Adjustment Disorder in Children and Adolescents JEFFREY H. NEWCORN, M.D.,

AND

JAMES STRAIN, M.D.

Abstract. The literature on adjustment disorder in children and adolescents is reviewed to evaluate the empirical and conceptual basis of this disorder as defined in DSM-III-R, and to determine whether revisions an, indicated in DSM-IV. Existing studies suggest that adjustment disorder is a disorder of high prevalence in all settings, which carries significant morbidity and poor outcome in children and adolescents. Problems identified with the DSM-lll-R definition include low reliability, the predominance of mixed rather than discrete symptom presentations in children and adolescents, and the persistence of symptoms in excess of 6 months in a significant number of cases. J. Am. Acad. Child Adolesc. Psychiatry, 1992,31,2:318-327. Key Words: adjustment disorder, stress, DSM-lll-R. Adjustment disorder (AD) is one of the most frequently diagnosed psychiatric conditions in children and adolescents. However, it may also be one of the most problematic diagnostic categories in DSM-III-R. On a theoretical level, the complex and uncertain relationship between stress and psychiatric disorder (Rutter, 1981; Woolston, 1988) raises questions regarding the suitability of the concepts that have formed the basis of the AD diagnosis in DSM-III (American Psychiatric Association, 1980) and DSM-III-R (American Psychiatric Association, 1987). There have been significant difficulties on a practical level as well. The lack of specificity of the AD diagnosis and the ease with which it may be assigned offer considerable potential for overuse of this category (Rapoport and Ismond, 1984; Wynne, 1975). However, indiscriminate use of the AD diagnosis as a means of "protecting" patients from receiving other diagnostic labels perceived to be more' 'stigmatizing" may result in the incorrect classification of children with more severe psychiatric disorders (Looney and Gunderson, 1978) and thereby contribute to delays in treatment planning (Weiner and Del Gaudio, 1976). A review of the DSM-III-R criteria for AD indicates that there are three essential components. First, there must be a maladaptive reaction to an identified psychosocial stressor that, by definition, involves impairment in either social, occupational, or school function. The maladaptive reaction must occur within 3 months of the occurrence of the stressor and is presumed to remit when the stressor ceases but, in any event, must not persist for longer than 6 months. Finally, the disturbance must not fulfill the diagnostic criteria for another major psychiatric disorder or the V code' 'uncomplicated bereavement." A variety of symptomatic presenta-

tions of AD are identified, and these are categorized as subtypes in DSM-lII and DSM-III-R. The combination of subsyndromal symptomatology and the presence of an identified psychosocial stressor serves to distinguish AD from all other Axis I and Axis II disorders in DSM-III-R. Thus, whereas AD and post-traumatic stress disorder (PTSD) both require the presence of a psychosocial stressor, PTSD is characterized by a more narrowly defmed concept of severe psychosocial stress and a specific constellation of affective and autonomic symptoms. In contrast, AD can be triggered by a stressor of any severity and may present with a wide range of possible symptomatologies. Similarly, while the individual subtypes of AD are similar in symptomatology to atypical or subthreshold presentations of many of the major classes of disorders (i.e., anxiety, affective, conduct, etc.), the latter conditions need not be stress-related and are therefore classified in DSM-III-R under the appropriate symptom domain using the designation NOS (not otherwise specified). It is apparent from the above discussion that AD is a diagnostic category whose definitional status and usage patterns pose significant problems. This review examines the existing literature on AD in children and adolescents, as well as the broader relationship between stress and psychiatric disorder in children, in order to evaluate the theoretical and empirical basis of AD as currently defined in DSM-III-R and identify areas in need of possible revision in DSM-IV. Issues to be considered are prevalence, nature of symptomatology, reliability and validity of diagnosis, and differences between children and adolescents and adults with AD. The adjustment of children to specific stressful life events (i.e., divorce, bereavement, reaction to physical illness) is also examined, since these circumstances must be considered to carry a high risk for the development of AD.

Accepted February 11, 1991. Dr. Newcom is Assistant Professor of Psychiatry and Dr. Strain is Professor of Psychiatry at Mount Sinai School of Medicine. Reprint requests to Dr. Newcom, Department of Psychiatry, Box 1268, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. The views expressed in this article are those of the authors and do not represent the official positions of the DSM-IV Task Force or the American Psychiatric Association. 0890-8567/92/31 02-Q3l8$03.00/0© 1992 by the American Academy of Child and Adolescent Psychiatry.

