention in which researchers aimed to increase protective factors in a community sample of Black urban adolescent girls. Girls and their mothers at 2 community agencies were pretested and, by agency, were randomized to either an intervention arm or a control arm. Intervention arm girls and their mothers received a program for improving mother- daughter rapport. Posttest data collected 3 weeks after program delivery revealed that intervention arm mothers and daughters improved more than did control arm mothers and daughters on measures of communication and closeness. At 3-month follow-up, intervention arm mothers, relative to control arm mothers, continued to report better communication with and closeness to their daughters. Girls and mothers in the intervention arm rated the computer program favorably on parameters of enjoyment, comfort, relevance, usefulness of information, improvements to their relationship with one another, and whether they would recommend the computer program to friends. Schinke, S., Di Noia, J., Schwinn, T., and Cole, K. Drug Abuse Risk and Protective Factors among Black Urban Adolescent Girls: A Group-Randomized Trial of Computer-Delivered Mother-Daughter Intervention. Psychol Addict Behav, 20(4), pp. 496-500, 2006.

Deviant Peer Affiliation Predicts Depressive Symptoms in High-risk Adolescents

This study examined peer predictors of variation and growth in depressed mood among high-risk adolescents, using child and parent reports of monthly symptoms. One hundred seventy-six parents and their 10- to 14-year-old children separately took part in a series of up to nine monthly interviews. Multilevel growth models examined both time-varying peer predictors of parent and child reports of the child's depressive symptoms, controlling for age, gender, and treatment status. Deviant peer affiliation significantly predicted elevated depressive symptoms in the monthly child-report of depressed mood, especially for younger adolescents. Children's level of delinquency was significantly related to parent-reported depressive symptoms, and to child-reported symptoms in older adolescents only. As expected, depressed mood was higher for girls and more prevalent among older adolescents. The results suggest that peer processes may be linked in time to the development of depression, especially among high-risk adolescents. Connell, A., and Dishion, T. The Contribution of Peers to Monthly Variation in Adolescent Depressed Mood: A Short-term Longitudinal Study with Time-varying Predictors. Dev Psychopathol, 18(1), pp. 139-154, 2006.

Relationship Between Substance Use and Sexual Risk in South African Students

Authors examined the co-variation of substance use and various sexual behaviors in students from one area of South Africa. Data were collected from 2204 eighth grade students from nine schools in a low-income, predominantly colored township as a part of baseline data collection for a randomized trial of a drug abuse and HIV prevention program. Twelve percent of the sample had ever had sexual intercourse. There was an association between lifetime substance use and lifetime sexual activity. Sexually active youth who had used alcohol and/or marijuana in their lifetimes were more likely to report sporadic condom use and more likely to report having had multiple sexual partners in the preceding six months. Youth who used alcohol or marijuana during their last sexual encounter were more likely to have just met their partner, but they were as likely to use condoms as youth who had not used these substances. Palen, L., Smith, E., Flisher, A., Caldwell, L., and Mpofu, E. Substance Use and Sexual Risk Behavior among South African Eighth Grade Students. J Adolesc Health, 39(5), pp. 761-763, 2006.

Immigration Status, Sexual Behavior and Drug Use

This paper contributes new evidence on the association between immigrant status and health by describing and attempting to explain patterns of co-occurring sex and drug use behaviors among Asian and Latino adolescents in the United States. Nine patterns of sex and drug use behaviors were identified from a cluster analysis of data from 3,924 Asian and Latino youth (grades 7-12) who participated in the National Longitudinal Study of Adolescent Health (Add Health). The relationship between immigrant status and risk cluster membership was evaluated with multinomial logistic regression. Compared to foreign-born youth, U.S. born Asian and Latino adolescents were more likely to engage in sex and drug risk behaviors. Family and residential characteristics associated with immigrant status partly accounted for this finding. The results indicate that among Asian and Latino adolescents, assimilation to U.S. risk behavior norms occurs rapidly and is evident by the second generation. Implications for screening, prevention and intervention are discussed. Hussey, J., Hallfors, D., Waller, M., Iritani, B., Halpern, C., and Bauer, D. Sexual Behavior and Drug Use Among Asian and Latino Adolescents: Association with Immigrant Status. J Immigr Minor Health, 9(2), pp. 85-94, 2007.

