Children and Youth Services Review 156 (2024) 107265

Contents lists available at ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Care practices and approaches with children experiencing attachment

difficulties: A scoping review
Lalita Kaur 1, Lauranne Gendron-Cloutier 2, Marjorie Montreuil 3, *
Ingram School of Nursing, McGill University, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Attachment difficulties in children are linked to negative outcomes including psychiatric disorders, low self-
Children esteem, and socioemotional difficulties. A scoping review was performed to identify evidence-informed care
Attachment disorders practices and approaches healthcare providers can employ when caring for children with attachment difficulties.
Care practices
Twenty articles were included. Beneficial approaches include: increasing care providers’ knowledge of attach­
Clinical interventions
Review
ment theories; fostering a better understanding of children’s needs; limiting the use of behaviour-modification
approaches; implementing clinical and organizational practices drawing from attachment theory that avoid re­
straint use; and adopting attitudes that promote healthy attachment. Ethical considerations raised by these
practices are discussed.

1. Introduction Bakermans-Kranenburg & van Ijzendoorn, 2008; Schofield & Beek,

2006).
Attachment theory posits that secure caregiving relationships are Different attachment patterns – in terms of security and insecurity –
crucial to the social and emotional development of children (Bowlby, emerge in the context of diverse caregiving experiences (Wright et al.,
1969; Wright et al., 2015). Infants develop secure attachments when 2015). The type of caregiving children receive greatly influences the
they consistently receive caregiving that is responsive sensitively to likelihood of developing a sense of security (Schofield & Beek, 2006).
their needs, including availability, accessibility, and flexibility (National Insecure forms of attachment – avoidant, ambivalent, disorganised – arise
Institute for Health and Care Excellence, 2015; Schofield & Beek, 2006). when caregiving does not respond sensitively to children’s socioemo­
Secure caregiving relationships promote a sense of security for children, tional needs by being rejecting, inconsistent and unpredictable, or
allowing them to safely explore their environment and learn how to cope frightening or frightened (Schofield & Beek, 2006; Turner et al., 2019).
with the challenges and anxieties they encounter, as well as help develop Insensitive and unresponsive parenting can lead to the development of
thinking and reflective skills (National Institute for Health and Care negative working models in children, resulting in children approaching
Excellence, 2015; Schofield & Beek, 2006; Wright et al., 2015). They social situations with avoidance, mistrust, anger, confliction, which may
support infants and young children in developing a sense of self and lead to externalizing issues such as oppositional behavior and reactive
others that help them navigate future relationships (National Institute aggression (Juffer, Bakermans-Kranenburg & van Ijzendoorn, 2008;
for Health and Care Excellence, 2015; Wright et al., 2015). Bowlby Schofield & Beek, 2006; Turner et al., 2019).
referred to this as the internal working model – a cognitive-affective Attachment disorders are a diagnosable psychopathology by the ICD-
representation of self, others, and relationships, which serves as a 10/11 and DSM-5 as ‘reactive’ and ‘disinhibited’ attachment disorders/
framework for expectations, beliefs, and responses, in order to become disinhibited social engagement disorder (RAD and DAD/DSED) (Amer­
autonomous, independent, and successful outside the family (Juffer, ican Psychiatric Association, 2022; International Classification of

* Corresponding author at: Marjorie Montreuil, 680 Sherbrooke Street West, Montreal H3A 2M7, Canada.
E-mail addresses: [email protected] (L. Kaur), [email protected] (L. Gendron-Cloutier), [email protected] (M. Montreuil).
1
Lalita Kaur, RN, MSc, Research Assistant, Ingram School of Nursing, McGill University, Montreal, Quebec, 680 Sherbrooke West, Montreal, QC H3A 2M7, Canada.
2
Lauranne Gendron-Cloutier, BA Psy, student PsyD, Research Assistant, Ingram School of Nursing, McGill University, Montreal, Quebec, 680 Sherbrooke West,
Montreal, QC H3A 2M7, Canada.
3
Marjorie Montreuil, RN, PhD, Assistant Professor, Ingram School of Nursing, McGill University, Montreal, Quebec, 680 Sherbrooke West, Montreal, QC H3A 2M7,
Canada.

https://doi.org/10.1016/j.childyouth.2023.107265
Received 17 May 2022; Received in revised form 31 July 2023; Accepted 22 October 2023
Available online 4 November 2023
0190-7409/© 2023 Published by Elsevier Ltd.
L. Kaur et al. Children and Youth Services Review 156 (2024) 107265

