Self-Regulation Issues in Children and Adolescents With ADHD, ODD, and OCD

Self-Regulation Issues in Children and Adolescence with ADHD, ODD, and OCD

Self-regulation in children and adolescence who suffer from ADHD, ODD, and OCD (Attention Deficit Hyperactive Disorder, Obsessive Compulsive Disorder, and Oppositional Defiant Disorder) is often evident due to several things. A lot of the issues in relation to self-regulation stem from additional anxiety the child/teen may feel from the difficulties experienced from these kinds of mental disorders. OCD is known to cause anxiety and isolationist behaviors leading to decreased emotional self-regulation. ADHD at times can cause hyperfocus, making it difficult for the child/teen to switch tasks therefore limiting their ability to handle their emotions and activities that assist in regulating themselves. ODD, connected to ADHD, is a disorder that has the child react angrily and spitefully to people in otherwise normally responsive situations. The extreme feelings of children or adolescence who manifest ODD make it hard for them to respond to things in a rational and balanced way.

Children who experience OCD are often stuck with repeating set and defined patterns to rid themselves of sad or disturbing thoughts. Self-regulation among children who suffer from this disorder is very difficult to attain because of the repetitions and obsessions that preoccupy their minds and in some more severe cases, their lives. Children experiencing OCD often report increased sensitivity to external events, especially when they are away from their comfort zones and unable to perform their rituals. Additionally, they lack objective reasoning which can also deter or limit self-regulation by enabling the child to focus on things that will heighten or continue bad or negative thoughts and/or behavior. Many theories exist on why behavioral disorders exists, but few thoroughly explain or connect actions and behaviors to the disorders, especially in young children who are often not diagnosed until older in age.

II. Social Theory & Analysis

Hyperfocus exhibited by children with ADHD, is an intense form of mental concentration (Wong & Butler, 2012, p. 141). Some topics may elicit daydreaming in some children who engage in hyperfocus. The heightened concentration limits what is otherwise easy to achieve in children without any signs of mental disorder such as multi-tasking, paying attention, and socialization. Socialization, an aspect of self-regulation elicits the child to engage in several activities. These activities may include observing, talking, responding, and thinking. When engaged in hyperfocus, the child will only be able to pay attention to one thing and can easily get side-tracked. Hyperfocus is one theory on why self-regulation appears to be a difficult activity for children who exhibit ADHD tendencies.

Self-regulation is a broad label for several activities belonging in different areas, all pertaining to controlling one's emotions, thoughts, actions, and responses. Emotional self-regulation (Campbell, 1990, p. 118). In sociology and psychology, self-control is representative of self-regulation. In educational psychology, self-regulated learning makes up self-regulation. Self-regulation theory (SRT), a system of conscious personal health management can apply to how a child regulates themselves in relation to hygiene and nutrition. Self-policing, a form of self-regulation, applies to how a child may respond to external stimuli brought on by society, authoritative, and/or peer-to-peer, interactions.

Self-control is the ability for one to control their emotions, behavior, and desires for the possible attainment of a reward or avoidance of a punishment (Wong & Butler, 2012, p. 141). In psychology it is often referred to as self-regulation. Children who suffer from OCD, ADHD, and ODD often lack self-control. OCD afflicted children become obsessed with rituals and therefore cannot stop even if there is the added possibility of an imminent reward or punishment. They are controlled by their behaviors, not the other way around. The mechanism that drives them to perform behaviors that limit self-control promote belief in greater punishment if they are not engaging in these obsessive-compulsive tendencies.

Children with ADHD cannot focus on the punishment and reward aspect of self-control and only view what they regard as interesting at the moment as the reward. They cannot control in what they focus on and if they do focus on something, they are limited in focusing on something else. This lack of self-control promotes the theory that self-regulation in ADHD children is a common issue.

ODD in children makes self-control difficult in that it keeps them from handling emotional situations in a typical and natural fashion. Anger and aggression are exacerbated in children with ODD so they will act harsher and are more sensitive than children who do not have ODD. Lack of effective reasoning, not possessing the ability to regulate their emotions when confronted with social situations, is a great indicator of decreased self-control, therefore, self-regulation. Aversive stimulation may increase desire for self-control in children with ODD, ADHD, and OCD, but further research is needed. Self-regulation as seen through self-regulated learning (Zelazo, 2013, p. 181-190).