The Cost of ADHD

Using a cost of illness (COI) framework, this article examines the economic impact of attention-deficit/hyperactivity disorder (ADHD) in childhood and adolescence. This review of published literature identified 13 studies, most conducted on existing databases by using diagnostic and medical procedure codes and focused on health care costs. Two were longitudinal studies of identified children with ADHD followed into adolescence. Costs were examined for ADHD treatment-related and other health care costs (all but 1 study addressed some aspect of health care), education (special education, 2 studies; disciplinary costs: 1 study), parental work loss (2 studies), and juvenile justice (2 studies). Based on this small and as yet incomplete evidence base, authors estimated annual COI of ADHD in children and adolescents at $14,576 per individual (2005 dollars). Given the variability of estimates across studies on which that number is based, a reasonable range is between $12,005 and $17,458 per individual. Using a prevalence rate of 5%, a conservative estimate of the annual societal COI for ADHD in childhood and adolescence is $42.5 billion, with a range between $36 billion and $52.4 billion. Estimates are preliminary because the literature is incomplete; many potential costs have not been assessed in extant studies. Limitations of the review and suggestions for future research on COI of ADHD are provided. Pelham, W., Foster, E., and Robb, J. The Economic Impact of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Ambul Pediatr, 7(1 Suppl), pp. 121-131, 2007.

Perceived Smoking Environment and Smoking Initiation Among Multi-ethnic Urban Girls

The purpose of this study was to examine associations between the perceived smoking environment and smoking initiation among urban multi-ethnic adolescent girls in New York City. Self-report surveys completed in grades 7, 8, and 9 assessed girls '' (n = 858) smoking initiation, and perceived smoking environment (family smoking, friends' smoking, smoking norms, and cigarette availability). Carbon monoxide breath samples were collected from girls using a variation of the bogus pipeline procedure. Differences were found in smoking prevalence with white girls reporting the highest prevalence of smoking at baseline and greatest increase in smoking prevalence from seventh to eighth grade. Black girls reported an initial increase in smoking prevalence from seventh to eighth grade followed by a decrease from eighth to ninth grade. Family smoking, friends' smoking, smoking norms, and cigarette availability were all associated with smoking initiation at eighth grade but only friends' smoking was associated with smoking initiation at ninth grade. Few ethnic differences were found in risk factors at baseline and racial/ethnic group did not modify associations between risk and smoking initiation. Urban adolescent girls of different racial/ethnic backgrounds had similar perceptions of the smoking environment. Despite the similarity of risk factors across racial/ethnic groups, urban white girls are at increased risk to initiate smoking. Preventive interventions that target girls' perceived smoking environment during early adolescence should be effective across ethnic groups. Nichols, T., Birnbaum, A., Birnel, S., and Botvin, G. Perceived Smoking Environment and Smoking Initiation among Multi-Ethnic Urban Girls. J Adolesc Health, 38(4), pp. 369-375, 2006.

Perceived Physical Maturity, Age of Romantic Partner, and Adolescent Risk Behavior

Early pubertal timing and advanced physical maturity for age confer elevated risk for problem behaviors for both boys and girls. However, examinations of possible biological and social mediators have been limited. Using more than 4,000 adolescents under age 15 who participated in Waves I and II of the National Longitudinal Study of Adolescent Health (Add Health), authors examined the relationship between perceived physical maturity and membership in risk behavior clusters, and tested whether having a romantic partner mediates the maturity/risk behavior relationship. Results of multinomial regression models indicated that for both boys and girls, advanced physical maturity was associated with membership in higher risk clusters, and that having a romantic partner plays an important mediating role in this association. For females, the additional impact of having an older partner, versus any partner at all, was substantial and particularly important for the highest risk clusters. The role of partner age could not be tested for males. Because romantic partners elevate risk for young adolescent males and females, there is a need to identify and understand facets and developmental functions of adolescent romantic relationships that play a role in substance use and sexual decisions. Halpern, C., Kaestle, C., and Hallfors, D. Perceived Physical Maturity, Age of Romantic Partner, and Adolescent Risk Behavior. Prevention Science, 8(1), pp. 1-10, 2006.

