Running Head: PEER EXPERIENCES IN ADOLESCENTS

Peer Experiences in Adolescents on Inpatient Psychiatric Units

Jamie L. Shope
Halley Estridge
Isabella Ramsay
Esther Suess
Ryan Adams
Cincinnati Childrens Hospital

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Psychiatric symptoms, especially internalizing and externalizing symptoms, have

concurrent and predictive associations with adolescent peer problems, especially peer
victimization. There are numerous studies that show that symptoms of internalizing and
externalizing problems are associated with peer analysis (Reijntjes et al. 2010 &2011). Even
though there are many studies that have shown such associations between peer issues and
symptoms of internalizing and externalizing problems, there is very little research on adolescents
who actually exceed clinical thresholds for these problems in terms of peer experiences. The
goal of the current study is to describe peer experiences that are reported by adolescents in an
inpatient psychiatric unit using information recorded in their charts during a three day visit with
a special focus on those diagnosed with internalizing and externalizing problems.
Health professionals have few supports and empirically guided recommendations for
addressing peer problems in adolescents exceeding clinical thresholds for psychiatric symptoms.
This is due to little information on the details of peer issues in this group that might inform such
interventions. Successful interventions around such issues require details around identifying the
specific types of peer issues that are faced by this specific group. In one study, patients in an
inpatient psychiatric unit were questioned and it was found that 16.7% of the sample reported
that they did not have a close friend, (Prinstein et al. 2000). The absence of a close friend in
adolescents can cause loneliness and a feeling of isolation. Additionally, studies have shown that
individuals who remember being victimized at school had an increased chance of being
diagnosed with depression in adulthood (Zwierzynska et al. 2013). Once more information is
known about the peer problems that these groups face then supports can be created that target the
unique experiences and characteristics of these specific groups.
Positive peer experiences have also been linked in past research to mental health
illnesses. Seemingly universal in the recovery of concept is the notion that critical to ones

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recovery is a person or persons in whom one can trust to be there in times of need, (Anthony
1993). An easy correlation can be assumed between the increase in social support and the
increase in coping mechanisms in patients with a mental illness, but research has been found that
could negate this hypothesis. Social supports could reinforce dependence amongst adolescence
with a mental illness and disable their autonomy. Additionally, studies have shown that stress can
be contagious for women. Womens propensity for intimate social involvements may
predispose them to the contagion of stress when stressful life events afflict those to whom they
feel emotionally close, (Kawachi and Berkman 2001). Women could use their positive peer
relationships as a buffer for their own stress, or they could take on the stress of those in which
they are close to. While it is unclear the extent to which positive peer relationships could decline
the mental health of a person, research has proven that there are positive effects of positive peer
relationships. Positive peer relationships could be used as a support to recover from a mental
illness. Research has demonstrated that these supportive relationships help to contribute to the
positive adjustment and to buffer against stressors and adversities, including medical as well as
psychiatric problems (Solomon 2004). Researchers have found both the positive and negative
correlations between positive peer relationships and mental illness, but more research needs to be
done to investigate the extent to which adolescents with a mental illness interact positively with
their peers. This future research could benefit the production of an intervention to rehabilitate
patients in a psychiatric unit. The current study examines two such global psychiatric groups,
individuals with clinical diagnoses of internalizing problems and those with clinical diagnoses of
externalizing problems.
Individuals in psychiatric in-patient units are not homogeneous. While there are many
groups that can be identified in these units, two classes of symptoms have long been studied in

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terms of peer problems: internalizing and externalizing problems. Reijntjes et al. (2010) found in
their meta-analysis that there is a significant predictive relationship from peer victimization to
internalizing problems in children over time, as well as a significant relationship from
internalizing problems to peer victimization over time. In other words, children who are often
the target of victimization can result in internalizing their problems; becoming lonely, depressed,
and avoidant and these same internalizing symptoms also puts individuals at risk for being
victimized.