General Characteristics of AD

318

Prevalence

Studies examining the prevalence of AD are summarized in Table 1. The variable use of structured diagnostic instruments suggests that clinician bias regarding diagnosis must be considered in interpreting the data, particularly in studies where retrospective reviews of clinical records provide the only basis for diagnosis. J. Am. Acad. Child Adolesc. Psychiatry, 3 J :2, March J992

CHILD AND ADOLESCENT ADJUSTMENT DISORDER TABLE

Study Bird et aI., 1988

Weiner and Del Gaudio, 1976 Mezzich et aI., 1989

Faulstich et aI., 1986

Hillard et aI., 1987

Doan and Petti, 1988

Jacobson et aI., 1980

1. Prevalence of Adjustment Disorder

Sample Type

Sample Size

Assessment Method

Epidemiologicalgeneral population Epidemiologicalclinical services Clinical screening evaluation (all services) Clinical (adolescent inpatient) Clinical (emergency room) Clinical (partial hospital) Clinical (4 outpatient pediatric clinics)

Probability estimate of 2,036 households 1,344

Structured rating scales; clinical interview Clinical diagnosis

7.6% (CGAS < 70) 4.2% (CGAS < 60)

Semi-structured assessment instrument Chart reviewclinical diagnosis Chart reviewclinical diagnosis Chart reviewclinical diagnosis Clinical diagnosis

10% (all ages) 16% « 18 yrs old)

11,282

392 100 adolescents 100 adults (random) 796

20,000 pediatric patients

Prevalence of AD

27% of all cases

12.5%

42% of adolescents 13% of adults 7%

25--65% of cases with psychiatric diagnosis

Note: CGAS = Children's Global Adjustment Scale.

Only one published study has examined the prevalence of AD in the general population (Bird et aI., 1988). This study employed a two-stage screening process using both structured and unstructured clinical assessment measures. Prevalence rates were calculated as a function of impairment using the Children's Global Assessment Scale (CGAS) (Shaffer et aI., 1983). When a CGAS cutoff of 70 or below was required for diagnosis, the prevalence of AD was determined to be 7.6% in the general population. However, if children with CGAS scores between 61-70 were excluded, the prevalence of AD dropped to 4.2%, suggesting a low level of impairment in about 40% of the cases. The prevalence of AD has more often been estimated in clinical populations. The largest and most systematically assessed data base was obtained by surveying all patients evaluated at a university-based hospital clinic (Fabrega and Mezzich, 1987; Fabrega et aI., 1987; Mezzich et al., 1989) using a semi-structured assessment form (Mezzich et aI., 1982) and DSM-III criteria sheets. Ten percent of a sample of over 11,000 patients (all ages) were found to have AD, making it the second largest diagnostic category represented. In patients under age 18, over 16% had AD, male and female patients being equally affected. Prevalence estimates of AD in other clinical populations have been characterized by considerable variability, with generally high rates. A survey of all adolescents receiving psychiatric care in a single geographic area (Weiner and Del Gaudio, 1976) found that 27% qualified for a diagnosis of transient situational disturbance (TSD) using DSM-ll criteria (American Psychiatric Association, 1968). Retrospective reviews of hospital records of adolescent inpatients (Faulstich et aI., 1986) indicated a 12.5% prevalence of AD. In an emergency room setting, 42% of adolescents were diagJ. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

nosed as having AD as compared with 13% of adults (Hillard et aI., 1987). AD was twice as common as any other single diagnosis in the adolescent population in that study, including substance abuse. In a survey of all adolescent partial hospital programs in a single geographic region (Doan and Petti, 1988), 7% of patients were determined to have AD. In pediatric settings, 25-65% of children who presented with psychiatric disturbance in a single calendar year were diagnosed AD (Jacobson et aI., 1980). Nature of Symptomatology Several studies have described the symptomatic presentation of AD in clinical samples (Table 2). In studies of adult or mixed child/adult populations, depressive symptoms have been found to predominate. Mezzich et aI. (1989) found that half of a mixed child/adult AD patient population evaluated by means of structured clinical ratings could be classified AD with depressed mood (ADDM). In an earlier publication from the same data set, Fabrega et al. (1987) reported that depressed mood was the most frequently occurring symptom in the AD population, being present in 76% of cases. Also frequently occurring were insomnia (53%) and other vegetative symptoms, social withdrawal (29%), and suicidal indicators (29%). However, the prominence of depressive symptoms has been less uniform in child and adolescent populations. Andreasen and Wasek (1980) reported that 87% of adults, as compared with 63% of adolescents, had depressive symptoms. In contrast, 77% of adolescents, but only 25% of adults, presented with behavioral symptoms. Studies that have examined the distribution of DSM-III subtypes of AD have indicated the predominance of mixed syndromes in children and adolescents. In an adolescent inpatient population, Faulstich et al. (1986) reported that 319

