Understanding internalizing disorders is very importantAs it is a subset of emotional problems that arise in childhood and too often go unnoticed.
They are characterized by the apparent discretion with which they present themselves, although the child who lives with them brings with him a very high degree of suffering.
Children who suffer from it may feel sad, shy, reproachful, fearful or demotivated.. Thus, if in the case of externalized disorders it is often said that they “fight against the world”, in that of internalization, they rather “run away”.
In this article, we will explain what internalizing disorders are, why a category like this has been created (as opposed to externalization), what are generally the most common causes, and what treatment strategies can be. applicable.
What are internalizing disorders?
In general, the mental disorders that a child may present fall into two broad categories: internalization and externalization. The criterion by which such a distinction is made refers to if they manifest themselves at a behavioral (or external) or cognitive (or internal) level, The former being more obvious to the observer than the latter. However, despite this dissection of the psychopathological reality of the child, it should be borne in mind that both can occur at the same time in the same child.
Parents and teachers are very sensitive to the behavioral expression of externalization disorder because it generates a substantial impact on the environment and even compromises coexistence at home or at school. Some of the problems that fall into this category would be a negativistic disorder or attention deficit hyperactivity disorder (especially with regard to motor excesses).
On the other hand, internalizing disorders often go unnoticed, or lead to diagnoses totally unrelated to what is really happening (since they have a behavioral expression different from that which manifests itself in adults). It is for this reason that they rarely constitute the reason for the consultation, And are usually discovered when the professional studies what the child is feeling or thinking. The most relevant (for their prevalence and impact) are depression, anxiety, social withdrawal, and physical or somatic problems. We will focus on them throughout this text.
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 tasks typical of this age period (school); although in the long term, it has very harsh effects on the psychological, social and cognitive development of the child. In addition, it is a strong predictor of psychopathological risk in adulthood.
Depression in children is different from that seen in adults in many aspects usually considered, although they tend to correspond to the symptomatic level as they enter adolescence. It is essential to note that many children have not yet developed a sufficient capacity for verbal abstraction to show others their inner states, There is therefore a significant risk of underdiagnosis (and resulting lack of treatment).
Despite this, children also experience sadness and anhedonia (understood as difficulty in experiencing pleasure), which manifests as a marked loss of motivation to engage in academic or other tasks, even in the past. . In terms of physical development, certain difficulties are generally observed to reach an age-appropriate weight and height, which is associated with loss of appetite or even rejection of food.
Insomnia (which over the years tends to develop into hypersomnia) is very common at bedtime, which contributes to your constant complaints of lack of energy or vitality. The level of activity can be altered by both an excess and a deficit (restlessness or psychomotor slowness) and even occasional thoughts about one’s own death or that of others arise. The feeling of worthlessness and guilt is usually also present, Live with difficulty concentrating which affects school performance.
Anxiety is a crippling symptom that can appear during childhood. As with depression, it often goes unnoticed in adults living with the child, as much of it expresses itself through experiences that are unleashed within them. By investigating this problem, it becomes very obvious the presence of disproportionate ideas about an event that the child feels is threatening and that it is at some point relatively close to the future (probability that one day their parents’ separation will occur, for example).
In childhood, anxiety manifests itself as an intensification of fears which are typical of different age periods, and which 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 completely overcome and eventually accumulate, exerting a summative effect that involves a permanent state of alert (tachycardia, tachypnea, etc.).
This hyperactivation has three fundamental consequencesThe first is that it increases the risk of triggering the first panic attacks (overwhelming anxiety), the second is that it triggers the tendency to be constantly worried (causing later generalized anxiety disorder) and the third is that it excessive attention is projected to internal sensations related to anxiety (a phenomenon common to all diagnoses in this category).
The most frequent anguish in childhood is that which corresponds to the moment when the child moves away from his connecting figures, that is to say that of separation; as well as certain specific phobias which tend to persist in adulthood in the event of non-articulation of appropriate treatment (animals, masks, strangers, etc.). After these early years, in adolescence, anxiety shifts to peer relationships and academic performance.
3. Social withdrawal
Social withdrawal can be present in depression and childhood anxiety, as an inherent symptom of them, or it can occur independently. In the latter case, it manifests itself as lack of interest in socializing with peers his or her age, For the simple reason that they do not motivate your curiosity. This dynamic is common in autism spectrum disorder, which should be one of the first diagnoses to rule out.
Sometimes, the social withdrawal is exacerbated by the presence of fear associated with the absence of parents (at school) or by the belief that contact should not be made with strangers, which is part of the criteria for aging. concrete. Sometimes social withdrawal is accompanied by a deficit in basic interaction skills, so that difficulty arises in attempts to approach others, even though they are desired.
