Metamodal Coupling of Vibrotactile and Auditory Speech Processing Systems through Matched Stimulus Representations.

It has been postulated that the brain is organized by "metamodal," sensory-independent cortical modules capable of performing tasks (e.g., word recognition) in both "standard" and novel sensory modalities. Still, this theory has primarily been tested in sensory-deprived individuals, with mixed evidence in neurotypical subjects, thereby limiting its support as a general principle of brain organization. Critically, current theories of metamodal processing do not specify requirements for successful metamodal processing at the level of neural representations. Specification at this level may be particularly important in neurotypical individuals, where novel sensory modalities must interface with existing representations for the standard sense. Here we hypothesized that effective metamodal engagement of a cortical area requires congruence between stimulus representations in the standard and novel sensory modalities in that region. To test this, we first used fMRI to identify bilateral auditory speech representations. We then trained 20 human participants (12 female) to recognize vibrotactile versions of auditory words using one of two auditory-to-vibrotactile algorithms. The vocoded algorithm attempted to match the encoding scheme of auditory speech while the token-based algorithm did not. Crucially, using fMRI, we found that only in the vocoded group did trained-vibrotactile stimuli recruit speech representations in the superior temporal gyrus and lead to increased coupling between them and somatosensory areas. Our results advance our understanding of brain organization by providing new insight into unlocking the metamodal potential of the brain, thereby benefitting the design of novel sensory substitution devices that aim to tap into existing processing streams in the brain.SIGNIFICANCE STATEMENT It has been proposed that the brain is organized by "metamodal," sensory-independent modules specialized for performing certain tasks. This idea has inspired therapeutic applications, such as sensory substitution devices, for example, enabling blind individuals "to see" by transforming visual input into soundscapes. Yet, other studies have failed to demonstrate metamodal engagement. Here, we tested the hypothesis that metamodal engagement in neurotypical individuals requires matching the encoding schemes between stimuli from the novel and standard sensory modalities. We trained two groups of subjects to recognize words generated by one of two auditory-to-vibrotactile transformations. Critically, only vibrotactile stimuli that were matched to the neural encoding of auditory speech engaged auditory speech areas after training. This suggests that matching encoding schemes is critical to unlocking the brain's metamodal potential.

Effects of Parental Acceptance-Rejection on Children's Internalizing and Externalizing Behaviors: A Longitudinal, Multicultural Study.

Background: Grounded in interpersonal acceptance-rejection theory, this study assessed children's (N=1,315) perceptions of maternal and paternal acceptance-rejection in nine countries (China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States) as predictors of children's externalizing and internalizing behaviors across ages 7-14 years. Methods: Parenting behaviors were measured using children's reports on the Parental Acceptance-Rejection Questionnaire. Child externalizing and internalizing behaviors were measured using mother, father, and child reports on the Achenbach System of Empirically-Based Assessment. Results: Using a multilevel modeling framework, we found that in cultures where both maternal and paternal indifference/neglect scores were higher than average-compared to other cultures -children's internalizing problems were more persistent. At the within-culture level, all four forms of maternal and paternal rejection (i.e., coldness/lack of affection, hostility/aggression, indifference/neglect, and undifferentiated rejection) were independently associated with both externalizing and internalizing problems across ages 7-14 even after controlling for child gender, parent education, and each of the four forms of parental rejection. Conclusions: Results demonstrate that the effects of perceived parental acceptance-rejection are panculturally similar.

Changes in General and Virus-Specific Anxiety During the Spread of COVID-19 in Israel: A 7-Wave Longitudinal Study.

We compared 3 hypothetical trajectories of change in both general and coronavirus disease 2019 (COVID-19)-specific anxiety during the first wave of the spread in the state of Israel: panic (very high anxiety, either from the outset or rapidly increasing), complacency (stable and low anxiety), and threat-sensitive (a moderate, linear increase compatible with the increase in threat). A representative sample of 1,018 Jewish-Israeli adults was recruited online. A baseline assessment commenced 2 days prior to the identification of the first case, followed by 6 weekly assessments. Latent mixture modeling analyses revealed the presence of 3 trajectories: 1) "threat-sensitivity" (29% and 66%, for general and virus-specific anxiety, respectively), 2) panic (12% and 25%), and 3) complacency (29% and 9%). For general anxiety only, a fourth class representing a stable mid-level anxiety was identified ("balanced": 30%). For general anxiety, women and the initially anxious-both generally and specifically from the spread of the virus-were more likely to belong to the panic class. Men and older participants were more likely to belong to the complacency class. Findings indicate a marked heterogeneity in anxiety responses to the first wave of the spread of COVID-19, including a large group evincing a "balanced" response.

