Rapid Results with Evidence Based Kernels in North Carolina


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The recent Institute of Medicine Report on Prevention highlights the use of evidence-based kernels as a strategic way to improve multiple outcomes in mental, emotional and behavioral disorders. An evidence-based kernel is the smallest unit of proven behavioral influence (Embry & Biglan, 2008; Embry, 2004). In a time of short funds, kernels offer a powerful way of providing evidence-based practices on a shoe-string budget—yet with powerful outcomes. The same kernel can be used prevention, intervention and treatment—which economizes on staff training and technical support. Additionally, this fact means that the same thing you are using for example to have a major impact on recovery and sobriety for adults can be used at home with success with the client's children. And.the same strategy used at home or in the clinic can be used in school or other community settings—including in the workplace. This workshop takes a number of powerful kernels and details how they can be used to create one of the most powerful substance abuse strategies in the world, the Good Behavior Game, or used to create one of NiDA's most powerful substance abuse treatment protocol. A slightly different recipe can be used in homes to reduce child-rearing problems or in the work place to improve productivity or decrease injuries.

Evidence-based kernels are the active ingredients of most evidence-based programs, but they are rarely denominated. Since kernels tend to produce immediately measurable benefits, practitioners can become more potent quickly. The fact that so many people can use the kernel also creates the possibility of a cultural shift.

In this workshop, Dr. Embry teach some basic kernels, the neuro and behavioral science behind them, and recipes for use in homes, schools, clinics and community settings. Participants will be able to learn to how to monitor the effects of those kernels, too.

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Rapid Results with Evidence Based Kernels in North Carolina

  1. 1. Rapid Using Evidence Base Kernels for Prevention, Intervention and Treatment by Dennis D. Embry, Ph.D. • PAXIS Institute • April 13, 2011Thursday, April 14, 2011 1
  2. 2. How many of you know a regular American family with a child with… a mental, emotional or behavioral disorder? Like a more Like ADHD or Like learning or serious mental Like a serious behavior developmental illness like bipolar addictions problems? disorder? or suicidal problem? actions?Thursday, April 14, 2011 2
  3. 3. How many here think it is acceptable that at least every other American child will be affected by MEB’s before age 18? This happens for every social class in America… Among your family, your child’s classmates, your neighbors, at church, and at work…every family.Thursday, April 14, 2011 3
  4. 4. Key messages about mental, emotional & behavioral disorders… MEB’s are Break-even for MEB prevention MEB prevention preventable. MEB prevention balances improves US is one year. budgets. business. Effective MEB MEB prevention prevention MEB prevention saves Social MEB prevention helps national helps US global Security & heals past security. success. Medicare. inequities.Thursday, April 14, 2011 4
  5. 5. Thursday, April 14, 2011 5
  6. 6. TUV"2003"4-/(560,"2(7-"W0&"#(56)=&"X&*7(0,"" Estimates Possible Benefits of Universal GBG Implementation in First Grade by State Select State: North Carolina 9,222,414 Estimated Total Population 2006 If every cohort of first-graders receives 36 138,336 Estimated No. of 1st Graders in 2006 Adjust for Percent of 1st Graders Protected by Good 100 100% 138,336 Estimated 1st Graders Reached the Good Behavior Behavior Game in the State Adust to reflect average cost per student for education 20 100% $8,701 compared to national average Average Cost Per Student Per Year Game just in first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grade, the good Estimated Adjust for Current Impact of Prevalence Population the Good After Adjust for Average Cost of Adjusted Average Annual Average Annual Total Cost of the Problem