Internalizing Problems in Childhood and Adolescence: The Role of the Family

Abstract

Objective:

Several studies have highlighted that internalizing problems have not received all the attention it deserves because they are not visible in children’s observable behavior. The aim of this study is to analyze the relationship between differences in parenting practices and internalizing problems in children and adolescents.

Methods:

Our study sample consisted of 554 children (288 boys and 266 girls) between 3 and 13 years of age who participated in the study. Their respective parents provided the information about them. The instruments used have been the Behavioral Assessment System for Children and Adolescents and parenting style, defined according to the Parental Parenting Questionnaire. The Parenting Questionnaire considers 7 factors: social and emotional support received by a mother or father, satisfaction with parenting, involvement, communication, limit setting, autonomy, and role orientation.

Results:

The results showed that children with high scores in internalizing problems tended to have parents with low levels of support, limit setting, and autonomy, along with low levels of maternal satisfaction with parenting. A regression analysis was also conducted, producing a model capable of predicting 14% of the variance in internalizing problems. The model was based on the following parenting variables: maternal support, autonomy and satisfaction with parenting, and paternal limit setting and role orientation.

Conclusion:

Our results indicate that the information obtained is very useful for the design of parenting programs related to certain aspects of current educational practice. Furthermore, parents’ responses to the instruments used revealed patterns of behavior that can be modified in both parents and children.

Main Points

• A predictive model has been developed that allows us to establish prevention guidelines.

• There are significant and indirect relationships between internalizing problems in children and some parental parenting style factors.

• Children with internalizing problems often have parents who perceive little support and set a limit setting and autonomy for their children.

• The mother’s support, autonomy, and satisfaction with parenting, and the father’s discipline acted as protective factors for children’s internalizing problems.

Introduction

According to data provided by the World Health Organization (WHO),¹ 1 in 7 children and adolescents between the ages of 10 and 19 suffer from mental health problems. To date, however, this situation has not received all the attention it deserves considering its impact on society.¹ The failure to adequately address mental health problems in minors is thought to limit the possibilities of leading an optimal life in the future.^1,2

Two main dimensions have been described in the psychological disturbances experienced during childhood and adolescence: the externalizing factor and the internalizing factor.³ Externalizing problems are characterized by disruptive behaviors such as aggressiveness, hyperactivity, and/or delinquency. Internalizing problems (the subject of this paper) are defined by Achenbach and Edelbrock³ as a combination of environmental problems that a child exhibits through symptoms such as anxiety, shyness, avoidance, nervousness, fears, sadness, and worry. This dimension has also been referred to globally as “overly controlled behavior.”³ Of all the different childhood problems recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),⁴ internalizing problems are the ones that are the most difficult to detect because they are not visible in children’s observable behavior.⁵

Family influence is largely determined by parental educational styles, defined as the set of behaviors or attitudes displayed by parents toward their children in everyday relationships, together with other types of conduct such as gestures, changes in tone of voice, and so on.⁶ Several studies argue that both problems tend to be found more in those children who perceive certain behaviors in their parents more frequently.^7-9 Previous research has already indicated that parenting practices characterized by high levels of affection and a high demand for maturity result in a democratic style of parenting that leads to balanced child development and reduces the likelihood of mental health problems.^10,11

Although it is still too early to obtain any results regarding the potential long-term consequences of COVID-19, it is no coincidence that much of the work done in recent years has focused on internalizing problems. Numerous studies, including Amorós-Reche et al.¹² have reported a considerable increase in emotional problems in children as a result of the pandemic. During lockdown, for example, it was easier for an unstructured parenting style with no established routines to trigger the onset of such problems.^13,14 A study by Ezpeleta et al¹⁴ suggested that children who were more emotionally affected after COVID-19 had perceived either more overprotection by their parents or less care, something characteristic of neglectful parents.

