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KeywordsAnxiety Disorder Cognitive Behavioral Therapy Generalize Anxiety Disorder Social Anxiety Disorder Posttraumatic Stress Disorder
Internalizing behaviors encompass a dimension of childhood psychopathology that includes behaviors that are directed inward or are overcontrolled and are associated with a number of depressive and anxiety disorders. Examples of internalizing behaviors may include fearfulness, somatic complaints, worrying, and withdrawal.
Internalizing behaviors are typically associated with a range of mood and anxiety disorders, primarily classified in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5; American Psychiatric Association 2015) as depressive disorders and anxiety disorders. Specific internalizing disorders historically include major depressive disorder, persistent depressive disorder (dysthymia), specific phobia, separation anxiety disorder, social anxiety disorder (social phobia), generalized anxiety disorder, panic disorder, selective mutism (which was previously classified as a disorder of childhood in DSM-IV; APA 2000), and other disorders formerly classified as anxiety disorders, such as obsessive-compulsive disorder (now classified as obsessive compulsive and related disorders) and posttraumatic stress disorder (now classified as trauma- and stressor-related disorders) (APA 2000, 2015).
Internalizing disorders are the source of significant distress and impairment, yet they often go unidentified and untreated. Depression and anxiety are associated with genetic, temperamental, and environmental risk factors that influence their development and course (APA 2015). A wide range of assessment tools is available for evaluation of children from early childhood (i.e., toddlerhood). There is also now good evidence to support efficacy of treatments for children and adolescents with a wide range of internalizing disorders, including cognitive-behavior therapy and interpersonal therapy for depression and cognitive-behavioral and exposure-based approaches for anxiety.
History of Internalizing and Externalizing Dimensions
In 1978, Achenbach and Edelbrock proposed an empirically derived system of classification within child psychopathology that identified two broadband dimensions of child behavior: Internalizing and Externalizing behavior. In their seminal study, Achenbach and Edelbrock used factor analytic methods across informants (parent, teacher, child) and several samples and revealed two broadband behavioral categories: overcontrolled behaviors, which included shyness, anxiety, personality disorders, and inhibition; and undercontrolled behaviors, which included aggression and conduct problems. Children were classified as internalizers if 60% of more of their symptoms were drawn from the overcontrolled dimension and externalizers if 60% of more of their symptoms were drawn from the undercontrolled dimension. The externalizing and internalizing behavior dimensions were found to be distinct, with specific, significant correlates associated with children who were categorized according to these dimensions. For example, overcontrolled children (those with more internalizing behaviors) were found to have lower levels of open conflict, were more socially competent, and appeared to be better candidates for conventional mental health treatment compared to externalizing, undercontrolled children (Achenbach and Edelbrock 1978). Further research has consistently supported these two broadband factors (e.g., Eisenberg et al. 2001). Consequently, this terminology has been widely adopted by the field and remains a primary means of conceptualizing behavior problems among youth.
Assessment of Internalizing Behaviors
Internalizing behaviors are often first assessed through use of empirically derived broadband and narrowband questionnaires. Children and adolescents are generally better informants of internal mood states than other informants, with youth ages 9 and older being considered reliable informants on self-report measures (Frick et al. 2010). When assessing internalizing behaviors, child and adolescent self-report should be given greater weight than reports from other informants (Mash and Hunsley 2005). Additionally, it is important to assess internalizing behaviors within a developmental context, as these behaviors may be normative given a child’s age (e.g., anxiety about beginning kindergarten, fear of the dark; Ollendick and Silverman 2005).
Broadband measures are helpful for screening for child psychopathology, for differentiating internalizing and externalizing behavior, and for identifying clinically problematic domains of behavior for additional evaluation. Broadband instruments typically assess several specific factors comprising higher order internalizing and externalizing factors (e.g., anxious/depressed, somatic complaints, aggressive behavior), as well as other problem behaviors (e.g., social problems). Reports are generally obtained from multiple informants (parent, teacher, and self). Narrowband rating scales, symptom checklists, and diagnostic interviews are used for further diagnostic evaluation of specific domains of concern and to assess symptoms associated with specific disorders. Narrowband instruments are also useful for progress monitoring throughout the intervention process.
When evaluating and monitoring symptoms of anxiety in children and adolescents, assessment tools include structured and semistructured interview schedules, observational measures, self-monitoring forms, and rating scales (Silverman and Ollendick 2005). Similarly, the assessment of symptoms of depression primarily involves the use of unstructured, semistructured, or fully structured interviews, as well as rating scales (Klein et al. 2005). Again, it is necessary to take developmental context into account, as the behaviors indicative of depression may manifest differently in younger children versus adolescents, with younger children appearing more depressed and having somatic complaints and adolescents experiencing more cognitive symptoms (i.e., low self-esteem, worthlessness, negative thinking; Klein et al. 2005).
Etiology and Associated Factors
Studies have examined biological and environmental factors associated with the development of internalizing behaviors and disorders in children. Heritability studies support moderate to strong genetic transmission of both depression and anxiety. About one-third of the variance for depression and up to nearly two-thirds of the variance in anxiety are attributable to heritable factors with rates differing across specific dimensions, disorders, and studies (e.g., Hammen et al. 2014; Higa-McMillan et al. 2014).
