J Child Fam Stud (2008) 17:779–790

DOI 10.1007/s10826-008-9189-y

ORIGINAL PAPER

A Prevalence Study on Internalizing Problems Among

Primary School Children in Hong Kong

Angela F. Y. Siu

Published online: 23 January 2008

Ó Springer Science+Business Media, LLC 2008

Abstract Studies in Hong Kong indicated that there is a tendency for young
children to use internalizing as a means to cope with their daily difficulties. Mother–
child relationship has been seen as a factor affecting a child’s adaptive coping skills.
In this study, we explored the prevalence of internalizing problems among primary
school children in Hong Kong, as well as the mother–child relationship that con-
tribute to children’s internalizing problems. Data used to assess the internalizing
behavior among 1598 primary school children were collected from their mothers.
The estimated prevalence of internalizing problem was 11.4%. This prevalence was
based on the cutoff point for internalizing disorders according to the Child Behavior
Checklist (CBCL). The CBCL internalizing score was significantly correlated with
mother–child relationship as measured using the Parent–Child Relationship Ques-
tionnaire (PCRQ). Results from the PCRQ indicated that children’s internalizing
problems were positively correlated with mother’s use of verbal punishment and
rejection as well as their possessiveness and protection on their children. On the
other hand, a nurturing and intimate relationship between mother and child was an
important factor contributing to the development of mentally healthy children.
Implications of this study and suggestions for further research were discussed.

Keywords Prevalence
Internalizing problems
Child Behavior Checklist

Parent–Child Relationship Questionnaire
Young children

A. F. Y. Siu (&)
Department of Educational Psychology, The Chinese University of Hong Kong, Shatin,
New Territories, Hong Kong
e-mail: afysiu@cuhk.edu.hk

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Introduction

Children’s internalizing behavioral problem is directed towards the individual and

represented an over-controlled and inner-directed pattern of behaviors (Compton
et al. 2002). Examples of these behaviors include depression and anxiety. Compared
to externalizing behavior problems, internalizing behavior problems are not
identified as frequent because of their covert and non-intrusive nature. Often,
internalizing behavior problems go unnoticed (Kauffman 2001). Furthermore, these
internalizing problems may intensify over time and are likely to develop into
psychiatric conditions (Kendall and Chu 2000; Lewinsohn et al. 1998). For
example, internalizing problems in childhood may play a causal role in the
development of depressive disorders and anxiety disorders (e.g., Seligman and
Ollendick 1998), conduct disorders as well as substance use disorders (e.g., Cheng
and Myers 2005). Failure to intervene early with effective treatments may render the
child vulnerable to impairments in a wide range of functioning and result in
deleterious effects on the person’s long-term emotional development (Costello et al.
2002; Lewinsohn et al. 2000).
Prevalence rate from epidemiologic studies of specific internalizing problems in
children has been increasing. For example, anxiety disorders affected 8.8% in
normal samples in the late eighties (Costello 1989) to about 13% of normal children
in the mid-nineties (Costello et al. 1996). In childhood, 2–10% of children under
12 years of age experience a clinical anxiety or depression, with these rates
increasing to between 15% and 20% in adolescence (e.g., Zubrick et al. 1997).
Lewinsohn and Clarke (1999) further indicated that the prevalence rate of
depressive disorder in children and adolescents was 28%. In fact, depression was
currently at the top of the cause of non-fatal disability (Mathers et al. 2000). As
noted by Murray and Lopez (1996), the burden of mental illnesses has been
seriously underestimated by traditional approaches that took account only of deaths
and not disability. While psychiatric conditions were responsible for around one
percent of deaths, they account for almost 11% of disease burden worldwide. When
projecting the burden of disease for the year 2020, depression would be the second
most common cause of disability globally.
The prevalence of internalizing problems among young children in Hong Kong
was also of concern to both local researchers and clinicians. In a study of the
prevalence of child psychiatric morbidity in the primary school population, Luk
et al. (1988) examined a sample of 899 children (6–12 years old) from all primary
schools in Hong Kong. It was reported that 6.3% of these children was regarded by
teachers as in need of psychiatric help on emotional problems. The authors
concluded that this was probably a conservative estimate of the prevalence. In
another study, Wong and Lau (1992) examined psychiatric morbidity in a sample of
718 children (aged 6–8) and found that there was an overall prevalence rate for
emotional disorder at 8.8%. Wong and Tsoi (1999) also pointed out that there were
about 10–16% of children in regular school suffering from emotional and behavioral
problems. Liu et al. (1999), in a study investigating prevalence of parent-reported
behavioral problems among Chinese children aged 6–11 in Mainland China,
reported that Somatic Complaints and Internalizing scores obtained from the

