**1. Introduction**

#### **1.1. Internalized problems of children and youth**

Internalized problems are defined as group of emotional symptoms turned toward individual that reveals more prevalent effortful control of behavior, feelings of sadness, low self-esteem,

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

behavioral inhibition, and fears. A substantive body of research indicates that although children and youth are a healthy subpopulation group, 20% of them could experience mental health issue until early twenties, anxiety and depression being the most prevalent [1–3]. That statement is not so surprising if we are aware of the fact that puberty and adolescence bring more sensitivity to social clues, seeking approval from important others, immaturity of neurobiological system connected with emotions, progressive reduction of parental control, and greater importance of peers. Half of all lifetime mental disorders begin before the age of 14, anxiety even before between age 6 and puberty [4]. That being said, school setting is unavoidable when talking about factors that support children and youth to thrive. It seems that students' feelings such as shy or withdrawn behavior, frequent worrying, fears, sadness, loneliness, hopelessness, and low sense of self-worth are unavoidable part of every classroom.

Many authors suggest that research of interventions for children and adolescents should be a priority since the first signs of disorder often happen in adolescence. Adolescence seems to be a crucial window for preventive interventions given the fact that rates of emotional ill health increase during this developmental stage. The 2009 Institute of Medicine report on prevention of mental, emotional, and behavioral disorders presented evidence that anxiety and mood disorders can be prevented [14]. Leaders in the field of mental health recommend further research on prevention and interventions for mental disorders of children and adolescents [1, 9, 15].

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Risk and protective factors on individual, family, school, and community level help to understand the possibilities of organized support for sustaining a state of mental well-being and buffering possible adverse circumstances. Offering opportunities that support strengths should be planned within regular, already existent settings and systems supporting development of children and youth [13]. Program activities and interventions should be theory driven

It is not surprising that research of developmental cascades implies crucial importance of family influences, early attachment, and parent-child relationship [16]. Transfer of emotional problems from parents to offspring is related both with shared genetic factors and vulnerability as well as with inadequate parenting [17]. It seems that maternal depression or existence of parental anxiety symptoms is a risk factor for elevated internalizing problems [17]. Parents' negative emotional expressiveness, including hostility and irritability, affect child's feeling of security [17, 18]: depressed mothers are less responsive to child's needs, more authoritarian, and rejecting, while anxious parents tend to be controlling and express less warmth. Additionally, internalized problems are related with family dynamics where emotion expression is quite restricted, i.e., both positive and negative emotions are suppressed, leading to heightened negativity and avoidance as a mean of regulation [17]. Children in such family context show less emotion recognition and lower emotion regulation strategies. Same authors explain risks specific to child's temperament, such as inhibition, fearfulness, shyness, and avoidance of new situations. Additionally, cognitive style characterized with pessimistic attributions, negative expectations, external locus of control, and rigidity is also a contributor.

One of few longitudinal studies [19] assessing internalized disorders has shown that academic problems, elevated parental stress, serious health issues, and social isolation strongly predict internalized symptomatology that lasts until early adulthood. Specifically, children with three or more negative life events were almost nine times likely to exhibit internalized problems. Such experiences were neglect, maltreatment, family violence, or sexual abuse, rarely found in sample, but also parental conflict and divorce which happen considerably more. Substantive influence on internalized problem development is reported upon peer victimization, rejec-

The more opportunities young people have to accumulate protective factors that outweigh the influence of risks, the more likely they are to preserve their mental health well-being. Key protective factors for stable emotional development include a sense of family belonging as well as school attachment, i.e., caring and warm environments where both adults and peers

tion, and bullying [20] what stresses the need of school interventions once again.

**1.2. Risk and protective factors for internalized disorder trajectories**

and science based, addressing well-known factors.

