Exploring the comorbidity between internalizing/externalizing dimensions and cognitive disengagement syndrome through twin studies: a narrative review

Abstract

Twin studies are cutting-edge design methodologies proper to behavioral genetics that aim to investigate how the interplay between genetic and environmental factors can concur to explain individual differences in psychopathology, temperamental traits, and behavior. This particular research design has been widely applied to the study of comorbidity between internalizing (INT) and externalizing (EXT) symptoms, especially in childhood and adolescence. Notably, the high co-occurrence of symptoms of both these diagnostic domains has led to the hypothesis that at their basis, there might be one single latent common susceptibility factor, namely p factor. Twin studies have contributed to marking a relevant turning point in this regard by highlighting the consistent genetic nature of this factor. In light of these premises, the present narrative review aims to outline the path for future twin studies in investigating the comorbidity between Cognitive Disengagement Syndrome (CDS) and INT-EXT disorders, examining the evidence supporting this need and its clinical implications. Since CDS has not been recognized as a stand-alone syndrome until very recently, research on this condition is still in its infancy and the etiological factors at the basis of its comorbidity with INT-EXT are still unclear. Being aware of the causal factors underneath the comorbidity between INT-EXT might pave the way for improving assessment diagnostic procedures as well as setting up preventive interventions for CDS.

Keywords

Cognitive disengagement syndrome / internalizing disorders / externalizing disorders / twin studies / comorbidity

References

[1] AchenbachTM.The classification of children's psychiatric symptoms: a factor-analytic study.Psychol Monogr1966;80:1-37

[2] NikstatA.On the etiology of internalizing and externalizing problem behavior: A twin-family study.PLoS One2020;15:e0230626 PMCID:PMC7089526

[3] BeckerSP,ByarsKC.Sluggish cognitive tempo in children referred to a pediatric Sleep Disorders Center: Examining possible overlap with sleep problems and associations with impairment.J Psychiatr Res2016;77:116-24 PMCID:PMC4826847

[4] BarkleyRA.Distinguishing sluggish cognitive tempo from attention-deficit/hyperactivity disorder in adults.J Abnorm Psychol2012;121:978-90

[5] BeckerSP,DvorskyMR.Initial Examination of the Bidirectional Associations between Sluggish Cognitive Tempo and Internalizing Symptoms in Children.J Clin Child Adolesc Psychol2021;50:258-66 PMCID:PMC6934933

[6] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders; Fifth Edition. https://repository.poltekkes-kaltim.ac.id/657/1/Diagnostic%20and%20statistical%20manual%20of%20mental%20disorders%20_%20DSM-5%20(%20PDFDrive.com%20).pdf [Last accessed on 26 Mar 2024]

[7] KoflerMJ,SarverDE.What cognitive processes are "sluggish" in sluggish cognitive tempo?.J Consult Clin Psychol2019;87:1030-42 PMCID:PMC6814302

[8] BellAS.A critical review of ADHD diagnostic criteria: what to address in the DSM-V.J Atten Disord2011;15:3-10

[9] HartmanCA,RheeSH.The relation between sluggish cognitive tempo and DSM-IV ADHD.J Abnorm Child Psychol2004;32:491-503

[10] BatesTC.Behavioral Genetics (5th edition)Robert Plomin, John C. DeFries, Gerald E. McClearn, Peter McGuffin. (2008). Worth Publishers, New York, 505 pp., US$115.95, ISBN 10 1 4292 0577 6.Twin Res Hum Genet2008;11:245-6

[11] RendeR. Nature, nurture and the development of psychopathology: Developmental Psychopathology. Volume 1: Theory and Method. In: Cicchetti D, Cohen DJ (Editors.). John Wiley & Sons: New York, NY, 1995; Vol. 1, pp. 291–314. Available from https://kclpure.kcl.ac.uk/portal/en/publications/nature-nurture-and-the-development-of-psychopathology-development [Last accessed on 26 Mar 2024]

[12] KendlerKS.Psychosocial resilience and protective mechanisms.Am J Orthopsychiatry1987;57:316-31

[13] KendlerKS.Twin studies of psychiatric illness. Current status and future directions.Arch Gen Psychiatry1993;50:905-15

[14] WilloughbyEA,BoutwellBB.Behavioural genetics methods.Nat Rev Methods Primers2023;3:10

