Children's attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care

This guideline covers the identification, assessment and treatment of attachment difficulties in children and young people up to age 18 who are adopted from care, in special guardianship, looked after by local authorities in foster homes (including kinship foster care), residential settings and other accommodation, or on the edge of care. It aims to address the many emotional and psychological needs of children and young people in these situations, including those resulting from maltreatment.

# 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 'offlabel' use).

# Principles of care in all contexts

## Using this guideline
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
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.
Assess all children and young people who enter the UK as unaccompanied asylumseeking 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 asylumseeking children are highly likely to have been traumatised, especially when coming from war zones. If they have posttraumatic stress disorder, offer treatment in line with the NICE guideline on post-traumatic stress disorder.
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.
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
Ensure that, whenever possible, children and young people enter the care system in a planned manner rather than in response to a crisis.
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 longerterm care or involvement if needed.
Help arrange kinship placements, if safe and in the best interest of the child or young person.
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.
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.
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
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 preplacement visit or showing them photographs of their new carers and home)
providing ongoing support during transitions, such as facetoface 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
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.
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.
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
Social care workers should offer children and young people in the care system, in special guardianship or adopted from care, accurate, comprehensive, uptodate and ageappropriate 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).
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
Ensure safeguarding is maintained during any intervention for a child or young person with attachment difficulties.
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
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.

# Supporting children and young people with attachment difficulties in schools and other education settings (including early years)
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.
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.
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.
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.
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.
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.
Schools and other education providers should avoid using permanent and fixedterm school exclusion as far as possible for children and young people in the care system with identified attachment difficulties.

# Assessing attachment difficulties in children and young people in all health and social care settings
Health and social care provider organisations should train key workers, social care workers, personal advisers and postadoption 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 evidencebased interventions for attachment difficulties (see sections 1.4, 1.5 and 1.6).
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 posttraumatic stress disorder), depression, alcohol misuse and emotional dysregulation.
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).
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 12 years
modified versions of the Strange Situation Procedure for children aged 24 years (either the Cassidy Marvin Preschool Attachment Coding System or the Preschool Assessment of Attachment)
Attachment Qsort for children aged 14 years
Manchester Child Attachment Story Task, McArthur Story Stem Battery and Story Stem Attachment Profile for children aged 47 years
Child Attachment Interview for children and young people aged 715 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.
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.
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 (DSM5; reactive attachment disorder and disinhibited social engagement disorder) or the International classification of diseases and related health problems, 10th revision (ICD10; reactive attachment disorder and disinhibited attachment disorder).
Do not offer genetic screening (including measuring specific gene polymorphisms) in children and young people to predict or identify attachment difficulties.
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.

# 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 reentering 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
Health and social care professionals should offer a video feedback programme to the parents of preschoolage 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.
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 34 months
include filming the parents interacting with their child for 1020 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.
If there is little improvement to parental sensitivity or the child's attachment after 10 sessions of a video feedback programme for parents of preschoolage children on the edge of care, arrange a multiagency review before going ahead with more sessions or other interventions.
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.
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 parentchild sessions (lasting 60 minutes) over a 6month period
is delivered by a trained health or social care professional
includes:
coaching the parents in behavioural management (not applicable for children aged 018 months) and limit setting
reinforcing sensitive responsiveness
ways to improve parenting quality
homework to practise applying new skills.
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 multiagency review before going ahead with more interventions.
If the multiagency review concludes that further intervention is appropriate, consider a home visiting programme to improve parenting skills delivered by an appropriatelytrained lay home visitor or a healthcare professional such as a nurse.
Ensure home visiting programmes:
consist of 12 weekly or monthly sessions (lasting 3090 minutes) over an 18month 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 parentchild 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
Consider parentchild psychotherapy for parents who have maltreated or are at risk of maltreating their child to improve attachment difficulties, ensuring that safeguarding concerns are addressed.
Ensure parentchild psychotherapy to improve attachment difficulties:
is based on the Cicchetti and Toth model
consists of weekly sessions (lasting 4560 minutes) over 1 year
is delivered in the parents' home by a therapist trained in the intervention
directly observes the child and the parentchild 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
Consider parental sensitivity and behaviour training for parents of primary and secondary schoolage 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
For children and young people who have been maltreated, and show signs of trauma or posttraumatic stress disorder, offer traumafocused cognitive behavioural therapy, and other interventions in line with the NICE guideline on post-traumatic stress disorder.
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.

