Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength of our recommendations, and has information about safeguarding, consent and prescribing medicines (including 'off‑label' use).

1.1 Principles of care in all contexts

Using this guideline

1.1.1 Use this guideline in conjunction with the NICE public health guideline on looked-after children and young people and the NICE clinical guideline on when to suspect child maltreatment.

Ensuring equal access to consistent care

1.1.2 Ensure that all children, young people and their parents or carers get equal access to interventions for attachment difficulties, regardless of whether they:

  • are on the edge of care, accommodated under Section 20 of the Children Act 1989, subject to a care order, under special guardianship or adopted from care

  • are placed with birth parents, foster carers (including kinship carers), special guardians or in residential care

  • are from a minority ethnic group

  • have a disability or a mental health problem

  • are from the UK or overseas.

1.1.3 Assess all children and young people who enter the UK as unaccompanied asylum‑seeking children for attachment difficulties once a stable placement has been found, and offer interventions and support if needed. Take into account that, in addition to attachment difficulties, children and young people who enter the UK as unaccompanied asylum‑seeking children are highly likely to have been traumatised, especially when coming from war zones. If they have post‑traumatic stress disorder, offer treatment in line with the NICE guideline on post-traumatic stress disorder.

1.1.4 Ensure that the health, education and social care processes and structures surrounding children and young people with attachment difficulties are stable and consistent. This should include:

  • using a case management system to coordinate care and treatment

  • collaborative decision making among all health, education and social care professionals, the child or young person if possible and their parents and carers

  • having the same key worker, social worker, personal adviser or key person in school throughout the period the child or young person is in the care system or on the edge of care.

1.1.5 Ensure that the stability or instability of the child or young person's placement does not determine whether psychological interventions or other services are offered.

Improving the stability of placements

1.1.6 Ensure that, whenever possible, children and young people enter the care system in a planned manner rather than in response to a crisis.

1.1.7 Ensure that carers are ready to accept the child or young person's need to be in a loving relationship and are able and, whenever possible, willing to think about providing longer‑term care or involvement if needed.

1.1.8 Help arrange kinship placements, if safe and in the best interest of the child or young person.

1.1.9 Consider comprehensive education and training for potential carers to prepare them for the challenges involved in looking after children and young people with attachment difficulties and the likely impact on them and their families.

1.1.10 Provide ongoing support and advice, either by telephone or in person, and proactively monitor difficulties in placements to identify opportunities to provide additional support, if there are significant attachment difficulties or if disruption to the placement is likely.

1.1.11 If a placement breaks down, aim to maintain the relationship between the child or young person and the foster carers (including kinship carers), adoptive parents or special guardians, whenever possible and if it is in the best interests of the child or young person.

Preparing the child or young person before they enter the care system or change placement

1.1.12 Actively involve children and young people, and their parents or current carers, in the process of entering the care system or changing placement. This may include:

  • explaining the reasons for the move

  • familiarising the child or young person with their new carers and placement (for example, by arranging a pre‑placement visit or showing them photographs of their new carers and home)

  • providing ongoing support during transitions, such as face‑to‑face meetings, telephone conversations and other appropriate methods of communication

  • making sure the child or young person has the opportunity to ask questions and make choices whenever appropriate and possible

  • supporting the child or young person in maintaining relationships with their parents or previous carers unless this would not be in the child or young person's best interests

  • taking account of the needs of children at different ages and developmental stages, including needs related to their mental health and any physical disabilities.

Improving the likelihood of a more permanent placement, including adoption

1.1.13 If a return to the birth parents or original family is not an option, keep siblings together if it is possible and in the best interests of all the children or young people.

1.1.14 Offer additional support and resources (such as mentoring or day visits with a social worker) to children and young people and/or their carers:

  • at the first sign of serious difficulties in the placement, or

  • if there have been frequent changes of placement, or

  • if there is more than one child with attachment difficulties in the placement.

1.1.15 When adoption is considered the best outcome for the child or young person ensure that:

  • their wishes are taken into account

  • they are offered information that is appropriate to their developmental level about the implications that adoption may have for future contact with their birth parents, siblings, wider family members and others

  • a full assessment of need is conducted before adoption

  • an assessment of attachment difficulties is offered at any stage after adoption

  • they are offered support (based on the assessment of need and attachment difficulties) before, during and after adoption.

