UNIT-4

INTERNALIZING PROBLEMS AND EXTERNALIZING PROBLEMS

Internalizing Problems in Child Development –

Internalizing problems involve inwardly focused emotional and behavioral issues where the
distress is primarily internalized. These issues are often less noticeable to others but
significantly impact the child’s psychological health.

Common Examples:

1. Anxiety Disorders:
o Symptoms include excessive worry, irrational fears, separation anxiety, and panic
attacks.
o Children may avoid specific situations or develop compulsive behaviors to cope
with their fears.
2. Depression:
o Symptoms include persistent sadness, loss of interest in activities, fatigue, changes
in sleep or appetite, and feelings of worthlessness.
o In children, depression often presents as irritability rather than overt sadness.
3. Social Withdrawal:
o Avoidance of peer interactions or group activities.
o May be accompanied by shyness, fear of rejection, or difficulties in social skills.
4. Somatic Complaints:
o Recurrent headaches, stomachaches, or other physical symptoms without a
medical explanation.
o These often result from underlying stress or anxiety.

Causes:

1. Genetic Factors:
o Family history of mental health disorders increases vulnerability.
o Genes influencing neurotransmitter functioning, like serotonin, may play a role.
 2. Environmental Stressors:
o Experiencing trauma, abuse, or significant life changes such as parental divorce.
o Chronic stress from bullying or academic pressure.
3. Parental Influence:
o Overprotective or authoritarian parenting styles can limit a child’s autonomy and
coping mechanisms.
o Parental mental health issues may also affect children.
4. Cognitive and Temperamental Factors:
o High levels of sensitivity, low self-esteem, and a tendency toward negative
thinking patterns.

Consequences:

• Social Impact: Difficulty forming and maintaining friendships, leading to isolation.

• Academic Challenges: Poor concentration and decreased academic performance.
• Long-Term Risks: Increased likelihood of developing chronic mental health issues in
adulthood.

Management:

1. Psychotherapy:
o Cognitive Behavioral Therapy (CBT): Helps children recognize and change
negative thought patterns.
o Play Therapy: Provides a safe space for younger children to express emotions
through play.
2. Family Interventions:
o Family therapy to improve communication and address systemic stressors.
o Educating parents on supportive strategies.
3. School Support:
o School counselors and social skills training programs.
o Anti-bullying campaigns and stress management workshops.
4. Medication:
o Antidepressants or anti-anxiety medications for severe cases.
o Prescribed cautiously, with monitoring for side effects.
Externalizing Problems in Child Development –

Externalizing problems are outward-directed behaviors that disrupt others and violate social
norms or expectations. These behaviors are more visible and may escalate if not addressed.

Common Examples:

1. Aggression:
o Physical (e.g., hitting, kicking) or verbal (e.g., yelling, insults).
o Can manifest as reactive aggression (response to a perceived threat) or proactive
aggression (intentional to achieve a goal).
2. Hyperactivity and Impulsivity:
o Symptoms include fidgeting, inability to stay seated, blurting out answers, and
difficulty waiting turns.
o Often associated with Attention-Deficit/Hyperactivity Disorder (ADHD).
3. Oppositional Defiant Disorder (ODD):
o Persistent defiance, refusal to follow rules, and frequent temper tantrums.
o Noteworthy for its hostility toward authority figures.
4. Conduct Disorder:
o A severe form of externalizing behavior (discussed below).

Causes:

1. Biological Factors:
o Impaired brain functioning in areas controlling impulse regulation, such as the
prefrontal cortex.
o Exposure to prenatal risks like substance abuse or malnutrition.
2. Family Dynamics:
o Harsh, inconsistent, or neglectful parenting.
o High-conflict family environments or exposure to domestic violence.
3. Peer Influence:
o Associating with delinquent peers.
o Rejection by socially adaptive peers may push the child toward negative
influences.
 4. Sociocultural Factors:
o Poverty, community violence, and lack of access to positive role models.

