An Examination of the 4 Rs 2 Ss for Problem Behaviors: A Preventive Approach

Abstract

Early treatment of behavioral problems can prevent their progression into intractable disorders. This study examined the impact of a multiple family group (MFG) intervention for children with behavior symptoms and their families. Fifty-four (n = 54) caregiver/child dyads with sub-clinical levels of oppositional defiant disorder (ODD) participated in a 16-week MFG. Child, caregiver, and family outcomes were assessed at baseline, post-treatment, and at 6 months follow-up. Significant decreases in impairment with parents, family members, and peers, and improvements in child self-esteem were found from baseline to follow-up. Caregiver stress increased; no significant changes in depression or perceived social support were found over time. The effectiveness of MFG as a preventive approach and areas of future research are discussed.

Introduction

Oppositional defiant disorder (ODD) is a chronic, impairing, and common disruptive behavior disorder (DBD) characterized by defiance, argumentativeness, and irritability (Acri, Gopalan, et al., 2018; Centers for Disease Control and Prevention [CDC], 2020a). Prevalence rates range from 1% to 21% depending upon study, sample characteristics, and variations in the assessment of ODD across studies (Acri, Gopalan, et al., 2018; CDC, 2020b; Ghandour et al., 2019; Nock et al., 2007). Variability notwithstanding, children living in poverty consistently evidence disproportionately high rates of externalizing behavior problems (Linver et al., 2002; Mistry et al., 2002; National Institute of Child Health and Human Development Early Child Care Research Network, 2005; Peisch et al., 2017) due to the impact of stressors, such as financial hardship, community violence, unemployment, inadequate housing, and/or limited health and mental health resources, which impinge upon the quality of parenting and the parent/child relationship (Acri, Gopalan, et al., 2018; Conger et al., 2002; Siefert et al., 2007).

Early detection and treatment can stem the negative impacts of DBDs, including academic difficulties and disruptions in relationships with peers and family members (Burke et al., 2014). In addition, DBDs are highly associated with comorbid mental health disorders, including depression and anxiety, substance use disorders (Acri, Bornheimer, et al., 2018; Nock et al., 2007), and death by suicide (Border et al., 2018). Further, DBDs often progress into adolescence and adulthood and are often linked to poor educational attainment, criminal activity and incarceration, and premature mortality due to homicide, suicide, and accidental death from risk-taking behaviors (Burke et al., 2014; Scott et al., 2017).

There is merit in addressing behavior problems before reaching a diagnostic level for the following reasons: (a) although they do not cross the clinical threshold, behavior problems are associated with considerable impairment and distress to the youth, family, and systems in which they intersect (Deković et al., 2012; Rojas et al., 2019); and (b) early intervention efforts have the potential to inhibit the developmental trajectory of behavior problems into a chronic, entrenched condition with accompanying functional impairment (Farrington et al., 2017). To this end, a robust literature has found prevention programs are associated with improvements in behavior among children and adolescents. Durlak and Wells’ (1997) germinal review of 130 interventions for children and adolescents with sub-threshold mental health and substance abuse disorders found large effect sizes specific to problem behaviors, and a second study that reviewed 50 systematic reviews of prevention programs for youth with conduct problems (e.g., aggressive behavior, bullying, and delinquency) found a clear benefit in favor of prevention interventions and a large median effect size (1.46) across studies (Farrington et al., 2017).

This study intends to contribute to the knowledge base through the examination of a family strengthening program for children with sub-clinical symptoms of ODD and their care-givers. This program, entitled the 4 Rs 2 Ss Strengthening Families Program (4 Rs 2 Ss), takes its name from the key treatment components it delivers related to Rules, Relationships, Responsibility, Respectful Communication, Stress, and Social Support, and incorporates behavior parent training and psychoeducational principles and components. The four Rs address key aspects of parenting and the parent-child relationship associated with externalizing behavior problems, such as inconsistent discipline; impaired family communication; lack of appropriate child supervision and monitoring; and decreased positive parental involvement and warmth (Chacko et al., 2015). In addition, the two Ss address stress and social isolation, which undermine parenting and contribute to serious child behavior problems (Kazdin & Whitney, 2003).

