B-93: When Everything Overlaps: Neuropsychological Assessment of an Adult With Borderline Intellectual Functioning, Severe Psychiatric History, and Reactive Attachment Disorder

Abstract

Objective: Adults with co-occurring intellectual developmental disorder (IDD), severe psychiatric history, and reactive attachment disorder (RAD) represent a diagnostically complex and clinically underserved population in which poly-etiological factors substantially complicate neuropsychological evaluation. Limited guidance exists for practitioners encountering this constellation of presentations, particularly regarding how attachment disruption can moderate assessment validity and patient-clinician interaction. Method/Data Selection: The patient is a female adult in her 30s with a longstanding psychiatric history including RAD diagnosis in childhood, presenting for comprehensive neuropsychological evaluation. Psychiatric history review revealed [NM1.1]the onset and course of severe mental illness across development. Structured clinical observation of patient-clinician interactions was conducted throughout the evaluation with discussion of RAD-related relational patterns and their impact on assessment engagement. Standardized cognitive and neuropsychological testing was administered with adaptations informed by the patient's cognitive, functional, and psychiatric profile. Results/Data Synthesis: The patient's cognitive profile was consistent with mild IDD, with low average verbal abilities representing a relative strength across an otherwise extremely low range of functioning. RAD-related relational patterns (e.g., mildly oppositional testing behaviors and inconsistent task engagement) were identified as active potential moderators of assessment validity requiring explicit clinical management. The psychiatric history further complicated diagnostic formulation by introducing symptom overlaps across neurodevelopmental, mood, and attachment-based etiologies. Conclusions: This case illustrates how poly-etiologic factors — neurodevelopmental, psychiatric, and attachment-based — interact to complicate neuropsychological assessment in adulthood. Verbal strengths within an IDD profile represent a meaningful target for individualized treatment planning. Findings underscore the need for attachment-informed assessment frameworks and adapted clinical approaches when evaluating adults with complex, multiply-determined presentations.