In the event that social withdrawal is a direct result of depression, the child usually points out that he is suspicious of his abilities or that he is afraid that by approaching others he may be rejected. Bullying, on the other hand, is a common cause of problems with social interaction during the school years, and is also associated with erosion of self-image and increased risk of disorders in adulthood, and even to a possible increase in suicidal ideation.
4. Physical or somatic problems
Physical or somatic problems describe a number of “diffuse complaints” about physical condition, including pain and bothersome digestive sensations (nausea or vomiting). It is also common the appearance of tingling and numbness in the hands or feet, as well as discomfort in the joints and in the area around the eyes. This puzzling clinical expression generally motivates the visits to pediatricians, who do not find an explanatory organic cause.
An in-depth analysis of the situation shows that these discomforts appear at specific times, generally when an event is about to occur and of which the child is afraid (going to school, away from his family or from home for a while, etc.), which indicates a psychological cause. Other somatic problems that may arise they involve retirement towards evolutionary milestones which had already been overcome (re-urinating in bed, for example), which is linked to stressful events of various kinds (abuse, birth of a new brother, etc.).
Why is this happening?
Each of the internalizing disorders that have been detailed throughout the article has its own potential causes. It is important to note that, since there are cases in which both internalizing and externalizing problems arise (such as the case of a child with ADHD who also suffers from depression), it is possible that two internalizing disorders occur together (both anxiety such as depression are related to social withdrawal and somatic discomfort in the child).
Childhood depression is usually the result of loss, social learning while living with one of the parents who has a similar condition and the failure to try to build constructive relationships with children of the same age. Physical, mental and sexual abuse are also a very common cause, as is the presence of stressful events (moves, school changes, etc.). Certain internal variables, such as temperament, can also increase your predisposition to suffer from it.
In terms of anxiety, it has been described that shyness in childhood can be one of the main risk factors. Overall, there are indicative studies where 50% of children describe themselves using the word “shy”, but only 12% of them meet the criteria for a disorder in this category. With regard to sex, we know that during childhood there are no differences in the prevalence of these problems according to this criterion, but that when they reach adolescence, they suffer from it more frequently. They can also occur as a result of a difficult event, such as depression, and living with parents who suffer from anxiety.
As for social withdrawal, we know that children who are not firmly attached may show resistance to interacting with a stranger, Especially the avoidant and the disorganized. Both are linked to specific parenting patterns: the first is forged from a primitive sense of parental helplessness, and the other from having experienced abuse or violence in your own skin. In other cases, the child is simply a little more shy than the rest of his peers, and the presence of an anxiety or depression problem accentuates his tendency to withdraw.
Diffuse physical / somatic symptoms generally occur (excluding organic causes) in a context of anxiety or depression, following the anticipation or imminence of an event that generates difficult emotions in the child (fear or sadness). It is not a fiction that is established to avoid these events, but the concrete way in which internal conflicts manifest themselves at an organic level, highlighting the presence of tension headaches and functional alterations.
How can they cope?
Each case requires an individualized therapeutic approach that adopts a systemic type approach, In which the relationships that the child maintains with his figures of affection or with any other person forming part of his spaces of participation (such as school, for example) are explored. From there, it will be possible to carry out functional analyzes aimed at understanding the relationships that exist in the family unit and the causes / consequences of the child’s behavior.
On the other hand, it is also important in helping the child to detect their emotionsSo you can express them in a safe environment and define what thoughts can be found behind each of them. Sometimes children with internalizing disorders coexist with overestimated ideas about an issue of particular concern to them, and it is possible to encourage them to debate that same extreme and find thought alternatives that best match their reality. objective.
In the event that the child’s symptoms are expressed at the 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 for the child to judge negatively the sensations that occur in his own body (this is common when he suffers from anxiety), so in the first place it will be essential to talk to him about the real risk they present. (restructuring). Otherwise, relaxation can become a counterproductive tool.
On the other hand, it’s also interesting teach children skills that facilitate their relationships with others, In case they do not have them or do not know how to take advantage of them. The most relevant are social (starting a conversation) or assertiveness, and can also be practiced in consultation through role-playing. If you already have these strategies, you will need to look at the emotions that may prevent their proper use in the context of your day-to-day relationships.
The treatment of internalizing disorders must necessarily include the family of the child. Involving her is crucial, as it is often necessary to make changes at home and at school to resolve a difficult situation that affects everyone.
- 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, evaluation and treatment of internalization problems in children: the role of longitudinal data. Journal of Consulting and Clinical Psychology, 62 (5), 918-27