C linical C hild and Family P sychology R eview, Vol. 5, N o. 4, D ecember 2002 ( C 2002) pages 273-297

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Good Behavior Game Review
Good Behavior Game Review
Good Behavior Game Review
Good Behavior Game Review
Good Behavior Game Review
Good Behavior Game Review
Good Behavior Game Review
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Good Behavior Game Review

  1. 1. 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 D ennis D . E mbry1 A “ behavioral vaccine” provides an inoculation against morbidity or mortality, impactingphys- 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 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. INT R OD U CT ION I n the late 1840s, D r I gnaz Semmelweis worked in the maternity wards of a V ienna hospital. B y metic- A behavioral vaccine is a simple, scientifically ulous observation, he discovered that the mortality 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 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% . 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 273 1096-4037/02/1200-0273/0 C 2002 Plenum Publishing C orporation
  2. 2. 274 Embry the single most important means of preventing the The Logic Model of Behavioral Vaccines spread of infection.” Other behavioral vaccines have been promoted Like any public-health measure, behavioral vac- on the premise of reduced mortality or morbidity. In cines must be able to be used across the whole popu- the 1960s and 1970s, seat-belt use for adults and car lation to achieve the full societal as well as individual seats for children were examples from the injury con- prevention effect. The need for universality can be trol literature. modeled mathematically and logically (e.g., Embry & In contemporary society, an epidemic affect- Flannery, 1999). Mathematically, prevalence rates of ing young people has waxed and waned since the multiproblem behaviors (e.g., substance abuse, mis- 1960s. Substance abuse; delinquency; school failure; use, juvenile crime) typically range from 1 to 15% psychiatric disorders such as ADHD, oppositional for the purposes of illustration here. Prediction of defiance, and depression; teen suicide; teen preg- who will develop these problems over life span is nancy; and youth violence have adversely affected quite clearly not 100%, and ranges vary dramatically the lives of America’s adolescents (see the various depending upon the complexity, comprehensiveness, Surgeon General’s reports on these topics). These and sensitivity of the prediction tools. Issues of false problems often co-occur in what Biglan (2001) de- negative and false positive identification loom large, scribes as multiproblem youth. Could there be a however (Embry & Flannery, 1999). If one presumes behavioral vaccine, nearly as simple as antiseptic that certain problem behaviors happen in around 5% hand washing, which might significantly reduce the of the population, then 500 out of 10,000 people ought mortality and morbidity of multiproblem behavior? to be afflicted. An 85% accurate prediction model Yes, there could be. This paper details what one (which would be the envy of most behavioral epidemi- might be and how it might become as common as ologists) could correctly classify 425 people, missing a doctor or nurse washing hands with antiseptic 75. How many might be false positives though? In a solution. rough way, that can be calculated by subtracting the 425 correct positive predictions from 10,000. Then, multiply that number by the prediction error term Behavioral Vaccine Defined (15%). The result is that public-health practitioners, school, law-enforcement, and/or parents might have A behavioral vaccine is a simple procedure that erroneously identified 1,436 people as at-risk when can dramatically change an adverse outcome. Unlike they are not. In times of scarce resources, implement- prevention programs, which are typically described ing selected or targeted interventions for those 1,436 as a collection of procedures delivered over a set time people makes little economic, logical, political, social, such as 8–12 weeks, a behavioral vaccine is given only or health sense—especially when the delivery of tar- once or used as a simple routine of daily life. Traf- geted or selected prevention strategies may run thou- fic safety research offers some useful examples. A sands of dollars per person, be very difficult to deploy, drivers’ education program is a prevention program. or both. Both optional air bags and seat belts are behavioral The logic of a behavioral vaccine improves the vaccines. In the case of optional air bags when they power, prediction, and cost-effectiveness of targeted were introduced, a person only needed to make a de- and selected prevention strategies. This can be il- cision to buy a new car with air bags to enjoy the ben- lustrated by problems posed by bioterrorism pre- efit of increased safety. In the case of seat belts, one vention and early detection. Chills, fevers, vomit- must buckle up each time to maximize safety from ing, and other such symptoms are common early sig- harm. Both types of behaviors are relatively easy, un- nals of some agents suitable for bioterrorism, such like the complexity of a drivers’ training course on as anthrax—necessitating an elaborate screening and accident avoidance. A hallmark of a behavioral vac- detection (U.S. Surgeon General, 2002). These sig- cine is that a simple action yields large results. Per nals are also the early symptoms of the flu and se, behavioral vaccines do not preclude other strate- colds, which are perversely common, resulting in false gies, and may even work synergistically with or be negatives or positives. Thus, an epidemic of flu-like combined with more strategies to leverage effects. symptoms could precipitate a dramatic overresponse Behavioral vaccines are typically very inexpensive, from authorities (false positive)—which uses up valu- and work for a broad population, with few adverse able social, economic and political capital making, effects. paradoxically making the society more vulnerable.
  3. 3. The Good Behavior Game as a Behavioral Vaccine 275 Or, the authorities might underrespond, dismiss- A final set of issues exists in the logical model of ing the events as simply colds or flu (false nega- behavioral vaccines: ability to scale to nearly universal tive). In the case of multiproblem behavior such coverage, low adverse reactions, and robustness to be as substance abuse and juvenile crime, behaviors used in combinations with other strategies. such as early impulsivity, inattention, and disruptive- Logically, a behavioral vaccine must be easily ness among children—nearly as common as flu-like scaled to cover large areas of social geography and symptoms metaphorically—predict serious problems its attendant population to achieve protective effects. a decade or so later (e.g., Tremblay, Masse, Perron, Logically, the behavioral vaccine would have to work and Leblanc, 1992); even though, a good half or so with very diverse ages and work across different eth- of the children will desist a decade later in these be- nic or cultural groups. Mathematically, it is virtually haviors (e.g., Walker, Colvin, & Ramsey, 1995). If ev- impossible to affect community-level outcomes (e.g., ery young child who exhibits these behaviors receives crime rates, drug use) without near universal coverage medication, behavioral interventions at home, and be- of a primary prevention strategy. A behavioral vac- havioral interventions at school, the personnel and cine must also have low negative side effects, if used economic cost would be substantial. And, substantial at scale. Why so? Lipsey (1992) reports that approx- numbers of children or families would be subjected to imately 29% of the interventions to prevent delin- medication or services simply not needed and possibly quency actually make young people worse, and this iatrogenic. Now, imagine that a universal precaution may be a significant underestimate because efforts can cut the incidence rate of the key manifestations with adverse results are less likely to be published for of a behavioral or a public-health problem from 20 to many reasons. Thus, a behavioral vaccine with signif- 50%. Such prevention effects dramatically improve icant adverse effects for a subset could actually make the sensitivity, power, and and cost-effectiveness of se- community-level results worse, instead of better. An lected or targeted interventions—which can be mod- extension of the logic of reducing adverse reactions eled mathematically. This efficiency effect can be ex- would extend to how the vaccine interacted with other emplified by the harried school counselor or psychol- prevention or intervention efforts, as a behavioral vac- ogist who now has 20–50% fewer referrals for eval- cine could be like certain drug interactions. To the dis- uation for conduct or attention problems, and who may of most program developers, users of prevention now has more time for more accurate screening and protocols often do not implement them with fidelity treatment. or may mix them with home grown strategies. A po- The logic of a behavioral vaccine has even more tential behavioral vaccine could have robust internal potency if there are suspected contagion effects. Con- validity in carefully randomized control-group stud- tagion can be real or via social learning in mul- ies, yet fail miserably in the field. Thus, a behavioral tiproblem behaviors. For example, placing a child vaccine would