Relatively several recent studies, such as Aguilar et al.⁷ have found that parenting styles focused on overprotection or excessive control by both parents have a greater impact on the development of anxiety during childhood and adolescence. With children between the ages of 3 and 12, it has been shown that parental behaviors focused on affection and communication not only affect acceptance and rejection but also increase the risk of depression.⁹ Rousseau et al¹⁵ found that parental stress may be a risk factor for the development of somatization in children, while Luijten et al² underlined the importance of the role parents play in the well-being of their children. For this reason, the following studies show which parental behaviors might increase the likelihood of internalizing problems in their children.

Analyzing these problems as a whole, Marcone et al¹⁶ argued that parents who employ an authoritarian style can inhibit the development of self-regulation in children. In this case, the parents’ own hostile or demanding behaviors may make their children emotionally overexcited, leading to self-regulating difficulties in other situations.¹⁶ This type of parent is also characterized by not offering enough affection or responding to the child’s needs: for them, obedience and order are paramount, and no value is attached to the child’s autonomy.^10,17

Toro¹⁸ found that educational styles with high levels of demand and control but lacking in affection are often associated with internalizing disorders. In contrast, greater parental autonomy prevents the development of internalizing problems in children.^18,19 According to the WHO,¹ a very rigid upbringing by parents is considered suboptimal and comparable to other serious, family-related problems.¹ A systematic review focusing on children aged 5-12 years found that lack of family interaction, conflict, and parental rejection all increase the risk of internalizing problems in children.¹⁹ Other more recent research has highlighted the fact that children with a higher risk of internalizing problems have more difficulty regulating their emotions. These children witness more family conflicts and perceive less family bonding and support.²⁰

Taking into account the parenting factors most frequently associated with internalizing problems, it is interesting to highlight, as Baumrind¹⁰ pointed out, that the democratic style (affection, control, and demand for maturity) is the most appropriate for raising children as it favors their optimal psychological development. Focusing on affection, Zarra-Nezhad et al²¹ found that a maternal parenting style characterized by high levels of affection and care alleviated possible rejection by peers during the first years of schooling, thus leading to a lower risk of developing internalizing problems.^21,22 It, therefore, follows that the cause of a person’s negative feelings can be determined by their relationship with their parents during childhood.¹⁸ Not setting limits for children is a characteristic trait of parents who use a permissive parenting style. However, contradictory impulsive behavior by parents (i.e., sometimes meting out punishment and sometimes showing affection) can cause confusion and bewilderment in the child, whose constant attempts to cope with this confusion can in turn cause internalizing problems.²² What generates this chaos in the child’s mind may be the lack of communication, since, as Yap and Jorm¹⁹ point out, lack of interaction in the family—an increasingly present factor—increases the likelihood of internalizing problems in children.

On the other hand, it is useful to assess and keep in mind several factors that affect the child–parent relationship. Parents who display unfavorable parenting behaviors or attitudes not only increase the likelihood of their children developing an internalizing problem but may also experience detrimental effects on their own health.²³ Changes in society, such as the incorporation of women into the labor market, for example, have led to higher levels of maternal stress, affecting mothers’ mental health.²⁴ Moreira et al²⁵ also argue that the trade-off between work and family life is associated with less involvement in parenting, not only resulting in some internalizing problems but also generating stress in parents. Parental emotional dysregulation is related to children’s internalizing symptoms.^26-28 Toro¹⁸ argued that when a child develops an internalizing problem during childhood, their own emotional and behavioral changes force parents to act differently than they did when the problem first arose.

As can be seen in the scientific literature, the study and influence of parental educational styles and their relationship with internalizing problems have been considered a subject of interest and concern for some years now. If we want our children to develop emotionally in a manner appropriate to their evolutionary stage, it is essential to assess the behavior of their parents. This way, we can provide the most appropriate guidelines for parenting. In this study, we, therefore, propose firstly to describe the relationship between parenting style and internalizing problems in children, and second to carry out a joint, interactive analysis of the factors involved, using multiple regression analysis to develop a model of parenting capable of addressing internalizing problems in children.

Methods

Participants

A sample of 554 children was selected from schools in Andalusia (Spain), together with their respective parents, who provided the information about them. Of these 554 participants, 266 were girls and 288 boys, with an age of 7.49 (SD = 2.69). The minimum age was 3 years and the maximum age was 12 years. The age of the fathers was 40.25 (SD = 5.55), while that of the mothers was 38.24 (SD = 4.91).

