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 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Children who suffer from them may report that they feel sad, shy, withdrawn, fearful or unmotivated Thus, while in the case of externalizing disorders it is usually said that they “fight against the world”, in the case of internalizing disorders they rather “run away 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 are and what therapeutic strategies can be applied.
In general, the mental disorders that a child may 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 both can occur at the same time in the same child.
Both parents and teachers are very sensitive to the behavioral expression of the externalizing disorder, since it generates a substantial impact on the environment and even compromises coexistence at home or at school. Some of the problems that are included in this category would be oppositional defiant disorder or attention deficit hyperactivity disorder (especially regarding motor excesses).
On the other hand, internalizing disorders often go unnoticed, or come to motivate diagnoses that are completely unrelated to what is actually happening (since they have a behavioral expression different from that manifested in adults). It is for this reason that They are rarely the reason for consultation , and they are usually discovered as the professional investigates 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 attention on them throughout this text.
1. Depression
Depression in childhood is often a silent and elusive disorder. The most common thing 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. Furthermore, it is a solid predictor of psychopathological risk during adult life.
Depression in children is different from that observed among adults in many of the aspects usually considered, although they tend to become similar at the symptomatological level as they enter adolescence. It is essential to keep in mind that many children have not yet developed a capacity for verbal abstraction sufficient to manifest their internal states to others so there is a significant risk of underdiagnosis (and consequent lack of treatment).
Despite this, children also feel sadness and anhedonia (understood as difficulty experiencing pleasure), which manifests itself with a clear loss of motivation to engage in academic or other types of 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 tends to become hypersomnia over the years), which contributes to their constant complaints of lack of energy or vitality. The level of activity can be altered by both excess and deficit (agitation or psychomotor slowness) and even thoughts about one’s own death or that of others occasionally arise. The feeling of worthlessness and guilt is usually also present living with concentration difficulties that make it difficult to perform in school demands.
2. Anxiety
Anxiety is a disabling symptom that can manifest during childhood. As with depression, it often goes unnoticed among the adults who live with the child, since it is largely expressed through experiences that are triggered within the child. When this question is investigated it becomes very evident the presence of disproportionate ideas regarding an event that the child feels is threatening and that it places at some relatively near time in the future (probability that one day the separation of their parents will occur, for example).
In childhood anxiety, an exacerbation of fears that are typical of different age periods can be seen, and which are initially adaptive. They most commonly fade as neurological and social maturation progresses but this symptom can contribute to the fact that many of them are not completely overcome and end up accumulating, exerting a additive effect that implies a permanent state of alert (tachycardia, tachypnea, etc.).
This hyperactivation has three fundamental consequences : the first is that the risk of triggering the first panic attacks (overwhelming anxiety) increases, the second is that the tendency to live constantly worried is triggered (causing a subsequent generalized anxiety disorder) and the third is that it is projected excessive attention to internal sensations related to anxiety (a phenomenon common to all diagnoses in this category).
The most frequent anxiety in childhood is that which corresponds to the moment in which the child distances himself from his bond figures, that is, separation; and also certain specific phobias that tend to persist into adulthood if adequate treatment is not provided (to animals, masks, strangers, etc.). After these first years, in adolescence anxiety shifts to relationships with peers and performance at 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 itself as lack of interest in maintaining relationships with peers of the same 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 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 unknown people, which is part of the specific parenting criteria. Sometimes social withdrawal is accompanied by a deficit in basic interaction skills, which is why some difficulty appears during attempts to approach others, even though they are desired.
In the event that social withdrawal is a direct result of depression, The child usually indicates that he or she distrusts his or her ability or that he or she fears that by approaching others he or she 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 adult life, and even a possible increase in suicidal ideation.
4. Physical or somatic problems
Physical or somatic problems describe a series of “diffuse complaints” about the physical state, most especially pain and uncomfortable 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 confusing clinical expression usually motivates visits to pediatricians, who cannot find an explanatory organic cause.
A thorough analysis of the situation shows that these annoyances emerge at specific moments, generally when an event that the child fears is about to happen (going to school, leaving the family or home for a while, etc.), which 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 failure to establish constructive relationships with children of the same age Physical, mental and sexual abuse is also a very common cause, as well as 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 may be one of the main risk factors. Still, 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 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 from them more frequently They can also arise as a result of some difficult event, such as depression, and from living with parents who suffer from anxiety.
Regarding social withdrawal, it is known that children with insecure attachment may show resistance to interacting with a stranger , especially the avoidant and disorganized ones. Both are related to specific parenting patterns: the first is forged from a primitive feeling of parental helplessness, and the other from having experienced a situation of abuse or violence firsthand. In other cases, the child is simply a little 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 a fiction that is established in order to avoid such events, but rather the specific 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 school, for example) are explored. From this point, functional analyzes can be drawn up 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 It is also important to help the child detect what his emotions are , so you 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 overvalued ideas about an issue that particularly concerns them, and it is possible to encourage them to debate this same issue and find alternative ways of thinking that better fit their objective reality.
In the event that the child’s symptoms are expressed on a physical level, a program aimed at minimizing the activation of the sympathetic nervous system can be articulated, which includes different relaxation strategies. It is important to consider the possibility that the child adversely judges the sensations that occur in their own body (this is common when they suffer from anxiety), so first of all it will be key to talk to them 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. If you already have these strategies, it will be necessary to delve deeper 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, as it is usually necessary to make changes at home and at school aimed at resolving a difficult situation that affects everyone.
