The Differential Relations Between Empathy and Internalizing and Externalizing Symptoms in Inpatient Adolescents Malgorzata Gambin & Carla Sharp Child Psychiatry & Human Development ISSN 0009-398X Child Psychiatry Hum Dev DOI 10.1007/s10578-016-0625-8 1 23 Your article is protected by copyright and all rights are held exclusively by Springer Science +Business Media New York. This e-offprint is for personal use only and shall not be self- archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Child Psychiatry Hum Dev DOI 10.1007/s10578-016-0625-8 ORIGINAL ARTICLE The Differential Relations Between Empathy and Internalizing and Externalizing Symptoms in Inpatient Adolescents 1 2,3 Malgorzata Gambin • Carla Sharp Ó Springer Science+Business Media New York 2016 Abstract Impaired empathy is associated with a variety Introduction of psychiatric conditions; however, little is known about the differential relations between certain forms of psy- Empathy—the ability to understand and share in another’s chopathology and cognitive and affective empathy in emotional state or context [1]—allows humans to interact adolescent girls and boys. The aim of this study was to effectively in the social world and promotes prosocial examine the relations between externalizing and internal- behaviors [2]. The ability to empathize is particularly izing disorders and cognitive and affective empathy, important in adolescence when social reorientation takes respectively, while controlling for covariance among dif- place that heightens the salience of peer relations and ferent forms of psychopathology, separately in girls and enhances the role of empathy for effective social func- boys. A total of 507 inpatient adolescents (319 girls and tioning [3, 4]. 188 boys) in the age range of 12–17 years completed the Empathy is a multifaceted construct and most Basic Empathy Scale that measures affective and cognitive researchers agree that it includes three primary compo- empathy. The Youth Self-Report Form and Child Behavior nents: (a) an affective response to another person facili- Checklist were used to assess the severity of psy- tating affective sharing of other people’s emotional states chopathological symptoms. Results demonstrated that (b) a cognitive capacity to take the perspective of the other affective and cognitive empathy were negatively associated person; and (c) regulatory mechanisms allowing for the with conduct problems only in girls, but not in boys. maintenance of self/other distinction during empathizing Affective empathy was positively related to internalizing (e.g., [5–7]). The affective component can be likened to problems observed by parents and youths and self-reported either sympathy defined as an other-oriented emotional ADHD symptoms in girls and boys. The clinical implica- reaction to another’s emotional state or condition or per- tions of these differential relationships for externalizing sonal distress—a self-oriented aversive reaction [5–7]. We versus internalizing symptoms and empathy are discussed. can also distinguish situational empathy concerning empathic emotions felt in a particular situation measured Keywords Empathy Á Anxiety Á Depression Á Conduct by experimental tasks and dispositional empathy, assessed disorders Á ADHD by questionnaires and explored in the current study, which is a general disposition to experience empathy [5]. Previous research revealed different patterns of associ- & Malgorzata Gambin ation between empathy and either externalizing or inter- [email protected] nalizing disorders. Several studies show that conduct 1 Department of Psychology, University of Warsaw, ul Stawki disorder (CD) and some of the associated traits (callous- 5/7, 00-183 Warsaw, Poland unemotional traits, aggressive behaviors) are related to 2 Department of Psychology, University of Houston, 126 lower levels of empathy [1, 8–12]. Sharing and under- Heyne Building, Houston, TX 77204, USA standing negative emotions of others that occur in reaction 3 Menninger Clinic, 12301 S. Main St., Houston, to aggressive and antisocial behavior is thought to prevent TX 77035-6207, USA individuals from harming others [9, 13]. The relationships 123 Author's personal copy Child Psychiatry Hum Dev between empathy and CD are stronger for adolescents than distortions that are characteristic of individuals with for children when self-report measures of empathy are used internalizing symptoms [28, 29]. In contrast, individuals [9, 10]. Moreover, more pronounced deficits have been with externalizing disorders have been shown to display an shown for affective empathy compared to cognitive opposite cognitive style characterized by self-serving and empathy in individuals with conduct disorders especially blaming others [28, 29]. These differences in cognitive when CU traits are present [11, 14, 15]. Studies that have styles that are characteristic of internalizing and external- investigated gender differences in relation to empathy and izing disorders may explain divergent directions of rela- conduct disorder (or related traits) are limited and tionships between empathy and these two dimensions of demonstrated mixed findings: (1) deficits in empathy are psychopathological symptoms. Self-debasing distortions present in both girls and boys with conduct disorder [1], (2) and self-focus seem to enhance empathic distress to other impaired empathy is observed only in boys, but not girls peoples’ suffering whereas self-serving distortions and with aggressive behaviors [16, 17]. blaming others decrease empathic responses and empathy- There is a lack of studies investigating relationships based guilt—we may assume that empathy is in mutual between empathy and symptoms of oppositional-defiant relationship with these cognitive styles. disorder (ODD) separately from CD. In addition, research Most of the above-mentioned research exploring rela- on the topic of empathy in children with ADHD is limited tionships between empathy and externalizing or internal- [18] and shows inconsistent results. Braaten and Rosen izing symptoms focused on categorical models of [19] demonstrated that children with ADHD have lower psychopathology and individual disorders. Only two stud- abilities in situational empathy in comparison to healthy ies [20, 21] that investigated empathy in ADHD and con- controls. In contrast, Deschamps et al. [20] showed that this duct or disruptive disorders took into account comorbidity group of children does not differ in situational and dispo- among externalizing disorders. Studies that do not take into sitional empathy reported by parents from their peers; account high comorbidity between various internalizing however, children were rated as less empathic by their and externalizing disorders [30] may lead to a biased teachers. A study by Marton et al. [21] revealed that chil- understanding of the relation between psychopathology and dren with ADHD were characterized by lower levels of empathy. Furthermore, previous work have largely empathy assessed by parents in comparison to their peers neglected to make distinctions between cognitive and without the disorder, but this difference was no longer affective empathy even though these two dimensions are significant when the level of oppositional and conduct related to distinct neural, somatic and behavioral correlates problems were controlled for. [30–32]. In particular, affective empathy increases activity Studies that have explored the association between in the brain network involved in emotional processing, internalizing disorders and empathy revealed opposite perceiving faces and bodies and understanding and simu- directions of associations compared to externalizing dis- lating other’s actions. In effect it facilitates mirroring of the orders. Higher levels of depression have been found to observed mental and bodily states to a greater extent than associate with the tendency to experience higher personal cognitive empathy. It was shown also to be more strongly distress as a response to other people’s suffering [22–25]. related to externalizing and internalizing symptoms than Similarly, a positive association between anxiety and per- cognitive empathy [14, 24]. Thus, it is essential to explore sonal distress has been found by Joireman et al. [26]. All relationships of psychopathology to cognitive and affective these studies were conducted among adults. While still empathy separately. untested, Zahn-Waxler and Van Hulle [27] proposed a Moreover, there is a lack of studies exploring associations hypothesis that children who are empathic and raised in between empathy and psychopathological symptoms other families that involve parental suffering may get overly than CD (ADHD, ODD, depressive and anxiety disorders) in engaged in caring for parents. In such cases, empathy may adolescents. As adolescence is a period of social reorienta- be positively correlated with guilt over hurting others, tion [3], which coincides with major changes in the ‘‘social sadness and anxiety.