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Chinese version of the Child Behavior Checklist (CBCL, Achenbach and Edelbrock
1983; Li et al. 1989), appeared to have increased with age. In a recent study
comparing the behavior and emotional problems of children in Hong Kong and
Chengdu (Guo et al. 2000), children in Hong Kong scored higher than those in
Chengdu in ‘‘Anxious/Depressed’’—one of the subscale scores obtained from the
CBCL. This further indicated that internalizing problems among primary school
children in Hong Kong warranted attention.
Family factors have been seen as highly relevant in the development and
maintenance of children’s internalizing problems such as anxiety, withdrawal,
loneliness, and depression (LaFreniere and Dumas 1992). One key family factor is
the relationship between mother and child. Children with internalizing problems
may have parental interaction characterized by insufficient parental praise and
reinforcement. Depressed parents tend to reward their children less, and are more
emotionally restricted, slower to respond and less consistent in their responses
(Downey and Coyne 1990). Chronic exposure to punishment, unrewarding,
unpleasant, or socially impoverished conditions contribute to the development of
internalizing problems by fostering feeling of helplessness and hopelessness,
negative thoughts and low self esteem.
Recent studies (e.g., McIntrye and Dusek 1995; Steele et al. 1997) suggested that
quality of mother–child interaction enhance children’s ability to be self-regulated
and to use adaptive coping skills. McIntrye et al. demonstrated that children who
perceived their parents as warm, supportive and firm reported higher levels of
problem-focused coping and low levels of emotion-focused coping. The pattern of
findings of these studies suggested that parental interaction plays a role in children’s
capacity to engage in self-regulated behavior through their parenting and their
affective relationships with their children (Steele et al. 1999). Barrett et al. (1996)
showed that anxious children, aged 7–14, increased the likelihood of reporting
avoidant coping responses to a hypothetical situation of ambiguous threat following
a discussion of the situation with their parents. Further analyses of the family
discussion revealed that parents of anxious children encouraged avoidant respond-
ing (Dadds et al. 1996; Rapee et al. 2000). In another study, Mills and Rubin (1998)
noted that mothers of children (aged 5–9) who have internalizing problems directed
significantly more behavior control statements to their children when compared to
mothers with normal children. Further, mothers of anxious-withdrawn children used
more psychological control statements that were defined as devaluation statements
of non-responsiveness to the child. These parenting practices might also be
accompanied by expressions of criticism and disapproval. Such negativity may
attack the child’s sense of self-worth.
As cultural values played an enormous role in determining the meanings of
behavioral adaptation, and that behavioral inhibition (such as shyness and
withdrawn) were positively evaluated in the Chinese culture (e.g., Chen et al.
1995), it might be worthwhile to look into the characteristics of the association
between mother and child relationship and children’s internalizing problems.
Furman and Giberson (1995) as well as Furman and Buhrmester (2001) talked about
the five characteristics of mother–child relationship, namely: Warmth (affection,
admiration of parent, admiration by parent), Disciplinary Warmth (praise, shared

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decision making), Personal Relationship (companionship, nurturance, intimacy),

Power Assertion (quarrelling, dominance, deprivation of privilege), and Posses-
siveness (protectiveness and possessiveness).
Given the impact of internalizing problems among young children as well as the
potential causes on mother–child relationship as described above, the present study
was to explore the prevalence and its characteristics of internalizing problems
among Hong Kong primary school children. Specifically, the objectives of this
study were: (i) to estimate the prevalence for mother-reported internalizing
problems among Hong Kong primary school; and (ii) to explore the association
between children’s internalizing problems and mother-child relationship. It was
hypothesized that factors like ‘‘warmth’’, ‘‘disciplinary warmth’’, and ‘‘personal
relationship’’ for mother–child relationship were negatively correlated with
children’s level of internalizing problems whereas factors like ‘‘power assertion’’
and ‘‘possessiveness’’ were positively correlated with children’s level of internal-
izing problems.

