Almost everyone involved in prevention, and many others in the country, has heard about or knows the alarming news. Alcohol and drug use (marijuana, Ecstasy) are up in multiple surveys: the Pride Survey, Monitoring the Future, from the Partnership for A Drug Free America.  This means delinquency and criminal behavior will increase, too, among youth and young adults. This means more already hard-pressed states, communities, businesses and families will have to “shovel up” for the astounding short and long-term costs of these trends—unless we collectively act. Before this alarming news of upward trends, of the $3.3 trillion total federal and state government spending, $373.9 billion – 11.2 percent, more than one of every ten dollars– was spent on tobacco, alcohol and illegal and prescription drug abuse and addiction and its consequences.¹

These trends ought not to be surprising since other mental, emotional and behavioral problems have become more common and serious in the past two decades among our country’s children and youth.² Rapidly reducing these problems would substantially improve the economic, public health and public safety conditions of every state and community in the Union. This problem and the possibility have not been openly discussed until now.

A diverse group of passionate individuals is now launching a cost effective, coherent, sensible plan to act that, ultimately, will reduce our collective tax burden and help us to work smart, spend wisely and make our kids, schools and communities safer and healthier.  We call this effort “Families United”— uniting all families, communities, and states, the private and public sectors, health-care, schools and the media in concerted action using simple, scientifically proven, low-cost prevention strategies.  We call them prevention “evidence-based kernels” or “behavioral vaccines” (e.g., like car safety seats) when used repeatedly to improve health, safety or wellbeing.^3-5

The Possibility & Promise: Recent research and new understandings now make it possible to reduce the problems of alcohol and drug use, delinquency and criminal behavior, quickly, using low-cost strategies that can be spread right away across communities.  Now, more than ever, this possibility could significantly help every state and community. First Spouses of governors and mayors (an impressive group who have historically demonstrated non-partisan efforts), for example, can convene and lead this transformation, improving all our futures.

Families United reignites the parent-networking strategy, by combining tested and proven strategies to reduce the risk of alcohol, tobacco, drug use and related problems with modern networking technologies and mass media. Families United leverages existing infrastructure of communities (e.g., coalitions, Drug Free Communities, Weed & Seed, CADCA, United Ways) and state governments (e.g., National Guard, Extension, Land Grant Colleges) to maximize reach and low-cost proven evidence-based kernels and behavioral vaccines to maximize reach and penetration.

Equipped with low-cost, proven, evidence-based prevention kernels and behavioral vaccines to address major risk and protective factors, multiple groups and organizations can be mobilized to make sure every family has access to these scientifically proven, yet simple strategies—like communities did for hand-washing around the H!N1 flu or for car-safety seats for new babies that have proven to protect us and our families. In the same way, prevention kernels and behavioral vaccines are easy, make common sense, conserve our fiscal resources in tight, difficult times and provide protection as well.

These very low-cost prevention kernel strategies, or behavioral vaccines, are unlike what people have come to know as prevention programs.  Although they are thoroughly researched and meet evidence-based criteria, they are easy to explain, simple to use and sustain, and can be spread by word of-mouth. These strategies—like hand washing or car seats—can be sustained locally, too. Prevention kernels and behavioral vaccines also have shown measurable, yet quick, effects and long-lasting results.

The Cost Efficiency & Savings: Each state can use a specially designed spreadsheet to compute the cost efficiency and savings across multiple problems using the proposed strategies.  For example, the largest populated state (California) could save $336 million, and the smallest state (Wyoming) would save $5.1 million. Cost savings come from reduced health-care costs such as prescription psychotropic drugs, unaddressed earning disabilities, accidental injuries, delinquency and crime, addictions, etc. Prior studies suggest that such cost savings and lives saved are measureable in two years. (Work on a community level spreadsheet that every neighborhood can use is under construction as well.)

Governments and families give medical vaccines to prevent public health problems mumps, measles and polio. Governments and families can now offer “behavioral vaccines”, in the form of scientifically proven prevention kernels to prevent mental, emotional, behavioral and addictive problems in children and youth.

Consider this simple cost comparison of medical and behavioral prevention. The cost of reaching every child with effective behavioral vaccines in Families United to prevent these most painful and costly problems affecting 25% to 35% of our nation’s future is less than a Big Mac—about $5. This behavioral vaccine and evidence-based kernels costs less than common medical vaccines such the one for Diphtheria (about $15) or Measles, Mumps, Varicella and Rubella ($125).  Behavioral vaccines can protect against the most costly and traumatic family and community connected problems: adolescent addictions, delinquency, violence exposure, crime, mental illness, suicide and school failure.^{2 4 6 7} These same behavioral vaccines can reduce the need for prescription medications, prescribed to 7% of children in America compared to countries like Germany and the Netherlands, where only 2% - 2.9% of the children take such medications.8 The same meds that are now being widely abused in America.⁸ Many of our economic competitors do provide such behavioral vaccines, but not America, and US prescription psychotropic drug costs and use for children are skyrocketing.^{9 10}

Deploying Five Evidence-Based Kernels to Every Parent for Large Effects

This plan involves offering “behavioral vaccines” via evidence-based prevention kernels—the smallest unit of behavioral influence, scientifically proven in one or more high-quality published studies.³ When used by many, such small units of change can address serious problems like methamphetamine use^{11 12} and even alter conditions in entire communities or states.^{5 13} Families United deploys five types of kernels to alter the context of risk and protective factors predicting youth alcohol, tobacco, and drug use along with related problems of delinquency, violence, poor academics, early sexual behavior, and some mental illnesses. The five prevention kernels to be promoted for all children, adapted to age and developmental stage, between the ages of 5 and 18 involve:

1. Increasing Positive Family Monitoring. The clear voice of positive parental and family commitment to children about not using alcohol, tobacco and other drugs (ATOD) and equally clear expectation about a child’s friends not using alcohol, tobacco and drugs as well nor engaging in delinquency or related problems.14-16 This includes a commitment to speak to the child’s friends’ parents. This clarity and commitment can significantly reduce ATOD use and related delinquency.¹⁷
2. Rewarding Not Using nor Breaking Rules. Family recognition and reinforcement of children and teens doing the right thing (e.g., not using ATOD nor engaging in deviant behaviors associated with ATOD) has been widely shown to reduce problematic behavior more effectively than punishments.3 ^18-22 The same procedure can dramatically reduce ATOD use, if a child has already started using—based on studies from the National Institute on Drug Abuse.^23-25 Such rewards increased parent-child warmth, key to children’s disclosure to parents.^{16 26}
3. Reducing Sleep Deprivation. Ensuring a child has good sleep patterns, by limiting access to electronic media before bedtime and other times, has multiple positive effects on risk and protective factors associated with ATOD use, school success, family relationships, mental health, aggression and obesity.^27-35 Indeed, just simple advice about this from a child’s doctor works.³⁶
4. Changing Fatty Acid Ratios in a Child’s Diet. Based on extensive data the National Institute on Alcohol and Alcohol Abuse reported through the Institute of Medicine’s Report on the Prevention of Mental, Emotional and Behavioral Disorders, that increasing children’s “brain food” (omega-3 found in fish oil) and reducing omega-6 found in processed foods 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, aggression and suicide.^37-50
5. Increasing Parent Networking Among the Families of Children’s Friends. Sharing and communicating the previous four prevention kernels with five of the parents of one’s child’s friends fosters a community norm—strengthening and reinforcing these protective factors by all families to benefit all children in the community. Such simple but effective action provides a population-level public health and safety benefit.

Next Steps for Bringing Families United to Every American Community

Beginning in April, the partners in this effort will begin hosting Families United webinars free of charge.  Each webinar will be limited to 45 participants. The specific action for communities to take will be laid out step-by-step.  New sustainable funding streams will be discussed. The beginning of the 2010-2011 school year will mark the launch. Families United webinars will cover the following:

1. How to use existing coalitions and bring new stakeholders to mobilize evidence-based prevention kernel efforts for measureable prevention outcomes (e.g., local mass media, local business sponsors, National Guard, local doctors/health care, both political parties).
2. How the effort will meet the goals of many federal and state initiatives such as SPF-SIG; Drug Free Communities; the new “Prevention Prepared Communities”; the Department of Education’s new efforts on Successful, Safe, and Healthy Students program, Race to the Top, dropout prevention; the Promise Neighborhood grants (e.g., like the Harlem Children’s Zone, Federal Parity Law on medical and behavioral health, as well as the White House obesity prevention effort and more.
3. How to recruit new stakeholders for fiscal sustainability of prevention in your state.
4. How to plan and implement Families United, while also creating a new method of self-sufficient, culturally-competent community-based prevention.
5. How existing archival data (e.g., delinquency, ER use, prescription meds, etc.) and student data (e.g., the Pride Surveys, Communities That Care or Prevention Needs Assessment data) can be used locally to demonstrate that prevention works.
6. How to blend Families United with other prevention, intervention and treatment efforts. And,
7. How to answer the inevitable doubts with hard data and examples, as well as with the profound but simple question, “How will doing nothing new or just what we have been doing make the future better for all our children, families and communities?”

To express your interest in this effort, please send an email to Miriam@paxis.org with the subject line of “Families United”.  Miriam Willmann may also be reached at the PAXIS Madison Wisconsin office at 608-772-0289 during normal business hours (CST), M-F.

We will post updates on the ONDCP listserve, Connected Communities, www.SimpleGifts.com and www.paxtalk.com—including the names of prospective partners and communities.

1. Shoveling Up II: The Impact of Substance Abuse on Federal, State and Local Budgets. 2nd ed. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University, 2009:165.

2. O'Connell ME, Boat T, Warner KE, editors. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. . Washington, DC: Institute of Medicine; National Research Council, 2009.

3. Embry DD, Biglan A. Evidence-Based Kernels: Fundamental Units of Behavioral Influence. Clinical Child & Family Psychology Review 2008;11(3):75-113.

4. L'Abate L, editor. Low-Cost Approaches to Promote Physical and Mental Health: Theory, Research and Practice. New York: Springer, 2007.

5. Embry DD. Community-Based Prevention Using Simple, Low-Cost, Evidence-Based Kernels and Behavior Vaccines. Journal of Community Psychology 2004;32(5):575.

6. Embry DD. The Good Behavior Game: A Best Practice Candidate as a Universal Behavioral Vaccine. Clinical Child & Family Psychology Review 2002;5(4):273-97.

7. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population-based prevention of child maltreatment:  The U.S. Triple P System Population Trial. Prevention Science 2009;10(March).

8. Zito JM, Safer DJ, Berg LT, Janhsen K, Fegert JM, Gardner JF, et al. A three-country comparison of psychotropic medication prevalence in youth. Child Adolesc Psychiatry Ment Health 2008;2(1):26.

9. Zito JM, Safer DJ, Valluri S, Gardner JF, Korelitz JJ, Mattison DR, et al. Psychotherapeutic medication prevalence in Medicaid-insured preschoolers. Journal of Child & Adolescent Psychopharmacology 2007;17(2):195-203.

10. Thomas CP, Conrad P, Casler R, Goodman E. Trends in the Use of Psychotropic Medications Among Adolescents, 1994 to 2001. Psychiatr Serv 2006;57(1):63-69.

11. Embry DD, Neri D, Capin T. Community Mobilization to Address Meth Using Social Marketing and Evidence-Based Kernels of Change. National Prevention Network. Indianopolis, ID, 2008.

12. Embry DD, Lopez D, Minugh PA. Stop the Methamphetamine Epidemic. Arizona Medical Association Journal 2005;16(4):30-34.

13. Embry DD, Biglan A. Reward and Reminder: An Environmental Strategy for Population-Level Prevention. National Registry of Effective Programsn and Practices. October, 2009 ed: Substance Abuse and Mental Health Administration, 20009.

14. Bailey JA, Hill KG, Oesterle S, Hawkins JD. Parenting practices and problem behavior across three generations: Monitoring, harsh discipline, and drug use in the intergenerational transmission of externalizing behavior. Developmental Psychology 2009;45(5):1214-26.

15. Bergman S. Parental monitoring and its role in alleviating child externalizing behaviors. US: ProQuest Information & Learning, 2009.

16. Hoeve M, Dubas JS, Eichelsheim VI, van der Laan PH, Smeenk W, Gerris JRM. The relationship between parenting and delinquency: A meta-analysis. Journal of Abnormal Child Psychology: An official publication of the International Society for Research in Child and Adolescent Psychopathology 2009;37(6):749-75.

17. Koutakis N, Stattin H, Kerr M. Reducing youth alcohol drinking through a parent-targeted intervention: the Orebro Prevention Program. Addiction 2008;103(10):1629-37.