need to have evidence of impact and with risk factors among other children who manifest utility in sloppy, naturalistic conditions. those same symptoms for an intervention or preven- The logic model for a behavioral vaccine shares tion can dramatically escalate the expression of the some elements of the risk and protective factor liter- rate and severity of symptoms, causing more harm ature currently driving much of the prevention pol- to the individuals, peers, and society (e.g., Dishion, icy in the United States (e.g., Catalano, 2001), yet is McCord, & Poulin, 1999). Even the simple random quite different in other ways more akin to large public- assignment of impulsive or disruptive 1st graders health campaigns. Both models rely on empirical data. to classrooms with high, medium, or low levels of In the risk and protective factor model (Catalano, peer aggression can dramatically escalate or miti- 2001), small units of government (e.g., schools, school gate serious behavioral problems a decade later (e.g., districts, or communities) attempt to create a plan pre- Kellam, Ling, Merisca, Brown, & Ialongo, 1998). sumptively based on their unique data. The behavioral These adverse contagion effects could be the re- vaccine model holds that certain risks or protective sult of imitation, peer reinforcement of antisocial factors must be considered at a population or near behavior, or escape conditioning from aversive be- universal level. The nature of the data construct (nor- haviors by adults, or some combination. One might mative based) of the risk and protective factor model usefully think about contagion effects as “tipping makes it very difficult to detect general population points,” which could be altered by classroom manage- factors adversely affecting child development vis-a- ment, school climate, or community-wide behavioral vis small unit prediction. Further, the risk and protec- vaccines. tive factor model does not take into account the time
  4. 4. 276 Embry sequence of prediction, only the current prediction in words for the children to form a generalized concept. a cross-sectional mode. The behavioral vaccine model Fourth, the adult explains that the Game is played at presumes a developmental sequence or vector, which intervals, like innings, but never for the whole day. if interrupted, has long-lasting effects. Fifth, the adult divides the group into teams and ex- If the logic model is true for behavioral vaccines, plains that a team may win the Game by having the then great benefits could accrue for individuals, fam- fewest fouls (or below a criterion in later research, ilies, schools, and communities from a powerful pre- enabling multiple winners), because that means more vention strategy that could be used in large-scale pub- good has happened. Every team can win some brief lic health models. The question begs: does preven- activity prize if they have less than a predetermined tion science suggest any strategies as potentially ap- number of fouls during an interval. Sixth, the adult propriate as a behavioral vaccine for multiproblem makes sure a daily scoreboard is highly visible, just behavior? like the scoreboard of baseball or football, with fouls much smaller than wins. The Game has procedures A Candidate Behavioral Vaccine for how to play in certain circumstances, how to keep it exciting, how to improve generalization, and how A bit over 30 years ago, two graduate students, to solve problems for players who cheat or flout the Harriet Barrish and Muriel Saunders, and one of the conventions. founders of behavior analysis, Montrose Wolf, pub- In this paper, I outline why and how the lished a study on the effects of something called widespread application of the Game might be one of the Good Behavior Game (hereinafter, the Game; the most cost-beneficial prevention strategies avail- Barrish, Saunders, & Wolf, 1969). It worked pretty able for schools and other settings. The paper will well, and became a behavior-modification “trick” also map out the scientific and practical ways that the most graduate students in behavior analysis or spe- Game might become a universal public-health mea- cial education learned during the heyday of be- sure or vaccine for the prevention of multiproblem havioral psychology. Neither Barrish, Saunders, or behavior. The rationale for the idea of a universal be- Wolf, nor the graduate students who learned to use havioral vaccine can be advanced on the basis of epi- the Game as a classroom strategy, had the slight- demiological research, findings from the neurochem- est idea then how powerful the strategy might be istry of behavior, evolutionary psychology, replicated for changing the future of children destined for life- behavioral studies, and simple mathematics. This pa- time multiproblems of substance abuse, violence, per also discusses research and practical issues related and school failure (Kellam & Anthony, 1998; Reid, to a “behavioral vaccine” for prevention. Eddy, Fetrow, & Stoolmiller, 1999; White, Loeber, Stouthamer-Loeber, & Farrington, 1999). EPIDEMIOLOGY OF MULTIPROBLEM Even with the spread of “best practice” guides, BEHAVIOR AS FOUNDATION FOR A very few policymakers, government agencies, educa- BEHAVIORAL VACCINE tors, prevention specialists, mental-health providers, or even research scientists know about the Good The foundation for a behavioral vaccine would, Behavior Game. Very few people know about the po- of necessity, make sense only if there were evidence tential for the Game to prevent multiproblem behav- of a behavioral trajectory that predicted adverse out- ior that gobbles up special education, juvenile delin- comes. That evidence would be even stronger for the quency, and treatment dollars. vaccine if the behavioral trajectory were measurable, The Game is the simplest of behavioral strate- meaningful, and malleable. Such a foundation is be- gies, which has been described in detail in a manual coming much stronger because of the quality and (Embry & Straatemeier, 2001). First, the adult inducts quantity of scientific research on multiproblem behav- children’s definitions of the rules of the setting, specifi- ior of substance abuse, delinquency, violence, school cally what would make the classroom or nonacademic failure, and related mental-health disorders. setting a good place to learn, more enjoyable, pleas- Just a few years ago, practitioners and scien- ant, etc., all labeled as the “good things we all want.” tists built program and scientific castles about the Second, the adult inducts children’s descriptions of causes, prevention, and treatment of substance abuse, behaviors that would interfere with desirable out- delinquency, violence, various mental-disorders, and comes and labels these generically as “fouls.” Third, school failure. Champions argued that each problem examples of both are presented physically and in was caused by very unique factors, necessitating a
  5. 5. The Good Behavior Game as a Behavioral Vaccine 277 tobacco prevention program, a marijuana prevention pathways. These studies clearly suggest that the be- program, a violence prevention program, etc. These havioral trajectory is measurable and meaningful. Are prevention castles have been defended to the death, the trajectories malleable? even when they are expensive and show weak or Some of the longitudinal studies, by happy cir- no effects. Typically, the prevention models emerged cumstance, indicate that environmental or social largely as a result of simple cross-sectional studies events alter the apparent trajectory of multiproblem or incomplete epidemiological information. It was behavior. Consider just a few examples from the lon- and is a classic case of inadequate experimental de- gitudinal literature. Patterson and colleagues have sign on developmental issues, leading to erroneous had the opportunity to study behavioral interactions conclusions—just as Schaie and Baltes (1975) warned. (interval-by-interval coding) in the context of longitu- Over time, well-controlled multiple longitudinal dinal study of antisocial children. What did they find? and twin-studies stormed and demolished the castles, Patterson, Dishion, and Yoerger (2000) reported that though defenders of the rubble still continue. Con- more than 50% of the outcome of substance use, sider some examples of the castle sieges. health-risking sexual behavior, and police arrests can In 1990, Shedler and Block published landmark be predicted by how much reinforcement of deviant results on substance abuse from a long-standing lon- behavior children receive. In a 1998 study, Patterson, gitudinal study. They reported that substance abuse Forgatch, Yoerger, and Stoolmiller argued that the (vs. substance experimentation) at age 18 could be prediction of lifetime deviancy had stable behavioral predicted by simple measures of coercive parent– roots at least as early as the 4th grade, based on their child interactions at age 8. Shedler and Block’s find- data. One of Patterson’s key colleagues has further ings mirrored the more fine-grained longitudinal documented that deviance reinforcement and delin- studies on the role of parent–child coercive interac- quent behavior follow the matching law (Dishion, tions in the cause of antisocial behavior by Patterson Spracklen, Andrews, & Patterson, 1996). The pat- and Stouthamer-Loeber (1984), by Patterson, De tern of reinforcement delivered by parents and the Baryshe, and Ramsey (1989), and more recently reciprocal interactions between parent and child have by Ary et al. (1999). Other