Diseases, 2023; Maercker & Eberle, 2022). Both disorders emerge under informed approaches should care providers employ when caring for
comparable risk conditions, characterized by early experiences, which children with attachment difficulties?
may include social neglect, frequent caregiver changes, or deprivation
often encountered in institutional settings (extreme insufficient care), 2. Methods
that hinder the child’s capacity to establish selective attachments
(Zeanah et al., 2016). However, the disorders diverge in terms of phe­ 2.1. Study design
nomenology, course, and vulnerability factors (Zeanah et al., 2016).
RAD is marked by significantly inhibited attachment patterns. The child This scoping review was guided by Arksey & O’Malley’s framework
exhibits minimal preference for an attachment figure to seek or respond (Levac et al., 2010; Tricco et al., 2018). This framework was used to
to comfort, support, protection, or nurturance – even when a caregiver is locate, critically appraise, and synthesize studies presenting and exam­
available. They display social unresponsiveness and struggle with ining evidence-informed approaches and practices for care providers
emotion regulation (American Psychiatric Association, 2022; Interna­ working with children who have attachment difficulties, including ex­
tional Classification of Diseases, 2023; Maercker & Eberle, 2022; Zeanah amples of desirable and poor practices. Since care providers are called to
et al., 2016). DAD/DSED involves any two of indiscriminately work collaboratively in child settings, the different and varied care
approaching and interacting with unfamiliar adults, unusual overly practices and approaches were mapped through an interdisciplinary
familiar verbal or physical behaviour, venturing away with an adult lens. As such, articles from multiple methodological approaches were
caregiver with diminished or absent checking back, or being willing to included to offer a more thorough view of the available literature on the
leave with an unfamiliar adult with little or no hesitation (American topic, including studies on both the experiences and outcomes of
Psychiatric Association, 2022; International Classification of Diseases, different approaches. A scoping review framework was selected as it best
2023; Maercker & Eberle, 2022; Zeanah et al., 2016). DAD/DSED has enabled the authors to consider the breadth of the question, through the
been found to be relatively rare, occurring mainly in a small proportion inclusion of various disciplinary perspectives and types of publications.
of children who have experienced extreme inadequate care (Maercker & This review seeks to better support healthcare providers and
Eberle, 2022; Zeanah et al., 2016). A critical difference between community-based workers in caring for children who manifest issues
attachment patterns and disorders is that insecure attachment is related to attachment.
relationship-specific, and attachment disorders either are not related to
the central construct of attachment or extends beyond attachment re­ 3. Search procedures
lationships across various care-giving relationships (Tuner et al., 2019;
Wright et al., 2015). Seven databases were searched (CINAHL, Cochrane, CBCA, Clinical
Children who have experienced abuse, neglect, or foster care are at a Key, ERIC, PsycInfo, and Scopus). Key search terms included: (Reactive
significant risk for developing attachment disorders (Kay & Green, 2013; Attachment Disorder OR attachment OR (disorder* or reactive) adj2
Lehmann et al., 2013; Minnis et al., 2013; Turner et al., 2019; Zeanah & attach*) AND (psycholog* OR mental health) AND (child* OR p?ediat­
Gleason, 2015). Its prevalence is estimated to be 19.4 % in children ric*) AND (approach* OR care* Or practice*). Full list of search terms
living in foster care (Lehmann et al., 2013) and as high as 40 % in are included in the online supplementary material.
maltreated young children in foster care (Zeanah et al., 2004), compared Inclusion Criteria and Screening Process.
to 1.4 % for children living in the general population (Minnis et al., A two-step screening process was applied. First, studies were
2013). Literature indicates that children with insecure attachment have screened by title and abstract. They were included if: 1) participants
lower levels of social competence and that children with attachment consisted of children or adolescents (4 to 17 years); 2) were related to
disorders are more likely to develop low self-concept, cognitive and care approaches and practices with children who have attachment dif­
socioemotional difficulties, and other psychiatric disorders that persist ficulties; 3) presented approaches and practices that could be imple­
in childhood and adulthood (Groh et al., 2017; Pritchett et al., 2013; mented by care providers, rather than medical treatment or approaches
Vacaru et al., 2018; Zeanah et al., 2016). Around half of children with employed by parents; 4) were published after 1988, to focus on the last
RAD are estimated to also have a diagnosis of attention-deficit hyper­ 30 years; and 5) were in English or French. Rayyan, a web-based
activity disorder (ADHD), which leads to additional challenges for them application for systematic reviews (Ouzzani et al., 2016), was used by
and their families (Pritchett et al., 2013). This review uses NICE’s um­ two research assistants to independently screen each abstract. A third
brella term ‘attachment difficulties’, a term used to include insecure reviewer was consulted to settle any disagreement regarding inclusion
attachment behaviours and/or diagnosed attachment disorders (Na­ or exclusion of a document. Next, full-text screening of the identified
tional Institute for Health and Care Excellence, 2015; Turner et al., records (n = 105) was undertaken independently by two research as­
2019) to help guide healthcare providers working with children expe­ sistants, with disagreements settled by a third research assistant (see
riencing these different attachment difficulties. Research shows that Fig. 1).
children can have either or both types (Pritchett et al., 2013).
Currently, the literature on effective approaches when caring for 4. Data extraction and analysis
children with attachment difficulties focuses on infants and young
children (Hoffman et al., 2006; Spieker et al., 2012; Zeanah et al., 2016). An in-depth analysis of all included articles was conducted. Data was
This is important but also limited since attachment disorders are known extracted based on the age range of the studied population, whether they
to persist in childhood and adulthood, and little is known about how were empirical or conceptual, the type of care context, and the way in
they manifest, and what approaches are most effective with older age which qualified attachment was defined in each study. Data related to
groups (Kay & Green, 2013; Zeanah & Gleason, 2015; Wright et al., the implemented practices and approaches were extracted in an Excel
2015). Moreover, much of the literature focuses on the psychiatric table, followed by the data related to the implementation process of
management of diagnosed attachment disorders (Zeanah et al., 2016), these approaches. The care provider and children’s experiences of these
with little to no guidance on interventions that other childcare workers approaches were extracted when available. The outcomes of these ap­
can employ, including with children who have no formal diagnosis. proaches were extracted, namely their clinical and ethical benefits, el­
Considering the prevalence and comorbidities associated with attach­ ements that hindered their implementation process, and their direct and
ment difficulties, care providers and community-based workers within indirect outcomes. The approaches were categorized to highlight the
child settings must implement effective strategies to improve the iden­ main types of beneficial and detrimental approaches, to be able to
tification and support offered to children in their care. In this context, compare them across care contexts and age groups.
the goal of this scoping review is to answer the question: What evidence-

