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

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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

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

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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.

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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.

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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.

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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.

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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.

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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.