longitudinal studies, been well documented to be malleable in high-quality, such as by Walker, Stieber, Ramsey, and O’Neill thorough behavior analysis or in other studies (e.g., (1993), followed, showing the links between early Kosterman, Hawkins, Spoth, Haggerty, et al., 1997; aggression in boys and lifetime problem behavior. Tremblay, Pagani-Kurtz, Masse, Vitaro, et al., 1995; Tremblay et al. (1992) observed these connections Webster-Stratton & Hammond, 1997). in boys in Montreal. Consistent reports emerged Most of the above work focuses on the family from researchers in other locations. Raine, Ven- context, and other researchers have examined school ables, and Mednick (1997) found similar relation- or community contexts in terms of behavioral tra- ships in a long-term study in Mauritius. In the long- jectory. Rutter, Maughan, Mortimore, Ouston, and standing Child Development Study in New Zealand, Smith (1979) and Rutter (1985) show powerful ef- Moffitt (1990, 1993) provided strong evidence for life- fects of school organization on delinquency, behav- course continuity of early problem behaviors and ad- ior problems, and other outcomes. Rutter proposes verse adolescent outcomes. Swedish studies showed that the structure and organization of school may dif- long-term relationships between aggression, alcohol ferentially reinforce resilient behavior versus antiso- use, and criminals behaviors (Andersson, Mahoney, cial behavior. One of the original descriptive studies Wennberg, Kuehlhorn, & Magnusson, 1999). In the of the Baltimore Prevention Project (Kellam, Mayer, United Kingdom, Champion, Goodall, and Rutter Rebok, & Hawkins, 1998) showed that classroom con- (1995) have shown the connections between various text had a 6-year impact on developmental outcomes adverse developmental outcomes in a decade-long for children with elevated developmental risk. Specif- study. Recently, more complex longitudinal studies ically, Kellam, Ling, et al. (1998) report that high- have revealed similar data (Loeber, Stouthammer- risk children who were randomly assigned to class- Loeber, & White, 1999), yet expand on how depres- rooms with naturally occurring low or high levels of sion and internalizing symptoms affect the outcomes aggression by other children had very adverse im- along with early aggression. What do all these lon- pact on the randomly assigned longitudinally stud- gitudinal data tell us? In general, the data suggest ied boys but not girls. Collectively, Kellam’s work that many serious behavioral problems of adolescence suggests that the boys in his research settings might and young adulthood emerge from similar behavioral have been reinforced for aggressive behavior by peers
  6. 6. 278 Embry (both negatively and positively), in much the same related publication from the Australian Twin Registry way as Patterson’s cycle of coercion was observed in (Slutske et al., 1995) showed that girls with conduct a family context. School context, at least, offers ev- disorder had a 10-fold greater risk of having prob- idence of a behavioral trajectory that is measurable lems with alcoholism than girls without conduct dis- and meaningful. order. The Minnesota Twin Study shows a strong asso- Some evidence suggests that the behaviors might ciation for alcoholism, ADHD, and other behavioral not be easily malleable, perhaps reducing the likeli- problems among 1,200 twins (Disney, Elkins, McGue, hood of a behavioral vaccine. It appears, from several & Iacono, 1999). Most of the twin studies suggest a types of inquiry, that some children have an innate strong linkage between problems of attention, hyper- vulnerability to the cycle of family or peer coercion, activity, and aggression as key underlying factors pre- and possibly, the reinforcement of aggressive behav- dicting multiproblem behavior in boys. Reduction in ior. Some of the longitudinal studies strongly suggest rate, intensity, and duration of these behaviors might a genetic modulation of outcome, as well as lever- be the logical target of a behavioral vaccine—unless age points for intervention or prevention. In a re- such behaviors were so profoundly genetically driven port from their Montreal study, Tremblay, Pihl, Vitaro, as to be immutable. The research on genetic mecha- and Dobkin (1994) obtained teacher ratings on 1,161 nisms of these findings has considerable implications kindergarten boys from 53 schools with the lowest for prevention. socioeconomic status, on the dimensions proposed by Genetic studies of multiproblem behavior have Cloninger, Sigvardson, and Bohman (1988). Tremblay advanced significantly in the last decade, and these et al. (1992) correlated the teacher survey results with advances suggest that genetic vulnerability is not the presence of self-reported delinquent behavior at static but sensitive to social events—potentially mak- age 13. Scores for high impulsivity and hyperactiv- ing the need for behavioral vaccine higher, which ity were the strongest predictors of delinquency ( p < might prevent the disturbing problems from un- .0001), whereas scores for low anxiety ( p < .016) folding. Few social scientists realize the significance and low reward dependence ( p < .029) provided a of advances in genetics research, which regulate lower level of prediction (see Fig. 1). The results con- some of the neurotransmitter candidates identified firmed the prediction of Cloninger’s neurotransmitter by Cloninger as implicated in multiproblem behavior model that high impulsivity and novelty seeking pre- (e.g., Comings, 1995; Comings et al. 2000; Comings, dict high risk for antisocial behaviors, which are be- Gade, Muhleman, & MacMurray, 1996; Comings, haviors modulated by serotonin, dopamine, and nore- Gade, Wu, et al., 1996). Importantly, candidate poly- pinephrine (e.g., Cloninger, 1994). genic alleles for multiproblem behaviors have strong If the longitudinal studies are correct, then the evidence for being turned on by exposure to per- need for a strong behavioral vaccine might be even ceived human stress (e.g., Madrid, Anderson, Lee, greater for individuals who have a genetic risk for MacMurray, & Comings, 2001), and the neurotrans- multiproblem behaviors. The question is whether such mitters implicated in multiproblem behavior are genetic vulnerability exists. The answer is yes. Stud- clearly related to social interactions (e.g., Quist & ies of twins amplify and refine the general longitu- Kennedy, 2001). Because the evolutionary psychol- dinal studies on multiproblem behavior, suggesting ogists and other scientists have convincingly docu- strong genetic linkages. Slutske et al. (1997) utilized mented that individuals who likely carry these genes the Australian Twin Registry for the largest twin study (and behaviors) do not randomly mate (e.g., Buss, of conduct disorder ever reported. They examined 1984; Krueger, Moffitt, Caspi, Bleske, & Silva, 1998), a 2,682 adult twins, and concluded that genetic fac- behavioral vaccine for multiproblem behavior in chil- tors contributed to at least 71% of the disorder. A dren might have to operate in schools or community. The advances in genetics research help resolve the tension between nature versus nurture debate (see Embry, in press, for a complete discussion), and a be- havioral vaccine might mitigate against the interac- tions between genetic vulnerability and common so- cial risk factors articulated by numerous investigators found in schools, communities, peers, and even homes. What are the implications of all of these di- Fig. 1. Longitudinal prediction from Montreal Study. verse epidemiological findings? First, reductions in
  7. 7. The Good Behavior Game as a Behavioral Vaccine 279 early inattention, disruptiveness, and related behav- The Good Behavior Game: General iors ought to decrease long-term adverse socially Theory and History undesirable outcomes—nothing particularly new but worth restating. Second, the biological processes of Some 100 years of solid psychological research multiproblem behaviors are clearly affected by social shows that behavior varies as a function of its con- events, and scientific advances now make it possible to sequences (e.g., Catania, 1992; Malott, Whaley, & understand how the social environment might affect Malott, 1997). Thorndike first labeled this as the the expression of genes related to the biology of mul- “Law of Effect” back in the early 1900s. Since that tiproblem behavior. Third, the epidemiological data time, the observations have been codified into the suggest that effective behavioral procedures, univer- most robust replicated general principles of the sci- sally promoted and used, might well be powerfully ence of behavior such as the “Matching Law” (e.g. effective environmental or behavioral “vaccines” to Herrnstein, 1970). There is a profound reason that sci- prevent the occurrence of multiproblem behavior. entists refer to this principle as a “law.” It is universal, highly replicated, easily demonstrated, and parsimo- A BEHAVIORAL VACCINE nious. Against this backdrop, graduate students like Harriet Barrish and Muriel Saunders and scientists Presently, society has two current operative defi- like Montrose Wolf thought disruptive, disagreeable nitions or venues of the vaccine concept. In medicine, behaviors by students might happen because peers a vaccine is a preparation containing weakened or and others somehow reinforced them in school set- dead microbes of the kind that cause a particular dis- tings. Perhaps, the smiles, giggles, laughs, and even ease administered