In a follow-up meta-analysis by Reijntjes et al., conclusions were also drawn about

peer victimization in children and externalizing behaviors (2011). This study also found
significant predictive effects from peer victimization to externalizing problems over time and
externalizing problems predicting peer victimization in adolescents over time. The results of this
study could conclude that children who exhibit externalizing behaviors such as aggression and
disruption, can irritate other children and provoke bullying, as well as bullying causing these
same symptoms. These studies exhibit a continuous cycle between children who are victimized
by their peers and exhibit internalizing and externalizing behaviors. While there are many
studies that have found associations between these two types of symptoms, relatively few have
examined those who have met thresholds for clinical diagnosis and none have examined this
distinction in those admitted to psychiatric inpatient units.
In 2001, Nansel et al. found that 30% of students in 6th through 10th grades reported being
involved in moderate or frequent victimization activities, as perpetrator, victim, or both. Three
out of every ten students in their adolescence reported being involved in peer problems, but when
studying adolescents who meet clinical thresholds for psychiatric symptoms the frequency
increases. Approximately 72% of adolescents admitted to the inpatient unit at Oulu University
Hospital from April 2001 and March 2006 reported to have been involved in bullying as the

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perpetrator, victim, or both (Luukkonen et al. 2010). It is twice as likely for adolescent
inpatients to be involved in bullying than for the average adolescent.
To provide crucial information needed to provide specific supports for peer problems for
those in psychiatric inpatient units the current study utilized clinical notes from adolescents
admitted into such a unit at a childrens hospital. Using these clinical notes from health care
providers based on their encounters with individual adolescents during their stay we answered a
series of questions:
1. Do these individuals report peer problems in general and peer victimization specifically?
2. Who is reported as the source of their peer problems and peer victimization?
3. For those that report peer problems and those that report peer victimization, are these issues
central to their reasons for admission or to their immediate circumstances?
For each of these questions, we examined the general group admitted to the unit and also
separately for those inpatients diagnosed with internalizing problems and for those with
externalizing problems at admission to the unit.
Method
This study was a retrospective chart review of the patients in an inpatient psychiatric clinic at
Cincinnati Childrens Hospital. By looking at their charts we examined clinical diagnosis
provided by clinicians as well as descriptions of peer issues in the clinical notes.
Patients
In this study 199 patient charts were examined. These patients were adolescents ranging
from 12.17-16.97 years old (M= 14.81, SD= 1.3) and 64.8% (n=129) of the population being
female. Of these adolescents, 25.1% (n= 50) of them labeled themselves as African American,
66.3% (n= 131) white, and 8.6% (n= 17) were other/multiple ethnicities. Across all ethnicities,
2.0% (n= 4) labeled themselves to be Hispanic. The percent of these adolescents considered to
be obese according to their BMI score as calculated when they were admitted was 20.6% (n= 41)
and 7% (n = 14) had attempted suicide.
Procedures

PEER VICTIMIZATION IN ADOLESCENTS

For this study we examined charts of adolescents in the in-patient psychiatric units at
Cincinnati Childrens Hospital Medical Center (CCHMC). We also extracted the chart data from
CCHMCs electronic health record system (EPIC) and by querying EPIC for patients between
the ages of 12 and 17 admitted through CCHMCs Emergency Department from January 1st,
2014 to June 30th, 2014 to one of four in-patient psychiatric units at CCHMC. This resulted in
chart data for 894 patients. Due to issues with resources around time and cost, only the first 201
individual charts were examined for this study. It should be mentioned that individuals admitted
to the Emergency Department with Psychiatric issues but first were in need of medical treatment
(e.g. overdose or physical wounds) and, thus, admitted first to a non-psychiatric unit were not a
part of this study. The focus of their treatment at this admission was on medical concerns and
therefore not comparable to the psychiatric notes described below who were admitted directly to
the psychiatric unit.
All information about peer issues were extracted from patient charts recorded during each
patients admission. For uniformity, the research team coded information from six sets of notes:
the subjects Psychiatric Intake Response Center (PIRC) assessment, the first two Registered
Nurses notes, the Occupational Therapists notes, the Speech Therapists notes, the Psychiatric
Intake Assessment Form, and the Psychiatry Initial Assessment. The PIRC Assessment, the
Occupational Therapists note, the Speech Therapists note, the Psychiatric Intake Assessment
Form, and the Psychiatry Initial Assessment only took place on one occasion during the patients
admission. Registered Nurses notes were taken more than once but for uniformity only the first
two notes were analyzed. After examining the data available for each patient, chart data for two
individuals were not complete, thus data analyses was completed on 199 individual charts.
Along with all chart information, demographic information (gender, race Hispanic (Y/N),
and year of birth), admission date and place, as well as the three ICD-9 diagnostic codes given at