Preserving the personal history of children and young people

1.1.16 Social care workers should offer children and young people in the care system, in special guardianship or adopted from care, accurate, comprehensive, up‑to‑date and age‑appropriate information about their history and family in a form that they are able to use and revisit at their own pace (for example, through photographs and life story work in line with the NICE guideline on looked-after children and young people).

1.1.17 Social care workers should keep a record of the significant people and places in the child or young person's life while they are in the care system.

Safeguarding and monitoring during interventions

1.1.18 Ensure safeguarding is maintained during any intervention for a child or young person with attachment difficulties.

1.1.19 Consider using a parental sensitivity tool (for example the Ainsworth Maternal Sensitivity Scale) and a parenting quality tool with parents and carers to help guide decisions on interventions and to monitor progress.

Pharmacological interventions

1.1.20 Do not treat attachment difficulties with pharmacological interventions. For the use of pharmacological interventions for coexisting mental health problems, see for example, antisocial behaviour and conduct disorders in children and young people, attention deficit hyperactivity disorder, depression in children and young people and alcohol-use disorders.

1.2 Supporting children and young people with attachment difficulties in schools and other education settings (including early years)

1.2.1 Schools and other education providers should ensure that all staff who may come into contact with children and young people with attachment difficulties receive appropriate training on attachment difficulties, as set out in recommendation 1.2.2.

1.2.2 Educational psychologists and health and social care provider organisations should work with local authority virtual school heads and designated teachers to develop and provide training courses for teachers of all levels on:

  • how attachment difficulties begin and how they can present in children and young people

  • how attachment difficulties affect learning, education and social development

  • understanding the consequences of maltreatment, including trauma

  • how they can support children and young people with attachment difficulties.
    Children and young people with attachment difficulties, and their parents or carers, should be involved in the design of the training courses, wherever possible.

1.2.3 Staff in schools and other education settings and health and social care professionals should work together to ensure that children and young people with attachment difficulties:

  • can access mental health services for children and young people and education psychology services for interventions

  • are supported at school while they are taking part in interventions following advice from mental health services for children and young people and education psychology services.

1.2.4 When providing support for interventions in schools and education settings, staff should:

  • be aware of the possibility of stigma, bullying and labelling as a result of any absences from school

  • take into account the child or young person's preferences for the setting of the intervention.

1.2.5 Schools and other education providers should ensure that the designated teacher:

  • has had specialist training:

    • to recognise and understand attachment difficulties and mental health problems

    • in data protection and confidentiality

  • is aware of and keeps accurate and comprehensive records about all children and young people in their school who:

    • are in the care system

    • have been adopted or subject to special guardianship orders

    • have or may have attachment difficulties

  • has contact details for the parents, carers and health and social care professionals for all the above groups

  • maintains an up-to-date plan (a personal education plan for children and young people in the care system) setting out how they will be supported in school

  • provides a key person who can advocate for the child or young person and to whom the child or young person can go for support

  • allocates a safe place in school, for example a room where a child or young person can go if they are distressed

  • attends looked-after children reviews

  • maintains an effective referral system with other agencies.

1.2.6 Social care professionals, schools and other education providers should ensure that changes or gaps in the education of children and young people in the care system are avoided by:

  • helping them to keep attending school when there are changes to their placements

  • supporting them while they develop new relationships and if they are worried about the new placement.
    If a change is unavoidable, it should be planned in advance so that disruption is minimal.

1.2.7 Schools and other education providers should avoid using permanent and fixed‑term school exclusion as far as possible for children and young people in the care system with identified attachment difficulties.

1.3 Assessing attachment difficulties in children and young people in all health and social care settings

1.3.1 Health and social care provider organisations should train key workers, social care workers, personal advisers and post‑adoption support social workers in the care system, as well as workers involved with children and young people on the edge of care, in:

  • recognising and assessing attachment difficulties and parenting quality, including parental sensitivity

  • recognising and assessing multiple socioeconomic factors (for example, low income, single or teenage parents) that together are associated with an increased risk of attachment difficulties

  • recognising and assessing other difficulties, including coexisting mental health problems and the consequences of maltreatment, including trauma

  • knowing when and how to refer for evidence‑based interventions for attachment difficulties (see sections 1.4, 1.5 and 1.6).