Self-regulated learning (SRL) is learning guided by metacognition, strategic action, and motivation to learn. Metacognition is self-reflection or thinking about one's thinking. Strategic action consists of activities that include monitoring, planning, and self-evaluation of personal progress when compared to a known standard. Self-regulated learning involves taking the process of learning and applying it to one's self through one's own actions (Scott, 2008, p. 63).

Self-regulated learning puts emphasis on autonomy and control through the individual's actions and thought processes. The direct, monitor, and regulate themselves towards goals and objectives of gaining knowledge, expanding expertise, and improvement. Moreover, self-regulated learners are aware of both their academic strengths and weaknesses. They have an internal database of methods and approaches they appropriately apply to handle daily challenges of academic tasks.

Self-regulated learning is virtually non-existent in ADHD children. They are often far too distracted to apply or develop strategies to learn. When they try to apply what they've learned to something, they at times get stuck or confused, unable to interconnect the several areas of information required to absorb, evaluate, and apply acquired knowledge. The same is for children with ODD.

ODD keeps children focused on emotional relief and satisfaction as they become agitated by someone or something fairly easily. Another aspect of this disorder that keeps children who suffer from it unable to perform self-regulated learning is the lack of responsibility they take for their actions. Self-regulated learning involves constant self-evaluation and reflection. If children with ODD cannot self-evaluate and reflect on past instances and actions, they cannot learn from them assess what they have to do to improve.

Children with OCD are not as unable to handle self-regulated learning. They can reflect and self-evaluate, but do so in a rigid and unyielding thought process. Children with OCD narrow what they can do and think in relation to what they experience or observe. In this way they are unable to truly apply self-regulated learning successfully because they cannot keep an open mind to incoming information. They can form strategies to cope with learning, etc., but they cannot execute in a broad sense and end up stuck in their compulsions.

Emotional self-regulation or regulation of emotion is the ability to respond to the continual demands of experience with the assortment of emotions in a fashion that is socially acceptable and adequately adaptable to allow unplanned reactions as well as the ability to prolong reactions as necessary. Furthermore the definition can include intrinsic and extrinsic processes culpable for evaluating, monitoring, and modification of emotional responses (Zelazo, 2013, p. 181-190). Emotion self-regulation is a part of a much wider set of emotion-regulation processes, which includes the regulation of one's own emotions as well as others.

Emotional regulation is an intricate process consisting of initiation, inhibition, or modulation of one's behavior or state of mind in any given circumstance. Because of its complexity, children who suffer from ADHD, for instance, often times cannot handle the various actions needed to consider their feelings and someone else's; let alone possess the ability to regulate them. Often time's children with ADHD cannot see past a situation and therefore cannot become aware of what they are doing, let alone feeling in the present time. Even if they are paying attention to what is around them, they may easily become distracted.

OCD has the same dilemma in that it takes up most of the time in a child's conscious life. Instead of thinking of how to respond to an emotional situation or the feelings of someone else, they are too caught up in how they feel with not performing their rituals. The intense suspense, anxiety, and then release and relief, followed by a growing urge, preoccupies the child's life in such a way he/she cannot accept other experiences. Unlike ADHD, where they get distracted by anything and everything, in OCD, the obsession becomes the only distraction.

ODD narrows the feelings/emotions children exhibit, therefore decreasing their capacity to emotionally self-regulate. With this disorder they proceed to feel mostly negative emotions of hate, anger, and spite, and therefore act from this basis, unable to understand other feelings needed to learn emotional regulation such as compassion, forgiveness, and temperance. Children who demonstrate behavior patterns associated with ODD cannot differentiate their feelings from their overly-sensitive reactions, inhibiting their ability to self-regulate.

Self-policing is a process or procedure where a group either by industry, profession or peers, monitors and checks its own members to be sure they adhere to accepted fundamentals or understanding (Zelazo, 2013, p. 181-190). As it applies to children, it allows them to, when in a group, learn how to cope with other's needs, demands, and assertions. It is an essential social skill that is often used in organizations and businesses in order to evaluate each other. When kids demonstrate mental disorders such as ADHD, ODD, and OCD, this skill often appears non-existent with children lacking understanding in implementing techniques and looking at themselves for proper action in relation to others and their behaviors.