Instruments

To compile information, the following instruments were used:

The Parenting Questionnaire by Roa and Del Barrio²⁹ adapted from the Parent–Child Relationship Inventory.³⁰ This questionnaire, which assesses paternal and maternal attitudes toward parenting, comprises 78 items with 4 response options (totally disagree, disagree, agree, and strongly agree), grouped into 7 scales:

• Support: social and emotional support received by a mother or a father.

• Satisfaction with parenting: satisfaction obtained by a parent from parenthood.

• Involvement: level of parental interaction and knowledge about their child.

• Communication: perception of the effectiveness of communication with their child.

• Limit setting: level of exigency regarding the child’s obedience to rules.

• Autonomy: ability to give the child independence.

• Role orientation: attitudes about the role played by each gender in parenting.

A small social desirability scale is also included.

A high score on some of the scales, such as support, commitment, communication, or discipline, indicates a good parenting attitude (democratic style). The internal consistency of the instrument for the sample in this study, obtained using Cronbach’s alpha coefficient, was 0.89. This coefficient varied for each scale, 0.71 for Support, 0.73 for Satisfaction, 0.62 for Involvement, 0.71 for Communication, 0.74 for Limit setting, 0.64 for Autonomy, and 0.70 for Role orientation.

The other instrument used was a Spanish adaptation of the Behavioral Assessment System for Children (BASC).⁵ This system assesses a wide range of pathological dimensions (aggression, hyperactivity, conduct problems, attention problems, learning problems, atypicality, depression, anxiety, withdrawal, and somatization) and adaptive dimensions (adaptability, social skills, leadership, and study skills), using different sources of information (parents, teachers, and children) and different methods (questionnaires, developmental history, and observation). In this case, the parent questionnaire was employed, using the “internalizing problems” dimension: anxiety, depression, and somatization. The questionnaires were divided into 3 levels according to age (3-6, 6-12, and 12-18), which have an internal consistency index of 0.70.

The scores obtained in each of the scales were transformed into T-scores that balanced the effects of age on the different variables, allowing comparisons between subjects of different ages. These T scores, which can vary between 0 and 100, gave a mean of 50 and an SD of 10. On the basis of the T scores, different levels were established: scores below 30 were considered very low, under 40 low, between 40 and 60 intermediate, over 60 at risk, and over 70 clinically significant.

Procedure

Following approval by Science and Innovation Ministry of University of Cordoba (Spain) (code EDU2009-12619), which certified that the project respected the principles established by international declarations and specific national legislation, several pre-schools and primary schools in Andalusia were contacted to explain the study. Once the schools’ management teams had given their consent, families were informed about their voluntary participation in the study. Families who agreed to participate received an envelope containing a copy of the BASC in its P form (parents), and 2 copies of the PCRI, one for the father and one for the mother. Each family had 15 days to return the questionnaires. To ensure anonymity, questionnaires were to be returned in a sealed envelope.

Data Analysis

Once the instruments had been applied and corrected, the results were processed and analyzed using the Statistical Package of Social Sciences Version (SPSS) version 25.0 (IBM SPSS Corp.; Armonk, NY, USA). A significance level of P < .05^* and P < .01^** was established.

This study was an ex post facto prospective cross-sectional design study. After having obtained the main descriptive data and finding the Pearson correlation coefficient between the different variables included, a multiple linear regression analysis was carried out to obtain the factors related to internalizing problems. “The ‘Stepwise method was used, selecting the model that predicts the most variance with the fewest possible variables.” This analysis resulted in an equation comprising a set of variables that are jointly related to the dependent variable, generating a model in which certain scores on those variables were associated with high or low scores in internalizing problems.

The dependent variable used in the study was internalizing problems and the independent variables were the parenting style factors of both parents measured using the Parent-Child Relationship Inventory.