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L. Kaur et al. Children and Youth Services Review 156 (2024) 107265

Fig. 1. PRISMA flow diagram.

5. Results in the articles was broad, including childhood (15), adolescence (4), and
adolescence and childhood combined (1). The settings of most of the
A total of 20 articles were included in the scoping review. Three articles were schools (9), followed by residential care treatment facilities
themes were identified to classify the approaches found in the reviewed (5), community-based settings with social workers or childcare workers
articles, namely (1) knowledge of attachment theories, (2) clinical and (3) and unspecified settings that involved care offered to children who
organizational practices, and (3) attitudes. A brief description of the are in foster care or have a history of abuse or maltreatment (3). A table
results is presented first, followed by an in-depth exploration of these summarizing the study characteristics is included in the online supple­
three categories. mentary material (Table 1).

5.1. Descriptive overview 5.2. The concept of attachment theory

Most articles were from the United States (7) and the United All articles referred to Bowlby’s Theory of Attachment and its prin­
Kingdom (6), while the rest were from Canada, Belgium, Australia and ciples, which posits that children need a secure attachment with their
the Netherlands (6). One article was from both the United States and primary caregivers to develop adequate socioemotional capacities
Canada. (Bowlby, 1969; Moore et al., 1997; Moses, 2000; Pearce & Pezzot-
Around a quarter of the included articles were conceptual (7), while Pearce, 1994; Wilkerson et al., 2008; Yu et al., 2019). However, not
over half of the studies were empirical (13). Of the empirical studies, a all of the reviewed articles explicitly defined secure attachments. For
third were case studies (5), and there were three quantitative, three this review, a secure attachment is broadly defined as a relationship
qualitative and two mixed-method studies. The age range of the children within which children’s socioemotional needs are consistently fulfilled.

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Most articles specified that children develop attachment difficulties making decisions related to what is in children’s best interests (Aprile
when they experience a lack of or a disruption in secure caregiving, et al., 2015; Hardy, 2007; Ryan, 2004). Three articles recommended that
which manifest as behavioural, emotional, and cognitive challenges the organizations’ therapist or psychologist assume an educational role
(Andrew et al., 2014; Aprile et al., 2015; Chaffin et al., 2006; Howe & by offering one-to-one consultations, workshops, and educational ma­
Fearnley, 2003; Moore et al., 1997). Authors varied in how they defined terial to increase literacy on attachment theory across organizations
attachment difficulties. Most included children who did not necessarily (Ryan, 2004; Schwartz & Davis, 2006; Spilt et al., 2016). However, upon
have a formal diagnosis (Chaffin et al., 2006; Ryan, 2004; Schofield, & better understanding the issues of children with attachment difficulties,
Brown. , 1999). All articles highlighted that the main goal of care ap­ care providers may experience significant distress when they recognize
proaches and practices are to foster a healthy attachment with care that these children require more support than what is available,
providers. For the purposes of this review, care providers include nurses, considering the limitations of their roles and available resources (Ryan,
childcare workers, teachers, social workers, clinicians, and other staff 2004).
members who participate in daily child caregiving activities outside of a
familial context. 6.2. Clinical and organizational practices