18. Bennett MM, B. An interdependent group contingency with mystery motivators to increase spelling performance. ProQuest Information & Learning: US, 2007.

19. Madaus MMR, Kehle TJ, Madaus J, Bray MA. Mystery Motivator as an Intervention to Promote Homework Completion and Accuracy. School Psychology International 2003;24(4):369-77.

20. Moore LA, Waguespack AM, Wickstrom KF, Witt JC, et al. Mystery motivator: An effective and time efficient intervention. School Psychology Review 1994;23(1):106-18.

21. Robinson KE, B. Using the mystery motivator to improve child bedtime compliance. ProQuest Information & Learning: US, 1998.

22. Robinson KE, Sheridan SM. Using the Mystery Motivator to improve child bedtime compliance. Child & Family Behavior Therapy 2000;22(1):29-49.

23. Petry NM, Martin B, Cooney JL, Kranzler HR. Give them prizes and they will come: Contingency management for treatment of alcohol dependence. Journal of Consulting & Clinical Psychology 2000;68(2):250-57.

24. Petry NM, Peirce JM, Stitzer ML, Blaine J, Roll JM, Cohen A, et al. Effect of Prize-Based Incentives on Outcomes in Stimulant Abusers in Outpatient Psychosocial Treatment Programs: A National Drug Abuse Treatment Clinical Trials Network Study. Arch Gen Psychiatry 2005;62(10):1148-56.

25. Petry NM, Tedford J, Austin M, Nich C, Carroll KM, Rounsaville BJ. Prize reinforcement contingency management for treating cocaine users: How low can we go, and with whom? Addiction 2004;99(3):349-60.

26. Cumsille P, Darling N, Martinez ML. Shading the truth: The patterning of adolescents' decisions to avoid issues, disclose, or lie to parents. J Adolesc 2009.

27. Abe T, Hagihara A, Nobutomo K. Sleep patterns and impulse control among Japanese junior high school students. J Adolesc 2009.

28. Chervin RD, Dillon JE, Archbold KH, Ruzicka DL. Conduct problems and symptoms of sleep disorders in children. Journal of the American Academy of Child & Adolescent Psychiatry 2003;42(2):201-08.

29. Fredriksen K, Rhodes J, Reddy R, Way N. Sleepless in Chicago: Tracking the Effects of Adolescent Sleep Loss During the Middle School Years. Child Development 2004;75(1):84-95.

30. Wong MM, Brower KJ, Fitzgerald HE, Zucker RA. Sleep problems in early childhood and early onset of alcohol and other drug use in adolescence. Alcoholism: Clinical & Experimental Research 2004;28(4):578-87.

31. Robinson TN, Killen JD, Kraemer HC, Wilson DM, Matheson DM, Haskell WL, et al. Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethnicity & Disease 2003;13(1 Suppl 1):S65-77.

32. Robinson TN, Wilde ML, Navracruz LC, Haydel KF, Varady A. Effects of reducing children's television and video game use on aggressive behavior: a randomized controlled trial.[see comment]. Archives of Pediatrics & Adolescent Medicine 2001;155(1):17-23.

33. Robinson TN, Saphir MN, Kraemer HC, Varady A, Haydel KF. Effects of reducing television viewing on children's requests for toys: a randomized controlled trial.[see comment]. Journal of Developmental & Behavioral Pediatrics 2001;22(3):179-84.

34. Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282(16):1561-7.

35. Al Mamun A, Lawlor DA, Cramb S, O'Callaghan M, Williams G, Najman J. Do childhood sleeping problems predict obesity in young adulthood? Evidence from a prospective birth cohort study. Am J Epidemiol 2007;166(12):1368-73.

36. Barkin SL, Finch SA, Ip EH, Scheindlin B, Craig JA, Steffes J, et al. Is Office-Based Counseling About Media Use, Timeouts, and Firearm Storage Effective? Results From a Cluster-Randomized, Controlled Trial. Pediatrics 2008;122(1):e15-25.

37. Oddy WH, Robinson M, Ambrosini GL, O'Sullivan TA, de Klerk NH, Beilin LJ, et al. The association between dietary patterns and mental health in early adolescence. Prev Med 2009;49(1):39-44.

38. O'Sullivan TA, Robinson M, Kendall GE, Miller M, Jacoby P, Silburn SR, et al. A good-quality breakfast is associated with better mental health in adolescence. Public Health Nutr 2009;12(2):249-58.

39. Ambrosini GL, Oddy WH, Robinson M, O'Sullivan TA, Hands BP, de Klerk NH, et al. Adolescent dietary patterns are associated with lifestyle and family psycho-social factors. Public Health Nutr 2009;12(10):1807-15.

40. Sinn N, Milte C, Howe PR. Oiling the Brain: A Review of Randomized Controlled Trials of Omega-3 Fatty Acids in Psychopathology across the Lifespan. Nutrients 2010;2(2):128-70.

41. Buydens-Branchey L, Branchey M, Hibbeln JR. Low plasma levels of docosahexaenoic acid are associated with an increased relapse vulnerability in substance abusers. Am J Addict 2009;18(1):73-80.

42. Mahaffey KR, Schoeny R. "Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): An observational cohort study": Comment. Lancet 2007;370(9583):216-17.

43. Hibbeln JR. From homicide to happiness--a commentary on omega-3 fatty acids in human society. Cleave Award Lecture. Nutrition & Health 2007;19(1-2):9-19.

44. Hibbeln J, Davis JM, Steer C, Emmett P, Rogers I, Williams C, et al. Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): an observational cohort study. The Lancet 2007;369(9561):578-85.

45. Hallahan B, Hibbeln JR, Davis JM, Garland MR. Omega-3 fatty acid supplementation in patients with recurrent self-harm: Single-centre double-blind randomised controlled trial. British Journal of Psychiatry 2007;190(2):118-22.

46. Conklin SM, Manuck SB, Yao JK, Flory JD, Hibbeln JR, Muldoon MF. High omega-6 and low omega-3 fatty acids are associated with depressive symptoms and neuroticism. Psychosomatic Medicine 2007;69(9):932-4.

47. Conklin SM, Harris JI, Manuck SB, Yao JK, Hibbeln JR, Muldoon MF. Serum omega-3 fatty acids are associated with variation in mood, personality and behavior in hypercholesterolemic community volunteers. Psychiatry Research 2007;152(1):1-10.

