Internalizing disorders

Internalizing disorders are mental health disorders in which the symptoms are primarily internal (keep inside) to the individual in ways such as social withdrawal, anxiety, negative thinking and beliefs and/or feelings of sadness and depression, problems that more centrally affect the child’s internal psychological environment rather than the external world. Other terms for this cluster of behavior problems include “neurotic” and “overcontrolled” ¹. Inevitably, this dichotomy is neither perfect nor complete. For example, a child’s internalizing behavior problems can have a negative impact on others, including siblings, parents, peers, and teachers. Similarly, children with externalizing behavior problems not only may negatively affect their outside world, but also may be psychologically suffering internally. In fact, there is significant and substantial co-morbidity between externalizing and internalizing behavior problems ². In other words, children who are aggressive also may experience anxiety and, conversely, depressed children also may exhibit conduct problems ³.

In contrast, externalizing disorders are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual’s environment such as various acting out, disruptive, delinquent, hyperactive, and aggressive behaviors, which cause impairment or interference in life functioning ⁴. Children with externalizing behavior disorders sometimes argue, are aggressive, or act angry or defiant around adults. A externalizing behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child’s age at the time, persist over time, or are severe. Within the externalizing disorders, there are two major categories of behavior problems: (1) Problems of inattention, impulsivity, and hyperactivity associated with a diagnosis of attention-deficit hyperactivity disorder (ADHD); and (2) conduct problems and aggressive behavior associated with a diagnosis of oppositional defiant disorder (ODD) or conduct disorder. These two domains of externalizing disorders can be separated in factor analyses and exhibit different correlates. For example, ADHD is specifically linked with poor academic achievement, problems in executive functioning, and parental inattention and impulsivity, whereas conduct problems are specifically associated with socioeconomic disadvantage, dysfunctional family backgrounds, and parental criminality and antisocial behavior.

The diagnosis and treatment of internalizing disorders is complicated by the fact that they are often co-morbid with each other as well as other psychiatric, non-internalizing disorders. Childhood depression is highly co-morbid with other psychological disorders – particularly anxiety (as high as 62%) ⁵ and conduct disorders (as high as 35%) ⁶. Anxiety also often appears with other psychiatric diagnoses, such as other anxiety disorders, depression, attention deficit and hyperactivity disorder, oppositional defiant disorder and conduct disorder ⁷. Anywhere from 15.9% to 61.9% of children identified as anxious or depressed have co-morbid anxiety and depressive disorders ⁵. Childhood anxiety disorders are often associated with development of adult anxiety disorders, major depressive disorder, suicidal behavior and psychiatric hospitalization ⁸.

Somatic complaints in toddlers have been linked to internalizing or externalizing problems in adolescence ⁹ and may make diagnosis of somatization disorder in adulthood more likely ¹⁰. Moreover, a higher occurrence of somatic complaints predicted poorer academic performance for schoolchildren ¹¹. Somatic complaints are typically co-morbid with other psychological disorders, particularly anxiety disorders. For example, 60% of children and adolescents with anxiety disorders reported somatic complaints ¹². As noted earlier, teenage suicide is associated with presence of psychopathology. Furthermore, changes in eating or sleeping habits, social withdrawal, violence, drug abuse, changes in personality, and somatic complaints correlate with teenage suicide. Substance abuse and behavioral disorders, such as antisocial personality disorder and conduct disorder, are more common in teenage suicides compared with older population groups ¹³. Attempted suicide by teenagers is also associated with a wide range of future adjustment difficulties, including increased risk for repeated suicide attempts, poor school attendance, interpersonal relationship problems, internalizing disorders (e.g. depression), externalizing behaviors (e.g. running away), substance use, criminal arrests, motor vehicle accidents and violent death (e.g. by homicide, by motor vehicle crash) ¹⁴.

Internalizing behavior disorders

Depression

Many children have times when they are sad or down. Occasional sadness is a normal part of growing up. However, if children are sad, irritable, or no longer enjoy things, and this occurs day after day, it may be a sign that they are suffering from major depressive disorder, commonly known as depression. Some people think that only adults become depressed. In fact, approximately 2% of children and at least 4% of adolescents suffer from depression at any given time. By the end of high school, approximately one young person in five will have had at least one episode of depression.

Children and adolescents who are under stress, who experience loss, or who have attentional, learning, conduct, or anxiety disorders are at a higher risk for depression. Depression also tends to run in families. The good news is that depression is a treatable illness.