The 4 Rs 2 Ss has demonstrated its effectiveness in prior studies at improving behavior problems and functional impairment, caregiver stress and depression, and family practices for poverty-impacted children who met criteria for ODD and their families (Acri et al., 2017; Chacko et al., 2015; Gopalan et al., 2015; McKay et al., 2011). In the most recent study of the 4 Rs 2 Ss, child/caregiver dyads who met criteria for ODD evidenced significant improvements in child inattention symptoms, parental descriptions of their child’s behavior as difficult, and reduced childrearing stress in comparison to the comparison group at posttest. In addition, while participants in both treatment groups reported reductions in child oppositional behavior, inattention skills, less difficulty to self-regulate, and less parental and child rearing stress over time, larger effect sizes were consistently reported for the experimental group participants (Gopalan et al., under review). This study extends our understanding of the applicability and effectiveness of the 4 Rs 2 Ss as an indicated preventive intervention for child ODD.

Method

Overview

This study explored child, caregiver, and family-level outcomes among families of children with sub clinical levels of ODD who participated in a larger, National Institute of Mental Health (NIMH)-funded Institutional Review Board (IRB)-approved study entitled the 4 Rs 2 Ss Family Strengthening Program (4 Rs 2 Ss). The 4 Rs 2 Ss is a manualized, multiple family group (MFG) service delivery model for children with ODD and their families. In this model, six to eight families encompassing two generations (including a child aged 7–11 and their primary caregiver, at minimum), participate in 16 sessions offered once a week (Gopalan et al., 2014, 2015). In the larger study, 533 dyads of primary caregivers and target children between seven and 11 years old who met diagnostic criteria for a ODD were enrolled. An additional 54 children (the sample for the current study) did not meet the criteria for the larger study and were included in the current analysis.

Procedure

Child/caregiver dyads were enrolled from 21 outpatient behavioral health clinics located throughout the five boroughs of New York City. To be eligible, clinics were required to be licensed by the New York State Office of Mental Health. Child/caregiver dyads received one of two treatment conditions; the 4 Rs 2 Ss for Strengthening Families Program (4 Rs 2 Ss) treatment (condition 1), or the 4 Rs 2 Ss with Clinic Implementation Teams (CIT) involving adaptations (condition 2). For a more detailed description of the overall study, see Acri et al. (2017). Recruitment was accomplished by two methods: (a) research staff positioned within clinics approached caregivers in the waiting room, described the study, and secured informed consent to participate; and (b) providers at the clinic who were trained to deliver the 4 Rs 2 Ss referred children who were on their caseloads, upon which research staff contacted interested families and obtained consent to participate. Child assent was also collected. Once enrolled, families participated in a 16-week group that met at the clinic weekly. Groups were co-facilitated by either two mental health professionals, or less often, a team consisting of one mental health professional and a peer facilitator (a trained caregiver of a child with mental health needs). Data about child, caregiver, and family-level factors were collected by research staff at baseline, posttest (16 weeks post-baseline), and at 6 months follow-up. Baseline data were collected via hard-copy paper surveys on site, while data at all other time points were collected via phone-based interviews.

Provider Training and Fidelity

Provider training involved several stages. First, seven online modules introduced the model, engagement and barriers to services; recruitment and orientation (inviting families who meet eligibility criteria to join the group); key facilitation skills, the group structure, the purpose and occurrence of supervision and fidelity, and common challenges to facilitating the program. The online training was followed by a 3-hour in-person training, in which participants reviewed module materials and participated in role plays to practice group facilitation. CIT team members participated in an additional meeting to review the content, process, and structural factors that were fixed and modifiable, select adaptations, and how to track implementation. See Acri et al. (2019) for additional information about the adaptation process.

