Quality standard


This quality standard covers the identification, assessment and treatment of attachment difficulties. It focusses on children and young people up to age 18:

  • on the edge of care (those considered to be at high risk of going into care)

  • looked after by local authorities in foster homes (including kinship foster care)

  • in special guardianship

  • adopted from care

  • in residential settings and other accommodation.

For more information see the children's attachment topic overview.

Why this quality standard is needed

Attachment is a type of behaviour displayed by children to draw their primary caregiver towards them at moments of need or distress. Children whose caregivers respond sensitively to their needs at times of distress and fear in infancy and early childhood develop secure attachments to them. 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, and self-control. Children and young people who have had insecure attachments are more likely to struggle in these areas and to have 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 may evolve into coercive controlling or compulsive caregiving patterns in children of preschool age or older. The term 'attachment difficulties' in this quality standard 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).

Children and young people in the care system, on the edge of care, or those who have previously been in care are at particular risk of attachment difficulties. The number of children and young people in the care system has risen in recent years. On 31 March 2015, there were approximately 69,540 looked-after children and young people in England[1].

The assessment of patterns of attachment is complex. Attachment is assessed for its quality or pattern, not quantitatively for its intensity. There are also different ways of assessing attachment that are appropriate to different ages on the basis of observed behaviour, representation of attachment relationships and coherence of the child's account of their attachment relationships.

Attachment can also be assessed indirectly by examining the primary caregiver's sensitivity to the child, particularly in response to the child's distress or fear. A significant association has been found between maternal sensitivity and child security of attachment.

Attachment difficulties are typically assessed using structured interviews with carers, and may be supplemented by questionnaires and direct observation of the child or young person's behaviour.

The quality standard is expected to contribute to improvements in the following outcomes:

  • children's social and emotional development

  • children's behavioural functioning

  • quality of parent or carer child relationship

  • wellbeing and quality of life for children and parents or carers

  • mental health problems in children and parents or carers

  • breakdown in fostering placements or adoption

  • youth offending rates

  • educational progress and attainment

  • school absences and exclusions.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – safety, experience and effectiveness of care – for a particular area of health or care. They are derived from high-quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS outcomes framework 2016–17


Overarching indicators and improvement areas

4 Ensuring that people have a positive experience of care

Improving experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Indicator in italics in development

Table 2 Public health outcomes framework for England, 2016–19


Objectives and indicators

1 Improving the wider determinants of health


Improvements against wider factors that affect health and wellbeing and health inequalities


1.02 School readiness

1.03 Pupil absence

1.04 First time entrants to the youth justice system

1.05 16–18 year olds not in education, employment or training

2 Health improvement


People are helped to live healthy lifestyles, make healthy choices and reduce health inequalities


2.05 Child development at 2–2½ years

2.08 Emotional wellbeing of looked-after children

2.23 Self-reported wellbeing

Safety and people's experience of care

Ensuring that care is safe and that people have a positive experience of care is vital in a high-quality service. It is important to consider these factors when planning and delivering services relevant to children's attachment.

Coordinated services

The quality standard for children's attachment specifies that services should be commissioned from and coordinated across all relevant agencies involved in the children's attachment care pathway. A person-centred, integrated approach to providing services is fundamental to delivering high-quality care to children with attachment difficulties.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high-quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high-quality children's attachment service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health, public health and social care practitioners involved in assessing, caring for and treating children with attachment difficulties and their parents and carers should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source on specific types of training for the topic that exceed standard professional training are considered during quality statement development.