[15] PlominR. Blueprint: how DNA makes us who we are. Allen Lanes: London, 2018. Available from https://www.goodreads.com/book/show/39074555-blueprint [Last accessed on 26 Mar 2024]

[16] PlominR,CorleyR.Nature, nurture, and cognitive development from 1 to 16 years: a parent-offspring adoption study.Psychol Sci1997;8:442-7

[17] Koeppen-SchomerusG,PlominR.Twins and non-twin siblings: different estimates of shared environmental influence in early childhood.Twin Res2003;6:97-105

[18] FagnaniC,MeddaE.Statistical methods for the analysis of twin data.Ann Ist Super Sanita2006, 42, 86-93 PMCID:PMC10815387

[19] NealeMC. Data summary. In methodology for genetic studies of twins and families. In: Neale MC, Cardon LR (Editors). NATO ASI Series; Springer Netherlands: Dordrecht 1992; pp. 35–53. Available from http://ibgwww.colorado.edu/workshop2006/cdrom/HTML/book2004a.pdf [Last accessed on 26 Mar 2024]

[20] ScainiS,FioccoV,OgliariA.A Genetically Informed Study of the Covariation Between Childhood Anxiety Dimensions and Social Competence.J Child Fam Stud2017;26:2519-28

[21] Pesenti-GrittiP,FagnaniC.The co-occurrence between internalizing and externalizing behaviors. A general population twin study.Eur Child Adolesc Psychiatry2008;17:82-92

[22] RijsdijkF.Independent Pathway Model. In: Kenett RS, Longford NT, Piegorsch WW, Ruggeri F (Editors). Wiley StatsRef: Statistics Reference Online. Wiley; 2014.

[23] RijsdijkF.Common Pathway Model. In: Kenett RS, Longford NT, Piegorsch WW, Ruggeri F (Editors). Wiley StatsRef: Statistics Reference Online. Wiley; 2014.

[24] AchenbachTM,RescorlaLA,AlthoffRR.Internalizing/externalizing problems: review and recommendations for clinical and research applications.J Am Acad Child Adolesc Psychiatry2016;55:647-56

[25] HaslamN,ViechtbauerW.Dimensions over categories: a meta-analysis of taxometric research.Psychol Med2020;50:1418-32

[26] CaspiA.All for one and one for all: mental disorders in one dimension.Am J Psychiatry2018;175:831-44 PMCID:PMC6120790

[27] KruegerRF.The structure of common mental disorders.Arch Gen Psychiatry1999;56:921-6

[28] KendlerKS,MyersJ.The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women.Arch Gen Psychiatry2003;60:929-37

[29] KruegerRF.Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology.Annu Rev Clin Psychol2006;2:111-33 PMCID:PMC2242354

[30] DurbeejN,NorénSelinus E.Trends in childhood and adolescent internalizing symptoms: results from Swedish population based twin cohorts.BMC Psychol2019;7:50 PMCID:PMC6679471

[31] MerikangasKR,KesslerRC.Epidemiology of mental disorders in children and adolescents.Dialogues Clin Neurosci2009;11:7-20 PMCID:PMC2807642

[32] VergunstF,GeoffroyMC.Association of childhood externalizing, internalizing, and comorbid symptoms with long-term economic and social outcomes.JAMA Netw Open2023;6:e2249568 PMCID:PMC9856729

[33] ChaplinTM.Gender differences in emotion expression in children: a meta-analytic review.Psychol Bull2013;139:735-65 PMCID:PMC3597769

[34] BorW,NajmanJ.Are child and adolescent mental health problems increasing in the 21st century?.Aust N Z J Psychiatry2014;48:606-16

[35] SwerdlowBA,TimpanoKR,DevA.Longitudinal associations between internalizing symptoms, social behavior, and social perceptions in the initial months of the COVID-19 pandemic: Findings from a transdiagnostic community sample.J Affect Disord2021;294:805-12 PMCID:PMC8488236

[36] Government of Canada, CI of HR. Mental health and substance use impacts of COVID-19. Available from https://cihr-irsc.gc.ca/e/52373.html [Last accessed on 26 Mar 2024]

[37] HaberstickBC,YoungSE.Contributions of genes and environments to stability and change in externalizing and internalizing problems during elementary and middle school.Behav Genet2005;35:381-96