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admission were recorded from EPIC. A Waiver of Informed Consent was acquired from the
human subject internal review board since we were working with already existing medical
records and the research involved no more than minimal risk to the patients.
Coding
All notes from all charts for each patient were coded for descriptions of general peer
problems, bullying, if the problems played a role in being admitted, who the problem was with,
and if there were mention of positive peer experiences. The first 40 individual set of charts were
divided equally between two teams with each team comprised of a principal investigator and one
research assistant. After both individuals on each team coded the first 20 charts, inter-rater
reliabilities were tested for each variable (Kappas ranged from .85 to .91) finding acceptable
reliability. In those instances where there were disagreements in the codes both coders reviewed
their rational for coding and resolved the discrepancy. Next, another 14 charts were coded for
each team and it was found that there was complete agreement on coding. Then, the remaining
charts were divided between the two research assistants to code on their own.
Measures
For each variable listed below, coders reviewed all information across all the charts for each
patient.
Peer experience. Two types of peer experiences were coded, general negative peer
experience and peer victimization. General peer problems would be coded as occurring
(occurring = 1 and not mentioned = 0) if there was specific mention of a negative experience of
with any peer (i.e. friend, girl/boy-friend, other peers, and any combination of individuals) across
all notes. This could include peer victimization, fighting, mention of not getting along with
others, etc. Peer victimization was coded as occurring (occurring = 1 and not mentioned = 0)
when there was any mention of peer victimization across all notes. Peer victimization would be
coded as occurring if there was specific mention of the word bullying or if any experience that fit

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the definition of peer victimization (i.e. the intent of others to harm them) in terms of physical,
verbal, relational, or cyber peer victimization. It should be mentioned that the speech therapist
assessment called for asking a specific question about the patients experiences of peer
victimization but a review of the notes indicated that this question might not have always been
asked. To clarify, any note coded as mentioning peer victimization would automatically also be
coded as general peer problems occurring.
Details of Experiences. For both general negative peer experiences and peer victimization,
additional details were coded when each experience was coded as occurring. First for each type
of experience, we wanted to know if the experience (negative peer experience or peer
victimization) was explained, mentioned, or a focus of the narrative around explaining the
rationale for the patient being admitted in the in-patient unit (reason for admittance, yes = 1 and
no = 0). This would be the case if in the notes if the description of their life leading up to or
narrative around being admitted focused on the experiences role in this process or action for
being admitted or specifically mentioned it as a trigger for admittance. Also, for the experience
to be coded as a reason for admittance, it had to mention across more than one set of notes.
Additionally, for each type of experience, we also coded for who was mentioned as
causing/playing a role in the experiences. In other words, who was the peer involved in the
negative experience. This was coded as friend (1), romantic partner (2), larger peer group (3), or
combination of individuals (4).
Positive peer experiences were also examined. Positive peer experiences were recorded
when the notes indicated that they had a friend, got along with their peers/classmates, or
mentioned a specific positive peer experiences. For this variable it was noted who this positive
peer was (peers in general, a friend, or both) and the details that the patient had used to describe

