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.
Welcome back! Lisa here. Hopefully Sarah’s post last week helped you find some bright spots in in our current situation, or at least have a good laugh. Now that the school year is underway in many places, your kids are likely starting to be assigned homework. Yes, the dreaded homework time is back. If your kids are doing virtual school or homeschooling, the “homework hour” may have become the homework day.
Are you expecting (or already experiencing) tears, yelling, begging, storming out of the room? Or maybe you anticipate homework stretching into an all-night affair due to dragging feet and off task behavior?
Every year, Sarah and I talk with parents and their kids about the battles that occur at home over homework. Instead of homework being used to practice skills and cement knowledge, it becomes a source of frustration, anger, and conflict that leaves both parents and kids feeling demoralized.
But what if homework time could be different?
Here are some useful strategies that you can adapt for homework time at your house.
Set up a dedicated homework area: This one might seem obvious, but there are some important features that need to be present. Having an area that is dedicated to homework signals your child’s brain that it’s time to work. So, an area that is also used for other things, especially for fun things, sends the opposite message. If the homework spot is at the kitchen table, don’t be surprised if you see more snack breaks and socializing.
Find a spot in your home that you can use solely for homework. This can be a desk, a table, etc. that is not used for anything else. If you’re doing virtual school or homeschooling this year, having a room set up for “class” is very helpful. If space is an issue, it may be helpful to have a homework space that can be put up and taken down daily (e.g., set up a folding table for the day’s schooling and then putting it and school materials away neatly at the end of the school day so that the room can be used for other purposes).
Once you’ve selected your homework space, make sure you set it up with all the necessary materials to complete work- pens/pencils, paper, folders, staplers, crayons, markers, etc.- anything your kids may need to complete homework for each subject. If you’re anything like Sarah, this is a great time to indulge in your love for back-to-school supply shopping. It’s okay to buy duplicates of items you already have elsewhere in the house and keep the new items in the homework area. If the supplies are right at hand, less time will be spent roaming around the house looking for a pen or a piece of scrap paper and your kids can get right to work.
Minimize distractions: Having a dedicated homework spot is important. To be effective, this location also needs to be in an area with minimal distractions. This means it should be out of sight of the television and is ideally in a low traffic area. For some kids, this may be in their bedrooms. For others, this may be at a table set up in a room that is infrequently used. For homes that are short on space, homework may be done in the family room, but the television remains turned off (and sometimes unplugged ). In families with siblings it’s often helpful for each sibling to have their own homework space where they can’t distract one another. It’s also really important that electronic devices are turned off or put away unless they are being used to complete an assignment.
Routine, routine, routine: Having a set homework time and schedule helps kids start their homework and stay on task. If your kids get into the habit of starting homework at a certain time or after a certain activity (e.g., after practice, after an afternoon snack), there will be less resistance to getting started. They will also be less likely to get involved in a fun activity that they won’t want to stop.
If your kids have trouble getting started even with a set homework time, it’s often helpful to sit with them to help them figure out the order in which they will complete their assignments. Some kids like to tackle each subject in the same order each day, while others like to vary the order day to day. But many kids, and not just those in elementary school, benefit from help with getting organized and figuring out the best order in which to complete assignments. This has the added benefit of ensuring that they don’t forget to complete a particular assignment. As a side note, giving your kids some choice here is important. In most cases, the order they do their assignments in doesn’t really matter, so let them choose. Over time, they’ll figure out the order that works best for them.
Something that often gets overlooked during homework time is breaks. Yes, that’s right, breaks. It’s really hard for kids of all ages to sit down and do all their homework in one long block of time. When you’re helping your kids come up with their homework schedule for the day, make sure to help them decide when they will take breaks. This may be after completing a particular assignment or it may be after a set amount of time, or even a combination of the two. Over time, you and your kids will figure out what works best. Here’s the key- breaks should not be long and should not involve preferred activities. A 5-minute break where your kids get up and move around, maybe go to the bathroom or get a drink of water are great. So are movement breaks where they get up and stretch or do a brief physical activity. Your kids shouldn’t stray too far away from the homework area and should avoid too much interaction with the rest of the family as this will make it harder for them to get back to work. Your kids, especially those who are more easily distracted or resistant to homework, may need reminders to end breaks.
