Children's attachment implementation: getting started

This section highlights 3 areas of the children's attachment guideline that could have a big impact on practice and be challenging to implement, along with the reason(s) why we are proposing change in these areas (given in the box at the start of each area). We identified these with the help of stakeholders and guideline committee members (see section 12 of the developing NICE guidelines manual). The section also gives information on resources to help with implementation.

The challenge: stability of care

See recommendation 1.1.3.

Stable care enables children to form secure attachments and has benefits for a child's education, health and emotional development. Greater stability can be delivered in part by a reduction in the number of care placements for any one child, which in turn will reduce immediate costs to the local authority by reducing social workers' time, use of expensive agency and residential placements, and therapeutic support. Providing more stable care will also help local authorities meet the Department for Education and Department of Health and Social Care's statutory guidance on the planning, commissioning and delivery of health services for looked-after children for promoting the health and wellbeing of looked-after children, and in delivering permanency planning.

Improve placement stability

Frequent moves in and out of care, and frequent placement changes within the care system damage children's capacity to form attachments and reinforce their experiences of transience, separation and loss. In England, the latest from the Department for Education statistics on looked-after children show that 11% (7,572) of all looked-after children had 3 or more placements in the year ending 31 March 2014. This percentage has remained the same since 2010. Multiple placements have significant cost implications, as the more frequently children move, the more difficult they are to place and, as a result, the costs of both arranging and maintaining new placements increase exponentially (Costs and Consequences of Placing Children in Care; Ward, Holmes and Soper, 2008. pp91–95).

To do this, Children's Service Managers could:

Increase the pool of available placements

Most of the moves for children in the care system are planned transitions, initiated by the local authority, in order to transfer a child from 1 placement to another that might better meet their needs. Although the vast majority of children who come into care are already known to social services, many admissions (and re‑admissions) are unplanned, following the breakdown of an already fragile family. About two‑thirds of abused and neglected children who return home from care are subsequently readmitted into care, often as emergencies. When children enter care as emergency admissions, immediate placements need to be found. If the pool of placements available is small, the first placement may not be appropriate. For example, siblings may not be able to stay together or the new circumstances may not meet the child's cultural needs.

The Fostering Network's Update to the cost of foster care report provides an estimate of the investment needed to provide a properly resourced foster care service.

To help increase available placements, Children's Service Managers could:

  • Monitor the number of emergency, unplanned admissions to care and introduce strategies to reduce them.

  • Identify and act on any changes in the system that could help to reduce delays in recruiting and approving adoptive carers.

Improve continuity of relationships

Creating stability in a child's life is multi-faceted, and instability in 1 area can have a knock‑on effect on a number of other important relationships in a child's life. For example, when children change care placement, they may be unable to remain in the same school, to continue in a health programme, or to continue to have support of the Children and Adolescent Mental Health Services (CAMHS) professionals. Encouraging continuity in all aspects of a child's life where possible will involve working across regional boundaries and the development of policies that enable professional and personal relationships to continue where these are beneficial.

To do this, children's service managers could develop policies to:

  • Encourage continuity of attachment figures, for example, by maintaining contact with former foster carers where possible after a child has been adopted.

  • Promote continuity of friendships, where these friendships are healthy for both parties, by allowing children to keep in contact with friends from home and those they have made in previous placements.

  • Enable children to stay in the same school and work with the same mental health worker or team regardless of where they are placed or whether they are in care or on the edge of care. Sometimes this will mean accessing services outside of the child's residential area.
    The Department for Education's Innovation Programme is funding several projects to investigate how best to support stable relationships for children in care.

The challenge: assessing attachment difficulties

See recommendation 1.3.1.

The terms attachment disorder and insecure or disorganised attachment behaviour are often confused and wrongly used interchangeably. Attachment disorder is a recognised mental disorder that affects a very small minority of children experiencing attachment problems. Insecure or disorganised attachment occurs much more commonly and is an indicator of possible dysfunction in a child's attachment system that can lead to poor outcomes, particularly in the case of disorganised attachment. Using terms consistently is important so that professionals can communicate effectively, and commissioners or service managers can plan care appropriately. A clearer and consistent understanding of both types of attachment problem will enable commissioners to distinguish between the capacity needed for more specialist children's services and for primary and secondary level services that are more widely available.

