Adjustment Disorder

A normal part of child development involves experiencing events that are unexpected or unpleasant and learning how to overcome these challenges. However, for some individuals, recovery after a stressful event is not so easy and distress appears long after the event is over. Children who exhibit problematic reactions to stressful experiences beyond typical levels may be demonstrating symptoms of an adjustment disorder.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000) describes adjustment disorder as a child's response to an identifiable stressor that is much more severe than would be expected. Adjustment disorder also applies when the reaction is expected or typical, but reaches the threshold for an adjustment disorder when that reaction begins to impair the child's social or school functioning. For example, if a child performed poorly on a test, it would not be surprising if, afterwards, the child had some significant anxiety when it was time to take another test. If, however, that anxiety prevented the child from being able to go back to school, the child's overly anxious response would begin to fit the criteria for adjustment disorder.

The duration of the distress and degree of impairment are also important. The diagnosis is not given until the symptoms are present for at least three months since the stress event ended, but not longer than six months. A less-than-six-month period of distress is deemed acute. The problem is considered chronic when the reaction is in response to a chronic stress event. That is, if the stress event is ongoing (e.g., poverty), the symptoms may persist longer than six months and still meet criteria for a diagnosis of adjustment disorder. However, if the event is not an ongoing event and the symptoms of distress continue past six months, the child may qualify for another disorder (e.g., depression, anxiety). In the latter example, further assessment would likely be needed.

Children with adjustment disorder often feel depressed and anxious. As a result, they often act out against the rules at home and in school. Teachers may notice that some children, who otherwise have been well behaved, may develop serious maladjustment problems after exposure to a stressful event. Other children exposed to the same stressful event may withdraw and become socially isolated. Both the acting out and the withdrawal types of reactions are included in the scope of the adjustment disorder diagnosis. Children in the midst of an adjustment disorder are likely to perform poorly in their schoolwork. Furthermore, they are likely to gather very little support, as their emotional and behavioral difficulties tend to create distance in their family and peer relationships. A key to the diagnosis is the documentation of the change in behavior (both internalizing and externalizing), the duration of the symptoms, and the impairment in functioning.

The distress associated with adjustment disorder can be related to suicide, suicide attempts, substance use, and physical complaints. The combination of an adjustment disorder with a preexisting medical illness may worsen the medical condition. Specifically, the symptoms of adjustment disorder can exacerbate the course of an illness, interfere with adherence to a medical regime, or lengthen a hospital stay. For children with medical conditions, the presence of a co-occurring adjustment disorder may result in increases in time spent outside the classroom and away from peers.

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