Predictors of Engagement and Retention in Parent-Centered Prevention

This study examined predictors of engagement and retention into a parent-centered, ecodevelopmental HIV preventive intervention for Hispanic adolescents and their families. The influence of retention on changes in adolescent HIV-risk attitudes was also examined. Participants in this study were 91 Hispanic adolescents and their primary parents. Structural equation modeling was used to identify predictors of initial engagement, the effects of group processes on retention, and the effects of retention on change in HIV-risk attitudes in adolescents. Although some participant characteristics predicted engagement, the parent-facilitator relationship quality at the initial contact was found to be the strongest predictor of engagement. Furthermore, within-group processes such as group cohesion positively predicted retention. Finally, parent retention predicted decreases in adolescent HIV-risk attitudes. The results may have important implications for engagement and retention in parent-centered interventions, as well as for reducing risks for HIV transmission in Hispanic adolescents. Prado, G., Pantin, H., Schwartz, S., Lupei, N., and Szapocznik, J. Predictors of Engagement and Retention into a Parent-Centered, Ecodevelopmental HIV Preventive Intervention for Hispanic Adolescents and their Families. J Pediatr Psychol, 31(9), pp. 874-890, 2006.

Targeting Adolescents' Norm-Related Beliefs About Marijuana Use

The integrative model of behavior prediction and priming theory were used to evaluate the effects of anti-marijuana advertisements in an experimental context. In 1 original study and 2 replications, 435 adolescents (42% male; mean age 15.2 years) were randomly assigned to condition, and those in the experimental condition viewed 3 ads that challenged undesirable normative beliefs about marijuana use. Results showed that ad exposure had small but positive (antidrug) effects on adolescents' considerations of the outcomes of using marijuana and their perceptions of the social normative climate surrounding marijuana use. These findings suggest that the normative ads used in this study were able to bring about some desirable changes in adolescents' considerations of using marijuana and their perceptions of the social normative climate surrounding marijuana use. Unfortunately, these changes were not strong enough to translate into statistically significant differences in the more proximal determinants of behavior (i.e., intention, attitude, subjective norm, and self-efficacy). Priming effects also were observed but generally ran counter to predictions. Such findings should be evaluated within the context of a general appreciation of the difficulty involved in persuading adolescents not to use marijuana. The evaluations of the National Youth Antidrug Media Campaign, for example, have shown either no effects or effects in an unfavorable direction over the course of the campaign. Zhao, X., Sayeed, S., Cappella, J., Hornik, R., Fishbein, M., and Ahern, K.R. Targeting Norm-Related Beliefs About Marijuana Use in an Adolescent Population. Health Commun, 19(3), pp. 187-196, 2006.

Synergistic Effect of Anti-Drug Ad Campaign & ALERT Plus Program

This analysis examined the possible synergistic effect of exposure to the National Youth Anti-Drug Media Campaign and a classroom-based drug prevention curriculum among 9th grade students participating in a randomized trial of ALERT Plus. A total of 45 South Dakota high schools and their middle-school feeder(s) were randomly assigned to an ALERT condition (basic prevention curriculum delivered in 7th and 8th grades), an ALERT Plus condition (basic curriculum with booster lessons added for 9th and 10th grades), or a control condition. Marijuana use in the past month was significantly less likely among ALERT Plus students reporting at least weekly exposure to anti-drug media messages. The National Youth Anti-Drug Media Campaign may have led to reductions in marijuana use among youth who simultaneously received school-based drug prevention. Longshore, D., Ghosh-Dastidar, B., and Ellickson, P. National Youth Anti-Drug Media Campaign and School-Based Drug Prevention: Evidence for a Synergistic Effect in ALERT Plus. Addict Behav, 31(3), pp. 496-508, 2006.

Who Benefited from an Efficacious Intervention for Youth Living with HIV: A Moderator Analysis

An efficacious intervention that results in young people living with HIV (YPLH) reducing their transmission risk has been identified. The present study identifies who is most likely to benefit from the intervention. Regression models were used to examine whether background contextual factors moderated the intervention's success. Percentage of protected sex was moderated by ethnicity, use of antiretroviral medications (ARV), healthcare utilization and mental health. Number of partners was moderated by anxiety and depression. When deciding if an intervention is appropriate and beneficial for an individual young person, consideration must be given to type of services the youth currently accesses and the youth's mental health. Lightfoot, M., Tevendale, H., Comulada, W. and Rotheram-Borus, M. Who Benefited From an Efficacious Intervention For Youth Living with HIV: A Moderator Analysis. AIDS Behav, 11(1), pp. 61-70, 2007.