Estimated Per Year Costs people of North Carolina will save Prevalence Behavior Universal Problem Cost of Behavior With SAVINGS for of Problem Game on 1st Grade Per Child Problem NOT DOING Percent of 1st or Behavior Problem Delivery Per Year Per Child GBG Graders Reached Move slider (or per each $250 million for each Move slider 100% left if think right if think disruption) Child, Adolescent & Adult will less be problem costs effective more Problems group of kids when Total daily disruptions in state $1.0 4,565,095 70000.00% 1,369,528 $0.01 $8,217,171 $5,752,020 before GBG ADHD 3rd Grade 2 7.00% 3000.00% 3.00% $750 $7,262,651 $4,150,086 they are young Oppositional Defiance 3rd Grade 3 5.00% 2700.00% 2.30% $900 $6,225,129 $3,361,570 Adolescent Conduct Disorder 4 14.00% 5600.00% 8.40% $1,400 $27,113,897 $10,845,559 Special Education 1st-Grade 12 5 7.00% 2200.00% 4.80% 500.00% $435 $4,212,822 $1,324,030 Adult Criminal Behavior Serious Adult Drug Addictions 6 7 12.00% 20.00% 1200.00% 800.00% 10.80% 12.00% 45000.00% 4900.00% $4,500 $490 $74,701,553 $13,556,949 $7,470,155 $5,422,779 adults. Teen/Adult Suicidal Ideations 8 14.00% 7000% 7.00% $992 $7,684,853 $3,842,427 Total Minimum Estimated Child, Adolescent and Adult Morbibity Costs for Each First Grade Cohort if Nothing is Done New Each Year: $148,975,025 Esimtated Cost of the Good Behavior Game Per First Grader as Behavioral Vaccine (this includes local staff, materials, incentives, training, technical support, and overhead) $62.00 This is less than cost of most childhood disease vaccines. Over the next 10 years, that’s $2.5 Esimtated Cost of Implementing the Good Behavior Game Per Classroom $1,550 Cost per 1st Grade Cohort Based on Percentage of Students Reached: $8,576,845 billion. Return on Investment Net Profit at Start of 2nd Grade Per 1st Grade Cohort: $931,003 11% Net Profit at 6th Grade Per 1st Grade Cohort: $32,517,918 379% Net Profit at 12th Grade Per 1st Grade Cohort: $110,701,906 1291% Net Profit at the 29th Year of Life Per 1st Grade Cohort: $247,316,107 2884% The cost? $62 per first grader. Note: Over a Decade of 1st Grade Cohorts Getting GBG, these numbers would be x10: References: 1 Tingstrom DH, Sterling-Turner HE, Wilczynski SM. The Good Behavior Game: 1969-2002. Behavior Modification 2006;30:225-53. 2 van Lier PAC, Muthen BO, van der Sar RM, Crijnen AAM. Preventing Disruptive Behavior in Elementary Schoolchildren: Impact of a Universal Classroom-Based Intervention. Journal of Consulting & Clinical Psychology 2004;72(3):467-78. 3 Ibid. 4 Ialongo N, Poduska J, Werthamer L, Kellam S. The distal impact of two first-grade preventive interventions on conduct problems and disorder in early adolescence. Journal of Emotional & Behavioral Disorders 2001;9(3):146-60.Thursday, April 14, 2011 6
  7. 7. Thursday, April 14, 2011 7
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  10. 10. National Media And “Good News…” State/local Business Donors/ Health Care Reform Act agency grants Sponsors Local/Regional Media These types of Local Family Private Health Social Media Prevention Foundations Donors prevention strategies Insurers Scoreboard Consumer Prevention Products can be sustained and (Retail & Online) United Way and/or Property/Auto & National Community grow because of laws Foundations Life Insurers Foundations School Personnel Local, State and regulations… and State Health Local Health Local NGO: Private Providers National Authority Professional Authority Prevention for Groups If we collectively act for Everyone* Agency Providers the future of all our Local Govts (prenatal thru age 21) Voluntary & Faith Groups children’s futures here Center for Medicaid Services FQHC & Lookalikes in this room. (Medicaid Administrative Match) Americorps, County Suppliers of Evidence- Teacher Extension Based Prevention Tribal Governments Corps Products or Tech. Asst. Other Federal Funds Dept. of Defense Example Enabling Regulations Universities & Comm. Colleges Preventive services Rehabilitative services (Act, 42 C.F.R. 440.130 (c), 2004) (Act, 42 C.F.R. 440.130 (d), 2004) Private Scientific Orgs Early and Periodic Screening, Medical Services under the Individuals Diagnostic, and Treatments with Disabilities Education Act *Can be existing entities (e.g., Services (IDEA, 2004) DFCs, non-profits)Thursday, April 14, 2011 10