Depression is a psychiatric mood disorder characterized by excessive sadness and loss of interest in usually enjoyable activities. The mean age of onset for adolescents is 14.9 years, but some children can develop depression as early as age 3 ¹⁵. Depression occurs in 1% of preschoolers, 2% of school-aged children, and 5–8% of adolescents ¹⁶, although prevalence rates appear to be increasing from generation to generation with earlier onset ages ¹⁷.

Common symptoms of depression in children and adolescents include:

• Feeling or appearing depressed, sad, tearful, or irritable
• Not enjoying things as much as they used to
• Spending less time with friends or in after school activities
• Changes in appetite and/or weight
• Sleeping more or less than usual
• Feeling tired or having less energy
• Feeling like everything is their fault or they are not good at anything
• Having more trouble concentrating
• Caring less about school or not doing as well in school
• Having thoughts of suicide or wanting to die

Children also may have more physical complaints, such as frequent headaches or stomach aches. Depressed adolescents may use alcohol or other drugs as a way of trying to feel better.

Scientists don’t always know the cause of depression. Sometimes it seems to come out of nowhere. Other times, it happens when children are under stress or after losing someone close to them. Bullying and spending a lot of time using social media may be associated with depression. Depression can run in families. Having another condition such as attentional problems, learning issues, conduct or anxiety disorders also puts children at higher risk for depression.

Sometimes parents are not sure if their child is depressed. If you suspect your child has depression, try asking them how they are feeling and if there is anything bothering them. When asked directly, some children will say that are unhappy or sad, while others will say they want to hurt themselves, be dead, or even that they want to kill themselves. These statements should be taken very seriously because depressed children and adolescents are at increased risk of self harm. Another way of identifying depression is through “screening” by your child’s pediatrician, who may ask your child questions about their mood or ask them to fill out a brief survey.

If you think your child or teenager might be depressed, it is important to seek help. A pediatrician, school counselor, or qualified mental health professional can help by referring your child to someone who can conduct a comprehensive assessment, diagnose depression, and identify the right treatments.

The good news is that there are several effective treatments for depression. Treatment may include psychotherapy (or “talk therapy”), meetings with your family, and, with your permission, discussions with your child’s school. Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are forms of psychotherapy shown to be effective in treating depression. Treatment may also include the use of antidepressant medication. The potential risks and benefits of any medicine should be carefully discussed. Learn more about medications used to treat depression in children and adolescents.

Anxiety

Anxiety can be described as a ‘state of apprehension without cause’ ¹⁸. All children experience some anxiety. Anxiety in children is expected and normal at specific times in development. For example, from approximately age 8 months through the preschool years, healthy youngsters may show intense distress (anxiety) at times of separation from their parents or other people with whom they are close. Young children may have short-lived fears, such as fear of the dark, storms, animals, or a fear of strangers.

Anxiety disorders result when anxiety is consistent and negatively interferes with school, social interactions, activities or family functioning. Anxiety disorders are the most common type of psychiatric disorders in children ¹⁹, with separation anxiety disorder and selective mutism occurring exclusively in children ²⁰. Depending on the diagnosis, mean age of onset can be as early as 7.5 years (e.g. separation anxiety disorder) ²¹. In worldwide studies, the prevalence of anxiety disorders in children was greater than 10% and ranged from 12% to 20% in the USA ²². There are five main anxiety disorders: separation anxiety disorder, social anxiety disorder, general anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder ²³.

There are quite a few different types of anxiety in children.

General descriptions of common anxiety disorders:

1. Separation anxiety: Characterized by excessive apprehension due to separation from a familiar person or place
   • Symptoms of separation anxiety include:
     • Constant thoughts and intense fears about the safety of parents and caretakers
     • Refusing to go to school
     • Frequent stomachaches and other physical complaints
     • Extreme worries about sleeping away from home
     • Being overly clingy
     • Panic or tantrums at times of separation from parents
     • Trouble sleeping or nightmares
2. Social anxiety disorder also known as social phobia: Extreme fear of public embarrassment or humiliation. Fears causing significant distress and interfering with usual activities.
   • Symptoms of social anxiety include:
     • Fears of meeting or talking to people
     • Avoidance of social situations
     • Few friends outside the family
3. General anxiety disorder: Chronic worry not specific to one person, situation or stimulus
4. Post-traumatic stress disorder (PTSD): Arises from exposure to trauma, such as abuse. Includes re-experiencing the trauma (e.g., flashbacks, nightmares), avoidance of reminders of the trauma and a hyper-aroused state (e.g. ‘jumpy’, easily startled)
5. Obsessive-compulsive disorder (OCD): Characterized by obsessions (uncontrollable thoughts) and/or compulsions (repetitive actions or rituals)
6. Selective mutism: Occurs when a child who is normally capable of speech cannot speak in certain situations or to certain people

Other symptoms of anxious children include:

• Many worries about things before they happen
• Constant worries or concerns about family, school, friends, or activities
• Repetitive, unwanted thoughts (obsessions) or actions (compulsions)
• Fears of embarrassment or making mistakes
• Low self esteem and lack of self-confidence

Anxious children are often overly tense or uptight. Some may seek a lot of reassurance, and their worries may interfere with activities. Parents should not dismiss their child’s fears. Because anxious children may also be quiet, compliant, and eager to please, their difficulties may be missed. Parents should be alert to the signs of severe anxiety so they can intervene early to prevent complications.