NEWCORN AND STRAIN TABLE

2. Nature of Symptomatology in Adjustment Disorder

Study

Sample Design

Mezzich et aI., 1989

Clinical population; semistructured evaluation instrument Outpatient speech and language clinic; follow-up design

Cantwell and Baker, 1989

Faulstich et aI., 1986

Chart review (inpatients)

Andreasen and Wasek, 1980

Chart review (outpatients)

Age

Finding

All ages (16% < 18 yr)

Half of AD group had AD with depressed mood

3.0-15.8 (mean, 6.4)

13/19 cases (68%) mixed types; 42% mixed emotions; 26% mixed emotions/conduct AD subtypes: mixed 35%; depressed 27%; atypical 22%, conduct 12% Behavioral symptoms77% adolescents 25% adults Depressive symptoms87% adults 50% adolescents

N

11,292 (10% with AD) 151 cases (19 with AD)

392 (49 with AD)

Adolescent

199

Adolescent

303

Adult

Note: AD = adjustment disorder.

35% of AD patients had mixed presentations, whereas 27% had depressed, 22% atypical, and 12% behavioral subtypes. Similarly, Cantwell and Baker (1989) found that 13 of 19 children with AD had mixed syndromes (42% mixed emotional; 26% mixed emotions and conduct). AD has been described as a transitional diagnostic category by Fabrega et aI. (1987) and Fabrega and Mezzich (1987) because levels of symptomatology and impairment were found to be intermediate between that observed in a "not ill" group (individuals with V code diagnoses only) and a heterogeneous group of patients with specific mental disorders. However, the symptomatic profile and level of impairment in patients with ADDM was quite similar to that found in dysthymic disorder and atypical depression, though distinct from major depression and bipolar depression (Fabrega et aI., 1986). Studies of adolescents and young adults with AD have reported a significant association with suicidal behavior. Minnaar et aI. (1980) used a prospective design to study all patients hospitalized for suicidal behavior in an urban hospital setting and found that the majority (56%) met DSM-III criteria for TSD. In a retrospective review of 325 consecutive admissions for deliberate self-poisoning admitted to one hospital over a single calendar year, McGrath (1989) reported that 58% met criteria for ADDM. By far, the greatest proportion of these cases were aged 15-24, with female patients predominating over male patients. Psychological autopsy studies also indicate a high representation of AD among individuals who have completed suicide. Runeson (1989) reported that 14% of 58 consecutive suicide victims age 15-29 could be diagnosed ADDM by this rigorous, though retrospective method. Similarly, Fowler et aI. (1986) reported that 12 of 133 (9%) suicide victims age 10-29 met criteria for AD. Reliability

Studies which have examined the reliability of AD are summarized in Table 3. These data are abstracted from larger surveys of DSM-II and DSM-III diagnostic categories. 320

Although not all such studies have included AD (Russell et aI., 1983; Strober et aI., 1981), there is sufficient data on AD to reveal serious problems in reliability. Mezzich et aI. (1985) determined the interrater agreement (Kappa) for AD to be 0.05 (p = NS) in a study in which psychiatrists and . psychologists evaluated 27 child and adolescent case histories. However, agreement regarding the DSM-II category TSD was higher (K = 0.28; P < 0.05). Similarly, Werry et aI. (1983), using a case conference method, found low reliability for the AD category (K = 0.23). In that study, subtypes of AD were also examined and, with one exception, found to have even lower reliability. The authors concluded that, although reliability for manyDSM-III categories is high, a few diagnoses such as AD and oppositional disorder, as well as subtypes of otherwise reliable disorders, added considerable "noise" to the system. The result of the UK-WHO study of the reliability of ICD-9 categories (Gould et aI., 1988) are generally consistent with the findings from studies of DSM-Ill. The kappa for AD was 0.23, considerably lower than for other categories studied. Since one possible source of low reliability is lack of clinician familiarity with the diagnostic criteria, reclassification was attempted using a psychiatric glossary. The reliability of AD was improved to 0.33 by this method. Similarly, Rey et aI. (1988) reported a kappa of 0.46 for AD between two psychiatrists using a combination of structured ratings and unstructured clinical interviews in an adolescent population, lending further support to the conclusion that structured methods can help generate acceptable reliability figures for AD. Confusion of oppositional disorder with AD was nevertheless found to be a source of interrater disagreement in that study. Low reliability figures have also been reported for ratings of DSM-III Axis IV (psychosocial stressors). Mezzich et aI. (1985) determined the kappa for Axis IV to be 0.25, significant at the 0.05 level but hardly convincing. This finding may have implications for understanding the low reliability of AD, since clinician judgements regarding psychosocial stress are required in the diagnosis of AD. Possible sources J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

