A Closer Look at Adolescent Mental Health: Prevalence of Internalizing and Externalizing Problems Across Educational and Gender Groups
,
Abstract
Objective: Given the importance of mental health during adolescence and the considerable prevalence of psychological problems among this age group, along with the limited epidemiological data available in South Khorasan province, Iran, the present research focused on determining the prevalence of internalizing and externalizing problems in regional school-aged adolescents and analyzing related demographic characteristics.
Method: This descriptive cross-sectional study included 1,152 adolescents aged 12 to 19 years (mean age = 15.42, SD = 1.65) from Birjand City. A multistage random sampling method was employed to select the participants. Data were collected using the self-report version of the Strengths and Difficulties Questionnaire (SDQ), which measures internalizing and externalizing problems. To analyze the data, descriptive statistics were computed and comparative analyses were performed. Demographic variables such as age, gender, academic performance, school grade, and school type were also included in the analysis.
Results: The prevalence of internalizing problems among the participants was 36.8% (95% confidence interval: 34.0 to 39.6), whereas externalizing problems were identified in 15.2% (95% CI: 13.0 to 17.4). Internalizing problems were significantly more prevalent among girls (40.1%) than boys (32%). However, no significant gender difference was found in externalizing problems (girls: 14.5%, boys: 15.8%). Emotional problems (28.6%) and hyperactivity (10.4%) were significantly more common in girls, while peer problems (61.7%) and conduct problems (17.5%) were higher in boys (P < 0.01). Adolescents with poor academic performance and those attending public schools reported higher levels of psychological problems (P < 0.01).
Conclusion: Internalizing problems are more common than externalizing problems among adolescents. The main risk factors include being female, poor academic performance, and attending public schools. Mental health programs and interventions should prioritize these high-risk subgroups to enhance preventive and therapeutic outcomes.
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27. González-Rubio M, Delgadillo-Ramos G, Valles-Medina AM, Caloca-Leon H, De-La-Mora S. Internalizing and externalizing behaviors in high school adolescents in a northern border city of Mexico and their type of family. Aten Primaria. 2023;55(12):102743.
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29. Dastjerdi R, Mohammadi MR, Alavi S, Ahmadi A, Farshidfar Z. The prevalence of psychiatric disorders among children and adolescents in Southern Khorasan Province, Iran. Modern Care Journal. 2019;16(2).
30. Mohammadi MR, Salmanian M, Keshavarzi Z. The Global Prevalence of Conduct Disorder: A Systematic Review and Meta-Analysis. Iran J Psychiatry. 2021;16(2):205-25.
31. Farnia V, Davarinejad O, Khanegi M, Ahmadi Jouybari T, Salemi S, Pajouhinia S, et al. The Prevalence of Internalizing and Externalizing Behavior Problems and Their Relationship with Demographic Characteristics in Children Surviving the 2017 Earthquake in West of Iran. Trauma Monthly. 2020;25(3):116–23.
32. Mohammadi MR, Ahmadi N, Salmanian M, Asadian-Koohestani F, Ghanizadeh A, Alavi A, et al. Psychiatric Disorders in Iranian Children and Adolescents. Iran J Psychiatry. 2016;11(2):87-98.
33. Lin J, Guo W. The Research on Risk Factors for Adolescents' Mental Health. Behav Sci (Basel). 2024;14(4):263.
34. Naing L, Nordin RB, Abdul Rahman H, Naing YT. Sample size calculation for prevalence studies using Scalex and ScalaR calculators. BMC Med Res Methodol. 2022;22(1):209.
35. Goodman R, Meltzer H, Bailey V. The Strengths and Difficulties Questionnaire: a pilot study on the validity of the self-report version. Eur Child Adolesc Psychiatry. 1998;7(3):125-30.
36. Ghanizadeh A, Izadpanah A, Abdollahi G. Scale validation of the strengths and difficulties questionnaire in Iranian children. Iran J Psychiatry. 2007;2(2):65–71.