to stimulate the immune system, pointed taunting from other students were reinforcing protecting the individual from future exposure. In the high rate of the behaviors that teachers found so computer science, it is a software program that pro- difficult to handle or harmful to the learning process. tects a computer from a virus or worm infection. Both In this context and time, the graduate students and of these concepts can be extended to the behavioral senior scientists reasoned that some kind of group- realm. based reward for inhibiting negative behavior might With a behavioral vaccine, a person might be ex- be a boon for classrooms. Already, there were power- posed to a weakened behavioral risk, which could ful precedents for such an idea. The idea for the Good stimulate a protective response to a more full-blown Behavior Game was born. exposure to the social, emotional, or psychological risk. Or, a person might learn a protective program Behavior Analysis Studies of Good Behavior of behavior that attacks, dislodges, or protects against Game Demonstrate Efficacy any exposure to a dangerous behavioral assault in the future. Applied behavior analysis (Baer, Wolf, & Risley, Vaccines are most effective when everyone who 1968) posits careful testing of strategies to change has a risk receives a critical dose. Under such circum- human behavior in context, most frequently us- stances, the virus has no host population to infect. ing time-series methodologies such as reversal or Childhood immunizations are classic cases of vaccines multiple-baseline evaluations, which have power- for a vulnerable population, with few children in deve- ful advantages in applied research (e.g., Barlow & loped countries now dying from scourges of the past. Hersen, 1973). The initial efficacy evaluations of the A vaccine is not like treatment, the latter of which Game occur in this context. is typically given after the onset of the disease or dis- order. Vaccines are typically given universally before First Test of Efficacy onset. Could certain simple-to-apply, universal behav- In 1969, Barrish et al. published the first study on ioral interventions confer some sort of “immunity” the Good Behavior Game using a multiple-baseline against multiproblem behaviors such as substance design in a very difficult classroom. It was this class abuse, juvenile delinquency, and other problems? The that became the first to try the Game in a controlled answer appears to be “yes.” The Good Behavior study. The 4th-grade children were observed during Game is a good candidate to consider as a potential maths and reading. Trained observers coded student behavioral vaccine, and the next sections of this paper behavior every minute for an hour, 3 days a week present the evidence and logic for the possibility. for several weeks. The children were out-of-seat or
  8. 8. 280 Embry talking-out for about 80–96% of each class period, design, using the class as its own control. They tested making instruction nearly impossible. Bedlam would the whole game and different components to see how have described the class. they worked. Game components included rules, red The Game was played everyday during maths, or green lights (response feedback using nonemo- with the class divided down the middle row into two tional cueing), and group consequences of extra recess teams. One or both teams could win privileges (e.g. and extra free time. Two observers counted talking- wear victory tags, be first in lunch line, get a star on out, disruptive, and out-of-seat behaviors. The graphs a winners’ chart, earn free time) by having the lowest from the study show that the total Game package re- number of marks tallied on the board for disruptive duced all the disruptive behaviors from their baseline behaviors. Teams with under 20 marks for the week rate by almost 99% for one group and 97% for the earned special privileges at the end of the week. other. The component analysis revealed that after as- The rate of disruptions fell immediately from sociation in the Game, the nonemotional cueing stim- about 91% to 10% in the hour, a great improve- uli of rules and lights were moderately effective in re- ment. Meanwhile, the disruptions during reading time ducing the problem behaviors; the whole Game pack- stayed pretty much the same. age was, however, most efficacious. What was partic- After a few weeks, the teacher stopped playing ularly noteworthy was the fact that the students and the Game during maths but started playing it in read- teacher were able to cover 25% more academic ma- ing. The results immediately showed the efficacy of terial during the Game. This study revealed that the the Game. Behavior during maths looked pretty bad use of the signal light decreased bad behavior, under- again, just like the “baseline.” Behavior during read- scoring the importance of a consistent, unemotional ing was greatly improved. After a week, the teacher response or cue about bad behavior. The study also played the Game during both times, and the rate of revealed that enunciation of the rules by the teacher problem behavior fell quite low. each day had a small effect, which could explain the often reported comment by teachers that the children Efficacy Test of Game Components “need to be nagged” about the rules. Figure 2 summa- rizes Medland and Stachnik results. The Good Behavior Game actually has several potentially “active ingredients” that might account for Efficacy Test With Higher Risk Population its efficacy. In 1972, Medland and Stachnik tested the good-behavior Game in a 5th-grade reading class con- Children who ultimately develop multiproblem sisting of two groups of 14 students each in a reversal outcomes often have a special-education history (e.g., Fig. 2. Medland and Stachnik (1972) results.
  9. 9. The Good Behavior Game as a Behavioral Vaccine 281 Walker et al., 1995), and it would be important multiproblem behavior. A good candidate for a be- to demonstrate that a potential behavioral vaccine havioral vaccine is likely to have a family of related could be efficacious with such higher risk populations. interventions, and finding the most efficacious alter- Grandy, Madsen, and De Mersseman tried the Game native would be logical. One of the most obvious alter- with elementary-age special-education students in native strategies is teacher attention, that is, training 1973 in a behavior analysis design. Again, the disrup- a teacher to pay more attention to a child’s good be- tive behaviors went way down. This study showed that havior. In 1977, Warner, Miller, and Cohen compared the Game could generalize to a higher risk population. the effects of the Game against simple teacher atten- tion for being good among 4th and 5th graders. The Game was much more effective and simpler to use, Refinement of the Efficacious Components which was important for building a case for it as a potential behavioral vaccine. Warner and colleagues Medland and Stachnik (1972) did not test all also provided a key finding for social validity of the the salient components of the Game package, which Game as a potential behavioral vaccine. As teachers might be crucial in understanding the active ingredi- often complain that they cannot praise for a variety of ents of this potential behavioral vaccine. Harris and reasons, the differential effects of the Game met a key Sherman tested the Game components in 1973, and objection to a common recommendation of increasing they too found that disruptive talking and out-of-seat praise. behavior fell dramatically in 5th- and 6th-grade stu- dents. By testing the Game in multicomponent rever- sal design, they allowed for a better understanding of The Role of Peer Pressure as Key Component key, effective components of the Game. Key ingre- dients turned out to be the division of the class into Deviant peers are clearly a risk factor in the epi- teams, positive consequences for a team winning the demiology of multiproblem behavior (e.g., Dishion Game, and a low number of marks set as criteria for et al., 1999), and the Game historically made explicit winning the Game. Harris and Sherman did find that use of peer-related variables: peer pressure, peer com- reductions in negative behavior only slightly affected petition, and peer recognition via teams. Was this an academic achievement, which flags the need for other important element for the Game achieving its ther- research to determine whether the Game could be apeutic effects, which is important to understand for combined with explicit academic improvement strate- the use of the Game as a behavioral vaccine. Hegerle, gies without adverse effects as teachers and schools Kesecker, and Couch directly replicated the Game would be likely to pursue additional components. again in 1979, but examined the efficacy of these peer- related components. They found that peer pressure, competition, and social recognition were all impor- Efficacy Test With Young Primary School Children tant components. This added to the understanding of why the Game might work. These components fit well In the chronology of efficacy studies, all had been into the notion of the matching law with peers and focused on intermediate-level students in elementary school systems (e.g., Dishion et al., 1996; Embry & schools. No evidence existed that it could be effi- Flannery, 1999). The matching law (Herrnstein, 1970) cacious with younger students, which would natu- can be expressed as rally boost its potential as behavioral vaccine. Bostow B = kr/(r + r e) and Geiger evaluated the Game’s effects using a be- havior analysis design on 2nd graders in 1976. Here B is the behavior in question. k is a asymptotic con- again, it was effective, expanding the generalizability stant and r is the rate of reinforcement of the B; this to younger ages. is divided by the same r plus re (the rate of rein- forcement of all other behaviors. Peer pressure and competition reduce the re term, thereby making the r Comparative Efficacy Trials for Rival Strategies (social recognition) more potent for positive actions in the classroom. This author believes this matching The Game is not the only school-based strat- law effect helps explain why just putting check marks egy that could be used to decrease the impulsive, up by individual children’s names is far less effective disruptive, and inattentive behaviors that predict than the strategy of a mark for a child’s team. The