CHILD AND ADOLESCENT ADJUSTMENT DISORDER TABLE 3. Reliability of Adjustment Disorder

Study Mezzich et aI., 1985

Method Case history

Werry et aI., 1983

Case conference

Gould et aI., 1988

Case history

N

Findings

72 psychologists 62 psychiatrists; 27 written case histories 195 cases; 2--4 clinicians

K

52 child psychiatrists; 14 written case histories

K

K K

(AD) = 0.05 (TSD) = 0.28 (AD) = 0.23 (lower for subtypes) K (ADDM) = 0.67 = 0.23 (0.33 using glossary)

Note: AD = adjustment disorder; TSD = transient situational disturbance; ADDM = adjustment disorder with depressed mood.

of low reliability of Axis IV have been reviewed by Rey et aI. (1988). Stability and Outcome

Two studies have examined the stability of AD over time. Weiner and Del Gaudio (1976) found a 15% stability rate for adolescents originally diagnosed TSD in the 1960s on lO-year follow-up. Similarly, as part of a larger follow-up study of children and adolescents with language disorders, Cantwell and Baker (1989) found that none of a group of 19 children and adolescents with AD retained the diagnosis after 4 years. Outcome studies suggest that the low stability rate in AD is accounted for both by movement toward improved health and more serious illness. Individuals with mild symptomatology generally recover (Thomas and Chess, 1984); however, a significant number of cases progress to more severe forms of psychopathology. Weiner and Del Gaudio (1976) found that 52% of an adolescent sample originally diagnosed TSD required follow-up treatment. Similarly, Fard et aI. (1978) found that 15 of 24 adolescents with psychiatric syndromes that could not be diagnosed were ill at 7-year follow-up, and 12 of these developed more characteristic psychiatric syndromes. The presence of psychotic symptoms in these adolescents predicted poor outcome. Andreasen and Hoenk (1982) reported that 44% of a group of 52 adolescents originally diagnosed AD in the early 1970s were well on 5-year follow-up. An additional 13% were well at follow-up but had intervening difficulties over the 5-year period. Thus, nearly 70% of the original AD sample was ill during the follow-up period. A number of these adolescents developed severe diagnoses including schizophrenia, bipolar disorder, major depression, antisocial personality, and drug abuse. Chronicity of behavioral symptoms was the best predictor of poor outcome in this study. More recently, Cantwell and Baker (1989) found that the recovery rate from AD was only 26%. The most frequent diagnoses at follow-up were attention deficit disorder with hyperactivity (ADDH), overanxious disorder, oppositional disorder, and avoidant disorder. In contrast to children and adolescents, adults with AD are more likely to have a benign outcome. In a follow-up study of a large number of military recruits, Looney and Gunderson (1978) found that TSD was a less severe and disabling condition than any other psychiatric disorder. Approximately 60% of the sample were well at follow-up; J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

many of the 40% who demonstrated impairment were subsequently diagnosed as having personality disorders. Andreasen and Hoenk (1982) also reported a high rate of recovery (71 %) in adults with AD. Comparisons between adolescents and adults in that study revealed that adolescents had a lower rate of successful outcome (44% vs. 71 %), as well as increased severity of diagnosis in cases of poor outcome. However, the subtype of AD did not predict the follow-up diagnosis, suggesting discontinuity in the nature of the symptomatology across developmental stage. Comorbidity

Only a few published studies have specifically addressed the issue of comorbidity of AD with other disorders. Fabrega et aI. (1987) reported that 70% of a large cohort of child and adult patients with AD had another Axis I diagnosis. Similarly, Kovacs et al. (1984) found that 45 % of 11 children with ADDM had a comorbid psychiatric diagnosis. A subsequent publication that included eight additional children in the ADDM group reported the incidence of comorbidity with any disorder to be 58% (Kovacs et aI., 1988). However, comorbidity in AD was lower than in either dysthymic disorder or major depressive disorder in that study. Unpublished data from the Puerto Rico epidemiologic study (Bird et aI., 1988) confirms the prominence of comorbid diagnoses in children and adolescents with AD in the general population. Defining Variables Temporal Characteristics

There are no studies that provide specific data regarding the suitability of the onset criterion in AD. However, several published studies provide data related to the duration of AD, and are therefore useful in evaluating the offset criterion. Andreasen and Wasek (1980) reported a prolonged duration of illness in a large percentage of 402 adolescent and adult patients with AD, though persistent symptomatology was more characteristic of adolescents than adults. Thus, 66% of adolescents and 35% of adults were symptomatic for greater than 6 months, whereas 47% of adolescents and 23% of adults were ill for over 1 year. Kovacs et al. (1984) studied the correlates of depressive disorders in children and found the mean duration of an episode of ADDM to be 25 weeks (SD = 18 weeks). The peak interval-specific probability of recovery was determined to be 6-9 months, and by 9 months, 90% of the children had recovered. In another study examining psycho-