Severe anxiety problems in children can be treated. Early treatment can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, and feelings of low self-esteem. Treatments may include a combination of the following: individual psychotherapy, family therapy, medications, behavioral treatments, and consultation to the school.

If anxieties become severe and begin to interfere with the child’s usual activities (for example separating from parents, attending school, and making friends), parents should consider seeking an evaluation from a qualified mental health professional or a child and adolescent psychiatrist.

Somatic complaints

Somatic complaints are physical symptoms with no identifiable, specific physiological cause ²⁴. Common pediatric somatic complaints include headaches, nausea or abdominal pain. Non-specific causes usually include psychological distress, anxiety, family patterns and life events ²⁵. Somatic complaints may result in a vicious cycle wherein the physical symptoms lead to emotional stress, which further exacerbates the somatic symptoms ²⁶. Somatic complaints have been mainly studied in children greater than 3 or 4 years of age, making it difficult to determine the onset age. However, prevalence rates have been estimated at 20%, increasing to 40% if children are 10 years old or younger, and 55% at 15 years old or younger ²⁷.

Teenage suicide

Teenage suicide is a significant public health problem. Suicide is the third leading cause of death for young people aged 10–24 years in the USA ²⁸. Suicide can occur in childhood, but the rate of incidence appears to increase over time ²⁹. In addition, according to the 2007 Youth Risk Behavior Surveillance, about 14.5% of high school students had seriously considered attempting suicide within the 12 months prior to the survey, with 11.3% actually having made a plan how they would attempt suicide ³⁰.

Parents and clinicians should be vigilant for the presence of risk factors and associated conditions among adolescent patients, including suicidal ideation or gestures in patients with substance abuse problems or mental health disorders. Risk reduction by addressing behavioral risk factors, such as substance use, environmental exposure and violence/abuse, is applicable to the prevention of all internalizing disorders. Specific suicide prevention strategies for adolescent include school-based prevention programmes, which some studies have found to have some success ³¹. Other studies, however, have concerns about how effective they actually are ³². Because cultural risk factors play an important role, programmes targeting specific groups should also be implemented as some have been found to be helpful ³³.

Internalizing disorders causes

Familial factors is considered one of the most highly implicated factors in the development of depression ³⁴ and anxiety ³⁵. Negative life events in the social environment, particularly violence, poverty, abuse, bereavement/loss of loved ones, or parental separation, are thought to increase the risk for depression ³⁶, anxiety ³⁷ and somatic complaints ³⁸.

Environmental hazards such as high serum lead levels and prenatal maternal tobacco exposure have been associated with higher levels of somatic complaints ³⁹, while the evidence linking depression to chemical exposure, toxicity, lead exposure, prenatal tobacco use, or prenatal cocaine use is weaker ³⁹. Prenatal marijuana exposure was linked with increased levels of depressive symptoms in 10-year-old children ⁴⁰.

Interpersonal relationships and social interactions appear to influence development of anxiety and somatic complaints as well. Behavioral inhibition, which occurs when a child retreats and withdraws from a novel situation or stimulus, may increase likelihood of an anxiety disorder ⁴¹ and may in fact even be a biological precursor to later anxiety ⁴². Temperament, parental somatic complaints and parental stress have all been implicated as potential risk factors ⁴³ for somatic symptoms. For instance, Eminson ⁴⁴ suggests a model of wherein child-, parent-, and healthcare professional-related factors each possess unique and different mechanisms that could increase or decrease the severity of the child’s symptoms.

Finally, determining a distinct cause for adolescent suicidal behavior is difficult, and likely there are numerous associated factors that may contribute to self-harm. One of the most important risk factors is family history of mental health disorders, which increases the likelihood of completed suicide ⁴⁵. Studies from the USA show that 90% of completed suicides were associated with a psychiatric disorder ⁴⁶, which also likely plays a role in increasing susceptibility to self-harm. Other risk factors include family history of suicide, family history of child maltreatment, previous suicide attempts, history of substance abuse, feelings of hopelessness, impulsive and/or aggressive tendencies, social isolation, as well as relational, social, work, or financial loss ³⁰.

