**2. Interventions for prevention of internalized problems of children and youth**

#### **2.1. Changing role of schools in modern era**

In the age of information, schools really have a duty to revise their mission: knowledge is available almost everywhere, but quality relationships are becoming quite rare. In order to prepare future adults for challenges in full scale, schools have to provide critical skills for future education, work, and life in general. Besides cognitive skills, to develop positively and be empowered and participating member of society, young people need social and emotional skills. Modern school has holistic focus and has to incorporate care for emotional and social well-being in their curricula [21–25]. Reduction of subjective distress as well as behavior problems is possible by implementing interventions and specific classroom-management practices that develop understanding of emotions, positive goal achievement, maintenance of positive relationships with others, and responsible decision-making. From preschool to middle school, those competencies are being taught within the process of socio-emotional learning and universal programs. International evidence strongly confirms that school interventions teaching socio-emotional learning advance mental health, social functioning, positive health behaviors, as well as academic success [21–25]. Cost benefit studies are also supporting the case: data from 2011 demonstrates that for every dollar invested in socio-emotional learning, average return is 11\$ [26]. It is important to determine if universal evidence-based programs can respond to the needs of young people with different characteristics and if enhancement of young people's social and emotional skills and resilience building is sufficient strategy [24].

#### **2.2. Evidence-based prevention programs for internalized problems**

Since lots of evidence suggests that large proportion of children and young people with anxiety disorders and depression are not included in the treatment, universal prevention programs that promote well-being and preventative interventions are even more essential [27, 28]. Lack of effective treatment probably has a lot to do with problems in the provision of care and poor access to services but also has a cause in low symptom awareness, stigma, inadequate treatment, and available funding [29]. Comprehensive answer to the issue of internalized problems is slowly directing its aims to prevention since it could relieve the burden on health care and social services. When thinking about general evidence-based approach to internalized problems, findings from literature review [30] propose that effective strategy is using cognitivebehavioral therapy model, educating adolescents how to cope with negative thoughts, to solve problems more effectively and develop active coping strategies, as well as to support caring relationships and quality interactions with important others.

are supportive [14]. Research shows that children who have a close emotional relationship with at least one peer have smaller chances to develop internalized problems than children who do not have such experience. Relationships with others are significant protective asset since they buffer negative experiences and low mood, symptoms often seen within children isolated by friends or by their own choice [20]. Active methods of coping such as problemsolving lessen the amount of negative feelings and improve functioning and regulation.

**2. Interventions for prevention of internalized problems of children**

**2.2. Evidence-based prevention programs for internalized problems**

Since lots of evidence suggests that large proportion of children and young people with anxiety disorders and depression are not included in the treatment, universal prevention programs that promote well-being and preventative interventions are even more essential [27, 28]. Lack of effective treatment probably has a lot to do with problems in the provision of care and poor access to services but also has a cause in low symptom awareness, stigma, inadequate treatment, and available funding [29]. Comprehensive answer to the issue of internalized problems is slowly directing its aims to prevention since it could relieve the burden on health care and social services. When thinking about general evidence-based approach to internalized problems, findings from literature review [30] propose that effective strategy is using cognitivebehavioral therapy model, educating adolescents how to cope with negative thoughts, to solve

In the age of information, schools really have a duty to revise their mission: knowledge is available almost everywhere, but quality relationships are becoming quite rare. In order to prepare future adults for challenges in full scale, schools have to provide critical skills for future education, work, and life in general. Besides cognitive skills, to develop positively and be empowered and participating member of society, young people need social and emotional skills. Modern school has holistic focus and has to incorporate care for emotional and social well-being in their curricula [21–25]. Reduction of subjective distress as well as behavior problems is possible by implementing interventions and specific classroom-management practices that develop understanding of emotions, positive goal achievement, maintenance of positive relationships with others, and responsible decision-making. From preschool to middle school, those competencies are being taught within the process of socio-emotional learning and universal programs. International evidence strongly confirms that school interventions teaching socio-emotional learning advance mental health, social functioning, positive health behaviors, as well as academic success [21–25]. Cost benefit studies are also supporting the case: data from 2011 demonstrates that for every dollar invested in socio-emotional learning, average return is 11\$ [26]. It is important to determine if universal evidence-based programs can respond to the needs of young people with different characteristics and if enhancement of young people's social and emotional skills and resilience building is sufficient strategy [24].

