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

J Clin Psychiatry. 2023 Oct 18;84(6):23m14994. doi: 10.4088/JCP.23m14994.


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.

MeSH terms

  • Adolescent
  • Adult
  • Attention Deficit Disorder with Hyperactivity* / diagnosis
  • Attention Deficit Disorder with Hyperactivity* / epidemiology
  • Attention Deficit Disorder with Hyperactivity* / psychology
  • Child
  • Child, Preschool
  • Comorbidity
  • Humans
  • Reactive Attachment Disorder* / diagnosis
  • Reactive Attachment Disorder* / epidemiology
  • Reactive Attachment Disorder* / psychology
  • Suicide, Attempted