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this occurrence. If the subject did not mention a positive peer within their charts then the
research team would record No Mention.
Diagnosis categories. Two variables were created to classify patients into diagnosis
categories: internalizing and externalizing diagnoses. For each variable, an individual was
coded as having that diagnosis if any of their three ICD-9 diagnosis codes indicated any specific
diagnosis (e.g. major depressive disorder) that fit into the larger category (e.g. internalizing
problem). See Appendix for all ICD-9 code diagnoses that were coded as internalizing and
externalizing diagnoses. This resulted 63.3% (n =126) of the participants having an internalizing
diagnosis and 28.6% (n= 57) had an externalizing diagnosis. Only 16 individuals did not have a
diagnosis of either internalizing or externalizing. It also should be mentioned that no individual
that had an internalizing diagnosis also had an externalizing diagnosis.
Results
Overall, 65.8% (n= 131) of the population reported having at least one peer problem and
27.6% (n= 55) noted experiences of peer victimization. Interestingly, 61.8% (n= 123) noted at
least one positive peer experience.
Internalizing Diagnoses (n = 126)
Peer Issues. As shown in Table 1, patients who had an internalizing diagnoses reported to
have experienced more peer problems (70.6% (n= 89)) than those without an internalizing
diagnoses (57.5% (n= 42)). Of these patients with internalizing problems who reported having
peer problems (n = 89), 50.6% (n= 45), which was not significantly different (2 = 1.27, p ns)
from those who did not report it as a trigger (49.4% (n= 44)).
Peer victimization. Within our population, 34.1% (n= 43) of patients who were admitted
to CCHMC with an internalizing diagnoses admitted to have experienced peer victimization
before, while 16.4% (n=12) of the patients who did not have internalizing diagnoses admitted to
have experienced peer victimization before. From these results we can conclude that patients

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who are admitted to an adolescent in-patient unit for an internalizing diagnose are significantly
more likely to report peer victimization than patients without an internalizing diagnoses. A chisquared analysis was conducted in order to determine if the frequency of children with
internalizing diagnoses and who admitted to being bullied before had a significantly higher
frequency of admitting that the peer victimization experience was their trigger for admission.
Patients with internalizing diagnoses who have peer victimization reporting trigger (62.8% (n=
27)), patients with no internalizing diagnosis who have peer victimization reporting trigger
(37.2% (n= 16)), the chi-square is 7.23 p<.005. From our analyses we were able to conclude that
there is a significant relationship between the number of patients with internalizing diagnoses
that report peer victimization and the frequency that they label the peer victimization as a reason
for their admission.
Positive Peers. As seen in Table 1, most of the patients (61.9% (n= 78)) with an
internalizing diagnosis mentioned at least one positive peer experience in their life but this was
not significantly different than those without an internalizing diagnosis (61.6% (n= 45)).
Externalizing Diagnosis
Peer Issues. Upon admission, 40.4% (n= 23) of the patients who had an externalizing
diagnosis admitted to having peer issues, and 59.6% (n= 34) of the patients with an externalizing
diagnoses claimed that they did not have peer issues. From this data we were able to conclude
that there was no significant difference in the amount of patients with externalizing diagnoses
who are having peer issues and those were not, but it is significant to note that the majority of
these patients are having peer issues. Patients with externalizing diagnosis who have peer issues
reporting trigger (23.5% (n = 23)), patients with no externalizing diagnosis who have peer issues
reporting trigger (49.5% (n = 48)), the chi-square is 7.02 p< .05. From this data we were able to
conclude that there is a significant correlation between the kids with external diagnosis that