1.3.2 Health and social care professionals should offer a child or young person who may have attachment difficulties, and their parents or carers, a comprehensive assessment before any intervention, including:

  • personal factors, including the child or young person's attachment pattern and relationships

  • factors associated with the child or young person's placement, such as history of placement changes, access to respite and trusted relationships within the care system or school

  • the child or young person's educational experience and attainment

  • parental sensitivity

  • parental factors, including conflict between parents (such as domestic violence and abuse), parental drug and alcohol misuse or mental health problems, and parents' and carers' experiences of maltreatment and trauma in their own childhood

  • the child or young person's experience of maltreatment or trauma

  • the child or young person's physical health

  • coexisting mental health problems and neurodevelopmental conditions commonly associated with attachment difficulties, including antisocial behaviour and conduct disorders, attention deficit hyperactivity disorder, autism, anxiety disorders (especially post‑traumatic stress disorder), depression, alcohol misuse and emotional dysregulation.

1.3.3 Offer children and young people who have or may have attachment difficulties, and who also have a mental health problem or neurodevelopmental condition, interventions as recommended in the relevant NICE guideline (for example, antisocial behaviour and conduct disorders in children and young people, attention deficit hyperactivity disorder, autism, post-traumatic stress disorder, social anxiety disorder, depression in children and young people and alcohol-use disorders).

1.3.4 Consider using the following assessment tools to guide decisions on interventions for children and young people who have or may have attachment difficulties:

  • Strange Situation Procedure for children aged 1–2 years

  • modified versions of the Strange Situation Procedure for children aged 2–4 years (either the Cassidy Marvin Preschool Attachment Coding System or the Preschool Assessment of Attachment)

  • Attachment Q‑sort for children aged 1–4 years

  • Manchester Child Attachment Story Task, McArthur Story Stem Battery and Story Stem Attachment Profile for children aged 4–7 years

  • Child Attachment Interview for children and young people aged 7–15 years

  • Adult Attachment Interview for young people (aged 15 years and over) and their parents or carers.

    See the table in appendix 1 for further information about these tools.

1.3.5 Health and social care provider organisations should ensure that health and social care professionals are skilled in the use of the assessment tools in recommendation 1.3.4.

1.3.6 Only diagnose an attachment disorder if a child or young person has attachment difficulties that meet diagnostic criteria as defined in the Diagnostic and statistical manual of mental disorders, 5th edition (DSM‑5; reactive attachment disorder and disinhibited social engagement disorder) or the International classification of diseases and related health problems, 10th revision (ICD‑10; reactive attachment disorder and disinhibited attachment disorder).

1.3.7 Do not offer genetic screening (including measuring specific gene polymorphisms) in children and young people to predict or identify attachment difficulties.

1.3.8 If, following assessment of attachment difficulties, an intervention is required, refer the child or young person, and their parents or carers, to a service that:

  • has specialist expertise in attachment difficulties in children and young people and their parents or carers

  • works with other services, including mental health services for children and young people, education and social care

  • actively involves children and young people with attachment difficulties in staff training programmes.

1.4 Interventions for attachment difficulties in children and young people on the edge of care

This section covers children and young people with attachment difficulties (or at risk of attachment difficulties) who currently live with their birth parents or original family and who are at high risk of entering or re‑entering the care system. It also covers children and young people who have been maltreated or are at high risk of being maltreated (see recommendations 1.4.9, 1.4.10 and 1.4.12).

Preschool-age children with, or at risk of, attachment difficulties

1.4.1 Health and social care professionals should offer a video feedback programme to the parents of preschool‑age children on the edge of care to help them:

  • improve how they nurture their child, including when the child is distressed

  • improve their understanding of what their child's behaviour means

  • respond positively to cues and expressions of the child's feelings

  • behave in ways that are not frightening to the child

  • improve mastery of their own feelings when nurturing the child.

