Internalizing Disorders: What They Are, Types And Treatments

A group of frequent emotional disorders during childhood.

Internalizing disorders

Knowing about internalizing disorders is very important, as they are a subset of emotional problems that occur in childhood and go unnoticed too often.

They are characterized by the apparent discretion with which they present themselves, despite the fact that the child who lives with them carries with him a very high degree of suffering.

Children who suffer from them may report that they feel sad, shy, withdrawn, fearful or unmotivated. Thus, while in the case of externalizing disorders it is often said that they “fight against the world”, in that of internalizing disorders they are rather “fleeing from it.”

In this article we will explain what internalizing disorders are, why a category like this was created (as opposed to externalizing), what the most common causes tend to be, and what therapeutic strategies can be applied.

What are internalizing disorders?

In general, the mental disorders that a child can present are grouped into two broad categories: internalizing and externalizing. The criterion by which such a distinction is made refers to whether they manifest themselves at a behavioral (or external) or cognitive (or internal) level, the former being more evident to the observer than the latter. However, despite this dissection of the infantile psychopathological reality, it must be taken into account that both can occur at the same time in the same child.

Both parents and teachers are very sensitive to the behavioral expression of externalizing disorder, since it generates a substantial impact on the environment and even compromises living together at home or at school. Some of the problems that are included in this category would be the oppositional defiant disorder or the disorder by attention deficit and hyperactivity (mainly concerning the motor excesses).

On the other hand, internalizing disorders go unnoticed many times, or come to motivate diagnoses that are completely unrelated to what actually happens (since they have a different behavioral expression than that manifested in adults). It is for this reason that they rarely constitute the reason for consultation, and are usually discovered as the professional inquires into what the child feels or thinks. The most relevant (due to their prevalence and impact) are depression, anxiety, social withdrawal, and physical or somatic problems. We will focus our attention on them throughout this text.

1. Depression

Depression in childhood is often a silent and elusive disorder. The most common is that it manifests itself in the form of irritability and loss of motivation for the tasks that are typical of this age period (school); although in the long term it has very severe repercussions on the psychological, social and cognitive development of the child. In addition, it is a strong predictor of psychopathological risk during adult life.

Depression in children is different from that seen in adults in many of the aspects commonly considered, although they tend to be symptomatically paired as they enter adolescence. It is essential to take into account that many children have not yet developed a sufficient capacity for verbal abstraction to express their internal states to others, which is why there is a significant risk of underdiagnosis (and consequent lack of treatment).

Despite this, children also feel sadness and anhedonia (understood as the difficulty to experience pleasure), which is manifested by a clear loss of motivation to get involved in academic or other tasks, although in the past they provided enjoyment. At the level of physical development, some difficulties are usually observed in reaching the appropriate weight for age and height, which is associated with lack of appetite or even rejection of food.

Insomnia is very common at bedtime (which over the years tends to become hypersomnia), which contributes to their constant complaints of lack of energy or vitality. The level of activity can be altered by both excess and deficit (psychomotor agitation or slowness) and even thoughts occasionally arise about one’s own death or that of others. The feeling of worthlessness and guilt is also usually present, living with concentration difficulties that hinder performance in school demands.

2. Anxiety

Anxiety is a disabling symptom that can manifest itself during childhood. As with depression, it often goes unnoticed among the adults living with the child, as it is largely expressed through experiences that are triggered within. When this question is investigated, the presence of disproportionate ideas regarding an event that the child feels as threatening and that he locates at some relatively near time in the future becomes very evident (probability that one day the separation of his parents will occur, for example).

In childhood anxiety, an exacerbation of fears that are typical of different age periods can be seen, and that are adaptive at first. The most common is that they fade as neurological and social maturation progresses, but this symptom can contribute to the fact that many of them are not totally overcome and end up accumulating, exerting a summative effect that implies a permanent state of alert (tachycardia, tachypnea , etc.).

This hyperarousal has three fundamental consequences : the first is that it increases the risk that the first panic attacks are triggered (overflowing anxiety), the second is that the tendency to live constantly worried is triggered (originating a subsequent generalized anxiety disorder) and the third is that excessive attention is projected to internal sensations related to anxiety (a phenomenon common to all diagnoses in this category).

The most frequent anxiety in childhood is the one that corresponds to the moment in which the child distances himself from his relationship figures, that is, that of separation; and also certain specific phobias that tend to persist until adulthood in the event of not articulating an adequate treatment (to animals, masks, strangers, etc.). After these first years, in adolescence, anxiety shifts to relationships with peers and performance in school.

3. Social withdrawal

Social withdrawal can be present in childhood depression and anxiety, as an inherent symptom of them, or present independently. In the latter case, it manifests as a lack of interest in maintaining relationships with peers of the same age, for the simple reason that they do not motivate their curiosity. This dynamic is common in autism spectrum disorder, which should be one of the first diagnoses to rule out.

Sometimes social withdrawal is exacerbated by the presence of fear associated with the absence of parents (at school) or the belief that contact should not be established with strangers, which is part of the specific criteria for parenting. Sometimes social withdrawal is accompanied by a deficit in basic interaction skills, which is why some difficulty manifests itself during attempts to get closer to others, even though they are desired.