These self-regulatory mechanisms all contribute to the social cognitive theory of self-regulation. The analysis attributed to the self-regulatory mechanisms reveals the inherent lack of success in self-regulating brought on by mental disorders like ADHD, ODD, and OCD. In order to determine further if children with these types of mental disorders can function within the constructs of self-regulation without the need for treatment in the instance of prescription medication, among other avenues remains more research on this topic is needed. The literature review however, will allow for better understanding of what is lacking in this kind of research and what possible biological, and psychological causes are responsible for the emergence of this disorder.

III. Literature Review

This literature review will focus on the gaps in research pertaining to the mental disorders known as ODD, ADHD, and OCD and how self-regulation is lacking in children and adolescence who exhibit behaviors particular to these disorders. The literature will also reveal the pertinent information regarding ways teachers and medical professionals circumvent the problems related to each disorder in order to better the self-regulatory mechanisms in children with ODD, ADHD, and OCD. It will cover in order: ADHD and the studies done on it, OCD and the studies done on self-regulation, and ODD and its effect on children.

In an article by Blum, Chen, & Oscar-Berman (2008), they discuss recent advancements in molecular genetic studies and how it is able to identify several genets that may facilitate susceptibility to attention deficit hyperactivity disorder (ADHD). "A consensus of the literature suggests that when there is a dysfunction in the "brain reward cascade," especially in the dopamine system, causing a low or hypo-dopaminergic trait, the brain may require dopamine for individuals to avoid unpleasant feelings" (Blum, Chen, & Oscar-Berman, 2008, p. 893). They offer an explanation of a high-risk genetic trait that leads to multiple drug-seeking behaviors. The reasons being is the drugs possess the ability to activate release of dopamine, lowering the abnormal cravings inherent in children with this kind of genetic disposition?

Many studies often associate biological factors with ADHD, but this article reveals actual genetic traits that create a disturbance and therefore become precursor to formation of this disorder. The article continues with description of the specific form and its connection to dopamine receptors. "Moreover, this genetic trait is due in part to a form of a gene (DRD2 A1 allele) that prevents the expression of the normal laying down of dopamine receptors in brain reward sites" (Blum, Chen, & Oscar-Berman, 2008, p. 893). This gene, as described by the authors, and others involved in neurophysiological processing of specific neurotransmitters, are linked with deficient functions. They state this predisposition promoted high risk for impulsive, addictive, and compulsive behavioral and predispose individuals to have a high risk for addictive, impulsive, and compulsive behavioral inclinations.

Another great discovery the article cites is the formulated proposal that certain genes are responsible for determinant behaviors of RDS. "It has been proposed that genetic variants of dopaminergic genes and other "reward genes" are important common determinants of reward deficiency syndrome (RDS), which we hypothesize includes ADHD as a behavioral subtype" (Blum, Chen, & Oscar-Berman, 2008, p. 893). They also add, that identification of this gene will lead to earlier diagnosis through use of genetic polymorphic identification in combination with DNA-based customized nutraceutical administration. This article was helpful in demonstrating a possible biological component to formation of ADHD as well as other disorders involving addiction, and dopamine and serotonin releasers.

In an article by Maher, Greene & Holmes (2012), they discuss the limited investigation in symptoms of deficient emotional self-regulation (DESR) and its connection with ADHD. They conducted a study to determine more causality and provide further evidence for the reason for this connection. Specifically, they aimed to "examine the predictive utility of DESR in moderating the course of ADHD children into adolescence" (Greene, Maher, & Holmes, 2012, p. 267). Their methods consisted of:

177 children with and 204 children without ADHD followed for an average of 4 years (aged 6 -- 18 years at baseline, 54% male). Subjects were assessed with structured diagnostic interviews and measures of psychosocial functioning. DESR was defined by the presence (n = 79) or absence (n = 98) of Child Behavior Checklist (CBCL)-DESR profile (score ? 180 < 210 total of Attention, Aggression, and Anxious/Depressed subscales) at the baseline assessment (Greene, Maher, & Holmes, 2012, p. 267).