Effects of School Social Climate on Student Alcohol Use

The school is a primary context for social interaction, cultivation of interpersonal skills, formation of peer groups, self-expression, and development of self. Several studies have demonstrated that the social context of the school has important implications for determining the likelihood that an adolescent will follow a prosocial path through adolescence as opposed to becoming involved in delinquent behavior. Using a data set of 4,216 youth who participated in a prevention trial in 32 middle schools and junior high schools across the United States, this paper examines the effect of a student's own level of school attachment as well as the contextual level of school attachment (the normative level of school attachment in a school) on 5 alcohol-related measures: recent use of alcohol, intention to use alcohol, normative beliefs about peer use of alcohol, attitudes toward alcohol use, and aspirations consistent with alcohol use. The data used in this paper represent the pretest assessment before any interventions were implemented. The results indicated that regardless of a student's own level of school attachment, students who attended schools where the pupils overall tended to be well attached to school were less likely to use alcohol. In addition, they also had lower intentions to use alcohol, perceived that fewer of their peers at school use alcohol, and more strongly held aspirations that were inconsistent with alcohol use. These findings, along with the findings of related studies, provide support for the hypothesis that improvement of school climate may result in less substance use among students. Henry, K., and Slater, M. The Contextual Effect of School Attachment on Young Adolescents' Alcohol Use. J Sch Health, 77(2), pp. 67-74, 2007.

Adolescent Girls Offending and Health-Risking Sexual Behavior: The Predictive Role of Trauma

Several studies have highlighted high levels of risk for girls who have been exposed to traumatic experiences, but little is known about the exact relationship between traumatic experiences and problems with delinquency and health-risking sexual behavior (e.g., precipitory and/or exacerbatory roles). However, numerous short- and long-term detrimental effects have been linked to trauma, delinquency, and health-risking sexual behavior. The utility of diagnostic and experiential trauma measures in predicting the greatest risk for poor outcomes for delinquent girls was examined in this study. Results indicate that the experiential measures of trauma (cumulative and composite trauma scores) significantly predicted adolescent offending and adolescent health-risking sexual behavior, whereas the diagnostic measures of trauma (full and partial diagnostic criteria) did not. Smith, D., Leve, L.D., and Chamberlain, P. Adolescent Girls' Offending and Health-Risking Sexual Behavior: The Predictive Role of Trauma. Child Maltreat, 11, pp. 346-353, 2006.

Spirituality as One-Year Predictor of Drug Use Among High Risk Youth

The present article explored two different dimensions of spirituality that might tap negative and positive relations with adolescent drug use over a 1-year period. Non-drug-use-specific spirituality measured how spiritual the person believes he or she is, participation in spiritual groups, and engagement in spiritual practices such as prayer, whereas drug-use-specific spirituality measured using drugs as a spiritual practice. Self-report questionnaire data were collected during 1997-1999 from a sample of 501 adolescents in 18 continuation high schools across southern California. Participants ranged in age from 14 to 19 and were 57% male, with an ethnic distribution of 34% White, 49% Latino, 5% African American, 7% Asian, and 5% other. A series of general linear model analyses were conducted to identify whether or not two different spirituality variables predict drug use (cigarettes, alcohol, marijuana, hallucinogens, and stimulants) at 1-year follow-up. After controlling for baseline drug use, non-drug-use-specific spirituality was negatively predictive of alcohol, marijuana, and stimulant use, whereas drug-use-specific spirituality failed to be found predictive of these variables one year later. Conversely, drug-use-specific spirituality was positively predictive of cigarette smoking and hallucinogen use, whereas non-drug-use spirituality failed to be found predictive of these variables. These results provide new evidence that suggests that spirituality may have an effect on drug use among adolescents. The drug-use-specific measure of spirituality showed "risk effects" on drug use, whereas the other measure resulted in "protective effects," as found in previous research. Knowledge of the risk and protective patterns and mechanisms of spirituality may be translated into future drug use prevention intervention programs. Sussman, S., Skara, S., Rodriguez, Y., and Pokhrel, P. Non Drug Use- and Drug Use-specific Spirituality as One-year Predictors of Drug Use Among High-Risk Youth. Subst Use Misuse, 41(13), pp. 1801-1816, 2006.

