October 26, 2017
My friend Samantha called me in a panic. Her 8-year-old daughter, Lindsey, was struggling with the fact that her parents were getting divorced. There had been a lot of conflict in the marriage. Samantha’s ex-husband was an alcoholic and, though he was receiving treatment, he had been frequently unemployed. Money had been tight and Lindsey had heard many arguments. Over the past year, Lindsey started to become more tearful and had difficulty sleeping. Her teacher was worried that she seemed sad at school and was reluctant to participate in class the way she used to.
When Samantha asked me what she should do, I suggested that she have Lindsey speak with a psychologist to determine whether Lindsey was having a fairly normal reaction to a stressful time or whether she was more significantly depressed.
Samantha found that Lindsey seemed better even after just a few appointments. Samantha was feeling much relieved – that is, until she got the bill from the psychologist, at which point she called me quite alarmed. “My child was diagnosed with an adjustment disorder! I had no idea things were so bad,” she said.
The words “adjustment disorder” seemed to imply a child who had many problems and who was poorly adjusted. Though it sounds scary, it usually is not. I assured her that despite the extreme-sounding name, a diagnosis of “adjustment disorder” simply meant that Lindsey was having difficulty adjusting to something in her environment. In fact, very often psychologists and psychiatrists will use the diagnosis when no other, more significant diagnosis (like depression or generalized anxiety) is appropriate.
“Once the stress is resolved or the person has started to cope with the change in circumstance, the symptoms start to fade.”
The official DSM-5 definition of an adjustment disorder is “The presence of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within three months of the onset of the stressor(s).”
The response to the stressor has to be more than a typical reaction and the symptoms have to cause the child a problem with his or her ability to function. The impairment has to be the result of the stressor and not an escalation of a problem that had been there before the stress occurred. Once the stress is resolved or the person has started to cope with the change in circumstance, the symptoms start to fade (within six months according to the DSM criteria).
In Lindsey’s case, her reaction to her parents’ divorce was causing her problems emotionally, in that she frequently cried and seemed sad. Her ability to function in school started to decline. Before the stress, Lindsey was a happy-go-lucky kid, so this wasn’t something that made a previous issue worse. Her problems weren’t better accounted for by another psychological disorder, like depression or anxiety. Once she started to talk about things, she started to feel better. All of these symptoms made an “adjustment disorder” the appropriate diagnosis for Lindsey.
Adjustment disorders can fit one of six subtypes. So, while all of them share the criteria mentioned above, they need to fit one of the following more specific categories:
When making a diagnosis of an adjustment disorder, the clinician will evaluate what types of symptoms seem primary. Is the child reacting to the stressor by feeling down or depressed? Is she anxious? Or is it a combination of the two? Sometimes kids react to stress by acting out – or having conduct problems such as becoming disruptive, acting aggressive, or violating rules. Sometimes it is hard to pinpoint any particular symptom, and that’s where the diagnosis of “unspecified” would be appropriate. In Lindsey’s case, she was given a diagnosis of “adjustment disorder with mixed mood and anxiety,” as she was sometimes sad (moody) and sometimes anxious.
As with any diagnosis, a diagnosis of “adjustment disorder” is used as a guide for treatment. In Lindsey’s case, her therapist used cognitive-behavior approaches to help her develop appropriate coping skills, communication skills, and stress management skills. She helped the family make some needed changes within the family system, such as improving communication, family interactions, and family support. She also collaborated with Lindsey’s school and they identified some strategies that would be helpful for Lindsey at school, such as checking in with her guidance counselor when she felt anxious.
Take away messages:
Within a few months, Lindsey was coping much better. Lindsey learned that she could cope with difficult situations and gained confidence in herself, making it more likely that she will successfully adjust to other unexpected situations that she will inevitably face.