Supervision was provided to facilitators monthly, and a fidelity observation was conducted every four sessions. Observations were attended by two research personnel who completed a 3-point checklist for each section of the week’s lessons ranging from not at all met (0) to completely met (2). Each research personnel completed the fidelity checklist independently, and then compared their scores to account for inter-rater reliability. Any discrepancies in scoring were discussed in detail, and the two research personnel came to a consensus on each item. Facilitators were provided with feedback based on the results of the group observation. Total scores were computed by summing the score of each item and dividing the total scores by the maximum number of possible points. Facilitators who received a fidelity score of less than 70% received additional supervision to trouble-shoot a lack of adherence to the model.

Participants

The study participants for this analysis included 54 caregiver/child dyads who participated in the 4 Rs 2 Ss Family Strengthening Program between February, 2017 and June, 2019 across 21 clinics. Children were retrospectively assessed for eligibility in this study from the larger 4 Rs 2 Ss study if they did not meet the diagnostic threshold for ODD as assessed by the Disruptive Behavior Disorders Rating Scale-Oppositional Defiant Subscale (DBD-RS) (Pelham et al., 1992), but met all other eligibility criteria (e.g., were within 7 and 11 years of age, and spoke English or Spanish). Caregiver/child dyads who received 4 Rs 2 Ss treatments were included in the analysis.

Measures

A sociodemographic questionnaire assessed contextual familial factors (e.g., gender, race, ethnicity, age, etc.), and the DBD-RS Oppositional Defiant Subscale, which was used as a screening tool for inclusion into the study, were administered at baseline. The DBD-RS Oppositional Defiant Disorder Subscale (Pelham et al., 1992) consists of eight items that are ranked using a 4-point Likert-type scale with the following categories: “not at all” (0); “just a little” (1); “pretty much” (2); and “very much” (3). A total of four or more items endorsed as “pretty much” or “very much” were needed to meet criteria for ODD. All other assessments were administered at baseline, post-treatment, and at 6 months follow-up.

Youth Clinical Characteristics

Child ODD was measured by the Iowa Conners Rating Scale–Oppositional/Defiant Subscale (Waschbusch & Willoughby, 2008). This subscale includes five items that are ranked on a 4-point Likert-type scale, ranging from “not at all” (0) to “very much” (3). Total scores range from 0 to 15, with higher scores indicating greater severity of symptoms. A previous randomized effectiveness study of the 4 Rs 2 Ss intervention found that this scale had good internal consistency (Chacko et al., 2015; Gopalan et al., 2015).

Inattention was measured by the Iowa Conners Rating Scale-Inattention Subscale. This subscale consists of five items scored on a 4-point Likert-type ranging from “not at all” (0) to “very much” (3). Total scores range from 0 to 15, with higher scores suggesting greater levels of inattention (Waschbusch & Willoughby, 2008).

Child impairment was measured using the Impairment Rating Scale (Fabiano et al., 2006). This scale measures children’s impairment and need for treatment across functional domains, including (a) their relationship with peers, (b) parent[s], and (c) academics, (d) self-esteem, (e) family, and (f) overall impairment. This instrument involves having parents rate the severity of impairment by placing an X that signifies a continuum of impairment. The line is spread into 7 segments, ranging from 0 (“no problem”) to 6 (“extreme problem”). An average score is calculated for each domain.

Caregiver Clinical Characteristics

Caregiver depression was measured using the short form of the Center for Epidemiologic Studies Depression Scale (Radloff, 1977). This scale consists of seven items that assesses the frequency of depressive symptoms within the past week. Items are scored on a 4-point Likert-type scale ranging from “rarely/none of the time” (0) to “most or all of the time” (3). Scores range from 0 to 21, with a score of 8 and above considered clinically significant depressive symptoms.

