Virginia Commission on Youth - Adjustment Disorders

Adjustment Disorders

An adjustment disorder is a behavioral response to a stressful event or variation in a child or adolescent’s life that is not a healthy response to the event or change (The Medical Center Online, 2002). Youth who experience distress in excess of what is expected as a response to a stressor may even experience significant impairment in normal daily functioning and activities (Institute for Health, Health Care Policy and Aging Research, 2002).

Adjustment disorders in children are created by factors similar to those found in adults. Four factors which may contribute to the development of adjustment disorders are the nature of the stressor, vulnerabilities of the child, intrinsic factors, and extrinsic factors (Benton & Lynch, 2002).

In order to be considered and diagnosed as an adjustment disorder, the child’s reaction must occur within three months of the identified event (The Medical Center Online, 2002). Typically, the symptoms do not last more than six months, and the majority of the children quickly return to normal functioning (United Behavioral Health, 2002). Adjustment disorders differ from post-traumatic stress disorder (PTSD) in that PTSD usually occurs in reaction to a life-threatening event and may be longer-lasting (Access Med Health Library, 2002).

In 1997, the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Service Administration and Center for Mental Health Services conducted a Client/Patient sample survey of 8,000 children in mental health facilities. These children were randomly selected and surveyed in order to calculate national estimates regarding mental health services. The findings of the study indicated that 16 percent of these children who were admitted had an adjustment disorder (Institute for Health, Health Care Policy and Aging Research, 2002).

The following six types of adjustment disorders are listed in the Diagnostic and Statistic Manual, IV Edition (DSM-IV):

· Adjustment disorder with depressed mood: Symptoms are that of a minor depression.

· Adjustment disorder with mixed anxiety and depressed mood: Symptoms are a combination of depression and anxiety.

· Adjustment disorder with disturbance of conduct: Symptoms are demonstrated in behaviors that break societal norms or violate the rights of others.

· Adjustment disorder with mixed disturbance of emotions and conduct: Symptoms include combined affective and behavioral characteristics with mixed emotional features and with disturbance of conduct.

· Adjustment disorder not otherwise specified: This residual diagnosis is used when a maladaptive reaction that is not classified under other adjustment disorders but occurs in response to stress.

Adjustment disorders are a behavioral or emotional reaction to an outside stressor and, accordingly, there is no single trigger between the stressor and the child’s reaction to it (The Medical Center Online, 2002). Furthermore, because children possess varying dispositions, as well as different vulnerabilities and coping skills, it is impossible to attribute a single cause to this mental disorder. Thus, the developmental stage of the child and the strength of their support system may influence their reaction to a stressor (The Medical Center Online). There is no evidence to indicate that biological factors influence the cause of adjustment disorders. The common thread in the cause of anxiety disorders is stress as the precipitating factor (Benton and Lynch, 2002).

According to Benton and Lynch (2002), the most important factor in the development of an adjustment disorder is the vulnerability of the child. Vulnerability depends on the characteristics of both the child and the child’s environment. A reliable assessment is not available to assess this variable.

Children with adjustment disorder may have a wide variety of symptoms. Symptoms normally include several of the symptoms shown in Table 1.

Because most features of adjustment disorders are subjective (e.g. the stressor, the maladaptive reaction, the accompanying mood and feature, and the time and relationship between the stressor and the response), these disorders can be very difficult to diagnose (Benton and Lynch, 2002). A qualified mental health professional should assess the child for an adjustment disorder following a comprehensive psychiatric evaluation and interview with the child and the family (The Medical Center Online, 2002). Specifically, a personal history appraising development, life events, emotions, behaviors, and the identified stressful event is performed during the assessment process in order to correctly diagnosis the adjustment disorder (The Medical Center Online).

Table 2
Characteristics of Adjustment Disorders
The Medical Center Online, 2002

° Adjustment disorders occur equally in males and females.

° Adjustment disorder stressors and symptoms may vary based on cultural influences.

° The characteristics of adjustment disorder in children differ from those in adults.

° Adolescent symptoms are more behavioral.

° Adult symptoms are more depressive.

Benton & Lynch (2002) indicate that adjustment disorders are most likely to occur with personality disorders, anxiety disorders, affective disorders, and psychoactive substance abuse disorder. More studies that focus on the association between adjustment disorders and other mental disorders, including substance abuse disorders, are needed.

There have been no significant studies conducted to assess the effectiveness of treatment for adjustment disorders. However, research has been conducted regarding the age of the child and its impact upon treatment results. Andreasen and Hoenk, as cited by Benton and Lynch (2002), reported that, in children and adolescents, more serious mental illnesses were present at five years following treatment for adjustment disorders.

However, the consensus on treating adjustment disorders is that because an adjustment disorder is a psychological reaction to a stressor, the stressor must be identified and communicated by the child (Benton and Lynch, 2002). If the stressor is “eliminated, reduced or accommodated" (Strain, as cited by Benton and Lynch), the child’s maladaptive response can also be reduced or eliminated. Accordingly, treatment of adjustment disorder usually involves psychotherapy that seeks to reduce the stressor, remove the stressor, or improve coping ability.

Treatments for adjustment disorders must be customized to the needs of the child based on the child’s age, health and medical history (The Medical Center Online, 2002). Other determining factors include the extent of the symptoms and the subtype of the adjustment disorder.

Psychotherapy is the treatment of choice for adjustment disorders, since the symptoms are a direct reaction to a specific stress (Turkington, 1995). However, the type of therapy depends on the needs of the child, with the focus being on addressing the stressors and resolving the problem.

Brief treatment using cognitive-behavioral strategies is the preferred practice (United Behavioral Health, 2002). Cognitive-behavioral approaches are used to improve age-appropriate problem solving skills, communication skills, impulse control, anger management skills, and stress management skills (The Medical Center Online, 2002). Additionally, therapy assists with formatting an emotional state and support systems to enhance adaptation and coping (Benton and Lynch, 2002).

Research conducted by Strain, as cited by Benton and Lynch (2002), suggest that the goals of psychotherapy should include the following:

· Analyze the stressors that are affecting the child, and determine whether they can be eliminated or minimized;

· Assist the child to gain perspective on the stressor and manage themselves and the stressor.

Stress management and group therapy are particularly beneficial in cases of high work/family stress. Family therapy is frequently utilized, with the focus being on making needed changes within the family system. These changes may include improving communication skills and family interactions and increasing support among family members (The Medical Center Online, 2002).

Medication is seldom used as a singular treatment for adjustment disorders due to the fact that the child requires assistance in coping with the stressor that is causing the maladaptive behavior. However, targeted symptomatic treatment of the anxiety, depression, and insomnia that occur with adjustment disorders may effectively augment therapy, but is not recommended as the primary treatment for adjustment disorders. As cited in Benton and Lynch (2002) in a retrospective study of 72 adolescents having adjustment disorder, the researchers (Ansari & Matar) found that disappointment in relationships was the primary stressor causing the disorder. Accordingly, such issues must be addressed through psychotherapy, rather than pharmacology, to address the symptoms of the disorder.

If a clinician determines that pharmacotherapy is necessary, short-term use of anxiolytics and hypnotics may be beneficial.

Institute for Health, Health Care Policy and Aging Research. (2002). Update: Latest Findings in Children’s Mental Health. 1:1. [Online]. Available: http://www.ihhcpar.rutgers.edu. [October 2002].