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logical adjustment in children with the acute onset of diabetes mellitus, Kovacs et al. (1985) found that the vast majority of children who qualified for a psychiatric diagnosis met DSM-III criteria for ADDM. These children did not have exacerbation of a preexisting mental disorder and had the onset of psychiatric symptoms within 3 months of being diagnosed as having diabetes. Recovery in this population was 50% by 2.5 months and 93% by 9 months. A number of studies have more broadly examined the temporal relationship between the occurrence of undesirable life events and the development of psychiatric disorders in children, and therefore have important implications for the study of AD. Goodyear et al. (1987) examined the timing and number of life events occurring in the year before the onset of emotional and/or behavioral disorders in schoolaged children in an outpatient setting compared with a population of community controls. Whereas the occurrence of negative life events increased the risk of disorder by 3-6 times, the temporal relationship of stressor to disorder varied. The onset of symptoms was within 16 weeks of an event for 49% of the cases, and 70% had the onset of symptoms within 6 months. However, 30% of cases did not develop symptoms until 6 months to 1 year following the undesirable event. Children who experienced multiple negative life events were more likely to have a shorter latent period between the occurrence of these events and the onset of symptoms. In contrast, a greater proportion of children who experienced only a single negative event had the onset of symptoms between 6 and 12 months afterward. Studies examining the duration of psychiatric disturbance (not linked to diagnosis) occurring in the context of specific psychosocial stressors indicate that the persistence of symptoms is not uncommon. Dew et al. (1987) compared the long-term mental health effects in adults of two different community-wide stressors (the Three Mile Island accident and widespread unemployment due to layoff) and found that subclinical symptomatology was equally present across both samples in the year following the occurrence of the stressor. Moreover, symptoms remained elevated as long as 42 months afterwards. Magni et al. (1986) reported that approximately two-thirds of 41 parents of children with acute lymphocytic leukemia and Hodgkin's disease demonstrated at least moderate distress on the SCL-90 checklist immediately following diagnosis. Reassessments at 8 and 20 months (in remission) indicated the continuation, and in some cases worsening of symptoms. In contrast, Boyd (1981) has observed that most children are resistant to stress following disasters, with symptoms such as insomnia, restlessness, clinging to parents, dependency, and fear being common but usually short-lived. However, he notes that more severe and persistent reactions also occur, particularly in children who have had previous psychiatric disturbances or a family history of psychiatric illness. These studies suggest that psychiatric disorders which occur in the context of stressful life events may not necessarily have their onset within 3 months following the event and do not always remit within 6 months. Studies linked to the DSM-III criteria for AD have been best able to demonstrate the existence of a group characterized by rapid onset and

322

offset of symptoms. However, even in carefully diagnosed AD groups, a percentage of cases demonstrate the persistence of symptoms beyond the 6 month limit. Studies in which the stress-related disturbance is not keyed to DSM criteria have found the onset and offset of symptoms to vary considerably, often falling outside the guidelines established for AD. Stressor Criterion

Nonspecificity of the stressor criterion in AD can be traced to DSM-III; the presence of an overwhelming stressor was previously required to fulfill DSM-ll criteria for TSD. However, this criterion was altered in response to criticism that transient situational disturbances may occur following any event (Wynne, 1975) and coincided with the establishment of a more specific syndrome (PTSD) linked to severe stress in DSM-III. Recent criticism of the stressor criterion in AD has focussed on a number of theoretical and operational problems. Woolston (1988) has argued that the linear model of stressdisease interaction, which most closely approximates the model of AD in DSM-III and DSM-III-R, is only one of many such models, the majority of which are not well accounted for in the current definition of AD. Fabrega and Mezzich (1987) have observed that the stressors in AD are difficult to specify and measure, and their clinical implications are often uncertain. They question whether AD patients are extraordinarily vulnerable to psychosocial events not likely to disturb others or whether they are individuals who have been exposed to high levels of stress, the accumulation of which would likely carry negative effects for most people. Malt (1986) contends that psychiatrists are not necessarily able to assess when subjective distress or observable symptomatology exceeds what would normally be expected for a given stressor, and hence are likely to be unreliable in their identification of AD. Breslau and Davis (1987), writing about the stressor criterion for PTSD, observe that even severe stressors do not uniformly produce psychiatric symptomatology. Andreasen and Wasek (1980) examined the types and duration of stressors in adolescents and adults with AD, and reported that stressors were more likely to be chronic (> 1 year) in adolescents than in adults (59% vs. 36%). School problems were the most frequently identified precipitant for symptomatology in the adolescent population (> 60%), though a variety of family, boyfriend-girlfriend and substance abuse problems were also common. In contrast, marital problems, including separation and divorce, were the most common stressors in adults. Additional data regarding the stressor criterion in AD may be extrapolated from studies that have more broadly examined the relationship between life events and psychiatric disturbance. Monroe (1982) demonstrated that individuals with and without preexisting psychiatric symptoms respond differently to the presence of stressful events. Vinokur and Caplan (1986) found that although control over life events seemed to increase stress, it resulted in improved ability to adjust. In that study, only negative events were J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