37. National and subnational burden of mental disorders in Iran (1990-2019): findings of the Global Burden of Disease 2019 study. Lancet Glob Health. 2024;12(12):e1984-e92.
38. Aloosh M, Salavati A, Aloosh A. Economic sanctions threaten population health: the case of Iran. Public Health. 2019;169:10-3.
39. Zerroug Y, Marin MF, Brendgen M, Beauchamp M, Séguin JR, Côté SM, et al. Sex differences in associations between hair glucocorticoids and internalizing symptoms in adolescents. Compr Psychoneuroendocrinol. 2025;23:100311.
40. Campbell OLK, Bann D, Patalay P. The gender gap in adolescent mental health: A cross-national investigation of 566,829 adolescents across 73 countries. SSM Popul Health. 2021;13:100742.
41. Sun HL, He F, Rao WW, Qi Y, Rao SY, Ho TI, et al. Gender differences in behavioral and emotional problems among school children and adolescents in China: National survey findings from a comparative network perspective. J Affect Disord. 2025;369:227-33.
42. 42. Chen CC, Cheng SL, Xu Y, Rudasill K, Senter R, Zhang F, et al. Transactions between Problem Behaviors and Academic Performance in Early Childhood. Int J Environ Res Public Health. 2022;19(15):9583.
2. Ledesma-Corvi S, Jornet-Plaza J, Gálvez-Melero L, García-Fuster MJ. Novel rapid treatment options for adolescent depression. Pharmacol Res. 2024;201:107085.
3. Hunduma G, Dessie Y, Geda B, Yadeta TA, Deyessa N. Prevalence and correlates of internalizing and externalizing mental health problems among in-school adolescents in eastern Ethiopia: a cross-sectional study. Sci Rep. 2024;14(1):3574.
4. Wang J, Yang Y, Chen Y, Lin H, Wang T, Wang Z, et al. Loneliness, Internalizing and Externalizing Problems, and Suicidal Ideation Among Chinese Adolescents: A Longitudinal Mediation Analysis. J Adolesc Health. 2025;76(1):96-104.
5. Dehestani N, Vijayakumar N, Ball G, Mansour LS, Whittle S, Silk TJ. "Puberty age gap": new method of assessing pubertal timing and its association with mental health problems. Mol Psychiatry. 2024;29(2):221-8.
6. Chiang S-C, Ting S-J, Hung Y-F, Sung Y-H, Chen W-C. The role of family conflict and school problems in adolescent emotion dynamics. Journal of Child and Family Studies. 2024;33(3):877–87.
7. Armitage J, Collishaw S, Sellers R. Explaining long-term trends in adolescent emotional problems: what we know from population-based studies. Discover social science and health. 2024;4(1):14.
8. Shabahang R, Shim H, Aruguete MS, Zsila Á. Adolescent sadfishing on social media: anxiety, depression, attention seeking, and lack of perceived social support as potential contributors. BMC Psychol. 2023;11(1):378.
9. Fuentes-Balderrama J, Turnbull-Plaza B, Ojeda-García A, Parra-Cardona JR, Cruz del Castillo C, Díaz-Loving R, et al. Insecure attachment to parents as a contributor to internalizing and externalizing problem behaviors in Mexican preadolescents. Trends in psychology. 2023;31(1):105–22.
10. Donoso J, Rattray F, de Bildt A, Tillmann J, Williams P, Absoud M, et al. Association of cognitive and adaptive skills with internalizing and externalizing problems in autistic children and adolescents. Autism Res. 2024;17(3):596-609.
11. Keyes KM, Platt JM. Annual Research Review: Sex, gender, and internalizing conditions among adolescents in the 21st century - trends, causes, consequences. J Child Psychol Psychiatry. 2024;65(4):384-407.
12. Royuela-Colomer E, Orue I, Visu-Petra L, Fernández-González L. The association between mindful parenting, and internalizing and externalizing symptoms in adolescence. Journal of Child and Family Studies. 2024;33(6):1844–56.