Brief Interventions for Behavior Change

This theoretical discussion addresses the potential of brief intervention (BI) as a modality for translating health behavior intervention research into practice. A brief intervention is any intervention that is purposely limited in the number and length of contacts and provides personalized information designed to increase motivation to improve health-related behavior. Systematic reviews of BIs have been conducted that demonstrate their potential applications across disease conditions. Findings from 13 systematic reviews of BI effects are described by the authors. Basic research on motivation, decision making, and persuasion may be applied to the design of BIs (Type 1 translation). Suggestions for translating BI research into practice (Type 2 translation) are discussed by the authors. The article concludes that efforts to use BIs to translate research into practice are currently underdeveloped. Recommendations are provided for using BI in translating research into practice. Werch, C., Grenard, J., Burnett, J., Watkins, J., Ames, S., and Jobli, E. Translation as a Function of Modality: The Potential of Brief Interventions. Eval Health Prof, 29(1), pp. 89-125, 2006.

Reading Problems, Psychiatric Disorders, and Functional Impairment from Mid to Late Adolescence

The goal of this study was to examine psychiatric morbidity and functional impairment of adolescents with and without poor reading skills during mid- to late adolescence. The sample consisted of 188 adolescents, 94 with poor reading skills and 94 with typical reading skills, screened from a larger sample in the public schools at age 15. To assess psychiatric disorders, participants were assessed annually with the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version (up to 4.5 years; maximum age, 20 years). Functional impairment was assessed with the Child and Adolescent Functional Assessment Scale. Adolescents with poor reading skills evidenced higher rates of current attention-deficit/ hyperactivity, affective, and anxiety disorders, particularly social phobia and generalized anxiety disorder. Anxiety disorders but not affective disorders were related to reading status after controlling for attention-deficit/hyperactivity disorder. Adolescents with poor reading evidenced more functional impairment across multiple areas than youths with typical reading skills, even after considering the presence of comorbid attention-deficit/hyperactivity disorder. The increased psychiatric morbidity and functional impairment of adolescents with reading problems highlight the importance of developing interventions that help these youths address reading deficits and associated vulnerabilities during the last years of secondary school. Goldston, D., Walsh, A., Mayfield Arnold, E., Reboussin, B., Sergent Daniel, S., Erkanli, A., Nutter, D., Hickman, E., Palmes, G., Snider, E., and Wood, F. Reading Problems, Psychiatric Disorders, and Functional Impairment from Mid- to Late Adolescence. J Am Acad Child Adolesc Psychiatry, 46(1), pp. 25-32, 2007.

Oppositional Defiant Disorder Toward Adults and Oppositional Defiant Disorder Toward Peers: Initial Evidence for Two Separate Constructs

Confirmatory factor analysis of 25 items on the Child and Adolescent Disruptive Behavior Inventory (CADBI, Version 2.3; G. L. Burns, T. K. Taylor, & J. C. Rusby, 2001) was conducted on teacher ratings of 824 kindergarten children and replicated on 534 children. Model fit was improved when correcting for 2 method effects: (a) adjacent items and (b) identical behaviors (e.g., argues with adults, argues with peers). The results show that the 25 items loaded on 3 distinct but correlated factors: Hyperactivity, Oppositional to Adults, and Oppositional to Peers. These more refined constructs from the CADBI may be useful for practitioners in identifying children who are at risk and for helping define appropriate contexts in which to intervene. The CADBI and analytic procedures also may contribute to future psycho educational research on the development of problem behavior. Taylor, T., Burns, G., Rusby, J., and Foster, E. Oppositional Defiant Disorder toward Adults and Oppositional Defiant Disorder toward Peers: Initial Evidence for Two Separate Constructs. Psychol Assess, 18(4), pp. 439-443, 2006.

The Relationship Between Cultural Practices and Commonly Used Markers of Acculturation

The current study was conducted to ascertain the validity of two commonly used markers of acculturation (nativity and years in the receiving culture). Relationships between these markers and a bidimensional measure of acculturation were examined in a convenience sample of Hispanic immigrant adolescents and their caregivers in Miami. Nativity was examined using adolescent-reported data; approximately half of the youth were U.S.-born and half foreign-born, but all of the caregivers were foreign-born. Years in the receiving culture was examined using both adolescent and caregiver data. Results indicated that nativity was significantly associated with adoption of receiving-culture practices, with a small to moderate effect size. Years in the receiving culture was significantly associated with adoption of receiving-culture practices only for adolescent girls and for female caregivers who immigrated as youth. Neither nativity nor years in the receiving culture explained even moderate amounts of variance in retention or loss of culture-of-origin practices. Schwartz, S.J., Pantin, H. and Sullivan, S. Nativity and Years in the Receiving Culture as Markers of Acculturation in Ethnic Enclaves. J Cross Cult Psychol, 37(3), pp. 345-353, 2006.