  11. 11. Consumer approach to prevention Car seats Bike helmets Prevention Store Safety gates Electric socket covers BUT WHAT ABOUT… Depression ADHD Suicide Substance abuse ObesityThursday, April 14, 2011 11
  12. 12. But at the new North Carolina prevention store Omega 3 @ $70 a year to Prevention Store prevent multiple mental, emotional and behavioral illnesses Dialogic storybooks to prevent behavior problems @ $86 per year Good Behavior Game for Teachers @ $54 per child per year to prevent mental/health emotional problems Families United @ $4 per child per year to prevent conduct disorders, suicide, ATODThursday, April 14, 2011 12
  13. 13. Thursday, April 14, 2011 13
  14. 14. Obesity Conduct Disorders Homicide & Suicide Depression Oppositional/ Addictions ADHD Aggression Self harm ANXIETYThursday, April 14, 2011 14
  15. 15. Nearly 75 percent of the nations 17- to 24-year-olds a ineligible for service • Medical/physical problems, 35 percent. • Illegal drug use, 18 percent. • Mental Category V (the lowest 10 percent of the population), 9 percent. • Too many dependents under age 18, 6 percent. • Criminal record, 5 percent. Army Times, Nov 5, 2009 • www.missionreadiness.org/PAEE0609.pdThursday, April 14, 2011 15
  16. 16. The US has 75 million children and teens. 40.4 million are on psychotropic medications Wall Street Journal, 12-28-2010Thursday, April 14, 2011 16
  17. 17. 2009: Institute of Medicine Report provides a concise review of the prevention of mental, emotional, and behavioral disorders.Thursday, April 14, 2011 17
  18. 18. America’s rate of mental, emotional and behavioral disorders is about twice that of the United Kingdom which is twice that of many other rich democracies.Thursday, April 14, 2011 18
  19. 19. Silo busting ideas in prevention science ADHD ODD Depression Obesity Injury ControlThursday, April 14, 2011 19
  20. 20. Thursday, April 14, 2011 20
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  23. 23. Thursday, April 14, 2011 23
  24. 24. What message do we need to promote?Thursday, April 14, 2011 24
  25. 25. Reaching the faithful ๏ Tell stories of how faith-based groups can use proven prevention strategies ๏ Pastor Smith uses Triple P to counsel his parishioners having common problems with their children. “It’s very easy for me to relate Triple P strategies to Scripture.” ๏ St. John’s uses the Good Behavior Game. “The Game helps us not only with behavior and academics, but also helping students understand how early Christians had to cooperate.”Thursday, April 14, 2011 25
  26. 26. Reaching businesses ๏ Give examples of immediate benefits to productivity. “Having workplace Triple P has reduced our employees having to take time off for dealing with problems of their children.” ๏ Link business competition. “Other rich democracies have extensive universal prevention, and those countries have more viable small business sector than the US.” ๏ Link to major cost of business, such as depression is now major cause of disability.Thursday, April 14, 2011 26
  27. 27. Like the Inuksuk, Reaching the traditional practices often point to the right way Tribes ๏ Link key cultural wisdom to proven science of prevention, such as: ๏ the use of omega-3 was discovered by the Arctic peoples ๏ the Good Behavior Game mimics common traditional practices of assuring cooperation among childrenThursday, April 14, 2011 27
  28. 28. Reach to the political right ๏ Universal access to prevention enables individual responsibility; rationing limits it. ๏ Use the metaphor of accepted prevention practices like universal inoculations of childhood diseases or car safety seats. ๏ Link to balancing budgets, national security and global competition.Thursday, April 14, 2011 28