  10. 10. 282 Embry competition diminishes the re (e.g., peer attention to and Wasik showed that the Game could be played negative behavior), making the rewards controlled by in the school library and bridge to the classroom at the teacher for wining the game (e.g., the r) more the same time. Their study also illuminated a variable potent. that could improve the social validity of the Game, its widespread use: A delightful twist involved hav- ing the students help set and define the rules, with Efficacy of the Game After Initial Training no loss of effects. As almost any classroom teacher could articulate, students are more likely to “buy in” How long might the effects of the Game last af- and not resist the Game, if they can help set the rules. ter being played briefly with no coaching from any- Although the efficacy of the Game in the library is one outside the classroom? Johnson, Turner, and nice, bad behavior in the library is not a huge known Konarski answered that question in 1978. The answer predictor of substance abuse, violence, and other ills. helps shape how an effective behavioral vaccine might In 1998, Patrick, Ward, and Crouch found that the be delivered. Among highly disruptive intermediate Game could be powerfully adapted to physical educa- classrooms, they found that the effects of the Game tion or play-type activities outside. This suggested that did last but started to decay after 2 months when the the Game could also be used to solve playground or “coach” stopped coming to the classroom to encour- recess problems—which is an epidemiologically rele- age the use of the Game. This particular study sug- vant risk predictor (e.g., Walker et al., 1995). gests, not surprisingly, that a diffusion model of the Game as behavioral vaccine might require some at- tention to produce longer term effects. Efficacy of the Game for Special Education Students in Regular Classrooms Efficacy of the Game Across Cultures A behavioral vaccine would have limited value if it could not buffer or protect a vulnerable child If the Game worked across different cultures in a high-risk setting. Children with special educa- then it might mean that the processes were very tion designation in regular classrooms are an exam- strong, profound, and universal. Such a finding would ple of such a risk. Did the Game work for really boost confidence that the Game could be a viable can- serious behavior-problem children who were “main- didate as a behavioral vaccine. Huber reported posi- streamed” in a regular classroom when the whole tive results in Germany in 1979 in a behavior analysis class played the Game? Yes, discovered Darveaux efficacy study. Saigh and Umar (1983) found strong in 1984. She had the Game played in a classroom effects for Sudanese 2nd graders whose parents could while observing two targeted children on each team. not read or write, in a reversal design. Saigh and Umar The two target behavior-problem children did im- were among the first investigators to report that the prove when the whole class played the Game. This Game reduced aggression. It is interesting to note that suggested that classroom teachers would be able to younger children vis-a-vis older children seem to show use the Game as an effective behavior management reversal effects rather quickly, suggesting that young strategy for children at-risk for placement in special children will require more consistent, lengthy use of services. the Game. These published studies suggest that the Game can be effective in culturally diverse contexts. Impact of Different Kinds of Rewards on Efficacy Generalized Efficacy of the Game to Teachers typically select and apply rewards for Non-classroom Settings behavior quite idiosyncratically, which could seriously impair the efficacy of the Game if significant fidelity of Previously, all published studies had focused on implementation were required for rewards for the be- the efficacy of the Game in classrooms. From a behav- havioral vaccine to work. What kind of rewards work ioral vaccine perspective, the odds for success would for the Game? Kosiec, Czernicki, and McLaughlin be strengthened if the “vaccine” could be adminis- found in 1986, that students did equally well when they tered in other settings where the epidemiologically played the Game for activity rewards versus candy. relevant behaviors are manifest. In 1981, Fishbein The children did like the candy as a reward, but it
  11. 11. The Good Behavior Game as a Behavioral Vaccine 283 was useful to discover that activity rewards were pow- Social Validity Studies erful. The fact that activity rewards appear to be as powerful as material or edible rewards helps with the A potential behavioral vaccine might be effica- acceptability of the Game by teachers and school ad- cious, but highly disliked by its putative users. Con- ministrators, who often express dislike for material sumer liking of a product can obviously affect word- rewards. of-mouth, fidelity of use, and other factors that would be relevant to long-term prevention. Social validity is an important concept in large-scale behavior change, Efficacy of the Game With Adolescents which measures (1) the social significance or impor- tance of the goals, (2) the social appropriateness of Previous prevention research has suggested that the procedures, and (3) the social importance of the boosters, rather like vaccine boosters, improve long- effects (Sulzer-Azaroff & Mayer, 1991). These ques- term results. Thus, it is reasonable to ask if the tions are pivotal in the diffusion of any science-based Game might work with adolescents. In 1986, Phillips practice. How does the Game measure in the field of and Christie found the Game worked quite well for consumer satisfaction? In 1994, Tingstrom found out intellectually impaired students whose ages ranged that over 200 teachers did like the Game and would from 12 to 23 years. In 1989, Salend, Reynolds, and use it. An important signal came from that study in Coyle proved that the Game worked for emotion- that teachers who did not “believe in positive rein- ally disturbed adolescents. The older students liked forcement” were not as likely to adopt it, however. the Game and stopped doing inappropriate verbal- izations, inappropriate touching, negative comments, cursing, and drumming. These findings suggest that Randomized Control Studies for Effectiveness the Game could be played, possibly as a booster, with of a Potential Behavioral Vaccine older youth. The efficacy studies discussed certainly point to the utility of the Good Behavior Game in chang- Efficacy With Very Young Children ing modifiable, meaningful, and measurable risk fac- tors of multiproblem behavior. However, the “Gold People often apply medications for other uses or Standard” of science is the use of random assignment for different age groups. It is natural to wonder if the to condition, especially large numbers of participants. Game might be used with very young children, which By the late 1980s, it was apparent that the Game had would broaden the basis for the Game as a behav- strong effects and could be something to try in a large ioral vaccine. A special puppet helped the preschool- randomized trial, which happened with the Baltimore ers learn the Game in the study by Swiezy, Matson, Prevention Project. and Box in 1992. Some other adaptations were re- A total of 864 1st-grade students from quired, however. Special colored badges were needed 19 Baltimore public schools participated in the by the teacher to track the preschoolers as they moved study during the 1985–86 academic year. Short-term from place to place in the room. results relied on assessments of all students in the fall and spring of 1st grade using three tools: • The Teacher Observation of Classroom Summary of Efficacy Studies Adaptation Revised (TOCA-R)—measuring a variety of childhood developmental psy- The early phases of science are best served by re- chopathologies, peated measure studies such as those used in applied • The Peer Assessment Inventory (PAI)— behavior analysis. Such studies provide a powerful, measuring peer social networks, and simple way of determining if the procedure has any • Direct observations of student behavior by probability of effect and helps identify how it varies classroom observers. based on different conditions, something not easy to do in randomized control group studies or is very The study had both control classrooms within very expensive. The early studies on the Good Be- (internal controls) and across schools (external con- havior Game show it to be a very promising, robust trols), making for a more powerful but complicated procedure. study.