48. Sublette ME, Hibbeln JR, Galfalvy H, Oquendo MA, Mann JJ. Omega-3 polyunsaturated essential fatty acid status as a predictor of future suicide risk. American Journal of Psychiatry 2006;163(6):1100-2.

49. Hibbeln JR, Nieminen LR, Blasbalg TL, Riggs JA, Lands WE. Healthy intakes of n-3 and n-6 fatty acids: estimations considering worldwide diversity. American Journal of Clinical Nutrition 2006;83(6 Suppl):1483S-93S.

50. Hibbeln JR, Ferguson TA, Blasbalg TL. Omega-3 fatty acid deficiencies in neurodevelopment, aggression and autonomic dysregulation: opportunities for intervention. International Review of Psychiatry 2006;18(2):107-18.

By Dennis D. Embry, Ph.D.**

Dianne Perukel submitted the following message on the Office of National Drug Control Policy (ONDCP) listserve on March 5, 2009

--------------------------------------------------------------------------

I have been working with several well-meaning traffic safety advocates that would like to print posters with some very graphic pictures of traffic crash victims. I'm having a hard time articulating WHY this is such a bad idea...does anyone know of any articles, research, etc. that would help me?  

The question is a good one, and the answers from others on the listserve are correct that scary stuff doesn’t work. Such graphic scare tactics are not effective, and can even have a negative effect on a population level basis.

Now the question is why do such things rebound or not work?

I have to turn to evolutionary findings, neuro-science, anthropology and developmental research to explain.

In the past 40K to 10K years, humans developed certain dopamine receptor gene variations.  NIDA and others have funded this research. Drugs are about dopamine, remember all those talks by Dr. Noral Volkow.¹  And, she observes that eating and many other survival related behaviors cause the firing of dopamine.²

Now why did these new dopamine genes arise some 10,000 to 40,000 years ago and then spread dramatically and keep spreading?   Why are certain dopamine genes positively selected recently by evolution? The clue is that they are associated with human migration across the planet.³ 

While not complete, genes associated with human migration and risk of substance abuse are generally associated with novelty seeking or sensation seeking,^3-13 often higher or “normal” IQ^{14 15} AND sensitivity to perceived human stressors.^16-18 These genes are also associated with increased risk of aggression against other humans.^{19 20} These genes have been positively selected by evolution, which means they have evolutionary advantages.

Not indulge a bit of “just-so” storytelling to explain what all this might mean to answer the question.  Why would humans move from the proverbial Garden of Eden in the Rift Valley where we began?²¹ There are a couple of interrelated sensible reasons:  something bad happened, food became scarce, people died, and people had wars or fight about that food or resources. Almost certainly some of the adolescents left in an aggressive huff rather impulsively, since puberty makes teens more reward dependent than adults and small children. These would not have been the shy, anxious adolescents who would have feared leaving their tribe or clan.  These would have most certainly have been the adolescents who were more what we would call, “hyper” today in terms of physical activity—running, jumping, and exploring.  They would not have been the timid kids either who followed the adult instructions.  And they would have more than likely been somewhat precocious sexually.²²  These young humans who left whatever was the current “Eden” founded the next communities some distance away where there was more food and safety. There they mated, and had babies who carried those same genes.  If a new bad thing happened of food or fighting problems, the process repeated and the gene penetration for these traits spread across the globe and still is.  In fact, one can see the increased prevalence of sensation seeking or thrill seeking all across the frontier—non-farming areas of the United States—on student survey instruments such as the Communities That Care Survey.

Accidentally, these genes conferred an increased risk of substance abuse—especially under conditions of stress as adults or childhood if parenting adults become aggressive or insensitive to the needs of the children who care those genes.^{18 23-25} These genes get “turned on” when life is hard,¹⁶ which is an epigenetic process.  This refers to changes in phenotype (appearance) or gene expression caused by mechanisms other than changes in the underlying DNA sequence (hence the name epi - "in addition to" - genetics). These changes may remain through cell divisions for the remainder of the cell's life and may also last for multiple generations. However, there is no change in the underlying DNA sequence of the organism; instead, non-genetic factors cause the organism's genes to behave (or "express themselves") differently.

Why doesn’t the fear mongering work? The scary pictures and scary story approach fails for several scientific reasons: 1) they are not addressing the underlying biological/social predictors; 2) for some, they may engage the epigenetic mechanisms that increase the risk of substance abuse and other risky behaviors; 3) for others who have a heavy loading of sensation seeking and novelty seeking, the “thrills” of such risky behavior are potentially reinforcing; 4) for the small group who have developed such underlying cognitive impulsivity with suicidal thoughts, such fear mongering explicitly shows ways to kill one’s self in a dramatic way; 5) the people who do respond to respond to fear approaches are not likely to have used drugs anyway.  The final fatal possibility is that the very fear mongering actually increases the desirability of the deviant behavior and decreases the perceived danger, which is an operant rather than biological causal factor.  That is, the social attention (which clearly affects dopamine) one receives for being deviant is highly reinforcing—a fact well documented in prevention science studies for many years.^26-29

The recent publications on the Montana Meth Project illustrate the perils of fear appeals.³⁰ The Montana Meth Project showed horrific TV ads, done with the highest production values of dramatic harms of meth. A peer-reviewed, independent study shows: “…the Claims that the campaign is effective are not supported by data. The campaign has been associated with increases in the acceptability of using methamphetamine and decreases in the perceived danger of using drugs.”

References Cited

1. Volkow N. Drug dependence and addiction, III: Expectation and brain function in drug abuse. American Journal of Psychiatry 2004;161(4):621.

2. Volkow ND, Wang G-J, Maynard L, Jayne M, Fowler JS, Zhu W, et al. Brain dopamine is associated with eating behaviors in humans. International Journal of Eating Disorders 2003;33(2):136-42.

3. Ding YC, Chi HC, Grady DL, Morishima A, Kidd JR, Kidd KK, et al. Evidence of positive selection acting at the human dopamine receptor D4 gene locus.[see comment]. Proceedings of the National Academy of Sciences of the United States of America 2002;99(1):309-14.

4. Roy A, Adinoff B, Roehrich L, Lamparski D, Custer R, Lorenz V, et al. Pathological gambling. A psychobiological study. Archives of General Psychiatry 1988;45(4):369-73.

5. Zuckerman M. Personality in the third dimension: A psychobiological approach. Personality & Individual Differences 1989;10(4):391-418.