**and youth**

126 Health and Academic Achievement

**2.1. Changing role of schools in modern era**

Terzian and colleagues have reviewed 37 programs [30] aiming at internalized problems in general, from depressive symptoms, suicidal thoughts or behaviors, anxious symptoms, PTSD, and shy/withdrawn behavior. Twenty-four out of thirty-seven programs had positive impact, three had mixed findings, and ten were not effective. Programs that were found to work were from either therapeutic approach (individual, family, and group) or skills training approach. Evidence suggest that good programs should teach children and youth to cope with negative thoughts and feelings through (1) building cognitive-behavioral skills such as thought monitoring, identification of triggers, and reframing of negative thoughts and (2) investment in coping skills such as relaxation, seeking help from others, and teaching participants to react adaptively on stress. When focusing only on prevention programs in this review: 10 out of 19 were found to have positive impact on at least one internalizing problem.

After 2010, several reviews and meta-analytic studies have considered effectiveness of various types of interventions, being universal or focused on specific populations in various levels of risk as well as for those with already diagnosable internalized problems [29–34]. Within Cochrane review [29], prevention studies were grouped in universal and targeted; targeted included both selective populations in higher risk and indicated programs focusing on signs suggesting the onset of disorder. Examples of population in higher risk are related with children of parents with diagnosable mental health issue; children with elevated family risks such as violence, neglect, and disputes; as well as children and youth with experience of trauma or bullying. Issue was raised [29] about the inclusion of secondary prevention studies, i.e., those that included children and youth with a history of anxiety or depression, but typically previous history is not described well. Preventive interventions aimed at internalized symptoms, especially those in school settings, need to be researched more thoroughly in the future. Findings are mixed or small to moderate, and it seems that the most problematic issue is that effects easily fade after the program completion. Universal prevention programs last for between 3 to 9 months. Evidence is promising in ways of reducing levels of depressive symptoms and only in some cases episodes of clinically significant depression [29].

Conclusions for internalized problems in general are even more difficult since studies are usually focused on specific problem, depression being most often nowadays, and not the whole group of issues. For example, Cochrane review of programs aiming at depression included 53 studies and more than 14,000 participants and concluded that both targeted and universal interventions are effective for prevention of depression although effects of selective interventions last longer. Also, it has been shown that psychological interventions are more effective than educational interventions since they do more than teach; they really change thinking strategies and skills. Secondary analysis of Cochrane trials [31] aimed at investigation whether specific therapeutic approach was more effective, indicating variation in outcomes across trials. There is some evidence that more consideration should be given to specific therapeutic approach since cognitive-behavioral interventions were more often proven effective. Also, that additional review showed that results were not moderated by the type of prevention. On the other hand, meta-analysis conducted by Horowitz and Garber [32] included 30 studies where prevention of depression of children and youth was in focus and their conclusion was that regarding depressive symptoms, selective and indicated interventions have larger effects than universal. Nevertheless, universal approach should not be neglected [33]: Australian examples show that universal programs involved less stigma and less attrition of participants.

teacher training [37]. There are several examples of promising interventions using the Internet, applied game or gamification interface for mental health, and meta-analysis shows a moderate effect of d = .55, favoring serious games over no intervention controls. Regarding the fact that this topic requires new chapter, just one illustration—excellent New Zealand example program, SPARX, interactive fantasy game using CBT approach—aims adolescents from 12 to 19 years with elevated depression symptoms, and it is goal-oriented and problem-solving. Each level module lasts 30 min and can be available online or at home computer [38]. Findings show positive impact on emotion regulation and depressive symptoms reduction, and there

