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4Rs2Ss

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Evidence rating: 2+
Cost rating: 1

4Rs2Ss is targeted at families who have a child between 7 and 11 years old who are diagnosed with oppositional defiant disorder or conduct disorder. All children over six years of age in the family are invited to attend the programme.

4Rs2Ss is comprised of 16 sessions and it is delivered by 2 practitioners in a multiple family group format to families with children between 7 and 11 years old who are diagnosed with oppositional defiant disorder or conduct disorder. The intervention is focused on 4 Rs (Rules, Relationships, Respectful Communication, Responsibilities) and the 2 Ss (Stress and Support) that are expected to mediate caregiver stress, child behavioral difficulties and family functioning.

EIF Programme Assessment

Evidence rating: 2+
Level 2 indicates that the programme has evidence of improving a child outcome from a study involving at least 20 participants, representing 60% of the sample, using validated instruments. This programme does not receive a rating of 3 as its best evidence is not from a rigorously conducted RCT or QED evaluation
Cost rating: 1
A rating of 1 indicates that a programme has a low cost to set up and deliver, compared with other interventions reviewed by EIF. This is equivalent to an estimated unit cost of less than €125. This figure is based on an analysis of UK costs and a conversion rate of 1.19.

What does the plus mean?

The plus rating indicates that a programme’s best available evidence is based on an evaluation that is more rigorous than a level 2 standard but does not meet the criteria for level 3.

Child outcomes

This programme can affect outcomes for children in Active and healthy, physical and mental wellbeing.

According to the best available evidence for this programme's impact, it can achieve the following positive outcomes for children:

Supporting children's mental health and wellbeing

Improved social skills

based on study 1a

based on study 1d

Improved impairment

based on study 1b

Preventing crime, violence and antisocial behaviour

Reduced oppositional defiant behaviours

based on study 1a

based on study 1b

based on study 1c

based on study 1d

This programme also has evidence of supporting positive outcomes for couples, parents or families that may be relevant to a commissioning decision. Please see About the evidence for more detail.

Who is it for?

The best available evidence for this programme relates to the following age-groups:

Primary school

How is it delivered?

The best available evidence for this programme relates to implementation through these delivery models:

  • Group

Where is it delivered?

The best available evidence for this programme relates to its implementation in these settings:

How is it targeted?

The best available evidence for this programme relates to its implementation as:

  • Targeted selective

Where has it been implemented?

  • United Kingdom
  • United States

Ireland provision

This programme has not been implemented in Ireland.

Ireland evaluation

This programme’s best evidence does not include evaluation conducted in Ireland.

About the programme

What happens during the delivery?

How is it delivered?

  • 4Rs2Ss is delivered in 16 sessions of around 1 hours’ duration each by 2 practitioners, to groups of families

What happens during the intervention?

  • During each session, families participate in conversations about an R (Rules, Relationships, Responsibilities, Respectful Communication) or S (Stress or Support).
  • Families then reflect, practice a skill associated with the "R" or "S" of the day, and discuss how to practice it during the week outside of the group.

What are the implementation requirements?

Who can deliver it?

  • The two practitioners who deliver this programme are a Social Worker or Mental Health Counselor with NFQ-9/10 level qualifications and one Family Peer Advocate or Family Advocate with NFQ-6 level qualifications.


What are the training requirements?

  • The practitioners have 5.5 hours of programme training. Booster training of practitioners is not required.

How are the practitioners supervised?

  • It is recommended that practitioners are supervised by one clinical supervisor (qualified to NFQ-9/10 level) with 5.5 hours of programme training.


What are the systems for maintaining fidelity?

  • Programme fidelity is maintained through the following processes:
    • Training manual
    • Other printed material
    • Other online material
    • Fidelity monitoring
    • Virtual training and online learning modules


Is there a licensing requirement?

There is no licence required to run this programme.


How does it work? (Theory of Change)

How does it work?

  • 4Rs2Ss aims to help decrease behavioral difficulties in children and help families improve their communication, their relationships, their family rules, and their satisfaction with services.
  • Families that participate in this programme practice targeted skills that can mediate caregiver stress and child behavioral difficulties.
  • In the longer term, children will have less behavior problems and improved relationships with their families and caregivers.
  • Participation in the programme will reduce the stigma associated with raising a child with mental health issues by normalising each family’s experience, therefore increasing receptivity to participation. 

Intended outcomes

  • Active and healthy, physical and mental wellbeing

Contact details

Kara M. Dean-Assael
Director of Clinical Innovation and Practice at the NYU McSilver Institute for Poverty Policy and Research


kara.dean@nyu.edu


About the evidence

4Rs2Ss’ most rigorous evidence coms from one comparison group study conducted in the United States.

This programme is underpinned by one study with a Level 2, hence the programme receives a Level 2 rating overall.

Study 1a

Citation:Chacko et al., 2015
Design:Comparison group study
Country:United States
Sample:320 children between the ages of 7-11 and their families
Timing:Post-test; 4-month follow-up
Child outcomes:
    Other outcomes:
      Study rating:2

      Chacko, A., Gopalan, G., Franco, L., Dean-Assael, K., Jackson, J., Marcus, S., Hoagwood, K., & McKay, M. (2015). Multiple Family Group Service Model for Children with Disruptive Behavior Disorders: Child Outcomes at Post-Treatment. Journal of Emotional and Behavioral Disorders, 23(2), 67–77.