Research on the Caretaking of Children of Incarcerated Parents: Findings and Their Service Delivery Implications

This paper reviews research findings on caretaking-related problems associated with the absence of parents from the home following incarceration. It focuses on the impact of incarceration on the welfare and adjustment of urban African American children and on the assumption of caretaking responsibilities by other caretakers, principally maternal grandmothers. Noting the complex situational difficulties involved and the potential burdens associated with surrogate parenting in general, and with this population in particular, the service-provider implications of this parenting arrangement are considered in this review. Findings indicate that problems associated with incarceration of parents tend to be intergenerational and vary considerably in complexity and severity. To the extent that they impact the children involved, these issues should be addressed in coordinated service delivery focusing on prevention. Hanlon, T.E., Carswell, S.B., and Rose, M. Research on the Caretaking of Children of Incarcerated Parents: Findings and Their Service Delivery Implications. Child and Youth Services Review, 29(3), pp. 348-362, 2006.

Prenatal Care Providers Differ in Approaches to Preventing Substance Use Risk During Pregnancy

This study explored prenatal care providers' methods for addressing four behavioral risks in their pregnant patients: alcohol use, smoking, drug use, and domestic violence. Qualitative, purposively sampled, focus group data were used. Groups met in professional focus group settings. Six focus groups (five with OB/GYN physicians, one with nurse practitioners and certified nurse midwives), with a total of N = 49 were conducted. The moderator used a focus group guide with open-ended questions, with probes where appropriate. Results demonstrated that providers' discussions reflected differences in how they approach each risk, including: (1) ambivalence about abstinence messages for alcohol; (2) relative comfort and confidence about assessing smoking and counseling to reduce smoking; (3) disparities across practice settings for toxicology screening for drugs; and (4) discomfort and pessimism with domestic violence. Investigators also analyzed providers' statements for each risk within the framework of the "Five A's" construct (Assess, Advise, Agree, Assist, and Arrange) for evaluating risk behavior interventions. A comparison of each risk across the Five A's illuminates the gaps between recommended and actual prevention methods and suggests directions for development of interventions and educational efforts. Herzig, K., Huynh, D., Gilbert, P., Danley, D., Jackson, R., and Gerbert, B. Comparing Prenatal Providers ' Approaches to Four Different Risks: Alcohol, Tobacco, Drugs, and Domestic Violence. Women Health, 43(3), pp. 83-101, 2006.

Sex Differences in Overt Aggression and Delinquency

Given the recent debate over whether differential pathways to overt aggression and delinquency exist between boys and girls, this study examined sex differences in overt aggressive and delinquent acts along with potential differences in precursors (anger, self-control, family disruption) to antisocial behaviors among a sample of urban minority adolescents (N = 1559). Overall the sample was 54% girls, 47% African American, 27% Latino/Hispanic, 5% Asian American, 7% Caucasian, and 13% biracial or other race/ethnicity. Almost all of the students (85%) attended public schools. Using a longitudinal design with data from 6th to 7th grade, results showed that girls had greater increases in rates of aggression relative to boys. Delinquency increased over time for both boys and girls, with boys consistently engaging in more delinquency. Girls and boys did not differ on the level of risk factors experienced except for a greater increase in anger over time for girls relative to boys. Across sex, anger and self-control predicted increases in both overt aggression and delinquency; family disruption also predicted increases in delinquency. Implications for subsequent studies on developmental process and preventive interventions are discussed. Nichols, T.R., Graber, J.A., Brooks-Gunn, J., and Botvin, G.J. Sex Differences in Overt Aggression and Delinquency Among Urban Minority Middle School Students. Applied Developmental Psychology, 27, pp. 78-91, 2006.

