Editing Reactive attachment disorder (section)

==Prognosis==
The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others.<ref name=AACAP-2005/> However, the course of RAD is not well studied and there have been few efforts to examine symptom patterns over time. The few existing [[longitudinal study|longitudinal studies]] (dealing with developmental change with age over a period of time) involve only children from poorly run Eastern European institutions.<ref name=AACAP-2005/>

Findings from the studies of children from Eastern European orphanages indicate that persistence of the inhibited pattern of RAD is rare in children adopted out of institutions into normative care-giving environments. However, there is a close association between duration of deprivation and severity of attachment disorder behaviors.<ref name="Connor &amp; Rutter (2000)">{{cite journal |vauthors=O'Connor TG, Rutter M |title=Attachment disorder behavior following early severe deprivation: extension and longitudinal follow-up. English and Romanian Adoptees Study Team |journal=J Am Acad Child Adolesc Psychiatry |volume=39 |issue=6 |pages=703–12 |year=2000 |pmid=10846304 |doi=10.1097/00004583-200006000-00008}}</ref> The quality of attachments that these children form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited RAD.<ref name="O'Connor et al. (2003)">{{cite journal |vauthors=O'Connor TG, Marvin RS, Rutter M, Olrick JT, Britner PA |title=Child-parent attachment following early institutional deprivation|journal=Dev. Psychopathol. |volume=15 |issue=1 |pages=19–38 |year=2003 |pmid=12848433 |doi=10.1017/S0954579403000026|s2cid=33936291}}</ref> The same group of studies suggests that a minority of adopted, institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving environments are provided.<ref name="Heller et al. (2006)"/> Indiscriminate sociability may persist for years, even among children who subsequently exhibit preferred attachment to their new caregivers. Some exhibit [[hyperactivity]] and attention problems as well as difficulties in peer relationships.<ref name="O'Connor et al.(1999)">{{cite journal |author=O'Connor TG, Bredenkamp D, Rutter M, & The English and Romanian Adoptees (ERA) Study Team |year=1999 |title=Attachment disturbances and disorders in children exposed to early severe deprivation |journal=[[Infant Mental Health Journal]] |volume=20 |pages=10–29 |doi= 10.1002/(SICI)1097-0355(199921)20:1<10::AID-IMHJ2>3.0.CO;2-S}}</ref> In the only longitudinal study that has followed children with indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer relationships.<ref name="Hodges &amp; Tizard (1989)">{{cite journal |vauthors=Hodges J, Tizard B |title=Social and family relationships of ex-institutional adolescents |journal=J Child Psychol Psychiatry |volume=30 |issue=1 |pages=77–97 |year=1989 |pmid=2925822 |doi=10.1111/j.1469-7610.1989.tb00770.x}}</ref>

Studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some institution-reared children were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment.<ref name="Roy et al.(2004)">{{cite journal |vauthors=Roy P, Rutter M, Pickles A |year=2004 |title=Institutional care: Associations between overactivity and lack of selectivity in social relationships|journal=Journal of Child Psychology and Psychiatry |volume=45 |issue=4 |pages=866–73  |doi=10.1111/j.1469-7610.2004.00278.x |pmid=15056316}}</ref>

There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the twins between the ages of 19 and 36 months, during which time they had multiple moves and placements.<ref name="Hinshaw-Fusilier et al. (1999)">{{cite journal|last1=Hinshaw-Fuselier|first1=Sarah|last2=Boris|first2=Neil W.|last3=Zeanah|first3=Charles H.|title=Reactive attachment disorder in maltreated twins|journal=Infant Mental Health Journal|volume=20|issue=1| year=1999| pages=42–59|doi=10.1002/(SICI)1097-0355(199921)20:1<42::AID-IMHJ4>3.0.CO;2-B}}</ref> The paper explores the similarities, differences and comorbidity of RAD, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of RAD while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. At age three, some lasting relationship disturbance was evident.

In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized children was again highlighted. The girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. The boy still exhibited self-endangering behaviors, not within RAD criteria but possibly within "secure base distortion", (where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment). At age eight the children were assessed with a variety of measures including those designed to access representational systems, or the child's "internal working models". The twins' symptoms were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each child differently. The [[Attachment measures#Other approaches|narrative measures]] used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.<ref name="Heller et al. (2006)"/>

One paper using questionnaires found that children aged three to six, diagnosed with RAD, scored lower on empathy but higher on [[Self monitoring|self-monitoring]] (regulating your behavior to "look good"). These differences were especially pronounced based on ratings by parents, and suggested that children with RAD may systematically report their personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than scores of the control children.<ref name="Hall &amp; Geher (2003)">{{cite journal |doi=10.1080/00223980309600605 |vauthors=Hall SE, Geher G |title=Behavioral and personality characteristics of children with reactive attachment disorder|journal=J Psychol |volume=137 |issue=2 |pages=145–62 |year=2003 |pmid=12735525|s2cid=32015193 }}</ref>