  29. 29. CEPR An International Comparison of Small Business Employment !"8 Key message by showing global competion !"#$%&!(%$)*#+)#,%-#$)*$.&.+,$,#/0123#&$.4$)*5#-%!)6#*7$#18#4!9)*.+$,#"!.#:7+47#*7$#;<=>#7-,# +)*$.)-*+!)-(#4!%&-.-?$#@-*-2## # FIGURE 3 Manufacturing, Employment in Enterprises with fewer than 500 Employees, 2001 LE7/BA4< )!#% All of these other rich F/4<9 )#% democracies have nearly 3K4.- )$#( J4K4- &+#) universal access to prevention for G0/I07<4-15 &%#" MEBs, compared to the rationing 6700=0 &!#" model in the US. G0:2H04<4-1 &#+ GE7:49 &$#$ Having “fitter” employees allows F70<4-1 &"# CB5/7.4 &*#+ these countries to have higher ,-./012D.-A1E8 %&#( paying manufacturing jobs and CB5/74<.4 %!#) compete globally. @0<A.B8 %!#( >0-847? %! ;74-=0 %#& ;.-<4-1 !&#! 3:010- !%#& 60784-9 !%#% ,-./0123/4/05 !"#$ * $! !* &! "** !"#$"%&()*+%,)+$&,#-%."*/0(1*"%& Source: Authors’ analysis of OECD data.Thursday, April 14, 2011 # 29
  30. 30. Explain universal prevention in terms of national security America’s retired 4-start generals find… Nearly 75 percent of the nations 17- to 24-year-olds are ineligible for service • Medical/physical problems, 35 percent. • Illegal drug use, 18 percent. • Mental Category V (the lowest 10 percent of the population), 9 percent. • Too many dependents under age 18, 6 percent. • Criminal record, 5 percent. Army Times, Nov 5, 2009 • www.missionreadiness.org/PAEE0609.pdThursday, April 14, 2011 30
  31. 31. Reach to the political left ๏ Explain universal prevention as remedying historic disparities such as: ๏ Good Behavior Game increases high-school graduation and college entry rates and reduces lifetime incarceration rates of inner city kids. ๏ Omega-3 improves IQ and reduces effects of poverty on children livesThursday, April 14, 2011 31
  32. 32. Explain how prevention for our kids protects elders Requiring more wealth transfer 5-Year 65-Year Olds But elders voting to stop funds to kids Olds Who are living Who are less longer though get and less able… progressively sicker…Thursday, April 14, 2011 32
  33. 33. Reach to the center ๏ Emphasize that MEB’s affect every family, every school, every neighborhood, and every business. ๏ Example: “How many of you know a reasonably OK middle class or upper class family with a child or teen with a mental illness, learning disability or addictions problem?”Thursday, April 14, 2011 33
  34. 34. Reach state legislators, county & city leaders ๏ Show how prevention for everyone will help balance the local budget and keep it balanced over time—use example estimators. ๏ Show data how universal access to prevention will help the jurisdiction specifically ๏ Share such data with advocates for local emotional impactThursday, April 14, 2011 34
  35. 35. Key message for every group “Mental illness is preventable, just like many childhood diseases, tra c injuries or even addictions are preventable.” In every communication say… ๏ Mental, emotional and behavioral disorders are preventable like most childhood diseases and childhood injuries. ๏ MEB’s harm and kill more children, youth and “Yes, it is preventable. Read all about it, in the ‘09 IOM Report young adults than any childhood diseases, and on the Prevention of Mental, Emotional, & Behavioral Disorders. the prevention of MEB’s is less expensive than We’ve been conditioned to think these were childhood medical vaccines. just manageable…” OConnell, M. E., T. Boat, et al., Eds. (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. . Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young Adults: Research Advances and Promising Interventions. Washington, DC, Institute of Medicine; National Research Council. TO READ THE IOM REPORT, GO TO: http://bit.ly/IOMPREVThursday, April 14, 2011 35
  36. 36. Thursday, April 14, 2011 36
  37. 37. Redness, rubor, a response of body tissues to injury or irritation; characterized by pain and swelling and redness and heat. Excitation, excitement, fervor, fervour the state of being emotionally aroused and worked up Inflaming arousal to violent emotion Firing, ignition, kindling, lighting the act of setting on fire or catching fire Hypothesis: Evolutionary “inflammatory” processesThursday, April 14, 2011 37
