Psychiatric Disorders: Adjustment Disorader
Corinn Johnson, B.S

You may have noticed that in the last couple of newsletters we have featured articles about psychiatric disorders. We are trying to help people understand how psychiatric disorders are diagnosed, as well as how some of the symptoms may differ for individuals with intellectual disabilities (ID). In this edition we will discuss Adjustment Disorders.

What are Adjustment Disorders?
Adjustment Disorders are characterized by "clinically significant" emotional or behavioral symptoms resulting from environmental stressors. We all sometimes exhibit emotional or behavioral reactions to things that happen in our lives, so it is important to understand the meaning of "clinically significant." This classification is used when the person is so upset, or his or her behavior is so disruptive, that it interferes with the activities of daily life, every day, for at least two weeks.

Adjustment Disorders can easily be confused with other types of mood disorders. This will be discussed more in a bit. The main difference, though, is that Adjustment Disorder occurs in response to an identifiable stressor, and it will either resolve or evolve within six months of the stressor's end. If it resolves, the symptoms stop and the person returns to their normal ways of coping. If it evolves, the person's mood or anxiety will continue to suffer even though the event is long past.

So what are these "stressors" that can cause such disruption? Stressors are events that happen in a person's life that change their situation. They can be positive (like getting married) or negative (like losing a job), but both types of stressors impact daily life. Sometimes it can be hard to understand why positive stressors can lead to mood problems, but think about all the changes that can happen to you when something wonderful occurs. Change can be hard on people, even when it is good change. For example, if you get married you may then have to deal with moving, sharing space with someone, getting used to their ways of doing things, etc. So, although you are happy about your marriage you may still feel stressed about all of the changes.

For an adjustment disorder to be diagnosed, the problems must begin within three months of when the stressor first occurred. The stressor(s) must lead to more distress than what would have been expected and lead to difficulty managing daily life. Usually the symptoms will subside within six months of the event that caused them. However, in the case of chronic stressors (such as a prolonged illness) or ongoing consequences of the event after it occurs (such as a parent's death leading to a child's being shuffled around to several new caregivers), the Adjustment Disorder symptoms may last much longer.

What kinds of stressors can lead to Adjustment Disorders in people with ID?
Stressors can be a single event (termination of romantic relationship) or multiple events (family problems), intermittent (concerns about being able to pay monthly bills) or continuous (living in a dangerous neighborhood), they may affect a single individual, an entire family, or a larger group or community (like a natural disaster), and may also accompany developmental events (going to school, leaving home, failing to attain goals). For individuals with ID stressors may occur frequently and require coping skills and resources that the individual may not possess.

Common stressors specific to this population include moving to a new home or away from family, the loss of or change in status of an important caregiver, promotions in educational, vocational, or residential placement, and/ or the onset of illness. Additionally, many stressors (such as a stressful job or bothersome housemate) are beyond their power to change and may only resolve after negotiations with caregivers, administrators, or guardians.

What are the symptoms you might see in an individual who also has an ID?
Symptoms vary by the type of Adjustment Disorder seen, as summarized below:
Adjustment Disorder with Depressed Mood: This subtype is characterized by depressed mood, tearfulness, feelings of hopelessness, and other features of Major Depressive Disorder (if you keep your newsletters, we featured Major Depressive Disorder in winter of 2008). Symptoms that may be present in individuals with ID can include clinginess, apparent loss of skills, withdrawal, and irritability.
Adjustment Disorder with Anxiety: This subtype is characterized by feelings of anxiety or worry. For those with ID we may see symptoms similar to the depressed subtype such as clinginess, apparent loss of skills, irritability or anger, as well as aggression, self-injury, and fear of separation from caregivers. Adjustment Disorder with Mixed Anxiety and Depressed Mood: This subtype is characterized by a combination of both depressed and anxious symptoms.
Adjustment Disorder with Disturbance of Conduct: This is characterized by the violations of the rights of others or norms/rules (such as vandalism, fighting, etc.). With individuals with ID one may see self-injury, threats, aggression, property destruction, and an increase in the frequency or severity of pre-existing challenging behaviors.
Adjustment Disorder with Mixed Disturbances of Emotions and Conduct: This is characterized by a combination of emotional symptoms (depression and/or anxiety) and behavioral disturbances (aggression, self-injury and destruction).

As you can see, there is a lot of overlap in these symptoms so making a diagnosis requires good information about exactly what kind of distress the person is experiencing. In the end, though, the first-line treatments are the same, regardless of what type of Adjustment Disorder the person has. We'll talk a bit about treatment later.

How can caregivers help to identify Adjustment Disorders?
Because a diagnosis can only be made if symptoms began within three months of the onset of the stressor, the stressor must be identifiable. Therefore, in order to diagnose adjustment disorder there must be a reliable continued on page 6 source for reporting the onset of stressors for individuals with ID. Stressors can be anything in the life of a person with ID that is beyond the person's ability to handle or resolve alone. Additionally, it should be taken into account that stressors for people with ID may have a more significant impact than what would typically be expected. For example, a change in vocational supervisors may be a significant stressor for someone with ID, when a person without ID may adjust to that change seamlessly. Also, it is important to bring up any changes you see in a person's mood or functioning, especially if their verbal skills are not well-developed. As verbal skills decrease, the relevance of the "additional symptoms" listed above goes up and the traditional symptoms go down. However, lots of things can lead to these symptoms (not just Adjustment Disorders), so caregiver reports about how, when, and where these symptoms occur are extremely important.

How can we help an individual with Adjustment Disorder?
For all individuals, the more nurturing and supportive the environment, the better the individual under stress will be able to cope. So, staff members, family members, and friends of individuals with Adjustment Disorder should be as supportive as possible and understand which coping skills the individual is able to use. The primary treatment for adjustment disorder in people with intellectual disabilities is behavioral therapy. At The Baddour Center, Behavior Intervention services are offered by The Programs and Residential Services Division. Additionally, The Education and Research Division offers behaviorally-based group and individual therapy for our residents at their request. Behavioral treatments tend to focus more on teaching appropriate coping skills, and helping the individual to identify how to match the skill to the situation.