Treatment-as-Usual Therapy Targets for Comorbid Youth Disproportionately Focus on Externalizing Problems

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This study examined whether psychological treatment for youth with comorbid externalizing and internalizing disorders targets externalizing rather than internalizing pathology. Therapist-reported treatment targets for youth (N = 679) with (a) only internalizing diagnoses (n = 195); (b) only externalizing diagnoses (n = 314); (c) a primary internalizing diagnosis and at least 1 additional externalizing diagnosis (n = 75); and (d) a primary externalizing diagnosis and at least 1 additional internalizing diagnosis (n = 95) receiving treatment-as-usual in a public mental health system of care were examined. Treatment targets that appeared significantly more often in the externalizing-only and internalizing-only diagnostic groups were empirically determined, and a derived proportional measure of these targets was analyzed across all 4 diagnostic groups, controlling for effects of additional client and treatment characteristics. As required by the target selection method, the proportion of externalizing targets selected in treatment was greatest for youth with externalizing-only diagnoses and least for youth with internalizing-only diagnoses. Importantly, the co-occurrence of a secondary externalizing disorder with a primary internalizing disorder resulted in a large increase in the proportion of externalizing targets endorsed, whereas the co-occurrence of an internalizing disorder with a primary externalizing disorder resulted in a comparatively small decrease in the proportion of externalizing targets endorsed. Results persisted despite several covariates also predicting increased focus on externalizing targets, including male gender and younger age. These findings suggest that community therapists tend to prioritize externalizing over internalizing problems during treatment for such comorbid youth. Implications for practice, research and dissemination/implementation efforts are discussed.

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