Internalizing behaviors mostly include symptoms that may lead to anxiety and depressive disorders (Witte, 2012). Merrel (2009) also suggests that social withdrawal and somatic or physical illness are common internalizing symptoms. The most recent version of the DSM 5, internalizing behaviors are most commonly antecedents and associated with generalized anxiety disorder (GAD), separation anxiety, social phobia or social anxiety, selective mutism, agoraphobia, and panic disorder, and depression. Because of myths that children can’t be depressed, internalizing behaviors among children are often overlooked and misunderstood.

Internalizing issues and disorders have a physiological, cognitive, and behavioral component. They are based on a person’s attempt to maintain inappropriate or maladaptive control over their emotional and cognitive internal states—trying to overly control the way they feel. Additionally, the term internalizing indicates that these problems are developed and maintained to a great extent within the individuals.

Example: For anxiety disorders, there is an anticipatory worry (cognitive), physiological arousal based on fear response (physiology) and avoidance (behavioral)

For depressive disorders, there is rumination and fixation on negative events which leads to distortion (cognitive), changes is sleep, energy, appetite (physiological), and irritability, sadness, hopelessness, and flat affect (behavioral)

All symptoms, per Sander (2012), are out of proportion to any actually or real threat or danger; cognitive threat is characteristically overestimated (APA, 2013; Hankin 2003). Prodromal symptoms that are commonly associated with internalizing disorders (anxiety, depression, social withdrawal, and somatic/physical illness) and more often discredited as just the general ups and downs of life and childhood include: persistent sadness, statements of hopelessness, lack of enthusiasm for previous interests, increased irritability, changes in eating and sleeping habits, poor concentration, forgetfulness, indecision, missing school, self-mutilation, thoughts of dying, and suicidal ideations (NAMI, 2009). Addressing these early warning symptoms and behaviors can help to prevent them from intensifying and turning into psychiatric disorders.

10-15% of children and youth ages 10-21 in the United States meet the criteria for anxiety or depression, and the number is growing (Copeland et al., 2014). Gender differences are not noted except in early and late adolescence when girls outnumber boys 2:1 for anxiety and depressive disorders (Copeland et al., 2014). Other factors which contribute to higher prevalence rates are: low SES, among students in special education (14% more than general population), and Caucasian students (Dvry & Toupin, 2004).

There are several self-report tools and questionnaires for warning signs for anxiety and depression. Most often, anxiety and depression assessments for children and youth also include a corresponding parent and/or teacher scale. The Student Risk Screening Scale-Internalizing 5 (SRSS-I5 or SIBSS) is a free, 5-question, teacher (school professional)-completed rating scale. According to Copeland et al. (2014) and Witte (2012), the SIBSS has been found to have excellent accuracy and sensitivity for predicting internalizing behavior problems at school and the increased likelihood of developing depression and anxiety. A pdf of the SRSS-I5 can be found in the module folder. Additionally, more information about the assessment can be found at http://miblsi.cenmi.org/MiBLSiModel/Evaluation/Measures/StudentRiskScreeningScale.aspx

Students with internalizing behaviors and associated emotional issues tend to have difficulty with academic goals and social participation at school. In particular, Bazyk (2012) noted that internalizing symptoms of somatic complaints, social isolation, hopelessness, and depressive mood are most commonly seen in school-aged children and often a factor in cases of dropout, refusals to attend school, adolescent incarceration, and hospitalizations which can lead to many school absences. Adolescents with or at-risk for depression find that negative mood interferes with in-class performance, having the desire to complete homework, concentrating during class, interacting with school professionals and students, and making friends at school (Sander, 2008). High levels of anxiety interfere with social participation, willingness to engage and participate in class, memory and thinking clearly, and interacting with classmates (Mazza, 2007). For girls, in particular, anxiety is highly associated with school failure.

Megan Shinnick’s TED Talk provides strong support for expanding school mental health efforts. Take a look https://www.youtube.com/watch?v=txJGm6zhiBA (or cut and paste into your browser).

Retrieved from : TOT 2: Internalizing Behaviors (2019)

Creating a Tier 2 Small Group Intervention for Students Presenting with Internalizing Behaviors

Go to the module folder and find your three clients: Amy, Andy, and Hannah. Read each adapted case report and consider how you might support school-based mental health efforts by providing them with a small group Tier 2 intervention. Think of how you might be able to use occupation-based interventions and occupation-focused processing to support them in better meeting student role expectations. After you brainstorm a bit, concretize your group intervention in the form of a group protocol. Send your completed protocol to lmahaf@midwestern.edu for review.

For those of you who have not yet had a group class or would like a refresher on how to structure a group protocol, I have included two resources.

• Look at a student mental health protocol from NYU OT students at http://spin-ot.com/all-articles/2013/12/8/keychains-to-inspire

Retrieved from : TOT 2: Internalizing Behaviors (2019)