Background: Internalizing disorders in children and adolescents are about as frequent as externalizing disorders in the US, but three times more prevalent than externalizing disorders in China. Aims: To examine why and how mental predispositions and stress lead to psychopathology in general and manifest as internalizing or externalizing problems in particular, and which role intercultural differences may play in understanding this. Method: A review of the literature. Results/conclusions: The interplay of personal freedom and societal duties in an individual’s development crucially influences whether psychopathologies appear as externalizing or internalizing issues. Eastern and especially Chinese cultures have long favored societal obligations over individual autonomy, guided by Confucian principles, promoting internalization over externalization. Understanding culture’s role in behavior can improve mental healthcare by fostering tailored, culturally informed interventions for children and adolescents.