Internalizing disorders: what they are, types and treatments

Knowing internalizing disorders is very important, since it is a subgroup of emotional problems that occur in childhood and too often go unnoticed.

They are characterized by the apparent discretion with which they present themselves, despite the fact that the child who lives with them carries with them 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Children who suffer from them may report that they feel sad, shy, withdrawn, fearful or unmotivated..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 the case of internalizing disorders they rather "flee from it".

In this article we will explain what internalizing disorders are, why a category like this was created (in opposition to that of externalizing), what are the most common causes and what therapeutic strategies can be of application.

• Related article: "the 16 disorder"

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 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 child's psychopathological reality, it must be taken into account that one and the other 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 coexistence at home or in the school. Some of the problems that fall into this category would be oppositional defiant disorder or attention deficit hyperactivity disorder (especially with regard to excesses motor).

On the other hand, internalizing disorders often go unnoticed, or even lead to diagnoses. completely oblivious to what is actually happening (since they have a different behavioral expression from the one manifest in adults). It is for this reason that 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

Childhood depression 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 solid predictor of psychopathological risk during adult life.

Depression in children is different from that seen among adults in many ways. usually considered, although they tend to even out at the symptomatological level as they go further into the adolescence. It is essential to keep in mind that many children have not yet developed a sufficient capacity for verbal abstraction to express their internal states to othersTherefore, there is a significant risk of underdiagnosis (and the consequent lack of treatment).

Despite this, children also feel sadness and anhedonia (understood as the difficulty to experience pleasure), which manifests with a clear loss of motivation to engage in academic or other tasks, even if 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.

At bedtime, insomnia is very common (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 due to both excess and deficit (agitation or psychomotor slowness) and even thoughts about one's own death or that of others arise occasionally. The feeling of uselessness and guilt is usually also present, living with concentration difficulties that hinder performance in school demands.

• You may be interested in: "Major Depression: Symptoms, Causes, and Treatment"

2. Anxiety

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

In childhood anxiety, a sharpening of the fears that are typical of the different age periods can be seen, and that are adaptive at first. Most commonly, they fade as neurological and social maturation progresses., but this symptom can contribute to the fact that many of them do not fully overcome themselves and end up accumulating, exerting a summative effect that implies a permanent state of alertness (tachycardia, tachypnoea, etc.).

This hyperactivation has three fundamental consequences.: the first is that it increases the risk of triggering the first panic attacks (overwhelming anxiety), the second is that it triggers the tendency to live constantly worried (causing a later generalized anxiety disorder) and the third is that projects excessive attention to internal sensations related to anxiety (a phenomenon common to all diagnoses of this category).

The most frequent anxiety in childhood is the one that corresponds to the moment in which the child distances himself from the bonding figures of it, that is, that of separation; and also certain specific phobias that tend to remain until adulthood in the case 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 at school.

• You may be interested in: "What is anxiety: how to recognize it and what to do"

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 lack of interest in maintaining relationships with peers of the same age, for the simple reason that they do not arouse his 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 with strangers should not be established, which is part of the specific criteria of breeding. Sometimes social withdrawal is accompanied by a deficit in basic interaction skills, so some difficulty is manifested during attempts to approach others, despite being desired.

In the event that social withdrawal is a direct result of depression, the child often points out that he distrusts her 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 erosion of self-image and a heightened risk of disorders during adult life, and even a possible increase in ideation suicide.

4. Physical or somatic problems

Physical or somatic problems describe a series of "diffuse complaints" about the physical state, especially pain and unpleasant digestive sensations (nausea or vomiting). It is also frequent 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 confusing clinical expression usually motivates visits to pediatricians, who do not find an explanatory organic cause.

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

Why do they happen?

Each of the internalizing disorders that have been detailed throughout the article has its own potential causes. It is essential 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 anxiety and 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 the failure to establish constructive relationships with children of the same age. Physical, mental and sexual abuse is also a very frequent cause, as is the presence of stressful events (moving, changing schools, etc.). Some internal variables, such as temperament, can also increase the predisposition to suffer from it.

Regarding anxiety, it has been described that shyness in childhood can be one of the main risk factors. Even with everything, there are studies indicating that 50% of children describe themselves using the word "shy", but only 12% of them meet the criteria for a disorder of 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 a difficult event, such as depression, and from living with parents who suffer from anxiety.

Regarding social withdrawal, it is known that insecurely attached children may show resistance to interacting with a strangerespecially the avoidant and disorganized. Both are related to specific parenting patterns: the first is forged from a feeling primitive of parental abandonment, and the other for having experienced in his own skin some situation of abuse or violence. In other cases, the child is simply more shy than the rest of his classmates, and the presence of an anxiety or depression problem accentuates his tendency to withdraw.

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

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 her attachment figures or with any other people who are part of their participation spaces (such as the school, for example) are explored. From this point, functional analyzes aimed at understanding the relationships that exist in the family nucleus and the causes/consequences of the child's behavior can be drawn up.

On the other hand, it is It is also important to help the child to detect what their emotions are, so that he can express them in a safe environment and define what thoughts can be found behind each one of them. Sometimes children with internalizing disorders live with overvalued ideas about an issue that particularly worries them, and It is possible to encourage them to discuss this very point and to find alternatives of thought that better fit their reality. objective.

In the event that the child's symptoms are expressed on a physical level, a program aimed at minimize the activation of the sympathetic nervous system, for which different strategies of relaxation. It is important to consider the possibility that the child adversely judges the sensations that occur in his own body (that is, habitual when they suffer from anxiety), so in the first place it will be key to talk with him about the real risk they represent (restructuring). Otherwise, relaxation can become a counterproductive tool.

On the other hand, it is also interesting 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 nature (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.

The treatment of internalizing disorders must necessarily include the child's family. Involving her is essential, since it is usually necessary to make changes at home and at school aimed at resolving a difficult situation that affects everyone.

Bibliographic references:

• Lozano, L. and Lozano, L.M. (2017). Internalizing disorders: a challenge for parents and teachers. Parents and Teachers, 372, 56-63.
• Ollendick, T.H. and King, N.J. (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