Adjustment disorders

Definition

Adjustment disorder is an umbrella term for several mental states characterized by noticeable behavioral and/or emotional symptoms. In order to be classified as an adjustment disorder, these symptoms must be shown to be a response to an identifiable stressor that has occurred within the past three months.

Description

The American Psychiatric Association (APA), in its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) , states that the behavioral and/or emotional signs observed must appear excessive for the stressor involved or have significant impact on the child's social and school functioning. The cause of the stress may be a single event affecting only the child, such as starting daycare or school, or an event that involves the entire family , such as a divorce . Multiple simultaneous stressors are also possible, such as starting daycare and having an abusive caretaker at the daycare or a divorce complicated by parental substance abuse. Chronic medical conditions of the child or parents, such as childhood leukemia or cancer , can also be a cause of stress.

Adjustment disorder, in some ways, is a hopeful diagnosis. Many mental health professionals consider it one of the less severe mental illnesses. It is normally a time-limited condition with manifestations arriving almost immediately after the appearance of the pressure-causing event and resolving within six months of the elimination of the stressor. However, the exception to this would be the duration of symptoms related to long-term stressors such as chronic illness or even the fall-out from divorce. Though these may appear within three months of the event, resolution may also take longer than six months.

Demographics

The diagnosis of adjustment disorder is a very common one for both children and teens, with a higher incidence among children than adults. Nearly one third (32%) of all adolescents are estimated to suffer from adjustment disorders during teenage years as opposed to a rate of occurrence of only 10 percent among adults. There is no identified difference between adjustment disorder rates between girls or boys. What provides the precipitating event and the symptoms manifested can vary, according to the culture in which a child lives. However, generally across all cultures, children and adolescents are more apt to experience conduct disorder symptoms manifested by acting out behaviors, while adults are more apt to experience depressive symptoms.

Causes and symptoms

Few descriptions of any mental illness specify its cause as precisely as the description of adjustment disorders does. An explicit incident or incidents causing stress for the child is always the precipitant. The cause of the stress seen in adjustment disorders can be events that for many children would be within the parameters of normal experience. These incidents are usually not the severe traumas associated with more serious stress-related illnesses such as post-traumatic stress disorder (PTSD). Though adjustment disorder precipitants are usually more "normal" events that can typically occur in the lives of most children, these events are still changes from everyday events. Especially for children, change is often the precursor of stress. For example, for a child who has always had daycare or babysitters , having caregivers other than his or her mother is a normal occurrence, so having a caregiver is not likely to be terribly stressful. However, a child who has never been separated from his or her mother may find going to daycare or kindergarten an extremely traumatic event.

Other examples of such childhood stressors include:

divorce or separation of parents
moving to a new place
birth of a sibling
natural disasters such as hurricanes or tornadoes
illness of either the child or another loved one
loss of a pet
problems in school
family conflict
sexuality issues
witnessing or being involved in an incidence of violence

Some psychological theorists and researchers consider adjustment disorders in adolescents less of an illness than a stage in establishing an identity. Adolescents may develop adjustment disorders as part of a defense mechanism meant to break their feelings of dependence on parents. This psychological maneuver may precipitate problems in families as adolescents begin seeking individuals outside the family as replacements for their parents. This behavior can be particularly destructive when these feelings of dependence are transferred to involvement with gangs or cults. However, it should be noted that the APA does classify adjustment disorder as a mental illness.

DSM-IV divides adjustment disorders into subgroups, based upon the symptoms manifested most prominently. These subgroups include:

Adjustment disorder with depressed mood. This is characterized by feelings of sadness or hopelessness of varying degrees. However depression usually interferes with the child's ability to function, i.e. attending school or playing with friends. The sad feelings are sometimes accompanied by feelings of anger or frustration. It is important to note that though depressed mood adjustment disorder is less common among children, when it does occur, suicidal thoughts and even suicide attempts can be one of the symptoms. This symptom requires careful monitoring and the involvement of a mental health professional.
Adjustment disorder with anxiety . This form typically includes agitation or nervous behavior and/or obsessive worrying. The child may feel or express fear of being separated from parents.
Adjustment disorder with mixed anxiety and depressed mood. This condition combines the symptoms seen in both adjustment disorders with depression and with anxiety.
Adjustment disorder with disturbance of conduct. Behavioral signs of this adjustment disorder include primarily actions that show a disregard for rules, laws, and the rights of others, such as picking fights, vandalism, truancy , and reckless driving for teens.
Adjustment disorder with mixed disturbance of emotions and conduct. This condition combines depression and anxiety symptoms with those of disturbance of conduct.
Unspecified adjustment disorders. This phrase is the catch-all term to describe any adjustment disorder not showing a predominance of any one set of the above-listed symptoms.

