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RUNNINGHEAD: Triple P Parenting and RAD

Designing, Implementing and Evaluating Quality Interventions for Reactive Attachment

Disorder

Lindsay A. Birchall
University of Calgary

Interventions to Promote Cognitive, Academic and Neuropsychological Well-Being

EDPS 658
Dr. Tina Parsons
June 20th, 2014

RUNNINGHEAD: Triple P Parenting and RAD

Introduction
Disturbances of attachment behavior and social functioning in early childhood have been
described in the clinical literature for over 50 years (Newman & Mares, 2007). Reactive
Attachment Disorder (RAD) is a severe and relatively uncommon disorder which arises when
children have failed to form normal attachments with their primary caregivers in early childhood.
This failure could result from severe early experiences of neglect, abuse, separation from
caregivers, frequent changes of caregivers or lack of a caregivers responsiveness to the child
(APA, 2013; Newman & Mares, 2007; Corbin, 2007). Some environments, such as foster-care,
orphanages or institutions, have been identified as risk factors in the development of RAD;
however, these environments are not consistent predictors of the disorder. Literature on evidence
based interventions for RAD is limited, however; the Triple P Parenting Program (TPPP) has a
significant evidence base and may be a viable option for intervention. TPPP is a multilevel
intervention designed to improve parenting confidence and competence by introducing a range of
parenting strategies using a self-regulatory framework (Sanders, 1999). Upah & Tilly, (2002)
have developed a logical and clear framework to assist clinicians in designing, implementing and
evaluating interventions, which we will apply to the TPPP. Before we examine this intervention
it is imperative to examine the relevant issues regarding the diagnosis of RAD, the theoretical
background of attachment and neuropsychological underpinnings of RAD.
Theoretical Considerations
The absence of a consistently available attachment figure in early childhood has been
documented as the greatest etiological link with attachment disorders (Newman & Mares, 2007).
Attachment experiences in the early caregiving environment are complex, including interactions
between physiological, biological, genetic, and behavioral factors. Bowlby, (1960; 1969)

RUNNINGHEAD: Triple P Parenting and RAD

theorized that children are pre-programmed to form attachments for survival, a child has an
innate need to attach to one main figure and there are long term consequences to maternal
deprivation. In 1967, Ainsworth categorized three basic patterns of attachment that describes the
quality and affective characteristics of a childs attachments through her Strange Situation
experiment. More recently, Dr. Gabor Mat termed attunement as the imperative factor in
attachment. Attunement is conceptualized as the caregivers response pattern to the childs needs
(i.e. to been seen, understood, empathized with and connected to on a social-emotional level),
separate from parental love and physical contact (2004). At present a continuum of four
categories of attachment are generally accepted to describe parent child interactions: secure,
insecure-resistant, insecure-avoidant, and insecure-disorganized/disoriented. A child with RAD
may display behaviours within all three insecure categories.
Importantly, attachment theorists agree that secure attachments protect against
psychopathology (Corbin, 2007; Fonagy 2001). Particularly, resilience, as defined by the ability
to withstand and cope effectively with adversity, is fostered by secure attachments (Corbin,
2007). This evidence of resilience provides support for interventions which target the
development of secure attachment patterns within relationships and the environment (i.e. stable,
nurturing, predictable, patient and calm parenting approaches) (Chaffin, Hanson, Saunders,
Nichols, Barnett, Zeanah & Miller-Perrin, 2006). Securely attached children feel consistent,
responsive, and supportive relations to their primary caregiver even during times of significant
stress. Insecurely attached children feel inconsistent, punishing, unresponsive emotions from
their caregivers and feel threatened during times of stress (Bretherton, 1992).
Diagnostic Considerations
Although the clinical significance of attachments has been well documented the existing
diagnostic conceptualization of attachment disorders remains problematic (Newman & Mares,