  38. 38. Human Infectious/Biological Threats Human Predatory Threats Evolutionary Adaptive Responses Evolutionary Adaptive Responses (Simplified) Neuro-Hormones (Simplified) Mood Modulators Reward Threat Attributional Delay Intra-Group Generalized Localized Modulators Affiliation Bias (Inflammatory) Inflammatory Inflammatory (Anti-Inflammatory) Out-Group Response Response Stress Aggress. (Inflammatory) Modulators Intra-Group Cooperation Tit-for-Tat Beh. Bias Anti-Inflammatory Regulators Puberty/Sex (Anti-Inflammatory) Modulators (Inflammatory) Modern culture commonly produces multiple evolutionary mismatches triggering multiple inflammatory responses.Thursday, April 14, 2011 38
  39. 39. K R Path Path Evolutionary Path of a Child’s Life Probability of short-life and doubtful Probability of long-life and reproductive success reproductive success R-Path can be triggered by evolutionary mismatch in social or physical environment.Thursday, April 14, 2011 39
  40. 40. Obesity Conduct Disorders Homicide & Suicide Depression Oppositional/ Addictions ADHD Aggression Self harm ANXIETY R PATH = Risky behaviors or healthThursday, April 14, 2011 40
  41. 41. Substance Work Obesity, Early Mental Illness Violence Cancer School Abuse Problems etc Sex Failure Mood Reward Executive Behavioral Attention Stability Delay Function Competencies Immune- STD’s Motor Healing Special Skills Multi-Inflammatory Threat Reaction Functions Ed Major Ecologic Causes of the Dual Inflammatory Threats to Children & Youth Physiological Antecedents Reinforcement Verbal RelationsThursday, April 14, 2011 41
  42. 42. Cultural Trend: Sleep Deprivation IOM Report (IOM, page 212)Thursday, April 14, 2011 42
  43. 43. Parental Monitoring and Parental Networking (IOM, page 168, 171, 189)Thursday, April 14, 2011 43
  44. 44. Peer, Family, & Cultural Rewards for NOT breaking rules IOM Report (page 165, 170,171, 181)Thursday, April 14, 2011 44
  45. 45. What are the social rewards for these behaviors? Billy Good Billy BadThursday, April 14, 2011 45
  46. 46. Constant (k) affected by physiology (e.g., diet, perceived stress and threats, exercise, medications, substance abuse) and genes Rate influenced by: Rate influenced by: •Reinforcements •Reinforcement •Antecedents •Antecedents •Relational-frames •Relational-framesThursday, April 14, 2011 46
  47. 47. Diet change in essential “brain food” IOM Report (page 211-2)Thursday, April 14, 2011 47
  48. 48. Data on “Brain Food”: Omega-3 deficiencyThursday, April 14, 2011 48
  49. 49. Apparent consumption o inoleic acid (% of dietary energy) among Australia, Canada, UK and USA for the years 1961–2000 #" +651.-:8- A-0-;- BC BD+2 +,,-./012340567,1840 492:804:/83 -38; $ & <=2/0/.>?@ ( % * ) ! # " #$(" #$(% #$" #$% #$&" #$&% #$$" #$$% !""" “Risky” Beh. Evolution Neonates Breast Milk & Mismatch In the Rife Valley, the Successful human American infants have human brain evolution neonates born with been getting steadily Theory the result of eating 60-day supply of less omega-3 (n3) and Almost all adolescent fish high in omega-3 omega-3 in more pro-inflammatory risky behaviors have omega-6 (n6) in breast now been documented not savannah animals subcutaneous fat from milk to be related to low n3 mother’s diet and high n6 in US diet See Broadhurst, Cunnane, & Crawford (1998). Rift Valley lake fish See HIbbeln et al. (2007).Maternal seafood consumption in pregnancy and See Ailhaud et al. (2006).Temporal change in last 50 years changes in dietary fats: Role of n6 and shellfish provided brain-specific neurodevelopmental outcomes in Hibbeln et al. (2006). Healthy intakes of polyunsaturated fatty acids in excessive nutrition for childhood (ALSPAC study): an adipose tissue n-3 and n-6 fatty acids: estimations early Homo observational cohort study considering worldwide diversity. development and relationship to obesityThursday, April 14, 2011 49
  50. 50. Syndemic = reverse of synergiesThursday, April 14, 2011 50
  51. 51. If we just hit the problem harder…Thursday, April 14, 2011 51
  52. 52. Thursday, April 14, 2011 52
  53. 53. Thursday, April 14, 2011 53
  54. 54. Reduce Omega 3 Brain Deficiency in baby’s brainThursday, April 14, 2011 54
  55. 55. Reduce Omega 3 Brain Deficiency in baby’s brainThursday, April 14, 2011 55