[38] HatoumAS,CorleyRP,FriedmanNP.Etiology of stability and growth of internalizing and externalizing behavior problems across childhood and adolescence.Behav Genet2018;48:298-314 PMCID:PMC6026557

[39] ReynoldsCA,GatzM.Sources of influence on rate of cognitive change over time in Swedish twins: an application of latent growth models.Exp Aging Res2002;28:407-33

[40] CaspiA,BelskyDW.The p factor: one general psychopathology factor in the structure of psychiatric disorders?.Clin Psychol Sci2014;2:119-37 PMCID:PMC4209412

[41] KruegerRF.Transdiagnostic factors of mental disorders.World Psychiatry2015;14:27-9 PMCID:PMC8129836

[42] WrightAG,HobbsMJ,EatonNR.The structure of psychopathology: toward an expanded quantitative empirical model.J Abnorm Psychol2013;122:281-94 PMCID:PMC3570590

[43] CosgroveVE,GelhornHL.Structure and etiology of co-occurring internalizing and externalizing disorders in adolescents.J Abnorm Child Psychol2011;39:109-23 PMCID:PMC3036783

[44] RendeR.Families at risk for psychopathology: Who becomes affected and why?.Dev Psychopathol1993;5:529-40

[45] GjoneH.The association between internalizing and externalizing behavior in childhood and early adolescence: genetic of environmental common influences?.J Abnorm Child Psychol1997;25:277-86

[46] LaheyBB,HakesJK,HaririAR.Is there a general factor of prevalent psychopathology during adulthood?.J Abnorm Psychol2012;121:971-7 PMCID:PMC4134439

[47] RheeSH,WaldmanID.Comorbidity among dimensions of childhood psychopathology: converging evidence from behavior genetics.Child Dev Perspect2015;9:26-31 PMCID:PMC4442026

[48] AllegriniAG,RimfeldK.The p factor: genetic analyses support a general dimension of psychopathology in childhood and adolescence.J Child Psychol Psychiatry2020;61:30-9 PMCID:PMC6906245

[49] BeckerSP,BurnsGL.The internal, external, and diagnostic validity of sluggish cognitive tempo: a meta-analysis and critical review.J Am Acad Child Adolesc Psychiatry2016;55:163-78 PMCID:PMC4764798

[50] FredrickJW.Cognitive disengagement syndrome (sluggish cognitive tempo) and social withdrawal: advancing a conceptual model to guide future research.J Atten Disord2023;27:38-45

[51] BeckerSP,LeopoldDR,WillcuttEG.Differential impact of trait sluggish cognitive tempo and ADHD inattention in early childhood on adolescent functioning.J Child Psychol Psychiatry2018;59:1094-104 PMCID:PMC6158103

[52] FredrickJW,KoflerMJ,BurnsGL.Disentangling the effects of attentional difficulties on fears of social evaluation and social anxiety symptoms: Unique interactions with sluggish cognitive tempo.J Psychiatr Res2020;131:39-46 PMCID:PMC7669641

[53] FroehlichTE,NickTG.sluggish cognitive tempo as a possible predictor of methylphenidate response in children with ADHD: a randomized controlled trial.J Clin Psychiatry2018;79:17m11553 PMCID:PMC6558969

[54] VuA,WillcuttE.Sluggish cognitive tempo: longitudinal stability and validity.Atten Defic Hyperact Disord2019;11:463-71 PMCID:PMC6751018

[55] BeckerSP,SmithZR.Sluggish cognitive tempo in adolescents with and without ADHD: differentiation from adolescent-reported ADHD inattention and unique associations with internalizing domains.J Abnorm Child Psychol2020;48:391-406 PMCID:PMC7007365

[56] SmithZR.Do sluggish cognitive tempo symptoms improve with school-based ADHD interventions?.J Child Psychol Psychiatry2020;61:575-83

[57] WillcuttEG,KinnearM.The internal and external validity of sluggish cognitive tempo and its relation with DSM-IV ADHD.J Abnorm Child Psychol2014;42:21-35 PMCID:PMC3947432

[58] RondonAT,JarrettMA.Sleep, internalizing problems, and social withdrawal: unique associations in clinic-referred youth with elevated sluggish cognitive tempo symptoms.J Atten Disord2020;24:524-34

