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What is “Fourth R” and Does it Prevent Long-term Adolescent Relationship Abuse?

September 8, 2023

In a recently released article in Pediatrics, Dr. Elizabeth Baumler and colleagues from the Center for Violence Prevention, Galveston TX, present the results of a 36 month follow up of an intervention to prevent adolescent relationship abuse (ARA) (10.1542/peds.2023-062281). ARA is unfortunately prevalent and reported in 20-30% of US teen relationships, with negative mental and physical health consequences, including depression and anxiety, and can predict future intimate partner violence.1 A preventive intervention, “Fourth R,” was tested initially in Canadian 9th grade classrooms with 2.5 year follow up2 and then in US 7th grade classrooms with 1 year follow up3 and was found to be effective in reducing physical ARA. For those wondering, the “Fourth R” represents “relationship”, adding to the traditional three “Rs” (reading, writing and arithmetic) of classroom education.  In this current study, the authors asked if the “Fourth R” program is also effective as a tertiary or targeted intervention that can reduce physical ARA 36 months later among those participants who were perpetrators of ARA at study baseline.

“Fourth R”4 is a semester-long classroom-based intervention, taught by existing teachers and designed to engage middle school students with lessons that support healthy relationships and target risk reduction and protective factors. There are 3 units:

  • Unit 1: Personal Safety and Injury Prevention
  • Unit 2: Substance Use, Addictions, and Associated Behaviors
  • Unit 3: Human Development and Sexual Health

Each unit has 7-8 lessons lasting about 45 minutes each that include videos and other material.

The authors had previously randomized 24 urban/suburban middle schools in southeast Texas to either receive “Fourth R” (intervention group – 12 schools and 1,237 participants) or health class as usual (control group – 12 schools and 1,531 participants).3 In this current study, the authors focused on the 76 intervention and 122 control participants who had a history of physical ARA perpetration at baseline and were followed up with a validated survey at 12, 24, and 36 months post intervention. The survey, the Conflict in Adolescent Dating Relationships Inventory, asks about specific perpetrator behaviors such as slapping, hair pulling, kicking, and shoving. The authors found that “Fourth R” did appear to effectively prevent re-perpetration of physical ARA, with a significantly lower rate in the intervention than control group.

While “Fourth R” was successful as intended, Dr. Baumler and colleagues emphasize that primary prevention is key, and that broad efforts to support individual and family mental health are needed to prevent and address initial and repeated physical ARA. Pediatricians can and should ask about intimate partner violence both in the home and in teen relationships, and counsel and refer as needed. A public health approach may reach even more teens and can complement individual care. Do your local schools offer “Fourth R” or another evidence-based ARA prevention curriculum?5 If not, consider advocating for implementation of the Fourth R curriculum as a valuable and effective piece of the puzzle to prevent teen dating violence.


  1. Miller E, Jones KA, McCauley HL. Updates on adolescent dating and sexual violence prevention and intervention. Curr Opin Pediatr. 2018 Aug;30(4):466-471. doi: 10.1097/MOP.0000000000000637. PMID: 29750769; PMCID: PMC6453661.
  2. Wolfe DA, Crooks C, Jaffe P, Chiodo D, Hughes R, Ellis W, Stitt L, Donner A. A school-based program to prevent adolescent dating violence: a cluster randomized trial. Arch Pediatr Adolesc Med. 2009 Aug;163(8):692-9. doi: 10.1001/archpediatrics.2009.69. PMID: 19652099.
  3. Temple JR, Baumler E, Wood L, Thiel M, Peskin M, Torres E. A Dating Violence Prevention Program for Middle School Youth: A Cluster Randomized Trial. Pediatrics. 2021 Nov;148(5):e2021052880. doi: 10.1542/peds.2021-052880. Epub 2021 Oct 6. PMID: 34615696; PMCID: PMC9645690.
  4. Strategies for Healthy Youth Relationships. Western Centre for School Mental Health, Western University, Ontario CA. Accessed 9/4/23.
  5. Niolon PH, Vivolo-Kantor AM, Tracy AJ, et al.. An RCT of dating matters: effects on teen dating violence and relationship behaviors. Am J Prev Med. 2019;57(1):13–23
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