Now, if you’re not home during homework time, you’re going to have to get a little creative. You may do phone or text check-ins, or your kids may send you a message if they need help setting their homework schedule. You may set up the schedule the night before and talk with your kids about how they will adjust it based on the assignments they get. You may even need to get other people involved- maybe a relative or family friend can help with homework duty.
Check in, but don’t micromanage: Kids vary in the amount of assistance they need with homework. Some may need you to sit with them while they complete tasks and others may just need you to check their work once they finish. For most kids, they at least need periodic check-ins to ensure that they are staying on task. For those attending school virtually, they will likely require more frequent check-ins if you are not the one providing their instruction. However, and this is important, give only as much oversight/monitoring as is necessary. No one likes to be micromanaged, especially kids. Give your kids a chance to monitor their own progress- if they struggle, then step in and provide just enough support to get them back on track. Avoid the urge to rescue them by stepping in and taking over.
Provide support and encouragement but let them do their own work: If your kids struggle with homework, it can be tempting to walk them through it step-by-step. Some kids may need this for particular assignments or problems/questions, but most do not. I know it’s hard to see them struggle and it’s even harder to allow them to turn in homework that is not 100% correct. But, an important part of the learning process is your kids learning how they learn. If they struggle and you tell them how to do it, they don’t actually learn very much. However, if you guide them in figuring out the answer, they learn a lot more- not just the information required by the task, but the best ways for them to learn and understand new information. They also learn that they are capable of figuring things out either on their own or with minimal help.
Rewards and celebrations: It would be great if kids immediately saw the usefulness of homework and were internally motivated to complete it.
Ok, you can stop laughing now. In the real world, most kids are not fans of homework. You may get some traction with reminders that homework is important to their grades, but many kids will need more than that to keep them motivated. Now, you don’t need to throw a parade every time your kids do their homework. But, rewards and incentives for homework completion can be helpful. This is a good time to check in with your kids’ teachers, since many teachers set up classroom reward systems that include homework completion. If that’s the case for your kids, you can use reminders of the teacher’s system as an incentive. Otherwise, you can come up with your own reward system. This does not need to be complicated. You know your kids- they may respond to small daily rewards, like being able to stay up an extra 15 minutes or they may be great at working toward longer-term goals, like a trip to the pool for completing the week’s homework. The rewards don’t need to be huge and it’s better if they are things that don’t cost you money- that can get very expensive very quickly. Also, whatever system you set up needs to be sustainable and you have to be willing to make adjustments as needed.
Communication is key: Communication with your kids and with their teachers is important. Communication with teachers ensures that you understand their requirements for homework, including grading and how they use homework to support learning. This is especially important for younger kids- high school students can usually (but not always) be more independent. It’s also great to make sure you understand how each teacher informs students about assignments (e.g., assignments written on the board, where assignments are posted in the classroom online portal). The other vital part of communication is with your kids. A common complaint Sarah and I hear from kids is that their parents don’t listen to them about their homework. Ask your kids to explain their homework assignments to you. If something doesn’t sound right to you, avoid jumping right in and correcting them- this sends kids over the edge and they are a lot less likely to listen to your input. Instead, ask clarifying questions. If you have information that seems different from what they tell you, let them know that and ask them to help you understand. This is a more effective way to get them to listen to your input. Many times, parents learn that their information is outdated or that the teacher gave the students additional information during class. If the two of you can’t come to an agreement, it can be helpful for you or your kids to reach out to their teacher or to a classmate to clarify the assignment.
Find what works: Now that you’re armed with some ideas, try one or two at a time and see what works for you and your kids. Homework may be unavoidable, but homework time doesn’t have to be miserable. Having a plan and working with your kids to figure out what works makes life a whole lot easier and homework a whole lot less stressful.
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Click here for a printable version of this post.
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.
Feel free to peruse our blog and see what Sarah and Lisa had to say about topics related to your needs as a busy parent. We will talk about everything from parenting values, to life hacks, to realistic self-care.