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When thinking about new wave of approaches, mindfulness practice also enhances the very qualities and goals of education in the twenty-first century and is usually seen hand in hand with socio-emotional learning approach. Since of it focuses on the body and different approaches to mind, it is a good choice when addressing internalized problems. The application of mindfulness with children and adolescents has increased more recently. Regarding changing lifestyles and risks, it would be helpful if children could learn to stop their mind wandering and regulate attention and emotions, to deal with feelings of frustration, and to self-motivate. A review of the emerging body of research on mindfulness-based interventions with children and adolescents reveals that such interventions might be beneficial in many different ways [39]. Mindfulness is considered one of many contemplative practices and has become a very popular practice due to its various mental and physical health benefits [40]. It is said to have originated two and a half thousand years ago from the religious traditions of Buddhism. Around the late 1970s, Jon Kabat-Zinn introduced mindfulness to Western cultures as a secular health practice [41]. It is defined as the practice of "paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment" ([42], p. 145). Mindfulness is considered as "the self-regulation of attention so that it is maintained on immediate experience… characterized by curiosity, openness, and acceptance" [43]. From this perspective, mindfulness practice can be understood as the foundation and basic precondition for education [44]. Modern education abilities embrace not only good attention skills and emotional competence but also prosocial abilities such as responsiveness, kindness, high ethics standards, sensitivity, imagination, and as well as good problem-solving. They allow children to face forthcoming challenges of the progressing envi-

are several other international examples [37, 38].

**2.3. Mindfulness interventions for internalized problem prevention**

ronment, preferably becoming thoughtful, kind, and dedicated people [45, 46].

There are clear indications now that mindfulness-based programs with children and youth within school setting are feasible and acceptable [39]. Many of the existing school-based mindfulness programs for mental health have been adapted from Mindfulness Based Stress Reduction (MBSR) to meet children's and adolescents' developmental needs and shorter attention spans [47, 48]. These programs include a number of mindfulness-based activities such as breath awareness, psycho-education components, body scans, sitting meditations, and mindful movement, among others [44, 49]. Lately, scientists have initiated studies of various short mindfulness-based interventions, from 1 to 4 weeks long, including mindful eating,

Since the focus of this chapter is related to school context, choice of school preventive intervention programs is presented in **Table 1**. Current literature suggests those programs are either promising since they have mixed results in various evaluations or are still being adapted from more clinical interventions to preventive approach and school settings [30, 33–36]. Brunwasser, Gillham and Kim [34] looked at various studies of Penn Resiliency Program and highlighted promising results for more than eight-session program of longer duration, delivered by a healthcare professional. Generally, many school prevention programs for internalized problems tend to have cognitive-behavioral foundations, and it is notable that they incorporate optimism and hope as their values. Besides school, partners in prevention have to be parents, especially if parental style and parent–child relationship have its difficulties but also if they have anxiety or depression disorder as well. Parental part of the program is adjunct to program activities with youth, and it is implemented simultaneously [33–35].

It is important to emphasize that the use of online and computer delivery of interventions for internalized problems and their prevention is rapidly growing. For new generations of children and adolescents, usage of the Internet or their computer and cellphone seems easy and cost-effective, increases uptake, and secures anonymity that is often being an issue in help seeking. Description of new technology wave interventions is out of the scope of this chapter, but it is necessary to address numerous benefits such as instant availability (especially for mobile phones and apps) and less need for face-to-face professional or time-consuming

2 https://learning2breathe.org/

**Table 1.** Mindfulness school-based programs found promising/effective for internalized problem prevention.

teacher training [37]. There are several examples of promising interventions using the Internet, applied game or gamification interface for mental health, and meta-analysis shows a moderate effect of d = .55, favoring serious games over no intervention controls. Regarding the fact that this topic requires new chapter, just one illustration—excellent New Zealand example program, SPARX, interactive fantasy game using CBT approach—aims adolescents from 12 to 19 years with elevated depression symptoms, and it is goal-oriented and problem-solving. Each level module lasts 30 min and can be available online or at home computer [38]. Findings show positive impact on emotion regulation and depressive symptoms reduction, and there are several other international examples [37, 38].