6. Zuckerman M, Kuhlman DM. Personality and risk-taking: common biosocial factors. Journal of Personality 2000;68(6):999-1029.

7. Birkas E, Horvath J, Lakatos K, Nemoda Z, Sasvari-Szekely M, Winkler I, et al. Association between dopamine D4 receptor (DRD4) gene polymorphisms and novelty-elicited auditory event-related potentials in preschool children. Brain Research 2006;1103(1):150-8.

8. Hill SY, Zezza N, Wipprecht G, Locke J, Neiswanger K. Personality traits and dopamine receptors (D2 and D4): linkage studies in families of alcoholics. American Journal of Medical Genetics 1999;88(6):634-41.

9. Lakatos K, Nemoda Z, Birkas E, Ronai Z, Kovacs E, Ney K, et al. Association of D4 dopamine receptor gene and serotonin transporter promoter polymorphisms with infants' response to novelty. Molecular Psychiatry 2003;8(1):90-7.

10. Laucht M, Becker K, Blomeyer D, Schmidt MH. Novelty seeking involved in mediating the association between the dopamine D4 receptor gene exon III polymorphism and heavy drinking in male adolescents: results from a high-risk community sample. Biological Psychiatry 2007;61(1):87-92.

11. Luciano M, Zhu G, Kirk KM, Whitfield JB, Butler R, Heath AC, et al. Effects of dopamine receptor D4 variation on alcohol and tobacco use and on novelty seeking: multivariate linkage and association analysis. American Journal of Medical Genetics 2004;Part B, Neuropsychiatric Genetics: the Official Publication of the International Society of Psychiatric Genetics. 124(1):113-23.

12. Schinka JA, Letsch EA, Crawford FC. DRD4 and novelty seeking: results of meta-analyses. American Journal of Medical Genetics 2002;114(6):643-8.

13. Szekely A, Ronai Z, Nemoda Z, Kolmann G, Gervai J, Sasvari-Szekely M. Human personality dimensions of persistence and harm avoidance associated with DRD4 and 5-HTTLPR polymorphisms. American Journal of Medical Genetics 2004;Part B, Neuropsychiatric Genetics: the Official Publication of the International Society of Psychiatric Genetics. 126(1):106-10.

14. Swanson J, Oosterlaan J, Murias M, Schuck S, Flodman P, Spence MA, et al. Attention deficit/hyperactivity disorder children with a 7-repeat allele of the dopamine receptor D4 gene have extreme behavior but normal performance on critical neuropsychological tests of attention. Proceedings of the National Academy of Sciences of the United States of America 2000;97(9):4754-9.

15. Kerns KA, Price KJ. An investigation of prospective memory in children with ADHD. Child Neuropsychology 2001;7(3):162-71.

16. Madrid GA, MacMurray J, Lee JW, Anderson BA, Comings DE. Stress as a mediating factor in the association between the DRD2 TaqI polymorphism and alcoholism. Alcohol 2001;23(2):117-22.

17. Pruessner JC, Champagne F, Meaney MJ, Dagher A. Dopamine Release in Response to a Psychological Stress in Humans and Its Relationship to Early Life Maternal Care: A Positron Emission Tomography Study Using [11C]Raclopride. J. Neurosci. 2004;24(11):2825-31.

18. Lakatos K, Nemoda Z, Toth I, Ronai Z, Ney K, Sasvari- Szekely M, et al. Further evidence for the role of the dopamine D4 receptor (DRD4) gene in attachment disorganization: interaction of the exon III 48-bp repeat and the -521 C/T promoter polymorphisms. Molecular Psychiatry 2002;7(1):27-31.

19. Raine A. Annotation: the role of prefrontal deficits, low autonomic arousal, and early health factors in the development of antisocial and aggressive behavior in children. Journal of Child Psychology & Psychiatry & Allied Disciplines 2002;43(4):417-34.

20. Barkley RA, Smith KM, Fischer M, Navia B. An examination of the behavioral and neuropsychological correlates of three ADHD candidate gene polymorphisms (DRD4 7+, DBH TaqI A2, and DAT1 40 bp VNTR) in hyperactive and normal children followed to adulthood. American Journal of Medical Genetics 2006;Part B, Neuropsychiatric Genetics: the Official Publication of the International Society of Psychiatric Genetics. 141(5):487-98.

21. Broadhurst CL, Cunnane SC, Crawford MA. Rift Valley lake fish and shellfish provided brain-specific nutrition for early Homo.[see comment]. British Journal of Nutrition 1998;79(1):3-21.

22. Charles KE, Egan V. Mating effort correlates with self-reported delinquency in a normal adolescent sample. Personality & Individual Differences 2005;38(5):1035-45.

23. Bakermans-Kranenburg MJ, van Ijzendoorn MH. Gene-environment interaction of the dopamine D4 receptor (DRD4) and observed maternal insensitivity predicting externalizing behavior in preschoolers. Developmental Psychobiology 2006;48(5):406-9.

24. Marian J. Bakermans-Kranenburg MHvI. Gene-environment interaction of the dopamine D4 receptor (DRD4) and observed maternal insensitivity predicting externalizing behavior in preschoolers. Developmental Psychobiology 2006;48(5):406-09.

25. Van Ijzendoorn MH, Bakermans-Kranenburg MJ. DRD4 7-repeat polymorphism moderates the association between maternal unresolved loss or trauma and infant disorganization. Attachment & Human Development 2006;8(4):291-307.

26. Poulin F, Dishion TJ, Haas E. The peer influence paradox: Friendship quality and deviancy training within male adolescent friendships. Merrill-Palmer Quarterly 1999;45(1):42-61.

27. Dishion TJ, McCord J, Poulin F. When interventions harm: Peer groups and problem behavior. American Psychologist 1999;54(9):755-64.

28. Dishion TJ, Eddy M, Haas E, Li F, al e. Friendships and violent behavior during adolescence. Social Development 1997;6(2):207-23.

29. Dishion TJ, Spracklen KM, Andrews DW, Patterson GR. Deviancy training in male adolescents friendships. Behavior Therapy 1996;27(3):373-90.

30. Erceg-Hurn D. Drugs, Money, and Graphic Ads: A Critical Review of the Montana Meth Project. Prevention Science 2008;9(4):256-63.

