Review
Internalizing/Externalizing Problems: Review and Recommendations for Clinical and Research Applications

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Objective

More than 75,000 articles have been published on internalizing and externalizing problems. To advance clinical and research applications of internalizing/externalizing concepts and data, our objectives were as follows: to provide an overview of recent research on internalizing/externalizing problems assessed at ages 1½ to 18 years; to identify issues raised by methods for assessing such problems; and to develop recommendations for more precise, consistent, informative, and productive assessment of such problems.

Method

A total of 4,870 peer-reviewed articles published from January 1, 2012 through December 31, 2014 were systematically reviewed and identified by the search terms “internalizing” or “externalizing,” followed by detailed coding of 693 articles that reported use of measures meeting criteria for methodologically sound assessment of internalizing/externalizing problems.

Results

Many articles reported data based on measures that did not meet criteria for methodologically sound assessment of internalizing/externalizing problems. The 693 articles that used measures meeting criteria for methodological soundness and that qualified for detailed coding reported findings for 649,457 children living in 65 societies on all inhabited continents. Data were obtained from parents, teachers, children, clinicians, caregivers, and others. Samples included general population, clinical, school, at-risk, multicultural, welfare, and various ethnic/racial and socioeconomic groups. Many analytic methods were used to test associations of diverse variables with internalizing/externalizing problems.

Conclusion

The diverse procedures used to assess internalizing/externalizing problems pose challenges for clinical and research applications. To meet the challenges, recommendations are provided for using assessment instruments supported by published standardization, reliability, validity, and normative data to advance clinical services and research.

Section snippets

DSM

In the introduction to the DSM-5, the American Psychiatric Association9 cites findings demonstrating that scientific efforts to validate disorders have been more useful for suggesting large groupings of disorders than for validating individual diagnostic categories. In particular, the

…clustering of disorders according to what has been termed internalizing and externalizing factors represents an empirically supported framework. Within both the internalizing group (representing disorders with

Method

We followed guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.17

Results

Not counting ad hoc items and scales that were idiosyncratic to particular studies, we found that 49 different measures were used to obtain internalizing and/or externalizing scores. In tallying the measures, we counted families of related instruments as a single measure; for example, the Achenbach System of Empirically Based Assessment (ASEBA) includes the Child Behavior Checklist for Ages 1½-5 and for Ages 6-18 (CBCL/1½-5 and CBCL/6-18), Caregiver-Teacher Report Form (C-TRF), Teacher’s Report

Discussion

Our review revealed that internalizing/externalizing problems have been assessed in thousands of studies that used a great variety of measures to assess children from diverse backgrounds for many different purposes. Differences among the measures pose challenges for integrating the findings, for drawing generalizable conclusions, and for advancing clinical and research applications. To focus on the most credible and generalizable findings, we limited our systematic review to measures that met

References (34)

  • Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., 5th ed

    (1980)
  • T. Insel et al.

    Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders

    Am J Psychiatry

    (2010)
  • T.M. Achenbach et al.

    The classification of child psychopathology: a review and analysis of empirical efforts

    Psychol Bull

    (1978)
  • H.C. Quay

    Classification

  • T.M. Achenbach et al.

    Manual for the Child Behavior Checklist and Revised Child Behavior Profile

    (1983)
  • Cited by (292)

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    This work was funded by the nonprofit University of Vermont Research Center for Children, Youth, and Families (RCCYF), which publishes the Achenbach System of Empirically Based Assessment (ASEBA).

    Disclosure: Dr. Achenbach is president of the nonprofit RCCYF, which publishes the ASEBA and from which he has received remuneration. He has received royalties from Guilford Press for a book published in 2007 and honoraria for invited presentations. Dr. Ivanova is corporate secretary of the nonprofit RCCYF, from which she has received remuneration. She has received honoraria for invited presentations. Dr. Rescorla is vice president of the nonprofit RCCYF, from which she has received remuneration. She has received royalties from Guilford Press for a book published in 2007 and honoraria for invited presentations. Dr. Althoff is employed, in part, by the nonprofit RCCYF. He has received grant or research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, the Klingenstein Third Generation Foundation, and the Marcus Autism Center. He has received honoraria from Oakstone Medical Publishing. He is a partner of WISER Systems, LLC. Ms. Turner is employed by the nonprofit RCCYF. She reports no biomedical financial interests or potential conflicts of interest.

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