peer review431

Abstract

Adjustment disorder is a mental illness with symptoms of continuous sadness, low moods, hopelessness, worthlessness and physical symptoms causing unproductivity in work, school and social life. Adjustment disorder is triggered by a stressor which makes the patient unable to cope, causing mental disturbance. Adjustment disorder in children is prevalent especially due to dysfunctional families where the parents are frequently in conflicts, aggressive behavior and separation or depression. The adjustment disorder is diagnosed according to the DSM-V criteria to differentiate the disorder from other mental diseases with similar symptoms or which co-occur with adjustment disorder. Once diagnosed, the patient is treated through a therapy approach to teach the child coping skills which will help deal with the symptoms and prevent the disorder from re-occurring in the future. The diagnostic paper details the symptoms in children from families with parental conflicts, causing the onset of the disorder and how the disease can be treated.

Adjustment Disorder: Effects of Parental Conflict

Diagnostic Criteria for Adjustment Disorder

Depressive symptoms occur in parents with young children which may affect the child’s development significantly. Children from homes with conflicts internalize the depression and show symptoms of anxiety and depression such as delinquency and aggression. Parental conflict directly affects the wellness of the children and indirectly through the adjustment of the custodial parent and the frequency of the interaction with the noncustodial parent. Adjustment disorder is the behavioral or emotional symptom expressed in response to an identifiable stressor occurring in three months of the onset of the stressor (Davis et al., 1998)

Diagnostic Criteria (DSM-V)

The children show loss of interest in daily activities including playing and education in more than two weeks.

The child shows depressed moods for more than two weeks- the child feels sad nearly all, feels empty or appears tearful

Distracted social, educational and functional performance

Suicidal thoughts- The child expresses thoughts of suicide or death, or even makes a suicide plan

Loss of concentration- The child’s ability to concentrate or think decreases and the child becomes indecisive

Feelings of Worthlessness and guilt- The child blames him/herself for her situation and expresses feelings of worthlessness

Low energy levels and Fatigue- The child becomes physically inactive and shows symptoms of fatigue

Change in behavior and activity-The child shows retarded growth and psychomotor agitation

Sleep disruption- The child either sleeps less or more than normal; hypersomnia or insomnia respectively

Significant change in appetite and thus body weight- Some children may eat more or experience loss of appetite

Note: As proposed by DSM-V, symptoms of anxiety may indicate depression. The therapist should thus look out for symptoms like irrational worries, trouble relaxing, fear that awful things will happen, and feeling tense (U.S. Department of Health and Human Services, 2019).

The therapist must screen for conditions that co-exist with or mimic the symptoms of adjustment disorder. Such conditions include medical illnesses which cause low energy levels, reduced concentration and performance and depressed moods, other mental illnesses like bipolar, mania, schizophrenia, hypomania, etc. Other conditions to screen for include substance abuse which causes depression, suicidal feelings, change in sleep and habits eating. Bereavement may also cause similar symptoms with adjustment disorder including feelings of worthlessness, functional impairment, suicidal feelings, among others, and thus the child needs to be screened if they experienced bereavement and if they have been able to recover from it (U.S. Department of Health and Human Services, 2019).

Adjustment disorder symptoms must be present and diagnosed within the first three months of the stressor event, before anxiety disorder, depression, or other mental illnesses are diagnosed. In comparison to other mental illnesses, adjustment disorder symptoms are mild in nature. If the stressor is removed, the symptoms decline within six months but when ignored, the disorder may escalate to severe mental illnesses.

Prevalence and Incidence of Adjustment Disorder

Patra and Sarkar (2013) emphasize the commonality of diagnosis of adjustment disorder, and the high rate of comorbidity it carries. Although adjustment disorder may be common, the DSM-V (2013) states that prevalence varies in relation to the population studied. Approximately 5% to 20% of individuals treated via outpatient mental health services received a principle diagnosis of adjustment disorder, whereas 50% of individuals in a psychiatric hospital setting were reported as receiving treatment for adjustment disorder (APA, 2013).

By definition, according to the DSM-V (2013), within three months of the onset of a stressor the disturbances related to adjustment disorder begin. Such disturbances do not last longer than six months after the discontinuance of the stressor (APA, 2013). The onset of the disturbance is most often immediate, lasting a relatively brief amount of time if the stressor is an acute event (APA, 2013). However, if the stressor is persistent the adjustment disorder may also be persistent. Disadvantaged or vulnerable children encounter an increased rate of stressors and therefore are at greater risk for adjustment disorders.

