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
, such as a
. 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
, 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
symptoms manifested by
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
, 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:
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
or cults. However, it should be noted that the APA does classify
adjustment disorder as a mental illness.
divides adjustment disorders into subgroups, based upon the symptoms
manifested most prominently. These subgroups include:
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:
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.
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.
—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.
—A type of psychotherapy in which people learn to recognize and
change negative and self-defeating patterns of thinking and behavior.
—Indirect strategies used to reduce anxiety rather than directly
facing the issues causing the anxiety.
—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
—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.
—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.
—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.
—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:
Federation of Families for Children's Mental Health.
1021 Prince Street, Alexandria, VA 22314–2971. Web site:
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).