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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’s12 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 1st grade looking like middle-class students in 4th 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 9th graders with failing grades using a 15-minute intervention in 7th 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 3rd 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.
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