Exclusion Expected? Cardiac Slowing Upon Peer Exclusion Links Preschool Parent Representations to School-Age Peer Relationships.

Attachment theory proposes that children's representations of interactions with caregivers guide information-processing about others, bridging interpersonal domains. In a longitudinal study (N = 165), preschoolers (Mage  = 5.19 years) completed the MacArthur Story Stem Battery to assess parent representations. At school-age (Mage  = 8.42 years), children played a virtual ballgame with peers who eventually excluded them to track event-related cardiac slowing, a physiological correlate of rejection, especially when unexpected. At both ages, parents and teachers reported on peer and emotional problems. During exclusion versus inclusion-related events, cardiac slowing was associated with greater positive parent representations and fewer emerging peer problems. Cardiac slowing served as a mediator between positive parent representations and peer problems, supporting a potential psychophysiological mechanism underlying the generalization of attachment-related representations to peer relationships.

Quality of life and psychological co-morbidities in children and adolescents with cardiac pacemakers and implanted defibrillators: a cohort study in Eastern Germany.

INTRODUCTION: The implantation of a pacemaker or an implantable cardioverter-defibrillator during childhood may reduce quality of life and lead to mental health problems. This study aimed to evaluate potential mental health problems (i.e., depressive and anxiety symptoms) and quality of life in children with cardiac active devices in comparison to healthy peers. METHODS: We analysed data of children with pacemakers or implantable cardioverter-defibrillators aged 6-18 years. Quality of life, depressive and anxiety symptoms were assessed by standardised questionnaires. The results were compared to age-matched reference groups. RESULTS: Children with implantable cardioverter-defibrillator showed significant lower quality of life in comparison to reference group (p = 0.03), but there was no difference in quality of life between children with pacemaker and reference group. There was no significant difference in depressive symptoms between children with a cardiac rhythm device compared to reference group (self-report: p = 0.67; proxy report: p = 0.49). There was no significant difference in anxiety (p = 0.53) and depressive symptoms (p = 0.86) between children with pacemaker and children with implantable cardioverter-defibrillator. CONCLUSIONS: Living with an implantable cardioverter-defibrillator in childhood seems to decrease the patients' quality of life. Although children with pacemaker and implantable cardioverter-defibrillator don't seem to show more depressive and anxiety symptoms in comparison to their healthy peers, there still can be an increased risk for those children to develop mental health problems. Therefore, treating physicians should be aware of potential mental health problems and provide the patients and their families with appropriate therapeutic offers.

[LIFE Child Depression - a prospective longitudinal cohort study on the origin of depressive disorders between childhood and early adulthood]. / LIFE Child Psychische Entwicklung/Depression ­ Prospektive longitudinale Kohortenstudie zur Erfassung von Entstehungsbedingungen depressiver Störungen von der Kindheit bis ins junge Erwachsenenalter.

LIFE Child Depression - a prospective longitudinal cohort study on the origin of depressive disorders between childhood and early adulthood LIFE Child Depression is a prospective longitudinal study on the origin and course of depressive symptoms and disorders between child- and adulthood. The aim of the study is to identify patterns of developmental courses of symptoms and disorders and to investigate the interplay of psychosocial, biological and genetic risk and protective factors in the development of depressive disorders. The present paper gives an overview on results of the study. The sample was already assessed three times. A clinical sample was recruited from two local child psychiatric in- and outpatient services in Leipzig, a control sample was recruited from a children's health check program at our medical faculty (LIFE Child Health) and from the local registration office. We found some important context- and parent-associated risk factors for depressive disorders, such as negative life events, low socioeconomic status and depression in mothers (but not in fathers). Moreover, we found some characteristic biological and cognitive-emotional characteristics of children with depressive disorders, such as low stress-related cortisol, low evaluation of own performance, and more negative cognitions in dealing with stressful situations, low self-esteem and a general impairment of emotional processing of human faces. Only some of the risk factors were found to be specific to depression. Instead, most of them can be regarded as general risk factors for psychological disorders in childhood. It is also noteworthy, that some of the risk associations were gender-specific and need to be looked at from a differential point of view. Our study gives important indications for prevention for children at risk for depressive disorders as well as for therapeutic approaches.

The Perspective Matters: A Multi-informant Study on the Relationship Between Social-Emotional Competence and Preschoolers' Externalizing and Internalizing Symptoms.

