New Hampshire Keynote on Prevention for Whole County 11 10-11

Creating Our Futures:
How we can better the
health of our community
and ourselves
by Dennis D. Embry, Ph.D.

Vision 2020 Community Summit
Keene, NH • November 10, 2011

Public-health kernel case studies of change

30.0% 12.0%

25.0% 10.0%
20.0% 8.0%
15.0% Youth Who Smoked During the Last 30 Days
6.0% Youth Who Smoked Every Day the Last 30 Days
Youth Who Smoked During the Last 30 Days
Baseline Youth Who Smoked Every Day the Last 30 Days
Baseline
Reward and Reminder Reward and Reminder
45.0% Baseline Reward and Reminder 18.0% Baseline Reward and Reminder
10.0%
45.0% Wyoming 4.0%
18.0% Wyoming
40.0% Wyoming 16.0% Wyoming
40.0% 16.0%
5.0%
35.0% 2.0%
14.0%
35.0% 14.0%
30.0% 12.0%
0.0%
30.0% 12.0%
25.0% 10.0%
25.0% 18.0%
10.0%
20.0% 8.0%
20.0% United States 8.0% United States
40.0%
15.0%
15.0% 16.0%
6.0%
6.0%
10.0% 4.0%
10.0% 4.0%
35.0%
5.0% 14.0%
2.0%
5.0% 2.0%
0.0%
30.0%0.0% 12.0%
18.0%
18.0%
Wisconsin Wisconsin
Wisconsin
40.0% Wisconsin 16.0%
25.0%
40.0% 10.0%
16.0%
35.0%
35.0% 14.0%
14.0%
20.0%
30.0%
30.0% 8.0%
12.0%
12.0%
25.0%
25.0% 10.0%
10.0%
15.0% 6.0%
20.0%
20.0% 8.0%
8.0%

10.0%
15.0%
15.0% 4.0%
6.0%
6.0%
10.0%
10.0% 4.0%
4.0%
5.0%5.0%
5.0% 2.0%
2.0%
2.0%
Source: YRBS, US Centers for Disease Control Source: YRBS, US Centers for Disease Control
0.0%
0.0%
0.0% 0.0%
18.0%
1995 1997 1999 2001 2003 2005 2007 1995 1997 1999 2001 2003 2005 2007

= Trend = Wyoming = Wisconsin =United States

Population level example of use of kernels for big change
Embry, D. D. and A. Biglan (2009). Reward and Reminder: An Environmental Strategy for Population-Level Prevention. National
Registry of Effective Programs and Practices, Substance Abuse and Mental Health Administration.

B e h a v i o r a l Vac c i n e s an d
Evidence-Based Kernels:
Nonpharmaceutical
A p p ro a c h e s f o r th e
P re v e n t i o n o f M e n t a l ,
Emotional, and
B e h a v i o r a l D i s o rd e r s
Dennis D. Embry, PhD

KEYWORDS
Evidence-based kernels Behavioral vaccines Prevention
Public health

Available at:
www.slideshare.net/drdennisembry

Clin Child Fam Psychol Rev
DOI 10.1007/s10567-008-0036-x

Evidence-based Kernels: Fundamental Units of Behavioral
Influence
Basic understanding of kernels
Embry, D. D. and A. Biglan (2008). Evidence-Based Kernels:
Dennis D. Embry Æ Anthony Biglan

Fundamental Units of Behavioral Influence. Clinical Child Family
Psychology Review 11(3): 75-113.
Ó The Author(s) 2008. This article is published with open access at Springerlink.com

Abstract This paper describes evidence-based kernels, This paper presents an analysis of fundamental units of
fundamental units of behavioral influence that appear to behavioral influence that underlie effective prevention and
underlie effective prevention and treatment for children, treatment. We call these units kernels. They have two
adults, and families. A kernel is a behavior–influence defining features. First, in experimental analysis,
procedure shown through experimental analysis to affect a researchers have found them to have a reliable effect on

Using kernels for population change
A R T I C L E

COMMUNITY-BASED
PREVENTION USING SIMPLE,
LOW-COST, EVIDENCE-BASED Embry, D. D. (2004). Community-Based Prevention Using Simple,
KERNELS AND BEHAVIOR
VACCINES Low-Cost, Evidence-Based Kernels and Behavior Vaccines.
Dennis D. Embry
PAXIS Institute
Journal of Community Psychology 32(5): 575.
A paradox exists in community prevention of violence and drugs. Good

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

T he G ood B ehavior G ame: A B est P ractice C andidate
Behavioral vaccines for disease control
as a U niversal B ehavioral V accine