Effects of the Strengthening Washington DC Families Project

The Strengthening Washington DC Families study examined implementation fidelity and effectiveness of a selective, evidence-based prevention program implemented with a sample of 715 predominantly African American families. The prevention program, based on cognitive-behavioral and family systems theories, was designed to reduce child antisocial behavior and its precursors. Families were randomized to four conditions: child skills training only, parent skills training only, parent and child skills training plus family skills training, and minimal treatment control. Major challenges with recruitment and retention of participants and uneven program coverage were experienced. No statistically significant positive effects for any of the program conditions were observed, and a statistically significant negative effect on child reports of Negative Peer Associations was observed for children of families assigned to the family skills training condition. Two marginally significant findings were observed: Child's positive adjustment favored families assigned to family skills training condition relative to minimal treatment and child training only, and family supervision and bonding was lower for children in family skills training than in the other three conditions. Despite its lack of effects, this work provides important lessons for the implementation of family-based prevention. Gottfredson, D., Kumpfer, K., Polizzi-Fox, D., Wilson, D., Puryear, V., Beatty, P., and Vilmenay, M. The Strengthening Washington D.C. Families Project: A Randomized Effectiveness Trial of Family-based Prevention. Prev Sci, 7(1), pp. 57-74, 2006.

Latino Students Perceptions of School Environment

This study describes results from an investigation of Latino students attending a Hispanic Education Summit (HES) in North Carolina. Findings from data gathered from 275 middle and high school students are presented (n= 142 female; n = 121 male). Self-report data assessed level of acculturation, as well as students' perceptions with regard to a variety of issues, including school programs, barriers to participation in programs, problems in the school environment, and academic aspirations. Results revealed that students reported few perceived barriers to school and aspirations. However, there was a significant relationship between acculturation level and the frequency with which students reported selected barriers and future life goals. Results indicated that low-acculturated students more often reported language-related problems as barriers to school involvement. Also reported by those students in the low-acculturation group were perceived discrimination, parental lack of time as a barrier, and low or no community involvement. These results indicate that high acculturation provides some students with a greater sense of belonging to their community and fewer barriers, including perceived discrimination. Gender differences were found with regard to acculturation level, perception of barriers, and academic aspirations. Specifically, with the exception of lack of interest, females reported more barriers than males and were rated as low in acculturation more frequently than males. Females also reported higher levels of academic aspirations, desires to do well in school, and a desire to be successful more frequently than males. Being female seems to promote resiliency with regard to academic aspirations for Latinos/as. These results lend support to previous research findings that females' higher value of academic achievement is related to being less acculturated or less vulnerable to assimilation of adversarial attitudes and behaviors responsible for academic failure. Overall this study suggests that there is not a linear relationship between acculturation and academic aspirations but, rather, this relationship may be mediated by a variety of factors including students' beliefs and attitudes, family cohesion, parental monitoring, parental attitudes concerning education, cultural identity, perceived stereotypes, and discrimination. Future studies examining acculturation would benefit from a framework that clearly captures the complex dynamics of acculturation and how this phenomenon affects academic achievement and the overall adjustment of Latino immigrant students into their environment. Valencia, E.Y., and Johnson, V. Latino Students in North Carolina: Acculturation, Perceptions of School Environment, and Academic Aspirations. Hispanic Journal of Behavioral Sciences, 28(3), pp. 350-367, 2006.

Attitudes Toward Alcohol and Cocaine Among Black and White Elementary School Students

To trace the origins of race differences in substance use, this study examined differences between Black and White elementary school children's knowledge of alcohol and cocaine, beliefs about their short- and long-term effects, and attitudes toward and intentions to use them across three independent samples of students in grades 1 through 6 (N = 181, N = 287, N = 234). Black children were more negatively oriented toward alcohol and cocaine than White children from an early age. Most notably, in all samples Black children had less positive attitudes toward adult alcohol use and lower intentions to use alcohol. Black children were also more likely to attribute negative long-term health and social effects to alcohol and cocaine use, but there were few significant race differences in knowledge or in expectancies regarding short-term effects of use. Since race differences in beliefs, exposure to alcohol, and socioeconomic factors could not explain race differences in attitudes toward substance use, other cultural differences must be considered. Rinehart, C., Bridges, L., and Sigelman, C. Differences between Black and White Elementary School Children's Orientations Toward Alcohol and Cocaine: A Three-study Comparison. J Ethn Subst Abuse, 5(3), pp. 75-102, 2006.


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