  56. 56. The benefits to the baby and society Verbal Suboptimal Prosocial Suboptimal A 35 C 15 children suboptimum (%) 30 children suboptimum (%) Verbal IQ 10 25 Prosocial 20 5 15 n=584 n=3493 n=1330 n=739 n=4260 n=1583 0 0 B 35 Fine Motor Skills Suboptimal D 35 Social Development Suboptimal 30 30 children suboptimum (%) children suboptimum (%) Social development Fine motor 25 25 20 20 15 15 n=875 n=4923 n=1798 n=875 n=4919 n=1798 0 0 None 0–340 g >340 g None 0–340 g >340 g per week per week per week per week Maternal seafood consumption in pregnancy Maternal seafood consumption in pregnancyThursday, April 14, 2011 56
  57. 57. Why not reproduce the rapid results in North Carolina to prevent multiple mental, emotional and behavioural It costs about $70 per person per year.Thursday, April 14, 2011 57
  58. 58. 1.0 Inpatient Discharge 0.8 0.6 Survival  Probability 0.4 High  DHA    (n=16) Low    DHA    (n=17) 0.2 (median  split  of  plasma  phospholipid  %  fa1y  acids) 0 0 200 400 600 800 Time  to  First  Suicide  A1empt  (days) Suble&e,  Hibbeln  et  al  Am  J  Psychiatry  2006;163:  1100-­‐1102  Thursday, April 14, 2011 58
  59. 59. The same universal works for high risk youth… 30% Percentage with Psychosis at 12 months 27.5% 24% 18% 12% 6% 4.9% 0% Omega-3 Placeo Psychosis Amminger, G. P., M. R. Schafer, et al. (2010). "Long-Chain {omega}-3 Fatty Acids for Indicated Prevention of Psychotic Disorders: A Randomized, Placebo-Controlled Trial." Arch Gen Psychiatry 67(2): 146-154.Thursday, April 14, 2011 59
  60. 60. Rapid Other rapid results to consider…Thursday, April 14, 2011 60
  61. 61. Young childrenThursday, April 14, 2011 61
  62. 62. Early stories and readingThursday, April 14, 2011 62
  63. 63. Why not distribute specially constructed books for parents with young children… Reduce dangerous, impulsive, disturbing behavior quickly? Increase social- competence quickly? Improve school readiness quickly? Embry, D. D. and L. Peters (1985). A three-city evaluation of the diffusion of a pedestrian-safety injury control intervention. R. S. Division, New Zealand Ministry of Transport, Wellington, NZ.Thursday, April 14, 2011 63
  64. 64. PeaceBuilders School-Community Reinforcement Study Positive Peer-to-Peer Social Home Notes Notes Competence ViolenceThursday, April 14, 2011 64
  65. 65. Promote the Triple P (Positive Parenting Program)Thursday, April 14, 2011 65
  66. 66. Substantiated Child Maltreatment 16 Control Counties Rates per 1,000 Children (0-8 Years) 15 13 Triple P Counties 12 10 Pre Post Two Years Later Prinz et al., 2009, Prevention ScienceThursday, April 14, 2011 66
  67. 67. Child Abuse Hospital Injuries 1.80 Rates per 1,000 Children (0-8 Years) 1.68 Control Counties 1.55 1.43 Triple P Counties 1.30 Post Pre Two Years Later Prinz et al., 2009, Prevention ScienceThursday, April 14, 2011 67
  68. 68. Child Out-of-Home Placements Control Counties 4.50 Rates per 1,000 Children (0-8 Years) 4.13 3.75 Triple P Counties 3.38 3.00 Post Pre Two Years Later Prinz et al., 2009, Prevention ScienceThursday, April 14, 2011 68
  69. 69. ClassroomsMuriel SaundersThursday, April 14, 2011 69
  70. 70. C linical C hild and Family P sychology R eview, Vol. 5, N o. 4, D ecember 2002 ( C 2002) pages 273-297 T he G ood B ehavior G ame: A B est P ractice C andidate as a U niversal B ehavioral V accine Key findings in the first 50 D ennis D . E mbry1 A “ behavioral vaccine” provides an inoculation against morbidity or mortality, impactingphys- studies of the GBG ical, mental, or behavior disorders. A n historical example of a behavioral vaccine is antiseptic hand washing to reduce childbed fever. I n current society, issues with high levels of morbidity, LY such as substance abuse, delinquency, youth violence, and other behavioral disorders ( multi- problems) , cry out for a low-cost, widespread strategy as simple as antiseptic hand washing. C ongruent research findings from longitudinal studies, twin studies, and other investigations N suggest that a possibility might exist for a behavioral vaccine for multiproblem behavior. A O simple behavioral strategy called the G ood B ehavior G ame ( G B G ) , which reinforces inhibi- tion in a group context of elementary school, has substantial previous research to consider its use as a behavioral vaccine. T he G B G is not a curriculum but rather a simple behavioral procedure from