#### **2.3. Mindfulness interventions for internalized problem prevention**

that regarding depressive symptoms, selective and indicated interventions have larger effects than universal. Nevertheless, universal approach should not be neglected [33]: Australian examples show that universal programs involved less stigma and less attrition of participants. Since the focus of this chapter is related to school context, choice of school preventive intervention programs is presented in **Table 1**. Current literature suggests those programs are either promising since they have mixed results in various evaluations or are still being adapted from more clinical interventions to preventive approach and school settings [30, 33–36]. Brunwasser, Gillham and Kim [34] looked at various studies of Penn Resiliency Program and highlighted promising results for more than eight-session program of longer duration, delivered by a healthcare professional. Generally, many school prevention programs for internalized problems tend to have cognitive-behavioral foundations, and it is notable that they incorporate optimism and hope as their values. Besides school, partners in prevention have to be parents, especially if parental style and parent–child relationship have its difficulties but also if they have anxiety or depression disorder as well. Parental part of the program is adjunct to pro-

It is important to emphasize that the use of online and computer delivery of interventions for internalized problems and their prevention is rapidly growing. For new generations of children and adolescents, usage of the Internet or their computer and cellphone seems easy and cost-effective, increases uptake, and secures anonymity that is often being an issue in help seeking. Description of new technology wave interventions is out of the scope of this chapter, but it is necessary to address numerous benefits such as instant availability (especially for mobile phones and apps) and less need for face-to-face professional or time-consuming

moment by moment, with open-minded curiosity and acceptance

Mindfulness Training [42] Universal, modified MBSR program, students aged 14–15, four 40-min group trainings one

**Table 1.** Mindfulness school-based programs found promising/effective for internalized problem prevention.

Universal, a set of nine scripted lessons tailored to secondary schools, supported by tailored teacher training; it involves learning to direct attention to immediate experience,

Universal and selective, for adolescents, consists of six themes that may be delivered in 6, 12, 18, or more sessions; the six core lessons are body, reflection, emotions, attention,

Universal, for students aged 13–20, includes eight weekly delivered 100-min sessions; it integrates elements of MBSR and mindfulness-based cognitive therapy (MBCT) [54]; students develop specific skills in their capacity to become nonjudgmentally aware of thoughts, feelings, and sensations and increase their capacity to replace automatic, habitual, and often judgmental reactions with more conscious and skillful responses

per week; training covers the concepts of awareness and acceptance, and practices include bodily awareness of contact points, mindfulness of breathing and finding an anchor point, awareness of sounds, understanding the transient nature of thoughts, and walking

gram activities with youth, and it is implemented simultaneously [33–35].

tenderness, and healthy mind habits

**Name of the program. Short description of the program**

meditation

https://mindfulnessinschools.org/what-is-b/b-curriculum/

Mindfulness in Schools Programme (MISP)1

128 Health and Academic Achievement

Learning to Breathe Mindfulness Curriculum2

Mindfulness Group Program [53]

https://learning2breathe.org/

1

2

When thinking about new wave of approaches, mindfulness practice also enhances the very qualities and goals of education in the twenty-first century and is usually seen hand in hand with socio-emotional learning approach. Since of it focuses on the body and different approaches to mind, it is a good choice when addressing internalized problems. The application of mindfulness with children and adolescents has increased more recently. Regarding changing lifestyles and risks, it would be helpful if children could learn to stop their mind wandering and regulate attention and emotions, to deal with feelings of frustration, and to self-motivate. A review of the emerging body of research on mindfulness-based interventions with children and adolescents reveals that such interventions might be beneficial in many different ways [39]. Mindfulness is considered one of many contemplative practices and has become a very popular practice due to its various mental and physical health benefits [40]. It is said to have originated two and a half thousand years ago from the religious traditions of Buddhism. Around the late 1970s, Jon Kabat-Zinn introduced mindfulness to Western cultures as a secular health practice [41]. It is defined as the practice of "paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment" ([42], p. 145). Mindfulness is considered as "the self-regulation of attention so that it is maintained on immediate experience… characterized by curiosity, openness, and acceptance" [43]. From this perspective, mindfulness practice can be understood as the foundation and basic precondition for education [44]. Modern education abilities embrace not only good attention skills and emotional competence but also prosocial abilities such as responsiveness, kindness, high ethics standards, sensitivity, imagination, and as well as good problem-solving. They allow children to face forthcoming challenges of the progressing environment, preferably becoming thoughtful, kind, and dedicated people [45, 46].

