**3. Croatian example: Effects of socio-emotional learning on internalized problems**

#### **3.1. Research studies**

The aim of this part of the chapter is to present two studies of empirical evaluation of social– emotional learning curriculum, Promoting Alternative Thinking Strategies (PATHS) [66], conducted in Croatian kindergartens [67] and elementary schools [68] in order to examine the effects on the level of internalized problems such as emotional withdrawal, depressive symptoms, and worry.

#### *3.1.1. Preschool study*

The preschool PATHS study involved a quasi-experimental design, evaluating the short-term outcomes of the preschool PATHS curriculum implemented in six buildings across three Croatian sites (Zagreb, the capital city of Rijeka, and the Region of Istria, Croatia). Within each building two groups were chosen, and twelve kindergarten groups were included in the 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 the sample were girls.

#### *3.1.2. School study*

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

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

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

The aim of this part of the chapter is to present two studies of empirical evaluation of social– emotional learning curriculum, Promoting Alternative Thinking Strategies (PATHS) [66], conducted in Croatian kindergartens [67] and elementary schools [68] in order to examine the effects on the level of internalized problems such as emotional withdrawal, depressive

The preschool PATHS study involved a quasi-experimental design, evaluating the short-term outcomes of the preschool PATHS curriculum implemented in six buildings across three Croatian sites (Zagreb, the capital city of Rijeka, and the Region of Istria, Croatia). Within each building two groups were chosen, and twelve kindergarten groups were included in the

programs for internalized problems are presented in **Table 1**.

and increase of social skills in students with learning disorders [64].

**3. Croatian example: Effects of socio-emotional learning on** 

well-being outcomes.

130 Health and Academic Achievement

**3.1. Research studies**

symptoms, and worry.

*3.1.1. Preschool study*

**internalized problems**

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. Since some teachers failed to complete assessments, final sample consisted of 568 children and 546 children (96% of the sample) had complete post-intervention assessments. 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 second grade.

#### *3.1.3. Measures*

Both preschool and schoolteachers were assessing children with the same battery. Among nine rated child behaviors, two of them are related with internalized symptoms:

#### *3.1.3.1. Emotion regulation*

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

#### *3.1.3.2. Withdrawn/depressed behavior*

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 almost never to usually (α = .81).

#### **3.2. Paths**

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 trials and implemented in many different contexts with children of various backgrounds. Various research and independent studies show that PATHS program is a successful example of whole-school generalization, enhances classroom climate and significantly contributes to children's emotion recognition and self-regulation, improves relationships with others, and diminishes externalizing problems [70, 71].

#### **3.3. Results in Croatia: effects of PATHS on internalized symptomatology**

To test intervention effects, hierarchical linear models were estimated, nesting children within classrooms. In school study, analyses were conducted for subgroups of children within the sample. Each of the child behaviors included in this study was dichotomized to specify whether a child was above or below average in terms of her/his functioning at the pre-intervention assessment. Latent class analysis was applied to nine indicators to determine whether children were relatively high or low risk. In this analysis, 223 children had the highest probability of being in the most elevated risk group. Those children had highest likelihood for lower scores on prosocial behavior, control of emotions, and school-related performance. In the same time, the same kids had a highest chance for high results on problem list (inattentiveness, hyperactivity, opposition, aggression, difficulties with peers, and inhibited/sad behavior). Analysis showed that 335 children had maximum chance of being in the low-risk subclass, which was characterized by above average scores on the positive behaviors and below average scores on the negative behaviors.

In preschool study, analyses were done in two stages: the first stage aiming to see changes in intervention sample across time and the second stage to compare scores with comparison condition. The first stage of preschool analyses shows insignificant change score for emotional symptoms of −.14, p < .0001, *d* = .41; ICC = .02, *p* = ns. Second-stage analyses show differences among children who were in comparison and PATHS condition: there was statistically significant difference in rates of change for emotional symptoms, β = −.33, *p* = < .05, *d* = .56; ICC = .27, *p* < .05. The magnitude of this difference in rates of change was over one-half of one standard deviation. Results for school study are shown in **Table 2**.