Stimulus Package Impact Plan for Change:

 American Recovery & Reinvestment Act of 2009 (ARRA)

Background:  The new legislation is designed to:

1.        Preserve and create jobs and promote economic recovery.

2.        Assist those most impacted by the recession.

3.        Provide investments to increase economic efficiency by spurring technological advances in science and health.

4.        Invest in transportation, environmental protection, and other infrastructure that will provide long-term economic benefits.

5.        Stabilize state and local government budgets, in order to minimize and avoid reductions in essential services and counterproductive state and local tax increases.

Additionally, the funds in the Act are supposed:

1.        Achieve rapid results

2.        Employ people (or keep them employed)

3.        Document results to help change public confidence in America’s direction

4.        Show ROI on 12 to 24 months

5.        Impact as many important outcomes as possible: a) Healthcare costs, b) Educational achievement, c) Public safety, d) Increase confidence in the economy, and e) Increase entrepreneurial products and economic competitiveness

Threats: Early warning data show that the downturn is already associated with more rapidly rising health-care costs driven significantly by drugs for the treatment of depression and other related mental-health problems, increases in danger to public safety, greater rates of mental illness and behavioral health problems that will harm recovery.  The ongoing pessimistic ruminations in the popular media are documented to reduce recovery ^{1 2}.  These threats are undermining public-faith in every public and private institution in America, which has long-term political and economic consequences. 

Facts: A new report from the National Research Council and Institute of Medicine (2/19/09)³ documents multiple evidence-based programs that can prevent serious lifetime or costly mental, emotional or behavioral disorders. For example, a multi-level model of providing universal access to parenting supports, known as Triple P,⁴ can prevent child out-of-home placements and child medical injuries from abuse, prevent ADHD and Conduct Disorders as well as reduce common parent-child issues for about $12-14 per child in a community. ^5-9 Another example is an effective school-based strategy—the Good Behavior Game,¹⁰ which divides elementary school classes into teams and reinforces desirable behaviors with rewards such as extra free time and other privileges. The strategy significantly reduces aggressive and disruptive behavior during school ^11-13.  When used just in first-grade, the low-cost strategy (about $15 per child) has benefits in adulthood, lowering the alcohol and drug abuse¹⁴,  suicidal thoughts and attempts¹⁵ and/or depression,¹⁶ plus antisocial personality disorder.¹⁷

There are also simple, low-cost, easy-to-use, proven strategies called “evidence-based kernels” ¹⁸ that increase educational outcomes, improve parenting, reduce mental-health problems, reduce illnesses, improve public safety, decrease crime, delinquency, and substance abuse, lower healthcare costs, improve workplace productivity, and more. The efficacy of prevention programs and various “kernels” are supported by extensive peer-reviewed scientific research.

Opportunities: New conditions favor actions that create rapid benefits and lower long-term costs (e.g., health, safety, human services) so that more resources can go into goods and services for global competiveness. The very existence of the economic downturn reduces organizational inertia to do things as we have always done them, thereby creating opportunities for rapid infusion of low-cost, cost-effective, scientifically proven solutions that can change health, safety, educational and other important outcomes for American communities. Further, the resulting changes can provide frequent news reports of about successes that can increase hopefulness, self-efficacy, and recovery in America.  Here are just a few examples:

·         Health-care.  Proven prevention practices can:

o         Reduce sudden cardiac arrest by as many as 36,000 in the US per year ¹⁹, and the same kernel can prevent or reduce many mental illnesses based that the largest single prescription medication category for Medicaid (based on a consensus recommendation of the American Psychiatric Association) ²⁰.

o         Reduce the use of rapidly rising prescription pain medications ²¹.

·         Mental, Behavioral-health. Proven prevention practices can:

o         Reduce serious substance abuse by methamphetamine or poly drug users who utilize emergency services ^22-25.

o         Reduce serious alcohol use among men and women of child-rearing age in standard health-care settings ^{26 27}.

o         Prevent ADHD and related disorders in children through adulthood without medication for the price of a couple of kids’ meals at McDonald’s^{12 14}.

·         Public safety. Proven prevention practices can:

o         Prevent at least 83,000 cases of confirmed child maltreatment and conduct disorders for whole states or counties for the per child cost of dinner at Olive Garden or Red Lobster ^{6 9}.

o         Prevent lifetime conduct disorders and criminal activities by a “behavioral vaccine” implemented in first-grade ¹⁷.

·         Education. Proven prevention practices can:

o         Increase school readiness and early literacy at age 4 thru primary school with 12 simple but carefully constructed storybooks ^28-33.

o         Result in Title 1 students from 1^st grade looking like middle-class students in 4^th grade and into middle school ^{34 35}.

o         Improve academic responding of children with autism-spectrum disorder for the price of Big Mac ³⁶.

o         Cut the number of African American 9^th graders with failing grades using a 15-minute intervention in 7^th grade ³⁷.

·         Workplace and Community. Proven prevention practices can:

o         Increase the chances that people who have been fired or lost their jobs in economic downturn get new jobs ³⁸.

o         Increase water and energy conservation ^39-41 .

Recovery-Stimulus Strategy. These low-cost, scientifically proven prevention strategies can have a large impact in recovery, only if used widely across America. When America had the polio epidemic in the 1950s, the entire country was mobilized after the discovery of a vaccine. Mobilization and diffusion of the low-cost strategies could happen using two existing channels: 1) the thousands of Drug-Free Communities and Weed & Seed Grantees in America who are required to mobilize around sustainable evidence-based practices and strategies rather than deliver services, and 2) Agricultural Extension through land-grant colleagues whose whole purpose has for a hundred years been to transfer and disseminate scientific knowledge for community good.   Both entities use relationship “marketing” and could engage local organizations and entities to hire/retain individuals to disseminate programs and kernels throughout communities via doctors’ offices, clinics, schools, neighborhoods associations, etc. The use of low cost, proven kernels can be monitored on-line, in a strategic way that links community-wide change to a mass media scoreboard for American recovery.

Can such major population-level change happen and has it been demonstrated using low-cost strategies that can mobilize communities and produce credible change?  Yes, it has been recently proven for child-maltreatment and parenting outcomes by the CDC and several foreign governments ^{5 6 8 9 42}; proven for tobacco control ^43-46; and proven for intentional and unintentional injury control ^47-53.  Yes, measurable change and recovery can happen quickly for whole communities and states.

