Internalizing disorders: what they are, types and treatments

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

They are characterized by the apparent discretion with which they are presented, 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Children who suffer from them may report that they feel sad, shy, withdrawn, fearful or unmotivated .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 ones they rather “flee from it.”

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

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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 obvious to the observer than the latter. However, despite this dissection of the psychopathological reality of children, it must be borne in mind 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 living together at home or at school. Some of the problems included in this category would be the defiant negativist disorder or attention deficit hyperactivity disorder (especially with regard to motor excesses).

On the other hand, internalizing disorders go unnoticed many times, or come to motivate diagnoses that are absolutely alien to what actually happens (since they have a different behavioral expression from that manifested in adults). It is for this reason that they 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 its prevalence and impact) are depression, anxiety, social withdrawal and physical or somatic problems. In them we will focus attention throughout this text.

1. Depression

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 the tasks that are typical of this period of age (schoolchildren); although in the long term it has very severe resonances on the psychological, social and cognitive development of the child. In addition, it is a strong predictor of psychopathological risk during adulthood.

Depression in children is different from that observed among adults in many of the aspects usually considered, although they tend to be matched at a symptomatic level as they enter adolescence. It is essential to bear 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 the consequent lack of treatment).

Despite this, children also feel sadness and anhedonia (understood as the difficulty in experiencing pleasure), which manifests itself with a clear loss of motivation for being involved in academic or other tasks, although in the past they provided enjoyment. At the level of physical development, some difficulties are often 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 (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 can be altered both by excess and deficit (agitation or psychomotor slowness) and sometimes even thoughts arise about one’s own death or that of others. The feeling of worthlessness and guilt is usually also present , living with concentration difficulties that hinder performance in school demands.

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2. Anxiety

Anxiety is an invalidating symptom that can manifest during childhood. As with depression, it often goes unnoticed among adults living with the child, since it is largely expressed through experiences that are triggered within. When inquiring about this issue, the presence of disproportionate ideas regarding an event that the child feels threatening and that locates at a relatively close time in the future becomes very evident (probability that one day there will be separation from his parents, for example).

In childhood anxiety can be seen an exacerbation of fears that are characteristic of different age periods, and that are adaptive at first. The most common is that they fade away as neurological and social maturation progresses , but this symptom can contribute to many of them 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 consequences : the first is that it increases the risk that the first panic attacks (overflowing anxiety) are triggered, the second is that the tendency to live constantly worried (resulting in a subsequent generalized anxiety disorder) is triggered 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 linked figures, that is, that of separation; and also certain specific phobias that tend to remain until adulthood in the case of not articulating an appropriate treatment (to animals, masks, strangers, etc.). After these first years, in adolescence, anxiety shifts to relationships with peers and to performance in school.

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3. Social withdrawal

Social withdrawal can be present in depression and childhood anxiety, as a symptom inherent in them, or present independently. In the latter case it 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 (in school) or the belief that contact with strangers should not be established, which is part of the specific criteria of parenting. Sometimes social withdrawal is accompanied by a deficit in basic interaction skills, so some difficulty manifests itself during attempts to approach others, even if they are desired.

In the event that social withdrawal is a direct result of depression, the child often points out that he distrusts his ability or fears that when approaching others he may be rejected . Bullying, on the other hand, is a common cause of problems in social interaction during school years, and is also associated with 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 physical condition, especially pain and annoying 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 thorough analysis of the situation shows that these discomforts emerge at specific times, usually when a fact that the child fears (going to school, moving away from family or home for a while, etc.) is about to happen. that points to a psychological cause. Other somatic problems that may appear involve the retreat to evolutionary milestones that had already been overcome (re-urinating in bed, for example), which is related to stressful events of different types (abuse, birth of a new brother, 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 note that, just as there are cases in which both internalizing and externalizing problems occur (such as the assumption that a child with ADHD also suffers from depression), it is possible that two internalizing alterations may occur together (both anxiety such as depression is related to social withdrawal and somatic discomfort in the child).

Child depression is usually the result of a loss, of social learning from living with one of the parents who suffers from a picture of the same type and failure to try 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, school changes, etc.). Some internal variables, such as temperament, may also increase your predisposition to suffer from it.

Regarding anxiety, it has been described that shyness in childhood can be one of the main risk factors. Even so, there are indicative studies 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 sex, it is known that during childhood there are no differences in the prevalence for these problems according to such criteria, but that when adolescence arrives they suffer more frequently . They can also arise as a result of some difficult event, like depression, and from living with parents who suffer from anxiety.

As for social withdrawal, it is known that children with insecure attachment may show resistance to interacting with a stranger , especially the avoidant and disorganized. Both are related to specific upbringing patterns: the first is forged from a primitive feeling of parental helplessness, and the other for having lived in their 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 a fiction that is established in order to avoid such events, but in the concrete way in which internal conflicts manifest themselves at an organic level, highlighting the presence of tension headaches and digestive function disorders.

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 participation spaces (such as school, by example). 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 also important to help the child detect what his emotions are , so that he 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 overvalued ideas about an issue that particularly concerns them, and it is possible to encourage them to discuss this same extreme and to find alternatives for thinking that best 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, for which different relaxation strategies are included. It is important to consider the possibility that the child adversely judges the sensations that occur in his own body (it is common when they suffer anxiety), so first of all 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 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 take advantage of them. The most relevant are those of a social type (starting a conversation) or assertiveness, and can also be practiced in consultation through a role-playing. In the event that you already have these strategies, it will be necessary to deepen what emotions might be inhibiting their proper use in the context of their daily relationships.

The treatment of internalizing disorders must necessarily include the child’s family. Making it a participant is essential, as it is usually necessary to make changes at home and at school aimed at solving a difficult situation that affects everyone.

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