      Available at: 
      https://journals.sagepub.com/doi/10.1177/1063426614532690

      Study design and sample


      This study is a non-random alternating assignment study including 13 community-based outpatient mental health clinics in New York City metropolitan area.

      In each clinic, the first 6-8 families whose children were screened and met eligibility criteria were enrolled in the experimental condition.  The next 3-4 families who were successfully screened and met eligibility criteria were then assigned to the comparison condition. 


      Measures


      Child behavioural disorder was measured using the Iowa Connors Rating scale - Oppositional/Defiant Subscale

      Child social skills were measured using the Social Skills Rating Scale.

      Child functional impairment was measured using the Impairment Rating Scale (IRS)


      Findings


      This study identified statistically significant positive impact on a number of
      child outcomes. This includes:

      • Reduced oppositional defiant behaviours
      • Improved social skills

      The conclusions that can be drawn from this study are limited by methodological issues pertaining to the baseline equivalence of the study groups, and accounting for clustering in the analysis, hence why a higher rating is not achieved.

      Study 1b

      Citation:Gopalan et al., 2015
      Design:Comparison group study
      Country:United States
      Sample:320 children between the ages of 7-11 and their families
      Timing:Post-test; 4-month follow-up
      Child outcomes:
        Other outcomes:
          Study rating:2

          Gopalan, G., Chacko, A., Franco, L., Dean-Assael, K., Rotko, L. E., Marcus, S. M., Hoagwood, K. E., & McKay, M. M. (2015). Multiple Family Groups for Children with Disruptive Behavior Disorders: Child Outcomes at 6-Month Follow-Up. Journal of Child and Family Studies, 24(9), 2721–2733.

          Available at: 
          https://link.springer.com/article/10.1007/s10826-014-0074-6

          Study design and sample

          Gopalan et al., 2015 describes additional outcomes from study 1a described above. In this case:

          • Child outcomes were measured post-test and at 4-month follow-up
          • Child behavioural disorder was measured using the Iowa Connors Rating scale - Oppositional/Defiant Subscale
          • Child social skills were measured using the Social Skills Rating Scale
          • Child functional impairment was measured using the Impairment Rating Scale (IRS)
          • This study identified statistically significant positive impact on a number of child outcomes. This includes reduced oppositional defiant behaviours, improved impairment impairment with playmates and overall impairment and need for services

          Study 1c

          Citation:McKay et al.,  2011
          Design:Comparison group study
          Country:United States
          Sample:320 children between the ages of 7-11 and their families
          Timing:Post-test; 6-month follow-up
          Child outcomes:
            Other outcomes:
            • Parent Stress
            Study rating:2

            McKay, M. M., Gopalan, G., Franco, L., Dean-Assael, K., Chacko, A., Jackson, J. M., & Fuss, A. (2011). A collaboratively designed child mental health service model: Multiple family groups for urban children with conduct difficulties. Research on Social Work Practice, 21(6), 664–674.

            Available at: 
            https://journals.sagepub.com/doi/10.1177/1049731511406740

            McKay et al., 2011 describes additional outcomes from study 1a described above. In this case:

            • Child outcomes were measured post-test and at 6-month follow-up
            • Child behavioural disorder was measured using the Iowa Connors Rating scale - Oppositional/Defiant Subscale
            • Child social skills were measured using the Social Skills Rating Scale
            • Child functional impairment was measured using the Impairment Rating Scale (IRS)
            • Parent stress was measured using the Parent Stress Index
            •  This study identified statistically significant positive impact on oppositional defiant behaviours

            Study 1d

            Citation:Small et al., 2015
            Design:Comparison group study
            Country:United States
            Sample:320 children between the ages of 7-11 and their families
            Timing:Post-test; 6-month follow-up
            Child outcomes:
              Other outcomes:
              • Parent Stress, Parent depression
              Study rating:2

              Small, L., Jackson, J., Gopalan, G., & McKay, M. M. (2015). Meeting the complex needs of urban youth and their families through the 4Rs 2Ss Family Strengthening Program: The “real world” meets evidence-informed care. Research on social work practice, 25(4): 433–445.

              Available at: 
              https://journals.sagepub.com/doi/10.1177/1049731514537900

              Small et al., 2015 describes additional outcomes from study 1a described above. In this case:

              • Child outcomes were measured post-test and at 6-month follow-up
              • Child behavioural disorder was measured using the Iowa Connors Rating scale - Oppositional/Defiant Subscale
              • Child social skills were measured using the Social Skills Rating Scale
              • Child functional impairment was measured using the Impairment Rating Scale (IRS)
              • Parent stress was measured using the Parent Stress Index
              • Parent depression was measured using the Center for Epidemiological Studies Depression Scale
              • This study identified statistically significant positive impact on a number of child outcomes. This includes reduced oppositional defiant behaviours and improved social skills

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