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report peer problems and the frequency with which they report these peer problems to be the
trigger for their current admission.
Peer victimization. Of our sampled population of patients with externalizing diagnoses,
15.8% (n=9) admitted to have been bullied recently and 84.2% (n= 48) of the patients with an
externalizing diagnoses did not admit that they had been bullied lately. From this data we were
able to conclude that of the patients with an externalizing diagnosis, there was significantly less
amount of people who admitted to being bullied in the recent past than people who did not admit
to being bullied in the recent past. Patients with externalizing diagnosis who have peer
victimization experiences reporting trigger (44.4% (n = 4)), patients without externalizing
diagnosis who have peer victimization experiences reporting it as a trigger (60.9% (n=28)), the
chi-square is 4.31 p ns. This data concludes that there is not a significant difference between the
patients with an externalizing diagnoses reporting their victimization as a trigger and reporting it
as not their trigger for admission.
Positive Peers. As seen in Table 2, patients (40.4% (n= 23)) with an externalizing
diagnosis admitted to having at least one positive peer in their life, consequently there is not a
significant difference between the percent of patients with an externalizing diagnosis who
reported to have a positive peer than the patients with externalizing diagnoses and reported to not
have a positive peer (62.7 (n=89)).
Discussion
This study is among the first to investigate peer victimization among adolescents who
have reached the clinical threshold for internalizing and externalizing diagnoses. We investigated
patients within a psychiatric in-patient unit and conducted analyses to test the correlation
coefficient between this population and their reported peer problems, peer victimization, and
positive peers, as well as to see if these topics were the trigger to their current admission.

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Over half of our total population reported some sort of negative peer experiences,
whether it be actual peer victimization or just a negative peer experience. Half of this group of
patients reported having a positive peer experience, despite the hardships that they were facing at
their time of admission. A large amount of patients described at least one friend whom they felt
they could confide in. Additionally, a quarter of our population reported to have had peer
victimization experiences in the recent past.
By looking at the data that was previously recorded in their patient charts, we were able
to find differences in peer experience for different types of diagnoses. We found that patients
with an internalizing diagnosis had more negative peer experiences and bullying experiences
than the rest of our population, and more patients than not in this population had a positive peer
experience. This finding supports the meta-analysis results of Reijntjes et al.s study in 2010 in
which they found significant results between peer victimization and internalizing problems in
adolescents. Additionally, we found that peer victimization was more often a particular focus or
trigger for being admitted to the unit for those patients diagnosed with internalizing problems
than those who did not have an internalizing problem. These findings suggest that patients with
an internalizing diagnosis are more often being targeted and harassed by their peers. Future
studies could develop around the type of peer interactions that these patients would categorize as
peer victimization. Research on uncovering the types of peer victimization that is happening to
this population as well as what characteristics that might make them more vulnerable to other
peers could be useful to develop future interventions on victimization prevention. Future
research could create tools against bullying that this population could benefit from, such as
focusing on their friends and their positive peer experiences rather than the negative peer

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experiences. Healthy friendship skills exercises could be useful to this population to help them
build peer experiences into positive experiences.
Patients with externalizing diagnoses did not have a greater number of peer and
victimization problems than the rest of the population, but half of this population did report to
have had some sort of peer problem. This conclusion could inspire future research on possible
interventions around the ways in which these adolescents with externalizing diagnosis work with
other peers, specifically on their ability to not react to perceived provocation. Future research
needs to be targeted at the specific types of peer problems that these patients are having,
considering this population does not report as much peer victimization as peer problems.
Interventions could be developed to target this populations peer interactions to help them better
communicate and interact with their peers to prevent future admissions.
From this data we hope to target prospective research upon this population to gain a
better understanding of the peer experiences that happen within this group. From our previous
research we can conclude that researchers have already found links and cycles between
adolescents who internalize their problems and their repeated victimization, as well as between
adolescents who externalize their problems and their repeated victimization. With adolescents
who have exceeded clinical thresholds for mental health problems, it is easy to assume how these
problems could escalate in an already unstable situation.
While this study does have significant findings, it is a retrospective chart review and
more data could be found from asking the patients direct questions regarding peer victimization
and peer experiences. The data for this analysis was taken from charts whose focus was on other
objectives besides the patients peer experiences, our measurement may be compromised by the
fact that these charts do not share the same focus as our research does. These charts are recording
the current and salient experiences of the patients instead of their peer experiences exclusively.