6. Approaches This category includes clinical and organizational practices that can
be readily implemented in childcare settings. From the studies, three
6.1. Knowledge of attachment theories main approaches were identified, notably (a) having few care providers
per child, (b) promoting predictability and stability, and (c) shift in
The first theme identified is Knowledge of attachment theories, which organizational and clinical practices including the removal of restraints.
informs the other two categories, clinical and organizational practices and Having Few Care Providers per Child. A few articles highlighted the
attitudes. More specifically, care providers should be given the oppor­ issue of children with attachment difficulties being assigned too many
tunity to gain knowledge of attachment theories to inform their prac­ care providers (Aprile et al., 2015; Hardy, 2007; Moses, 2000). Assign­
tices with the children they care for. ing children to multiple care providers led to a lack of time and resources
There was a consensus across all the reviewed articles that in prac­ necessary to provide individualized care and socioemotional support,
tice, care providers and treatment programs typically focus on which, in turn led care providers to resort to behavioural methods of
behaviour-modification approaches, which were all considered inef­ control and punishment (Aprile et al., 2015; Moses, 2000). Moreover, in
fective in caring for children with attachment difficulties (Andrew et al., a residential care facility, Aprile et al. (2015) reported that it also
2014; Aprile et al., 2015; Hardy, 2007; Moses, 2000). A few articles contributed to a general climate of crisis in the setting, which led to an
provided examples of behaviour-modification approaches typically increased use of restraints.
employed with children who have attachment difficulties, including Three studies conducted in residential care facilities suggested that
point systems progressively enforced through rewards and punishments, children be assigned to one primary care provider (Aprile et al., 2015;
physical restraints, forced confinement and seclusion, and drug regi­ Hardy, 2007; Moore et al., 1997). Hardy (2007) explained that the
mens (Hardy, 2007; Moore et al., 1997). A few articles explained that assignment of a primary care provider encourages the formation of an
these approaches are employed to address children’s behaviours that are attachment relationship, as children with attachment difficulties require
typically regarded as problematic by programs and care providers a minimum of several years in the same location with the same care
(Andrew et al., 2014; Chaffin et al., 2006; Moses, 2000). Examples of providers to show significant improvements. Moore et al. (1997) found
these behaviours included refusing to speak, being aggressive towards that, in comparison to a shared responsibility setting, having a primary
others, destroying equipment, appearing to be manipulative and unre­ care provider was beneficial, as when challenges arise, care providers
sponsive, being emotionally guarded, and displaying unpredictable be­ were empowered to be more creative and flexible in finding alternative
haviours (Andrew et al., 2014; Chaffin et al., 2006; Moses, 2000). Moore approaches. They described that when children were assigned to a
et al. (1997) argued that such approaches are, at best, ineffective and, at specific care provider, it became more difficult for care providers to
worst, detrimental to the well-being of children with attachment diffi­ overlook children’s socioemotional needs, which led them to be more
culties. Behavioural-based approaches were considered to be ineffective accountable and sensitive to children’s unique needs.
because the behaviours they aim to counter are understood to be man­ Promoting Predictability and Stability. Most of the reviewed articles
ifestations of children’s attachment difficulties (Hardy, 2007; Howe & emphasized the importance of stability and predictability for children
Fearnley, 2003; Moore et al., 1997). Thus, these articles highlighted that with attachment difficulties. As per some of the reviewed articles, pro­
care providers should look beyond the presenting behaviours and learn moting predictability and stability counteracts the belief that care pro­
to employ attachment-based approaches that are geared towards viders are inconsistent, and provides children with a secure environment
resolving the underlying issues. Knowledge of attachment theories was from which they can explore and engage in activities and interactions
found to dispel false beliefs that are used to justify the employment of more confidently (Aprile et al., 2015; Pearce & Pezzot-Pearce, 1994;
coercive, ineffective, and controlling treatment (Chaffin et al., 2006; Schwartz & Davis, 2006; Wilkerson et al., 2008).
Moore et al., 1997) and improve the identification of attachment diffi­ Three areas in which stability and predictability should be promoted
culties and subsequent referrals to appropriate services (Wilkerson et al., were identified: (1) in children’s daily environment and schedule (Aprile
2008). et al., 2015; Pearce & Peazzot-Pearce, 1994; Schwartz & Davis, 2006;
Many articles explicitly or implicitly explained that increasing Ubha & Cahill, 2014; Webber, 2017; Wilkerson et al., 2008); (2) be­
knowledge of attachment theories among care providers improves the tween children’s different environments and care providers (Shaw and
uptake of attachment-based strategies (Hardy, 2007; Moore et al., 1997; Páez, 2007; Webber, 2017); and (3) in program expectations of children
Ryan, 2004). Roughly half of the articles recommended increasing when standardized approaches are used (Hulme & Cormish, 2015; Ryan,
knowledge by educating youth and care providers on attachment theory 2004). The interventions to promote stability and predictability in the
and difficulties (Hardy, 2007; Howe & Fearnley, 2003; Ryan, 2004; three previously mentioned areas are presented briefly here.
Shaw & Páez, 2007; Webber, 2017). Only one of the reviewed articles For children’s daily environment and schedule, stability and pre­
specified the importance of educating children in helping them under­ dictability were promoted by rigorously following a consistent daily
stand and overcome their own behaviours (Howe & Fearnley, 2003). routine (Aprile et al., 2015; Hulme & Cornish, 2015; Pearce & Peazzot-
A few articles highlighted the importance of sharing this knowledge Pearce, 1994), incorporating greeting or playing rituals (Pearce &
throughout organizations, otherwise conflicting views can lead care Peazzot-Pearce, 1994) and preparing children for any changes to their
providers to experience significant interprofessional conflict when schedule or environment so that they may anticipate, as much as

