Adjustment disorders in childhood

General

  • Adjustment disorders are reactive disorders associated with the child's life situation.
  • The balance between individual predisposition and resources, on the one hand, and the mental burden, on the other, play an important role in the genesis of the disorder.
  • Life changes, such as moving house, the parents’ divorce, losses, separation from family, being bullied or the patient’s or a family member’s illness can lead to an adjustment disorder.
  • Reacting to changes in life is normal. Having such a strong reaction to a psychosocial stressor that it disturbs social functioning is called an adjustment disorder.

Epidemiology

  • The prevalence of adjustment disorders is not known exactly but according to some studies it is 2–8%.
  • Determining the prevalence is complicated by the tendency to spontaneous recovery and by the fact that the duration of symptoms is one of the diagnostic criteria – if symptoms persist, the diagnosis needs to be defined further.
  • Adjustment disorders are more common in certain groups of paediatric patients and among children who have had changes in life and stressful experiences, when compared with the average population.

Symptoms and clinical picture

  • Symptoms appear within one month after a change or stressful event.
  • If they persist for more than 6 months, the diagnosis must be further defined depending on the symptoms.
  • An extended depressive reaction may persist for more than 6 months.
  • The symptoms are similar to those of many common mental disorders. The clinical picture depends strongly on the child's age and stage of development.
  • Symptoms may include various emotional symptoms (such as anxiety, depression or psychosomatic symptoms), behavioural symptoms (such as restlessness or aggressiveness), regressive behaviour (such as secondary nocturnal enuresis, clinging behaviour or thumb sucking) or combinations of various symptoms.
  • The reactions of parents and other individuals close to the child to the stressor behind the disturbance, as well as their capacity and possibilities for supporting the child, probably play a role in the occurrence of adjustment disorder, as well as in recovery.
Types of adjustment disorders

  • Brief depressive reaction
  • Prolonged depressive reaction
  • Mixed anxiety and depressive reaction
  • Adjustment disorder manifesting as other emotional disorder
  • Adjustment disorder manifesting as conduct disorder
  • Mixed emotional and behavioural disorder
  • Adjustment disorder manifesting as other symptoms

Treatment

  • There is little scientific information available on the treatment of adjustment disorders.
  • Mild adjustment disorders can be treated in primary health care.
  • In primary health care, a child's reactive symptoms should be recognized, the duration and severity of the disorder, as well as the child’s functional ability in relation to his/her environment should be assessed, and the need for further examination and treatment should be defined.
  • If a child has somatic symptoms or regressive behaviour, it is important to investigate any psychosocial stress in addition to performing a physical examination.
  • Guidance of the child and the family, support visits and cooperation with the day-care centre or school, as necessary, together with follow-up may be sufficient to support recovery.
  • In more severe cases, cognitive therapies have proved effective.
  • According to current knowledge, children and adolescents recover relatively well from adjustment disorders. Early diagnosis and treatment are considered prognostically important.
  • If there has been an exceptionally severe, threatening or shocking event, the possibility of developing an acute stress reaction or post-traumatic stress disorder should be kept in mind.
  • If stress is also experienced by the parents, taxing their emotional resources available for parenting, the need for individual help for the child should be separately assessed.
  • Children can also have post-traumatic stress disorder (PTSD) (for adults, see (Acute stress reaction and post-traumatic stress disorder)), even more often than expected, and this may be more difficult to recognize in children than in adults.
  • After any threatening or shocking event, it is important to calm things down and to increase the feeling of safety with support by close adults. Debriefing has not been shown to be useful in the prevention of post-traumatic symptoms.
  • After a traumatic event, a child’s symptoms and adjustment should be followed up together with the parents or other adults taking care of the child. Children showing symptoms should be assessed individually and referred for child psychiatric treatment, as necessary.
  • A child may be traumatized in many ways if subjected to extended or recurrent traumatic experiences and showing extensive symptoms.

Related resources

  • Cochrane reviews

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