Some Next Steps 

1.       By executive order, the President could declare the parent-child strategies that are proven by CDC and others to prevent child maltreatment and behavioral/emotional diagnoses to be reimbursable under Medicaid/Medicare/TRICARE/SCHIP Rules.  They are not presently reimbursable unless both the child and parent are seen simultaneously, which is inadvertently causing skyrocketing increase of Schedule II and psychotropic medications—because a medical practitioner has no other choice for helping the family. Secretary Gates should expedite this in DOD, because deployed or combat service member families have typically higher rates of physical maltreatment.^54-56 Governors may also be able to issue executive orders achieving similar purposes.

2.       Executive orders or directives could also be issued by the President, Secretary Gates and Governors that would allow 3^rd party billing and/or blended funding for proven strategies delivered to schools or youth-serving that prevent DSM-IV or ICD mental, behavioral, emotional or physical disorders. Often, Federal or state regulations do not allow blending of funds or services that generate or mix treatment and prevention benefits.

3.       Health and Human Services and the Office of National Drug Control Policy could create an addendum to Drug Free Communities Grantees to accelerate the diffusion of low-cost strategies that prevent mental illness, substance abuse and related criminal or health problems rapidly, and allow billing for such low-cost strategies. 

4.       The Congress and President can enable the US Department of Agriculture to expand the reach of the Cooperative State Research, Education and Extension Services to use the extension offices to promote and disseminate these low-cost evidence-based strategies to small business owners, organizations, youth, consumers, and others in rural areas and communities of all size.

5.       Policies can be drafted that create incentives for state and local governments to implement low-cost or cost-effective evidence based strategies that cut across government silos and that produce quick change.

6.       Use the various “First Spouses” initiatives supported by Federal agencies to promote rapid diffusion of such strategies in the States.

Best Practice  Literature Cited

1. Zullow HM. Pessimistic rumination in popular songs and newsmagazines predict economic recession via decreased consumer optimism and spending. Journal of Economic Psychology 1991;12(3):501-26.

2. Zullow HM, Seligman ME. Pessimistic rumination predicts defeat of presidential candidates, 1900 to 1984. Psychological Inquiry 1990;1(1):52-61.

3. O'Connell ME, Boat T, Warne KE, editors. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. washington, DC: National Academices Press, 2009.

4. http://www.triplep-america.com/. Triple P America. Columbia, SC: Triple P International PTY, 2009.

5. Sanders MR, Ralph A, Sofronoff K, Gardiner P, Thompson R, Dwyer S, et al. Every family: a population approach to reducing behavioral and emotional problems in children making the transition to school. J Prim Prev 2008;29(3):197-222.

6. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population-based prevention of child maltreatment:  The U.S. Triple P System Population Trial. Prevention Science 2009;10(March).

7. Mihalopoulos C, Sanders MR, Turner KMT, Murphy-Brennan M, Carter R. Does the Triple P-Positive Parenting Program provide value for money? Australia and New Zealand Journal of Psychiatry 2007;41(3):239-46.

8. Nowak C, Heinrichs N. A comprehensive meta-analysis of Triple P-Positive Parenting Program using hierarchical linear modeling: Effectiveness and moderating variables. Clinical Child and Family Psychology Review 2008;11(3):114-44.

9. Foster EM, Prinz R, Sanders M, Shapiro CJ. Costs of a Public Health Infrastructure for Delivering Parenting and Family Support. Children and Youth Services Review 2007;30:493-501.

10. http://www.hazelden.org/web/public/pax.page. Good Behavior Game Kit: Hazelden, 2009.

11. Tingstrom DH, Sterling-Turner HE, Wilczynski SM. The Good Behavior Game: 1969-2002. Behavior Modification 2006;30:225-53.

12. 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.

13. Embry DD. The Good Behavior Game: a best practice candidate as a universal behavioral vaccine. Clinical Child & Family Psychology Review 2002;5(4):273-97.

14. Kellam S, Brown CH, Poduska J, Ialongo N, Wang W, Toyinbo P, et al. Effects of a universal classroom behavior management program in first and second grades on young adult behavioral, psychiatric, and social outcomes,. Drug & Alcohol Dependence 2008(Special Issue):24.

15. Wilcox HC, Kellam S, Brown CH, Poduska J, Ialongo N, Wang W, et al. The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts. Drug & Alcohol Dependence 2008(Special Issue):14.

16. Yan W, Dorothy CB, Hanno P, Elizabeth AS, Fernando AW, Sharon FL, et al. Depressed mood and the effect of two universal first grade preventive interventions on survival to the first tobacco cigarette smoked among urban youth. Drug and Alcohol Dependence 2009;100(3):194-203.

17. Petras H, Kellam S, Brown CH, Muthen B, Ialongo N, Poduska J. Developmental epidemiological courses leading to antisocial personality disorder and violent and criminal behavior: Effects by young adulthood of a universal preventive intervention in first- and second-grade classrooms. Drug & Alcohol Dependence 2008(Special Issue):15.

18. Embry DD, Biglan A. Evidence-Based Kernels: Fundamental Units of Behavioral Influence. Clinical Child & Family Psychology Review 2008;11(3):75-113.

19. Zhao Y-T, Chen Q, Sun Y-X, Li X-B, Zhang P, Xu Y, et al. Prevention of sudden cardiac death with omega-3 fatty acids in patients with coronary heart disease: A meta-analysis of randomized controlled trials. Annals of Medicine 2009;99999(1):1 - 10.

20. Freeman MP, Hibbeln JR, Wisner KL, Davis JM, Mischoulon D, Peet M, et al. Omega-3 fatty acids: evidence basis for treatment and future research in psychiatry. Journal of Clinical Psychiatry 2006;67(12):1954-67.

21. Smyth JM, Stone AA, Hurewitz A, Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial.[see comment]. JAMA 1999;281(14):1304-9.

22. Sindelar J, Elbel B, Petry NM. What do we get for our money? Cost-effectiveness of adding contingency management. Addiction 2007;102(2):309-16.

23. Roll JM, Petry NM, Stitzer ML, Brecht ML, Peirce JM, McCann MJ, et al. Contingency management for the treatment of methamphetamine use disorders. American Journal of Psychiatry 2006;163(11):1993-9.

24. Petry NM, Peirce JM, Stitzer ML, Blaine J, Roll JM, Cohen A, et al. Effect of Prize-Based Incentives on Outcomes in Stimulant Abusers in Outpatient Psychosocial Treatment Programs: A National Drug Abuse Treatment Clinical Trials Network Study. Arch Gen Psychiatry 2005;62(10):1148-56.