Criterion for adjustment disorder includes clinically notable symptoms, yet the notion of normalcy is obscure. What constitutes as a notably normal symptom can vary across culturally different groups (Patra and Sarkar, 2013). An account of an individual’s cultural context should be considered when evaluating their response to a stressor and when clinically judging whether the response is maladaptive or exceeding expectancy (APA, 2013). Stressors and coordinating responses differ across cultures due to the varying nature, meaning, and experiences associated with stressors (APA, 2013).

Review of Theoretical Perspectives on Causes of the Disorder

Adjustment disorder is explained by theories to understand its causes and treatment. First is the developmental theory which states that the problem occurs in early life of the children when exposed to a stressor like being withdrawn from their parents and may go on to teen-age (Sturge‐Apple et al., 2006). The theory suggests that the children with the disorder experience trouble coping like other children, which affects their learning and functionality independent from a person they are emotionally attached to, especially a parent or a care giver with whom they are close to. The condition disrupts normal child’s development and goes beyond the toddler years. L

earning theory is also used to explain the adjustment disorder in children. The theory suggests that the negative behaviors and symptoms of the disorder are learnt from people in the child’s environment (Strain and Friedman, 2011). Children learn their parent’s attitude and emotions especially due to marital conflict, violence, and divorce and mirror the same behavior. Use of negative reinforcement increases the child's adjustment disorder behaviors since the child is able to attract reaction and attention from the parents and others, which what they at times desire (Brummert Lennings and Bussey, 2017). Adjustment disorder causes depressed mood due to psychosocial stressors but the depressive mood is not severe to be described as a depression disorder.

Children are largely affected by their parents’ divorce, and they find difficulties adjusting. The children are disrupted by their parents’ marital distress, partner violence, bitter divorce and unfair criticism of one parent by another (Patra and Sarkar, 2013). The reactions of the child consists of the beginning or worsening of an internal loyalty conflict, somatic complaints, psychological symptoms, and in the end may lead to parental alienation, causing a strained parent-child relationship. The affected children may produce physical, affective, cognitive, and behavioral symptoms depending on the level of distress within the parental relationship. Research shows that apart from the adverse effects of physical and verbal violence on a child’s mental health, conflict between parents, even in the absence of violence, influences children. The levels of disharmony constitutes a critical environmental difficulty which exposes children to developmental and mental health risk. As consequence of their exposure to distress within the parental relationship, children react to such domestic and parental conflict by demonstrating heightened physical, affective, cognitive, or behavioral symptoms.

According to Keller et al. (2009), children who witness intense, frequent and poorly resolved conflict between parents are at greater risk for several negative developmental effects including increased anxiety, drug and substance abuse, depressive symptoms, criminal activities, antisocial behavior, aggression, poor academic attainment, and suicidal thoughts, all of which are symptoms of adjustment disorder.  However, it is important to note that parental conflict must be perceived as a natural and normal aspect of family life, which affects the child depending on its duration, severity and intensity, nature of conflict, the degree of its resolution, and not on simple incidence of mild conflicts between parents (Kressel, 1988).

Parental alienation is when parents reciprocate conflicts, by way of revenge to show power. In such cases, the child develops a loyalty conflict, and not parental alienation, which mostly occurs after the end of parental relationship.  Moreover, separation and divorce is a great risk factor since it is a potentially and critical traumatic event and may commence or escalate violence between the couple. Violence and aggression between partners make the process of divorce more challenging, thus doubling the risk of adjustment disorder for partners by developing depressive moods, among other symptoms and for children who are exposed to a double stress due to parents’ separation and violence. Additionally, violence during the separation process increases the negative post-divorce results due to the difficulty in settling general agreements amongst themselves and deciding on matters of co-parenting relationship, and child custody, which further affects the child’s wellbeing (Maercker et al., 2015). Thus, some researches emphasize that the divorce, separation, and parents’ marital conflicts are significant stressors that trigger adjustment disorder in children causing developmental disorders, and the child copies the parents’ behaviors as explained in the learning theory. The negative effects of marital conflicts on children's adjustment could be resolved by developing a stable co-parenting agreement to reduce the perceived parental distress (Davis et al., 1998)

Review of Treatment Approaches

The primary objective of the treatment for adjustment disorder is to relieve symptoms and help the patient regain normal functionality as they used to have before the occurrence of the stressor (Israelashvili, 2012). Adjustment disorder in children caused by parental marital conflict can be treated through family therapy, individual psychotherapy, self-help groups and behavior therapy. The therapist should first understand the intensity of the condition by assessing the symptoms in the child and then developing short-term realistic goals with the therapy will seek to achieve. The therapy focuses on recognizing the social support system the patient has including the available parent, friends, family, and the community.

