Beyond Rhetoric: Why Not Use Good Science to Reduce Homicide, Suicide and Mental Illnesses? Part 1

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Morning Zen Guest Blog Post ~ Dennis D. Embry, PhD 

My fellow scientists and I are among a small number of people who have conducted and published peer-reviewed experimental studies to reduce human violence. Conducting experimental studies to reduce great causes of human suffering is much riskier than gambling in Los Vegas.  Good intentions can be harmful.

Perhaps the most important understanding about preventing homicides is that humans are the primary vertebrate predator of humans, something well documented in anthropology and archaeology. It’s not a new insight. Genesis tells the story of Cain killing Abel. Paradoxically, the fact that other humans are the primary predator is the same reason we associate with non-related humans in pro-social activities to protect ourselves. You can read our paper about those implications in Brain and Behavioral Sciences [1].

My journey into violence prevention began with an epiphany on special assignment by the Secretary of Defense during the Gulf War [2]. My assignment was to report to the Secretary why so many children during the Gulf War manifested rapid, serious mental, emotional, and behavioral symptoms and what could be done about it. Later, both the Secretary and the American Psychological Association (APA) asked that I give Congressional testimony. During Secretary Cheney’s tenure, many of those recommendations were implemented.

A year later, the newly elected president of the APA asked that I participate in a press conference on the prevention of violence in the aftermath of the LA Riots. Having learned precision behavioral epidemiology and applied that science to population-level prevention, I had a practical idea. There was robust evidence that that increasing positive reinforcement from peers for prosocial behavior could significantly reduce crime, violence and even homicide. 

A New York Times reporter there thought I was full of cotton candy in my brain. However later that day, I did a TV interview for the NBC affiliate in Washington, and it was aired in my hometown of Tucson. Shortly after I got back to Tucson, I received a commitment from a local hospital to fund such a test, and the local police department and county attorney also contributed substantial funds for the test. The local paper gave me two full pages each Sunday to promote the strategies for 12 weeks, and the local CBS station promised 10-second bumpers in all the newscasts, and a feature story each week and three Town Halls. A new assistant professor at the University of Arizona, Dr. Dan Flannery (who now heads the highly regarded Violence Prevention at Case Western Reserve), and I wrote a CDC violence prevention grant that funded the randomized control experiment embedded across eight schools.

 

The project was called, “PeaceBuilders [3].” The students had an identity of PeaceBuilders who learned to praise people, to give up put-downs, to seek wise people, to notice and speak up about hurts, to right wrongs, and to help others. Peacebuilders worked in reducing violence. The CDC sent its first epi-team to investigate an outbreak of prevention. The CDC epi team was led by Etienne Krug, who is now the director of the World Health Organization’s center on violence prevention. Medically coded violent injuries were reduced in the schools, as well as virtually every type of illness or visit [4]. The percentage of students reporting bringing a gun or knife to school declined substantially [5]. Psychometrically coded prosocial behaviors increased significantly, and antisocial or aggressive behaviors also decreased [5]. The effects were strongest for the children with the most serious histories of aggression and exposure to trauma and other difficulties [6].

Then, the Columbine shootings happened. I knew I’d get a call because my study was one of the most successful violence prevention studies funded by CDC. In June 1999, about 25 of people were invited to meet with the Surgeon General, the Attorney General, and the Secretary of Education. I got to present the PeaceBuilders results, though not all of them were yet published. Another scientist presented his findings, Dr. Sheppard Kellam [7, 8]. I did not know about those results.

The results Dr. Kellam at Johns Hopkins were astounding, but Dr. Kellam did not say what the intervention was. I asked him, and he replied: “The Good Behavior Game.” I knew what it was immediately because I was a doctoral student at the university where it was created. The procedure also involved a similar mechanism of my dissertation, involving reinforcement of voluntary control over inhibition of impulsive, dangerous or aggressive behaviors [9]. We had included the Good Behavior Game in PeaceBuilders, but did not emphasize it in training or coaching.

Like a car, the human brain has a “gas pedal” and a “brake pedal.” Both are necessary. Throughout the course of human evolution until very recently, child rearing, teaching by community adults, and children’s play involved positive reinforcement for thoughtful initiation of behavior (“go”) for a goal and ability to “stop” when behaviors might interfere with a beneficial outcomes for self, the family, and the group. Children’s outdoor play taught these skills; chores taught these skills, and general social activities reinforced these skills. Today, we call this skill, “self-regulation” and “group self-regulation.” The lack of self- and group-regulation predicts just about every DSM diagnoses epidemic among kids today—especially drug use, aggression, and violence. These are three horses of the Apocalypse.