RUNNINGHEAD: Triple P Parenting and RAD

2007; Allen, 2011). Supporting this, the diagnostic criteria for RAD have undergone multiple
modifications throughout the course of the Diagnostic and Statistical Manuals (DSM)
publications (APA, 1980, 1994, 2013). Additionally, the DSM criteria differ from the World
Health Organizations criteria for RAD in the International Statistical Classification of Diseases10 (Who.int). Furthermore, specific assessment protocols have not been developed for the
reliable identification of RAD. Symptoms and criteria for RAD include: the experience of
pathogenic care, persistent developmental delays and emotional disturbance characterized by
hyper-vigilance, disturbed social relatedness, socially withdrawn behaviours, limited positive
affect and fearful behaviours in non-threatening situations (APA, 2013, Who.int).
Although these diagnostic guidelines are helpful, many of these behaviours are subject to
clinical interpretation and are dependent on obtaining an accurate developmental history.
Because neglect and maltreatment have developmental and behavioural consequences on their
own, only clinicians with expertise in RAD should diagnose the disorder (Schore 2003; Newman
& Mares, 2007). As Newman & Mares (2007) state the lack of agreed definition and
conceptualization of these conditions is reflected in disparate approaches to intervention and
limited empirical data, p. 334). If we cannot reliably diagnose RAD, how can we develop and
assess quality evidence based interventions?
Neurological Underpinnings
It is believed there is a critical period for the development of neurological pathways
underlying the organization of the attachment system and that early care experiences, such as
secure attachment, are paramount to this development (Newman & Mares, 2007; Schore, 2003).
Sadly, the neurobiological effects of childhood neglect can equal and even surpass the impact of
abuse and trauma (Corbin, 2007). These early experiences of neglect, abuse and trauma can
dramatically alter the structures, neuro-chemicals, and connectivity within the brain, particularly

RUNNINGHEAD: Triple P Parenting and RAD

in the right hemisphere, leaving life-long deficits (Schore 2003). Childhood trauma has been
shown reduce the size of the corpus collosum which may impair communication and integration
between the left and right hemispheres (Gabbard 2005; Teicher 2002). Research using magnetic
resonance imaging (MRI) has shown decreased cortical, hippocampal and amygdalal size in
adults who have experienced early maltreatment (Tiecher, 2002). The functioning of the
hypocampus and the amygdala are imperative in the formation of both emotional and verbal
memories. It is believed that early traumatic experiences create memory prototypes which impair
a childs perceptions and experiences later in life (Liggan & Kay, 1999). Specifically, cortisol
regulation in the hypothalamic-pituitary-adrenal (HPA) Axis can be disrupted, resulting in
enduring hyperaroused states that have been linked to dysregulation later in life (Gabbard 2005;
Petitto et al., 1992). This overexposure to stress hormones early in life can change the shape of
the largest neurons in the hippocampus, supress production of new neurons and can even kill
neurons (Teicher, 2002, p. 73). Sadly, recent research has shown that changes to the
hippocampus and its connections caused by severe trauma may not be reversible (McEwen 1999;
Starkman et al. 1999; Teicher 2002; Van der Kolk 2003).
Evidence Based Interventions
Controversial Interventions. The current literature on quality interventions for children with
RAD is exploratory and controversial. Although many interventions have been well documented,
they often lack empirical support, are not congruent with attachment theory or have even been
associated with harm (Chaffin et al., 2006). One such intervention, termed Holding
Time/Therapy, uses a form of physical restraint to promote the development of attachments or
desensitize the child to physical touch (Kelly, 2006; Kelly, 2003; Hughes, 2003; Federici, 1998
Zaslow & Menta, 1975). Holding therapy is pervasive in the literature; however, numerous
organizations have understandably labelled such treatments as unethical and dangerous (Chaffin