  12. 12. 284 Embry In Baltimore, as in the earliest versions of the There were other long-term effects, not wholly Game, classes were divided into teams, which were predicted when the study started, strengthening the rewarded when members behaved appropriately and potential of the Game as a behavior vaccine for mul- participated in classroom activities rather than broke tiproblem behavior. For example, males were signif- rules and fought. Three teams were created per class, icantly less likely to initiate smoking (a 50% reduc- with equal distributions of aggressive and shy children tion in initiation rate) in the early teens (Kellam & per team. During the first weeks of the intervention, Anthony, 1998). Teacher ratings and self-reported age the Good Behavior Game was played three times each at first use of tobacco showed that (1) boys who had week, for a period of 10 min. Over successive weeks, received the Good Behavior Game intervention were duration per Game period was increased by 10 min, rated as better-behaved than their counterparts in the up to a maximum of 3 hr. other study conditions ( p < .05), and (2) the risk of What were the early results? Dolan and the other starting to smoke tobacco by age 13–14 years was Johns Hopkins scientists made an initial report in substantially greater for boys in the “standard set- 1993. First, both teachers and peers rated boys as more ting” control classrooms as compared to those who aggressive. Second, boys were seen as more shy by had spent 1st and 2nd grades in the Good Behav- teachers, but not by peers. Third, the Good Behavior ior Game classrooms ( p < .05). Kellam and Anthony Game had a significant short-term impact on teacher (1998) concluded from the long-term follow-up that ratings of aggressive and shy behavior for both males targeting early risk of aggressive behavior is an im- and females. There were some useful subfindings: portant smoking prevention strategy, something that longitudinal tracking studies with no intervention had • The intervention had greater impact in reduc- suggested but not proved. To this author’s knowledge, ing aggressive behavior in students who be- the result published by Kellam and Anthony is the gan the year with high aggressive ratings com- first inkling that a single classroom teaching strategy pared with students who began with low ag- by an individual teacher might substantially reduce gressive ratings—an important finding if the substance abuse, misuse, or initiation (see Fig. 3). Game were to be viable as a potential behav- A whole array of publications exist on the ioral vaccine. Baltimore project, noting its theory, design, and re- • Peer nominations of aggressive behavior sults (e.g., Ialongo et al.,1999; Kellam et al., 2000; among boys by their classmates were also sig- Kellam, Ling, et al., 1998; Kellam, Mayer, et al., 1998; n nificantly reduced. Only one of the three peer Kellam & Rebok, 1992; Kellam, Rebok, Ialongo, & nominations of shy behavior showed signifi- Mayer, 1994). Kellam and associates are continuing cant impact (“has few friends”) and that was longitudinal follow-ups of the original cohorts, which only in the case of females. will likely reveal more information about the life- • Finally, the Good Behavior Game increased course effect of the Game on such issues as arrest, edu- students’ on task performance in the classroom cational attainment, and other milestones. When new as assessed through direct observations. What were the longer term results? These are exceptionally important from a developmental per- spective, because the real problems, related to early predictors such as aggression, do not show up un- til the adolescent years. In Baltimore, the longitu- dinal results were collected 6 years later. Kellam, Mayer, et al. (1998) reported that although the pos- itive effects reported by teachers during interven- tion years in 1st and 2nd grades waned somewhat in the 3rd and 4th years, they reappeared in 5th grade and strengthened in 6th grade. More aggressive 1st- grade males benefited the most from the Game, with the aggression rating of over 30% significantly drop- ping by 6th grade. It appears, then, that the Game might function as a behavioral vaccine in a long-term study. Fig. 3. Good Behavior Game impact on tobacco initiation.
  13. 13. The Good Behavior Game as a Behavioral Vaccine 285 medicines are introduced and approved by the Fed- parent discipline and monitoring—many of the vari- eral Drug Administration, it is rare for the approvals ables targeted by Kellam and colleagues. The LIFT to cite ongoing inquiries with a decade or more long- is (a) classroom-based child social and problem skills term follow-up. Game is similarly rare in the preven- training, (b) playground-based behavior modification tion science literature, and the long-term follow-up using an adaptation of the Good Behavior Game, and strengthens the case for the use of the Game as a po- (c) group-delivered parent training. The results of a tential behavioral vaccine. randomized controlled evaluation of the LIFT are re- Not all reviewers concur about the value of the viewed. To date, during the 3 years following the pro- Game for prevention. Greenberg, Domitrovich, and gram, the LIFT delayed the time that participants first Bumbarger (1999) offer a critique of Kellam’s studies, became involved with antisocial peers during middle observing that the intervention did not include family school, as well as the time to first patterned alcohol or the larger school ecology (which this author views use, to first marijuana use, and to first police arrest. as a strength, in terms of the utility of the Game as Reid et al. (1999) report reductions in playground ag- a behavior vaccine). The 1999 critique did not have gression, with the largest effect size among the most the benefit of the Ialongo, Poduska, Werthamer, and aggressive children, as well as improvements in family Kellam (2001) study comparing the impact of com- problem-solving actions. At 30-month posttest, chil- bined classroom intervention (both the Game and dren from the treatment group were also significantly Mastery Learning) against a Family Program, which less likely to have been arrested. Microcoding of real- showed that the combined classroom approach was time playground aggression showed that intervention superior to the family-only program. Greenberg and benefited the most aggressive children at recess with colleagues also argue that two of the primary sources substantially high effect sizes (Stoolmiller, Eddy, & of data (teachers and peers) were aware of the treat- Reid, 2000). ment condition and in some ways had a stake in the The LIFT effort by Reid and his colleagues is outcome, which may have affected internal validity. noteworthy, because it is a systematic rather than di- Again, the fact that these two sources of data did show rect replication of the Game, which was imbedded in change is a source of strength, considering that both a larger effort. This means that the Game can be in- peer nominations and teacher ratings are extremely corporated with family and social skills interventions resistant to any intervention, yet are highly predictive with no apparent adverse effects. From the perspec- of serious antisocial behavior many years later (e.g., tive of a behavioral vaccine, it is vital that a strategy Embry & Flannery, 1999; Embry, Flannery, Vazsonyi, be able to work in combination with other strategies Powell, & Atha, 1996; Walker et al., 1995). To provide and still show benefit. a comparison in top-rated prevention programs, Sec- ond Step (a violence prevention curriculum for ele- mentary students) shows no impact on teacher ratings Awards and Recognition for the Good or parent ratings after a considerably more intensive Behavior Game classroom intervention in a randomized control group study (e.g., Grossman et al., 1997). Greenberg and col- The positive effects of the Game have been rec- leagues review (Greenberg et al., 1999) of the Good ognized by a number of sources. The Game is one Behavior Game erroneously reported that there had of the few “universal,” simple strategies identified by been no independent replications of the intervention, the Colorado Violence Prevention Blueprints Project, failing to cite the extensive, prior, peer reviewed stud- funded by the U.S. Centers for Disease Control, as ies mentioned herein while also observing that the meeting the scientific standards for a truly promising Linking the Interests of Families and Teachers (LIFT) violence prevention practice. The Substance Abuse project incorporated the Game as part of its overall and Mental Health Administration has also identi- strategy. fied the Game as a research-based promising practice. Linking the Interests of Families and Teachers The Surgeon General’s Report on Youth Violence (LIFT), a prevention program designed for delivery (U.S. Surgeon General, 2001) lists the Good Behavior to children and parents within the elementary school Game as a desirable practice. setting (e.g., Eddy, Reid, & Fetrow, 2000), worked in These awards and recognition are all the more 12 public elementary schools with about 700 students remarkable, because the Game is the only such in- in higher risk neighborhoods. The LIFT targets child tervention in the public domain, and something that oppositional, defiant, and socially inept behavior and an individual teacher or staff member can implement