The Parenting Stress Index (PSI) short form (Abidin, 1995) measured parental stress. This scale is comprised of 36 items scored on a 5-point Likert-type scale, ranging from “strongly disagree (1)” to “strongly agree (5).” The PSI short form consists of three subscales: Parental Distress (PD), which describes the extent to which parents feel competent, supported, conflicted with their spouse, and/or restricted; Parent-Child Dysfunctional Interaction (P-CDI), which describes the parent’s perception that a child does not meet expectations; and Difficult Child (DC), which describes how a parent views their child’s defiance, noncompliance, and temperament (Reitman et al., 2002). Each subscale has 12 items which are scored on a 5-point Likert-type Scale, ranging from “strongly disagree” (1) to “strongly agree” (5), with scoring ranging from 12 to 60. The PSI’s total scores range from 36 to 180, with higher scores indicating increased levels of parent stress.

Family Characteristics

Family support was measured using the family subscale of the Multidimensional Scale of Perceived Social Support (MSPSS; Dahlem et al., 1991). This 4-item subscale uses a 7-point Likert-type scale ranging from “very strongly disagree “(1) to “very strongly agree” (7). Scores are summed, with higher scores reflecting greater perceived support.

Finally, to measure fidelity, the authors created a checklist that assessed adherence to the model’s content. The checklist consisted of 15-items that was divided into three sections corresponding to the structure of each session: the beginning of the group sessions (for example, “facilitators reviewed the agenda for the day”); the middle of the group session (for example, “facilitators explained the purpose of the practice activity to group members”); and the end of the session (e.g., “facilitator explained the take-home assignment for the upcoming week.”). Items were scored on a 3-point scale to indicate whether sections of the lesson were met (ranging from not at all met (0) to completely met (2). Final scores were summed and divided by the highest possible score value for that week to reach a fidelity percentage.

Analytic Plan

Data were analyzed using SPSS 24. Univariate demographic and clinical characteristics were examined to describe the sample. Second, pre-and post-assessment clinical characteristics were examined to determine if any significant change took place between the two time points using paired sample t-tests. Institutional Review Board approval was obtained.

Results

Table 1 presents the sociodemographic characteristics of the sample. On average, children were nine years of age (SD = 1.44), over half were male (n = 34, 63%), 22 (40.7%) identified as Black/African American, half (n = 27, 50%) identified as non-Hispanic, all but two (3.7%) were born in the United States, and almost two thirds of children were Englishspeaking (n = 34, 69.4%). Over two thirds of the sample’s primary caregivers identified themselves as the child’s mother (n = 34, 68%), over three quarters were female (n = 41, 83.7%), n = 22 (59.9%) were African American, almost half were single (n = 22, 44%). Nine caregivers (18.4%) had completed high school while an equal number had some high school education but did not graduate, 23 (46%) were employed full time. Approximately 13.3% of families (n = 6) reported an annual income as less than $9,999, followed by 10 (22.2%) who reported their annual income level as over $50,000. See Table 1 for a complete overview of the sample’s sociodemographic characteristics.

Table 1.