In fall 1999, my staff and I immediately started replicating the Good Behavior Game, infused with the strategies from our PeaceBuilders study. We started full bore in South Chicago with one of the first Safe and Drug Free Schools grants (which came out of that meeting with the Surgeon General, Attorney General, and the Secretary of Education that Dr. Kellam and I were at). Eventually, we were able to show positive, replicated immediate results in 247 classrooms in South Chicago, which were reported in 2002 [10]. We merged previously proven strategies from PeaceBuilders (now called evidence-based kernels [11]) to GBG, which made results easier to achieve with less training and coaching.

I would not have thought about using behavioral psychology to prevent violence at a population, public-health level were it not for chance meetings and events. Such is much of science. Two tragedies compelled me to think out of the box, and to dig very deep into multiple fields from anthropology, developmental psychology, epigenetics, evolution, behavioral economics, neuroscience, and even my own faith and religion.

In 2010, after the release of the Institute of Medicine Report on the Prevention of Mental, Emotional, and Behavioral Disorders Among Young People [12], SAMSHA funded 20 sites across America to replicate GBG. My colleagues and supervised 18 of those sites, and they all replicated the basic, early results of GBG. That success has now led to more than 15,000 teachers in the US to adopt and use GBG. Ohio, for example, funded more than 2,000 teachers to use GBG this past year. New Mexico, Oregon, Washington, and Montana have easily impacted thousands of teachers.

The leap of faith in those scientific connections has resulted in systematic replication of many proximal (1-2 year) results at Johns Hopkins studies by Drs. Kellam and Ialongo in the United States, Canada and Europe [13-17]. Most importantly, the Government of Manitoba implemented a province-wide randomized-waitlist control, public-health level implementation [14].  Such real-world population-level, public health studies are not easy; they are messy and hard. The results are very similar to the first year results of the very tightly controlled efficacy studies at Hopkins [18, 19].

The promise of achieving population-level prevention of violence, substance abuse, risky sex, school failure, etc. from a proven strategy is now “on time” from the history of dissemination and use of scientifically proven strategies. Next year will be the 50th anniversary of the first publication of the Good Behavior Game [20].

Using the outcome data (e.g., effect sizes) from the Hopkins trials where I am a co-investigator since 2003, we can guestimate outcomes if every first grader had two (2) years of exposure GBG. My colleagues at Hopkins have followed two cohorts of about 2,000 first-graders into adulthood from two comparative effectiveness trials, and we now have a third such randomized trial. The potential impact could change the future of America. Here is that “guesstimate” for the 4 million first graders in the US when they reached age 19-20 after being protected by two years of GBG:

And, what does it cost to protect each American 1st grader through adulthood? It would cost about the price of taking a child to a movie, getting some popcorn and a soda, and then going for a pizza afterward. The rate of return on investment is 60-to-1 ROI [21]. And what is the rate of return for our children’s futures? Priceless.

Conflict of Interest Statement: Dr. Embry is president of PAXIS Institute, which owns the intellectual property for the PAX Good Behavior Game. PAXIS Institute requires that any research team publish results on the research on the Good Behavior Game, regardless of outcome in the interest of improving the public health of current and future generations. All current studies of PAX GBG have, or are being, conducted by independent scientists in the United States, Canada, Europe, and Australia.

