Alexithymia in Children and Adolescents

Introduction to Alexithymia

Alexithymia was first proposed in the 1970s by a psychoanalyst Peter Sifenos when working with patients with personality disorders (Sifenos, 1973 as cited in Vanheule et al., 2011). According to Nemiah et al. (1976), alexithymia “is characterized by an impaired ability to be aware of, explicitly identify, and describe one’s feelings” (Hogeveen & Grafman, 2021, p. 2). In other words, alexithymia is a disruption in emotional awareness (Hogeveen & Grafman, 2021). Although alexithymia is not a diagnostic disorder in the current Diagnostic Statistical Manual, fifth edition (DSM-5; American Psychological Association, 2013; 2022), it is gaining interest due to  its connection with individuals with autism and other psychiatric disorders because of its association with emotional understanding and expression.

It is hypothesized that there are two types of alexithymia, primary alexithymia and secondary alexithymia (Krystal, 1988; Sifneos, 1973; Way et al., 2010). Primary alexithymia is considered a characteristic of a neurobiological disorder, suggesting that  a genetic component contributes to the manifestation of symptoms related to alexithymia (Sifneos, 1973; Way et al., 2010). In contrast,  secondary alexithymia manifests as the result of a traumatic experience (Krystal, 1988; Way et al., 2010). Additionally, characteristics of alexithymia include: a) impairments in explaining or understanding feelings, b) impairments with differentiating feelings and physical or sensory experiences (i.e., interoception), c) impairments with imaginative thinking, and d) a cognitive style that is externalized (Hendryx et al., 1991, as cited in Way et al., 2010; Shah et al., 2016). 

Alexithymia and Neurodiversity:

Researchers and professionals have noted the similarities between alexithymia and other psychiatric disorders, including autism. It is currently estimated that up to 50% of people with autism also have co-occurring alexithymia (Kinnaird et al., 2019). Characteristics that are similar between the two include impairments in social competence (i.e., difficulties in  social interactions), and impairments in emotion processing (i.e., emotion awareness and emotion regulation) (Poquérusse et al., 2018; Scheerer et al, 2021). These difficulties align with the DSM-5 diagnostic criteria A for autism, which  focuses on social communication deficits and can be manifested by deficits in sharing personal emotions (American Psychological Association, 2013; 2022). 

It is important to note that not every child with autism has  alexithymia, and not every child with alexithymia has  autism (Scheerer et al, 2021). However, some researchers theorize that when individuals with autism exhibit  symptoms associated with emotional impairments, these  are more likely attributed to alexithymia than autism (Scheerer et al, 2021).

Other Common Disorders Associated with Alexithymia:

Although alexithymia is highly associated with autism spectrum disorder (Kinnaird et al., 2019), there are also other disorders that commonly co-occur. Such disorders include anxiety, depression, Post Traumatic Stress Disorder (PTSD), and medical disorders like Traumatic Brain Injury (TBI) and Parkinson’s Disease (Hogeveen & Grafman, 2021)

Assessing Alexithymia:

To assess symptoms associated with alexithymia in children and  adolescents, there are two common rating scales cited in the literature: The Children’s Alexithymia Measure (CAM; Way et al., 2010) and the Alexithymia Questionnaire for Children (AQC; Rieffe et al., 2006). 

The CAM is a 14-item screening measure for children between the ages of 5 and 17. Parents or caregivers rate their child’s emotional behaviors within the past three months. Respondents  indicate their agreement on a 3-point Likert scale from “Almost Never” to “Almost Always”, with  higher scores indicating behaviors associated with alexithymia (Way et al., 2010). 

The AQC is a 20-item self-report adapted from the TAS-20 (adult version; Bagby et al., 1994). The measure assesses three domains: a) difficulty identifying feelings, b) difficulty describing feelings, and c) externally-oriented thinking. Children indicate their agreement on a 3-point Likert scale from “Not True” to “True” (Rieffe et al., 2006). 

Alexithymia in a Therapeutic Setting:

What to do when a child has a high rating on an alexithymia scale or is showing characteristics of alexithymia?

Currently, there is no evidence-based or manualized intervention specifically for alexithymia treatment. However, there are a few suggestions for the focus of treatment approaches that appropriately address characteristics related to alexithymia (Nunes da Silva, 2021; Scheerer et al., 2021). The main suggestion focuses on providing psychoeducation for children and parents on emotion awareness, emotion understanding, emotion regulation, and emotion expression (da Silva, 2021; da Silva et al., 2018). It is also suggested that social skills interventions be provided in  groups settings whenever possible, rather than  individual therapy (da Silva, 2021; da Silva et al., 2018).