25. Rawson RA, McCann MJ, Flammino F, Shoptaw S, Miotto K, Reiber C, et al. A comparison of contingency management and cognitive-behavioral approaches for stimulant-dependent individuals. Addiction 2006;101(2):267-74.

26. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices.[see comment]. JAMA 1997;277(13):1039-45.

27. Manwell LB, Fleming MF, Mundt MP, Stauffacher EA, Barry KL. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcoholism: Clinical & Experimental Research 2000;24(10):1517-24.

28. Wedel JW, Fowler SA. "Read me a story, Mom": A home-tutoring program to teach prereading skills to language-delayed children. Behavior Modification 1984;8(2):245.

29. Whitehurst GJ, Epstein JN, Angel AL, Payne AC, et al. Outcomes of an emergent literacy intervention in Head Start. Journal of Educational Psychology 1994;86(4):542.

30. Whitehurst GJ, Arnold DS, Epstein JN, Angell AL, et al. A picture book reading intervention in day care and home for children from low-income families. Developmental Psychology 1994;30(5):679.

31. Arnold DH, Lonigan CJ, Whitehurst GJ, Epstein JN. Accelerating language development through picture book reading: Replication and extension to a videotape training format. Journal of Educational Psychology 1994;86(2):235.

32. Valdez-Menchaca MC, Whitehurst GJ. Accelerating language development through picture book reading: A systematic extension to Mexican day care. Developmental Psychology 1992;28(6):1106.

33. Embry DD. Designing Instructional Materials for Young Children. In: Gallagher J, editor. New Directions in Special Education. San Francisco, California: Jossey-Bass, Inc., 1980:440.

34. Greenwood CR. Classwide peer tutoring: Longitudinal effects on the reading, language, and mathematics achievement of at-risk students. Journal of Reading, Writing, & Learning Disabilities International 1991;7(2):105-23.

35. Greenwood CR. Longitudinal analysis of time, engagement, and achievement in at-risk versus non-risk students. Exceptional Children 1991;57(6):521-35.

36. Schilling DL, Schwartz IS. Alternative Seating for Young Children with Autism Spectrum Disorder: Effects on Classroom Behavior. Journal of Autism and Developmental Disorders 2004;34(4):423-32.

37. Cohen GL, Garcia J, Apfel N, Master A. Reducing the Racial Achievement Gap: A Social-Psychological Intervention. Science 2006;313(5791):1307-10.

38. Spera SP, Buhrfeind ED, Pennebaker JW. Expressive writing and coping with job loss. Academy of Management Journal 1994;37(3):722-33.

39. Staats H, van Leeuwen E, Wit A. A longitudinal study of informational interventions to save energy in an office building. J Appl Behav Anal 2000;33(1):101-4.

40. Winett RA, Leckliter IN, Chinn DE, Stahl B, Love SQ. Effects of television modeling on residential energy conservation. J Appl Behav Anal 1985;18(1):33-44.

41. Agras WS, Jacob RG, Lebedeck M. The California drought: A quasi-experimental analysis of social policy. J Appl Behav Anal 1980;13(4):561-70.

42. de Graaf I, Speetjens P, Smit F, de Wolff M, Tavecchio L. Effectiveness of the triple P positive parenting program on behavioral problems in children: A meta-analysis. Behavior Modification 2008;32(5):714-35.

43. Embry DD, Biglan A, Dahl MJ, Galloway D. Reward and Reminder Visits to Reduce Tobacco Sales to and Tobacco Use by Young People: A Multiple-Baseline Across Two States. Journal of Community Psychology in preparation.

44. Biglan A, Ary D, Koehn V, Levings D, al e. Mobilizing positive reinforcement in communities to reduce youth access to tobacco. American Journal of Community Psychology 1996;24(5):625-38.

45. Biglan A, Henderson J, Humphrey D, Yasui M, Whisman R, Black C, et al. Mobilising positive reinforcement to reduce youth access to tobacco. Tob Control 1995;4(1):42-48.

46. Embry DD. Community-Based Prevention Using Simple, Low-Cost, Evidence-Based Kernels and Behavior Vaccines. Journal of Community Psychology 2004;32(5):575.

47. Krug EG, Brener ND, Dahlberg LL, Ryan GW, Powell KE. The impact of an elementary school-based violence prevention program on visits to the school nurse. American Journal of Preventive Medicine 1997;13(6):459-63.

48. Embry DD, Rawls JM, Hemingway W. My Safe Playing Book:  An Experimental Evaluation of a Bibliotherapuetic Approach to Reduce the Risk of Pedestrian Accidents to 4-Year Old Children. Wellington, New Zealand: Ministry of Transport, Road Safety Division, 1985:38.

49. Embry DD, Peters L. A three-city evaluation of the diffusion of a pedestrian-safety injury control intervention. In: Division RS, editor: New Zealand Ministry of Transport, Wellington, NZ, 1985.

50. Embry DD. The safe-playing program:  A case study of putting research into practice. In: Paine S, Bellamy B, editors. Human Services That Work: From Innovation to Standard Practice. Baltimore, MD: Brookes Co., 1984:624.

51. Embry DD, Flannery DJ, Vazsonyi AT, Powell KE, Atha H. PeaceBuilders: A theoretically driven, school-based model for early violence prevention. American Journal of Preventive Medicine 1996;12(5, Suppl):91.

52. Flannery DJ, Vazsonyi AT, Liau AK, Guo S, Powell KE, Atha H, et al. Initial behavior outcomes for the PeaceBuilders universal school-based violence prevention program. Developmental Psychology 2003;39(2):292-308.

53. Vazsonyi AT, Belliston LM, Flannery DJ. Evaluation of a School-Based, Universal Violence Prevention Program: Low-, Medium-, and High-Risk Children. Youth Violence and Juvenile Justice 2004;2(2):185-206.

54. McCarroll JE, Fan Z, Newby JH, Ursano RJ. Trends in US army child maltreatment reports: 1990-2004. Child Abuse Review 2008;17(2):108-18.

55. Gibbs DA, Martin SL, Kupper LL, Johnson RE. Child maltreatment in enlisted soldiers' families during combat-related deployments. JAMA: Journal of the American Medical Association 2007;298(5):528-35.

56. Rentz ED, Martin SL, Gibbs DA, Clinton-Sherrod M, Hardison J, Marshall SW. Family Violence in the Military: A Review of the Literature. Trauma, Violence, & Abuse 2006;7(2):93-108.