As held by Saint Leo, the therapists should respect and value all individuals unique talents, the dignity of life and should be committed to excellence in their work. Thus, the therapists should offer professional services to all their clients, including the children from hostile families, to help them cope with the stressors causing the mental disorder. The aim of the therapy sessions should be to restore the normal life for the distressed children to help them achieve their full potential in their social, emotional and functional lives, thus regaining their human dignity. The therapy sessions use the child’s existing skills to help them fully utilize them to cope with their situation. Saint Leo’s value of respect also states that the community depends on the diversity and unity of the people, free exchange of ideas and learning, living and working harmoniously. The patients are dependent on the therapists and doctors to help them recover from the symptoms disrupting their normal lives and lowering their dignity. Both the patient and the therapists should cooperate to achieve the objective. The patient will be counseled on how to handle their stressor to avoid symptoms that make it hard for them to co-exist with the community effectively. Saint Leo’s value for respect code is a key guide to the treatment of the adjustment disorder.

Therapists and their patients explore and develop coping and problem-solving skills to help children cope with the divorce, separation, violence or marital conflict. Sessions also involve exploring relaxation techniques to help children overcome the feelings of stress. Therapists can help children understand their role in the stressor, to review and reinforce the positive steps a client may have taken, and to teach new coping techniques to overcome the situation both now and in future stressors. The role of a therapist is to help affected children understand their reaction to the stressors and to view them as opportunities for improvement and positive change.

Due the stressor is family conflict, family therapy is an effective technique for treating adjustment disorder (Zemp et al., 2018). The family may jointly attend a therapy where they are all taught coping skills and communications skills to reduce the tension which intensifies the depressive symptoms in the child. For severe cases, antidepressants may be used alongside psychotherapy. The medication relieves the child of depression and stress symptoms caused by the disorder to help them effectively engage in the psychotherapy. In many cases, adjustment disorder does not require treatment as it fades away within three to six months after the occurrence. The children are provided with stable social support system, sleep pattern and healthy diet (Zemp et al., 2018).

Case Study

Celine is a 10-year old girl. She was referred for counseling due to her recent disruptive behavior. Celine’s parents divorced recently and she is living with her mother and her baby sister (2-years old Phiona). Celine says that she feels very sad almost the whole day for the last two weeks. She says she rarely feels happy after her parents divorced (Amato, 1993). Celine expresses hopelessness and she said she felt like her entire life will be sad and boring. Celine has reduced concentration levels, is feeling anxious and worried. Celine says she feels tired almost at all times and is unwilling to engage in any physical activities. Celine says she feels angry and explodes very fast, and in a recent episode could not control her temper and hid Phiona, her baby sister. After that incident, she felt guild and unworthiness and locked herself up in her room.

Celine states that her parents’ divorce caused substantial changes in her family life and she at times feels like taking her own life. Celine was diagnosed with Adjustment disorder with disruptive behavior. The doctor recommended individual psychotherapy and took her through six sessions of counseling. It was discovered that Celine’s coping mechanism was withdrawing from people, as she says being with people cause her arguments and fights (Amato, 1993). She knows that that is not the right thing to do and wishes to know how to cope with what she is feeling. She wishes to change her reactions and to feel better in all areas of her life. Celine complied with all aspects of the therapy in teaching her coping techniques and the therapist is confident that in six weeks she will be leaving a normal life and resume her academic and functional activities. Celine will be able to lead a normal life, even after experiencing the pain of seeing her parents in marital conflicts all through her life, and the recent divorce which affected her intensely.

Conclusion

Research shows that parents verbal and physical aggression negatively affect the children’s mental development leading to adjustment disorders. The parents marital conflicts increases the children’s externalizing and internalizing problems leading to disruptive behavior including depressed moods, stress, anger, sadness, reduced energy levels, poor academic and functional performance, feelings of unworthiness and suicidal feelings and attempts, among other self-harm behaviors. Adjustment disorder can be easily confused with other mental disorders, which have similar symptoms. However, the DSM-V definition clearly differentiates the disease by giving diagnostic criteria to separate adjustment disorder from depression, oppositional disorder, bipolar, among others. First the definition says that the adjustment disorder is triggered by a psychosocial stressor. The patient is screened for clinical conditions, bereavement, or substance abuse. The diagnostic criterion is then used and if positive for adjustment disorder, psychosocial therapy is recommended. Adjustment disorder can be treated through family therapy, individual therapy, and behavior therapy and self-help groups. The patient is taken through the journey of identifying their role in controlling the stressor and in developing coping skills to be able to overcome the symptoms. Where the child is experiencing severe depression and stress symptoms, medication may be administered together with the therapy. The disorder symptoms can disappear within six months even without intervention by having a strong support system.

References

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