# 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
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.
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 preschoolage children, arrange a multiagency review before going ahead with more sessions or other interventions.
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
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 912 months after, combined with group therapeutic play sessions for the child for the same duration (see recommendation 1.5.7).
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.
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.
Ensure group therapeutic play sessions for primary schoolage children after placement:
consist of weekly sessions (lasting 6090 minutes) over the 912month 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
Consider a groupbased 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 groupbased training and education programme for late primary and early secondary schoolage 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).
Ensure groupbased training and education programmes for foster carers, special guardians and adoptive parents:
consist of twiceweekly sessions (lasting 6090 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.
Ensure training and education programmes for late primary and early secondary schoolage children and young people in the care system, subject to special guardianship orders and adopted from care:
consist of twiceweekly sessions (lasting 6090 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 selfconfidence
encourage them to get involved in a range of educational, social, cultural and recreational activities
help them develop a positive outlook.
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
reawakening 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.

# Interventions for attachment difficulties in children and young people in residential care
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
-ffer parental sensitivity and behaviour training adapted for professional carers in residential care.
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 carerchild 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 018 months) and limit setting
reinforcing sensitive responsiveness
ways to improve caring quality
homework to practise applying new skills.
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 012 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 lookedafter children. Academies, with their funding agreement with the Secretary of State, are also required to appoint a designated teacher for lookedafter 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 stepparents), 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, shortterm or longterm 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 stepgrandparents. 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 stepparent 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 lookedafter children.

## Young people
Aged 1317 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.
 Cicchetti D, Rogosch FA, Toth SL (2006) Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology 18: 62349 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: 877908.# Context
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 nonsecurely 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, selfcontrol 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 (DSM5; reactive attachment disorder and disinhibited social engagement disorder) and the International classification of diseases and related health problems, 10th revision (ICD10; 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 lookedafter 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 012 years) and young people (aged 1317 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
-n 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.# Recommendations for research
The Guideline Committee has made the following recommendations for research. The Committee's full set of research recommendations is detailed in the full guideline.

# Screening assessment tools
Develop reliable and valid screening assessment tools for attachment and sensitivity that can be made available and used in routine health, social care and education settings.
Why this is important
Validated attachment and sensitivity tools are needed. They must be sensitive enough to detect children and young people at risk of attachment difficulties and changes in behaviour in response to an attachmentbased intervention.
The window of opportunity to intervene before a child develops attachment difficulties is small, therefore the sensitivity tool should have strong psychometric properties.
Tools are needed for assessing sensitivity and attachment for biological parents and foster or adoptive parents of children and young people across all groups (017 years).
The tool must be readily available and able to be used in routine and social care settings before and after an intervention.
A cohort study is needed to validate any tool (new or existing) that can identify children and young people who have attachment difficulties at different ages. The study should include the following outcomes:
sensitivity and specificity
predictive validity (more than 12 months for outcomes such as behavioural problems and ongoing attachment difficulties).
A cohort study is also needed to validate any tool (new or existing) that can measure the sensitivity of parenting (by biological parents and new carers and adoptive parents) in relation to the child (of any age). The study should include the outcomes listed above.

# Attachment-focused interventions
This research recommendation is composed of 2 parts.
Develop attachmentfocused interventions to treat attachment difficulties in children aged over 5 years and young people who have been adopted or are in the care system.
Develop attachmentbased interventions to promote secure attachment in children and young people who have been, or are at risk of being, maltreated.
Why this is important
Attachment-focused interventions targeting adoptive parents, carers and children and young people are scarce. Most studies have targeted families of children on the edge of care and the evidence suggests some interventions are effective, therefore it is important to know whether similar interventions will work with other populations. Even less evidence is available on children aged over 5 years and young people, therefore attachmentfocused interventions should consider targeting this age group.
There is also limited evidence on attachmentbased interventions targeting attachment difficulties and parental sensitivity in children and young people who have been, or are at risk of being, maltreated. Maltreatment is strongly associated with children entering care. If ways to improve the parentchild relationship and prevent maltreatment can be identified, the likelihood of children and young people entering care and having attachment difficulties can be minimised. Evidence from groups aged 1117 years is limited, therefore ageappropriate interventions targeting this age group are needed.
A randomised controlled trial should be carried out to compare the clinical and cost effectiveness of attachmentfocused interventions to treat attachment difficulties in children aged over 5 years and young people who have been adopted or are in the care system. The intervention (for example, parental sensitivity and education training) should target the adoptive parents and carers with or without the children. Primary outcome measures may include:
attachment
parental sensitivity
placement disruption
educational performance
behavioural problems.
A randomised controlled trial should also be carried out to compare the clinical and cost effectiveness of an attachmentbased intervention to promote secure attachment in children and young people who have been, or are at risk of being, maltreated, with usual care.
The intervention may target the child and/or the parent depending on the type of maltreatment (for example, sexual abuse or neglect).
Primary outcome measures may include the above, as well as ongoing maltreatment.
For both trials, there should be at least a 6month to 1year follow-up. Qualitative data may also be collected on the parents and child's experience of the intervention.