The results led to persistent association of ADHD with DESR. "At follow-up, ADHD + DESR subjects had significantly more comorbidities (z = 2.55, P = 0.01), a higher prevalence of oppositional defiant disorder (z = 3.01, P = 0.003), and more impaired CBCL social problems t-score (t (227) = 2.41, P = 0.02) versus ADHD subjects" (Greene, Maher, & Holmes, 2012, p. 267). Certain gaps in research often create confusion in how to properly connect the causalities for certain disorders and diseases. Studies such as these provide concrete proof that the long ago hypothesized links do hold truth and weight to them.

In an article by Shiels & Jr. (2010), the article discusses the characteristics of Attention deficit hyperactivity disorder (ADHD). "…characterized by persistent and impairing developmentally inappropriate levels of inattention, hyperactivity, and impulsivity" (Shiels & Jr., 2010, p. 951). They offer a theory that behavioral dysregulation may be a consequence of the deficits normally apparent ADHD children when self-monitoring or attempting adaptive control. Self-monitoring and adaptive control are two vital components of effective adaptive behavior. They continue their explanation with: "Processing of contextual demands, ongoing monitoring of one's behavior to evaluate whether it is appropriate for a particular situation, and adjusting behavior when it is suboptimal are components of self-regulation" (Shiels & Jr., 2010, p. 951). As mentioned earlier, there are gaps within this field as related to research and this article attempts to cover that gap by examining and integrating recent on error-processing and adaptive control as aspects of self-regulation in relation to the widely accepted etiological theories of ADHD. Their review highlights availability of data on error-processing, as reflected in event-related potentials (ERN and Pe) and behavioral performance, thus suggesting that the two components of early error detection and later error-evaluation may decrease in children with ADHD. The lack of mechanism processes interferes with adaptive control processes. Another important part of the article suggest that the variability in the results diminishes definite conclusions on early error detection.

Shiels & Jr. (2010), state: "A range of methodological issues, including ERP parameters and sample and task characteristics, likely contribute to this variability, and recommendations for future work are presented" (Shiels & Jr., 2010, p. 951). Lastly the article mentions continual research on this phenomenon will provide a concrete and general methods for specifically testing self-regulation models. Most of the discussions surrounding this topic often offer varied and mixed results when it concerns self-regulation. It is important to continue research to determine a general way of identifying self-regulation in order to provide detailed and uniform conclusions.

In a study by Strehl et al. (2007), they investigate the "effects of self-regulation of slow cortical potentials for children with attention deficit hyperactivity disorder" (Strehl et al., 2007, p. e1530). Their study suggests slow cortical potentials are slow event-related direct-current shifts of the electroencephalogram. "Slow cortical potential shifts in the electrical negative direction reflect the depolarization of large cortical cell assemblies, reducing their excitation threshold" (Strehl et al., 2007, p. e1530). The study helps shed light on possible attempts being made to regulate cortical excitation thresholds. Cortical excitation thresholds are thought to be impaired in ADHD children. As the previous study mentioned, finding a general method of identifying, examining and analyzing the reasons behind impaired self-regulation could beneficial in understanding and therefore treating the problems associated with ADHD.

Their method involved:

Twenty-three children with attention deficit hyperactivity disorder aged between 8 and 13 years received 30 sessions of self-regulation training of slow cortical potentials in 3 phases of 10 sessions each. Increasing and decreasing slow cortical potentials at central brain regions was fed back visually and auditorily. Transfer trials without feedback were intermixed with feedback trials to allow generalization to everyday-life situations. In addition to the neurofeedback sessions, children exercised during the third training phase to apply the self-regulation strategy while doing their homework (Strehl et al., 2007, p. e1530).

The study also demonstrated, the first time in this kind of field, the electroencephalographic data during the course of slow cortical potential neurofeedback. The information derived from the measurements revealed ADHD children learn to regulate only negative slow cortical potentials. The authors of the study also implemented training to the children exhibiting ADHD behavior. The children responded positively to the training demonstrated major improvement in attention, IQ score, and most importantly, behavior. The results lasted over 6 months and proved that with adequate training, ADHD children can exhibit positive differences in behavior and attention span.

The study did a great job of identifying a particular reaction in ADHD children which can then be utilized in other mental disorders. "Regulation of slow cortical potentials may involve similar neurobiological pathways as medical treatment" (Strehl et al., 2007, p. e1530). One issue the study had was the lack of a control group to verify causal relationship amidst observed improvements and brains ability to self-regulate. This gap in information should be researched further in order to fully understand the nature of self-regulation within the brain to better improve the chances of ADHD children responding well to treatment. Furthermore, researching cause and effect can then shift over to other mental disorders such as OCD and ADHD's closely related disorder, ODD.

