Attachment Difficulties: NICE NG26 Guide for Care Staff

Attachment difficulties are one of the most important and least understood reasons why some children and young people struggle to trust adults, manage their feelings or form stable relationships. Care and support staff may meet them in children's homes, fostering and adoption support, schools, health services and, later, in the adults those children become. This guide explains what attachment difficulties are, who NICE guideline NG26 is for, and how staff can respond in a way that is sensitive, safe and realistic. It should be read alongside our guide to trauma-informed care in practice, because the two areas overlap closely.

What are attachment difficulties?

Attachment is the bond a child develops with the adults who care for them. When a child has a caregiver who is reliably available and responsive, they usually learn that other people can be trusted and that their feelings can be managed with support. When early caregiving is inconsistent, frightening or absent, a child may develop insecure or disorganised patterns of attachment instead.

The NICE guideline NG26 context explains that the term "attachment difficulties" is used to cover insecure or disorganised attachment patterns, and it also includes the formal diagnoses in the DSM-5 diagnostic manual of reactive attachment disorder and disinhibited social engagement disorder. These are different from the normal range of attachment styles that all children show, and they should only be diagnosed by suitably qualified clinicians.

What causes them?

NICE describes the causes of attachment difficulties as mainly relating to the quality of early caregiving. Examples include repeated changes of carer, neglect and maltreatment. This is why attachment difficulties are particularly relevant to children who have been in care, adopted from care or who are at high risk of entering care. It does not mean that every child with these experiences will have attachment difficulties, and many children recover well with stable, loving care and the right support.

Who does NICE NG26 cover?

NICE guideline NG26 looks at attachment in children and young people who are adopted from care, who are in special guardianship, who are looked after, or who are on the edge of care. It covers two age groups: children aged 0 to 12 and young people aged 13 to 17. The guideline is limited in scope to needs related to attachment, so it sits alongside, rather than replacing, wider safeguarding, mental health and education guidance.

The scale of the issue is significant. NICE's guideline context cited around 69,000 looked-after children in England on 31 March 2014. That figure is now several years old, so staff who need current numbers should check the latest Department for Education statistics on children looked after in England.

How attachment difficulties can look in practice

Children and young people are individuals, and behaviour is communication. Attachment difficulties can show up in different ways, and none of the following is proof of a diagnosis on its own:

• difficulty trusting carers, or testing whether adults will stay or reject them
• strong reactions to separation, changes of routine or changes of staff
• being very wary or withdrawn with adults, or overly friendly with strangers
• difficulty calming down after distress, or intense outbursts that seem out of proportion
• difficulties with friendships and with understanding other people's feelings
• controlling behaviour that may be a way of feeling safe

Because some of these behaviours overlap with trauma, autism, ADHD and other needs, a careful assessment by a clinician is important. Staff should avoid labelling a child as "having attachment disorder" unless a professional has diagnosed it.

What helps: principles for staff

NICE NG26 is a guideline for services, and the detailed recommendations on assessment and intervention are for commissioners and clinicians. Care staff should read the guideline itself for those details. The principles below reflect widely accepted good practice in trauma-informed care and are not a substitute for the guideline.

• Be consistent and reliable. Predictable routines, keeping promises and giving advance notice of changes help a child learn that adults can be depended on.
• Keep staffing as stable as possible. Where a child has a history of repeated carer changes, frequent changes of staff can reopen old wounds. Plan handovers and leavers carefully.
• Respond to the need behind the behaviour. Stay calm, name feelings, and repair the relationship after difficult moments. Punitive responses can confirm a child's belief that adults are not safe.
• Support the carers. Foster carers, adopters and residential staff are doing demanding work. Access to supervision, training and specialist advice helps them to stay emotionally available.
• Work as a team. Share information appropriately between social workers, health professionals, education and carers so that the child has one consistent approach.

Safeguarding and escalation

Any concern that a child is at risk of harm must follow your safeguarding procedures straight away. Our guide to safeguarding children for health and care staff sets out the duties of staff and how to raise concerns. If a child is in immediate danger, call 999. For non-urgent clinical concerns, speak to the child's GP, social worker or local child and adolescent mental health service about a referral.

Frequently asked questions

Are attachment difficulties the same as a diagnosis of reactive attachment disorder?

No. Attachment difficulties is a broader term. Reactive attachment disorder and disinhibited social engagement disorder are specific diagnoses within it, and they need a clinical assessment.

Can children recover from attachment difficulties?

Many children make real progress when they have stable, sensitive caregiving and access to the right support. Progress is often gradual and may be uneven, so patience and consistency matter.

Do attachment difficulties continue into adulthood?

Early experiences can shape how a person relates to others later in life, which is one reason trauma-informed approaches are valuable in adult services too. Every person is different and support should be tailored to them.

Where can staff build their knowledge?

Read the NICE guideline NG26 directly, and use the health and social care learning available through Learnsignal CPD to keep your skills up to date.

This article is general information for care staff, based on NICE guideline NG26 context and good-practice principles, and does not replace the advice of a child's own clinicians or social care team. If you are worried about a child's safety, follow your safeguarding procedures or call 999 in an emergency.