Recent research demands a multi-informant and multi-factorial assessment of preschool-age psychopathology. Based on a tripartite model, we tested the relationship between emotional and social competence and their contribution to externalizing and internalizing symptoms in a preschool-age community sample (N = 117, M = 4.67 years, SD = 2.75 months). We assessed teachers' (N = 109) and parents' (N = 77) perspective using the Strengths-and-Difficulties-Questionnaire and children's perspective using the Berkeley-Puppet-Interview and a standardized emotional-competence-test (MeKKi). We found externalizing symptoms being negatively related to prosocial behavior in teachers' and parents' reports and positively related to social initiative in teachers' reports. In teachers' reports only, a mediation effect of emotional competence via social competence on externalizing symptoms was shown. Children, but not caregivers, reported internalizing symptoms being positively related to prosocial behavior. These results highlight the importance of multiple informants and especially of children's self-perception in preschool-age psychopathology.

[Various socioeconomic factors as predictors of internalizing and externalizing disorders in children and adolescents]. / Verschiedene sozioökonomische Faktoren als Prädiktoren für internalisierende und externalisierende Störungsbilder des Kindes- und Jugendalters.

Various socioeconomic factors as predictors of internalizing and externalizing disorders in children and adolescents Abstract. Objective: Socioeconomic status (SES) is an important risk factor for psychiatric disorders in children and adolescents. Various SES parameters are included in research efforts. This paper investigates the predictive value of different individual SES measures and the combination thereof regarding internalizing and externalizing disorders in children and adolescents. Method: We used data from N = 381 8- to 14-year-olds who had been recruited in child and adolescent psychiatric facilities and in the general population. Based on a diagnostic parent interview (K-SADS-PL), we divided the sample into internalizing and externalizing groups and a healthy control group. The SES data of both parents were collected. Education, occupational status, and income were integrated as single factors as well as combined factor to form the SES index. Additionally, we assessed unemployment. Results: Using multivariate analyses, we controlled for age and sex. All single factors turned out to be significant risk factors for internalizing and externalizing disorders. Occupational status was the most important single factor. The explained variance for the SES index was as high as for occupational status. Unemployment was not predictive when examined simultaneously with the SES index. Conclusion: Future studies should integrate the SES as risk factor and use the SES index or occupational status as single factor. The integration of unemployment is not necessarily needed.

Endocrinological and subjective stress responses in children with depressive, anxiety, or externalizing disorders.

In this study, we used a stress test to investigate endocrinological and subjective stress responses of 8- to 14-year-old children with internalizing or externalizing disorders and healthy controls. The sample (N = 170) consisted of clinical and community children. Parents were given a diagnostic interview to diagnose their children's psychiatric condition. We measured saliva cortisol and subjectively experienced arousal in children before and after the Trier Social Stress Test for Children. Children also rated their performance immediately after the stress test, and 1 hr later they rated their positive and negative thoughts about this stressful event. Children with internalizing or externalizing disorders exhibited a blunted cortisol response compared to healthy controls. Depressed children rated their test performance lower and reported more negative thoughts after the test in comparison to healthy controls, anxious children reported more arousal before and after the task, and children with externalizing disorders reported more positive thoughts. In regression analyses, cortisol and subjective stress responses were both predictive of psychiatric disorders. The study extends previous work on the relation between psychiatric disorders and children's stress responses to an experimentally induced stress task by including a broad range of psychiatric disorders and by integrating endocrinological and subjective stress responses.

Self-Esteem of 8-14-Year-Old Children with Psychiatric Disorders: Disorder- and Gender-Specific Effects.

In this study, we investigated the relation between global and domain-specific self-esteem and psychiatric disorders. A sample of 577 children aged 8-14 years was recruited via psychiatric hospitals and from the general population. Parents were given a diagnostic interview to assess children's psychiatric diagnoses (current/past). Parents and children completed questionnaires on child symptoms. Children completed a questionnaire on global and domain-specific self-esteem (scales: scholastic competence, social acceptance, athletic performance and physical appearance, global self-esteem). Self-esteem of children with current psychiatric disorders was lower than that of healthy controls (η p2 between 0.01 and 0.08). Concerning scholastic competence, social acceptance and global self-esteem, children with past psychiatric disorders scored also lower than healthy controls. Different current psychiatric disorders showed specific but small effects on dimensions of self-esteem (ß between -0.08 and 0.19). Moreover, we found a gender × group interaction, indicating that girls with depressive and adjustment disorders were specifically impaired in their global self-esteem and perception of their physical appearance. Findings might help clinicians to focus on particular domains of self-esteem during the diagnostic process and to define adequate treatment goals.