There are clear indications now that mindfulness-based programs with children and youth within school setting are feasible and acceptable [39]. Many of the existing school-based mindfulness programs for mental health have been adapted from Mindfulness Based Stress Reduction (MBSR) to meet children's and adolescents' developmental needs and shorter attention spans [47, 48]. These programs include a number of mindfulness-based activities such as breath awareness, psycho-education components, body scans, sitting meditations, and mindful movement, among others [44, 49]. Lately, scientists have initiated studies of various short mindfulness-based interventions, from 1 to 4 weeks long, including mindful eating, walking contemplation, and coloring, as well as combination of mindfulness and yoga activities. Findings suggest this is effective in diminishing emotional problems and problem behaviors in school settings [50–52]. Some of the promising/effective mindfulness school-based programs for internalized problems are presented in **Table 1**.

study. The impact of the PATHS program was tested within the sample of 443 children (aged 3–6) for whom their preschool teachers collected data during three time points within a 2-year period. The first measurement was within the usual practices, before implementation, while second was at the start of the program and third in the end. Forty-five percent of children in

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The study relied on a randomized controlled design to evaluate the impact of PATHS.Originally, 30 schools were recruited with the help of local authorities in three abovementioned implementation sites in Croatia. Within each region, equivalent pairs of schools were coordinated according to area features, household financial status, and proportion of pupils getting freeof-charge meals, number of pupils in school and classroom, as well as overall marks. Within each pair, one school was intervention and other continued typical program. Within each building, two first classrooms were chosen for the program. Only ten children from whole classroom were randomly nominated for assessment.  Forty-seven percent of the school children participants were girls. At the beginning of this study, all children were 7 years old in average and in the middle of the first grade. At the end of the study, children were near the end of the

Both preschool and schoolteachers were assessing children with the same battery. Among

Emotion regulation was measured with seven items from the *Social Competence Scale* from Fast Track Project (http://www.fasttrackproject.org/techrept/s/sct/). Sample item was "accepts things not going her/his way." All items were rated on a 6-point Likert scale with response

Withdrawn/depressed behavior was assessed with six commonly used items compiled for Head Start REDI [28–30]. Sample items were "avoids playing with other children" and "sad, unhappy." All items were rated on a 6-point Likert scale, with response options ranging from

PATHS is one of the most effective socio-emotional learning programs for children from preschool to middle school worldwide. It has been tested in multiple randomized controlled

nine rated child behaviors, two of them are related with internalized symptoms:

options ranging from almost never to usually (α = .89) [68, 69].

the sample were girls.

*3.1.2. School study*

second grade.

*3.1.3. Measures*

*<IP_ADDRESS>. Emotion regulation*

*<IP_ADDRESS>. Withdrawn/depressed behavior*

almost never to usually (α = .81).

**3.2. Paths**

In terms of school-based mindfulness intervention effectiveness, these programs have been associated with decreases in stress levels [55–58], rumination, intrusive thoughts, emotional arousal [59, 60], and depression symptoms [53, 55, 57, 58, 61] along with increases in emotional well-being [62] and self-compassion among participants [57]. A study conducted by Britton et al. [47] on a sample of 100 elementary school students involved into Integrative Contemplative Pedagogy program has shown reduced suicidal ideations and affective disturbance among students after 6 weeks of everyday short meditation training (3–12 min per day). Studies have also confirmed that mindfulness-based interventions in schools lead to a reduction in symptoms of depression in minority children [63] and to a reduction in anxiety and increase of social skills in students with learning disorders [64].

Zenner and colleagues [44] have conducted a systematic review and meta-analysis to summarize data available on the effects of 24 studies of mindfulness-based trainings for children and youth in a school setting and report a significant medium effect size of *d* = .40 across all controlled studies and domains. In 2017, big meta-analysis of 24 studies (n = 3977) was led to examine specific moderators contributing to school-based mindfulness interventions for mental health in youth [65]. Overall, mindfulness interventions were found to be helpful, with small to moderate significant effects pre-post intervention compared to control groups; however, interventions that were delivered during late adolescence (15–18) and that consisted of combinations of various mindfulness activities had the largest effects on mental health and well-being outcomes.