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

Use this guideline in conjunction with the NICE guidelines on looked-after children and young people and child maltreatment.

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 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.

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.

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 longer-term care or involvement if needed.

Help arrange kinship placements, if safe and in the best interest of the child or young person. See the Department for Education guidance on information sharing for people who provide safeguarding services to children, young people, parents and carers.

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.

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.

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 1 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.

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).

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.

Ensure safeguarding is maintained during any intervention for a child or young person with attachment difficulties. See the Department for Education and Department of Health and Social Care statutory guidance on the planning, commissioning and delivery of health services for looked-after children.

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.

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

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.

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 to 4 months

• include filming the parents interacting with their child for 10 to 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.

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.

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 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 to 18 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 multi-agency review before going ahead with more interventions.

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.

Ensure home visiting programmes:

• consist of 12 weekly or monthly sessions (lasting 30 to 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.

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.

Ensure parent–child psychotherapy to improve attachment difficulties:

• is based on the Cicchetti et al. (2006) and Toth et al. (2002) model

• consists of weekly sessions (lasting 45 to 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.

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.

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.

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.

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 preschool-age children, arrange a multi-agency 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.

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 to 12 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 or 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 school-age children after placement:

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

• are delivered by a trained health or social care professional

• include monitoring of behavioural, social and developmental progress.

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).

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

• consist of twice-weekly sessions (lasting 60 to 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.

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 to 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.

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.