When to call the doctor

In order to even establish a diagnosis of adjustment disorder, a mental health professional needs to meet and evaluate the child or teen. As this illness can be debilitating, making it quite difficult for the child to function, that evaluation should take place as soon as possible after symptoms are observed. As noted above, suicidal ideation can be a potential facet of depressed mood adjustment disorders, and untreated adjustment disorder with depressed mood can lead to more serious mental illness, including major depression. These two facts give additional impetus to quickly involving a psychiatrist or psychologist.

Diagnosis

One of the primary measurements used in diagnosing adjustment disorder is the occurrence of the stress-causing event within the past three months. The only usual life-stressor not considered a possible cause for adjustment disorder is bereavement. Adjustment disorders are also differentiated from other reactions to stress such as PTSD by both symptoms and the relative severity of the causative event. Adjustment disorders can be caused by almost any stressor and manifest a wide variety of symptoms, while PTSD is normally associated with severe stress-causing life events and has a more specific set of symptoms.

The child being evaluated for an adjustment disorder needs to meet the following criteria in order to confirm the diagnosis:

has had a psychological evaluation
has experienced a psychological stressor within the past three months
shows symptoms that appear disproportionate to the stressful event
does not appear to be suffering from any other underlying mental or physical illness

Treatment

The most important goal in the treatment of adjustment disorder is relieving the symptoms a child or teen experiences so that they can return to the same level of functioning they possessed prior to the onset of illness. Treatment depends upon the age and overall health of the child as well as the severity of the symptoms. Medication is only ordered on an extremely limited basis or not ordered at all because psychotropic medications have been shown to have little efficacy in treating adjustment disorders. Age-appropriate cognitive-behavioral individual psychotherapy, focusing on problem solving, communication, impulse control, and stress and anger-management is a usual component of treatment. Family therapy to improve communication between the child or teen and parents and siblings is often helpful, as is group therapy with peers (other children also suffering from adjustment disorder).

Prognosis

Early detection and treatment of adjustment disorders in children has been shown to appreciably reduce the severity of symptoms and improve their quality of life. Most recoveries from adjustment disorder uncomplicated by other mental illness are both rapid and complete returns to the child's former level of functioning.

Prevention

The National Institute for Mental Health (NIMH) notes that there is no way to predict who will develop an adjustment disorder given the appearance of certain life-situation stressors. Since there is also no known way to prevent the occurrence of these stressors, prevention seems impossible. However, it is known that understanding and support from family and friends can help.

KEY TERMS

Anxiety —Worry or tension in response to real or imagined stress, danger, or dreaded situations. Physical reactions, such as fast pulse, sweating, trembling, fatigue, and weakness, may accompany anxiety.

Cognitive-behavioral therapy —A type of psychotherapy in which people learn to recognize and change negative and self-defeating patterns of thinking and behavior.

Defense mechanisms —Indirect strategies used to reduce anxiety rather than directly facing the issues causing the anxiety.

Depression —A mental condition in which a person feels extremely sad and loses interest in life. A person with depression may also have sleep problems and loss of appetite and may have trouble concentrating and carrying out everyday activities.

Post-traumatic stress disorder (PTSD) —A disorder that occurs among survivors of extremely stressful or traumatic events, such as a natural disaster, an airplane crash, rape, or military combat. Symptoms include anxiety, insomnia, flashbacks, and nightmares. Patients with PTSD are unnecessarily vigilant; they may experience survivor guilt, and they sometimes cannot concentrate or experience joy.

Psychological evaluation —Examination of a patient by a psychologist through interviews, observation of behavior, and psychological testing with the goal of determining personality adjustment, identifying problems, and helping to diagnose and plan treatment for a mental disorder.

Psychotherapy —Psychological counseling that seeks to determine the underlying causes of a patient's depression. The form of this counseling may be cognitive/behavioral, interpersonal, or psychodynamic.

Psychotropic drug —Any medication that has an effect on the mind, brain, behavior, perceptions, or emotions. Psychotropic medications are used to treat mental illnesses because they affect a patients moods and perceptions.

Stressor —A stimulus, or event, that provokes a stress response in an organism. Stressors can be categorized as acute or chronic, and as external or internal to the organism.

Resources

BOOKS

Bell, Susan Givens, et al. Mosby's Pediatric Nursing Reference , 5th ed. Kent, UK: Elsevier Science, 2003.

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW Washington, DC 20016–3007. Web site: http://www.aacap.org.

Federation of Families for Children's Mental Health. 1021 Prince Street, Alexandria, VA 22314–2971. Web site: http://www.ffcmh.org.

WEB SITES

"Adjustment Disorder." National Institute of Mental Health. Available online at http://www.nimh.nih.gov.htm (accessed October 16, 2004).

Franklin, Donald. "Adjustment Disorders." Psychology Information Online. Available online at http://www.psychologyinfo.com (accessed October 16, 2004).

Joan Schonbeck, R.N.