[59] SáezB,BeckerSP.Optimal items for assessing sluggish cognitive tempo in children across mother, father, and teacher ratings.J Clin Child Adolesc Psychol2019;48:825-39 PMCID:PMC6599489

[60] HarringtonKM.Evaluating the utility of sluggish cognitive tempo in discriminating among DSM-IV ADHD subtypes.J Abnorm Child Psychol2010;38:173-84

[61] SkirbekkB,OerbeckB.The relationship between sluggish cognitive tempo, subtypes of attention-deficit/hyperactivity disorder, and anxiety disorders.J Abnorm Child Psychol2011;39:513-25

[62] Mdel M, Servera M, Becker SP, Burns GL. Sluggish cognitive tempo and adhd inattention as predictors of externalizing, internalizing, and impairment domains: a 2-year longitudinal study.J Abnorm Child Psychol2016;44:771-85 PMCID:PMC6613784

[63] BiedermanJ,DiSalvoM.Clinical correlates of mind wandering in adults with ADHD.J Psychiatr Res2019;117:15-23

[64] PennyAM,KleinRM,EskesG.Developing a measure of sluggish cognitive tempo for children: content validity, factor structure, and reliability.Psychol Assess2009;21:380-9

[65] BurnsGL,BernadMdel M,CardoE.Distinctions between sluggish cognitive tempo, ADHD-IN, and depression symptom dimensions in Spanish first-grade children.J Clin Child Adolesc Psychol2013;42:796-808

[66] LeeS,SnellJ.Validity of the sluggish cognitive tempo symptom dimension in children: sluggish cognitive tempo and ADHD-inattention as distinct symptom dimensions.J Abnorm Child Psychol2014;42:7-19

[67] ServeraM,CarrilloJM,BurnsGL.Longitudinal correlates of sluggish cognitive tempo and ADHD-inattention symptom dimensions with Spanish children.J Clin Child Adolesc Psychol2016;45:632-41

[68] SevincokD,OzbekMM,AksuH.ADHD symptoms in relation to internalizing and externalizing symptoms in children: the mediating role of sluggish cognitive tempo.Nord J Psychiatry2020;74:265-72

[69] BeckerSP,LeopoldDR.Report of a work group on sluggish cognitive tempo: key research directions and a consensus change in terminology to cognitive disengagement syndrome.J Am Acad Child Adolesc Psychiatry2023;62:629-45 PMCID:PMC9943858

[70] GarnerAA,MrugS,HodgensB.Dimensions and correlates of attention deficit/hyperactivity disorder and Sluggish Cognitive Tempo.J Abnorm Child Psychol2010;38:1097-107 PMCID:PMC3278310

[71] BarkleyRA.Distinguishing sluggish cognitive tempo from ADHD in children and adolescents: executive functioning, impairment, and comorbidity.J Clin Child Adolesc Psychol2013;42:161-73

[72] GustavsonK,EilertsenEM.Genetic and environmental contributions to co-occurring ADHD and emotional problems in school-aged children.Dev Psychol2021;57:1359-71

[73] ScainiS,BattagliaM.A Twin Study of the relationships between cognitive disengagement syndrome and anxiety phenotypes in childhood and adolescence.Res Child Adolesc Psychopathol2023;51:949-60

[74] MoruzziS,BattagliaM.A twin study of the relationships among inattention, hyperactivity/impulsivity and sluggish cognitive tempo problems.J Abnorm Child Psychol2014;42:63-75

[75] LeopoldDR,BurnsGL,OlsonRK.Attention-deficit/hyperactivity disorder and sluggish cognitive tempo throughout childhood: temporal invariance and stability from preschool through ninth grade.J Child Psychol Psychiatry2016;57:1066-74 PMCID:PMC4938772

[76] AchenbachTM.Child behavior checklist for ages. Encyclopedia of clinical neuropsychology. In: Kreutzer JS, DeLuca J, Caplan B (Editors). Springer, 2011; pp. 546–552.

[77] AchenbachTM. Manual for the ASEBA School-age forms & profiles: child behavior checklist for ages 6-18, Teacher’s report form, youth self-report: an integrated system of multi-informant assessment; University of Vermont, research center for children youth & families, 2001. Available from https://search.worldcat.org/it/title/53902766 [Last accessed on 26 Mar 2024]