Deep Learning Algorithms for Interpretation of Upper Extremity Radiographs: Laterality and Technologist Initial Labels as Confounding Factors.

Convolutional neural networks (CNNs) trained to identify abnormalities on upper extremity radiographs achieved an AUC of 0.844 with a frequent emphasis on radiograph laterality and/or technologist labels for decision-making. Covering the labels increased the AUC to 0.857 (p = .02) and redirected CNN attention from the labels to the bones. Using images of radiograph labels alone, the AUC was 0.638, indicating that radiograph labels are associated with abnormal examinations. Potential radiographic confounding features should be considered when curating data for radiology CNN development.

Change in Caregivers' Attitudes and Use of Corporal Punishment Following a Legal Ban: A Multi-Country Longitudinal Comparison.

We examined whether a policy banning corporal punishment enacted in Kenya in 2010 is associated with changes in Kenyan caregivers' use of corporal punishment and beliefs in its effectiveness and normativeness, and compared to caregivers in six countries without bans in the same period. Using a longitudinal study with six waves of panel data (2008-2016), mothers (N = 1086) in Colombia, Italy, Jordan, Kenya, Philippines, Thailand, and United States reported household use of corporal punishment and beliefs about its effectiveness and normativeness. Random intercept models and multi-group piecewise growth curve models indicated that the proportion of corporal punishment behaviors used by the Kenyan caregivers decreased post-ban at a significantly different rate compared to the caregivers in other countries in the same period. Beliefs of effectiveness of corporal punishment were declining among the caregivers in all sites, whereas the Kenyan mothers reported increasing perceptions of normativeness of corporal punishment post-ban, different from the other sites. While other contributing factors cannot be ruled out, our natural experiment suggests that corporal punishment decreased after a national ban, a shift that was not evident in sites without bans in the same period.

Mapping the road to elimination: a 5-year evaluation of implementation strategies associated with hepatitis C treatment in the veterans health administration.

BACKGROUND: While few countries and healthcare systems are on track to meet the World Health Organization's hepatitis C virus (HCV) elimination goals, the US Veterans Health Administration (VHA) has been a leader in these efforts. We aimed to determine which implementation strategies were associated with successful national viral elimination implementation within the VHA. METHODS: We conducted a five-year, longitudinal cohort study of the VHA Hepatic Innovation Team (HIT) Collaborative between October 2015 and September 2019. Participants from 130 VHA medical centers treating HCV were sent annual electronic surveys about their use of 73 implementation strategies, organized into nine clusters as described by the Expert Recommendations for Implementing Change taxonomy. Descriptive and nonparametric analyses assessed strategy use over time, strategy attribution to the HIT, and strategy associations with site HCV treatment volume and rate of adoption, following the Theory of Diffusion of Innovations. RESULTS: Between 58 and 109 medical centers provided responses in each year, including 127 (98%) responding at least once, and 54 (42%) responding in all four implementation years. A median of 13-27 strategies were endorsed per year, and 8-36 individual strategies were significantly associated with treatment volume per year. Data warehousing, tailoring, and patient-facing strategies were most commonly endorsed. One strategy-"identify early adopters to learn from their experiences"-was significantly associated with HCV treatment volume in each year. Peak implementation year was associated with revising professional roles, providing local technical assistance, using data warehousing (i.e., dashboard population management), and identifying and preparing champions. Many of the strategies were driven by a national learning collaborative, which was instrumental in successful HCV elimination. CONCLUSIONS: VHA's tremendous success in rapidly treating nearly all Veterans with HCV can provide a roadmap for other HCV elimination initiatives.

Cross-Cultural Associations of Four Parenting Behaviors With Child Flourishing: Examining Cultural Specificity and Commonality in Cultural Normativeness and Intergenerational Transmission Processes.

