This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Healthy attachments (or bonds) between a child and their caregivers promote positive social and emotional development. Children whose caregivers are consistent and responsive tend to develop secure attachments. But those who have had a difficult upbringing, and experienced abuse or neglect for example, may experience severe attachment problems. Services offer a range of interventions to strengthen children’s relationship with their caregivers and improve attachment.
New research explored the strength of evidence for the attachment interventions in use for children. Researchers asked services which interventions they use most often, and then searched for evidence to support their use. 734 services from across the UK responded.
The study identified interventions with a strong evidence base, but these were not widely used. It also found that the more commonly used interventions had a limited evidence base. This does not mean they are ineffective but there is an urgent need to evaluate them.
The findings provide information for child mental health researchers and commissioners on the evidence base for child attachment interventions.
The issue: how strong is the evidence for interventions to improve child attachment?
Secure attachment is linked with consistent and responsive parenting. It promotes positive social and emotional development.
If parenting is inconsistent, neglectful or abusive, children may develop attachment problems. Some severe attachment problems (such as disorganised attachment or attachment disorders) have been associated with poor development (such as delayed speech), emotional and behavioural problems, and mental ill-health later in life (such as personality disorders).
Many interventions have been developed to promote secure attachments through improving the quality of care parents provide. Caregivers might be given feedback on their parenting, for example. Such interventions need to be tested to be sure they are helpful.
This study investigated which interventions are being used in the UK and assessed what evidence supports them. It explored practitioners’ views of attachment difficulties.
The researchers carried out a survey to identify the 10 most commonly used attachment interventions (for children aged 0 – 13) in the UK. The survey covered 734 services across all four nations (including child mental health services, local authorities, and the voluntary sector). Most responses were from England.
Many services did not use gold standard measures to assess attachment outcomes (such as the Strange Situation Procedure or Attachment Q-Sort). The definitions of attachment used by practitioners also varied widely. Researchers identified the top 10 commonly used attachment interventions from survey responses, then searched for evidence to support them. They analysed 61 papers. Interventions were ranked according to the strength of evidence supporting them.
The strongest evidence base
The evidence for the following 4 interventions was mixed but generally positive. Each was supported by 8 – 17 high-quality studies (multiple randomised controlled trials). These 4 interventions had the best evidence to support them, but were the least used (of the top 10 commonly used interventions), as reported by survey respondents.
- Video Feedback Intervention to Promote Positive Parenting: a professional records a child’s behaviour and interactions at home, and provides feedback on the parent’s interactions with the child, focusing on positive moments in which the parent responded to the child’s attachment signals, communications or needs.
- Attachment and Biobehavioural Catch-up: at home, a professional advises parents on how to promote their child’s healthy attachment, and provides live feedback on the parent’s interactions with their child.
- Circle of Security: training and resources (such as videos and information packs) for parents on attachment and parenting, usually delivered in a group format; professionals also support parents in recognising how their own experience of growing up affects their parenting.
- Parent–Infant Psychotherapy: a caregiver and child (under 2) visit a therapist who helps the caregiver work through psychological, emotional and relationship issues that could impact their caregiving and their child’s attachment to them.
Intermediate evidence base
Both of these interventions were supported by a small number (3 – 6) of mixed quality studies (randomised and non-randomised controlled trials and case studies). Findings were generally positive. They were used less often (5th and 6th most widely used).
- Child–Parent Psychotherapy: therapy for children (from birth to age 5) and their caregivers, to strengthen relationships and help families move on from negative experiences.
- Video Interaction Guidance: a professional records an interaction that caregivers are struggling with and advises on how they could improve their and their child’s behaviour. This approach is similar to the video feedback intervention described above, but is less structured and not explicitly about attachment.
Weak evidence base
These interventions were each supported by 1 – 2 low-quality studies (non-randomised trials and case series); Individual Child Psychotherapy was not supported by any studies that met the inclusion criteria. The findings were mixed. They were the most commonly used interventions (except for Watch, Wait, and Wonder, which was 8th most common intervention).
- Dyadic Developmental Psychotherapy: a talking therapy for children that examines past experiences.
- Watch, Wait, and Wonder: a professional watches a child and caregiver at play and encourages the caregiver to reflect on what the child is thinking and feeling.
- Theraplay: builds caregiver-child relationships through play, under the supervision of a professional.
- Individual Child Psychotherapy: therapeutic approaches for children which do not specifically focus on attachment.
Why is this important?
NICE guidelines recommend that caregivers of children with (or at risk of) severe attachment problems are offered an evidence-based intervention to support their caregiving. These findings suggest that practice is not following research. Equally, research does not reflect current practice, and commonly used interventions have not been evaluated in rigorous research.
The interventions with the strongest evidence base were used least of the top 10 interventions. Commissioners may consider whether these interventions could be more widely adopted.
By contrast, the most common interventions had the weakest evidence base of the top 10 interventions. This does not mean that they are ineffective, but that there is limited evidence to support their use. The researchers call for high-quality research on these interventions to make sure they are appropriate and effective.
Some interventions (such as Parent–Infant Psychotherapy and Child–Parent Psychotherapy) may overlap.
The researchers recommend better links between research and practice to ensure families receive effective and safe interventions. Researchers and practitioners could co-develop guidelines for practice, for example. The researchers also call for improved understanding of attachment difficulties, to ensure consistent and appropriate terminology and approaches to assessment.
Commissioners and managers who organise and pay for services need to be aware of the latest research on effective treatments. At the same time, practitioners need extra training to be able to offer different interventions. Workshops with experts and members of the public revealed that the cost and accessibility of training could prevent practice from following evidence.
Research on the most widely-used interventions is urgently needed, the authors say. High-quality research, based on an agreed definition of attachment, would improve practitioner reports, treatment recommendations, and the quality of interventions. Studies that measure gold-standard outcomes (rather than the variety in many studies analysed) are needed.
You may be interested to read
This Alert is based on: Wright B, and others. Routinely used interventions to improve attachment in infants and young children: a national survey and two systematic reviews. Health and Technology Assessment 2023; 27: 1 – 256.
Resources and support from Attachment Parenting UK.
Information about attachment and child development from the NSPCC.
Advice on promoting secure attachment from the NHS.
Society for Emotion and Attachment Studies information on the use of attachment terminology.
An NIHR article about a new toolkit to support services aiming to improve parent-child relationships.
Funding: this study was funded by the NIHR Health and Technology Assessment programme.
Conflicts of Interest: none declared.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.