RUNNINGHEAD: Triple P Parenting and RAD

et al., 2009). Another well-known proposed therapy, with little to no empirical basis, uses Age
Regression Techniques to build secure attachments, by engaging in attachment related caregiver
activities the child missed earlier in life (e.g. rocking, bottle feeding, cradling, etc.) (Mercer,
Misbach, Pennington, & Rosa, 2006). A third well documented intervention called Theraplay is
a play-based attachment intervention designed to repair the parent-child attachment by providing
experiences to re-start the healthy life cycle for the child (e.g. repeated and sustained eye contact,
nurturing activities such as applying powder and lotion, hugging, holding, rocking, and tickling
(Booth, 2005; Jernberg,1984). Needless to say, Theraplay has no empirical evidence base. New
interventions continue to make their way into the literature (e.g. Dyadic Developmental
Psychotherapy (Hughes, 1997, 2006; Becker-Weidman & Hughes, 2008), however these
interventions lack acceptable theory and empirical research support.
Evidence Based Recommendations. Most published research on RAD interventions is scant. It
lacks empirical evidence and replication, shows limited sample sizes, is not congruent with
attachment theory and does not provide the reader with clear intervention protocols. Therefore,
clinicians may find it challenging to develop and implement evidence based interventions for a
child with RAD. Evidence supports that a child with RAD should be placed in a stable home with
alternative attachment figures if interventions are to have positive outcomes. Children who are
removed from institutional care before six months of age do better than those in care for longer
(Rutter, OConnor and the ERA Study Team, 2004; Johnson, Browne & Hamilton-Giachritsis,
2006). If the child with RAD is living with their parents, it is imperative that the family is
provided with interventions as early as possible (Newman & Mares, 2007). The nature and
quality of the caregiver, stability of the environment, specific symptoms of the child, parent-child
interaction patterns and the treatment of co-morbid disorders need to be considered carefully
before appropriate interventions can be determined (Allen, 2011).

RUNNINGHEAD: Triple P Parenting and RAD

In a meta-analysis of attachment interventions Bakermans-Kranenburg, VanIJzendoorn,
and Juffer (2003) found that those interventions that enhanced attachment security the most were
those that were clear-cut, focused on the family and prioritized enhancing parental sensitivity. In
a review of current attachment therapies, Allen, (2011) identified four critical therapy
components: 1. The child requires an attachment figure who should serve as the primary vehicle
for change, 2. The caregiver must learn to respond in a consistent, nurturing, nonthreatening and
non-coercive manner excluding power assertion techniques and confrontation based approaches,
3. Intervention should be parent focused and designed to foster the development of the child and
techniques should not involve remediation of past experiences and 4. Intervention should
consider the childs cognitive ability and foster the childs sense of competence, respect and
worth.
The Triple P Positive Parenting Program. Taking Allens (2011) recommendations into
consideration, the TPPP may be a viable option for intervention. The TPPP has evidence based
success within families that have typically developing children and those with disabilities such as
Conduct Disorder, Attention Deficit Disorder and Autism Spectrum Disorder (Sanders, MarkieDadds Tully & Bor 2000; Bor, Sanders & Marike-Dadds, 2002; Whittingham, Sofronoff,
Sheffield, & Sanders, 2008). The program incorporates five levels of intervention on a tiered
continuum of increasing strength and narrowing reach, directed by trained Triple P professionals
(Triplep.net). At Level 1 parents are provided with general positive parenting strategies such as
being affectionate, setting ground rules, praising good behaviour, giving clear an calm
instructions, planned ignoring and using assertive discipline (Sanders & Turner, 2004).
Enhanced Triple P (Level 5) provides adjunctive interventions for families in which parenting
concerns occur in the context of other major adult adjustment problems, such as marital conflict
and depression (Triplep.net). Specifically, Pathways Triple P is for parents at risk of child