# Evaluation of extensively used interventions
Evaluate currently unevaluated but extensively used interventions for attachment difficulties.
Why this is important
Various interventions are currently used to help address attachment difficulties that may be clinically effective, but without good quality evidence they cannot be considered by NICE.
A randomised controlled trial should be carried out that compares currently unevaluated interventions, such as playtherapy, dyadic developmental psychotherapy, and attachment aware schools program with an evidencebased treatment for attachment difficulties. The interventions should address children in a wide variety of placements and ages.
Primary outcome measures may include:
attachment
parental sensitivity
placement disruption
educational performance
behavioural problems.
There should be at least a 6month to 1year followup. Potential harms also need to be captured. Qualitative data may also be collected on the parents' and child's experience of the intervention.

# Interventions in a school setting
Assess the clinical and cost effectiveness of an attachment-based intervention delivered in a school setting for children and young people on the edge of care, in the care system or adopted.
Why this is important
Providing an attachmentbased intervention in a school setting is important for 3 reasons: teachers may be the first to identify some of the broader problems associated with attachment difficulties in children and young people; school may be one of the only stable environments for children and young people moving in and out of care; and school may provide a safe environment for the child or young person to take part in a therapeutic intervention.
The majority of the evidence to date has been collected in non-UK settings that have different healthcare systems and types of care provided, therefore it is important that more studies are carried out in a relevant UK setting. In addition, evidence on young people is limited, therefore ageappropriate interventions targeting attachment difficulties in this age group are needed.
A randomised controlled trial should be carried out to assess the clinical and cost effectiveness of an attachment-based intervention that can be delivered in a school setting for children and young people on the edge of care, in the care system or adopted, and for the wide range of children in schools who may have attachment difficulties. The intervention should be deliverable by teachers within the school setting, and not disrupt the delivery of the curriculum. It should focus on improving the functioning of children and young people with attachment difficulties within the school setting, as well as more widely, and increasing the skills of teachers to meet the children and young people's needs.
Primary outcome measures may include:
attachment
teacher sensitivity
placement disruption
educational performance
behavioural problems.
There should be at least a 6month to 1year followup. Qualitative data may also be collected on the child or young person's experience of the intervention.

# Relationship between attachment difficulties and complex trauma
This research recommendation is composed of 2 parts:
Assess the prevalence of attachment difficulties (including attachment disorders), complex trauma and the combination of both in children and young people in the care system and on the edge of care.
Investigate the effect of various factors, such as multiple placements, on the likelihood of having attachment difficulties, complex trauma or both.
Why this is important
Little is known about the prevalence of attachment difficulties, complex trauma or both in children and young people in the care system and on the edge of care in the UK. This information is important for understanding the needs of these populations and will highlight how complex trauma can be considered as a potential explanation for a child or young person's behaviour, with or without the diagnosis of attachment difficulties. The effect various factors have on the outcome of attachment difficulties and complex trauma also needs investigating. For example, multiple placements may decrease the risk of a child or young person developing a secure attachment with a primary caregiver. This will provide evidence for minimising placement disruption often experienced by children and young people and the importance of finding a stable, supportive home for those in care.
The study design may be a cross-sectional study of children and young people on the edge of care, in care and adopted from care to ascertain the number of children who have attachment difficulties and/or complex trauma.
In addition, data are collected on potential explanatory factors (for example, multiple placement) for the outcome of attachment difficulties, complex trauma or both.
Primary outcome measures may include:
attachment
carer sensitivity
placement disruption
complex trauma.
A large number of children are needed to attain power to detect a difference and for running a multiple regression analysis. Qualitative data may also be collected on the child or young person's experience in care.# Appendix 1
Tool
Setting
Format
Age (years)
Classification
Insecure attachment
Disorganised attachment
Strange Situation Procedure
Clinic
Observation
Y
Y
CassidyMarvin Preschool Attachment Coding System
Clinic
Observation
Y
Y
Preschool Assessment of Attachment
Clinic
Observation
Y
Y
Attachment Q-sort
Home
Observation
Y
N
Manchester Child Attachment Story Task
Any setting
Interviewerresearcher/clinician
Y
Y
McArthur Story Stem Battery
Any setting
Interviewerresearcher/clinician
Y
Y
Story Stem Attachment Profile
Any setting
Interviewerresearcher/clinician
Y
Y
Child Attachment Interview
Any setting
Interviewerresearcher/clinician
Y
Y
Adult Attachment Interview
Any setting
Interviewerresearcher/clinician
- and parents or carers
Y
Y
ISBN: 978-1-4731-1531-6