Immunoassay or LC-MS/MS for the measurement of salivary cortisol in children?

BACKGROUND: Dysregulation of the adrenal cortex has been assessed with measurement of salivary cortisol. So far salivary cortisol is routinely measured with immunoassay (IA). However, liquid chromatography-tandem mass spectrometry (MS) is known to offer better specificity. We compared the concentrations of salivary cortisol measured by MS and IA at basal and stress induced conditions and evaluated reasons for the difference in method-dependent cortisol results. METHODS: Saliva samples (n=2703) were collected from 169 children (age range: 8-14 years; 81 healthy children; 55 with internalizing and 33 with externalizing disorders) under circadian conditions and during the Trier Social Stress Test for Children (TSST-C). Biochemical analyses were performed with MS for cortisol and cortisone, IA (IBL, RE62011) for cortisol, and enzyme kinetic assay for α-amylase. RESULTS: MS and IA showed mostly comparable results for circadian activity and TSST-C response with similar statistical power. However, IA measured cortisol concentrations about 2.39-fold higher than MS. We found that this difference in measured values between MS and IA was mainly due to different standardization of IA compared to MS. In addition, at cortisol IA concentration below 5 nmol/L, cross-reactivity with cortisone was found to contribute to the lower concordance between MS and IA. CONCLUSIONS: Immunoassay and LC-MS/MS were largely comparable in the interpretation of salivary cortisol dynamics in stress research. But the IA method revealed a restricted accuracy in the measuring range below 5 nmol/L.

Early processing of emotional faces in a Go/NoGo task: lack of N170 right-hemispheric specialisation in children with major depression.

Emotionally biased information processing towards sad and away from happy information characterises individuals with major depression. To learn more about the nature of these dysfunctional modulations, developmental and neural aspects of emotional face processing have to be considered. By combining measures of performance (attention control, inhibition) in an emotional Go/NoGo task with an event-related potential (ERP) of early face processing (N170), we obtained a multifaceted picture of emotional face processing in a sample of children and adolescents (11-14 years) with major depression (MDD, n = 26) and healthy controls (CTRL, n = 26). Subjects had to respond to emotional faces (fearful, happy or sad) and withhold their response to calm faces or vice versa. Children of the MDD group displayed shorter N170 latencies than children of the CTRL group. Typical right lateralisation of the N170 was observed for all faces in the CTRL but not for happy and calm faces in the MDD group. However, the MDD group did not differ in their behavioural reaction to emotional faces, and effects of interference by emotional information on the reaction to calm faces in this group were notably mild. Although we could not find a typical pattern of emotional bias, the results suggest that alterations in face processing of children with major depression can be seen at early stages of face perception indexed by the N170. The findings call for longitudinal examinations considering effects of development in children with major depression as well as associations to later stages of processing.

From Maltreatment to Psychiatric Disorders in Childhood and Adolescence: The Relevance of Emotional Maltreatment.

Different forms of maltreatment are thought to incur a cumulative and non-specific toll on mental health. However, few large-scale studies draw on psychiatric diagnoses manifesting in early childhood and adolescence to identify sequelae of differential maltreatment exposures, and emotional maltreatment, in particular. Fine-grained multi-source dimensional maltreatment assessments and validated age-appropriate clinical interviews were conducted in a sample of N = 778 3 to 16-year-olds. We aimed to (a) substantiate known patterns of clinical outcomes following maltreatment and (b) analyse relative effects of emotional maltreatment, abuse (physical and sexual), and neglect (physical, supervisory, and moral-legal/educational) using structural equation modeling. Besides confirming known relationships between maltreatment exposures and psychiatric disorders, emotional maltreatment exerted particularly strong effects on internalizing disorders in older youth and externalizing disorders in younger children, accounting for variance over and above abuse and neglect exposures. Our data highlight the toxicity of pathogenic relational experiences from early childhood onwards, urging researchers and practitioners alike to prioritize future work on emotional maltreatment.

