Internalizing problems of childhood are broadly defined as problems that occur within the child. Children with internalized problems often appear withdrawn, fearful, and shy. Internalized problems are managed within the child rather than being acted out externally in the environment. Beyond differing in their diagnostic criteria, externalizing problems differ from internalizing problems primarily in their expression. However, there is significant evidence that externalizing problems and internalizing problems occur comorbidly. Broadly speaking, the class of internalizing problems in childhood includes depression and anxiety. Subcategories of childhood anxiety disorders are also internalized disorders and include separation anxiety disorder, panic disorder, social phobia, simple phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. Similarly, subcategories of depressive disorders have been identified and include major depressive disorder, dysthymia, cyclothymia, and bipolar disorder.
Internalizing Problems Defined
Though the next section is not comprehensive, its intent is to provide an overview of some internalizing problems in childhood, guided by the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Only the broad categories of depressive disorders and anxiety disorders will be reviewed.
Childhood Depressive Disorders
As one of the most pervasive disorders, depressive disorder (often referred to as mood disorder) has a tremendous impact on a child’s energy, mood, and expression of emotions. Children who suffer from any form of depression experience challenges with peer relationships, familial relationship, academic success, and overall psychosocial development. Though many similarities exist between depression in adults and depression in children, there are some distinct differences. Specifically, children exhibit an irritable mood and, at times, an inability to sit still, including fidgeting or pacing.
Depression has a profound impact on a child’s well-being similar to its effect on adults. Children with depression experience profound sadness, frequent periods of crying, feelings of helplessness and/or hopelessness, and a decrease or increase in appetite. Along with these symptoms often come feelings of discouragement or worthlessness and a loss of interest in pleasure and subsequent disinterest in previously interesting activities. Children with depression may be fearful and anxious and often experience a significant drop in school performance. Finally, these children may experience significant changes in their sleeping habits, specifically an increase or decrease, and they often complain of physical aches and pains that have no medical explanation.
Childhood Anxiety Disorders
Children experiencing significant anxiety often experience intense fear, irritability, worry, and overall uneasiness. Anxiety can have a profound impact on a child’s well-being and can influence or profoundly affect the child’s school success, relationships with peers, self-esteem, and ongoing anxiety into adulthood. The specific symptoms of anxiety disorders differ according to diagnosis; therefore, below is a general overview of the broad diagnostic category of childhood anxiety.
When children experience a general sense of anxiety, they worry about things that occur in their everyday lives, such as school activities, peer relationships, and extracurricular activities. These fears often result in lower self-esteem, physical complaints without a medical explanation, and a strong need for reassurance. Other anxiety problems may be a result of unrealistic fear of a particular situation or object (phobias). Examples of such phobias may include fear of storms, snakes, spiders, height, water, or social situations. Children with phobias may attempt to avoid situations that may expose them to the environment or object that produces their fears, thus restricting their activity and social interaction. Other types of anxiety may manifest in a child through an intense fear of leaving his or her parents (separation anxiety), through patterns of repetitive thoughts or behaviors (obsessive-compulsive disorder), or a constant replaying of a stressful event (posttraumatic stress). Anxiety overall limits children’s willingness and at times capacity to freely experience the world and subsequently impacts their overall psychosocial development.
There is a high degree of comorbidity between anxiety and depression in children, meaning that children with symptoms of one, either anxiety or depression, often eventually exhibit symptoms of the other. It is important to note that to be considered significant, all symptoms associated with any of these internalizing problems must be present beyond what is to be expected with normal development and to a significant degree must cause problems with psychosocial and educational development. Any single symptom cannot lead to a diagnosis of one of the above internalizing disorders.
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