In the event that social withdrawal is a direct result of depression, the child usually indicates that he mistrusts his ability or that he fears that by approaching others he may be rejected. Bullying, on the other hand, is a common cause of problems in social interaction during the school years, and is also associated with the erosion of self-image and a heightened risk of disorders during adulthood, and even a possible increase in suicidal ideation.

4. Physical or somatic problems

Physical or somatic problems describe a series of “diffuse complaints” about physical condition, most especially pain and upset digestive sensations (nausea or vomiting). It is also common to have tingling and numbness in the hands or feet, as well as discomfort in the joints and in the area around the eyes. This confusing clinical expression usually motivates visits to pediatricians, who do not find an explanatory organic cause.

A careful analysis of the situation shows that these annoyances emerge at specific times, generally when an event that the child fears is about to happen (going to school, being away from family or home for a while, etc.). that points to a psychological cause. Other somatic problems that may appear involve the regression to evolutionary milestones that had already been overcome (re-wetting the bed, for example), which is related to stressful events of various kinds (abuse, birth of a new brother, etc. ).

Why do they happen?

Each of the internalizing disorders that have been detailed throughout the article has its own potential causes. It is elementary to point out that, just as there are cases in which internalizing and externalizing problems occur at the same time (such as the assumption that a child with ADHD also suffers from depression), it is possible that two internalizing disorders occur together (both the anxiety like depression are related to social withdrawal and somatic discomfort in the child).

Childhood depression is usually the result of a loss, of social learning from living with one of the parents who suffers from a condition of the same type and of failure to try to establish constructive relationships with children of the same age. Physical, psychological and sexual abuse is also a very frequent cause, as well as the presence of stressful events (moving, school changes, etc.). Some internal variables, such as temperament, can also increase the predisposition to suffer it.

Regarding anxiety, it has been described that shyness in childhood can be one of the main risk factors. Still, there are studies suggesting that 50% of children describe themselves using the word “shy”, but only 12% of them meet the criteria for a disorder in this category. Regarding sex, it is known that during childhood there are no differences in the prevalence of these problems according to this criterion, but that when adolescence arrives, they suffer them more frequently. They can also arise as a result of some difficult event, like depression, and from living with parents who suffer from anxiety.

Regarding social withdrawal, it is known that children with insecure attachment can show resistance to interact with a stranger, especially the avoidant and disorganized. Both are related to specific upbringing patterns: the first is forged from a primitive feeling of parental helplessness, and the other from having experienced a situation of abuse or violence in their own skin. In other cases, the child is simply somewhat more shy than the rest of her classmates, and the presence of an anxiety or depression problem accentuates her tendency to withdraw.

Diffuse physical / somatic symptoms usually occur (ruling out organic causes) in the context of anxiety or depression, as a result of anticipation or the imminence of an event that generates difficult emotions in the child (fear or sadness). It is not a fiction that is established in order to avoid such events, but rather the concrete way in which internal conflicts manifest themselves at an organic level, highlighting the presence of tension headaches and alterations in digestive function.

How can they be treated?

Each case requires an individualized therapeutic approach that adopts a systemic approach, in which the relationships that the child maintains with their attachment figures or with any other people who are part of their spaces of participation (such as the school, for example, are explored). example). From this point on, functional analyzes can be drawn aimed at understanding the relationships that exist in the family nucleus and the causes / consequences of the child’s behavior.

On the other hand, it is also important to help the child to detect what his emotions are, so that he can express them in a safe environment and define what thoughts can be found behind each of them. Sometimes children with internalizing disorders live with overrated ideas about an issue that worries them particularly, and they can be encouraged to debate this very point and find alternative thinking that better fits their objective reality.

On the assumption that the child’s symptoms are expressed on a physical level, a program can be articulated aimed at minimizing the activation of the sympathetic nervous system, for which different relaxation strategies are included. It is important to consider the possibility that the child will adversely judge the sensations that occur in their own body (it is common when they suffer from anxiety), so it will be essential to talk with them first about the real risk they represent (restructuring). Otherwise, relaxation can become a counterproductive tool.

On the other hand, it is also interesting to teach children skills that facilitate their way of relating to others, in the event that they do not have them or do not know how to take advantage of them. The most relevant are those of a social type (starting a conversation) or those of assertiveness, and they can also be practiced in consultation through role-playing. In the event that you already have these strategies, it will be necessary to delve into what emotions could be inhibiting their proper use in the context of your daily relationships.

Treatment of internalizing disorders must necessarily include the child’s family. Involving her is essential, since it is often necessary to carry out changes at home and at school aimed at solving a difficult situation that affects everyone.

Bibliographic references:

  • Lozano, L. and Lozano, LM (2017). Internalizing disorders: a challenge for parents and teachers. Parents and Teachers, 372, 56-63.
  • Ollendick, TH and King, NJ (2019). Diagnosis, assessment, and treatment of internalizing problems in children: The role of longitudinal data. Journal of Consulting and Clinical Psychology, 62 (5), 918-27

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