D ennis D . E mbry1 Embry, D. D. (2002). The Good Behavior Game: A Best Practice
A “ behavioral vaccine” provides an inoculation against morbidity or mortality, impactingphys-
Candidate as a Universal Behavioral Vaccine. Clinical Child
Family Psychology Review 5(4): 273-297.
ical, mental, or behavior disorders. A n historical example of a behavioral vaccine is antiseptic
hand washing to reduce childbed fever. I n current society, issues with high levels of morbidity,
LY

such as substance abuse, delinquency, youth violence, and other behavioral disorders ( multi-
problems) , cry out for a low-cost, widespread strategy as simple as antiseptic hand washing.
C ongruent research findings from longitudinal studies, twin studies, and other investigations
N

suggest that a possibility might exist for a behavioral vaccine for multiproblem behavior. A
O

simple behavioral strategy called the G ood B ehavior G ame ( G B G ) , which reinforces inhibi-
tion in a group context of elementary school, has substantial previous research to consider
its use as a behavioral vaccine. T he G B G is not a curriculum but rather a simple behavioral

What is a kernel?
Is the smallest unit of scientiﬁcally proven behavioral
inﬂuence.

• Is indivisible; that is, removing any part makes it
inactive.

Produces quick easily measured change that can
grow much bigger change over time.

Can be be used alone OR combined with other
kernels to create new programs, strategies or
policies.

• Are the active ingredients of evidence-based
programs

• Can be spread by word-of-mouth, by modeling, by
non professionals.

• Can address historic disparities without stigma, in
part because they are also found in cultural wisdom.

Relational
Antecedent Reinforcement Physiological
Frame
Kernel Kernel Kernel
Kernel

Changes Creates verbal
Happens BEFORE Happens AFTER the
biochemistry of relations for the
the behavior behavior
behavior behavior

Embry, D. D., Biglan, A.
(2008). Evidence-Based

Four Types of Kernels
Kernels: Fundamental Units of
Behavioral Inﬂuence. Clinical
Child Family Psychology
Review, 39.

Kernels are building
blocks of behavior change
Humans survive individually and collectively by
inﬂuencing the behavior or other humans
The 2008 paper by Embry and Biglan identiﬁes
52 evidence based kernels that can be used to
design or or improve programs.

What is a behavioral vaccine?
It is a simple procedure (a kernel or a
recipe of kernels) that, when used
repeatedly, reduce morbidity and mortality
and/or increase wellbeing or health.
Behavioral vaccines can be used by
individuals, families, schools, businesses,
organizations to produce rapid population
level change.
Embry, D. D. (2004). Community-Based Prevention Using Simple,
Low-Cost, Evidence-Based Kernels and Behavior Vaccines.
Journal of Community Psychology 32(5): 575.

Increase nurturance of prosociality for
persons of all ages
This can be individual, family, school and/or community action

Reduce toxic inﬂuences of all ages
This can be at an individual, family, school and/or community level

Increase psychological ﬂexibility among
people of all ages
This can be achieved across settings, as the above.

From Biglan, Flay, Embry, and Sandler. Nurturing Environments and the Next Generation of Prevention Research and Practice

Trend-line for humorous warnings on binge drinking
by women of child-rearing age
No Warnings Humorous Warnings

Antecedent
Kernel

Trend-line for humorous warnings on binge drinking
by women of child-rearing age
No Warnings Humorous Warnings
20
Antecedent
Kernel 16

Percentage
12

8

4

0
1995 1997 1999 2001 2002 2003 2004 2005 2006 2007

Population level effort to prevent child
maltreatment - in two years

Substantiated Child Maltreatment
16
Rates per 1,000 Children (0-8 Years)

15

13

12

10

Pre Post
Two Years Later
Prinz et al., 2009, Prevention Science

16

Control Counties

15

13

12

10

Pre Post
Two Years Later

16

Control Counties

15

13

Triple P Counties
12

10

Pre Post
Two Years Later

Child Abuse Hospital Injuries
1.80

1.68

1.55

1.43

1.30

Post
Pre
Two Years Later


1.80

1.68 Control Counties
1.55

1.43

1.30

Post
Pre
Two Years Later


1.80

1.68 Control Counties
1.55

1.43 Triple P Counties
1.30

Post
Pre
Two Years Later


Child Out-of-Home Placements
4.50

4.13

3.75

3.38

3.00
Post
Pre
Two Years Later


Control Counties
4.50

4.13

3.75

3.38

3.00
Post
Pre
Two Years Later


Control Counties
4.50

4.13

3.75
Triple P Counties

3.38

3.00
Post
Pre
Two Years Later


Reduce Omega 3 Brain Deﬁciency in
baby’s brain

The beneﬁts to the baby and society
Verbal Suboptimal Prosocial Suboptimal
A 35 C 15
children suboptimum (%)

