Adult Outcomes of Children With Reactive Attachment Disorder in a Non-Institutionalized Sample

Hannah K. Betcher, MD; Tanner J. Bommersbach, MD, MPH; Bruno A. Perossa, MD; Beth Larrabee, MS; Paul E. Croarkin, DO, MS; Magdalena Romanowicz, MD; Jennifer L. Vande Voort, MD; Alastair J. McKean, MD

J Clin Psychiatry 2023;84(6):23m14994

ABSTRACT

Objective: Research on reactive attachment disorder (RAD) has focused on institutionalized samples, and long-term outcomes have not been described. This study examines the natural history of RAD into adulthood in a US community sample.

Methods: The electronic medical record of a tertiary care center was reviewed for individuals who received an ICD-9 or ICD-10 diagnosis of RAD between 3–12 years old and were ≥ 18 years old at the start of the study; data were collected between February and June 2018. Children with RAD (n = 49) were identified and psychiatric, social, and medical outcomes were collected in childhood and adulthood. A subset of the RAD cohort with comorbid attention-deficit/hyperactivity disorder (ADHD) based on ICD codes (n = 34) was compared with age-matched controls with ADHD and without attachment disorders (n = 102).

Results: Children with RAD had high rates of adult psychiatric diagnoses (73.5%), substance use (42.9%), suicide attempts (28.6%), and psychiatric hospitalizations (71.4%). They also demonstrated poor psychosocial outcomes, including low high school (34.7%) and college (2.0%) graduation, high unemployment (26.5%), state-funded health insurance (65.3%), and legal issues (34.7%). Compared to children with ADHD alone, children with RAD and ADHD had higher rates of comorbid adult psychiatric diagnoses (OR 3.0, P = .02), suicide attempts (OR 7.5, P < .01), and hospitalizations (OR 6.4, P < .01).

Conclusions: This study describes the natural history of RAD into adulthood in a non-institutionalized sample. The findings suggest that children with RAD have a high burden of psychiatric comorbidities and reduced psychosocial functioning into adulthood that extend beyond the impairment associated with ADHD, a common comorbidity in RAD. These findings highlight the continuous impact of early attachment difficulties on the developmental trajectory of children.

J Clin Psychiatry 2023;84(6):23m14994

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