Internalizing disorders: what they are, types and treatments.

A group of emotional disorders common during childhood.

Knowing about internalizing disorders is very importantThey are 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 living with them brings with him/her a very high degree of suffering.

Children who suffer from them may report feeling sad, shy, withdrawn, fearful, or unmotivated..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 "run away from it".

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

What are internalizing disorders?

In general, the mental disorders that can present a child are grouped in two great categories: internalizing and externalizing. The criterion by means of which such a distinction is made alludes to whether they manifest themselves at a behavioral (or external) or cognitive (or internal) level, being more evident to the observer.the former being more evident to the observer than the latter. However, despite this dissection of the child psychopathological reality, it should be noted 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 coexistence at home or at school. Some of the problems included in this category would be oppositional defiant disorder or attention deficit hyperactivity disorder (especially concerning motor excesses).

On the other hand, internalizing disorders often go unnoticed or lead to diagnoses that are completely unrelated to what is really happening (since they have a different behavioral expression to that which manifests itself in adults). It is for this reason that rarely constitute the reason for consultationThey 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 on them throughout this text.

1. Depression

Depression in childhood is often a silent and elusive disorder. Most commonly, it manifests itself in the form of irritability and loss of motivation for the tasks of this age group. It most commonly 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 resonances on the psychological, social and cognitive development of the child. Moreover, it is a strong predictor of psychopathological risk during adulthood.

Depression in children is different from that seen among adults in many of the aspects usually considered, although they tend to match each other at the symptomatological level as they enter adolescence. It is essential to keep in mind that many children have not yet developed sufficient verbal abstraction verbal abstraction capacity to express their internal states to others, so there is a significant risk of under-diagnosis (and consequent lack of treatment).There is therefore a significant risk of under-diagnosis (and consequent under-treatment).

Despite this, children also experience sadness and anhedonia (understood as the difficulty to experience pleasure), which is manifested by 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, there are usually some difficulties in reaching the appropriate weight for age and size, which is associated with poor appetite or even refusal of food.

When it comes to sleep, insomnia (which over the years tends to become hypersomnia) is very common, contributing to their constant complaints of lack of energy or vitality. The level of activity may be altered by both excess and deficit (psychomotor agitation or slowness) and even thoughts of death or death of others occasionally arise. The feeling of uselessness and guilt is usually also present.The feeling of uselessness and guilt is usually also present, coexisting with difficulties of concentration that hinder the performance in the school demands.

2. Anxiety

Anxiety is a disabling symptom that can manifest itself during childhood. As with depression, it often goes unnoticed by the adults who live with the child, since it is largely expressed through experiences that are triggered within the child. When probed on this issue, the presence of disproportionate ideas becomes very evident the presence of disproportionate ideas regarding an event that the child feels as threatening and that it locates in some relatively near moment of the future (probability that one day the separation of its parents takes place, for example).

In the infantile anxiety a sharpening of the fears can be appreciated that are characteristic of the different periods of age, and that are adaptive in a first moment. Most commonly they fade away as neurological and social maturation progresses.However, this symptom can contribute to the fact that many of them are not completely overcome and end up accumulating, exerting a summative effect that implies a permanent state of alertness (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 live constantly worried (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 that which corresponds to the moment in which the child distances himself from his bonding figures, that is, separation anxiety; and also certain specific phobias that tend to be maintained into adulthood if adequate treatment is not articulated (to animals, masks, strangers, etc.). After these early years, in adolescence anxiety shifts to relationships with peers and school performance.

3. Social withdrawal

Social withdrawal may be present in childhood depression and anxiety, as a symptom inherent to 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 want to be with their peers.The latter manifests itself 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 with strangers should not be established, which is part of the specific parenting criteria. Sometimes social withdrawal is accompanied by a deficit in basic interaction skills, so that some difficulty is manifested during attempts to approach others, even though they are desired.

In the event that social withdrawal is a direct result of depression, the child often indicates that he or she is suspicious of his or her ability or fears that approaching others may lead to rejection.. 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 an increased 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 the physical state, most notably pain and uncomfortable 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. and in the area around the eyes. This confusing clinical expression often prompts visits to pediatricians, who cannot find an explanatory organic cause.

A careful analysis of the situation shows that these discomforts emerge at specific times, usually when an event is about to happen 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 a regression to evolutionary milestones that had already been overcome (returning to bedwetting, 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 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 (as in the case of a child with adhd also suffering from depression), it is possible for two internalizing disorders to occur together (both anxiety and depression are related to social withdrawal and somatic complaints in the child).

Childhood depression is usually the result of a loss, of social learning from living with a parent suffering from the same type of condition, and of the failure to establish constructive relationships with the child. failure 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 house, change of school, etc.). Some internal variables, such as temperament, may also increase the predisposition to suffer from it.

As for anxiety, it has been described that shyness in childhood may be one of the main risk factors. Even so, 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. As for gender, 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, women suffer from them. but when adolescence arrives, women suffer more frequently from these problems.. They may also arise as a result of some difficult event, as well as depression, and from living with parents who suffer from anxiety.

With regard to social withdrawal, it is known that children with insecure attachment may show resistance to interacting with a stranger.The former is mainly 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 abuse or violence. In other cases the child is simply 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 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 the concrete way in which internal conflicts manifest themselves at an organic level, highlighting the presence of tension headaches and alterations of the digestive function.

How can they be treated?

Each case requires an individualized therapeutic approach that adopts a systemic type of approachThis approach explores the relationships that the child maintains with his attachment figures or with any other people who are part of his spaces of participation (such as the school, for example). From this point on, it will be possible to draw functional analyses 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 also important to help the child to detect what his or her emotions are.The child can express them in a safe environment and define what thoughts may lie behind each of them. Sometimes children with internalizing disorders live with overvalued ideas about an issue that is of particular concern to them, and it is possible to encourage them to discuss this very issue and to find alternative ways of thinking that better fit their objective reality.

If 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, including various relaxation strategies. It is important to consider the possibility that the child may adversely judge the sensations occurring in his own body (this is common when suffering anxiety), so first of all it will be key to talk to him about the real risk they represent (restructuring). Otherwise, relaxation can become a counterproductive tool.

On the other hand, it is also interesting to to teach children skills that facilitate their way of relating to others, in case they do not have them or do not know how to use them.If they do not have them or do not know how to take advantage of them, it is also interesting to teach children skills that facilitate their way of relating to others. The most relevant are the social ones (initiating a conversation) or assertiveness, and they can also be practiced in consultation through role-playing. In the case that these strategies are already available, it will be necessary to deepen in which emotions could be inhibiting their adequate use in the context of their daily relationships.

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

Bibliographical references:

• Lozano, L. y Lozano, L.M. (2017). Los trastornos internalizantes: un reto para padres y docentes. Padres y Maestros, 372, 56-63.
• Ollendick, T.H. y 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