Adjustment Disorders in Children and Adolescents

What is an Adjustment Disorder?

An Adjustment Disorder is when there is a development in a child or adolescent of significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor (or stressors).  The clinical significance of the reaction may be seen either by marked distress that is in excess of what would normally be expected given the nature of the stressor, or by impairment in social or academic (occupational) functioning.  This disorder should not be given if the disturbance meets the criteria for another more significant disorder (such as Anxiety or Depression).  This disorder can be given with the presence of another more significant disorder if the other disorder does not account for the symptoms that have occurred in response to the stressor.

These criteria are currently designated by the American Psychiatric Association for this disorder.  They are published in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, 1994), and are available in the public domain.

An Adjustment Disorder is not given when the symptoms represent Bereavement, an expectable response to the death of a loved one.  It may be an appropriate diagnosis when the reaction is in excess of, or lasts longer, than what would generally be expected with a death.  This disorder should also be differentiated from other nonpathological reactions to stress that do not lead to significant distress in excess of what is expected and that do not cause marked impairment in social or academic (occupational) functioning.

This disorder must resolve within 6 months of the end of the stressor, by definition.  The symptoms may persist longer if they occur in response to a chronic stressor (like a chronic disabling general medical condition), or to a stressor that has lasting consequences (like the financial and emotional difficulties resulting from divorce).

The stressor may be a single event (the end of a serious relationship), or there may be a number of stressors (like parental substance abuse and peer rejection or bullying).  Stressors may be recurrent (like starting school each fall), or continuous (like living in a high crime neighborhood).  Stressors may affect a single child or adolescent, an entire family, or a larger group or community (as in a natural disaster).  Some stressors may accompany specific developmental events, like starting school the first time, leaving home for camp or college, getting married, becoming a parent, failing a schoolyear, or retirement.

There are several types of Adjustment Disorders, characterized by the predominant symptoms.  There is one with a Depressed Mood, with symptoms of tearfulness, feelings of hopelessness, or other depression.  There is one with Anxiety, with symptoms of nervousness, worry, or fears of separation from major attachment figures (like parents).  There is one with Mixed Anxiety and Depression, which is a combination of the first two.

There is one with a Disturbance of Conduct, in which there is a violation of the rights of others or major age-appropriate social norms and rules (such as truancy, vandalism, careless driving, or fighting).  There is one with a Mixed Disturbance of Emotions and Conduct, when both emotional symptoms and a disturbance of conduct are present.

The duration of symptoms can be indicated as being either acute (lasting less that 6 months), or chronic.

Adjustment Disorders are frequently seen as decreased performance at school or work, and temporary changes in social relationships.  They are associated with an increased risk of suicide attempts and suicide.  They may complicate the course of a medical illness through decreased compliance with treatment or lengthier recovery.  They may occur in any age group, and males and females are equally affected.  The percentage of individuals in outpatient treatment for this disorder range from 5% to 20%. 

Children and adolescents from a disadvantaged life experience a high rate or stressors and may be at risk for the disorder.

What Can Be Done about and Adjustment Disorder?

Therapy is the most common and effective intervention for a child or adolescent with an Adjustment Disorder.  Individual counseling can be helpful to assist the child in identifying and understanding their reaction to a stressor.  Therapy can restore self esteem, build emotional coping strategies, and help return the child or teenager to their previous level of functioning.  Strategies to help decrease emotional interference at school help to improve learning and performance.  Often teachers or guidance/adjustment counselors can support children and assist with recovery and coping after a stressor.  Informed consent (signed permission) is required before a therapist can communicate with anyone about a child's treatment and recommended strategies to employ at school.

Family therapy is often helpful in improving parental understanding and assisting a child or adolescent in handling their reaction to a stressor.  Restoring hope and learning to be positive are important for both the family and for the individual with the disorder.

An Adjustment Disorder, a Posttraumatic Stress Disorder, and an Acute Stress Disorder all require the presence of a psychosocial stressor.  PTSD and Acute Stress Disorder are characterized by the presence of an extreme stressor and specific constellations of symptoms.  In contrast, this disorder can be triggered by a stressor of any severity, and may involve a wide range of possible symptoms.

If you think that your child or adolescent may have this disorder, or any other mental health issue, you should talk to a professional about what to do and how to get help.  Talking to your child's pediatrician is often a good way to get a referral to a competent psychologist or social worker.  Another great source for referrals is your health insuarance company.  Many have on-line lists of professionals in their network or providers, or have a phone number on your insurance card to consult for referral sources.  If you live in southeast Massachusetts, in Plymouth county, Cranberry Counseling in Marshfield would be more than happy to answer your questions and to make an appointment to help diagnose and start a treatment plan for your child or adolescent and your family.  See the Cranberry Counseling, P.C. page, or use the Contact Us form.