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possible, every element of their day (Schwartz & Davis, 2006; Wilkerson children who have attachment difficulties (Andrew et al., 2014; Aprile
et al., 2008). In school settings, Wilkerson et al. (2008) also raised the et al., 2015; Hardy, 2007; Moore et al., 1997; Moses, 2000; Pearce &
importance of increasing time awareness and perception in children Pezzot-Pearce, 1994; Ryan, 2004; Schofield, & Brown. , 1999; Schuengel
with attachment difficulties by using a “build the month” calendar, & van Ijzendoorn, 2001; Schwartz & Davis, 2006; Spilt et al., 2018; Spilt
starting the day by going over the daily schedule, sequencing all in­ et al., 2016; Ubha & Cahill, 2014; Yu et al., 2019). We categorized the
structions into actionable steps and using a teaching clock to indicate the sub-themes into six patterns of attitudes: (a) promoting emotional
ending time of activities. closeness, (b) individualizing care approaches, (c) maintaining a
Articles highlighted that similar approaches and goals should be mindful practice, (d) focusing on positive characteristics and abilities,
implemented across care providers to promote consistency in the child’s (e) offering unconditional emotional support, and (f) having realistic
environment (Shaw and Páez, 2007; Webber, 2017). In a school setting, expectations. When possible, we expanded on interventions and ap­
Webber (2017) found that the experience of transitions to superior proaches highlighted in articles to promote these attitudes.
grades in children with attachment difficulties was improved when a
child’s previous teacher provided support and advice to their subsequent 6.4. Promoting emotional closeness
teacher. Many articles also highlighted the importance of collaborating
with care providers in children’s home environments to promote more Across different age groups and settings, the importance of promot­
sustainable changes (Hardy, 2007; Moore et al., 1997; Schofield, & ing emotional closeness between children and their care providers was
Brown., 1999; Shaw & Páez, 2007; Webber, 2017). underscored as the basis for developing attachment relationships
A few articles also suggested to incorporate individualized ap­ (Andrew et al., 2014; Hardy, 2007; Moore et al., 1997; Moses, 2000;
proaches in terms of rules and consequences within standardized ap­ Schofield, & Brown. , 1999; Yu et al., 2019). Andrew et al. (2014)
proaches (Hulme & Cornish, 2015; Moses, 2000). For example, Moses mention that approaches promoting emotional closeness are important
(2000) suggested a two-tiered approach whereby a universal set of rules because they allow care providers to “communicate and demonstrate to
is initially used to allow children to socialize into the care environment young people that they are in [their] minds, that [they] will offer sup­
while allowing staff to familiarize themselves with each child, followed port when [children] need it and this serves, with time, to disconfirm
by the incorporation of individualized approaches (Hulme & Cornish, their firmly held belief that others cannot be relied upon” (Andrew et al.,
2015; Moses, 2000). 2014). This led children to experience a greater connection with their
Shift in Organizational and Clinical Practices Including the Removal of care providers (Andrew et al., 2014). Yu et al. (2019) support that
Restraints. Certain authors supported the removal of restraint practices children with attachment difficulties have specific socioemotional needs
(Chaffin et al., 2006; Howe & Fearnley, 2003; Moore et al., 1997). Re­ in comparison to children with “normal” attachment patterns, and thus
straint practices are defined as physical coercion, restraint, or domina­ require caregiving that is sensitive to their socioemotional needs. When
tion, or physical or psychological enforced holding (Chaffin et al., 2006). they received emotional support in their relationships, children with
Chaffin et al. (2006) posited that the use of physical restraints must only attachment difficulties reported a “greater sense of well-being” and
be limited to situations of crisis when restraints are deemed necessary “feeling more included and capable of overcoming challenges” (Yu et al.,
for physical safety, as there is an absence of proven benefit and a risk of 2019).
harm with the use of restraint practices. In the reviewed articles, examples of methods that promoted
To address the overuse of restraint practices, Moore et al. (1997) emotional closeness included sending birthday cards, offering telephone
suggested that institutions increase care providers’ knowledge on coaching, sending text messages of encouragement or acknowledge­
attachment difficulties and implement attachment-based practices. ment, buying small gifts, offering flexible appointment times, and being
These authors found this led to the removal of physical restraints and available outside clinical sessions on an as-needed basis (Andrew et al.,
locked doors of seclusion rooms, disarming of automatically locking 2014; Schofield, & Brown. , 1999). Andrew et al. (2014) also highlighted
doors, opening of staff offices to youth, and promoted the establishment the importance of a process they call “intersubjectivity,” whereby care
of trusting relationships with children. In turn, these changes led to a providers are to “[join] a child or adult in his experience, [experience] it
marked reduction of “damage to property, threats of violence or self- with him, [match] his affective state and [explore] the experience of it
harm, as well as injuries to staff or youth” (Moore et al., 1997). Fewer with him to make better sense of it” (p. − 508). In this “self-disclosing”
injuries also led to a decrease in staff absences and turnover (Moore practice, care providers allow themselves to be affected emotionally by
et al., 1997). the young persons, whether it is positively or negatively, and to share
A few articles highlighted the importance of implementing appro­ these feelings with the children they care for. Remaining professionally
priate limits/boundaries that do not involve restraints or coercion for distant can oftentimes lead them to be perceived as being cold and de­
actions considered unsafe or challenging (e.g., the use of drug or alcohol, tached (Andrew et al., 2014). This self-disclosing practice was also found
stealing, having intense emotional dysregulation, or refusing to speak to be promoted through non-verbal communication by adjusting one’s
during meetings) (Andrew et al., 2014; Chaffin et al., 2006; Pearce & tone, body language, facial expression and eye contact (Andrew et al.,
Pezzot-Pearce, 1994; Shaw and Páez, 2007). When children display 2014).
unsafe or challenging behaviours, care providers can set appropriate Moses (2000) also found that care providers can hold negative biases
limits by voicing their feelings of disproval and sharing their in­ towards children who appear not to be as receptive or appreciative of
terpretations of children’s behaviours. They explained that these limits the care providers efforts or who appear to manipulate the flexibility
“teach children more adaptive ways of handling their anger, such as they’ve been granted. As a result, care providers might relegate these
verbalizing their feelings,” thus increasing children’s capacity to have children to the back of their list and be more emotionally distant (Moses,
control over the situation (Pearce & Pezzot-Pearce, 1994). They added 2000). This was found to be highly problematic because these children
that care providers must set limits while also empathizing with children are oftentimes the most in need of sensitive caregiving and less likely to
and reinforcing that they will not abandon them, which helps disprove receive such type of caregiving, since caregivers may hold negative
children’s expectations of rejection from care providers (Chaffin et al., biases towards them (Moses, 2000). Thus, measures need to be taken to
2006; Pearce & Pezzot-Pearce, 1994). ensure that emotional closeness is promoted equitably.