CHILD AND ADOLESCENT ADJUSTMENT DISORDER

associated with psychological distress; pleasurable events were associated with psychological well-being. Similarly, Brown and Siegel (1988) reported that internal, global attributions for negative life events were positively correlated with depression in adolescents when the causes were uncontrollable, but not when the causes were controllable. Hammen (1988) found the children's cognition about self-worth and self-efficacy were mediating factors in determining the likelihood of depression in response to stressfullife events. Wagner et aI. (1988) demonstrated that major negative life events exerted their effect in the development of psychological symptomatology through a series of negative daily life events. Taken together, these findings challenge the notion that stress is universally related to the development of psychopathology. Rather, specific types of stressful events and individual patterns of stress-response appear to be differentially related to the onset of psychiatric syndromes. By implication, these findings argue for increased specificity of the stressor criterion in AD. However, they do not provide clear direction as to how this criterion might be reformulated. Reactions of Children to Specific Life Events: Evidence for the Existence of Chronic Adjustment Problem Syndromes Adjustment after Bereavement

A number of recent studies have examined the reactions of children to the loss of a parent or sibling. Van Eerdewegh et aI. (1982) studied 105 2- to 17-year-old children of a consecutive sample of 50 widowed adults in the community, and compared them with children of controls using a structured interview with the surviving parent. Dysphoric mood, sleep problems, appetite problems, social withdrawal, bedwetting, and decreased school performance were frequently observed at 1 month. However, the acute reactions were usually shortlived. At 13-month follow-up, there was a significant decrease in dysphoric symptoms, though a significant increase in somatic complaints, fights with siblings, and a preference for nonacademic interests were also reported. Pettle Michael and Lansdown (1986) studied 28 children and adolescents age 5-21 from 14 families 18-30 months after the death of a sibling from cancer by using parent and teacher behavior checklists, children's self-concept scales, and a semistructured interview of parents in an uncontrolled design. Symptoms encountered shortly after the loss included behavior problems, sleep disturbance, and emotional difficulties, which generally did not persist. However, low self-esteem, chronic behavior problems, poor concentration at school, and problems with peers were reported in a large percentage of the children over an extended period. A series of publications has examined the reactions of 25 preadolescent kibbutz children who suffered the sudden loss of a father during the October 1973 war in a longitudinal design (Elizur and Kaffman, 1982, 1983; Kaffman and Elizur, 1983; Kaffman et aI. 1987). At 3 months after the loss, the majority of children evidenced grief reactions characterized by crying, moodiness, sorrow, and longings in their verbalizations, play, and drawings. Anger, aggression, and J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

protest were further seen in approximately half of the sample. Follow-up evaluation by means of semistructured interview with the widowed mother and teacher at 6, 18, and 42 months revealed a bimodal distribution; some children evidenced relatively few problems whereas others demonstrated an increase in the number and intensity of clinical symptoms. The rate and severity of the behavioral symptoms remained consistent 18 and 42 months after the loss in those children who experienced complicated grief reactions. Retrospective analyses indicated the presence of premorbid hyperactivity and behavior problems, premorbid family conflict and post-traumatic situational problems in those children with persistent symptomatology. The most prevalent DSM-III diagnosis in this group was AD with mixed disturbance of emotions and conduct. These findings are consistent with the widely held belief that grief reactions in most children are brief; however, they demonstrate the existence of chronic adjustment problems in a subset of bereaved children. Extended grief reactions associated with an increased incidence of AD and other forms of psychopathology have also been documented in a large number of adults psychiatric outpatients (Zisook et aI., 1985). Adjustment to Serious Physical Illness

