Children are born with a range of innate behaviours to maximise their survival. Among these is attachment behaviour, which allows the child to draw their primary caregivers towards them at moments of need or distress.

Children whose caregivers respond sensitively to the child's needs at times of distress and fear in infancy and early childhood develop secure attachments to their primary caregivers. These children can also use their caregivers as a secure base from which to explore their environment. They have better outcomes than non-securely attached children in social and emotional development, educational achievement and mental health. Early attachment relations are thought to be crucial for later social relationships and for the development of capacities for emotional and stress regulation, self-control and mentalisation. Children and young people who have experienced insecure attachments are more likely to struggle in these areas and to experience emotional and behavioural difficulties.

Attachment patterns and difficulties in children and young people are largely determined by the nature of the caregiving they receive. Attachment patterns can be adaptations to the caregiving that they receive from all primary caregivers, including birth parents, foster carers, kinship carers, special guardians and adoptive parents. Repeated changes of primary caregiver, or neglectful and maltreating behaviour from primary caregivers who persistently disregard the child's attachment needs, are the main contributors to attachment difficulties.

Attachment difficulties include insecure attachment patterns and disorganised attachments, which can often evolve into coercive controlling or compulsive caregiving patterns in children of preschool age or older. The term 'attachment difficulties' in this guideline also covers attachment disorders in the Diagnostic and statistical manual of mental disorders, 5th edition (DSM‑5; reactive attachment disorder and disinhibited social engagement disorder) and the International classification of diseases and related health problems, 10th revision (ICD‑10; reactive attachment disorder and disinhibited attachment disorder).

The number of children and young people in the care system has risen in recent years. On 31 March 2014, there were approximately 69,000 looked-after children and young people in England. Children and young people in the care system, or on the edge of care, are at particular risk of attachment difficulties.

This guideline covers the identification, assessment and treatment of attachment difficulties in children (aged 0 to 12 years) and young people (aged 13 to 17 years) who are:

  • adopted from care (and those adopted in England who are from overseas)

  • in special guardianship

  • looked after by local authorities in foster homes (including kinship foster care), residential settings and other accommodation

  • on the edge of care.

Children and young people in these situations have many needs, including those resulting from maltreatment. This guideline will only address their needs in relation to attachment relationships.

  • National Institute for Health and Care Excellence (NICE)