Learning Objectives
By the end of this section, you will be able to:
- Identify and define the features of common behaviors that can be problematic for children’s socioemotional well-being
- Identify the features of developmental disorders common in middle childhood
- Discuss typical developmental pathways and interventions for promoting mental health, well-being, and resilience in childhood
Adam is seven years old. In his first-grade classroom, he is on the edge of his seat or on the floor most of the day. When his teacher asks the students to complete a page of work including two descriptive sentences and a picture, he completes the assignment but usually takes longer than most of his classmates. He has difficulty following the sequence of instructions, and he sometimes completely skips questions in a seemingly random way. He also has difficulty keeping his hands to himself and blurts out the first thing that comes to his mind at any time.
At lunch and on the playground, Adam is very active and moves around a lot. While eating lunch, he wanders around talking to friends and often doesn’t finish his meal. He thrives at recess where he has more flexibility in how he chooses to play with peers and with a variety of activities. Adam’s teachers seem to always be telling him to sit still. The teachers seem to be bothered by his fidgeting, but he rather enjoys learning while squirming. Adam doesn’t understand why his behaviors seem to be a problem for teachers and is beginning to feel like school might not be as much fun as it was in kindergarten.
In this section, you’ll learn about some of the more common behaviors that can be problematic for children, including internalizing and externalizing behaviors, and the mental health disorders like depression and anxiety that sometimes require support in middle childhood. Neurodevelopmental diversities, including attention-deficit/hyperactivity disorder and autism spectrum disorder, can also play a role in socioemotional well-being. Prevention and intervention supports can help to promote mental health and well-being in middle childhood. When those working with or caring for children are better educated on supporting the development of children with diverse learning needs, these children are better able to thrive.
Internalizing and Externalizing Behaviors
Children experience a great deal of development in middle childhood, including dramatic growth in emotion regulation abilities, coping strategies, and social cognitive skills. Children also are exposed to a much wider world and different environments than they may have known in early childhood. This can provide positive opportunities for their development such as new friendships, new mentors and teachers, and new hobbies or extracurriculars. However, for some children, this broadening set of environments, personal relationships, and experiences can increase a child’s risk of socioemotional struggles, such as bullying or sometimes difficult teacher-child or peer relationships.
While some children develop positive coping strategies, others may struggle with negative coping strategies that can in turn lead to some common behaviors that can be problematic for children’s socioemotional well-being. Developmental psychologists and researchers often discuss and define these behaviors in terms of how they manifest and whether they are problematic for the child, teachers, and/or parents (Bordin et al., 2013). By identifying and understanding how these behaviors create problems and who they create problems for, psychologists can better design mental health supports that can reduce risk and promote resilience in children.
When a behavior is negative or harmful and internal to a person, psychologists often call it an internalizing behavior. Internalizing behaviors include feeling withdrawn or lonely, anxious or depressed, and/or having related physical health issues (Achenbach & Edelbrock, 1991; Bordin et al., 2013). For example, a child might struggle with anxiety in new and large social settings. This anxiety can include negative self-talk and fear of interacting with others and may even lead to physical problems such as an upset stomach or headaches. Internalizing behaviors could also include feelings of helplessness, low self-esteem, or any other negative feelings or thoughts that are mostly within the person (Aguilar-Yamuza et al., 2023; Wang et al., 2018).
When a behavior is negative or harmful and external to a person, psychologists often call it an externalizing behavior. Such behaviors include aggressive behaviors, rule-breaking behaviors, and other negative behaviors that are more social or interpersonal (Achenbach & Edelbrock, 1991; Bordin et al., 2013). For example, a child might struggle with angry feelings and acting out toward others in a bullying manner. These impulsive behaviors can be disruptive to others or disruptive to the social setting, such as in school environments (Woltering & Shi, 2016). Externalizing behaviors could also include inflated self-esteem, delinquent behaviors, or any other negative behaviors that typically involve interaction with others.
Often internalizing and externalizing behaviors may be the result of a child’s continuing emotional regulation development or a lack of positive coping strategies. While many children primarily turn their negative behaviors either inward or outward, many children struggle with poor regulation and both internalizing and externalizing behaviors (Deutz et al., 2019). Sometimes children grow out of these behaviors as they mature and develop improved emotional regulation and/or through the support of caregivers and other community members (Baker, 2018; Deutz et al., 2019). However, for other children, this can be an early indication that a child is at risk of poor mental health or certain mental health disorders (Deutz et al., 2016; Nikstat & Riemann, 2020). By better understanding the immense transitions of middle childhood and how they can impact overall mental health, psychologists can better provide supports to promote socioemotional well-being in middle childhood and long-term development (Voss et al., 2023).