Consequences:

• Interpersonal Struggles: Conflicts with peers, teachers, and family members.

• Educational Disruption: Higher rates of suspension, expulsion, and school dropout.
• Legal Issues: Increased likelihood of juvenile delinquency.

Management:

1. Behavioral Interventions:
o Positive reinforcement to encourage appropriate behaviors.
o Token economy systems for younger children.
2. Parent Training Programs:
o Focused on improving parenting skills and consistency in discipline.
o Programs like the Triple P (Positive Parenting Program) are widely used.
3. School-Based Interventions:
o Structured classroom environments and individualized support plans.
o Peer mediation and conflict resolution programs.
4. Medication:
o Used sparingly to manage co-occurring conditions like ADHD.
 CONDUCT DISORDER

Conduct Disorder (CD) is a complex psychological condition in children and adolescents

characterized by persistent patterns of aggressive, disruptive, and antisocial behavior. It
significantly impairs academic, social, and familial functioning. Below is an exhaustive
examination of this disorder, addressing every major aspect:

Definition:

Conduct Disorder is defined as a repetitive and persistent pattern of behavior that violates
societal norms, rules, or the rights of others. These behaviors may include aggression,
deceitfulness, destruction of property, and serious violations of rules.

Diagnostic Criteria (DSM-5) -

To be diagnosed with CD, a child or adolescent must display at least three or more symptoms
across the following categories within the past 12 months, with at least one symptom occurring
in the past six months:

1. Aggression to People and Animals:

o Frequent bullying or threatening others.
o Initiating physical fights.
o Using weapons capable of causing serious harm.
o Physical cruelty to people or animals.
o Forced sexual activity.
2. Destruction of Property:
o Deliberately setting fires with intent to cause damage.
o Willful destruction of others' property.
3. Deceitfulness or Theft:
o Breaking into homes, buildings, or cars.
o Persistent lying for personal gain or to avoid obligations.
 o Shoplifting or stealing items without confrontation.
4. Serious Rule Violations:
o Staying out at night despite parental prohibitions (before age 13).
o Running away from home overnight at least twice.
o Truancy from school (before age 13).

Specifiers:

• Onset:
o Childhood-Onset: Symptoms present before age 10.
o Adolescent-Onset: Symptoms begin at age 10 or later.
o Unspecified Onset: Age of onset is unclear.
• Severity:
o Mild: Few problems beyond what is required for diagnosis and minor harm to
others.
o Moderate: Intermediate levels of severity.
o Severe: Numerous problems and considerable harm to others.

Prevalence and Epidemiology -

• Prevalence:
o Occurs in approximately 2-10% of children.
o Higher prevalence in males, particularly for aggressive behaviors.
• Gender Differences:
o Boys: More likely to exhibit physical aggression and property destruction.
o Girls: More likely to engage in relational aggression (e.g., social exclusion).
• Cultural Variations:
o Socioeconomic factors, exposure to violence, and cultural norms can influence
prevalence rates.
Manifestations and Symptoms -

Behavioral Patterns:

1. Physical Aggression: Fighting, bullying, or inflicting physical harm intentionally.

2. Relational Aggression: Manipulating social relationships to harm others (more common
in girls).
3. Impulsivity: Acting without considering consequences, often leading to dangerous
behaviors.
4. Callous-Unemotional Traits:
o Lack of guilt or remorse for actions.
o Absence of empathy for others.
o Indifference to performance in school or at home.

Associated Features:

• Low frustration tolerance and frequent temper outbursts.

• Lack of accountability or externalizing blame for their actions.
• Thrill-seeking or risk-taking behaviors.
• Poor academic performance and high rates of school dropout.

Etiology (Causes and Risk Factors) -

1. Biological Factors:

• Genetics:
o Strong heritability linked to impulsivity and aggression.
o Family history of antisocial behavior or substance abuse increases risk.
• Neurobiological Factors:
o Dysregulation in the amygdala and prefrontal cortex, affecting emotional
regulation and decision-making.
o Lower resting heart rates and reduced autonomic arousal, linked to a blunted
emotional response.
 • Prenatal and Perinatal Risks:
o Maternal substance use during pregnancy.
o Birth complications or low birth weight.