  14. 14. 286 Embry versus a comprehensive school-wide program. The also a made-up word. The word for the goal helps breadth of replications of the Game by so many dif- foster positive debriefs (e.g., “What did you do to cre- ferent investigators across time only strengthens the ate PAXIS today?”), which has been shown to as- accolades. sist in the generalization of self-management and is a substitute behavior for teachers to avoid negative attention. Spleems are a word designed to reduce the Support From Current Field Trials and Other verbally inflected emotionality attached to noticing a Studies for Potential Behavioral Vaccine rule-breaking event, a key ingredient. Conversation- ally, it is much less explosive to say “that was a spleem” As established in the early parts of this paper, than “you broke the rule.” The PAXIS version in- a behavioral vaccine envisions widespread use of a cludes many small but useful stratagems needed to procedure. The Game needs to have some evidence package a research-based practice for diffusion—a of real-world diffusability. critical factor in a bringing a potential behavioral vac- Presently, my colleagues and I are engaged in a cine to scale. number of trials of the Game in a larger context. These The new words like PAXIS and spleems help community trials are described below. track the behavioral contagion effects of the Game, as Approximately 15 schools in the Greater Cleve- the words are completely novel. The words are what land area are involved in an open field trial of the some cultural anthropologists define as “memes”— Game to determine if the game can be simply pack- a sort of potentially self-replicating cultural concept, aged and trained in the course of 4–6 h. The Game again to a gene. Lynch (2001) describes a meme (pro- is referred to here as the PAX Game to denote the nounced “meem”) as a self-spreading thought, idea, inclusion of some ancillary components documented attitude, belief, or other brain-stored item of learned to improve compliance and classroom management culture. The idea of memes are frequently used in mar- such as “beat the timer,” nonverbal cues for stop (see keting as a way to track name recognition and build Medland & Stachnik, 1972) and transition cues for up brand recognition. walking in hallways. Early data show that schools can The use of words for the Game such as PAXIS implement the game, and have impact on such vari- and spleems create a “meme” in a school setting, pro- ables as student referrals and suspensions. viding a way to assess the frequency of the use of the Several years ago, my colleagues and I helped Game. For example, children who have played the Cook County Health Department in Cook County, Game in the last week are able to explain in great de- Illinois, design a protocol to have paraprofessionals tail if their team received any “spleems” that week. visit classrooms and teach the Game to the students Children who do not know what the Game is, will look and their teachers. To date, Cook County Health De- quite blankly at a visitor if you ask what “spleems” partment has taught numerous classrooms the Game their team committed yesterday. Thus, prevention and collected simple observational data on those specialists such as the ones in Cook County Health classrooms. The iteration of the Game designed by Department can quickly assess whether staff are re- the author and colleagues incorporates the identified ally following through with the daily repetitions—a active ingredients from the efficacy and effectiveness necessary element of a putative behavior vaccine. It studies, and it has been put together in such a way to is rather like the question, “did you floss your teeth encourage the use of other research-based protocols this morning” versus “do you practice good dental that might round out the effectiveness of the Game. hygiene?” Besides the components of teams, peer pressure, The teaching of the Game by Cook County para- competition, activity rewards, nonemotional cues, professionals is the first attempt to move the Game to enunciation of the rules, and group-based rewards, a behavioral vaccine model, capable of being taught the iteration includes some simple procedures to help outside the context of graduate students and research improve the social acceptability, participant buy-in, personnel. A sample of data from one school and facilitate generalization, and assist the tracking of the classrooms in Cook County appears in Fig. 4, showing game. Here are a few examples. The students induct observed “spleems” over time before and after the the rules and vision of the class using some special teaching of the Game, which are very encouraging. lessons. They pursue productivity, peace, health, and Not all schools and classrooms have the same results. happiness by creating PAXIS. Things that get in the The current effort in Cleveland and the past ef- way of PAXIS, a made-up word, are called spleems, fort in Cook County suggest that the Game can be
  15. 15. The Good Behavior Game as a Behavioral Vaccine 287 Fig. 4. Impact of Game taught by paraprofessionals. practically disseminated in a real-world context. In It is documented that an effective behavior man- the case of greater Cleveland, the Game was trained agement protocol will reduce the dose need of medi- on a school site or across school sites in a brief train- cation (i.e., Carlson, Pelham, Milich, & Dixon, 1992). ing for teachers. In the case of the effort by Cook Recent reviews suggest that behavioral protocols County, paraprofessionals learned how to implement ought to be the first line of defense for the treat- and teach the game to many different schools in the ment of such conditions as ADHD (e.g., Pelham & actual classrooms. Other field trials are in place by the Fabiano, 2000), for a variety of legal, ethical, and prac- first author in Wyoming (a rural area with extremely tical considerations. The issue here is not whether be- high rates of substance abuse), in Tucson, AZ, with havioral interventions or medical interventions are very high rates of Hispanic and Native American pop- better. ulations, in the multicultural context of some schools The fact that both medication and a powerful undergoing comprehensive school reform, and even strategy like the Game result in inhibition of negative in Singapore and Malaysia to assess the acceptability behavior suggests that the two techniques probably in very different systems and cultures. operate in similar ways in the brain. In science, this is called the Law of Parsimony or Occam’s Razor. It typ- ically means that if two things have similar effects they MEDICAL RESEARCH ON INHIBITION most likely have common causal mechanisms. In the RELATED TO A BEHAVIORAL VACCINE beginning of this paper, I have hypothesized that the common factor is the inhibition circuitry of the brain, Various studies implicate the problems of in- which may have been altered as a result of genetic hibition in the etiology of multiproblem behavior expression, gene–environment interaction, exposure (e.g., Frick, Kuper, Silverhorn, & Cotter, 1995). For to traumatic events, coercive parenting practices, de- some time, it has been evident that medications, such viant peer reinforcement, or even exposure to envi- as methylphenidate, increase inhibition and improve ronmental toxins such as lead. The potential mecha- the kinds of behaviors studied in all of the studies nisms for this are becoming more apparent with var- on the Good Behavior Game (see Gadow, Nolan, ious scanning technologies and reaction-time studies Sverd, Sprafkin, et al., 1990). In the United States, the (e.g., Lazzaro, Gordon, Whitmont, Meares, & Clark daily use of such stimulant medication is extremely 2001). Reaction times can be measured in two ways: widespread—representing a rival treatment for the go reaction and stop reaction. risk factors that might be addressed by a behavioral Hyperactive children and children with op- vaccine. positional defiant disorder compared to “normal”
  16. 16. 288 Embry children have similar “go” reaction times, but wards. The use of rewards for attention or positive have longer stop times (e.g., Oosterlaan, Lo- behavior for individual behavior does not seem to gan, & Sergeant, 1998). Methylphenidate improves have the same power compared with medication (e.g., children’s stop times (Tannock, Schachar, Car, Solanto, Wender, & Bartell, 1997). The fact that this Chajczyk, & Logan, 1989). A study by Tannock, simple Game can have profound long-term effects on Schachar, and Logan shows various dose ef- the “stop circuitry” is very promising from a putative fects for stimulant medication. Pharmacologically, medical explanation of it as a potential behavioral methylphenidate stimulates the inhibition circuitry of vaccine. the brain via dopaminergic and serotonergic mecha- nisms. The Game creates social, activity, and primary MAKING THE GAME INTO A UNIVERSAL reward for inhibition as well as a sense of belong- BEHAVIORAL VACCINE ing for inhibition—which appear to be dopamniner- gic and serotonergic respectively. The Game clearly Good research and best practices do not neces- and rapidly increases “stop” behavior, by rewarding sarily translate into public benefit. An effective be- it. The Game is not like most behavior programs (e.g., havioral vaccine must overcome a number of barriers. Kolko, Bukstein, & Barron, 1999) that reward posi- First, policymakers must be sold on the idea. Second, tive behavior (e.g., social skills or attention to task); the vaccine must be appropriately packaged for deliv- the Game rewards not doing things such as blurt- ery. Third, the vaccine must have appropriate infras- ing, interrupting, getting out of seat, etc. All behav- tructure to support diffusion and practice. Fourth, reg- ior modification is not the same in effectiveness on ulations, policies, and even laws may need to change children with these attention or behavior problems, to support the distribution of a behavioral vaccine. even with or without the use of medication (e.g., Bald- Fifth, current practitioners may need enticement to win, 1999; Northup et al., 1999). The Game is differ- change. It is wise to note that it took some 80 years ent from most behavioral protocols in that it is group to make the practice of antiseptic hand washing com- based, decreases peer reinforcement for antisocial be- mon practice. Figure 5 summarizes what is required haviors, and provides yoked individual and group re- to create a system for a universal behavioral vaccine. Fig. 5. System diagram for behavioral vaccine.
