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.
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.
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.
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
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).
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.
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.
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.
Bell, Susan Givens, et al. Mosby's Pediatric Nursing Reference, 5th ed. Kent, UK: Elsevier Science, 2003.
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW Washington, DC 20016–3007. Web site: <www.aacap.org>.
Federation of Families for Children's Mental Health. 1021 Prince Street, Alexandria, VA 22314–2971. Web site: <www.ffcmh.org>.
"Adjustment Disorder." National Institute of Mental Health. Available online at <www.nimh.nih.gov.htm> (accessed October 16, 2004).
Franklin, Donald. "Adjustment Disorders." Psychology Information Online. Available online at <www.psychologyinfo.com> (accessed October 16, 2004).
Joan Schonbeck, R.N.
"Adjustment Disorders." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Encyclopedia.com. (October 17, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/adjustment-disorders
"Adjustment Disorders." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Retrieved October 17, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/adjustment-disorders
An adjustment disorder is a debilitating reaction, usually lasting less than six months, to a stressful event or situation. It is not the same thing as post-traumatic stress disorder (PTSD), which usually occurs in reaction to a life-threatening event and can be longer lasting.
An adjustment disorder usually begins within three months of a stressful event, and ends within six months after the stressor stops. There are many different subtypes of adjustment disorders, including adjustment disorder with:
- mixed anxiety and depression
- conduct disturbances
- mixed disturbance of emotions and conduct
Adjustment disorders are very common and can affect anyone, regardless of gender, age, race, or life-style. By definition, an adjustment disorder is short-lived, unless a person is faced with a chronic recurring crisis (such as a child who is repeatedly abused). In such cases, the adjustment disorder may last more than six months.
Causes and symptoms
An adjustment disorder occurs when a person can't cope with a stressful event and develops emotional or behavioral symptoms. The stressful event can be anything: it might be just one isolated incident, or a string of problems that wears the person down. The stress might be anything from a car accident or illness, to a divorce, or even a certain time of year (such as Christmas or summer).
People with adjustment disorder may have a wide variety of symptoms. How those symptoms combine depend on the particular subtype of adjustment disorder and on the individual's personality and psychological defenses. Symptoms normally include some (but not all) of the following:
- headaches or stomachaches
- reckless driving
- other destructive acts
It is extremely important that a thorough evaluation rule out other more serious mental disorders, since the treatment for adjustment disorder may be very different than for other mental problems.
In order to be diagnosed as a true adjustment disorder, the level of distress must be more severe than what would normally be expected in response to the stressor, or the symptoms must significantly interfere with a person's social, job, or school functioning. Normal expression of grief, in bereavement for instance, is not considered an adjustment disorder.
Multiple sclerosis— A progressive disorder of the central nervous system in which scattered patches of the protective sheath covering the nerves is destroyed. The disease, which causes progressive paralysis, is marked by periods of exacerbation and remission. There is no cure.
Post-traumatic stress disorder (PTSD)— A specific form of anxiety that begins after a life-threatening event, such as rape, a natural disaster, or combat-related trauma.
Psychotherapy (counseling) is the treatment of choice for adjustment disorders, since the symptoms are an understandable reaction to a specific stress. The type of therapy depends on the mental health expert, but it usually is short-term treatment that focuses on resolving the immediate problem.
Therapy usually will help clients:
- develop coping skills
- understand how the stressor has affected their lives
- develop alternate social or recreational activities
Family or couples therapy may be helpful in some cases. Medications are not usually used to treat adjustment disorders, although sometimes a few days or weeks of an anti-anxiety drug can control anxiety or sleeping problems.
Self-help groups aimed at a specific problem (such as recovering from divorce or job loss) can be extremely helpful to people suffering from an adjustment disorder. Social support, which is usually an important part of self-help groups, can lead to a quicker recovery.
Most people recover completely from adjustment disorders, especially if they had no previous history of mental problems, and have a stable home life with strong social support. People with progressive or cyclic disorders (such as multiple sclerosis) may experience an adjustment disorder with each exacerbation period.
Luther, Suniya G., Jacob A. Burack, and Dante Cicchetti. Developmental Psychopathology: Perspectives on Adjustment, Risk, and Disorder. London: Cambridge University Press, 1997.
"Adjustment Disorders." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (October 17, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/adjustment-disorders-0
"Adjustment Disorders." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved October 17, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/adjustment-disorders-0
The development of significant emotional or behavioral symptoms in response to an identifiable event that precipitated significant psychological or social stress.
Adjustment disorders are maladpative, or unhealthy, responses to stressful or psychologically distressing life events, such as the end of a romantic relationship or being terminated from a job.
The American Psychiatric Association has identified and categorized several varieties of adjustment disorders, depending on accompanying symptoms and their duration. These subtypes include adjustment disorder with depressed mood , with anxiety, with anxiety and depressed mood, and with disturbances of conduct. The disorders can additionally be classified as acute or chronic. It is thought that adjustment disorders are fairly common; recent figures estimate that 5 to 20 percent of persons seeking outpatient psychological treatment suffer from one of these disorders. Psychiatrists rigidly define the time frames in which these disorders can occur to differentiate them from other types of responses to stressful events, such as post-traumatic stress disorder and acute stress disorder. Adjustment disorders must occur within three months of the stressful event and can, by definition, last no longer than six months.
Symptoms of these various adjustment disorders include a decrease in performance at work or school, and withdrawal from social relationships. These disorders can lead to suicide or suicidal thinking and can complicate the course of other diseases when, for instance, a sufferer loses interest in taking medication as prescribed or adhering to difficult diets or exercise regimens.
Adjustment disorders can occur at any stage of life. In early adolescence , individuals with adjustment disorders tend to be angry, aggressive, and defiant. Temper tantrums are common and are usually well out of balance with the event that caused them. Other adolescents with adjustment disorders may, alternately, become passive and withdrawn, and older teens often experience intense anxiety or depression . They may experience what psychologists call "depersonalization," a state in which a person feels he or she can observe their body interacting with others, but feels nothing.
Many psychological theorists and researchers consider adjustment disorders in adolescents as 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 their parents. This sort of psychological maneuver may precipitate problems in families as adolescents begin seeking individuals outside the family as replacements for their parents. This can be particularly destructive when these feelings of dependence are transferred to involvement with gangs or cults .
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.
Nicholi, Armand, ed. The New Harvard Guide to Psychiatry. Cambridge, MA: Harvard University Press, 1988.
"The Not-So Maddening Crowd: Crowding Stress Leads to Coping Behavior in Primates." Discover (February 1994): 14.
Shanok, Rebecca. "Coping with Crisis." Parents Magazine (October 1991): 169.
"Adjustment Disorders." Gale Encyclopedia of Psychology. . Encyclopedia.com. (October 17, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/adjustment-disorders-2
"Adjustment Disorders." Gale Encyclopedia of Psychology. . Retrieved October 17, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/adjustment-disorders-2