30

Verbal IQ

10
25

Prosocial
20
5

15
n=584 n=3493 n=1330 n=739 n=4260 n=1583
0 0

B 35
Fine Motor Skills Suboptimal D 35 Social Development Suboptimal
30 30

Social development
Fine motor

25 25

20 20

15 15
n=875 n=4923 n=1798 n=875 n=4919 n=1798
0 0
None 0–340 g 340 g None 0–340 g 340 g
per week per week per week per week
Maternal seafood consumption in pregnancy Maternal seafood consumption in pregnancy

Before Omega 3

Omega-3 can improve school
grades and success
Omega 3 Placebo
7
These were gains in
6
After Omega 3 academics after 3
5
months of exposure
4
to ﬁsh oil.
3
2
1
0
-1
-2
Reading Spelling See www.durhamtrial.org/

Why not help our high-risk
children youth with
omega-3?
30%
Percentage with Psychosis at 12 months

27.5%
24%

18%

12%

6%
4.9%
0%
Omega-3 Placeo
Psychosis

Amminger, G. P., M. R. Schafer, et al. (2010). Long-Chain {omega}-3 Fatty Acids for Indicated
Prevention of Psychotic Disorders: A Randomized, Placebo-Controlled Trial. Arch Gen
Psychiatry 67(2): 146-154.

Reduced Felony Violent Offences Among Prisoners
with recommended daily amounts of vitamins, minerals and
essential fatty acids
Ratio of Disciplinary Incidents Supplementation/Baseline

1.00

Active -37.0% Placebo -10.1%
0.75 p ‹ 0.005 p = ns

0.50

Active
0.25 Placebo

0
Before supplementation During supplementation

UK maximum security prison - 338 offences among 172 prisoners over 9 months
treatment in a compared to 9 months baseline.
Gesch et al. Br J Psychiatry 2002, 181:22-28

Matsuoka BioPsychoSocial Medicine 2011, 5:3
http://www.bpsmedicine.com/content/5/1/3

REVIEW Open Access

Clearance of fear memory from the hippocampus
through neurogenesis by omega-3 fatty acids:
a novel preventive strategy for posttraumatic
stress disorder?
Yutaka Matsuoka1,2

Abstract
Not only has accidental injury been shown to account for a significant health burden on all populations, regardless
of age, sex and geographic region, but patients with accidental injury frequently present with the psychiatric
condition of posttraumatic stress disorder (PTSD). Prevention of accident-related PTSD thus represents a potentially
Clearance of fear memory from the hippocampus important goal. Physicians in the field of psychosomatic medicine and critical care medicine have the opportunity
through neurogenesis by omega-3 fatty acids: a novel to see injured patients in the immediate aftermath of an accident. This article first briefly reviews the prevalence
preventive strategy for posttraumatic stress disorder? and associated factors of accident-related PTSD, then focuses on a conceptual model of fear memory and
Matsuoka proposes a new, rationally hypothesized translational preventive intervention for PTSD through promoting
hippocampal neurogenesis by omega-3 fatty acid supplementation. The results of an open-label pilot trial of
Matsuoka BioPsychoSocial Medicine 2011, 5:3
http://www.bpsmedicine.com/content/5/1/3 (8 February 2011) injured patients admitted to the intensive care unit suggest that omega-3 fatty acid supplementation immediately
after accidental injury can reduce subsequent PTSD symptoms.

Omega-3 for PTSD symptoms could help our
returning vets from 10 years of war…

Classrooms

Muriel Saunders

Instant change in disturbing or disruptive behaviours

PAX GBG decreased distraction in classrooms by an average of 86% after
only one month
2011 Replication in rural
Tennessee by coaches
trained just like you…

only one month
Baseline Disruptions
Six 1st-grade classrooms
averaged 136 per hour before
coaching

only one month
coaching

PAX Introduced
The distractions per hour
decreased by 56% with the
introduction of the PAX
environment of PAX language
and several PAX kernels.

only one month
coaching

PAX Introduced
The distractions per hour
decreased by 56% with the
introduction of the PAX
environment of PAX language
and several PAX kernels.

PAX GBG Played
Disruptions per hour
decreased an additional 30%
after learning to play PAX
GBG .