  17. 17. The Good Behavior Game as a Behavioral Vaccine 289 Fig. 6. Cost-effectiveness formula. “Selling” the Game to Policymakers widely in primary grades, on projections of public ex- penditures in a decade, for Wyoming—a state with Proven practices can take decades to become the smallest population of all the 50 states yet with common practice, with many lives in forfeit as a con- very high rates of multiproblem behavior that merit sequence. A public-health model of prevention envi- prevention. Why the example of Wyoming? Having sions that most effective practices must be universal just completed an extremely detailed blueprint for for positive effect. This can be seen in a formula shown prevention of substance abuse in Wyoming (Embry & in Fig. 6. For a behavioral vaccine to work, the formula McDaniel, 2001), the author has easy access to state requires that the resource cost per participant be low, budget numbers. the effects potent, and the reach of the strategy be • A 5% reduction in special education place- wide and long-lasting with few adverse side effects. ment, not improbable based on the results from The Game works potentially well in this formula. the Baltimore Prevention Project, could poten- The costs of implementation are low compared to tially save $2–4 million dollars per year—which other alternatives. The comparison between several has grown from $50 million to $83 million per alternatives illustrates the point. These types of data budget period. are crucial for selling state policymakers on the ben- • A 2% reduction in involvement with correc- efits of a behavioral vaccine. tions, not excessive based on the Baltimore Medication costs about $70 per child per month, Prevention Project, might yield at least $3–10 plus medical supervision. Just 10 children in a school million per year in projected savings based on will cost at least $7,000 per year. Long-term posi- an analysis of growth in arrests of juveniles for tive results of medication are not well documented serious drug arrests by the Wyoming Statistical by comparison. Trademarked interventions such as Analysis Center at the University of Wyoming. Second Step, which are highly rated or extolled, have • A 4% reduction in lifetime prevalence of to- little or no impact on aggression in the classroom (e.g., bacco use, again not improbable from the Bal- Grossman et al., 1997), yet may cost at least $10,000 timore Prevention Project, could save the state per school to use. (Note: this is not an exhaustive anal- millions of dollars per year in deferred medical ysis of all the rival strategies). costs associated with tobacco-related diseases Measures of lifetime prevention benefits are mi- based on cost data calculated by the U.S. Cen- croscopic from a mathematical perspective at the time ters for Disease Control and Prevention for the of this writing. Favorite strategies such as character state of Wyoming. education, peer mediation, conflict mediation, or po- lice officers on campus have little or no effect size These savings from a prevention-effect sum to impact at this writing, though future studies or pub- something like $15–20 million per year over time in lications might change that. The fact that the Game Wyoming. What might be the cost of the prevention might only cost a few hundred dollars per classroom to effort? There are about 5,000 1st and 2nd graders in implement and reduce placement in special services Wyoming total. If the Game cost $200 per child per represents an immediate cost savings; its long-term year to implement in those grades, the annual cost of cost-effectiveness becomes even more impressive. For implementation would run about $1,000,000 per year example, the long-term effects on reduced special ed- and thereafter. Breakeven would occur in about 3– ucation and correctional expenditures from the use of 5 years against special-education expenses, and the the Game are calculable and mind-boggling. Here are lifetime savings of the prevention effort would pro- a just a few of the implications of the Game, if used vide even stronger cost-savings.
  18. 18. 290 Embry Packaging of a Behavioral Vaccine innovations might combine to produce ad- verse effects. Public health models versus disease or disor- 4. Strengthen linkages to other science-based der models envision universal coverage. To achieve strategies. The Game has excellent results in the large-scale prevention or vaccine effect from reducing aggression and disruptive behaviors. something like the Game, it will be necessary to This is good but not good enough. For exam- solve a number of problems for widespread social ple, the reduction in problem behavior only marketing: modestly translates into improvements in aca- demic performance, unless there are other 1. Make the research-based prevention strategies strategies introduced. The decline in problem easy to use in the real world. The public-domain behavior sets the stage for potent academic protocols for the Game are not easy to use interventions such as class-wide peer tutoring or understand. During the past 2 years, the (e.g., Greenwood, Terry, Utley, & Montagna, author and colleagues have been conducting 1993), peer-assisted learning (e.g., Mathes, open trials on exactly this concern. For ex- Howard, Allen, & Fuchs, 1998), or cooper- ample, we have found it necessary to build ative learning (e.g., Slavin, 1992). Presently, in simple behavioral cueing strategies to im- the author and colleagues have been conduct- prove effectiveness (e.g., Posavac, Sheridan, ing pilot efforts on such integration, combin- & Posavac, 1999), because many new teachers ing several strategies. Although Kellam and do not know these strategies. colleagues originally tested both the Game 2. Increase social acceptability of the science- and Mastery Learning singly and in combina- based intervention. Unless large numbers of tion, we found Mastery Learning simply not people adopt or participate in the strategy, possible to implement in the current condi- the prevention effect will be small. It has tions of U.S. schools. Adoption and use of been over 30 years since the Game was first the Game as a daily practice would seem invented, and very few classrooms use it to be hypothetically better (and testable) if nationally. Although the underlying princi- linked explicitly with some compatible em- ples are rock solid scientifically, they do re- pirically driven strategies that also improved quire some social marketing elements. The academics. emphatic behavioral language of the origi- 5. Address common barriers for adoption. A nal research manual used by Kellam is po- well-proven science-based strategy can elicit tentially off-putting to many who typically many practical, emotional, or logistical barri- have little exposure to such language, wit- ers. The private sector typically responds to nessed by the fact that strong behavioral con- such issues by figuring out how to remove bar- cepts can impair adoption (e.g., Tingstrom, riers to purchase or adoption, which is not 1994). always the case in the public sector. Current 3. Integrate interventions for more difficult chil- field trials have identified some significant bar- dren in the front end. Although the Game riers to adoption of the Game as a behav- has powerful effects for aggressive children, ioral vaccine. Each barrier has testable poten- staff typically voice worry about the children tial solutions. Barriers and potential solutions who are seen as the “worst kid ever.” Hav- follow: ing some front-end strategies for staff to use • Restricted staff development time. Some with such children when introducing the Game states or local districts now only have a or “customizing it” could provide a greater few days available for any staff devel- confidence for the adoption of the Game as a opment. Mass media, Internet, and other sound practice. Explicit links need to be built approaches might help resolve this bar- in for more intensive clinical interventions for rier. Mini demonstrations might be another children who require higher doses of inter- mechanism. vention such as in classroom behavioral coa- • Competing demands for staff development ching (e.g., Kotkin, 1998). Providing explicit time. Major federal, state, or local initiatives components for higher risk young people with funding contingencies or political con- would also minimize the chance that local sequences attached tend to compete for staff