Conclusion:

To summarize, people with alexithymia typically have difficulty understanding, expressing, and explaining their own feelings (Hogeveen & Grafman, 2021). Due to emotional understanding regulation being associated with neurodiverse populations, specifically autism, accurate assessment and effective treatments that target emotion recognition are crucial (Kinnaird et al., 2019). Utilizing validated rating scales and suggested intervention strategies can provide support to individuals with alexithymia (da Silva, 2021; da Silva et al., 2018; Kinnaird et al., 2019; Nunes da Silva, 2021; Scheerer et al., 2021). 

References:

Bagby, R. M., Parker, J. D., & Taylor, G. J. (1994). The twenty-item Toronto Alexithymia Scale–I. Item selection and cross-validation of the factor structure. Journal of psychosomatic research, 38(1), 23–32. https://doi.org/10.1016/0022-3999(94)90005-1

da Silva, A. (2021). Developing emotional skills and the therapeutic alliance in clients with alexithymia: Intervention guidelines. Psychopathology, 54(6), 282–290. https://doi.org/10.1159/000519786 

da Silva, A. C. N., Vasco, A. B., & Watson, J. C. (2018). Alexithymia and therapeutic alliance: a multiple case study comparing good and poor outcome cases. Research in psychotherapy (Milano), 21(2), 313. https://doi.org/10.4081/ripppo.2018.313

Hendryx, M. S., Haviland, M. G., & Shaw, D. G. (1991). Dimensions of alexithymia and their relationships to anxiety and depression. Journal of Personality Assessment, 56(2), 227–237. https://doi.org/10.1207/s15327752jpa5602_4 

Hogeveen, J., & Grafman, J. (2021). Alexithymia. Handbook of clinical neurology, 183, 47–62. https://doi.org/10.1016/B978-0-12-822290-4.00004-9

Kinnaird, E., Stewart, C., & Tchanturia, K. (2019). Investigating alexithymia in autism: A systematic review and meta-analysis. European psychiatry : the journal of the Association of European Psychiatrists, 55, 80–89. https://doi.org/10.1016/j.eurpsy.2018.09.004

Krystal, H. (1988). Integration and self healing: Affect, trauma, alexithymia (1st ed.). Routledge. https://doi.org/10.4324/9781315799032 

Poquérusse, J., Pastore, L., Dellantonio, S., & Esposito, G. (2018). Alexithymia and autism spectrum disorder: A complex relationship. Frontiers in psychology, 9, 1196. https://doi.org/10.3389/fpsyg.2018.01196

Rieffe, C., Oosterveld, P., & Terwogt, M. M. (2006). An alexithymia questionnaire for children: Factorial and concurrent validation results. Personality and Individual Differences, 40(1), 123–133. https://doi.org/10.1016/j.paid.2005.05.013

Scheerer, N. E., Boucher, T. Q., & Iarocci, G. (2021). Alexithymia is related to poor social competence in autistic and nonautistic children. Autism research : official journal of the International Society for Autism Research, 14(6), 1252–1259. https://doi.org/10.1002/aur.2485

Shah, P., Hall, R., Catmur, C., & Bird, G. (2016). Alexithymia, not autism, is associated with impaired interoception. Cortex; a journal devoted to the study of the nervous system and behavior, 81, 215–220. https://doi.org/10.1016/j.cortex.2016.03.021

Sifneos, P. E. (1973). The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychotherapy and Psychosomatics, 22(2-6), 255–262. https://doi.org/10.1159/000286529

Vanheule, S., Verhaeghe, P., & Desmet, M. (2011). In search of a framework for the treatment of alexithymia. Psychology & Psychotherapy: Theory, Research & Practice, 84(1), 84–97. https://doi-org.proxy1.cl.msu.edu/10.1348/147608310X520139

Way, I. F., Applegate, B., Cai, X., Franck, L. K., Black-Pond, C., Yelsma, P., … Muliett, M. (2010). Children’s Alexithymia Measure (CAM): A New instrument for screening difficulties with emotional expression. Journal of Child & Adolescent Trauma, 3(4), 303–318. https://doi.org/10.1080/19361521.2010.523778