Demographic characteristics of participants

Characteristic	n	%
Child age (M ± SD)	50	9.0 ± 1.44
Child gender
Male	34	63.0
Female	16	29.6
Child race
American Indian/Alaska Native	2	3.7
Asian	1	1.9
Black/African American	22	40.7
Native Hawaiian/Pacific Islander	1	1.9
White	13	24.1
Child ethnicity
Non-Hispanic	27	50.0
Hispanic/Latino	21	38.9
Child nativity
Born in US	47	87.0
Not born in US	2	3.7
Child primary language
Only English	34	69.4
Mostly English/Some native language	11	22.4
Half English/half native language	3	6.1
Mostly native language/some English	1	2.0
Only native language	0	0.0
Child primary caregiver
Mother	27	54.0
Father	3	6.0
Grandparent	6	12.0
Mother and father	8	16.0
Other	6	12.0
Child began treatment in clinic
0 to 3 months ago	11	22.9
3 to 6 months ago	5	10.4
3 to 9 months ago	6	12.5
6 to 12 months ago	3	6.3
More than 12 months ago	23	47.9
Caregiver relationship to child
Mother	34	68.0
Father	5	10.0
Grandparent	4	8.0
Mother and father	1	2.0
Other	6	12.0
Caregiver age (M ± SD)	49	40.9 ± 10.39
Caregiver gender
Male	8	16.3
Female	41	83.7
Caregiver race
Asian	1	2.7
Black/African American	22	59.5
Native Hawaiian/Pacific Islander	1	2.7
White	13	35.1
Caregiver ethnicity
Non-Hispanic	30	63.8
Hispanic/Latino	17	36.2
Caregiver nativity
Born in US	31	66.0
Not born in US	16	34.0
Caregiver primary language
Only English	32	64.0
Mostly English/Some native language	8	16.0
Half English/half native language	4	8.0
Mostly native language/some English	2	4.0
Only native language	4	8.0
Caregiver marital status
Single	22	44.0
Married	13	26.0
Common law marriage	2	4.0
Domestic partnership	2	4.0
Divorced	6	12.0
Separated	3	6.0
Widowed	1	2.0
Other	1	2.0
Caregiver education
8th grade or less	5	10.2
Some high school	9	18.4
Completed high school/GED	9	18.4
Some college	5	10.2
Associates degree	7	14.3
Vocational/trade school	3	6.1
Bachelor degree	6	12.2
Some graduate or professional school	1	2.0
Completed graduate or professional school	4	8.2
Caregiver employment status
Full time	23	46.0
Part time	8	16.0
Retired	1	2.0
Disabled	3	6.0
Unemployed	12	24.0
Other	3	6.0
Family annual income level
Less than $9,999	6	13.3
$10,000 to $19,999	8	17.8
$20,000 to $29,999	9	20.0
$30,000 to $39,999	8	17.8
$40,000 to $49,999	4	8.9
Over $50,000	10	22.2
Within the past 12 months, how often were you worried whether food would run out before you got money to buy more?
Often	2	4.1
Sometimes	17	34.7
Never	30	61.2
Within the past 12 months, how often did the food not last and you didn’t have money to get more?
Often	1	2.0
Sometimes	13	26.0
Never	36	72.0
Investigated for suspected abuse or neglect of child
No	35	70.0
Yes	15	30.0

N = 54

Child Outcomes

Significant improvements in impairment were found with respect to the child’s problems with playmates, both from baseline to posttest (t = 3.28, df = 20, p < .01) and baseline to follow-up (t = 3.04, df = 8, p = .01). In addition, significant reductions were found regarding impairment with parents (t = 2.89, df = 8, p = .02), self-esteem (t = 2.63, df = 8, p = .03) and difficulties with family members from baseline to follow-up (t = 3.33, df = 8, p = .01). No significant changes in impairment pertaining to academic performance or overall impairment were found. In addition, there was no significant change in the IOWA Conners Scale over time, and there was a nonsignificant increase in the Overactive/Defiant Behavior subscale.

Caregiver and Family-Level Outcomes

There was a significant decrease from baseline to posttest (t = −2.29, df = 18, p = .03) and baseline to follow-up in the Parent/Child Dysfunction Interaction subscale of the PSI (t = −2.28, df = 8, p = .04). No significant change in the Center for Epidemiologic Studies Depression Scale or the Multidimensional Scale of Perceived Social Support was found over time. See Table 2.

Table 2.