RUNNINGHEAD: Triple P Parenting and RAD

maltreatment. This program focuses on reducing further physical and emotional harm to their
children by developing the parents emotional regulation abilities through Cognitive Behavioural
Therapy techniques (Triplep.net). Anger management and other behavioural strategies are used
to improve a parent's ability to cope with raising children.
So, how can you take an intervention like the TPPP and effectively implement it for
children with RAD and their families? We can use Upah and Tillys (2002) framework for
designing, implementing and assessing quality interventions. This review will reference each of
the 12 steps of quality interventions outlined by Upah & Tilly (2000) in concordance with
information provided in current Triple P research (Sanders, Markie-Dadds Tully & Bor 2000;
Bor, Sanders & Marike-Dadds, 2002; Whittingham, Sofronoff, Sheffield, & Sanders, 2008;
Shapiro, Prinz & Sanders, 2012) and documentation available on the Triple P website
(triplep.net) .
12 Quality Indicators (Upah & Tilly, 2002)
Step 1: Behavioural Definition. Parents that have a child diagnosed with RAD are likely
demonstrating ineffective and possibly harmful parenting techniques. Specific behaviours such
as anger, escalation, positive and unhelpful thought patterns, relaxation techniques and planning
pleasurable activities are all identified as target behaviours within the Pathways program
(Triplep.net). Because these behaviours may look different for individual parents, it would be
helpful to operationalize behaviours (e.g. anger red face, clenched fists, difficult to speak,
unhelpful thought patterns - he is doing this to make me mad, relaxed muscles feel calm) so
a parent is better able to engage in the Cognitive Behavioural process of the Pathways program
(e.g. escalation- physically shaking with rage may an antecedent to physical abuse for the child).
Step2: Baseline Data. Triple P does not identify specifically how they compile baseline data.
Their research outlines several processes including structured parent-child observations using

RUNNINGHEAD: Triple P Parenting and RAD

standardized scales (e.g. Revised Family Observation Schedule (FOS-RIII; Sanders, Waugh,
Tully, & Hynes, 1996), formal assessment data (e.g. Beck Depression Inventory (Beck et al.,
1979), Child Abuse Potential Inventory (Milner, 1986), unstructured parent-child observation,
coding negative behaviours, behaviour rating scales, behaviour checklists, frequency data of
negative behaviours, Antecedent Behaviour Consequence (ABC) data and parent report data.
Importantly, the general protocol for data collection fits with Upah & Tillys (2002)
recommendation that data is acquired prior to intervention, collected on specific measurable
behaviours and gathered over multiple sessions.
Step 3: Problem Validation. If parents were mandated to participate in the Pathways program,
problem validation is obvious and a discrepancy exists that warrants intervention. If parents
referred themselves, the trained Triple P clinician must not only confirm diminished parental
capacity, but may also be required to involve the consultation of other appropriate supports,
depending on the nature of maltreatment (e.g. Child and Family Services, Family Services for
Children with Disabilities, Alberta Learning, etc.).
Step 4: Problem Analysis Steps. It is likely there is an ongoing cycle of maladaptive
interactions between the parent and the child, therefore; The Triple P clinician will engage in
ongoing problem analysis through their sessions. The clinician must identify all relevant known
information (e.g. history of neglect) and unknown factors (e.g. exposure to family violence,
exposure to abuse, parental mental health). When a family is mandated, this information would
be easier to access then if a family has initiated services on their own. Because abuse often
occurs generationally, the clinician should consider that the underlying cause of the parents
behaviours may not be consciously understood (e.g. history of maltreatment in the family,
parents grew up with abuse, maternal attachment issues, etc.). The parents behaviours are likely
as complex as the child with RAD. Upah & Tilly, (2002) recommend Functional Behavioural