Results

First, a description was made of the internalizing problems variable, as measured in the children through the perception of their parents. For this variable, 49.78 (SD = 10.56) was obtained, with scores ranging from a minimum of 29 to a maximum of 105. Subjects were classified according to the levels established by the BASC. Figure 1 shows the percentage of subjects classified as very adapted, adapted, within the normal range, at risk, and clinically significant.

Figure 1.

Classification of children according to their score on internalizing problems. The percentage of subjects can be classified as very adapted, adapted, within the normal range, at risk, and clinically significant. Classification established by BASC.

The Pearson correlation coefficient was then calculated for the variables used in the study (see Table 1), with special emphasis on the relationship between internalizing problems and the different factors in the fathers’ and mothers’ PCRIs. Here, significant indirect relationships were observed between internalizing problems and factors such as father support (r = −.230 (P < .001)), discipline (r = −.248 (P < .001)), and autonomy (r = −.244 (P < .001)). In addition, there are significant indirect relationships in maternal support (r = −.314 (P < .001)), discipline (r = −.318 (P < .001)), autonomy (r = −.260 (P < .001)), and satisfaction with parenting (r = −.228 (P < .001)). This suggested that children whose parents score higher on these factors tend to have lower scores on internalizing problems.

Table 1.

Correlation Coefficient Between Internalizing Problems and Parenting Style Factors

	1	2	3	4	5	6	7	8	9	10	11	12	13	14
1.	—	—	—	—	—	—	—	—	—	—	—	—	—	—
2.	−.230*	—	—	—	—	—	—	—	—	—	—	—	—	—
3.	−.158*	.396*	—	—	—	—	—	—	—	—	—	—	—	—
4.	−.144*	.412*	.552*	—	—	—	—	—	—	—	—	—	—	—
5.	−.099*	.317*	.408*	.586*	—	—	—	—	—	—	—	—	—	—
6.	−.248*	.468*	.431*	.401*	.195*	—	—	—	—	—	—	—	—	—
7.	−.244*	.400*	.288*	.191*	.084	.518*	—	—	—	—	—	—	—	—
8.	−.002	.181*	.304*	.254*	.152*	.299*	.264*	—	—	—	—	—	—	—
9.	−.314*	.560*	.292*	.374*	.281*	.342*	.305*	.157*	—	—	—	—	—	—
10.	−.228*	.311*	.613*	.447*	.297*	.297*	.236*	.172*	.418*	—	—	—	—	—
11.	−.143*	.295*	.445*	.556*	.358*	.297*	.168*	.187*	.379*	.566*	—	—	—	—
12.	−.037	.212*	.294*	.402*	.500*	.139*	.043	.078	.199*	.351*	.603*	—	—	—
13.	−.318*	.297*	.292*	.298*	.154*	.554*	.386*	.178*	.481*	.389*	.429*	.182*	—	—
14	−.260*	.243*	.241*	.115*	.038	.273*	.562*	.235*	.313*	.289*	.210*	.028	.502*	—
15	−.155*	.305*	.344*	.335*	.201*	.319*	.291*	.350*	.288*	.358*	.423*	.291*	.333*	.428*

1 = Internalizing problems; 2 = Father´s support; 3 = Father´s satisfaction; 4 = Father´s involvement; 5 = Father´s communication; 6 = Father´s limit setting; 7 = Father´s autonomy; 8 = Father´s role orientation; 9 = Mother´s support; 10 = Mother´s satisfaction; 11 = Mother´s involvement; 12 = Mother’s communication; 13 = Mother´s limit setting; 14 = Mother´s autonomy; 15 = Mother´s role orientation.

*P < .05.

Finally, multiple linear regression analysis was used to study the predictive nature of the PCRI factors with respect to internalizing problems. This allowed a model to be generated capable of predicting high or low scores on each dependent variable. As can be seen in Table 2, the first 5 variables included in the model were those that represented a significant change in F and could therefore be said to contribute significantly. The P values for each variable can be observed in Table 2. The R² value in the model was .14, thus explaining 14% of the variance with respect to internalizing problems. The adjusted R² value in the model was .13. This model has an overall significance F = 12.238 and P < .001. Negative beta coefficients were obtained for all the variables except for paternal role orientation, so high scores in this variable are predictive of high scores in internalizing problems. The opposite applies to the rest of the variables.