Method

Participants

Two thousand and two hundred questionnaires were distributed to mothers of the
target children group. For mothers with more than one child eligible for
participation in this study, they were asked to identify one of their children as the
target child when filling in the questionnaire. Some mothers refused to participate
for various reasons or returned incomplete questionnaires. Usable data from 1,598
mothers were analyzed. The overall return rate was 73%. Among these mothers,
24% had tertiary education, 67% completed secondary school education, and 9%
completed primary school education. In this sample, there were 528 children in
Grade 2 (280 boys and 248 girls), 602 in Grade 3 (260 boys and 342 girls) and 468
in Grade 4 (235 boys and 233 girls). There were a total of 775 boys and 823 girls.
The percentage of boys versus girls was 48 and 52 respectively. Their age ranged
from 7.1 years old to 11.6 years old (M = 8.71, SD = 1.60).

Measures

Child Behavior Checklist (CBCL)

CBCL (Achenbach 1991) was the most commonly used and best-validated
behavioral rating scale (Achenbach and Edelbrock 1983; Lochman and Dodge
1998; Leung and Wong 2003). It was designed to quantify a broad range of clinical
relevant behavioral and emotional problems. The CBCL was translated into
Chinese, with reported satisfactory to excellent reliability. There was an internal
consistency of 0.89 on Total Problems in a Mainland Chinese sample (Liu et al.
1999), and 0.72–0.90 on various subscales in a Taiwanese sample (Yan et al. 2000).

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The Chinese CBCL was also adopted for use in Hong Kong, with local norms
established (Leung et al. 1998).
The CBCL contained 113 items related to child functioning and problem
behaviors in a variety of contexts. Parents indicated the degree or frequency of each
behavior described in the item on a scale of 0 (not true), 1 (somewhat or sometimes
true) or 2 (very true or often true). By summing 1 s and 2 s on all items, a total score
on problem behaviour was created. Achenbach’s original Principal Component
Analyses (Achenbach 1991) of the individual items from a normative sample
yielded eight narrowband syndromes. These were: Withdrawn, Somatic Complaints,
Anxious/Depressed, Thought Problems, Social Problems, Attention Problems,
Delinquent Behavior, and Aggressive Behavior. On the basis of a second order
factor analysis, two broadband syndromes were formed. Symptoms on Withdrawn,
Somatic Complaints, Anxious/Depressed were combined to form a composite score
on Internalizing, while symptoms on Delinquent Behavior and Aggressive Behavior
formed a composite score on Externalizing. The remaining symptoms were not
clearly externalizing or internalizing. For the purpose of this study, only items
related to the subscales on Withdrawn, Somatic Complaint, Anxious/Depressed were
used. There were 9 items in Withdrawn, 10 in Somatic Complaint, and 14 in
Anxious/Depressed. The item on ‘‘sad’’ (#103) belongs to both the Withdrawn and
the Anxious/Depressed subscales and it would be counted only once for the
summation of the broadband score on Internalizing.
The CBCL problem behavior scales were normed according to age and gender
categories (boys: 4–11, girls: 4–11, boys 12–18, and girls 12–18) on both clinically
referred and non-referred samples of children. In addition, clinical cutoffs on
normalized T-scores have been specified for distinguishing referred and non-
referred children. For each syndrome, the clinical cutoff corresponded to the 98th
percentile (T = 70) with a borderline clinical range defined as the 95–98th
percentile (T = 67–70). For the composite scales (Internalizing, Externalizing), the
clinical cutoff was set at the 90th percentile (T = 63) and the borderline clinical
range was at the 83rd percentile (T = 60–63). Similar pattern of cutoff point for
Internalizing were identified from Leung, et al. (1998) in the Hong Kong norm for
CBCL. That is, the clinical cutoff for Internalizing was set at the 90th percentile
(T = 63) and the borderline clinical range started at the 83rd percentile (T = 60–63;
i.e. the summation of Internalizing at raw score from 13 to 16). Scores above 16
were considered as in the clinical range. Hence, in the present study, children with
Internalizing score at or above 13 in the CBCL were considered as high risk for
having internalizing problems.

