The 4 Rs & 2 Ss for Strengthening Families Program
What are the 4 Rs & 2 Ss?
The 4 Rs & 2 Ss (also referred to as Multiple Family Groups or MFG) service delivery model to reduce
disruptive behavior disorders, developed by Dr. Mary McKay and colleagues at the Mount Sinai School of
Medicine (MSSM), is specifically tailored to improve engagement, retention, and effectiveness of services for
children. Using a multiple family group approach, this model involves school-age children from diverse
backgrounds who meet diagnostic criteria for Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD)
and their families (including adult caregivers and siblings between the ages of 6 to 18 years) in a 16-week series
of group meetings with 6 to 8 families1. The intervention focuses on evidence based parenting techniques that
enhances Rules, Relationships, Responsibilities, and Respectful Communication in the family, in addition to
interventions that reduce Family Stress and increase Social Support). These techniques are critical to the
reduction in parental stress and improvement in child behavioral outcomes. The 4 Rs & 2 Ss help participating
families in incorporating these principles into their everyday lives.
The 4 Rs & 2 Ss service delivery model addresses those family factors (i.e., parental discipline and monitoring,
behavioral limits, parent-child bonding, conflict, stressors, organization, communication, within family support,
and family interactions) which are consistently implicated in the onset and maintenance of childhood behavioral
difficulties and predict the development of child ODD and CD. In addition, 4 Rs & 2 Ss content addresses
specific family factors related to socioeconomic disadvantage, social isolation, high stress, and lack of social
support. These factors hinder effective parenting and contribute to childhood conduct difficulties, as well as
relate to early drop out from services. In addition, intervention sessions have been designed to target factors
(e.g., parental stress, use of emotional and parenting support resources, family involvement with the child in
multiple contexts, and stigma associated with mental health care) which potentially impact child mental health
service use and outcomes. Key components are delivered via content and activities based on core elements of
parent training and family therapy.
Results to Date of 4 Rs & 2 Ss
This approach has been shown to improve child behaviors, increase family engagement in treatment, and
improve key caregiver factors that contribute to the development and maintenance of conduct problems. Funded
by the National Institute of Mental Health (NIMH), the 4 Rs & 2 Ss service delivery strategy to reduce child
disruptive behavior disorders was tested in a large-scale effectiveness study within community-based clinics.
Findings (McKay et al., 2010; McKay et al., 2011; McKay et al., under review) reveal that engagement rates for
families in the MFG treatment condition far surpass what would normally be seen in urban child mental health
clinics. For primary child outcomes, participants of the MFG groups showed significant improvement over time
on youth oppositional behaviors and social skills relative to the comparison group (youth receiving standard
services) at the end of treatment. At 6 month follow up, participants continued to show improvement in
oppositional behaviors and now also exhibited significant improvement in overall impairment and need for
services. Further, among caregivers that reported clinical levels of stress and depression, we find a significant
reduction in symptoms among caregivers who participated in MFG groups as compared to those that received
standard services. Lastly, among families with substantially low levels of positive involvement with their
children, we find a significant increase in positive involvement and interaction as compared to those who
received standard services at end of treatment and up to 6 months afterwards.
1
Of note, groups with a membership of less than 6 families have also been shown to be effective.