Emotional symptoms from kindergarten to middle childhood: associations with self- and other-oriented social skills.

The study investigated the interactive impact of different dimensions of social skills on children's emotional symptoms. We differentiate between self-oriented social skills which focus on considering own goals and needs in social interactions (assertiveness, social participation) and other-oriented social skills which focus on considering other's goals and needs (pro-social and cooperative behavior). 167 children participated in the study at the ages of 5, 6, and 9 years. A multi-informant approach (parents, teacher, and child) was employed to assess children's psychopathology. Teachers rated children's social skills. The study demonstrated the importance of deficits in self-oriented social skills for the development of emotional symptoms. Low levels of assertiveness predicted later emotional symptoms. In children with low levels of pro-social behavior, high assertiveness protected from emotional problems. In contrast, high levels of pro-social behavior emerged as a risk factor for later emotional symptoms, especially when is goes along with low levels of social participation.

[Application of story stems to the diagnosis of the axis "structure" of OPD-CA]. / Verwendung von Geschichtenergänzungsaufgaben zur OPD-KJ-Strukturdiagnostik.

The continued play of story stems, introduced by a diagnostician, can add to the diagnostic of the axis "structure" of the OPD-CA in a useful way. Story stems (e.g., the MacArthur Story Stem Battery (MSSB) or the Attachment Story Completion Task (ASCT)) are already used in different research fields and in the clinical context. In this article we propose the administration of story stems, which are supposed to represent certain mental skills. A case study will demonstrate the possibility to complement the evaluation of the axis "structure" by symbolic play with story stems.

Attenuated LPP to Emotional Face Stimuli Associated with Parent- and Self-Reported Depression in Children and Adolescents.

Individuals diagnosed with a depressive disorder have been found to show reduced reactions to emotional information consistent with the hypothesis of an emotional context insensitivity. However, there are contradictory findings of enhanced reactivity and mood-congruent processing. Electroencephalography (EEG) recordings of the late positive potential (LPP) can display such blunted or enhanced activity. Due to these contradictory findings, there is a need to clarify the role of the LPP in the emergence and presence of depressive disorders especially in children. We used an emotional Go/NoGo task to investigate modulations of the LPP to emotional (fearful, happy, sad) and calm faces in a sample of children and adolescents (age 11;00-14;11) diagnosed with a depressive disorder according to diagnostic parent interviews (K-SADS-PL) (n = 26) compared to a group of age-matched healthy controls (n = 26). LPP positivity was attenuated in children and adolescents with a depressive disorder as well as with higher self-reported depressive symptoms, suggesting reduced reactivity to emotional and calm faces. This is the first study to find generally blunted LPP responses in a clinical sample of depressed youth across reporters. Such dysfunctional modulation of neural activity may represent a potential biomarker for depressive disorders. The results call for further prospective studies investigating the course of the LPP before and after the onset of a depressive disorder in youth.

Electroencephalographic sleep profiles and hypothalamic-pituitary-adrenocortical (HPA)-activity in kindergarten children: early indication of poor sleep quality associated with increased cortisol secretion.

OBJECTIVES: In children, objective data carried out from sleep EEG monitoring are scarce. Furthermore, results associating the hypothalamic-pituitary-adrenocortical (HPA)-activity with sleep EEG measurements in children are missing. Therefore, our study aimed to investigate in preschool-children the association between sleep patterns and endocrine activity. Furthermore, children's behavioral/emotional difficulties and competences were assessed in order to correlate psychological strain with sleep measures. PARTICIPANTS AND METHODS: Sixty-seven kindergarten children (35 boys and 32 girls) aged 5.34 underwent EEG-monitoring for one night. For baseline HPA-activity assessment, saliva samples were collected immediately after awakening, whereas saliva samples before, while and after a psychological challenge were used to assess the HPA-activity under stress conditions. RESULTS: Compared to girls, boys showed significantly more REM sleep time. After cluster analysis, children labeled as 'poor' sleepers (n=27; 40,30%) showed significantly increased morning cortisol values, as compared to 'good' sleepers (n=22; 32,83%). Furthermore, increased cortisol AUC values under stress conditions were significantly associated with an elevated number of awakenings after sleep onset, and more sleep time in stages 1 and 2. In addition, an increased sleep efficiency was significantly correlated with self-reported emotional/behavioral difficulties, i.e. with low degrees of impulsivity (r=-.31; p<.05) and lower degrees of social inhibition and peer victimiziation (r=-.26, p<.05). CONCLUSIONS: Our results underlined that already in preschool years, associations between objectively examined unfavorable sleep patterns, increased HPA-system activity and more difficult behavioral and psychosocial dimensions may be observed.