Internalizing disorders diagnosis

A diagnostic screening for depression is often performed using the Pediatric Symptom Checklist, which is completed by caregivers of children aged 6–12 years and has good specificity (range 68–100%) and sensitivity (80–95%). Other pediatric depression screening tools include the Children’s Depression Inventory (CDI) for children aged 7–17 years, the Beck Depression Inventory (BDI) for adolescents and the Center for Epidemiologic Studies Depression (CES-D) Scale ⁴⁷. An advantage of the Children’s Depression Inventory, in addition to its strong validity, is that it is easy for young children to understand as it is written at a first-grade reading level ⁴⁸. Both the Beck Depression Inventory and Center for Epidemiologic Studies Depression have been shown to be reliable and valid and are useful for older children and adolescents ⁴⁹. Both are meant for adolescents aged 14 years and older and are written at a sixth-grade reading level ⁴⁸.

Diagnosis of anxiety is traditionally aided by the widely used Child Behavior Checklist (CBCL) ⁵⁰. Other scales that can be used for diagnosis and classification are the Multidimensional Anxiety Scale for Children (MASC), the Revised Children’s Manifest Anxiety Scale (RCMAS) and the State-Trait Anxiety Inventory for Children (STAIC) ⁵¹. In a meta-analysis of the RCMAS, STAIC and CBCL, Seligman et al. ⁵² found that all were comparably effective for differentiating children with an anxiety disorder to children without an anxiety disorder. However, they found these tools are not as effective in differentiating between anxiety disorder and another psychological disorder ⁵². In addition, Seligman et al. ⁵² advised that for clinicians, these tools only be used as part of the comprehensive assessment in addition to diagnostic interviewing. The MASC is a newer scale that includes four dimensions of childhood anxiety: physical symptoms, social anxiety, separation anxiety and harm avoidance ⁵³. It has shown to be effective and reliable, but again for clinicians is only part of a comprehensive diagnostic assessment ⁵³.

Somatic complaints are not by themselves a diagnosable disorder in DSM-IV ²⁰. Instead, somatization disorder is a diagnosis that characterizes the occurrence of numerous and broad somatic complaints in adults, not children. There are a few diagnostic scales that can be used for assessing somatic complaints in children. The Child Behavior Checklist (CBCL) includes a subscale for somatic complaints ⁵⁰, as does the Center for Epidemiologic Studies Depression (CES-D) ⁴⁷, but again, both should be used in the context of more thorough evaluation.

Internalizing disorders treatment

Treatment for depression and anxiety has generally involved medication and/or psychotherapy – and cognitive-behavioral therapy (CBT) in particular. Studies suggest CBT is highly effective for child and adolescent depression ¹⁶ and anxiety ⁵⁴, as well as somatic symptoms ⁵⁵. In a randomized clinical trial of children aged 4–7 years with anxiety disorders, children treated with CBT showed a significantly greater decrease in anxiety disorders compared with controls ⁵⁶. Another study found effect sizes of improvement were large for children’s fears and dysfunctional beliefs, and medium for children’s internalizing symptoms ⁵⁷. Data on pharmacological therapy are mixed. For childhood depression, the effectiveness of medication remains unclear ⁵⁸. For instance, selective serotonin reuptake inhibitors (SSRIs), frequently effective in adults, appear to be effective in children and adolescents but may bring an increased risk of suicide ⁵⁹. Some studies found no effect for SSRIs compared with a placebo in the treatment of depression ⁶⁰. A study comparing the cost-effectiveness of CBT compared with SSRIs for treating depression found CBT to be the more cost-effective option ⁶¹. However, availability of this therapy is often limited ⁶⁰. Therefore, a concerted effort must be made to increase access for CBT. A randomized controlled trial comparing use of CBT, fluoxetine (an SSRI), or both for treatment of adolescent depression found that fluoxetine combined with CBT had the greatest efficacy relative to fluoxetine or CBT alone ⁶².

Anxiety appears to be highly amenable to SSRIs ⁶³. In a comparison study, it was found that treatment with only CBT or only sertraline (an SSRI), or a combination of CBT and sertraline was effective ⁶⁴. Combination therapy was superior to both monotherapies, with the percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale being 80.7% for combination therapy, 59.7% for CBT and 54.9% for sertraline ⁶⁴. Therefore, all three options are indicated, with family preferences, access to treatment, cost and time being taken into consideration on a case-to-case basis ⁶⁴.

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