Table 2.

Linear Regression Model for Internalizing Problems

Model	Beta	Standard Error	t	P	95% Confidence Interval
					Lower	Higher
(Constant)	82.248	5.200	15.817	< .001	72.023	92.474
Mother´s support	−.412	.136	−3.03	.003	−.680	−.144
Mother´s autonomy	−.465	.149	−3.11	.002	−.759	−.171
Father´s limit setting	−.280	.115	−2.43	.016	−.507	−.053
Father´s role orientation	.188	.075	2.52	.012	.041	.335
Mother´s satisfaction	−.191	.133	−1.43	.153	−.453	.071

Discussion and Conclusion

This study analyzed the relationship between parenting style and internalizing problems in children. It also considered the possibility of developing a model for internalizing problems based on the characteristics of the parenting styles adopted by a child’s parents.

With regard to the first objective, the results showed that internalizing problems in children occur less frequently when both parents receive more support in parenting, show greater discipline, provide more autonomy to their children, and when the mother feels greater satisfaction with parenting. The results coincide with those obtained by Aguilar et al.⁷ Raya et al.⁹ Toro,¹⁸ and Yap et al.¹⁹ which also showed that these were the parenting style factors most closely related to the frequency of some internalizing problems. Regarding autonomy, the results obtained coincided with those of Ezpeleta et al¹⁴ in that the children who manifested more emotional problems after COVID-19 had perceived more overprotection by their parents. Another factor found to be significantly related to internalizing problems was discipline understood as the setting of rules and limits for children. As noted by the WHO,¹ a very rigid upbringing is considered suboptimal. The support that parents receive in parenting also produced some significant results with regard to internalizing problems. This could be related to lower parental stress, which leads to a more favorable family environment and, in turn, fewer emotional problems for children. As Cheunga et al.²⁶ Han and Shaffer et al.²⁷ and Özkula et al²⁸ point out, parental emotional dysregulation is related to children’s internalizing symptoms. Raposo and Francisco²⁰ affirm that children who witness more family conflicts are at greater risk of developing these types of problems.

With regard to the second objective, the results of this analysis yielded some relevant data. Maternal support, autonomy, and satisfaction with parenting and paternal discipline were all found to act as protective factors against internalizing problems. It should be borne in mind that, at a predictive level, the regression models generated allow us to assess the effect of each variable in interaction with the others. This means that certain variables may appear to have contradictory effects. It should be emphasized that the discipline variable considered in the study was understood to refer to an adequate establishment of rules and limits rather than a characteristic of an authoritarian model. On the other hand, paternal role orientation was found to be a risk factor. This could be related to the changes that have taken place in the family environment, where parenting tasks are now shared more equally between parents but where responsibilities are sometimes still not assumed, leading to more family conflicts that may be witnessed by children. It could also be related to the findings of authors like Moreira et al.²⁵ who suggest that the difficulty of achieving a balance between family and work life is associated with less involvement in parenting and with greater stress in parents, potentially leading to unfavorable parenting behavior and an increase in internalizing problems among children.²³

Regarding limitations, on the one hand, we have found that the study has been performed through self-reporting. This could give rise to some possible biases when answering the questionnaires. On the other hand, despite the results obtained, another limitation is that the methodology used did not allow us to establish causal relationships. However, the sample size was relatively large, making it possible to generalize the results to cover most Spanish children. In future work, it will nevertheless be interesting to take into account the evaluation of tutors. This would open up a new avenue of research.

In conclusion, the role of parents in the well-being of their children is considered to be of great importance.² In particular, the democratic parenting style is the most balanced, appropriate style as it favors optimal psychological development in children.¹⁰ The results obtained in this study constitute a good starting point for the development of parenting education programs. They also invite us to consider possible lines of research and intervention in which protective mechanisms can be analyzed and applied to guide certain aspects of the relationship between parents and children, thus preventing most internalizing problems in the early stages of development.