Gill, Papageorgiou, Gaskell, & Wells (2013), used in their study, the Thought Control Questionnaire to measure individual variances in thought suppression strategies. Many studies that utilize the TCQ use it on adults, this study however, generated an adolescent version in order to measure and describe the development and psychometric properties of the modified questionnaire. They achieved this through modification of the items asked within the questionnaire while still retaining its original purpose and meaning. As the study states: "The adolescent version of the questionnaire and measures of emotional disorder were then administered to 589 school pupils aged 13 -- 17 years" (Gill, Papageorgiou, Gaskell, & Wells, 2013, p. 242). One of the reasons this study was used in the literature review is to show how methods normally adapted for adults can be modified for children and adolescents.

The results, which appear to be common in these kinds of studies, yielded mixed results. Analysis of the questionnaire and its responses did highlight five factors that adolescents demonstrate with behavioral disorders. "The five factors were distraction, social control, worry, punishment and reappraisal. The TCQ -- A showed good internal consistency and evidence of stability over time. Scores on the worry and punishment subscales were positively correlated with measures of emotional symptoms" (Gill, Papageorgiou, Gaskell, & Wells, 2013, p. 242). Studies such as these are useful in further examining the processes of a child or adolescent brain, helping to identify faster, any patterns or causes for behavioral problems.

Sportel, Nauta, Hullu, Jong, & Hartman (2011), discuss in their article, behavioral inhibition (BI) and its association with the development of internalizing disorders such as attentional control in children and adolescents. The article states: "The combination of high BI and low AC may particularly lead to elevated symptomatology of internalizing behavior" (Sportel, Nauta, Hullu, Jong, & Hartman, 2011, p. 149). Studies such as these help add to the existing information available through investigation of processes related to behavioral disorders such as the interacting and additive effects of BI and AC.

A sample of non-clinical adolescents (N = 1806, age M = 13.6 years), completed the Behavioral Inhibition System/Behavioral Activation System Scales (BIS/BAS), the attentional control subscale of the Adult Temperament Questionnaire (ATQ) and the Revised Child Anxiety and Depression Scale (RCADS). As expected, BI was positively, and AC was negatively related to internalizing dimensions, with stronger associations of BI than of AC with anxiety symptoms, and a stronger association of AC than of BI with deprssive symptoms. (Sportel, Nauta, Hullu, Jong, & Hartman, 2011, p. 149)

Studies done on OCD often focus on treatment and identifying OCD tendencies. In a study by Freeman et al. (2012), they use a similar modification of a questionnaire enabling further analysis of children with OCD. The study offered a randomized-control trial (which lacks in other studies) where there is no control group, and observed the outcomes of family-based cognitive behavioral treatment (CBT) and family-based relaxation therapy for children aged 5-8 who exhibited OCD tendencies. They measured any reduction in symptoms, improvement in quality of life, and functional impairment. As the study mentions in their modification within the study: "Aspects that are highlighted include: choice of control group, inclusion/exclusion criteria, assessment/measurement issues, treatment adaptations, training, and recruitment" (Freeman et al., 2012, p. 294). Modification of current methods to tailor the specific actions and behaviors of children is important means of gaining valuable knowledge on an often confusing varied subject.

Often gaps in literature appear due to lack of investigation in specific areas. Wilson & Hall (2012), provide examination of an often neglected topic: thought control strategies in younger populations. Much like the previous studies, they modified a thought control questionnaire and received data on "thought control strategies and meta-cognitive beliefs in relation to Obsessive Compulsive (OC) interference scores in an adolescent sample" (Wilson & Hall, 2012, p. 438). The results showed adolescents used distraction and worry as coping mechanisms similarly to adults. The difference to an adult method is lack of social control and reappraisal. They also noted adolescent males used punishment as a thought control strategy less frequently. It also showed: "The strategies of worry and punishment, and positive beliefs about worry, uncontrollability and danger beliefs (UCD) and superstition punishment and responsibility beliefs (SPR) predicted OC interference scores" (Wilson & Hall, 2012, p. 438).