1.4.2 Ensure 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 and:

  • consist of 10 sessions (each lasting at least 60 minutes) over 3–4 months

  • include filming the parents interacting with their child for 10–20 minutes every session

  • include the health or social care worker watching the video with the parents to:

    • highlight parental sensitivity, responsiveness and communication

    • highlight parental strengths

    • acknowledge positive changes in the behaviour of the parents and child.

1.4.3 If there is little improvement to parental sensitivity or the child's attachment after 10 sessions of a video feedback programme for parents of preschool‑age children on the edge of care, arrange a multi‑agency review before going ahead with more sessions or other interventions.

1.4.4 If parents do not want to take part in a video feedback programme, offer parental sensitivity and behaviour training to help them:

  • understand their child's behaviour

  • improve their responsiveness to their child's needs

  • manage difficult behaviour.

1.4.5 Ensure parental sensitivity and behaviour training:

  • first consists of a single session with the parents followed by at least 5 (and up to 15) weekly or fortnightly parent–child sessions (lasting 60 minutes) over a 6‑month period

  • is delivered by a trained health or social care professional

  • includes:

    • coaching the parents in behavioural management (not applicable for children aged 0–18 months) and limit setting

    • reinforcing sensitive responsiveness

    • ways to improve parenting quality

    • homework to practise applying new skills.

1.4.6 If parents do not want to take part in a video feedback programme or parental sensitivity and behaviour training, or, if there is little improvement to parental sensitivity or the child's attachment after either intervention and there are still concerns, arrange a multi‑agency review before going ahead with more interventions.

1.4.7 If the multi‑agency review concludes that further intervention is appropriate, consider a home visiting programme to improve parenting skills delivered by an appropriately‑trained lay home visitor or a healthcare professional such as a nurse.

1.4.8 Ensure home visiting programmes:

  • consist of 12 weekly or monthly sessions (lasting 30–90 minutes) over an 18‑month period

  • include observing the child (not using video) with their parents

  • give the parents advice about how they can improve their communication and relationship with their child by:

    • supporting positive parent–child interaction using role modelling

    • reinforcing positive interactions and parental empathy

  • provide parental education and guidance about child development.

Preschool-age children who have been or are at risk of being maltreated

1.4.9 Consider parent–child psychotherapy for parents who have maltreated or are at risk of maltreating their child to improve attachment difficulties, ensuring that safeguarding concerns are addressed.

1.4.10 Ensure parent–child psychotherapy to improve attachment difficulties:

  • is based on the Cicchetti and Toth model[1]

  • consists of weekly sessions (lasting 45–60 minutes) over 1 year

  • is delivered in the parents' home by a therapist trained in the intervention

  • directly observes the child and the parent–child interaction

  • explores the parents' understanding of the child's behaviour

  • explores the relationship between the emotional reactions of the parents and perceptions of the child, and the parents' own childhood experiences.

Primary and secondary school-age children and young people with, or at risk of, attachment difficulties

1.4.11 Consider parental sensitivity and behaviour training for parents of primary and secondary school‑age children and young people (as described in recommendation 1.4.5) to improve attachment difficulties, adapting the intervention for the age of the child or young person.

Primary and secondary school-age children and young people who have been, or are at risk of being, maltreated

1.4.12 For children and young people who have been maltreated, and show signs of trauma or post‑traumatic stress disorder, offer trauma‑focused cognitive behavioural therapy, and other interventions in line with the NICE guideline on post-traumatic stress disorder.

1.4.13 Consider parental sensitivity and behaviour training (as described in recommendation 1.4.5) for parents at risk of maltreating their child to improve attachment difficulties, ensuring that safeguarding concerns are addressed and adapting the intervention for the age of the child or young person.

1.5 Interventions for attachment difficulties in children and young people in the care system, subject to special guardianship orders and adopted from care

This section covers children and young people with attachment difficulties (or at risk of attachment difficulties) who are in the care system, subject to special guardianship orders or adopted from care; it also covers their foster carers (including kinship carers), special guardians and adoptive parents.