Timeline of benefits from PAX GBG
Age of
Benefits
Child
75% reduction in disturbing, disruptive and destructive behavior;
1st Grade
25% increase academic achievement; less bullying and intimidation
43% reduction in ADHD diagnoses; 33% reduction in Oppositional Defiant Disorder;
3rd Grade 30%+ reduction special services needs;
50%+ reduction in conduct disorders; 25% to 50% reduction tobacco use; reduction in
6th grade bullying or harassment behaviors

8th Grade 75%r reduction in serious drug use and engagement in delinquent acts

12th Grade Major increase in high-school graduation; lower utilization of special services

Early 20’s Increase in college entry; Major reductions drug use; reductions in prison time

Age 29 Lifetime reduction in violent crime, suicide, psychiatric diagnoses, and lifetime addictions

Kellam et al., Addiction Science Clinical Practice; 6:73-84, 2011

GBG delays
vaginal sex by
two years
among high-
risk males

Would happen if every first
grader in Keene had the Good
Behavior Game?
Good Behavior
Game Universal
Behavioral Net Economic
Number of Vaccine Cost Benefit for All
1st ($150 each Taxpayers the
Graders child X 282) Children

282 = $42,360 = $4,054,699
(Total Cost of (Total Benefit of
Lifetime Prevention) Lifetime Prevention)

Source: Washington State Institute for Public Policy (July, 2011),Return on Investment:
Evidence-Based Options to Improve Statewide Outcomes

Prevention for Planner for Population Level Change
everyone… Using Evidence-Based Kernels*

1. Total number of people (ages) 2. How will your plan get at least Who might
to be reached in the 25% of the reached population sponsor the
Start population (www.census.gov): to adopt the kernel? 2b. effort?

Baseline
This is the number to be reached.
Data
3.
What are the ways actual implementation of the
kernel will be promoted, reinforced and supported:

What is the monitoring for % adoption?
2c.
What is the monitoring for
3b. implementation?

4.
How will individuals, groups and organizations use of the kernel be maintained over time?

5. 6.
How will changes in behavior be measured each day, week or How will change be celebrated?
month and reported as a public scoreboard?

* Embry DD. Community-Based Prevention Using Simple, Low-Cost, Evidence-Based Kernels and Behavior Vaccines. Journal of Community
Psychology 2004;32(5):575.
Embry DD, Biglan A. Evidence-Based Kernels: Funda uence. Prevention Science revised and re-submitted.

Author's personal copy
Behavioral Vaccines and Evidence-Based Kernels 11

From Embry DD, Biglan A. Evidence-Based Kernels: Fundamental Units of Behavioral Influence. Clinical
Child Family Psychology Review. Accepted for publication. Table 1
Table 2: Example Kernel Utility Across Age Groups
Example of kernel utility for selected, indicated, and universal prevention
Legend: NA = not applicable, * = experimental evidence, P = predicted utility
Evidence-Based
Infants Children Teens Adults
Verbal Praise * * * *
Kernel Selected Prevention Indicated Prevention Universal Prevention
Peer-to-peer written praise--“Tootle” Notes, NA * * * Prize bowl/mystery Reduce alcohol, Reduce problem Improve engaged
compliments books/ praise notes
Beat the timer or beat the buzzer * * * * motivator tobacco or drug behavior in high- learning of whole
Mystery motivators/ Grab Bag/ Prize Bowl/ Game P * * * (reinforcement use161,163,164 risk children or class and reduce
of Life kernel) Improve engagement youth222–224 disruptions of
Public posting (graphing) of feedback of a NA * * *
targeted behavior in treatment whole class225–227
Principal Lottery NA * * goals169,170
Safety or Performance Lottery NA * * *
Contingent music * * * * Goal/node mapping Reduce relapse or Prevent use rates of Increase academic
Team competition NA * * * (relational frame recidivism alcohol, tobacco, success or cognitive
Special Play * *
Choral responding * * P P
kernel) rates228,229 and other processes233–236
Mystery shopper/Reward Reminder NA P P Improve recovery230 drugs228,231
Peer-to-peer tutoring NA * * * Improve attainment
Computer action game P * * *
Correspondence training, “Say-Do” NA * * P of therapeutic
Correspondence training, “Do-Say” NA * * P goals231,232
Time out * *
Sit and Watch, Contingent Observation or * * * * Omega-3 fatty acid Treat depression, Prevent emergence of Improve children’s
Response Lock Out supplementation borderline and/or psychotic episodes cognitive
Taxation on consumptive behaviors NA NA * *
Positive Note Home for Inhibition NA * *
(physiological bipolar disorder70 in prodromal performance and
Timed Rewards for Inhibition (DRO) * * * * kernel) Reduce autism adolescents47 prevent behavioral
Premack Principle * * * * symptoms71,142 disorders69,237–239
Response-cost (point loss) P * * *
Low emotion or “Private” reprimands * * * * Public posting Reduce community Improve problematic Reduce impulsive or
Stop Clock NA * * * (antecedent illegal behavior in risky behaviors in
Law enforcement fine or citation NA NA * *
Over-correction or Positive Practice * * * * kernel) behaviors100,101,120 therapeutic general
“Buzzer/Noise Training” P * * settings240,241 population242,243
Non-verbal transition cues * * * * Improved
Stop lights in school settings or traffic settings NA * * *
Boundary cues and railings * * * * academics244–246
Cooperative, Structured peer play P * * Promoting
Self-modeling P * * *
participation or
Self-monitoring NA * * *
Paragraph Shrinking NA * * P community
Errorless Discrimination Training * * * * goods247,248
Adjectival Noun for Belonging to Status Group P * * *