6.3. Attitudes 6.5. Individualizing care approaches

Most of the reviewed articles underline a wide range of attitudes and Individualization of care approaches was brought up in nearly half of
characteristics that care providers should embody when interacting with the reviewed articles (Aprile et al., 2015; Hardy, 2007; Moore et al.,

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1997; Moses, 2000; Ryan, 2004; Schuengel & van Ijzendoorn, 2001; manner (Andrew et al., 2014; Hardy, 2007; Pearce & Pezzot-Pearce,
Schwartz & Davis, 2006; Spilt et al., 2018; Spilt et al., 2016; Yu et al., 1994). Andrew et al. (2014) suggested regular mindfulness meetings
2019). Articles varied in how they defined this approach. Moses (2000) and periods of personal reflection for staff members to reflect on how
described that care providers should acknowledge and understand that a they are relating to young people, whereby care providers are encour­
particular child’s needs are specific to them and therefore negotiate or aged to express their judgments while other team members provide
accommodate their care approach to meet these needs. Most articles alternative perspectives.
implied that children’s needs are determined by care providers. One
study, by Schofield and Brown (1999), suggested that rather than
imposing approaches on children, care providers and children should 6.7. Focusing on positive characteristics and abilities
collaboratively explore their needs and what they found helpful.
A few articles mentioned concrete ways to achieve individualization Another effective practice to address care provider bias, which was
of care (Moore et al., 1997; Moses, 2000; Spilt et al., 2018; Spilt et al., highlighted by a few articles—especially in adolescent pop­
2016). Moses (2000) highlighted that care providers must proactively ulations—was to intentionally focus on youths’ strengths, positive be­
seek to adapt their care to the individual by adjusting their behaviour to haviours, and abilities (Moore et al., 1997; Moses, 2000; Schofield, &
fit youths’ perceived needs, and through a continuous reflexive process Brown. , 1999; Yu et al., 2019). Moreover, it was highlighted that care
in which their behaviour can be adapted as needed. Here, the onus of providers should share this focus with the children they care for, because
responsibility is on the care provider to continuously strive to respond it helps build their self-esteem and sense of agency, characteristics that
appropriately to children’s unique needs. This was found to increase are often low for young people with attachment difficulties (Moses,
staff members’ sense of agency and competency and decrease the pre­ 2000; Schofield, & Brown. , 1999; Yu et al., 2019). However, little de­
viously described negative impacts of care providers’ biases (Moses, tails were provided on how this can be achieved.
2000).
Many of the reviewed articles found that the rigid program structures
and standardized approaches typically promoted in residential care 6.8. Offering unconditional emotional support
programs impeded individualization of care and led care providers to
withhold their emotional responses (Andrew et al., 2014; Moore et al., Adopting an attitude characterized by unconditional emotional
1997; Moses, 2000; Ryan, 2004). Two articles support that in such support was a recurrent theme across many of the articles reviewed
programs, care providers often feel obliged to follow standardized ap­ (Andrew et al., 2014; Aprile et al., 2015; Moore et al., 1997; Pearce and
proaches to avoid complaints of unfairness by other children (Moore Pezzot-Pearce, 1994; Schofield, & Brown. , 1999; Wilkerson et al., 2008;
et al., 1997; Moses, 2000). Moore et al. (1997) consider that caregivers Yu et al., 2019). A few articles highlighted that care providers can
feared that they would be accused of “playing favourites” and be rep­ display this attitude in a variety of ways, including by providing
rimanded by their supervisors when they allowed for flexibility in the emotional support, reassurance, encouragement, validation, and being
application of the program rules and chose to adjust their approaches to available for children (Schofield, & Brown. , 1999; Yu et al., 2019). It