1
Table 1. Tests of Between Group Differences (MFG vs. SAU)
Outcome Variable
Iowa Connors OD
SSRS-SSS
IRS #6
PSI Full ScaleCS
CESDCS
APQ Positive Involvement
SubscaleCS
Contrast
Assessment Period Estimate
(b)
Post-test
6 month Follow-up
Post-test
6 month Follow-up
Post-test
6 month Follow-up
Post-test
6 month Follow-up
Post-test
6 month Follow-up
Post-test
6 month Follow-up
-1.22
-1.17
3.44
1.33
-0.14
-0.39
-3.12
-9.79
-4.33
-5.16
8.62
8.18
Effect
ZpSize
SE
statistic value
(Cohen’s
d)
0.49 -2.47
0.01 *
0.35
0.51 -2.29
0.02 *
0.34
1.52
2.26
0.02 *
0.32
1.59
0.84
0.40
0.12
0.18 -0.78
0.43
0.12
0.19 -2.12
0.03 *
0.35
3.37 -0.93
0.35
0.14
3.46 -2.83
0.00 **
0.43
1.66 -2.60
0.01 *
0.38
1.79 -2.88
0.00 **
0.46
3.01
2.86
0.00 **
1.03
3.66
2.24
0.03 *
0.97
Note: IOWA Connors OD= Iowa Connors Oppositional/Defiant Subscale; SSRS-SSS= Social Skills Rating Scale Social
Skills Subscale; IRS#6= Impairment Rating Scale Overall Impairment/Need for Services; PSI = Parenting Stess Index;
CESD = Center for Epidemiological Studies Depression Scale; APQ = Alabama Parenting Questionnaire; CS =
subpopulation of caregivers scoring above established clinical cut-off scores
* p < .05, **p < .01
2
Figure 1: Improvement in Child Behavior
Significant differences were found between the 4 Rs & 2 Ss Groups and standard services at post-test (p = 0.01) and 6 month follow-up
(p = 0.02), where the experimental group exhibited improvements in oppositional and defiant behavior.
Figure 2: Improvement in Social Skills
4 Rs &2 Ss Groups showed improvement in child social skills at post-test with maintenance of improvement at 6 months follow up. Due
to improvement in social skills of those receiving standard services at 6 month follow up, the two conditions were no longer significantly
different.
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Figure 3: Improvement in Overall Functioning
4 Rs & 2 Ss Groups had a reduction in overall impairment and need for treatment at 6 month follow up as compared with standard
services.
Figure 4: Improvement in Parenting Stress among Caregivers with Clinical Levels of Stress
Among caregivers with high levels of stress, those that participated in 4 Rs & 2 Ss groups had significant improvement at 6 month follow
up compared to caregivers in standard services.
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Figure 5: Improvement in Parenting Depression among Caregivers with Clinical Levels of Depression
Among caregivers with high levels of depression, those that participated in 4 Rs & 2 Ss groups had significant improvement in depressive
symptoms at end of treatment and 6 month afterwards compared to caregivers in standard services.
Figure 6: Improvement in Positive Parental Involvement
Among families with very low levels of positive involvement, those that participated in 4 Rs & 2 Ss groups had significant improvement in
at end of treatment and 6 month afterwards compared to caregivers in standard services.
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Dissemination of 4 Rs & 2 Ss
To date, the 4 Rs & 2 Ss intervention has been implemented in 13 mental health clinics in the New York City
area as part of the NIMH-funded effectiveness study with 35 groups reaching approximately 200 families. In
addition, the program was recently implemented in 29 clinics statewide through the NYS Office of Mental
Health funded New York State Children’s Technical Assistance Center. Currently, it is being implemented in
14 clinics across the country through collaboration with the National Council for Behavioral Health.
References:
McKay, M.M., Gopalan, G., Franco, L.M., 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.
McKay, M.M., Gopalan, G., Franco, L.M., Kalogerogiannis, K.N., Umpierre, M., Olshtain-Mann, O., Bannon,
W., Elwyn, L., & Goldstein, L. (2010). It takes a village to deliver and test child and family-focused services.
Research on Social Work Practice, 20(5), 476-482.
Chacko, A., Gopalan, G., Franco, L., Dean-Assael, K., Jackson, J., Marcus, S. & McKay, M.M. (Under
Review). Randomized Clinical Trial of Multiple Family Group Service Model for Children with
Disruptive Behavior Disorders
Gopalan, G., Chacko, A., Franco, L., Dean-Assael, K., Rotko, L., Marcus, S. & McKay, M.M. (In
Preparation). Randomized Clinical Trial of Multiple Family Group service delivery model for youth
with disruptive behavior disorders: Child outcomes at 6 month follow-up.
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