Associations between behavioral/emotional difficulties in kindergarten children and the quality of their peer relationships.

OBJECTIVE: The aim of this study was to investigate the associations between children's difficulties (conduct problems, hyperactivity/impulsivity, and emotional symptoms) and peer victimization and rejection in kindergarten. For the assessment of children's difficulties, the authors used a multi-informant approach. METHOD: A total of 153 five-year-old children were interviewed (Berkeley Puppet Interview). Teachers and parents completed the Strengths and Difficulties Questionnaire. Teachers reported on peer victimization. Peer nominations (rejection and acceptance) were conducted in a subgroup of 92 children. Combining teacher, parent, and self-reports of children's difficulties, three components were established: trait (degree of problems), informant differences resulting from perspective (self versus others), and context (kindergarten versus home). RESULTS: Children's difficulties were significantly associated with teacher- and self-reported victimization and peer rejection (r = 0.20-0.35), but not with peer acceptance. Conduct problems and emotional symptoms, but not hyperactivity/impulsivity, contributed independently to the variance of peer victimization and rejection. Perspective differences between children and adults according to hyperactivity/impulsivity also predicted peer rejection. CONCLUSION: Behavioral and emotional difficulties as well as a lack of self-awareness regarding hyperactive/impulsive behavior may place children at risk of peer victimization and rejection. Child psychiatric assessments and therapeutic strategies should thus take children's self-perception of symptoms and their peer relationships into account.

Implementing the K-SADS-PL as a standard diagnostic tool: Effects on clinical diagnoses.

Diagnostic interviews are valuable tools for generating reliable and valid psychiatric diagnoses. However, little is known about the diagnostic effects of implementing such an interview into the standard diagnostic procedure of a child psychiatric clinic. Therefore, we reviewed discharge diagnoses of psychiatric patients (age: 8-12 years; combined sample of inpatients and day hospital patients) over two intervals before and after implementing the semi-structured diagnostic interview K-SADS-PL as a diagnostic tool during intake. Each interval was a two year period spanning from 2009-2010 (pre sample; n=177) and from 2012-2013 (post sample; n=132). The number of diagnoses per patient and the co-morbidity rate increased significantly in the post sample. Furthermore, the percentage of children with a nonspecific diagnosis "other mixed disorders of conduct and emotions" (ICD-10: F92.8) decreased significantly after using the K-SADS-PL. Regarding the main diagnostic categories, a significant increase in the number of anxiety disorders and stress-related and somatoform disorders was found in the post sample. The results suggest that implementing a semi-structured interview into the daily routine of child psychiatry may have a substantial impact on discharge diagnoses. Practical implications are discussed and ideas for future research are given.

Maternal stress and internalizing symptoms in preschoolers: the moderating role of narrative coherence.

In the present study, we examined whether maternal psychosocial stress and children's coherence in story-stem narratives are associated with preschool children's internalizing symptoms and disorders, and whether narrative coherence moderates the association between maternal stress and children's internalizing symptoms and disorders. The sample consists of 236 preschool children (129 girls, 107 boys; Mage = 5.15 years) and their mothers. Mothers completed questionnaires on their psychosocial stress burden and on child symptoms. A diagnostic interview (the Preschool Age Psychiatric Assessment; Egger & Angold, 2004) was conducted with one of the parents to assess children's psychiatric diagnoses. Children completed 8 story stems of the MacArthur Story Stem Battery (Bretherton & Oppenheim, 2003). Story-stem narratives were coded for narrative coherence. Multivariate analyses were controlled for children's age, gender, verbal performance, and externalizing symptoms. Results showed that maternal psychosocial stress was significantly associated with child internalizing symptoms and disorders. Neither maternal stress nor children's internalizing symptoms or disorders were associated with narrative coherence. However, narrative coherence moderated the association between maternal stress and child internalizing symptoms. For children with more incoherent narratives, the association between maternal psychosocial stress and children's internalizing symptoms was significantly stronger than for children with more coherent narratives. The moderation effect of narrative coherence concerning children's internalizing disorders was found not to be significant. Our findings indicate that preschool children's cognitive-emotional organization in dealing with relational conflict themes seems to buffer their mental health when exposed to adverse circumstances in their everyday family life.