Mental Health Risks and Disorders
While some amount of internalizing and externalizing behaviors is fairly common over the life course for children and adults, for others, middle childhood can be a time when mental health risks and disorders are first exhibited and diagnosed. A U.S. study found that around 16.5 percent of children nationwide had at least one mental health disorder, with only half of those children receiving treatment and support (Whitney & Peterson, 2019). Common mental health risks and disorders that may begin in childhood include depression, anxiety, obsessive-compulsive disorder (OCD), post-traumatic stress disorder, and behavioral disorders such as oppositional defiant disorder (ODD) and conduct disorder (CD) (American Psychiatric Association, 2022; CDC, 2023a).
Research also indicates that childhood onset of some of these diagnoses, specifically depression and anxiety, have increased over time and may increase risks for mental health struggles and/or suicide across the lifespan (CDC, 2023b; Janiri et al., 2020). Factors that can increase risks of mental health disorders in childhood include emotion dysregulation, angry parenting, poor parent mental health, adverse childhood experiences, and childhood trauma (Wang et al., 2018). Children may be at an even greater risk when they experience lower socioeconomic resources, such as poverty or inadequate health care, or systemic barriers related to race, ethnicity, or gender (CDC, 2023b, Thyberg & Lombardi, 2022). As indicated in the Figure 8.12, there is a dramatic increase in depression, anxiety, and behavior disorders beginning around age six years (CDC, 2023b).
Some disorders such as anxiety, OCD, and depression not only start in middle childhood but are likely to be comorbid, or occur simultaneously (Cervin et al., 2020; CDC, 2023b). This means that children who are at risk of one disorder, such as depression, are likely to also be at a risk of other disorders. Often, anxiety is characterized by excessive and persistent fear and anxious feelings, and by related disturbances in behavior. Children may also experience, depression disorders, which are mood disorders involving feelings of sadness that are disruptive and can make functioning difficult for individuals (American Psychological Association, 2022). Depression, anxiety, and OCD can manifest with symptoms like stress, upset stomach, sleeping problems, self-esteem issues, and/or physical symptoms like headache or stomachache (American Psychological Association, 2022; Thapar et al., 2022). These disorders can also involve changes in sleeping or eating behaviors, though these symptoms may be less common in children than in adults. These disorders might also be underdiagnosed in children because the symptoms may be harder to observe.
Children of marginalized races, including Black children, are more likely to be underdiagnosed when it comes to things like depression and anxiety. In fact, they face a risk of being misdiagnosed or overdiagnosed with behavioral disorders such as ODD and CD (Thyberg & Lombardi, 2022). These behavioral disorders involve longer-term and high levels of some of the externalizing behaviors discussed earlier, such as hostility, aggressive behavior, and defiance (American Psychological Association, 2022). Some children might outgrow these behaviors, but in many cases, they can lead to low academic performance and poor social relationships. A diagnosis of ODD or CD can sometimes become a label that follows children as they move into adolescence and early adulthood. There is some concern that Black boys in particular might be overdiagnosed with this disorder because of bias and systemic racism (Ballentine, 2019).
Finally, middle childhood can mark the beginning of body dissatisfaction and body image issues that can lead to a higher risk of eating disorders as children enter adolescence and early adulthood (Mendo–Lázaro et al., 2017; Neves et al., 2017). As children enter middle childhood, they become more aware of their body in comparison to others, the media, and other cultural influences they experience (Rice et al., 2016). Some researchers suggest that middle childhood may be a critical time for early prevention of self-esteem and body image issues (Neves et al., 2017). For example, some early prevention strategies include parents modeling a healthy body image through focusing on overall health and well-being rather than numbers like weight (Jensen et al., 2018).
Neurodevelopmental Diversity
During early and middle childhood, neurodevelopmental disorders are often first recognized as children enter grade school and the environmental demands on their behavior increase.
Attention-Deficit/Hyperactivity Disorder
As discussed in Chapter 7 Physical and Cognitive Development in Middle Childhood (Ages 7 to 12), attention-deficit/hyperactivity disorder (ADHD) is often first diagnosed during middle childhood. Increased academic demands require more attention and self-regulation from children. Children with ADHD often struggle to adjust to school and academic demands (Sánchez–Perez & González–Salinas, 2017). Children with ADHD often struggle to adjust to school and academic demands and are at a higher risk of having poor relationships with teachers (Sánchez–Perez & González–Salinas, 2017; Zendarski et al., 2020). This means teachers might be the first to notice symptoms and refer a child for assessment and support (Tahıllıoğlu et al., 2021). While teachers may be trained in detecting a need for assessment, they do not and cannot diagnose ADHD themselves.