Being able to assess attachment problems may also be helpful for staff working regularly with a child in order to establish whether an intervention has been successful or if more support is needed.


Initially the guidance may present a resource challenge because all health and social care staff working with children and young people in any setting should be trained in the recognition and assessment of attachment difficulties.

To do this, children's service managers could:

  • Train staff to use assessment tools to guide decisions on children and young people who have or may have attachment difficulties. There are a number of tools currently available. These are listed in recommendation 1.3.4 of the guideline.

Local authorities and CAMHS services could:

  • Consider commissioning high-quality training at 2 levels:

    • A generic training, for everyone who works with children in foster care, special guardianship, and adoption, or children on the edge of care, about what assessment problems are and what they look like. The MindEd e-learning programme has a module on attachment and human development, aimed at a universal audience, and another module on attachment and attachment problems for experienced or specialist users.

    • Face-to-face training that covers how to reliably and consistently conduct an assessment of possible attachment problems using recognised attachment tools. Such training is regularly advertised but creating a 'notice board' shared by local authority teams could be helpful.

Also, organisations responsible for professional training qualifications could:

  • Integrate training on attachment into the generic training of psychiatrists, psychologists, social workers, nurses and teachers.

  • Work together to develop a national training toolkit for assessing attachment problems and for working with children with attachment needs.

The challenge: using video feedback programmes

See recommendations 1.4.1, 1.4.2 and 1.5.1.

Video feedback is a relatively low-cost intervention that can be used to help improve a carer's responsiveness to a child's emotional needs and to promote secure attachment. About 40% of placement moves occur following a breakdown of the relationship between child and carer. Insufficient emotional and practical support for carers and inadequate therapeutic support for children who have experienced abuse and neglect are major reasons for placement breakdown. The use of video feedback programmes to improve parenting skills should help provide a more stable environment for the child, and may prevent problems from escalating to the point where a child needs to be taken into the care of the local authority.


The guidance recommends that video feedback programmes are delivered in the parental home by a trained health or social care worker who has experience of working with children and young people. In the UK, Video Interaction Guidance (VIG) is the most widely available training programme. There are other types of video feedback training available in Europe. The Tavistock and Portman NHS Foundation Trust is currently working with the Consortium of Voluntary Adoption Agencies (CVAA) to introduce Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP‑SD), which is a video feedback programme developed by Leiden University that is available on a national scale to all adopters in the Netherlands.

To find out more about training, children's service managers could:

  • Visit the website for the Association for Video Interaction Guidance UK (AVIGuk), which has information about how to get started with an introductory training course, as well as details of how to contact members of the association close to you who have been accredited to provide training. Tavistock and Portman NHS Foundation Trust has details of available courses.

  • Stay informed about training developments in this field, for example, the Infant Caregiver project in California, USA and attachment training workshops at the University of Quebec, Canada, which were reviewed as part of the evidence supporting the recommendations for this guideline.

Concerns about filming

Both professionals and carers are sometimes wary of using video feedback because of a fear about how the film may later be used.

To help address some of these concerns, the professional delivering a video feedback intervention could:

  • Ensure that permission to film is granted by the head of service and that there is a service policy on video recordings.

  • Ensure that carers are given a clear explanation of who could potentially view the video and under what circumstances, and that they provide written consent for themselves and their child to be filmed for the purpose of the intervention. The AVIGuk website has a sample permission form that may help you construct your own documents.

  • Ensure that any staff booking appointments can talk confidently and competently to carers about the clinical use of video and confidentiality.

  • Ensure all filming equipment and footage is stored in accordance with the Data Protection Act 1998. There needs to be a clear protocol for storing information so that carers can trust a practitioner to store the video clips of their 'better than usual interaction' securely and how these will be used. The AVIGuk website has a sample NHS protocol that may help you construct your own documents.

Need more help?

Further resources are available from NICE that may help to support implementation.

  • NICE produces indicators annually for use in the Quality and Outcomes Framework (QOF) for the UK. The process for this and the NICE menu can be found on the NICE Quality and Outcomes Framework indicator webpage.

  • Uptake data about guideline recommendations and quality standard measures are available on the NICE website.

  • National Institute for Health and Care Excellence (NICE)