Does the squeaky wheel get the grease ? Therapy targets for youth with comorbid internalizing and externalizing diagnoses

Abstract

Categorizing many youth mental health problems into internalizing and externalizing domains has been common in children's mental health since Achenbach's first factor analysis in 1966. While much work has been done to understand these dimensions of developmental psychopathology, very little is known about how these two sets of problems are addressed in community-based treatment-as-usual (TAU), particularly in youth with multiple challenges or disorders. Given that many thousands of youth across the country receive TAU through various community-based systems of care, and that several studies have questioned the quality of such services compared to best practice psychotherapy models, it is important to identify potential deficiencies in TAU. At the treatment access level, there is some evidence that children with externalizing problems are referred for care at a disproportionately higher rate than children with internalizing problems. Such a tendency, which suggests that usual care mental health treatment for youth might be more focused on addressing externalizing rather than internalizing pathology, might also be manifested in the behavior of therapists when targeting problems to treat, particularly in youth with comorbid internalizing and externalizing problems. To examine this tendency, the present study compared therapist treatment target choices for youth with both externalizing and internalizing disorders to those for youth with externalizing-only or internalizing-only diagnoses. Therapist-reported treatment targets for youth (N=679) with (1) one or more internalizing-only diagnoses (n=195); (2) one or more externalizing-only diagnoses (n=314); (3) a primary internalizing diagnosis and at least one additional externalizing diagnosis (n=75); and (4) a primary externalizing diagnosis and at least one additional internalizing diagnosis (n=95) receiving intensive in-home (IIH) services from the State of Hawaiʻi, Child and Adolescent Mental Health Division (CAMHD) were examined. Treatment targets significantly related to externalizing-only and internalizing-only diagnoses were determined via Mann-Whitney nonparametric tests, and a derived measure of these targets was analyzed across the four diagnostic groups via contrast-coded ANOVA and ANCOVA, the latter controlling for potential effects of additional client, therapist, and treatment characteristics. As hypothesized, the addition of an externalizing diagnosis to a primary internalizing diagnosis resulted in a significantly larger change in targets selected for treatment compared to the change in treatment targets when an internalizing diagnosis was added to a primary externalizing diagnosis. These findings suggest that therapists tend to prioritize externalizing problems during treatment, even after internalizing problems have been identified via formal diagnosis. Factors that contribute to these decisions are unclear, but might involve a greater salience of externalizing behaviors, difficulties inherent in targeting and treating internalizing problems, and carry-over effects of the disproportionate focus on externalizing problems in the referral process. Future directions include a follow-up study examining whether treatment outcomes differ as a result of the disparity described here.