Children with ADHD may be at a higher risk of increased socioemotional difficulties and symptoms based on family dynamics and caregiving. For example, children with more ADHD symptoms are more likely to have a caregiver with poorer parenting behaviors and/or a caregiver who has a mental health disorder (Breaux & Harvey, 2019; Dekkers et al., 2021). Greater ADHD symptoms can also be disruptive to positive family interactions for both caregivers and children. Educational opportunities for parents to improve their positive parenting techniques show some evidence of improving well-being for children and families with ADHD (Haack et al., 2017). For example, parents might benefit from receiving support and education that improve their ability to set clear expectations with their children, avoid power struggles, and effectively praise children when they are doing well.
Children with ADHD also often have difficulties with peer relationships (Powell et al., 2020). More than half struggle to make and maintain friendships (Gardner & Gerdes, 2015). They may stumble when reading social cues, such as when another child is growing weary of hyperactivity and intensity in their social interactions. As a result, children with ADHD are more likely to be rejected by peers or to experience peer victimization or bullying (Chou et al., 2018). Interventions and preventions that help caregivers and children with ADHD improve their social and academic skills may reduce other long-term mental health risks, such as depression (Evans et al., 2018).
Attention-deficit/hyperactivity disorder is also comorbid with (frequently occurring with) other disorders, including anxiety, depression, and conduct disorder (Koyuncu et al., 2022). Children with ADHD are also more likely to have a conduct disorder (27 percent) or a learning disability (46 percent) (Larson et al., 2011). When children with ADHD have comorbid mental health issues, they are more likely to have poor academic outcomes. Children with ADHD who experience better environmental support, such as school and community resources, are more likely to show improved outcomes (Shabat et al., 2021). For example, ensuring teachers and parents are effectively trained on the child’s cognitive and sensory needs may improve their overall well-being.
Link to Learning
Kirsten Weir discusses the connection between ADHD and difficulties with emotional regulation in this article in the APA Monitor. The author talks about the link between these in terms of both the underlying neurobiology of neurodivergent brains and the environmental demands placed on individuals with ADHD. Treatments are also discussed.
Autism Spectrum Disorder
Socioemotional challenges often face children experiencing autism spectrum disorder (ASD). As introduced in 6.1 Social and Emotional Development in Early Childhood, one feature of an autism diagnosis is difficultly with social communication and interaction. For example, these children may have increased difficulties recognizing and understanding the emotions of others (Fridenson–Hayo et al., 2016; Gev et al., 2021). They may also express their emotions in ways that are harder for others to interpret, resulting in trouble forming peer relationships and friendships. Social skills training programs, in particular, have been useful in helping autistic children develop important capabilities (Odom et al., 2021). For example, some promising interventions that may improve emotional expression include using robots or computers to train children on emotion recognition and expression (Lecciso et al., 2021).
Caregivers often describe their autistic children as having difficulty with expressing emotions and poorer emotion regulation skills (Reyes et al., 2020). Autistic children often show normal attachment behaviors with their caregivers, though some may struggle with aspects of attachment, including using their caregiver as a secure base, using their caregiver as a source of support in emotion regulation, and/or forming mental attachment representations (Keenan et al., 2017; Giannotti et al., 2022). The challenges of raising an autistic child when they struggle with communication and language skills may also increase parent stress (Stanojevic et al., 2017). Caregivers of autistic children are likely to report higher levels of stress than parents of typically developing children (Padden & James, 2017). Among these, African American caregivers report higher levels of stress than Euro American caregivers, particularly when they experience less cultural belonging (Williams et al., 2019).8 Hispanic parents cite the lowest stress, perhaps because they also report higher levels of psychological well-being and greater satisfaction living with their child (Valicenti–McDermott et al., 2015). Promoting well-being for parents and in the family household may be beneficial to reducing familial stress for families and caregivers.
Diagnoses of ASD have risen rapidly, and society’s response and understanding have varied (Anthony et al., 2019). There is more inclusion for autistic children thanks to strong advocacy efforts; however, autistic individuals still experience isolation and discrimination. Many programs are working to decrease the stigma and stereotypes and increase acceptance of those with ASD (Anthony et al., 2019).
Supports for Promoting Well-Being and Resilience in Middle Childhood
Many individual differences, developmental diversities, and mental health risks may put some children at a higher risk of long-term mental health problems and/or other maladaptive, or poor, health outcomes. You’ve learned about various interventions may benefit the individual child or their family in reducing these risks. Researchers have also identified protective factors that can promote well-being and resilience for children.