Family aggregation studies suggest that depression and anxiety run in families, with both children of parents with anxiety and parents of children with anxiety being at increased risk (Hammen et al. 2014; Higa-McMillan et al. 2014). Anxiety appears to employ a more specific genetic risk for transmission of anxiety, and depression appears to employ a more general risk for psychopathology, with children of depressed mothers experiencing a range of externalizing and internalizing disorders (Beidel and Turner 1997). However, within the domain of anxiety, the risk transmitted appears to a general risk for anxiety, rather than a disorder-specific risk (Higa-McMillan et al. 2014).
Imaging studies suggest a role of the limbic system, specifically the amygdala and hippocampus, in depression and anxiety due to their role in emotion processing, emotion responding, encoding of long-term memories, and threat assessment. Studies have also examined activity of the hypothalamic-pituitary-adrenal axis (HPA) and increased secretion of stress hormones such as cortisol in relation to stress, with persistent anxiety and depression both being associated with dysregulation of the HPA axis (Hammen et al. 2014; Higa-McMillan et al. 2014).
Temperament and personality characteristics may also serve as emotional vulnerabilities for the development of internalizing behaviors and disorders. Specifically, negative affectivity appears to be a common factor across depression and anxiety, while positive affectivity appears to differentiate depression and anxiety in youth, with depressed youth experiencing high negative and low positive affectivity, respectively (Lonigan et al. 1999). In addition, shyness/inhibition and neuroticism are often associated with anxiety (e.g., Higa-McMillan et al. 2014).
Additionally, environmental risk factors have been identified in relation to the development of internalizing behaviors. Specifically, parental overcontrol, parental rejection, marital conflict, and parental modeling of behaviors indicative of anxiety such as avoidance have been associated with anxiety. Environmental exposure to adversity in early childhood (e.g., family disruption, economic challenges, parental depression) tends to be more associated with depression. Finally, difficult or hostile childhood experiences (e.g., stressful events, child maltreatment) are associated with increased risk for symptoms of both depression and anxiety (APA 2015; Hammen et al. 2014).
A range of psychological influences also has been associated with internalizing behaviors and disorders. Cognitive vulnerabilities such as negative schemas and biased information processing (i.e., negative cognitive triad, anxious apprehension) are associated with both depression and anxiety, respectively. Interpersonal vulnerabilities tend to be more associated with depression and selective attention (to perceived threat), whereas learning theory influences (e.g., classical conditioning, reinforcement, and modeling of fears) tend to be more associated with anxiety. All of these theories have been the basis for efficacious interventions designed to treat anxiety disorders in youth and adults (Higa-McMillan et al. 2014).
Thus, there appear to be a variety of pathways through which internalizing behaviors develop and progress. Early identification and treatment are important, as these dimensions of behavior tend to be quite stable over time and the source of significant distress (APA 2015; Higa-McMillan et al. 2014).
The primary interventions currently used to treat internalizing behaviors in children and adolescents are based on the cognitive behavioral model, with some variations based on the specific behaviors that are targeted. For example, Cognitive Behavioral Therapy (CBT) for anxious children typically targets the somatic, cognitive, and behavioral components of the specific anxiety symptomatology (Kendall et al. 2010). In general, components of CBT for anxiety include psychoeducation, cognitive restructuring, and exposure to feared situations. Additionally, CBT treatments for anxious children and adolescents frequently include parent and family-based components to enable clients to generalize and sustain skills learned during therapy (Kendall et al. 2010).
Similarly, for symptoms of depression, evidence-based treatments often involve some form of CBT or behavioral therapy. A review of evidence-based treatments for children with depression found that several interventions significantly decreased depression symptoms and improved overall functioning compared to controls (David-Ferdon and Kaslow 2008). Common components of CBT for child and adolescent depression include social skills training, problem-solving strategies, mood monitoring, pleasant activities scheduling, and self-control methods (David-Ferdon and Kaslow 2008).
Interpersonal therapy has also generated empirical support for treatment of adolescent depression. Interpersonal therapy was created to address the higher levels of interpersonal conflict seen among depressed adolescents compared to their non-depressed peers (Jacobson and Mufson 2010). The goal of interpersonal therapy is to reduce the symptoms of depression by improving interpersonal skills such as communication, problem-solving, and affect expression. Participants and their parents also receive psychoeducation about depression. Interpersonal therapy has been shown to reduce symptoms of depression and improve overall functioning in adolescents (Jacobson and Mufson 2010).
Overall, internalizing behaviors entail symptoms typically associated with a variety of psychological disorders (e.g., anxiety, depression, obsessive-compulsive disorder, and posttraumatic stress disorder). Examples of internalizing behaviors include sadness, withdrawal, shyness, somatic complaints, and inhibition. As discussed above, a number of etiological factors, such as genetic predisposition, temperament, and exposure to adverse environmental circumstances, have been associated with the development of internalizing behaviors. Given the stability of these behaviors over time, it is important to identify, assess, and treat these behaviors as early as possible to alleviate long-term negative consequences and reduce impairment.
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