1
POLICY ACTIONS

The IOM Reportpp388–92 notes that other rich countries are far more advanced in applying
prevention science, with the irony that most of the research for these efforts comes from
the United States, and is even true for northern neighbors Canada. For example, the

Multi-Inﬂammatory Brain Body Response

Major Connected Ecologic Causes of the Adverse Trends to Children, Youth and Adults

Reinforcement Antecedents Physiological Verbal Relations
more for anti-social cue anti-social inﬂuences trigger occasion perceived
than prosocial more than prosocial adverse biological threats and related
behaviors behaviors mechanisms reactions

Mood Lo Reward Lo Executive Lo Behavioral
Inattention Delay Function
Instability Competencies
Poor Immune-
Motor Healing
Skills Multi-Inﬂammatory Brain Body Response Dysfunction



Substance Work Obesity,
Early Mental Illness Violence Cancer School
Abuse Problems etc
Sex Failure

Mood Lo Reward Lo Executive Lo Behavioral
Inattention Delay Function
Instability Competencies
Poor Immune-
STD’s Motor Healing Special
Skills Multi-Inﬂammatory Brain Body Response Dysfunction Ed



Our Own Children’s or Loved-ones’ Futures

Our Own Children’s and Loved-ones’ Futures
ADHD

stealing aggression
asthma depression
learning disabilities
obesity cancer
depression
hi-blood pressure heart-disease
violence bipolar
suicide diabetes alcohol
crime drugs tobacco
dangerous acts

Lifetime Prevalence of Disorders in US Adolescents (N=10,123)
Merikangas et al., 2010 40%

35%

30%

25%

20%

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


35%
Anxiety
30%

25%

20%

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


35%
Anxiety
30%

25%
Behavior
20%

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


35%
Anxiety
30%

25%
Behavior
20%
Mood
15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


35%
Anxiety
30%

25%
Substance
Behavior
20%
Mood
15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years

Nearly 3 out of 4 of the nation's 17- to 24-year-olds are
ineligible for military service for based on national
epidemiological data

• Medical/physical problems,
35 percent.

• Illegal drug use, 18 percent.
• Mental Category V (the
lowest 10 percent of the
population), 9 percent.

• Too many dependents under
age 18, 6 percent.

• Criminal record, 5 percent.

Army Times, Nov 5, 2009 • www.missionreadiness.org/PAEE0609.pd

Cumulative prevalence of psychiatric disorders by
young adulthood: a prospective cohort analysis from
the Great Smoky Mountains Study.
By 21 years of age, 61.1% of
participants had met criteria for a well-
speciﬁed psychiatric disorder. An
additional 21.4% had met criteria for a
not otherwise speciﬁed disorder only,
increasing the total cumulative
prevalence for any disorder to 82.5%.

The US has 75
million children
and teens.
40.4 million are
on psychotropic
medications

Wall Street
Journal,
12-28-2010

If we just hit the
problem harder…

Policy Action and Lessons from Manitoba

Manitoba is using new word prompt generalization
of behaviors to support healthy children adults…

We need to spread health wellbeing like dandelions

How come we are just hearing about this now…

My perspective
Full disclosure as a prevention scientist and advocate
Born premature, exposed Parents hospitalized for
Gay man in
to alcohol tobacco and diagnosed mental illness and
20-year relationship
Descendent of a freed slaves educably mentally retarded die of addictions

Thank you,
Dennis D. Embry, Ph.D.
dde@paxis.org
ph: 520-299-6770
www.paxis.org
www.slideshare.net/drdennisembry

New Hampshire Keynote on Prevention for Whole County 11 10-11

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