Many supports and protective factors for promoting socioemotional health in middle childhood involve promoting certain skills in the individual child such as positive coping, social skills that improve friendships, and emotional regulation. Still, many developmental psychologists and researchers advocate for promoting a goodness of fit and a supportive set of environments and contexts for the child. For example, you may recall the importance during early childhood of the role of parents in promoting a good fit between young children’s temperament and their environment. When children feel supported and scaffolded by their environment, including caregivers, teachers, schools, and community supports, they are more like to be resilient (Masten, 2014).
The first important context to promote protective factors in middle childhood is at the family or caregiver level, an important microsystem. Caregivers can promote resilience and boost protective factors for their children by teaching emotional regulation, modeling positive coping, and providing warm, supportive parenting (Kural & Kovacs, 2021). Caregivers might also benefit from parent skills training to reduce their parenting stress and improve their confidence as caregivers (Aguilar–Yamuza et al., 2023). They might also seek mental health supports including private counselors, therapists, or support groups, particularly if the child is struggling with internalizing or externalizing behaviors or has experienced a trauma or adversity (Cervin et al., 2020; Janiri et al., 2021). Finally, parents can promote an overall healthy lifestyle including healthy body image and good family routines that support sleep, exercise, and physical health (Voss et al., 2023). Every child’s mental health needs are unique, but caregivers have many options for supporting them.
Another important context that can reduce risks, promote protective factors, and support resilience in childhood is the school and teachers (Janiri et al., 2020). Schools can create individual interventions and support for children with disabilities or other exceptional needs by using individualized education programs (IEPs) and other referrals to individual supports as discussed in 7.4 Contexts: School and Learning Diversity in Middle Childhood. In the United States, children with disabilities or other mental health diagnoses that affect their learning are entitled to free and appropriate education by law (Edsource, 2022). Parents and teachers can refer children for services or assessment by a school psychologist, trained in best determining the specific needs of that child (NASP, 2024). Approximately 14 percent of U.S. children receive some special education services in public schools (National Center for Education Statistics, 2022). Because these are provided free of charge for any eligible student, many children benefit from therapies they would not otherwise receive because they are too expensive for many families.
Children can also benefit from improved resilience when interventions and support involve multiple community levels, often involving mesosystems and exosystems. For example, communities and schools can work together to create and promote engagement in PYD programs. These can be implemented by community organizations, nonprofit organizations, or mentor programs. Schools can also provide curriculum and programs that support social-emotional learning and protective factors such as self-regulation and problem-solving skills (Wallender et al., 2020). These programs are likely to benefit all children, including those who might not otherwise be detected as needing services or whose symptoms may have been less visible.
Life Hacks
Do You Want to Make the Difference in the Life of a Child?
Many children can benefit from having a positive role model or just another caring adult in their life. Children with internalizing or externalizing behaviors and those who struggle with academics might especially benefit from having a mentor (DuBois et al., 2018; McQuillin et al., 2015). Mentoring relationships can be either informal, occurring naturally as children interact with adults in their lives, or formal like the organized mentorship programs of Big Brothers Big Sisters of America. Child mentoring programs are designed to provide children with a volunteer nonparental positive role model, matching them with someone who can regularly spend time with them.
One of the major benefits of mentoring programs is that they are widely accepted and as a result serve many children who would otherwise not receive any services (Hagler et al., 2019). For example, caregivers from marginalized groups are more likely to allow their children to take part in a mentoring program than to opt for services from professionals like mental health practitioners (Vázquez & Villodas, 2019). The success of mentoring programs depends on volunteers who are willing to donate a few hours a month to develop a relationship with a child.
Are you interested in making a difference in the life of a child? Consider starting by looking up the local nonprofit organizations that serve youth in your city or region. If you live in the United States, you may also want to check out the MENTOR National website.
Finally, at the macrosystem level, cultural beliefs and education can reduce risk and promote resilience for children who may be at a higher risk due to systemic disparities or those who have experienced adverse risks. For example, research has identified racial and ethnic disparities in the diagnosis of many mental and behavioral health disorders (Thyberg & Lombardi, 2022). In addition, cultural differences in attitudes toward mental health services often mean that some families, including Black families, are less likely to seek services for mental health and/or behavioral disorders (Ballentine, 2019).9 Better training for health professionals and those working with children can improve accurate diagnosis and treatment for children across a variety of externalizing and internalizing behaviors. Providing multiple sources of support and promoting protective factors at various levels can better promote well-being and resilience in middle childhood and across the lifespan for all.
Link to Learning
Nadine Burke Harris talks about how childhood trauma affects lifelong health in this TEDTalk. This talk illustrates the multiple contexts and issues for children’s health and development in general.
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