Does objectively assessed sleep at five years predict sleep and psychological functioning at 14 years? - Hmm, yes and no!

BACKGROUND: We tested the hypothesis that objectively assessed sleep at kindergarten level predicts sleep and psychological functioning in adolescence. METHOD: Thirty-seven adolescents aged 14 years (SD = 1.3), of 67 participants assessed as preschoolers, took part in a follow-up study nine years later. Participants completed a series of questionnaires related to sleep and psychological functioning. Sleep-EEG clusters of poor, normal and good sleepers assessed as children nine years earlier were used as predictors for subjective sleep and psychological functioning in adolescence. RESULTS: At the age of 14, those who were normal and good sleepers rather than poor sleepers at the age of five had more positive psychological functioning on dimensions including mental toughness, peer relationship, self-esteem, and perceived stress, but did not differ in current sleep patterns. CONCLUSIONS: Objectively assessed sleep patterns at the age of five are predictive of aspects of psychological functioning during adolescence.

The acceptance of the K-SADS-PL - potential predictors for the overall satisfaction of parents and interviewers.

The presented study investigated the interviewee (parents) and interviewer acceptance of the semi-structured diagnostic interview Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children Present Lifetime version (KSADS-PL; German version). Seventeen certified interviewers conducted 231 interviews (interviewers conducted several interviews; interviewees were only questioned once). Interviewees and interviewers anonymously rated their acceptance right after the interview was finished. The nested data structure was analysed regarding an individual interviewer bias and potential predictors of overall satisfaction. Therefore, factors improvable by interviewer training were included, as well as fixed factors which cannot be improved by professional training. The overall satisfaction was evaluated as highly positive with significant higher interviewee and interviewer ratings in the research as compared to the clinical recruitment setting. An individual bias of the interviewer on his or her own acceptance over time, but not on the evaluation of the corresponding interviewee was found. Neither the professional background nor the gender of the interviewer had a significant contribution in predicting these differences. The interviewer model showed no significant change over time and only the interview duration and the interviewee acceptance were significant predictors for interviewer overall satisfaction. Regarding the interviewee model, just the interviewer acceptance was a significant predictor. Copyright Copyright © 2015 John Wiley & Sons, Ltd.

The hyporeactivity of salivary cortisol at stress test (TSST-C) in children with internalizing or externalizing disorders is contrastively associated with α-amylase.

BACKGROUND: Stress biomarkers of the autonomic nervous system and hypothalamic-pituitary-adrenal axis (HPA-axis) can be measured via alpha-amylase (AA) and cortisol and cortisone in saliva. Objectives were to determine 1) the response patterns of cortisol, cortisone, and AA under both circadian conditions and the Trier Social Stress Test for Children (TSST-C), 2) which reactivity index is most suitable to differentiate internalizing or externalizing disorders from controls, and to explore 3) the interaction between AA and cortisol in the presence of internalizing or externalizing disorders. METHODS: Saliva samples (n = 2893) from children with internalizing (n = 55) or externalizing disorders (n = 33) and healthy children (n = 81) were analyzed for cortisol, cortisone, and AA under circadian conditions and TSST-C. RESULTS: Circadian rhythm of three biomarkers did not differ between diagnostic groups. Age and gender were significant predictors for cortisol and awakening time influenced all three biomarkers significantly. TSST-C responses appeared sequentially in the order of AA, cortisol, and cortisone. Trajectories of cortisol and cortisone responses, not in AA, were significantly lower in children with internalizing or externalizing disorders than in healthy children. Cortisol percentage increase appeared to be the most suitable reactivity index to detect the difference between the diagnostic groups. Internalizing disorders had a negative association between AA decrease and cortisol increase (ß = -.199, p < .05, R(2) = .304). Externalizing disorders had a positive association between AA baseline and cortisol increase (ß = .229, p < .05, R(2) = .304). CONCLUSION: An altered HPA-axis response during stress might result from chronic allostatic load in internalizing disorders and underaroused stress response system in externalizing disorders.