Nice | Attachment in children in care or at risk of going into care

This is a new guideline from NICE on trying to avoid and manage attachment problems in children in all sorts of care scenarios.

Most of this will hopefully be implemented by social workers, but we may need to refer patients on. I have also seen several patients who have been in the care system and I think that it is useful to know what is being advised, so that we can check that they have accessed what they are entitled to. Skip the assessment section for a quicker read.

Help should be offered at the first signs of 'serious difficulties', or if there is more than one child with attachment difficulties in the placement.


There are a range of assessment tools that can be used if needed. These are listed in Appendix 1 of the guideline.

ICD 10 criteria for attachment disorders:

  • Reactive attachment disorder of childhood. "Starts in the first five years of life and is characterized by persistent abnormalities in the child's pattern of social relationships that are associated with emotional disturbance and are reactive to changes in environmental circumstances (e.g. fearfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling"
  • Disinhibited attachment disorder of childhood "A particular pattern of abnormal social functioning that arises during the first five years of life and that tends to persist despite marked changes in environmental circumstances, e.g. diffuse, nonselectively focused attachment behaviour, attention-seeking and indiscriminately friendly behaviour, poorly modulated peer interactions; depending on circumstances there may also be associated emotional or behavioural disturbance."

Pre-School Children on the 'edge of care'

This is defined as being children still living with their birth parents who are at high risk of entering or re-entering the care system. It also covers children who have been maltreated or who are at high risk of being maltreated.

Offer a 'video feedback programme' to parents. This covers several sessions which are supervised by a trained social worker or healthcare worker. This includes information on how to nurture their child, how to understand what their child's behaviour means, how to respond positively to their child's cues and how to manage their own feelings among other things. It sounds like this is accessed through the social workers or CAMHS.

If this isn't successful, then offer 'parent sensitivity and behaviour training' . After this a 'home visiting programme' can be considered.

Older children on the 'edge of care'

Consider 'parental sensitivity and behaviour training'.

Be aware that children who have been maltreated may develop PTSD.

Children in care (including adopted children)

Pre-schoolers. Offer a 'video feedback programme' as above first-line.

Primary school children. Consider intensive training before the placement, 9-12m after the placement and group therapeutic play for the child.

Late primary and secondary age children. Consider group based education and training both for the parents and children.

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