children’s unique needs and capacities (Moses, 2000). In this case, care was found that support should be unconditional in the sense that it is
providers felt limited in their independent decision-making capacity and given regardless of children’s behaviours. Articles contrasted this to
instead resorted to behavioural approaches, which exacerbated the issue behaviour modification paradigms, wherein care providers displayed
and led to an increased use of restraints, thus perpetuating the belief that accepting or rejecting attitudes based on the child’s behaviours, which
it is safer for care providers to avoid being emotionally close to children reinforces children’s feelings of rejection and their attachment diffi­
with attachment difficulties (Moore et al., 1997; Moses, 2000). culties (Aprile et al., 2015; Chaffin et al., 2006; Hardy, 2007; Moore
Alternatively, in order to promote individualization of care within et al., 1997).
the context of structured programs, two articles suggested that care Instead, a few articles highlighted that when children display chal­
providers can negotiate program rules with children (Moses, 2000; lenging behaviours, care providers should maintain an empathic
Ryan, 2004). Another study by Moore et al. (1997) suggested using approach and reassure children that they will continue to support them
guiding principles rather than rules to allow for flexibility and individ­ (Andrew et al., 2014; Moore et al., 1997; Pearce & Pezzot-Pearce, 1994).
ualization of practices. This was found to convey to children that they are worthy of respect
despite their challenging behaviours and that they are truly cared for,
6.6. Maintaining a mindful practice which helps shift their expectations of rejection and instead foster an
attachment (Andrew et al., 2014; Moore et al., 1997; Pearce & Pezzot-
As per almost half of the reviewed articles, care providers were found Pearce, 1994).
to significantly struggle with the emotional challenges of working with
children with attachment difficulties (Andrew et al., 2014; Hardy, 2007;
Moore et al., 1997; Pearce & Peazzot-Pearce, 1994; Schofield, & Brown. 6.9. Maintaining realistic expectations
, 1999; Spilt et al., 2016; Spilt et al., 2018; Wilkerson et al., 2008).
Namely, care providers were found to experience significant frustrations A few articles highlighted the importance of maintaining realistic
and feelings of helplessness when their attempts to connect with youth expectations with regards to caring for children with attachment diffi­
failed or when confronting children’s challenging or risky behaviours culties (Andrew et al., 2014; Pearce & Pezzot-Pearce, 1994; Shaw and
(Moore et al., 1997; Moses, 2000). Moreover, care providers were Páez, 2007; Wilkerson et al., 2008). Although children can improve
considered as inadvertently contributing to attachment difficulties when significantly in terms of their attachment difficulties (Aprile et al.,
their own feelings, stigmatizing thoughts, biases, beliefs, patterns of 2015), two articles suggested that progress can be slow, difficult and
behaviour, and attachment needs interfered with the care provided fluctuating, rather than linear and rapid (Andrew et al., 2014; Pearce &
(Andrew et al., 2014; Moses, 2000; Ryan, 2004). Pezzot-Pearce, 1994). However, these articles did not explain what
Several articles recommend mindful practice to help in addressing consisted of improvements. According to Pearce and Pezzot-Pearce
these challenges (Andrew et al., 2014; Howe & Fearnley, 2003; Moore (1994), when children’s progress did not meet their expectations, care
et al., 1997; Moses, 2000; Ryan, 2004; Wilkerson et al., 2008). More providers tended to take these shortcomings personally, which ulti­
specifically, a few articles suggested that in these situations, care pro­ mately undermined their morale and ability to sustain their efforts. They
viders are cognisant of their own emotions, thoughts and behaviours and therefore suggested that care providers should maintain realistic ex­
work through them to ensure that they continue to act in a therapeutic pectations (Pearce & Pezzot-Pearce, 1994).