13. Essau CA, de la Torre-Luque A. Comorbidity Between Internalising and Externalising Disorders Among Adolescents: Symptom Connectivity Features and Psychosocial Outcome. Child Psychiatry Hum Dev. 2023;54(2):493-507.
14. Vergunst F, Commisso M, Geoffroy MC, Temcheff C, Poirier M, Park J, et al. Association of Childhood Externalizing, Internalizing, and Comorbid Symptoms With Long-term Economic and Social Outcomes. JAMA Netw Open. 2023;6(1):e2249568.
15. Treanor M, Troncoso P. Poverty, parental work intensity and child emotional and conduct problems. Soc Sci Med. 2022;312:115373.
16. Matos A, Salvador M, Costa J, Pinheiro M, Arnarson E, Craighead W. The relationship between internalizing and externalizing problems in adolescence: does gender make a difference? Canadian International Journal of Social Science and Education. 2017(8):45–63.
17. Bobrowski KJ, Ostaszewski K. Risk and protective factors associated with internalizing and externalizing mental health problems among 13-15-year-old youth. Psychiatr Pol. 2022;56(5):1033-48.
18. Babicka-Wirkus A, Kozłowski P, Wirkus Ł, Stasiak K. Internalizing and Externalizing Disorder Levels among Adolescents: Data from Poland. Int J Environ Res Public Health. 2023;20(3):2752.
19. Liu K, Thompson RC, Watson J, Montena AL, Warren SL. Developmental Trajectories of Internalizing and Externalizing Symptoms in Youth and Associated Gender Differences: A Directed Network Perspective. Res Child Adolesc Psychopathol. 2023;51(11):1627-39.
20. Segura-Frontelo A, Girela-Serrano B, Gutiérrez-Rojas L, Porras-Segovia A, Peñuelas-Calvo I, Spiers A, et al. Prevalence and stability of internalizing symptoms in children and adolescents: gender differences and associated factors. J Child Fam Stud. 2025;34(2):490–501.
21. Askari MS, Rutherford CG, Mauro PM, Kreski NT, Keyes KM. Structure and trends of externalizing and internalizing psychiatric symptoms and gender differences among adolescents in the US from 1991 to 2018. Soc Psychiatry Psychiatr Epidemiol. 2022;57(4):737-48.
22. Segura-Frontelo A, Girela-Serrano B, Gutiérrez-Rojas L, Porras-Segovia A, Peñuelas-Calvo I, Spiers A, et al. Prevalence and stability of internalizing symptoms in children and adolescents: gender differences and associated factors. J Child Fam Stud. 2025;34(2):490–501.
23. Riasi H, MOGHARAB M, SALEHI AM, HASANZADEH TE, HASANZADEH TM. A COMPARATIVE STUDY OF DEPRESSION IN GIFTED AND NORMAL STUDENTS IN BIRJAND CITY D URING 2008-2009 SCHOOL YEAR. 2012.
24. Wagner G, Zeiler M, Waldherr K, Philipp J, Truttmann S, Dür W, et al. Mental health problems in Austrian adolescents: a nationwide, two-stage epidemiological study applying DSM-5 criteria. Eur Child Adolesc Psychiatry. 2017;26(12):1483-99.
25. Barker MM, Beresford B, Bland M, Fraser LK. Prevalence and Incidence of Anxiety and Depression Among Children, Adolescents, and Young Adults With Life-Limiting Conditions: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019;173(9):835-44.
26. Ma L, Mazidi M, Li K, Li Y, Chen S, Kirwan R, et al. Prevalence of mental health problems among children and adolescents during the COVID-19 pandemic: A systematic review and meta-analysis. J Affect Disord. 2021;293:78-89.
27. González-Rubio M, Delgadillo-Ramos G, Valles-Medina AM, Caloca-Leon H, De-La-Mora S. Internalizing and externalizing behaviors in high school adolescents in a northern border city of Mexico and their type of family. Aten Primaria. 2023;55(12):102743.
