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4Rs2Ss

Evidence rating
2
Cost rating
1
Review: January 2021

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

4Rs2Ss has preliminary evidence of improving a child outcome, but we cannot be confident that the programme caused the improvement.

What does the evidence rating mean?

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 £100.

Child outcomes

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

Reduced oppositional defiant behaviours - based on study 1a, study 1b, study 1c, study 1d

Improved social skills - based on study 1a, study 1d

Improved impairment - based on study 1b

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.

4Rs2Ss

Key programme characteristics

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:

  • Children's centre or early-years setting
  • Primary school
  • Community centre
  • In-patient health setting
  • Out-patient health setting

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

UK provision

This programme has been implemented in the UK.

UK evaluation

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

Spotlight sets

EIF includes this programme in the following Spotlight sets:

  • Improving interparental relationships
4Rs2Ss

About the programme

What happens during 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 QCF-7/8 level qualifications and one Family Peer Advocate or Family Advocate with QCF-4/5 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 QCF-7/8 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

Supporting children's mental health and 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

4Rs2Ss

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: Reduced oppositional defiant behaviours
Improved social skills
Other outcomes: None measured
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.

More Less about study 1a

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: Reduced oppositional defiant behaviours
Improved impairment
Other outcomes: None measured
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
More Less about study 1b

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: Reduced oppositional defiant behaviours
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

More Less about study 1c

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: Reduced oppositional defiant behaviours
Improved social skills
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.

More Less about study 1d

Published March 2021