  1. Wilson, D.S., et al., Evolving the Future: Toward a Science of Intentional Change. Brain and Behavioral Sciences, 2014. 37(4): p. 395-416.
  2. Embry, D.D., The impact of Desert Storm on Military Families: Testimony on Persian Gulf War Veterans' Re-Adjustment Hearings, in Veterans' Affairs Committee, United States Senate. 1991, Congressional Record Daily Digest.
  3. Embry, D.D., et al., PeaceBuilders: A theoretically driven, school-based model for early violence prevention. American Journal of Preventive Medicine, 1996. 12(5, Suppl): p. 91.
  4. Krug, E.G., et al., The impact of an elementary school-based violence prevention program on visits to the school nurse. American Journal of Preventive Medicine, 1997. 13(6): p. 459-63.
  5. Flannery, D.J., et al., Initial behavior outcomes for the PeaceBuilders universal school-based violence prevention program. Developmental Psychology, 2003. 39(2): p. 292-308.
  6. Vazsonyi, A.T., L.M. Belliston, and D.J. Flannery, Evaluation of a School-Based, Universal Violence Prevention Program: Low-, Medium-, and High-Risk Children. Youth Violence and Juvenile Justice, 2004. 2(2): p. 185-206.
  7. Kellam, S.G., et al., The course and malleability of aggressive behavior from early first grade into middle school: Results of a developmental epidemiology-based preventive trial. Journal of Child Psychology and Psychiatry, 1994. 35: p. 259-281.
  8. Kellam, S.G., et al., The effect of the level of aggression in the first grade classroom on the course and malleability of aggressive behavior into middle school. Development and Psychopathology, 1998. 10: p. 165-185.
  9. Embry, D.D., The safe-playing program: A case study of putting research into practice., in Human Services That Work: From Innovation to Standard Practice, S. Paine and B. Bellamy, Editors. 1984, Brookes Co.: Baltimore, MD. p. 624.
  10. Embry, D.D., The Good Behavior Game: A Best Practice Candidate as a Universal Behavioral Vaccine. Clinical Child & Family Psychology Review, 2002. 5(4): p. 273-297.
  11. Embry, D.D. and A. Biglan, Evidence-Based Kernels: Fundamental Units of Behavioral Influence. Clinical Child & Family Psychology Review, 2008. 11(3): p. 75-113.
  12. O'Connell, M.E., T. Boat, and K.E. Warner, eds. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth and Young Adults: Research Advances and Promising Interventions. 2009, Institute of Medicine; National Research Council: Washington, DC. 576.
  13. Smith, E.P., et al., Promoting Afterschool Quality and Positive Youth Development: Cluster Randomized Trial of the Pax Good Behavior Game. Prev Sci, 2017.
  14. Jiang, D., et al., A Comparison of Variable- and Person-Oriented Approaches in Evaluating a Universal Preventive Intervention. Prev Sci, 2018.
  15. Streimann, K., et al., Effectiveness of a universal classroom-based preventive intervention (PAX GBG): A research protocol for a matched-pair cluster-randomized controlled trial. Contemporary Clinical Trials Communications, 2017. 8(Supplement C): p. 75-84.
  16. O’Donnell, M., et al., Supporting the development of pupils’ self-regulation skills: Evaluation of the PAX GBG Programme in Ireland. Irish Teachers’ Journal, 2016. 4 (1): p. 9-29.
  17. Domitrovich, C.E., et al., How Do School-Based Prevention Programs Impact Teachers? Findings from a Randomized Trial of an Integrated Classroom Management and Social-Emotional Program. Prev Sci, 2016. 17(3): p. 325-37.
  18. Dolan, L.J., et al., The short-term impact of two classroom-based preventive interventions on aggressive and shy behaviors and poor achievement. Journal of Applied Developmental Psychology, 1993. 14: p. 317-345.
  19. Ialongo, N., et al., Proximal impact of two first-grade preventive interventions on the early risk behaviors for later substance abuse, depression, and antisocial behavior. American Journal of Community Psychology, 1999. 27(5): p. 599-641.
  20. Barrish, H.H., M. Saunders, and M.M. Wolf, Good behavior game: Effects of individual contingencies for group consequences on disruptive behavior in a classroom. Journal of Applied Behavior Analysis, 1969. 2(2): p. 119-124.
  21. Aos, S., et al. Good Behavior Game, Return on Investment: Evidence-Based Options to Improve Statewide Outcomes. 2013. 8. 

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embryDennis Embry, President/Senior Scientist at PAXIS Institute – Dennis D. Embry is a prominent prevention scientist in the United States and Canada, trained as clinician and developmental and child psychologist. He is president/senior scientist at PAXIS Institute in Tucson, Arizona. Dennis Embry serves on the scientific advisory board for the Children’s Mental Health Network and the U.S. Center for Mental Health Services Advisory Council.

Comments

  1. Dennis Embry's avatar
    Dennis Embry
    | Permalink
    Dear Claudette,

    Thank you for the thoughtful reply. You are truly thinking about these issues. Reflecting on additions to tier 1, 2 and 3 to reduce the problem of mental illness, addictions and violence to self and others among our children and teens is needed.