Families from nine countries (N = 1,338) were interviewed annually seven times (Mage child = 7-15) to test specificity and commonality in parenting behaviors associated with child flourishing and moderation of associations by normativeness of parenting. Participants included 1,338 children (M = 8.59 years, SD = 0.68, range = 7-11 years; 50% girls), their mothers (N = 1,283, M = 37.04 years, SD = 6.51, range = 19-70 years), and their fathers (N = 1,170, M = 40.19 years, SD = 6.75, range = 22-76 years) at Wave 1 of 7 annual waves collected between 2008 and 2017. Families were recruited from 12 ethnocultural groups in nine countries including: Shanghai, China (n = 123); Medellín, Colombia (n = 108); Naples (n = 102) and Rome (n = 111), Italy; Zarqa, Jordan (n = 114); Kisumu, Kenya (n = 100); Manila, Philippines (n = 120); Trollhättan & Vänersborg, Sweden (n = 129); Chiang Mai, Thailand (n = 120); and Durham, NC, United States (n = 110 White, n = 102 Black, n = 99 Latinx). Intergenerational parenting (parenting passed from Generation 1 to Generation 2) demonstrated specificity. Children from cultures with above-average G2 parent warmth experienced the most benefit from the intergenerational transmission of warmth, whereas children from cultures with below-average G2 hostility, neglect, and rejection were best protected from deleterious intergenerational effects of parenting behaviors on flourishing. Single-generation parenting (Generation 2 parenting directly associated with Generation 3 flourishing) demonstrated commonality. Parent warmth promoted, and parent hostility, neglect, and rejection impeded the development of child flourishing largely regardless of parenting norms.

Longitudinal Trajectories of Four Domains of Parenting in Relation to Adolescent Age and Puberty in Nine Countries.

Children, mothers, and fathers in 12 ethnic and regional groups in nine countries (N = 1,338 families) were interviewed annually for 8 years (Mage child = 8-16 years) to model four domains of parenting as a function of child age, puberty, or both. Latent growth curve models revealed that for boys and girls, parents decrease their warmth, behavioral control, rules/limit-setting, and knowledge solicitation in conjunction with children's age and pubertal status as children develop from ages 8 to 16 across a range of diverse contexts, with steeper declines after age 11 or 12 in three of the four parenting domains. National, ethnic, and regional differences and similarities in the trajectories as a function of age and puberty are discussed.

Getting to implementation: a protocol for a Hybrid III stepped wedge cluster randomized evaluation of using data-driven implementation strategies to improve cirrhosis care for Veterans.

BACKGROUND: Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care. METHODS: Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these "data-driven" implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs' use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care. DISCUSSION: Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices. TRIAL REGISTRATION: This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.

Opportunities and peer support for aggression and delinquency during adolescence in nine countries.

This study tested culture-general and culture-specific aspects of adolescent developmental processes by focusing on opportunities and peer support for aggressive and delinquent behavior, which could help account for cultural similarities and differences in problem behavior during adolescence. Adolescents from 12 cultural groups in 9 countries (China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States) provided data at ages 12, 14, and 15. Variance in opportunities and peer support for aggression and delinquency, as well as aggressive and delinquent behavior, was greater within than between cultures. Across cultural groups, opportunities and peer support for aggression and delinquency increased from early to mid-adolescence. Consistently across diverse cultural groups, opportunities and peer support for aggression and delinquency predicted subsequent aggressive and delinquent behavior, even after controlling for prior aggressive and delinquent behavior. The findings illustrate ways that international collaborative research can contribute to developmental science by embedding the study of development within cultural contexts.

Cost analysis of a randomized trial of Getting to Outcomes implementation support for a teen pregnancy prevention program offered in Boys and Girls Clubs in Alabama and Georgia.