A number of studies have examined the psychiatric sequellae of serious physical illness in children; however, only a few can be considered to have important implications for AD. Kovacs et aI., (1985) found that approximately 30% of a sample of newly diagnosed insulin-dependent diabetic children met DSM-III criteria for AD, as characterized by the acute onset of subthreshold symptomatology and the relatively short-lived persistence of symptoms. However, other studies point to the insidious development or the enduring nature of psychiatric symptoms that occur in the context of severe medical illness. O'Malley et aI. (1979) found that 59% of 114 childhood cancer survivors (in remission) had at least mild psychiatric symptoms on a standardized clinical interview at least 5 years after the original diagnosis, and 12% were rated as having a significant impairment. Though psychiatric diagnosis was not determined, it is likely that a high percentage of the mild cases were subthreshold and, consequently, might have qualified for a diagnosis of AD. Length of time from the time of the illness to the time of assessment correlated with improved adjustment in this population (Koocher et aI., 1980). However, Kashani and Hakami (1982), studying the occurrence of major depression in children and adolescents with malignancies (the occurrence of AD in this sample is not reported), found that when depression occurred, it rarely developed immediately after the initial diagnosis. Rather, it was more likely to be observed during the transition phase from acute to chronic illness. Studies evaluating the relationship between serious medical illness and the development of psychiatric symptoms in adults closely resemble the results of studies with children. Von Ammon Cavanaugh (1986) found that depressive symptoms were frequent but mild in hospitalized adults, most being consistent with a diagnosis of ADDM. Linn and

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Husaini (1985) also found that chronic medical problems predicted depressive symptoms; however, they noted that internal and external resources served as moderating factors. Kaneko et al. (1986) reported that poor psychological outcome in a cohort of hemodialysis patients was associated with the presence of family problems and the absence of work, and that poor outcome was more likely to occur in specific personality types. The occurrence of psychiatric maladjustment was bimodally distributed; the most common time periods being in the first 3 months after the beginning of hemodialysis and also again after 12 months. Studies with burn-injured patients (Ward et aI., 1987) and cancer patients (Robinson et aI., 1985) have similarly indicated that the presence and severity of psychiatric symptoms is related to personality functioning and past psychiatric history. These studies suggest that reactions to severe medical illness are variable in their severity and duration. The importance of social support systems, personality type, and history of prior psychiatric disturbance in modulating the nature of the adjustment reaction are well documented, and suggest that individuals with unusually severe adjustment problems may represent a vulnerable or previously compromised group. Adjustment to Divorce

A number of longitudinal studies have examined the reactions of children to parental separation and divorce over time. These studies have not been tied to diagnostic classification or AD, per se, but their findings have relevance for understanding AD because parental divorce represents one of the most common chronic stressors experienced by large numbers of children in the United States. Giubaldi and Perry (1985) found an elevated level of maladjustment on a wide variety of academic and mental health indices in children of divorced families compared to children of intact families at both 2- and 6-year time intervals following the divorce. Covarying IQ did not reduce the magnitude of the difference but controlling for socioeconomic status did, and boys had more adjustment problems than girls. Hetherington et aI. (1985) found that divorce carried a more negative risk for boys than girls at 6-year follow-up, but noted that the adjustment of girls to parental remarriage was poorer. Children in divorced families were shown to experience more negative life changes than children in nondivorced families, and these events were associated with subsequent behavior problems. Similarly, Wallerstein (1984, 1985) has reported a strong positive correlation between the overall quality of life in postdivorce families and successful adjustment. Her extensive though uncontrolled study demonstrates the presence of both an acute adjustment problem period, characterized by worry, anxiety, depressive affect, and decreased school performance, and a variety of chronic adjustment problems. These studies suggest that adjustment problems in children of divorce may be enduring, often related to the cascading sequence of negative life changes that can be seen to follow divorce in many families. However, use of the AD diagnosis in this population poses particular theoretical and operational problems, because there are often many life