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The data indicates correlations between experiences in general and the patients diagnoses, but
because of the lack of details in the patients reports there could not be any further interpretation
between the correlation and the causation. The limitations of this study limit us from concluding
a direction of these effects, but it is most likely bi-directional. Patients with internalizing
diagnosis are having more negative peer experiences because of their diagnosis and their
negative peer experiences are creating more severe internalizing symptoms. The case would be
the same with patients with an externalizing diagnosis.
Additionally, it is helpful to keep in mind while reading this data that these results
exclude patients who had severely harmed themselves and needed immediate medical attention
before their psych admission. Excluding the population of patients who had severely injured
themselves in an attempt at suicide diverts the data to look at patients with a less severe case, and
likely less severe peer experiences. Similarly, keep in mind issues of generalization. These
results should not be generalized to a larger population of adolescents; this data was taken from a
sub-clinical population of kids with extreme cases and should not be generalized to include all
adolescents. These results could not be interpreted to find out the specifics of the patients peer
experiences; again this is a retrospective chart review and not a designed survey in which the
study could have asked direct questions that were focused on the patients peer experiences and
the part that the experiences played in the patients admission. These results could only say at
most that there is a peer victimization problem and the particulars of the patients background
with peer experiences prior to the admission was not always a focus of the patients treatment.
Future research on this topic and a deeper look into the specifics of the victimization
could help develop interventions to target these situations and prevent further victimization. This
is a very unstable population and previous research has shown the correlations between peer
victimization in adolescents leading to mental heal problems into adulthood. If interventions

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could be created that focus on the termination of peer victimization then fewer children would be
admitted into psychiatric in-patient units during their adolescents and possibly in their adulthood.
This study was a retrospective chart review in which we analyzed and coded for peer
problems, peer victimization, and positive peer experiences. By analyzing our findings we found
noteworthy results with the amount of positive peers reported overall in the population, the
amount of patients with internalizing diagnoses who also had peer victimization experiences and
peer problems in general, as well as the amount of patients with externalizing diagnoses and peer
victimization experiences. From these analyses we hope to direct future research towards this
population and eventually research could design an intervention to decrease the amount of peer
victimization and peer issues that this group experiences.

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References
Anthony, W. (1993). Recovery from mental Illness: The Guiding Vision of the Mental Health
Service System in the 1990s. Psychosocial Rehabilitation Journal, 16(4), 11-23.
Hawker, D. S., & Boulton, M. J. (2000). Twenty years' research on peer victimization and
psychosocial maladjustment: a metaanalytic review of crosssectional studies. Journal
of child psychology and psychiatry, 41(4), 441-455.
Kawachi, I., Berkman, L.F. (2001). Social Ties and Mental Health. Journal of Urban Health:
Bulletin of the New York Academy of Medicine, 48(3), 458-467.
Kokkinos, C. M., & Panayiotou, G. (2004). Predicting bullying and victimization among early
adolescents: Associations with disruptive behavior disorders. Aggressive Behavior, 30(6),
520-533.
Luukkonen, A-H., Rsnen, P., Hakko, H., Riala, K. (2010). Bullying behavior in relation to
psychiatric disorders and physical health among adolescents: A clinical cohort of 508
underage inpatient adolescents in Northern Finland. Psychiatry Research, 178, 166-170.
Nansel, T.R., Overpeck, M., Pilla, R.S., Raun, W., Simons-Morton, B., & Scheidt,P. (2001).
Bullying behaviors among us youth: Prevalence and association with psychological
adjustment. JAMA, 285(16), 2094-2100.
Prinstein, M.J., Boergers, J., Spirito, A., Little, T.D., & Grapentine, W.L. (2000) Peer
Functioning, Family Dysfunction, and Psychological Symptoms in a Risk Factor Model
for Adolescents Inpatients Suicidal Ideation Severity. Journal of Clinical Child
Psychology, 29(3), 392-405.
Reijntjes, A., Kamphuis, J.H., Prinzie, P., M., & Telch, M.J. (2010) Peer Victimization and
internalizing problems in children: A meta-analysis of longitudinal studies. Child Abuse
& Neglect, 34, 244-252.
Reijntjes, A., Kamphuis, J.H., Prinzie, P., Boelen, P. A., van der Schoot, M., & Telch, M.J.
(2011). Prospective Linkages Between Peer Victimization and Externalizing Problems in
Children: A Meta-Analysis. Aggressive Behavior, 37, 215-222.