Implementation support can improve outcomes of evidence-based programs (EBP) for adolescents, but with a cost. To assist in determining whether this cost is worthwhile, this study estimated the cost of adding Getting To Outcomes© (GTO) implementation support to a teen pregnancy and sexually transmitted infection prevention EBP called Making Proud Choices (MPC) in 32 Boys and Girls Clubs (BGCs) in Alabama and Georgia. Enhancing Quality Interventions Promoting Healthy Sexuality (EQUIPS) was a 2-year, cluster-randomized controlled trial comparing MPC with MPC + GTO. We used micro-costing to estimate costs and captured MPC and GTO time from activity logs completed by GTO staff. Key resource use and cost components were compared between the randomized groups, years, and states (to capture different community site circumstances) using 2-sample t tests. There were no significant differences between randomized groups in attendees per site, resource use, or costs for either year. However, there were significant differences between states. Adding GTO to MPC increased the societal costs per attendee from $67 to $144 (2015 US dollars) in Georgia and from $106 to $314 in Alabama. The higher Alabama cost was due to longer travel distances and to more BGC staff time spent on GTO in that state. GTO also improved adherence, classroom delivery, and condom-use intentions more in Alabama youth. Thus, Alabama's GTO-related BGC staff time costs may be better estimates of effective GTO. If teen childbearing costs taxpayers approximately $20,000 per teen birth, adding GTO to MPC would be worthwhile to society if it prevented one more teen birth per 140 attendees than MPC alone.Trial registration. ClinicalTrials.gov , NCT01818791. Registered March 26, 2013, https://clinicaltrials.gov/ct2/show/NCT01818791?term=NCT01818791&draw=2&rank=1.

Effects of Parental Warmth and Behavioral Control on Adolescent Externalizing and Internalizing Trajectories Across Cultures.

We investigated the effects of parental warmth and behavioral control on externalizing and internalizing symptom trajectories from ages 8 to 14 in 1,298 adolescents from 12 cultural groups. We did not find that single universal trajectories characterized adolescent externalizing and internalizing symptoms across cultures, but instead found significant heterogeneity in starting points and rates of change in both externalizing and internalizing symptoms across cultures. Some similarities did emerge. Across many cultural groups, internalizing symptoms decreased from ages 8 to 10, and externalizing symptoms increased from ages 10 to 14. Parental warmth appears to function similarly in many cultures as a protective factor that prevents the onset and growth of adolescent externalizing and internalizing symptoms, whereas the effects of behavioral control vary from culture to culture.

From shape to meaning: Evidence for multiple fast feedforward hierarchies of concept processing in the human brain.

A number of fMRI studies have provided support for the existence of multiple concept representations in areas of the brain such as the anterior temporal lobe (ATL) and inferior parietal lobule (IPL). However, the interaction among different conceptual representations remains unclear. To better understand the dynamics of how the brain extracts meaning from sensory stimuli, we conducted a human high-density electroencephalography (EEG) study in which we first trained participants to associate pseudowords with various animal and tool concepts. After training, multivariate pattern classification of EEG signals in sensor and source space revealed the representation of both animal and tool concepts in the left ATL and tool concepts within the left IPL within 250 â€‹ms. Finally, we used Granger Causality analyses to show that orthography-selective sensors directly modulated activity in the parietal-tool selective cluster. Together, our results provide evidence for distinct but parallel "perceptual-to-conceptual" feedforward hierarchies in the brain.

Sustaining an Evidence-Based Program Over Time: Moderators of Sustainability and the Role of the Getting to Outcomes® Implementation Support Intervention.

Problematic rates of alcohol, e-cigarette, and other drug use among US adolescents highlight the need for effective implementation of evidence-based programs (EBPs), yet schools and community organizations have great difficulty implementing and sustaining EBPs. Although a growing number of studies show that implementation support interventions can improve EBP implementation, the literature on how to improve sustainability through implementation support is limited. This randomized controlled trial advances the literature by testing the effects of one such implementation intervention-Getting To Outcomes (GTO)-on sustainability of CHOICE, an after-school EBP for preventing substance use among middle-school students. CHOICE implementation was tracked for 2 years after GTO support ended across 29 Boys and Girls Club sites in the greater Los Angeles area. Predictors of sustainability were identified for a set of key tasks targeted by the GTO approach (e.g., goal setting, evaluation, collectively called "GTO performance") and for CHOICE fidelity using a series of path models. One year after GTO support ended, we found no differences between GTO and control sites on CHOICE fidelity. GTO performance was also similar between groups; however, GTO sites were superior in conducting evaluation. Better GTO performance predicted better CHOICE fidelity. Two years after GTO support ended, GTO sites were significantly more likely to sustain CHOICE implementation when compared with control sites. This study suggests that using an implementation support intervention like GTO can help low-resource settings continue to sustain their EBP implementation to help them get the most out of their investment. ClinicalTrials.gov Identifier: NCT02135991.