Baseline and post-test & baseline and follow-up means of outcome variables

Outcome	Time point	n	M ± SD	Siga
IOWA CRS-OD	Baseline	20	5.8 ± 2.2
	Post-test		6.3 ± 3.1
	Baseline	6	6.5 ± 3.6
	Follow-up		6.2 ± 2.6
IOWA CRS-IO	Baseline	20	6.6 ± 4.0
	Post-test		6.3 ± 4.0
	Baseline	8	5.9 ± 4.7
	Follow-up		5.9 ± 4.0
IRS1	Baseline	21	2.8 ± 1.6	**
	Post-test		1.7 ± 1.8
	Baseline	9	3.3 ± 2.0	*
	Follow-up		1.9 ± 1.5
IRS2	Baseline	21	2.1 ± 1.7
	Post-test		1.5 ± 1.4
	Baseline	9	1.9 ± 1.8	*
	Follow-up		0.2 ± 0.7
IRS3	Baseline	22	3.4 ± 1.8
	Post-test		3.0 ± 1.9
	Baseline	9	3.0 ± 2.1
	Follow-up		2.0 ± 2.0
IRS4	Baseline	21	3.0 ± 1.8
	Post-test		2.9 ± 1.7
	Baseline	9	3.2 ± 2.7	*
	Follow-up		2.0 ± 2.2
IRS5	Baseline	21	2.8 ± 1.4
	Post-test		2.0 ± 1.5
	Baseline	9	2.6 ± 1.4	*
	Follow-up		0.9 ± 1.5
IRS6	Baseline	21	4.0 ± 1.3
	Post-test		3.3 ± 1.7
	Baseline	9	3.1 ± 1.8
	Follow-up		3.8 ± 2.3
CES-D	Baseline	20	4.95 ± 4.44
	Post-test		3.75 ± 4.36
	Baseline	9	5.89 ± 4.57
	Follow-up		5.33 ± 3.81
PSI	Baseline	17	77.94 ± 20.43
	Post-test		79.76 ± 17.54
	Baseline	7	83.71 ± 19.98
	Follow-up		87 ± 26.70
PSI PD	Baseline	21	25.0 ± 8.2
	Post-test		26.0 ± 7.5
	Baseline	8	27.6 ± 6.3
	Follow-up		27.6 ± 8.7
PSI DC	Baseline	20	29.8 ± 6.3
	Post-test		29.2 ± 6.3
	Baseline	8	30.8 ± 6.2
	Follow-up		31.5 ± 8.4
PSI P-CDI	Baseline	19	22.3 ± 7.5	*
	Post-test		25.1 ± 6.9
	Baseline	9	23.9 ± 9.0	*
	Follow-up		27 ± 9.2
MSPSS	Baseline	3	9.33 ± 4.16
	Post-test		11.67 ± 5.13
	Baseline	1	6
	Follow-up		8

^aSignificance examined using independent samples t-tests

^*p<.05

^**p<.01

^***p<.001

IOWA CRS‐OD, Iowa Connors Rating Scale–Oppositional/Defiant Subscale; IOWA CRS-IO, Iowa Connors Rating Scale–Inattentive/Impulsive/Overactive Subscale; IRS1, Impairment Rating Scale Impairment Playmates 1; IRS2, Impairment Rating Scale Impairment Parents; IRS3, Impairment Rating Scale Impairment Academics; IRS4, Impairment Rating Scale Impairment Self-Esteem; IRS5, Impairment Rating Scale Impairment Family; IRS6, Impairment Rating Scale Overall Impairment/Need for Services; CES-D, Center for Epidemiologic Studies – Depression; PSI, Parenting Stress Index; PSI PD, Parenting Stress Index Parent Distress Subscale; PSI DC, Parenting Stress Index Difficult Child Subscale; PSI P-CDI, Parenting Stress Index Parent-Child Dysfunctional Interaction Subscale; MSPSS, Multidimensional Scale of Perceived Social Support.

Fidelity

The mean fidelity across sessions was 88% (SD = 11.86%), with 72.5% (n = 58) sessions demonstrating 85% or better mean fidelity, and 41.3% (n = 33) demonstrating 95% or better mean fidelity.

Discussion

ODD exacts a devastating cost to the child, family, and the larger systems upon which the child interacts. ODD is associated with impairment at home, school, and with peers. Caregivers are at high risk for stress, strain, and depression (Christenson et al., 2016; Kazdin, 2004). However, treatment has been estimated to save approximately 2.3 million dollars over the course of the child’s lifespan (Christenson et al., 2016). For these reasons, early intervention is critical. The purpose of this study was to examine benefits associated with a family strengthening program with embedded parenting strategies and psychoeducation for children with sub-clinical levels of ODD, their caregivers, and the family.