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Solomon, P. (2004). Peer Support/Peer Provided Services Underlying Processes, Benefits, And
Critical Ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401.
Zwierzynska, K., Wolke, D., & Lereya, T.S. (2014). Peer Victimization in Childhood and
Internalizing Problems in Adolescence: A Prospective Longitudinal Study. Journal of
Abnormal Child Psychology, 41(2), 309-323.

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Table 1
Patients peer experiences with an internalizing diagnosis
Internalizing Diagnosis
Yes (n=126)
Any Peer Problems
Peer victimization
Positive Peers
Note. +p<.1 *p<.05

70.6% (n= 89)

34.1% (n= 43)
61.9% (n= 78)
**p<.01 ***p<.001

No (n=73)
57.5% (n= 42)
16.4% (n= 12)
61.6% (n= 45)

3.53*
7.23**
0.00

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Table 2
Patients peer experiences with an externalizing diagnosis
Externalizing Diagnosis
Yes (n=57)
Any Peer Problems
Peer victimization
Positive Peers
Note. +p<.1 *p<.05

59.6% (n= 34)

15.8% (n= 9)
59.6% (n= 34)
**p<.01 ***p<.001

No (n= 142)
68.3% (n= 97)
32.4% (n= 46)
62.7% (n= 89)

1.36
2.90*
0.15

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Appendix
The externalizing diagnoses that our population had been previously diagnosed with are
as follows: ADHD (attention deficit hyperactivity disorder); adjustment disorder with mixed
disturbance of emotions and conduct; aggression; aggressive behavior; behavioral problems;
conduct disorder; conduct disorder, adolescent onset type; homicidal ideation; impulse control
disorder; intermittent explosive disorder; ODD (oppositional defiant disorder); and reactive
attachment disorder.
The list of Internalizing Diagnoses are as follows: Bipolar 1 disorder, mixed, moderate;
bipolar affective disorder; bipolar disorder; bipolar disorder, current episode depressed, severe,
with psychotic features; bipolar disorder, current episode manic severe -with psychotic features;
bipolar disorder, mixed; bipolar disorder, unspecified; bipolar I disorder, most recent episode (or
current) mixed, unspecified; bipolar I disorder, most recent episode (or current) unspecified;
depression; depression with suicidal ideation; depression, recurrent; depressive disorder;
depressive disorder, not elsewhere classified; disruptive mood dysregulation disorder; major
depression; major depressive disorder; major depressive disorder, recurrent; major depressive
disorder, recurrent episode; major depressive disorder, recurrent episode, severe; major
depressive disorder, recurrent episode, severe degree, without mention of psychotic behavior;
major depressive disorder, recurrent episode, severe, specified as with psychotic behavior; major
depressive disorder, recurrent episode, unspecified; major depressive disorder, recurrent episode,
with atypical features; major depressive disorder, recurrent severe without psychotic features;
major depressive disorder, single episode; major depressive disorder, single episode, severe;
major depressive disorder, single episode, severe degree, without mention of psychotic behavior;
major depressive disorder, single episode, severe without psychotic features; major depressive

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disorder, single episode, severe, with psychosis; major depressive disorder, single episode,
severe, without mention of psychotic behavior; major depressive disorder, single episode,
unspecified; mood disorder; severe bipolar affective disorder with psychosis; severe major
depression; severe major depression with psychotic features; severe major depression, single
episode, with psychotic features, mood-incongruent; severe major depression, single episode,
without psychotic features; and severe recurrent major depression with psychotic features.