Cross-cultural effects of parent warmth and control on aggression and rule-breaking from ages 8 to 13.

We investigated whether bidirectional associations between parental warmth and behavioral control and child aggression and rule-breaking behavior emerged in 12 cultural groups. Study participants included 1,298 children (M = 8.29 years, standard deviation [SD] = 0.66, 51% girls) from Shanghai, China (n = 121); Medellín, Colombia (n = 108); Naples (n = 100) and Rome (n = 103), Italy; Zarqa, Jordan (n = 114); Kisumu, Kenya (n = 100); Manila, Philippines (n = 120); Trollhättan/Vänersborg, Sweden (n = 101); Chiang Mai, Thailand (n = 120); and Durham, NC, United States (n = 111 White, n = 103 Black, n = 97 Latino) followed over 5 years (i.e., ages 8-13). Warmth and control were measured using the Parental Acceptance-Rejection/Control Questionnaire, child aggression and rule-breaking were measured using the Achenbach System of Empirically-Based Assessment. Multiple-group structural equation modeling was conducted. Associations between parent warmth and subsequent rule-breaking behavior were found to be more common across ontogeny and demonstrate greater variability across different cultures than associations between warmth and subsequent aggressive behavior. In contrast, the evocative effects of child aggressive behavior on subsequent parent warmth and behavioral control were more common, especially before age 10, than those of rule-breaking behavior. Considering the type of externalizing behavior, developmental time point, and cultural context is essential to understanding how parenting and child behavior reciprocally affect one another.

Cross-Cultural Examination of Links between Parent-Adolescent Communication and Adolescent Psychological Problems in 12 Cultural Groups.

Internalizing and externalizing problems increase during adolescence. However, these problems may be mitigated by adequate parenting, including effective parent-adolescent communication. The ways in which parent-driven (i.e., parent behavior control and solicitation) and adolescent-driven (i.e., disclosure and secrecy) communication efforts are linked to adolescent psychological problems universally and cross-culturally is a question that needs more empirical investigation. The current study used a sample of 1087 adolescents (M = 13.19 years, SD = 0.90, 50% girls) from 12 cultural groups in nine countries including China, Colombia, Italy, Jordan, Kenya, Philippines, Sweden, Thailand, and the United States to test the cultural moderation of links between parent solicitation, parent behavior control, adolescent disclosure, and adolescent secrecy with adolescent internalizing and externalizing problems. The results indicate that adolescent-driven communication, and secrecy in particular, is intertwined with adolescents' externalizing problems across all cultures, and intertwined with internalizing problems in specific cultural contexts. Moreover, parent-driven communication efforts were predicted by adolescent disclosure in all cultures. Overall, the findings suggest that adolescent-driven communication efforts, and adolescent secrecy in particular, are important predictors of adolescent psychological problems as well as facilitators of parent-adolescent communication.

Associations Between Perceived Material Deprivation, Parents' Discipline Practices, and Children's Behavior Problems: An International Perspective.

This study investigated the association between perceived material deprivation, children's behavior problems, and parents' disciplinary practices. The sample included 1,418 8- to 12-year-old children and their parents in China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States. Multilevel mixed- and fixed-effects regression models found that, even when income remained stable, perceived material deprivation was associated with children's externalizing behavior problems and parents' psychological aggression. Parents' disciplinary practices mediated a small share of the association between perceived material deprivation and children's behavior problems. There were no differences in these associations between mothers and fathers or between high- and low- and middle-income countries. These results suggest that material deprivation likely influences children's outcomes at any income level.

Examining effects of parent warmth and control on internalizing behavior clusters from age 8 to 12 in 12 cultural groups in nine countries.