6
L. Kaur et al. Children and Youth Services Review 156 (2024) 107265

7. Discussion children learn new ways to relate to others (Andrew et al., 2014; Moore
et al., 1997; Pearce & Pezzot-Pearce, 1994). Yet, when possible, having
This scoping review’s objective was to identify evidence-informed multiple healthy attachments—including with people outside of the
practices and approaches care providers should and should not healthcare context—could decrease the potential harms of the rela­
employ when caring for children experiencing attachment difficulties. tionship ending (Yu et al., 2019). Our focus in this review was on
Three main categories of practices and approaches were identified, identifying practices and approaches for care providers specifically;
relating to knowledge of attachment theories, clinical and organiza­ coupling these strategies with greater support being provided to primary
tional practices, and care providers’ attitudes. We will focus here on: (1) care providers, such as parents, to develop a trusting relationship with
the concept of relationship that was central to most approaches; (2) their child—which would likely be long-lasting—appears particularly
certain ethical considerations that may arise in the care of children with relevant. Although attachment disorders are often studied in the context
attachment difficulties; and (3) the strengths and limitations of this of foster care, it is estimated that around half of the children with a
scoping review. diagnosis of reactive attachment disorder live with their biological
parents (Pritchett et al., 2013). Different programs have been developed
7.1. Relationship: A central concept to support parents in developing their competencies, for example, their
sensitivity, in order to better perceive and respond to their child’s needs,
Within attachment theory, attachment refers to a strong emotional for children to develop secure attachments (e.g., Juffer et al., 2008;
bond between two people, which originally referred primarily to Moretti et al., 2012; O’Connor et al., 2013; Suchman et al., 2011;
mother-infant relationships (Bowlby, 1969). This strong relationship is Weihrauch et al., 2014). These programs contribute to increasing par­
based on trust from the child to the mother; for example, trust that their ents’ knowledge related to attachment and could foster a change in their
needs will be met and that an attunement between the child’s expres­ attitudes, similar to what was reported for healthcare providers in the
sions and the mother’s actions will occur (Bowlby, 1969). Many authors articles reviewed. Involving parents could thus be a way to try to reduce
in the articles included in this review emphasized the importance of the potential harms from a relationship ending between the care pro­
developing a trusting, sensitive, and secure relationship between the vider and child.
child and care providers to help address attachment difficulties. More Many articles referred to the importance of an active effort on the
recent conceptions of attachment highlight the multiplicity of attach­ care provider’s part to understand attachment theory and to provide
ment relationships children can have beyond parental attachment, care that is specific to children’s needs. This perspective changes the
which can be of significance to them, and these attachment relationships focus from the child as the object of behaviour modification in­
can differ in form, function or dynamic (Keller, 2016; Schofield & Beek, terventions applied universally, to a practice in which care providers
2006). A core aspect of forming attachment relationships being security aim to orient the care to each child’s unique situation and experience.
and trust, their development through relationships with care providers Adopting this tailored practice aligns with person-centred care. Person-
can extend the range of trusting relationships, allowing for them to work centred care refers to care providers considering the person’s physical,
together to reach shared goals (Keller, 2016). The child’s perception of mental, and spiritual well-being in a holistic manner and in which the
the relationship therefore becomes central to the establishment of a person being cared for is involved in decision-making (Morgan & Yoder,
trusting relationship, in which the care provider is well situated to help 2012). Individualization of care is provided, based on the person’s
the child. By having knowledge about the importance of a trusting values, preferences, and needs (Morgan & Yoder, 2012). The concept of
relationship, care providers can develop these relationships in practice children’s needs would, however, require further elaboration to un­
and adopt attitudes that foster the establishment of trust. Furthermore, derstand its meaning in practice. Woodhead (2015) argues that the
trust is a building block in families, from which children can develop a concept of children’s needs can lose its meaning when used without
sense of belonging. Incorporating children in routines is an approach to reference to who is defining these needs and what they entail. Care
help children to develop this sense of belonging, which, according to providers tend to act based on the child’s best interests, defining what
Schofield & Beek, 2006, is one dimension necessary to provide a secure they consider children’s needs are and how to fulfil them (Carnevale
base. As such, by promoting predictability and stability through routines et al., 2015). Instead, we propose that opening a dialogue with children
and expectations, while maintaining continuous relationships, specific and working towards a collaborative approach could be an effective way
care providers can help develop a sense of belonging in children. to co-identify children’s needs and work towards shared objectives.
Similarly, certain authors highlight the importance of an authentic
relationship when caring for children with attachment difficulties. An 7.3. Strengths and limitations
authentic relationship refers to a commitment to get to know the person
one works with, taking time to invest in this relationship and getting to This scoping review provides an overview of interventions that care
know the person’s experiences and needs (Hogan et al., 2013). An providers and programs can employ when working with children with
authentic relationship contrasts with “script-based” interactions (Hogan attachment difficulties. While studies were conducted in various set­
et al., 2013), such as within behavioural approaches whereas specific tings, the interventions highlighted within this scoping review appear
interventions aim to control behaviours. Having an authentic bond with applicable to most care settings. Some of the interventions were sup­
a care provider would contribute to the establishment of a trusting ported by case studies or conceptual studies and only a few provided
relationship that could benefit children experiencing attachment information on the specific outcomes related to the different ap­
difficulties. proaches. Literature searches were limited to English and French
publications.
7.2. Ethical considerations Future Directions
There was a clear gap in the available literature as to the perspectives
An important ethical consideration when caring for children with of stakeholders. No information was available related to the perspectives
attachment difficulties relates to the harms that can result from fostering and experiences of children, parents, and staff members in relation to
attachments with care providers when it cannot be guaranteed that children’s attachment difficulties, and what approaches help and how.
these relationships will be sustained. However, since trusting relation­ Moreover, there were very few studies on the outcomes related to the
ships are generally difficult to foster, emphasizing the stable presence of care practices and approaches. Future research would be warranted to
one care provider in a care context maximizes the possibility that chil­ address these gaps and better understand both the process and outcomes
dren will have at least one healthy attachment relationship. Developing of care approaches with children who experience attachment
such trusting relationships could significantly contribute to helping difficulties.

7
L. Kaur et al. Children and Youth Services Review 156 (2024) 107265

Funding of Consulting and Clinical Psychology, 74(6), 1017–1026. https://doi.org/10.1037/

0022-006X.74.6.1017
This work was supported by an Insight Development Grant from the
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Social Sciences and Humanities Research Council of Canada (number: caring as an expression of an authentic relationship between self and other. Issues in
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