Preschool-age children

1.5.1 Health and social care professionals should offer a video feedback programme to foster carers, special guardians and adoptive parents, as described in recommendation 1.4.2.

1.5.2 If there is little improvement to parental sensitivity or the child's attachment after 10 sessions of a video feedback programme for foster carers, special guardians and adoptive parents of preschool‑age children, arrange a multi‑agency review before going ahead with more sessions or other interventions.

1.5.3 If foster carers, special guardians or adoptive parents do not want to take part in a video feedback programme, offer parental sensitivity and behaviour training as described in recommendation 1.4.5.

Primary school-age children

1.5.4 Consider intensive training and support for foster carers, special guardians and adoptive parents (see recommendations 1.5.5 and 1.5.6) before the placement and for 9–12 months after, combined with group therapeutic play sessions for the child for the same duration (see recommendation 1.5.7).

1.5.5 Ensure intensive training for foster carers, special guardians and adoptive parents includes:

  • positive behavioural management methods

  • help with peer and parent/carer relationships for the child

  • support for schoolwork

  • help to defuse conflict.

1.5.6 Ensure intensive support for foster carers, special guardians and adoptive parents includes:

  • supervision by daily telephone contact

  • weekly support group meetings

  • a 24-hour crisis intervention telephone line.

1.5.7 Ensure group therapeutic play sessions for primary school‑age children after placement:

  • consist of weekly sessions (lasting 60–90 minutes) over the 9–12‑month period

  • are delivered by a trained health or social care professional

  • include monitoring of behavioural, social and developmental progress.

Late primary and early secondary school-age children and young people

1.5.8 Consider a group‑based training and education programme for foster carers, special guardians and adoptive parents to maintain stability in the home and help transition to a new school environment (see recommendation 1.5.9), combined with a group‑based training and education programme for late primary and early secondary school‑age children and young people in the care system, subject to special guardianship orders and adopted from care to improve social skills and maintain positive peer relationships (see recommendation 1.5.10).

1.5.9 Ensure group‑based training and education programmes for foster carers, special guardians and adoptive parents:

  • consist of twice‑weekly sessions (lasting 60–90 minutes) in a group for the first 3 weeks, then weekly sessions over the remaining school year

  • are delivered by a trained facilitator

  • have a behavioural reinforcement system to encourage adaptive behaviours across home, school and community settings

  • provide weekly telephone support if needed

  • give homework to practise applying new skills.

1.5.10 Ensure training and education programmes for late primary and early secondary school‑age children and young people in the care system, subject to special guardianship orders and adopted from care:

  • consist of twice‑weekly sessions (lasting 60–90 minutes) in a group for the first 3 weeks, then individual weekly sessions over the remaining school year

  • are delivered by trained mentors, which may include graduate level workers, at a time that ensures schooling is not disrupted

  • teach skills to help reduce involvement with peers who may encourage misbehaviour, and to increase their levels of self‑confidence

  • encourage them to get involved in a range of educational, social, cultural and recreational activities

  • help them develop a positive outlook.

1.5.11 Modify interventions for young people in the care system, subject to special guardianship orders and adopted from care when needed to allow for:

  • physical and sexual development

  • transition to adolescence

  • re‑awakening of emotions about their birth parents or original family.
    Take into account that these factors can complicate therapeutic interventions and relationships with foster carers, special guardians and adoptive parents. Discuss making contact with their birth parents or original family sensitively.

1.6 Interventions for attachment difficulties in children and young people in residential care

1.6.1 Professionals with expertise in attachment difficulties should:

  • work with the residential staff group and identify any key attachment figures to work specifically with the child or young person in residential care

  • offer parental sensitivity and behaviour training adapted for professional carers in residential care.

1.6.2 Ensure parental sensitivity and behaviour training for professional carers:

  • first consists of a single session with the carers followed by at least 5 (and up to 15) weekly or fortnightly carer–child sessions (lasting 60 minutes) over 6 months

  • is delivered by a trained health or social care professional

  • includes:

    • coaching the residential carers in behavioural management (for children aged 0–18 months) and limit setting

    • reinforcing sensitive responsiveness

    • ways to improve caring quality

    • homework to practise applying new skills.