28. Mohammadi MR, Ahmadi N, Khaleghi A, Mostafavi SA, Kamali K, Rahgozar M, et al. Prevalence and Correlates of Psychiatric Disorders in a National Survey of Iranian Children and Adolescents. Iran J Psychiatry. 2019;14(1):1-15.
29. Dastjerdi R, Mohammadi MR, Alavi S, Ahmadi A, Farshidfar Z. The prevalence of psychiatric disorders among children and adolescents in Southern Khorasan Province, Iran. Modern Care Journal. 2019;16(2).
30. Mohammadi MR, Salmanian M, Keshavarzi Z. The Global Prevalence of Conduct Disorder: A Systematic Review and Meta-Analysis. Iran J Psychiatry. 2021;16(2):205-25.
31. Farnia V, Davarinejad O, Khanegi M, Ahmadi Jouybari T, Salemi S, Pajouhinia S, et al. The Prevalence of Internalizing and Externalizing Behavior Problems and Their Relationship with Demographic Characteristics in Children Surviving the 2017 Earthquake in West of Iran. Trauma Monthly. 2020;25(3):116–23.
32. Mohammadi MR, Ahmadi N, Salmanian M, Asadian-Koohestani F, Ghanizadeh A, Alavi A, et al. Psychiatric Disorders in Iranian Children and Adolescents. Iran J Psychiatry. 2016;11(2):87-98.
33. Lin J, Guo W. The Research on Risk Factors for Adolescents' Mental Health. Behav Sci (Basel). 2024;14(4):263.
34. Naing L, Nordin RB, Abdul Rahman H, Naing YT. Sample size calculation for prevalence studies using Scalex and ScalaR calculators. BMC Med Res Methodol. 2022;22(1):209.
35. Goodman R, Meltzer H, Bailey V. The Strengths and Difficulties Questionnaire: a pilot study on the validity of the self-report version. Eur Child Adolesc Psychiatry. 1998;7(3):125-30.
36. Ghanizadeh A, Izadpanah A, Abdollahi G. Scale validation of the strengths and difficulties questionnaire in Iranian children. Iran J Psychiatry. 2007;2(2):65–71.
37. National and subnational burden of mental disorders in Iran (1990-2019): findings of the Global Burden of Disease 2019 study. Lancet Glob Health. 2024;12(12):e1984-e92.
38. Aloosh M, Salavati A, Aloosh A. Economic sanctions threaten population health: the case of Iran. Public Health. 2019;169:10-3.
39. Zerroug Y, Marin MF, Brendgen M, Beauchamp M, Séguin JR, Côté SM, et al. Sex differences in associations between hair glucocorticoids and internalizing symptoms in adolescents. Compr Psychoneuroendocrinol. 2025;23:100311.
40. Campbell OLK, Bann D, Patalay P. The gender gap in adolescent mental health: A cross-national investigation of 566,829 adolescents across 73 countries. SSM Popul Health. 2021;13:100742.
41. Sun HL, He F, Rao WW, Qi Y, Rao SY, Ho TI, et al. Gender differences in behavioral and emotional problems among school children and adolescents in China: National survey findings from a comparative network perspective. J Affect Disord. 2025;369:227-33.
42. 42. Chen CC, Cheng SL, Xu Y, Rudasill K, Senter R, Zhang F, et al. Transactions between Problem Behaviors and Academic Performance in Early Childhood. Int J Environ Res Public Health. 2022;19(15):9583.
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| Adolescent Anxiety Disorders Mental Health Mood Disorders Prevalence Problem Behavior | ||
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How to Cite
1.
Malakooti F, Khamesan A, Samadieh H, Sorbi MH. A Closer Look at Adolescent Mental Health: Prevalence of Internalizing and Externalizing Problems Across Educational and Gender Groups. Iran J Psychiatry. 2026;:1-10.