Newer American epidemiological studies state [4] that there is a prevalence of 32% of anxiety disorders and 14.3% mood disorders in the group of youth from 13 to 18 years old, while around 8% of American youth had a major depressive disorder. A British study included younger children, from 5 to 15, and found a prevalence of 3.7% for any anxiety disorder [4]. 1-year incidence rate for the first onset of major depression in adolescents is between 5.6 and 10%, while 17.9% of adolescents have a recurrent episode within a year [5–7]. Adolescent depression is associated with high rates of comorbid anxiety disorders, disruptive behavior disorders, and suicide attempts. It predicts future adjustment problems including marital difficulties, unemployment, and attachment problems in offspring [5–7]. By late adolescence, twice as many girls are depressed as boys, and 40% of those who experienced depression during youth end up with a diagnosis of major depression in adulthood [7]. After the first major depressive episode, the chance of recurrence and chronicity is very high [8]. Worldwide data shows that depression is a major public health problem that requires the development, implementation, and evaluation of interventions preventing its onset. The World Health Organization estimates that depression is the third leading cause of global disease with projections that it will rank first until 2030 [9]. There is also a great impact of depression on physical health: 40–60% of people who have experienced depression die prematurely [9], often show greater rates of smoking, and, as an aftermath of various circumstances affecting the quality of life, deal with heart disease [10]. When talking about the costs for adults, comprehensive European study estimates annual cost of mood disorders on 113. 4 billion Euros for 33.3 million affected people [11]. Burden is not only personal but also economic, affecting families, communities, and governments.

All this evidence shows that it is crucial to tackle emotional health problems early and shift focus from treatment to prevention and early intervention [4], enabling full potential for future adults. Emotional well-being has implications on children's and adolescent's self-esteem, prosocial behavior, school attendance, and success and increases risk of suicidal behavior, smoking, substance abuse, and delinquency [1, 12, 13] as well as choices of profession, directly leading to circumstances for adulthood [6] and future life chances [9]. Good sense of self in childhood is transferred to adulthood, together with good problem-solving skills, social competence, and feeling of purpose [13]. These resources vouch for good outcomes, serving as buffers in times of risks, stress, and hardship, and they are not only dependent upon child or a teen but also upon family characteristics and various environments in which they live [13, 14]. Many authors suggest that research of interventions for children and adolescents should be a priority since the first signs of disorder often happen in adolescence. Adolescence seems to be a crucial window for preventive interventions given the fact that rates of emotional ill health increase during this developmental stage. The 2009 Institute of Medicine report on prevention of mental, emotional, and behavioral disorders presented evidence that anxiety and mood disorders can be prevented [14]. Leaders in the field of mental health recommend further research on prevention and interventions for mental disorders of children and adolescents [1, 9, 15].

#### **1.2. Risk and protective factors for internalized disorder trajectories**

behavioral inhibition, and fears. A substantive body of research indicates that although children and youth are a healthy subpopulation group, 20% of them could experience mental health issue until early twenties, anxiety and depression being the most prevalent [1–3]. That statement is not so surprising if we are aware of the fact that puberty and adolescence bring more sensitivity to social clues, seeking approval from important others, immaturity of neurobiological system connected with emotions, progressive reduction of parental control, and greater importance of peers. Half of all lifetime mental disorders begin before the age of 14, anxiety even before between age 6 and puberty [4]. That being said, school setting is unavoidable when talking about factors that support children and youth to thrive. It seems that students' feelings such as shy or withdrawn behavior, frequent worrying, fears, sadness, loneliness, hopelessness, and low sense of self-worth are unavoidable part of every classroom.

