Adjustment Disorders and Typical Adjustment

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​Sarah here. This week or shortly hereafter, most school-aged children will be back to school- virtually and/or in person. So, now that you’ve hopefully gotten over the initial hurdle of helping your kids start school, we thought we’d change gears. Over the past several months, Lisa and I have gotten lots of questions about kids developing emotional and behavioral symptoms in response to COVID-19 and the changes caused by the pandemic. While COVID-19 is certainly one of the most salient stressors kids (and adults) are experiencing, it’s certainly not the only one. Given that youth are living in stressful times, we thought it would be useful to differentiate between Adjustment Disorders and typical adjustment or coping difficulties.

Adjustment Disorders involve significant problems coping with stressful events. This diagnosis is currently classified as a Trauma and Stress-Related Disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5thEdition (DSM-5). I wanted to provide some information on the prevalence of Adjustment Disorders in children and adolescents…except I couldn’t find that information. After a 30-minute search, I couldn’t find data about the prevalence of Adjustment Disorders in youth (or adults) in the United States…or anywhere. What I found is that globally, Adjustment Disorders are under-researched and there isn’t a lot of information available about their prevalence in in the general population. They are often seen in primary care and Emergency Departments, are more likely to occur (or be identified) in people with acute and/or chronic medical diagnoses, people receiving inpatient medical and/or psychiatric care, and, not surprisingly, in those who have been exposed to major stressors.  
 
The below table summarizes the diagnostic criteria for and subtypes of Adjustment Disorders, courtesy of Maercker & Lorenz, 2018:

As is apparent in the criteria outlined in the table above, for someone to be diagnosed with an Adjustment Disorder, they need to have experienced a stressor within the past few months and be experiencing a disproportionate amount of stress and/or functional impairment as a result. That in itself is pretty straightforward- if we take into account that there isn’t a one-size-fits-all metric for what “counts” as a stressor or meaning of the word “disproportionate.” Some people can manage mild stressors without incident but when bigger stressful events come their way, they fall apart. Some people can deal with planned major life changes but can’t deal with unplanned stressors. Some people are far more affected by global issues while others are impacted by interpersonal issues. 
 
There are events that we can all agree are both inevitable and stressful- moving, death of a loved one (including a pet) and changing schools. There are other events that aren’t inevitable for all children but if they do occur, we can all agree are stressful- birth of a sibling, divorce, a parent’s military deployment, serious medical illness and treatment (in one’s self, parent and/or siblings), domestic violence and physical or sexual abuse. Then, there are events that we don’t plan for- that we can’t plan for or don’t want to plan for- that may touch our lives- stuff like hate crimes, school shootings, war and global pandemics. While some of these events are traumatic and may result in severe trauma responses, many people experience these stressors indirectly. For example, after the Stoneman Douglas High School shooting in 2018, schools across the country began having Active Shooter/Code Red drills. When they started having drills in our area, a lot of patients who werenot seeing me for anxiety-related issues became incredibly stressed and anxious about going to school. Their anxiety about school shootings was related to the preventative measures that were being taken- not the traumatic event. 
 
All this to say, there isn’t a clear definition of what “counts” as a stressor since we experience life events differently based on our history, thoughts, feelings, attributions, developmental level, intellect, cultural context, etc. In other words, we view life through our own lens. 

Now that we’ve thought through the kinds of stressors that may trigger an Adjustment Disorder, let’s talk about what Adjustment Disorders actually look like. Here again, there isn’t a clear and easy answer because Adjustment Disorders don’t feature a unified set of symptoms. In terms of symptoms, Adjustment Disorders are not as severe as Posttraumatic Stress Disorder (PTSD) or Acute Stress Disorder. While people with PTSD or Acute Stress Disorder may have intrusive thoughts, flashbacks, acute physiological symptoms and engage in significant avoidance, the symptoms demonstrated by people with Adjustment Disorders are far more variable. Individuals with an Adjustment Disorder may present with internalizing symptoms- depressive symptoms or anxiety or both. Alternatively, they may present with externalizing symptoms- conduct problems, being oppositional and/or aggressive. Or, they may present with some combination of both internalizing and externalizing symptoms. 
 