Parent–Child Relationship Questionnaire (PCRQ)

The Parent–Child Relationship Questionnaire (PCRQ; Furman and Buhrmester

2001) assessed perceptions of qualities of individual parent–child relationships. It
was used as an objective measure for identifying the mother–child interaction in the
current study. In PCRQ, there were five areas, namely: Warmth (affection,
admiration of parent, admiration by parent), Disciplinary Warmth (praise, shared

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decision making), Personal Relationship (companionship, nurturance, intimacy),

Power Assertion (quarrelling, dominance, deprivation of privilege), and Posses-
siveness (protectiveness and possessiveness). The short-form consisted of 40 items.
Examples of items for each area are as follows. Warmth: ‘‘How much do you and
your child love each other?’’; Disciplinary Warmth: ‘‘How much do you talk to this
child about why he/she is being punished or not allowed to do certain things?’’;
Personal Relations: ‘‘How much do you help this child with things he/she can’t do by
himself/herself?’’; Power Assertion: ‘‘How much do you bug this child to do
things?’’, Possessiveness: ‘‘How much do you not let this child go to places because
you are afraid something might happen to him/her?’’ Responses were assessed on a
5-point scale, with each item from 1 (hardly at all) to 5 (extremely much). The score
for each factor was the summation of responses from items in that area. Alphas for
the areas ranged from 0.68 to 0.88 (M = 0.81) (Furman and Gibson 1995). Forward
and backward translations were conducted several times before a satisfactory
Chinese version was adopted for use in the present study.

Reliability Estimates of CBCL and PCRQ in the Present Study

Table 1 showed the reliability estimates of CBCL and PCRQ. The reliabilities of
each subscale (except for Somatic) showed consistent results with those reported by
Achenbach (1991) with the test–retest reliability ranged from 0.70 to 0.90. The
reliability coefficient for the PCRQ was consistent with that reported by Furman and
Giberson (1995) with the alpha for the subscales ranged from 0.68 to 0.88
(mean = 0.81). This indicated that both the CBCL and the PCRQ were, in general,
reliable measures for the present study.

Procedures

To investigate the prevalence of internalizing problems among primary school

children in Hong Kong, schools from various districts were chosen to represent
children coming from various socio-economic backgrounds. The questionnaires,

Table 1 Reliability estimates

Scale name Reliability No. of items
of CBCL (internalizing) and
(standardized alpha) in the scale
PCRQ subscales (n = 1,598)
CBCL: withdrawn 0.71 9
CBCL: somatic 0.60 10
CBCL: anxious/depressed 0.80 14
PCRQ: warmth 0.83 6
PCRQ: disciplinary warmth 0.83 6
PCRQ: personal relations 0.75 10
PCRQ: power assertion 0.76 12
PCRQ: possessiveness 0.69 6

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together with a letter explaining the purpose of the study, were distributed through
the school personnel to the mothers with children from Grade 2 to Grade 4.
Informed consent was obtained before proceeding to the data collection process.
Mothers were invited to complete the questionnaires on a voluntary basis and return
the questionnaires within two weeks after they received them. Class teachers and/or
school guidance personnel from the respective schools helped in collecting the
returned questionnaires.