applied behavior analysis. A pproximately 20 independent replications of the G B G across different grade levels, different types of students, different settings, and some with long-term follow-up show strong, consistent impact on impulsive, disruptive behaviors of children and teens as well as reductions in substance use or serious antisocial behaviors. T he G B G , named as a “ best practice” for the prevention of substance abuse or violent be- havior by a number of federal agencies, is unique because it is the only practice implemented by individual teachers that is documented to have long-term effects. Presently, the G B G is ๏ This was the first widely replicated scientific only used in a small number of settings. H owever, near universal use of the G B G , in major political jurisdictions during the elementary years, could substantially reduce the incidence of substance use, antisocial behavior, and other adverse developmental or social consequences at a very modest cost, with very positive cost-effectiveness ratios. K E Y W O R D S: substance abuse prevention; violence prevention; public policy; best practice. demonstration that disturbing, disruptive, INT R OD U CT ION A behavioral vaccine is a simple, scientifically I n the late 1840s, D r I gnaz Semmelweis worked in the maternity wards of a V ienna hospital. B y metic- ulous observation, he discovered that the mortality destructive and inattentive behaviors of proven routine or practice put into widespread daily rate in a delivery room staffed by medical students use that reduces morbidity and mortality. A powerful was up to three times higher than in a second deliv- example comes from an epidemic that occurred 150 ery room staffed by midwives. Semmelweis postulated years ago. that the students might be carrying the infection from children from preschool through secondary D uring the nineteenth century, women died in their dissections to mothers giving birth. H e tested the childbirth at alarming rates in E urope and the U nited hypothesis by having doctors and medical students States. U p to 25% of women who delivered their ba- wash their hands with a chlorinated solution before bies in hospitals died from childbed fever ( puerperal examining women in labor. T he mortality rate in his sepsis) , discovered later to be caused by Streptococcus maternity wards eventually dropped to less than 1% . education could be reliably reduced by pyogenes bacteria. Washing of hands with antiseptic solution—a behav- ioral vaccine—now saves millions of lives every year. 1 PA X I S I nstitute, PO B ox 68494, Tucson, A rizona 85737; e-mail: Today, the C enters of D isease C ontrol and Prevention dde@paxis.org. ( C D C ) web site states, “ [A ntiseptic] hand washing is individual teachers using a simple recipe for a 273 1096-4037/02/1200-0273/0 C 2002 Plenum Publishing C orporation 3x daily behavioral vaccine. Embry, D. D. (2002). The Good Behavior Game: a best practice candidate as a universal behavioral vaccine. Clinical Child & Family Psychology Review, 5(4), 273-297.Thursday, April 14, 2011 70
  71. 71. Behavior Tracking Results in Baltimore 150+ classrooms No or Low Implementation High Implementation of PAX (Good Behavior) Game of PAX (Good Behavior) Game 17 per/hr X 5.5 class hours X 30 students = 2,805 disruptions 6 per/hr X 5.5 per school day class hours X 30 per classroom students = 990 disruptions per school day per classroomThursday, April 14, 2011 71
  72. 72. PAX  GBG  decreased  distracLon  in  classrooms  by  an  average  of    86%  aQer  only  one  month 2011 Replication in rural Tennessee by coaches trained just like you… Baseline  DisrupIons   Six  1st-­‐grade  classrooms  averaged   136  per  hour  before  coaching PAX  Introduced The  distracLons  per  hour  decreased   by  56%  with  the  introducLon  of  the   PAX  environment  of  PAX  language   and  several  PAX  kernels. PAX  GBG  Played DisrupLons  per  hour  decreased  an   addiLonal    30%    aQer  learning  to   play  PAX  GBG  .Thursday, April 14, 2011 72