    Paradoxically, additions to Tier 1 are the hardest to sort out scientifically—especially in terms of cost in time and money to achieve the best results. Changing human behavior at a population-level scale efficiently and with impact is not easy. We often get bound to putative solutions because of cultural fads.

    As a child psychologist, a scientist and a fierce advocate for children, I want to know what can produce the biggest bang for the buck. There are three ways I sift through ideas: epidemiological trends, evolution/cultural anthropology, and actual scientifically controlled experiments. This can lead to 24K gold.

    Using and Making Proven Tier 1 (Universal) Strategies More Universal

    My prevention around the world colleagues have been hypothesizing and testing solutions. Some look promising and others less so. For example, we’ve conducted a randomized control, comparative effectiveness trial with the Good Behavior Game, Good Behavior Game plus a top rated SEL program against control. It seemed like a brilliant idea, but the benefits were small compared to the time and effort. Time and money are scarce in schools.

    In another study, we compared GBG to GBG delivery an extremely well proven parenting program delivered in the schools and control. The combo of GBG plus site-based parenting programs services could not get off the ground because the clinicians did not want to do the brief parenting supports after school and in the evening. In today’s economy, parents must work long to feed and shelter their children.

    So, now we are experimenting with providing the same types of low-cost yet proven parenting supports via an App. One of my colleagues has proven that a TV show can achieve population-level impact on parenting. The British TV show was entitled “Driving Mum and Dad Mad.” When this was aired, it outdrew “Desperate Housewives.” In this amazing population-level study, more than 11,000 mental health professionals would have to be been trained AND delivered services to tens of thousands of families to have achieved similar clinical effects.

    In a similar approach, funded by the Centers for Disease Control, another colleague proved that child maltreatment can be prevented at a population level in a randomized trial across counties by very brief, practical tip sheets and brief public presentations for about $12 per child. If these very low-cost Tier 1 approaches to parenting supports can be replicated and scaled up, we will have far fewer ACE’s affecting children and, by implication, their children.

    Practical Considerations for Using Tier 2 and 3 Strategies
    The first rule for Tier 2 and 3 strategies is to have powerful Tier 1 strategies widely and effectively implemented. If you don’t, kids will “relapse” or likely fail with Tier 2 and 3 strategies. Let me explain. When I was the clinical advisor and program developer for an incredible therapeutic day treatment program, school people would remark upon visiting the program that “they could do what we did.” I replied that was right, but the reason they were paying for the kid in our program was because they had NOT used the same tested and proven strategies at Tier 1 and 2 level. If good Tier 1 are absent at discharge, Tier 3 kids will almost certainly stumble.

    I am struck by peculiar data about America versus other developed countries, because of my work in Canada, Europe, and Australia/New Zealand. America seems to have worse prevalence rates for mental, emotional, and behavioral disorders among children. We appear to have a cultural miasma. I have epidemiological hypotheses for why, after scouring epidemiological data. Given U.S. scientific leadership, we should have the best outcomes, but we don’t

    The irony of our cultural failure to avert the epidemic of mental, emotional, and behavior disorders in America is that America largely invented the single best Tier 1 strategies but does not use them. We just blame parents and schools, while other countries use our science to give their children a leg up.

    PS. One of our early grad students, John Vanderberg, was key creator of wraparound. I’ll write more about Tier 2 and 3 strategies that might be easily scalable.
  2. Claudette Fette's avatar
    Claudette Fette
    | Permalink
    Love this! I would add adult education on social-emotional learning, identifying and enabling strengths, and recognition of concerning behaviors at the “everybody” level.

    Then at tier 2, for children/youth identified at risk (due to exposure to domestic violence, bullying, learning disability, behavioral health diagnoses, etc ...), implement multidisciplinary group interventions that identify and build on individual child strengths, enable guided practice for effective social and emotional skill building. Lean into at risk populations and create individual mentoring by students who are thriving and teachers and administrators.

    Then at tier 3, with children who are identified as having concerning behaviors, build capacity for high fidelity, individualized wraparound planning and implementation that is true to principles laid out by the Nat Wraparound Initiative. Make sure these teams build and include natural supports, are individualized, identify and build youth strengths, have access to funded family partners and true flex funds as well as skilled multidisciplinary facilitators who know their community and just refuse to give up. This tier will not be cheap, but if we have done a really thorough job at tiers 1 & 2, it will be needed for fewer youth.

    I look forward to part 2!
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