2. Psychological Factors:

• Temperament:
o Difficult or irritable temperament in infancy.
o Poor attachment to caregivers.
• Cognitive Deficits:
o Impaired problem-solving, social cognition, and moral reasoning.
o Hostile attribution bias, where neutral situations are interpreted as threatening.

3. Family Dynamics:

• Parenting Style:
o Harsh or inconsistent discipline.
o Neglect, abuse, or lack of parental involvement.
• Parental Psychopathology:
o Parental depression, substance abuse, or antisocial behavior.
• Family Structure:
o Divorce, separation, or unstable home environments.

4. Social and Environmental Factors:

• Peer Influences:
o Association with delinquent peer groups.
o Rejection by prosocial peers.
• Socioeconomic Status:
o Poverty, neighborhood violence, and limited access to resources.
Consequences -

Immediate Impact:

• Poor academic achievement.

• Strained family relationships.
• Social rejection and isolation.

Long-Term Outcomes:

• Increased risk of Antisocial Personality Disorder in adulthood.

• Higher rates of substance abuse, criminal activity, and incarceration.
• Poor occupational and relational functioning.

Differential Diagnosis -

1. Oppositional Defiant Disorder (ODD):

o Shares some defiant behaviors but lacks the severe aggression and violation of
rights seen in CD.
2. Attention-Deficit/Hyperactivity Disorder (ADHD):
o Impulsivity in ADHD is not driven by hostility or antisocial intentions.
3. Mood Disorders:
o Aggression in mood disorders is often episodic and linked to emotional
dysregulation.

Management and Treatment -

1. Psychosocial Interventions:

• Cognitive Behavioral Therapy (CBT):

o Focuses on restructuring distorted thoughts and teaching coping skills.
o Emphasizes anger management and conflict resolution.
 • Multisystemic Therapy (MST):
o Addresses multiple systems (family, school, community) influencing the child.
o Reduces risk factors and strengthens protective factors.
• Parent-Child Interaction Therapy (PCIT):
o Improves parent-child relationships and teaches effective discipline strategies.

2. Family-Based Interventions:

• Parent Management Training (PMT):

o Teaches parents to reinforce positive behaviors and reduce problematic behaviors.
o Focuses on consistency and structure in parenting.
• Family Therapy:
o Addresses family conflict and communication patterns.

3. School-Based Programs:

• Behavioral Plans:
o Individualized education plans (IEPs) tailored to manage behaviors in school.
• Peer Mediation:
o Programs to teach social skills and improve peer interactions.

4. Medication:

• Used cautiously and often as a supplement to psychosocial treatments.

• Options may include:
o Mood Stabilizers (e.g., lithium) for severe aggression.
o Antipsychotics for comorbidities like severe irritability.
o Stimulants if ADHD symptoms are present.
5. Community and Recreational Programs:

• Structured activities like sports or arts that promote teamwork and self-discipline.
• Mentorship programs to provide positive role models.

Prevention -

1. Early Identification:
o Screening at-risk children for behavioral problems.
2. Parent Training:
o Teaching effective discipline and communication before problems escalate.
3. School-Based Interventions:
o Anti-bullying campaigns and social-emotional learning curricula.
4. Community Support:
o Access to resources like counseling, after-school programs, and community
centers.

Prognosis -

• Favorable Outcomes:
o Early intervention and consistent treatment can significantly improve behavior.
• Poor Outcomes:
o Delayed treatment, untreated comorbidities, or ongoing exposure to adverse
environments can lead to chronic antisocial behavior in adulthood.

By comprehensively addressing the multifaceted nature of Conduct Disorder, caregivers and

professionals can create a structured, supportive environment to foster healthier development
and reduce negative outcomes.

DIKSHA BHATI

ADCGC (2024-25)