The main finding was significant functional improvements were evidenced across domains (with playmates, parents, and family members): In addition, child self-esteem improved across timepoints. This is a promising finding given the impact of behavior problems upon families, schools, and other child-serving systems, and particularly remarkable given other studies of the 4 Rs 2 Ss with children who had greater clinical severity did not find significant improvements in functioning at 6-month follow-up (Chacko et al., 2015; Gopalan et al., 2015). While future research is warranted, particularly given the exploratory nature of this study, favorable changes in impairment may be due to the core elements of the 4 Rs 2 Ss model, and specifically an emphasis on building positive relationships. The 4 Rs 2 Ss employs family strengthening techniques, such as reframing negative ideas or beliefs toward family and behavior, modeling behavior, providing specific feedback and positive reinforcement and helping families create positive ways of relating to each other. The child may have benefited particularly from this aspect of the model as a way to interact with others. Moreover, siblings and caregivers who attended the program may have also learned prosocial ways to interact to each other and the child. Future research is needed to confirm the relationship between this content, participants, and improvements in functioning; however, this finding is encouraging and worthy of additional investigation.

However, this study did not find any significant changes in oppositional or disruptive behaviors. This may be due to a ceiling effect, as caregivers rated their child’s symptoms as relatively minor at baseline. Nonetheless, future research using more rigorous research designs would be informative for understanding this finding and whether any true relationship between the 4 Rs 2 Ss and behavior symptoms was obfuscated by mild symptoms at baseline.

Finally, while there was an encouraging decrease in depression (although not significant), there was a significant uptick in stress related to the dysfunctional interaction between the caregiver and child. While this finding is somewhat contradictory to an improvement in impairment with family members, this subscale assesses satisfaction with the relationship, and the parent’s relationship with the child (e.g., “My child rarely does thing for me that make me feel good,” “I expected to have a closer and warmer feeling for my child than I do and this bothers me”), unlike impairment, which is how the child is relating to the family member. Nonetheless, an increase in stress is curious, particularly given previous studies of 4 Rs 2 Ss which showed significant improvements in parental stress over time for caregivers with clinically significant scores at baseline (Gopalan et al., 2017). Future research that can clarify this relationship is needed, as well as, if found, ways to support caregivers to reduce parenting-related stress.

Implications for Practice

In light of the high costs associated with untreated behavior problems to children, their families, communities, and child-serving systems, this study has multiple implications for practice. As noted previously, results are preliminary and future research is required. However, that the MFG model was associated with improvements in functioning across multiple domains is promising, and if replicated, could be utilized as a secondary prevention program for children at risk for DBDs. In other studies, the 4 Rs 2 Ss, which are manualized and publicly available, were found to be feasible to administer, favorably perceived by families, delivered by both mental health professionals and parent peers, and easily adapted to setting and population (Acri et al., 2019; Acri, Gopalan, et al., 2018). Considering such, the delivery of 4 Rs 2 Ss in schools or other naturalistic settings could reduce the risk of untreated behavior problems progressing into DBDs.

In sum, several of the findings were encouraging and suggest the need for future research to better untangle the effectiveness of the 4 Rs 2 Ss for sub-clinical children and their families, particularly respective to functional outcomes. Caution should be exerted when interpreting the findings of this study, as it has several limitations, including a small sample size, a selective approach to recruitment, the exploratory nature of this study, and a low response rate at the follow-up timepoint. In addition, responses were gathered through caregiver self-report, which introduces the potential for bias. Limitations notwithstanding, these findings contribute to the field’s knowledge base concerning early intervention efforts, and identify the need for future investigative efforts to determine the benefits of this model for poverty-impacted families.