BACKGROUND: Studies of U.S. and European samples demonstrate that parental warmth and behavioral control predict child internalizing behaviors and vice versa. However, these patterns have not been researched in other cultures. This study investigates associations between parent warmth and control and three child-reported internalizing behavior clusters to examine this question. METHODS: Data from 12 cultural groups in 9 countries were used to investigate prospective bidirectional associations between parental warmth and control, and three child-reported internalizing behavior types: withdrawn/depressed, anxious/depressed, and somatic problems. Multiple-group structural equation modeling was used to analyze associations in children followed from ages 8 to 12. RESULTS: Parent warmth and control effects were most pervasive on child-reported withdrawn/depressed problems, somewhat pervasive on anxious/depressed problems and least pervasive on somatic problems. Additionally, parental warmth, as opposed to control, was more consistently associated with child-reported internalizing problems across behavior clusters. Child internalizing behavior effects on parental warmth and control appeared ubiquitously across cultures, and behaviors, but were limited to ages 8-10. Most effects were pancultural, but culture-specific effects emerged at ages 9-10 involving the associations between parent warmth and withdrawn/depressed and somatic behaviors. CONCLUSIONS: Effects of parent warmth and control appear stronger on some types of child-reported internalizing behaviors. Associations are especially strong with regard to parental warmth across cultures, and culture-specific effects may be accounted for by cultural normativeness of parent warmth and child-reported somatic symptoms. Child internalizing behavior effects on subsequent parenting are common across cultures.

Examining the internalizing pathway to substance use frequency in 10 cultural groups.

Use of alcohol, tobacco, and drugs (i.e., substance use) is a leading cause of global health burden for 10-to-24-year-olds, according to the World Health Organization's index of number of years of life lost, leading international health organizations to prioritize the prevention of substance use before it escalates in adolescence. Pathways defined by childhood externalizing symptoms and internalizing symptoms identify precursors to frequent substance use toward which interventions can be directed. However, these pathways are rarely examined beyond the United States and Europe. We investigated these pathways in our sample of 1083 children from 10 cultural groups followed from ages 8-14. We found that age-10 externalizing symptoms predicted more frequent mother-reported age-13 and self-reported age-14 substance use. We also found that a depressive pathway, marked by behavioral inhibition at age 8 and subsequent elevation in depressive symptoms across ages 8-12 predicted more frequent substance use at age 13 and 14. Additionally, we found a combined externalizing and internalizing pathway, wherein elevated age-9 depressive symptoms predicted elevated externalizing symptoms at age-10 which predicted greater peer support for use at age-12, which led to more frequent substance use at age-13 and -14. These pathways remained significant within the cultural groups we studied, even after controlling for differences in substance use frequency across groups. Additionally, cultures with greater opportunities for substance use at age-12 had more frequent adolescent substance use at age-13. These findings highlight the importance of disaggregating between- and within-culture effects in identifying the etiology of early adolescent substance use.

Cost Analysis of a Randomized Trial of Getting to Outcomes Implementation Support of CHOICE in Boys and Girls Clubs in Southern California.

Costs of supporting prevention program implementation are not well known. This study estimates the societal costs of implementing CHOICE, a voluntary after-school alcohol and other drug prevention program for adolescents, in Boys and Girls Clubs (BGCs) across Southern California with and without an implementation support system called Getting To Outcomes© (GTO). This article uses micro-costing methods to estimate the cost of the CHOICE program and GTO support. Labor and expense data were obtained from logs kept by the BGC staff and by the GTO technical assistance (TA) staff, and staff time was valued based on Bureau of Labor Statistics estimates. From the societal perspective, the cost of implementing CHOICE at BGCs over the 2-year study period was $27 per attendee when CHOICE was offered by itself (all costs incurred by the BGCs) and $177 per attendee when CHOICE was offered with GTO implementation support ($67 cost to the BGCs; $110 to the entity funding GTO). These results were most sensitive to assumptions as to the number of times CHOICE was offered per year. Adding GTO implementation support to CHOICE increased the cost per attendee by approximately $150. For this additional cost, there was evidence that the CHOICE program was offered with more fidelity and offered more often after the 2-year intervention ended. If the long-term benefits of this better and continued implementation are found to exceed these additional costs, GTO could be an attractive structure to support evidence-based substance misuse prevention programs. Trial Registration. This project is registered at ClinicalTrials.gov with number NCT02135991 (URL: https://clinicaltrials.gov/show/NCT02135991). The trial was registered May 12, 2014.