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events that would qualify as stressors in those children who are most symptomatic following divorce, many of which are likely to persist over an extended period of time. Conclusions It is apparent that the published literature on AD in children and adolescents is lacking in a number of important areas. Very few systematic studies have actually been undertaken; some of those which have were begun before 1980 and did not use DSM-lIlor DSM-III-R criteria. Other studies of adjustment problems have not been linked to clinical diagnosis at all, so conclusions about specific categories such as AD are at best inferential. In many of the studies that report on AD, subject groups were identified by means of unstructured clinical methods rather than structured diagnostic instruments and may therefore be subject to observer bias. Unfortunately, the absence of algorithms for AD on most structured diagnostic interviews currently available for use in research has compounded this problem, because data on AD were not collected in a number of recent surveys of child and adolescent psychopathology (Anderson et aI., 1987; Kashani et aI., 1987; Offord et aI., 1987). Despite these criticisms of the literature, it is clear that AD is an important clinical entity in children and adolescents, as evidenced by the following: (1) According to whichever method of identification is used, AD accounts for a significant number of cases in all treatment settings. (2) Although the severity of pathology is not uniformly high, AD is nevertheless associated with considerable morbidity (emergency room visits and hospital admissions) and even mortality (completed suicide) in a significant number of individuals. (3) Although AD is not, in and of itself, a condition that persists over an extended time period, a large number of children and adolescents with this condition go on to develop other, more severe disorders. This last point deserves attention because, in this respect, AD appears to be different in children and adolescents than it is in adults. Unfortunately, studies that have examined the relationship between AD symptoms (i.e., subtype) and diagnosis at follow-up have failed to demonstrate any consistent correlation. Consequently, it is uncertain whether subtyping according to symptom domain has any predictive validity. The large number of children and adolescents with AD who present with either mixed emotional or mixed emotional and behavioral syndromes provides further evidence that subtyping according to symptom domain may be of limited utility. Perhaps the most serious problem with the AD diagnosis as currently constituted is its low reliability. Some authors have speculated that the interpretation of descriptors such as "maladaptive" and "symptoms in excess of a normal and expectable reaction" may contribute to low reliability, because these terms are culturally bound and their meaning may vary greatly among physicians and patients alike. Lack of clarity as to whether comorbidity of AD and other psychiatric disorders is permitted in DSM-III-R may further contribute to low reliability. Attention to the wording of criteria in DSM-IV could perhaps address these problems and promote improved reliability. However, the absence of a specific symptom profile and lack of clarity regarding what J. Am. Acad. Child Adolesc. Psychiatry, 31:2, March 1992

CHILD AND ADOLESCENT ADJUSTMENT DISORDER

should constitute a stressor represent formidable obstacles to achieving reliability, solutions to which are not readily apparent. Studies that have examined the temporal characteristics of stress-related conditions expose further difficulties with the DSM-III-R defmition of AD. The prevailing wisdom has been that children's reactions to psychosocial stressors are brief and occur shortly after the stressful event. Although this conclusion had found considerable support in the literature, a number of studies have also demonstrated the existence of more chronic maladjustment, most often occurring in the context of enduring stress. Instability of the AD diagnosis at 5-year follow-up argues against creating an openended "chronic AD" category; over time, those disorders that persist generally progress to meet criteria for another specific mental disorder. However, although the point at which that change occurs is not easily identified, it apparently does not routinely occur within 6 months. Other important questions also remain unanswered. There are no data available to assess the discriminant validity of AD with regard to "minor" affective, anxiety and behavioral syndromes, other subthreshold disorders, and PTSD. Such information would be useful in determining whether AD should be viewed as representing a subthreshold presentation of PTSD, a variant of the' 'minor" affective, anxiety and behavioral disorders, or a separate disorder independent of any of these conditions. In addition to its heuristic value, this data would be useful in guiding decisions regarding the placement of AD in DSM-IV. References American Psychiatric Association (1968), Diagnostic and Statistical Manual of Mental Disorders (DSM-II) 2nd Ed., Washington, DC: American Psychiatric Association. - - (1980), Diagnostic and Statistical Manual of Mental Disorders (DSM-III) 3rd Ed., Washington, DC: American Psychiatric Association. - - (1987), Diagnostic and Statistical Manual ofMental Disorders (DSM-III-R) 3rd Ed., Revised, Washington, DC: American Psychiatric Association. Anderson, J. c., Williams, S., McGee, R. & Silva, P. A. (1987), DSMIII disorders in preadolescent children: prevalence in a large sample from the general population. Arch. Gen. Psychiatry, 44:69-76. Andreasen, N. C. & Wasek, P. (1980), Adjustment disorders in adolescents and adults. Arch. Gen. Psychiatry, 37: 1166-1170. - - Hoenk, P. R. (1982), The predictive value of adjustment disorders: a follow-up study. Am. J. Psychiatry, 139:584-590. Bird, H. R., Canino, G., Rubio-Stipec, M. et al. (1988), Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico: the use of combined measures. Arch. Gen. Psychiatry 45:1120-1126. Boyd, S. T. (1981), Psychological reactions of disaster victims. S. Afr. Med. J., 60:744-748. Breslau, N. & Davis, G. C. (1987), Post-traumatic stress disorder: the stressor criterion. J. Nerv. Ment. Dis. 175:255-264. Brown, J. D. & Siegel, J. M. (1988), Attributions for negative life events and depression: the role of perceived control. J. Pers. Soc. Psychol., 54:316-322. Cantwell, D. P. & Baker, L. (1989), Stability and natural history of DSM-III childhood diagnoses. J. Am. Acad. Child Adolesc. Psychiatry, 28:691-700. Dew, M. A., Bromet, E. J. & Schulberg, H. C. (1987), A comparative analysis of two community stressors' long-term mental health effects. Am. J. Community Psycho/., 15:167-184. Doan, R. J. & Petti, T. A. (1988), Clinical and demographic character-

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