What are the recommended interventions for a child with attachment disruptions or disorders to build a secure attachment with their caregiver?

Parent-Child Therapy to Build Attachment

For children with attachment disruptions or disorders, prioritize evidence-based dyadic interventions that focus on enhancing caregiver sensitivity and responsiveness through structured parent-child interaction therapy, with Child-Parent Psychotherapy (CPP) and Attachment and Biobehavioral Catch-Up (ABC) having the strongest evidence for improving attachment security. 1

Core Therapeutic Approach

The foundation of attachment repair centers on relational health care—the ability to form and maintain safe, stable, and nurturing relationships (SSNRs) between caregiver and child. 2 This approach recognizes that:

• Attachment remains malleable beyond infancy, extending into adolescence and adulthood, meaning intervention at any age can potentially shift attachment patterns toward security 2
• Dyadic interactions between caregiver and child are the "primary engines" of development, making parent-child therapy more effective than child-only interventions 2
• Secure attachment develops through predictable, compassionate availability of the caregiver, which promotes healthy brain growth, emotional regulation, and resilience 2

Evidence-Based Interventions

First-Line Recommendations

Child-Parent Psychotherapy (CPP) and Attachment and Biobehavioral Catch-Up (ABC) emerge as interventions with the strongest evidence bases for shifting children toward secure and organized attachment patterns. 1 These programs have demonstrated efficacy in randomized controlled trials and should be prioritized when available.

Parent-Child Interaction Therapy (PCIT) serves as an attachment-based intervention with pilot data supporting its use, particularly with adoptive children experiencing attachment disruptions. 2

Age-Specific Considerations

For toddlers (12-24 months), multiple attachment-based parenting interventions show evidence of improving attachment security, though most have limited replication studies. 1

For middle childhood (ages 6-12), consider:

• Middle Childhood Attachment-Based Family Therapy (MCABFT), which uses less conversation and more play compared to adolescent versions, placing parents at the center of therapy 3
• Lifespan Integration (LI) therapy with the adoptive parent present, which shows promise for repairing attachment disruptions in this age group 4

Critical Implementation Elements

Caregiver-Focused Strategies

The intervention must target caregiver sensitivity and emotional attunement, not just child behavior. Key components include:

• Teaching caregivers to provide predictable, empathic responses when children are distressed, which helps children learn emotional regulation 2
• Enhancing the quality of caregiver-child interactions through coaching on responsiveness, warmth, and consistency 2
• Building caregiver capacity for "psychological ownership" of the child, fostering personal investment in the relationship 2

Structural Modifications

When children are in institutional or foster care settings:

• Reduce the number of different caregivers a child interacts with regularly to promote attachment figure consistency 2
• Ensure case management systems connect families to needed psychosocial, parenting, and material supports to prevent further disruptions 2

Common Pitfalls to Avoid

Avoid "attachment therapies" that use coercive, physically intrusive, or confrontational techniques. 5 The field of attachment therapy is diverse, and some subset practitioners use potentially harmful techniques that lack scientific validation. 5

Do not rely solely on child-focused interventions. Attachment security develops within the caregiver-child relationship, making dyadic work essential. 2

Recognize that many routinely used attachment interventions in practice have weak evidence bases. 6 A national survey found significant disparity between interventions with strong research support and those commonly implemented in services. 6

Measuring Progress

Use validated attachment measures rather than relying on subjective clinical impression alone. 6 The survey data revealed limited use of validated measures in routine practice, which hampers ability to track meaningful change.

Monitor for shifts toward:

• Increased secure attachment behaviors (child seeks comfort from caregiver when distressed, uses caregiver as secure base for exploration) 2
• Decreased disorganized attachment patterns (meta-analyses show pooled odds ratio of 0.54 for reducing disorganization with parenting interventions) 6
• Improved caregiver sensitivity and responsiveness in real-time interactions 1

Supporting Resilience

Build on family protective factors rather than emphasizing deficits. 2 Resilience is a dynamic process requiring reliable support from attachment figures, developed through:

• Play, exploration, and exposure to normal developmental activities with caregiver support 2
• Effective parenting skills that provide the context for secure attachment development during and after traumatic experiences 2
• Addressing caregiver trauma and stress, as caregiver well-being directly impacts capacity for sensitive caregiving 2