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MNAAP Newsletter

Diagnosis and Treatment of Adjustment Disorders

By Joel V. Oberstar, MD, CEO and Chief Medical Officer at PraireCare

Many youngsters experience adverse childhood events and psychosocial stressors and seem to take it “all in stride.” Indeed, many clinicians who work with children on a regular basis find their resilience to be inspiring.

Some kids, however, find that adverse events and the stress of everyday life can become overwhelming. In those instances, accurate diagnosis and treatment of a mental illness is essential.

The top three most prevalent mental illnesses in children relate to anxiety, depression and disruptive behavior disorders. Adjustment disorders with disturbance of mood or conduct present in response to an identifiable stressor or stressors occurring within 3 months of the onset of the stressor. In these instances, the symptoms or behaviors are evidenced by either marked distress or significant impairment in functioning, but do not rise to the severity of another specific DSM-IV-TR Axis I disorder (e.g., generalized anxiety disorder, major depressive disorder, etc.).

Treatment of adjustment disorders frequently involves supportive psychotherapy—either individually for the child or for both the child and family—as well as psychosocial supports. A child who has experienced an acute stress related to bullying at school, for example, might respond well to individual cognitive behavioral therapy and social skills training to help him deal more effectively with his peers. Likewise, contacting the school counselor may provide an opportunity for adult intervention with the bully.

Should emotional and/or behavioral symptoms progress in severity, diagnosis of an Axis I disorder is appropriate and more aggressive treatment frequently indicated. In such instances, more aggressive psychotherapy may be paired with pharmacological interventions. For example, a teenage girl who suffers from major depressive disorder relating to parent-child conflict and parent-parent conflict in the home may benefit from interpersonal psychotherapy along with family psychotherapy. Consideration may be given to initiating a low dose antidepressant such as citalopram or sertraline.

In either instance, recognition of the emotional and/or behavioral symptoms is essential to facilitating intervention. All children have access to children’s mental health case management through their county of residence; parents may call themselves to receive support. Referral to any one of a number of psychotherapists for an initial diagnostic assessment is frequently the first step in receiving psychotherapy. Of course, the primary care clinician may elect to initiate pharmacotherapy. Such clinicians are encouraged to utilize the newly established Minnesota Collaborative Psychiatric Consultation Service (referenced elsewhere in the newsletter) for diagnostic and therapeutic support. Referral to a child and adolescent psychiatrist is less commonly indicated but may certainly be appropriate in certain instances.