1.6.3 Modify interventions for young people in residential care when needed to allow for:

  • physical and sexual development

  • transition to adolescence

  • re-awakening of emotions about their birth parents or original family.

    Take into account that these factors can complicate therapeutic interventions and relationships with professional carers. Discuss making contact with their birth parents or original family sensitively.

Terms used in this guideline

Carer

A foster carer, professional carer in residential care, special guardian or kinship carer.

Children

Aged 0–12 years.

Designated teacher

A teacher who must be appointed by the governing body of all maintained schools, as set out in the Children and Young Persons Act 2008, to promote the educational achievement of looked‑after children. Academies, with their funding agreement with the Secretary of State, are also required to appoint a designated teacher for looked‑after children.

Edge of care

This covers children and young people who are considered by social care workers to be at high risk of going into care (for example, because of maltreatment, parental mental health problems or parental substance misuse). This includes those currently living with their birth parents or original family (such as step‑parents), and those adopted from care but who are at high risk of returning to care.

Foster care

The placement of a child or young person with a foster carer, who may or may not be related to the child or young person. This might be an emergency, short‑term or long‑term placement in a private family home.

In the care system

This covers all children and young people looked after by a local authority, including those subject to care orders under section 31 of the Children Act 1989 and those provided with accommodation under section 20.

Kinship care

Care provided by adults who have a relationship with or connection to the child or young person, including grandparents, siblings, aunts, uncles, godparents or step‑grandparents. Kinship care includes children and young people living in an informal arrangement, looked after by the local authority and placed with kinship foster carers, or in an arrangement planned to lead to adoption by a relative or friend.

Looked after

A child is looked after by a local authority if they have been provided with accommodation for a continuous period of more than 24 hours (in the circumstances set out in sections 20 and 21 of the Children Act 1989), or placed in the care of a local authority by virtue of an order made under part 4 of the Act.

Maltreatment

This is physical, sexual or emotional abuse or neglect.

Parent

A birth parent, adoptive parent or step‑parent who has parental responsibility for a child or young person.

Personal adviser

Someone who is responsible, as set out in Children (Leaving Care) (England) Regulations 2001, for making sure that children and young people receive care and support from appropriate services when they leave the care system. They provide advice and support to the child or young person, are involved in preparing a 'pathway plan' (covering health and development, education training and employment, contact with parents, wider family and friends and managing finances), and are responsible for keeping it up to date.

Placement

A home environment, whether in a family or residential setting, which may be temporary or permanent for a child or young person who is either voluntarily, or by order of a court, 'looked after' or placed with a view to adoption by a local authority.

Post-adoption support worker

A social worker or family support worker who is employed by local authorities and other regulated adoption agencies to assess adoption support needs when requested by an adopted child, their adoptive parents or former guardians, and who provides appropriate services if needed.

Residential care

Care provided under the Children Act 1989 in a children's home run by a local authority, voluntary or private provider, where 1 or more children or young people are cared for by a team of employed staff.

Safeguarding

A multi-agency action to protect children from maltreatment, prevent the impairment of their health and development, ensure that they grow up in circumstances consistent with the provision of safe and effective care, and actively enable all children to have the best outcomes.

Special guardianship

Under the Children Act 1989, amended by the Adoption and Children Act 2002, special guardianship is a legally secure placement for children and young people who cannot live with their birth parents that confers parental responsibility on the special guardian.

Virtual school head

An officer who must be appointed by local authorities, as set out in the Children and Families Act 2014, who ensures that the authority properly carries out its duty to promote the educational achievement of its looked‑after children.

Young people

Aged 13–17 years.

You can also see this guideline in the NICE pathway on attachment difficulties in children and young people.

To find out what NICE has said on topics related to this guideline, see our web page on children and young people.



[1] Cicchetti D, Rogosch FA, Toth SL (2006) Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology 18: 623–49 and Toth SL, Maughan A, Manly JT et al. (2002) The relative efficacy of two interventions in altering maltreated preschool children's representational models: implications for attachment theory. Development and Psychopathology 14: 877–908.

  • National Institute for Health and Care Excellence (NICE)