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Assessment (FBA) within problem analysis. Although FBA will identify the function of the
behaviours (e.g. maternal stress relief) it will not identify the complex underlying emotional
issues that are likely present in the family system. Carrying out the intervention plan may involve
additional support such as Community Mental Health Services.
Step 5 & 6: Goal Setting and Intervention Plan Development. Triple P has very specific
intervention protocols which makes their goal setting consistent and clear. Within the Pathways
program, the parental outcomes that are expected are the improvement in anger management and
coping strategies. Appendix A outlines the Pathways intervention plan (Triplep.net).
Step 7: Measurement Strategy. Although it is unknown what specific strategies and tools are
used for the measurement of parental progress within the TPPP, one would assume the clinician
may take observational data during in home sessions. From professional experience, parents are
also required to take some ongoing data (e.g. ABC).
Step 8: Decision-Making Plan. Because there is a set intervention plan, one may assume that
clinicians have a specific framework for making and changing the course of the intervention.
From professional experience, specific types of data (e.g. ABC) can be used to assist the parents
in understanding how their behaviours may contribute to negative parent-child interactions,
thereby providing rationale for behaviour change. However, specific means to alter intervention
protocols is not available.
Step 9: Progress Monitoring. Within the structure of the pathways program it is unknown what
factors may warrant deviance from the planned intervention. From the literature it appears that
continuous evaluation of parental progress may occurs during weekly sessions, though
behavioural observation. However information is not provided on what situations or parental
behaviours may warrant modified interventions. And, although behavioural observation is fairly

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reliable means of measuring progress, a clinician will never really know a parents true
adherence to recommended interventions within an intervention that lasts only weeks.
Step 10: Formative Evaluation. The success of the TPPP has been documented in the
prevention of maltreatment (Whittingham, Sofronoff, Sheffield, & Sanders, 2008; Shapiro, Prinz
& Sanders, 2011). Although specific processes for formative evaluation were not identified on
the Triple P website, they do specify that report writing occurs at the end of the intervention.
Once would assume this report would include an evaluation of parental outcomes, but this is
speculative.
Step 11: Treatment Integrity & Summative Evaluation. This can be a questionable area with
parents. Consultation to school personnel gives those implementing the intervention some level
of accountability that does not occur with parents. From professional experience there is varying
degrees to which parents adhere to treatment recommendations. With mandated interventions one
would assume this is more likely than with parent initiated support. Triple P provides parents
with resources and support to promote treatment integrity (e.g. handouts, direct parent
observations, feedback sessions, homework, etc.). In general, strategies are not complex, nor are
they ecologically intrusive (Upah & Tilly 2002). However, Triple P does assert that they are a
self-regulatory program, which may reduce parental accountability. From professional
experience, although the treatment integrity of the clinician is highly monitored, the treatment
integrity of the parents is not. Research supports the efficacy of the TPPP. However, one would
assume variability in the efficacy between individual families, based on treatment integrity and
possible mandatory participation.
Conclusion

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In conclusion, Allen (2011) recommends that treatment from an attachment perspective
need not be an isolated approach that requires the development of new techniques or modalities
that can be labeled as attachment therapy. Attachment therapy with maltreated school-age
children should be an integration of techniques that are aimed at achieving the goals set forth by
attachment theory, (p. 19). TPPP, at any Level, aims to do just that; develop positive parentchild relationships. With Upah & Tillys (2002) quality intervention framework, a clinician can
be confident in recommending the TPPP to any family. When the family has a child with RAD,
the Level 5 Pathways program may play an integral part in the development of positive parenting
behaviours, as part of a multi-resource and multidisciplinary team.

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Appendix A

Triple P Parenting Program: Outline of Pathways Parent Sessions:

Module 1, Session 1: Parent traps Parents learn to identify parent traps, understand the impact
of their own behaviour on their children, and identify dysfunctional attributions.

Module 1, Session 2: How to get out of the parent trap This session covers the reasons parents
get caught in parent traps and teaches parents thought switching and breaking out of the trap

Module 2, Session 1: Understanding Anger This session introduces cognitive behavioural

strategies to recognize and understand anger, how to stop anger escalating, abdominal breathing
and relaxation techniques, and planning pleasurable activities.

Module 2, Session 2: Coping with Anger During this session parents with learn to catch
unhelpful thoughts, develop personal anger coping statements, challenge unhelpful thoughts, and
develop coping plans for high risk situations

Module 3, Session 1: Maintenance and Closure This final session focuses on how parents can
maintain changes, problem solve, and create future goals.

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