Results

The CBCL-internalizing score reflected the severity of internalizing problem. The

higher this score, the more severe the internalizing problem was as more
internalizing symptoms were noted. Using an internalizing score of 13 as a cutoff
point (as suggested in the CBCL-Chinese version, Leung, et al. 1998) for
identifying children with internalizing problems at sub-clinical and clinical ranges,
the overall prevalence of internalizing problems identified from the present sample
was 11.40%. The rates for boys and girls were comparable—12% for boys and
11% for girls. With reference to Grade, no significant difference was found,
F (2, 181) = 1.49, n.s. (see Table 2). With the total population of school children in
Grade 2 to Grade 4 as 221,950 (according to the figures on student enrolment by age
from the School Places Allocation Section of Education and Manpower Bureau,
HKSAR, 2004), it was estimated that around 25,300 students within these grades
were at a borderline range for developing clinical problems relating to internalizing
behavior.
Mother–child relationship was measured using the Parent–Child Relationship
Questionnaire (PCRQ). The means and standard deviations of the response among
the PCRQ subscales in this sample were as follow. Warmth: M = 3.51, SD = 0.64;
Disciplinary Warmth: M = 3.67, SD = 0.57; Personal Relations: M = 3.52,
SD = 0.56; Power Assertion: M = 2.74; SD = 0.50; and Possessiveness:
M = 3.25, SD = 0.65. This result pattern showed that respondents acknowledged
most of the statements in PCRQ as ‘‘sometimes’’ true. From the current sample,
Disciplinary Warmth was ranked first among the mother–child relationship domains

Table 2 Means, SDs and F-values of CBCL subscale scores by Grade

Grade Means (SD)

Overall Subscales
internalizing
Withdrawn Somatic Anxious/Depressed

2 (n = 528) 6.18 (5.69) 1.86 (2.27) 0.63 (1.22) 3.69 (3.34)

3 (n = 602) 6.32 (6.13) 1.88 (2.51) 0.58 (1.12) 3.86 (3.77)
4 (n = 468) 6.26 (6.01) 2.10 (2.47) 0.53 (0.90) 3.64 (3.71)
F (2, 1595) 0.94 1.53 1.09 0.53

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as measured by PCRQ, i.e., behaviors such as praises and shared decision-making

were reported to be the most by mothers in their relationship with children.
Correlations between PCRQ domain scores and CBCL Internalizing score were
shown in Table 3. Similar pattern was observed in the three CBCL subscale scores
in relation to mother–child relationship identified in the PCRQ. PCRQ subscales on
Warmth and Disciplinary Warmth were negatively correlated with CBCL subscales
on Withdrawn, Somatic Complaints and Anxious/Depressed. PCRQ factor on
Personal Relation was also negatively correlated with Withdrawn and Anxious/
Depressed. PCRQ Power Assertion was positively correlated with CBCL factor on
Withdrawn, Somatic Complaints and Anxious/Depressed while PCRQ factor on
Possessiveness was positively correlated with Somatic and Anxious/Depressed. The
overall result of the present findings suggested that variables on mother–child
relationship were significant in relating to children’s internalizing problems.

Discussion

Results of the present study provided updated information on prevalence of

internalizing problems among young children in Hong Kong. The importance of
mother–child relationship in association to children’s internalizing behavior was
also highlighted.
The mean scores of internalizing problem identified in the present study were
higher than those found by Liu et al. (1999) in children samples from Mainland
China. Local studies such as Wong and Tsoi (1999) indicated that the prevalence
rate of behavior problems, including both internalizing and externalizing, was about
10–16%. The estimated prevalence of the internalizing problem as identified in the
current sample was within the range as suggested by Wong and Tsoi. However, it
was the author’s speculation that the estimated prevalence of internalizing problem
was higher than what’s noted in this study. In Hong Kong, it would be easier for

Table 3 Correlations among CBCL subscale scores and PCRQ subscale scores (n = 1,598)
PCRQ CBCL
subscales
Overall Subscales
internalizing
WDN SOM ANXDEP

WARM -0.38** -0.38** -0.16** -0.33**

DW -0.17** -0.19** -0.05* -0.13**
PR -0.15** -0.19** -0.02 -0.11**
PA 0.20** 0.18** 0.09** 0.19**
PO 0.06* 0.03 0.08** 0.06*