Often, people regress when they’re experiencing stress. That is, they fall back on old habits or behaviors that they had when they were younger and less mature. Think about what happens when adults are faced with a crisis- people may start smoking again or may stop following their health or medical regimen. They may not be their most responsible selves- they may miss deadlines, they may be short with others, they may burst into tears…adults have a hard time adulting when faced with a crisis. Kids and teens also regress when faced with stress- it just looks different. An elementary school-aged child who is struggling to manage stress may start having toileting accidents, start sucking their thumb or want to sleep in the bed with their parents again.    
 
Clinically speaking, Lisa and I often work with kids and teens with Adjustment Disorders. One thing that can be challenging is differentiating between disordered and typical adjustment difficulties. It’s important to consider the whole person in context when making this determination: given the person’s age, developmental level and environment (culture, immediate family, living situation and environment), is his or her response to stress what we’d expect? Is the person’s response to stress getting in the way of his or her life and creating problems (at home, school, with friends, etc.)? Remember that “disproportionate” part of the diagnostic criteria? Here’s where it comes into play. 
 
Don’t get me wrong- some symptoms are clearly severe and problematic, like suicidal ideation or explosive aggressive outbursts. But, many times, I’m not looking for a specific symptom or the frequency or “size” of a reaction. Instead, I’m looking at the functional impairment that the reaction is causing. For example, crying is a common emotional response to stress in children and adults. Crying in itself is not a problem. Crying can be a problem for youth if it impacts peer relationships (e.g., a 4th grader cries when he becomes distressed so his peers call him a “cry baby”) or academic performance (e.g., a high schooler bursts into tears while presenting to the class and refuses to finish her presentation when given the chance, so fails the assignment).  
 
Consider for a moment the many stressors that you experience. Some stressors are daily hassles (e.g., interacting with someone who is rude, forgetting a work deadline), while others may be bigger transitions that you knew were coming (e.g., moving, having a baby or starting a new job) and others may be totally unexpected major changes (e.g., death of a loved one, being in a car accident). You are an adult with years of life experience under your belt and a mature, fully developed brain. Hopefully, you have developed strategies for managing stress when it arises and an adequate support network. So, when you experience these small and large, expected and unanticipated stressors, hopefully you can cope and bounce back, even if you are not a roll-with-the-punches kind of person. 

Now, imagine dealing with some of these same types of stressors as a child or teen- daily hassles (e.g., getting into an argument with a friend, forgetting homework), bigger life transitions (e.g., moving, the birth of a sibling, starting school) and unexpected major life changes (e.g., death of a loved one, being in a car accident). As a young person, you’d have a less mature brain, so your emotional and behavioral self-regulation would be weaker, you may not understand what’s going on as well (intellectually), you may not see the big picture, you probably would be less able to articulate the problem (emotional awareness and intelligence) and you’d have less cognitive flexibility. Your ability to roll with the punches would be lower. As a young person, you’d also have less life experience to guide you and fewer coping skills and social supports to utilize. So, it shouldn’t come as a surprise that kids and teens can have a difficult time managing life’s stressors- even if they don’t “seem” that stressful to us as adults.
 
We all struggle at times to cope with life’s stress. We all manage life’s storms differently- if our reaction is causing problems in our lives and relationships, then that’s a sign that we do need additional support. Know yourself. Know your family. Pay attention to how your kids respond to stress. If you know that your child struggles with transitions, it will probably make everyone’s life easier to ease him or her into transitions. You can also help your child understand that life doesn’t always go the way we plan or the way we want it to. If life throws unexpected stress your way, take the opportunity to talk with your kids about it in a developmentally appropriate way. Model the importance of talking about your feelings, using coping skills and seeking social support. And if you have a hard time dealing with a stressor, that’s okay. You can help your kids see that you’re human too- you get stressed, you struggle, you make mistakes. Doing so can help foster a sense of empathy, compassion and caring in your children. None of us can avoid life’s storms. There are always things to which we must adjust. But the silver lining is that by fostering adaptability in your kids, you’ll be giving your family and the world a huge gift.

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As a reminder, we have an amazing handout for families with information about COVID-19 that you may find helpful when speaking with your kids. Click here to take a look.​​