  73. 73. Johns Hopkins Centre for Prevention and Early Intervention ๏ Five longitudinal studies of the effects of the Good Behavior Game now being studied ๏ All involve random assignment of teachers in schools and schools to use or not use GBG ๏ Here are data from Cohort 1 and 2 studies showing effects 20 years later, after just getting GBG in 1st grade ONLYThursday, April 14, 2011 73
  74. 74. 3 GBG games a day in just first grade during your normal teaching… ๏ Reduces disturbing, disruptive and destructive behaviors by 75% ๏ Prevents ADHD and other mental illnesses- without medication or therapy ๏ Prevents lifetime crime, violence and drug addiction ๏ Increases high-school graduation & college entryThursday, April 14, 2011 74
  75. 75. Timeline of benefits from PAX GBG Age of Child Benefits 75% reduction in disturbing, disruptive and destructive behavior; 1st Grade 25% increase academic achievement--especially in reading if played well 43% reduction in ADHD diagnoses; 33% reduction in Oppositional Defiant Disorder; 3rd Grade 30%+ reduction special services needs; 50%+ reduction in conduct disorders; 25% to 50% reduction tobacco use; major reduction in 6th grade bullying behaviors 8th Grade 75%r reduction in serious drug use and engagement in delinquent acts 12th Grade Major increase in high-school graduation; lower utilization of special services Early 20’s Increase in college entry; Major reductions drug use; reductions in prison time Age 29 Lifetime reduction in violent crime, suicide, psychiatric diagnoses, and lifetime addictionsThursday, April 14, 2011 75
  76. 76. AdolescentsThursday, April 14, 2011 76
  77. 77. Why not invite families to promise clear rules about alcohol, tobacco & drugs if… It produces a 23% reduction binge drinking and 27% reduction delinquency rates among 7th graders in 2 years and this has been adopted nationally by Sweden and being adopted by the State of Tennessee? PS. Effect sizes were 0.35 for drunkenness and 0.38 for delinquency. Koutakis, N., H. Stattin, et al. (2008). "Reducing youth alcohol drinking through a parent-targeted intervention: the Orebro Prevention Program." Addiction 103(10): 1629-1637.Thursday, April 14, 2011 77
  78. 78. Thursday, April 14, 2011 78
  79. 79. What is Families Together? A set of simple, proven, and powerful tools to protect all our children from the leading causes of lifetime suffering, illness, disability and death—securing all our futures.Thursday, April 14, 2011 79
  80. 80. What do Families Together do? Increase Family Positive Monitoring. Parental & family clarity and commitment to their child about risky or disturbing behaviors such as not using alcohol, tobacco and drugs (ATOD) and about that child’s friends’ not using of alcohol, tobacco and drugs. The type of monitoring changes by age of child.Thursday, April 14, 2011 80
  81. 81. What do Families Together do? Reward Not Using or Breaking Rules. Family recognition and reinforcement of children and teens doing the right thing (e.g., not using ATOD or not engaging in deviant or risky behaviors. The rewards and recognition increase intrinsic motivation to do the right thing, and cost little or no money The rewards and recognition create perceived warmth by children from parents and family.Thursday, April 14, 2011 81
  82. 82. What do Families Together do? Reduce Sleep Deprivation. Ensuring a child has good sleep patterns, by reducing access to electronic media before bedtime. Sleep deprivation is the silent but deadly cause of many behavioral, school and health problems —including addictions.Thursday, April 14, 2011 82
  83. 83. What do Families Together do? Change Brain Food or Fatty Acid Ratios in Child’s Diet. Increasing children’s “brain food” (omega-3 found in fish oil) protects a child’s basic brain function, brain receptors and brain chemistry from the risk of ATOD as well as other problematic behaviors including depression and aggression. The main biological factor that has radically changed in the last 20 years, dramatically affecting behavior, mental health and physical health of our children.Thursday, April 14, 2011 83
  84. 84. What do Families Together do? Increase Parent Networking to Adolescents’ Friends Families. Sharing and communicating the above with five of the parents of one’s child’s friends.Thursday, April 14, 2011 84