Note: WARM, Warmth; DW, Disciplinary Warmth; PR, Personal Relationship; PA, Power Assertion;
PO, Possessiveness; WDN, Withdrawn; SOM, Somatic Complaints; ANXDEP, Anxious/Depressed
* p \ 0.05; ** p \ 0.01

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parents to accept their shy, withdrawn children as ‘‘normal’’ than to accept those
with aggressive behavior as ‘‘normal’’ (e.g., Chen et al. 1995). Hence, the number
of local children who were at risk for developing internalizing disorders could be
much higher as problems sometimes go unnoticed by parents. To further confirm the
prevalence of internalizing problems among Hong Kong children, other means of
assessment on children’s internalizing problems (such as self-reported measures,
interviews) could be used.
Another noteworthy issue from this result was the relatively low score on the
subscale on somatic complaint in CBCL. Hong Kong mothers seemed to lack
awareness on the somatic symptoms associated with childhood internalizing
problems. One possible explanation was that Hong Kong mothers did not perceive a
connection between somatic symptoms and internalizing behavior. Another
explanation could be because Hong Kong children’s internalizing problems were
more reflected by social behaviors and less by bodily symptoms. After all, others’
perception on one’s bodily symptoms could be a limitation in reflecting the person’s
somatic problems.
The overall result on children’s internalizing problems and mother–child
relationship supported the literature (e.g., Rapee et al. 2000) that parents were
involved in the maintenance of children’s internalizing problems. The use of verbal
punishment and rejection as well as possessiveness and protection were positively
correlated with children’s internalizing problems. This further supported Weissman
et al. (2000) that chronic exposure to unpleasant and harsh conditions may create a
sense of rejection, which fosters feelings of helplessness and hopelessness as well as
negative thoughts on children. The factor on ‘‘possessiveness’’ might illustrate that
greater degree of protection and over-involvement in parenting were identified to be
factors relating to children’s internalizing problems, as suggested by Hudson and
Rapee (2004). On the other hand, providing a nurturing and intimate relationship
with children was an important factor contributing to the development of mentally
healthy children. Such observation was supported by previous reports indicating that
close and supportive relationship were important for helping children to reduce
internalizing problems (Kazdin and Weisz 1998; Jenberg and Booth 1999). Also,
interventions for children with internalizing problems could focus more on the
different variables relating to mother–child relationship when planning for
programs.
The present study examined the prevalence of internalizing problems among
primary school children in Hong Kong and the relationships of such problems and
characteristics of the mother–child relationship. Results further indicated the
importance of relationship component in parenting as well as for effective
intervention. Disciplinary warmth, including shared decision-making and praises,
was important in reducing internalizing problems among children.
Several limitations were noted in this study. First, the prevalence of children’s
internalizing problem was only based on mother-reported CBCL scores. Incorpo-
ration of father-reported or teacher-reported CBCL scores could help to assess the
severity of childhood internalizing problems in a more objective way (Greenberg
et al. 2001). Second, the prevalence could also be estimated and cross-checked via
diagnostic interviews with the children and their parents in addition to using

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standardized questionnaires in order to know the different perspectives from

significant others on a child’s internalizing problem. In addition, the current study
on prevalence was based on a convenient sample only. Cross replication of the
prevalence rate could be done using larger samples in order to confirm the
estimation of the prevalence. It was also important to note that patterns of
externalizing problems could have included in the understanding of internalizing
problems as there has been high levels of co-morbidity observed between and within
childhood externalizing and internalizing problems (Lilienfeld 2003). Future
research could explore more on the connection between internalizing and
externalizing behavior. In addition, measures to assess children’s coping, family
functioning and quality of life could be included in order to explore the effect of
different variables on contributing to children’s internalizing problems. Another
potential limitation of this study was that the connection between mother and child
relationship and internalizing score of children could be due to shared method
variance (as mother was the only person providing the ratings). Any future study
would benefit from data collected from different perspectives, including both
qualitative as well as quantitative measures.

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