Newer American epidemiological studies state [4] that there is a prevalence of 32% of anxiety disorders and 14.3% mood disorders in the group of youth from 13 to 18 years old, while around 8% of American youth had a major depressive disorder. A British study included younger children, from 5 to 15, and found a prevalence of 3.7% for any anxiety disorder [4]. 1-year incidence rate for the first onset of major depression in adolescents is between 5.6 and 10%, while 17.9% of adolescents have a recurrent episode within a year [5–7]. Adolescent depression is associated with high rates of comorbid anxiety disorders, disruptive behavior disorders, and suicide attempts. It predicts future adjustment problems including marital difficulties, unemployment, and attachment problems in offspring [5–7]. By late adolescence, twice as many girls are depressed as boys, and 40% of those who experienced depression during youth end up with a diagnosis of major depression in adulthood [7]. After the first major depressive episode, the chance of recurrence and chronicity is very high [8]. Worldwide data shows that depression is a major public health problem that requires the development, implementation, and evaluation of interventions preventing its onset. The World Health Organization estimates that depression is the third leading cause of global disease with projections that it will rank first until 2030 [9]. There is also a great impact of depression on physical health: 40–60% of people who have experienced depression die prematurely [9], often show greater rates of smoking, and, as an aftermath of various circumstances affecting the quality of life, deal with heart disease [10]. When talking about the costs for adults, comprehensive European study estimates annual cost of mood disorders on 113. 4 billion Euros for 33.3 million affected people [11]. Burden is not only personal but also economic, affecting

All this evidence shows that it is crucial to tackle emotional health problems early and shift focus from treatment to prevention and early intervention [4], enabling full potential for future adults. Emotional well-being has implications on children's and adolescent's self-esteem, prosocial behavior, school attendance, and success and increases risk of suicidal behavior, smoking, substance abuse, and delinquency [1, 12, 13] as well as choices of profession, directly leading to circumstances for adulthood [6] and future life chances [9]. Good sense of self in childhood is transferred to adulthood, together with good problem-solving skills, social competence, and feeling of purpose [13]. These resources vouch for good outcomes, serving as buffers in times of risks, stress, and hardship, and they are not only dependent upon child or a teen but also upon family characteristics and various environments in which they live [13, 14].

families, communities, and governments.

124 Health and Academic Achievement

Risk and protective factors on individual, family, school, and community level help to understand the possibilities of organized support for sustaining a state of mental well-being and buffering possible adverse circumstances. Offering opportunities that support strengths should be planned within regular, already existent settings and systems supporting development of children and youth [13]. Program activities and interventions should be theory driven and science based, addressing well-known factors.

It is not surprising that research of developmental cascades implies crucial importance of family influences, early attachment, and parent-child relationship [16]. Transfer of emotional problems from parents to offspring is related both with shared genetic factors and vulnerability as well as with inadequate parenting [17]. It seems that maternal depression or existence of parental anxiety symptoms is a risk factor for elevated internalizing problems [17]. Parents' negative emotional expressiveness, including hostility and irritability, affect child's feeling of security [17, 18]: depressed mothers are less responsive to child's needs, more authoritarian, and rejecting, while anxious parents tend to be controlling and express less warmth. Additionally, internalized problems are related with family dynamics where emotion expression is quite restricted, i.e., both positive and negative emotions are suppressed, leading to heightened negativity and avoidance as a mean of regulation [17]. Children in such family context show less emotion recognition and lower emotion regulation strategies. Same authors explain risks specific to child's temperament, such as inhibition, fearfulness, shyness, and avoidance of new situations. Additionally, cognitive style characterized with pessimistic attributions, negative expectations, external locus of control, and rigidity is also a contributor.

One of few longitudinal studies [19] assessing internalized disorders has shown that academic problems, elevated parental stress, serious health issues, and social isolation strongly predict internalized symptomatology that lasts until early adulthood. Specifically, children with three or more negative life events were almost nine times likely to exhibit internalized problems. Such experiences were neglect, maltreatment, family violence, or sexual abuse, rarely found in sample, but also parental conflict and divorce which happen considerably more. Substantive influence on internalized problem development is reported upon peer victimization, rejection, and bullying [20] what stresses the need of school interventions once again.

The more opportunities young people have to accumulate protective factors that outweigh the influence of risks, the more likely they are to preserve their mental health well-being. Key protective factors for stable emotional development include a sense of family belonging as well as school attachment, i.e., caring and warm environments where both adults and peers 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.

problems more effectively and develop active coping strategies, as well as to support caring

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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

relationships and quality interactions with important others.