Literature like this confirms effective use of adult questionnaires for children and adolescents. Children with mental or behavioral disorders exhibit similar thought processes to adults with some exceptions. Gaps in literature can be lessened if more studies were formed using adult data methods on children with some modification. As the authors state: "Given the similarities between our results and those from research exploring these variables in adults, it is proposed that cognitive behavioral models of OCD that have been developed in adult populations may be relevant to adolescents, but that meta-cognitive beliefs about superstition, punishment and responsibility may be important in adolescence (Wilson & Hall, 2012, p. 438).

In an article by Simon, Kaufmann, Kniesche, Kischkel, & Kathmann (2013), "Elevated anxiety in obsessive-compulsive disorder (OCD) has been linked to cortico-limbic hyper activation, whereas hyper arousal of the autonomous nerve system (ANS) has inconsistently been found" (Simon, Kaufmann, Kniesche, Kischkel, & Kathmann, 2013, p. 635). The investigation allowed for observance of OCD-triggers, neutral and aversive control. A weakness found within this study was the relatively small size of the study group. Their findings: "…findings suggest ANS hyperactivity during OCD symptom provocation that could reflect arousal to the perceived threatening value of OCD-triggers and might mediate elevated anxiety. (Simon, Kaufmann, Kniesche, Kischkel, & Kathmann, 2013, p. 635), were not accurate enough to infer a definite conclusion.

Most often than not, research made concerning OCD focuses on identifying and diagnosing OCD. In an article by Pace, Thwaites, & Freeston (2011), they connect the concept of external criticism with various aspects of Obsessive Compulsive Disorder. Their research illustrates criticism as a potential catalyst for development of the disorder, or rather, the continual progression of it. It also points out the lack of evidence present and the failure of current research to successfully interpret the association. "The fragmented nature of the findings makes it difficult to identify how or why criticism impacts on OCD" (Pace, Thwaites, & Freeston, 2011, p. 361).

In the last study done by Cheng & Boggett-Carsjens (2005), their investigation highlights dysregulation which is typically found in children who exhibit ODD.

Standard DSM-IV differential diagnoses for affect instability include bipolar disorder, ADHD and oppositional defiant disorder. However, clinicians may wish to consider the possibility of sensory processing difficulties, which are difficulties with the processing of sensory input, which can lead to problems with under- or over-arousal, thus contributing to affect dysregulation (Cheng & Boggett-Carsjens, 2005, p. 44).

Very little literature is found that researches ODD. ODD is often connected to ADHD which is why there was more literature presented on ADHD than the other two disorders. If more articles studied the effects of ODD on children, perhaps they will have a much more in depth awareness of the mechanics behind ODD and ADHD.

This literature review highlighted several recent studies that contribute to the ongoing understanding of the biological processes behind disorders like ADHD, OCD, and ODD. Innovations such as modified questionnaires commonly used for adults, and reports on genes playing a role in predisposition to such disorders lends greater awareness of potential causes for ADHD, OCD, and ODD. Continual efforts will help with self-regulating strategies and treatment.

IV. Discussion

As seen in the literature review, studies often lack tools to help them analyze behavioral disorders in children. They have to modify existing methods in order to get information on these kinds of children. Society in general tends to dismiss or ignore mental illness in children simply identifying the behavior of children as being ordinary or normal. The reality is, children exhibit similar thoughts and behaviors that adults due with some differences due to age, exposure, and experience. Making the connection that children have similar thought patterns to adults, will allow for greater analysis in what causes behavioral disorders and what can promote self-regulation to aid children afflicted with these behavioral disorders to properly maintain management of symptoms and triggers.

Although autism is not the kind of disorder discussed in this paper, it is important to include studies on autism to discern how self-regulatory behaviors exist within children who do not present typical behaviors. In a study conducted by Henderson et al. (2013), they examined "the error related negativity (ERN), an electrophysiological index of response monitoring, in relation to behavioral, social cognitive, and emotional presentation in higher functioning children (8 -- 16 years) diagnosed with autism (HFA: N = 38) and an age- and IQ-matched sample of children without autism (COM: N = 36)" (Henderson et al., 2013, p. 1). The data they gathered can be used to explain the reasons why self-regulating decreases in children with behavioral disorders. Self-reporting, self-evaluating is generally lacking in children who exhibit behavioral disorder characteristics because they are not fully aware of what they are thinking and feeling in relation to the outside world. Consistent internalization promotes limited coping mechanisms.