In school study, the pre-intervention level of functioning on the outcome and child sex were included as covariates. Among the children who were relatively high risk, there were no statistically significant differences between intervention and control group children.

Among the children who were relatively low risk, there was a small to moderate effect for emotion regulation and a marginally statistically significant difference in withdrawn/ depressed behavior but no changes for high-risk group. To examine the robustness of effects among the low-risk children, latent class analysis was used again to determine whether children exhibited any problems. In this analysis, 81 children had the highest probability of being in the low risk with social difficulties subgroup, which was characterized by below average scores on prosocial behavior and emotion regulation and above average scores on withdrawn/depressed behavior. The other 254 children had the highest probability of being in the low risk without social difficulties subgroup, which was characterized by above average scores on all the positive behaviors and below average scores on all the negative behaviors.

Among the children who were relatively low risk with social difficulties, there were statistically significant differences on emotion regulation and withdrawn/depressed behavior. Intervention effects of this magnitude shown in **Table 3** would be considered moderate to large. Among the children who were low risk without social difficulties, there was a small

Both of the presented studies of PATHS curriculum in Croatia indicate participation of children in universal, social-emotional curriculum that promotes emotion recognition and

effect on emotion regulation but no effect on withdrawn behavior.

**Table 3.** Prevention programs found promising/effective for internalized problems prevention.

**3.4. Discussion of results**

**School study Complete** 

**Legend:**\**level of significance p* = <.05; \*\**level of significance p* = <.01.

Emotion regulation

Withdrawn behavior

of schoolchildren.

Suicidal thoughts or behaviors

1

2

3

4

Depressive symptoms

**sample (N = 568)** **High-risk children (n = 223)**

**Problem in focus Found to work Short description of program**

Adolescents coping With

Problem-solving for life Penn Prevention Program/ Penn Resiliency Program

Signs of Suicide Prevention

https://www.childtrends.org/programs/adolescent-coping-with-stress/

https://www.childtrends.org/programs/problem-solving-for-life/

stress

Anxiety symptoms FRIENDS Program/Friends for Life Program

Program

https://ppc.sas.upenn.edu/research/resilience-children

https://nrepp.samhsa.gov/ProgramProfile.aspx?id=85

**All low-risk children (n = 335)**

.18+ .06 .38\*\* .65\*\* .32\*

−.09 .06 −.26+ −.52\* −.19

**Table 2.** School PATHS effects on emotion regulation and withdrawn behavior for the complete sample and subgroups

widely disseminated

from Coping with Depression Course1

**Low-risk children with social difficulties (n = 81)**

Prevention of Internalized Problems of Children and Youth in Academic Setting

Fifteen sessions for group from three to ten participants, adapted

intervention for adolescents in risk, managed by educated therapist

olds, 8 sessions, focusing on life problem-solving skills, positive problem-solving orientation, and optimistic-thinking styles

at depression and anxiety symptom reduction, special accent on optimism, coping strategies and perspective taking, one of the most

Cognitive-behavioral approach for adolescents, delivered by school staff supported by trained graduate psychology student, 10 one and half hour sessions, teaching coping skills and problem-solving +

Universal, school-based program for middle school and high school; central activities are raising awareness for depression and suicide

Universal, teacher-implemented classroom program<sup>2</sup>

School based, facilitated by school counselor3

parallel parent intervention, four sessions

signs and help seeking behavior4

**Low-risk children without social difficulties (n = 254)** 133

http://dx.doi.org/10.5772/intechopen.75590

, group CBT preventive

, for 12–14 year

, 12 sessions, aimed


\*\**level of significance p* = <.01.

trials and implemented in many different contexts with children of various backgrounds. Various research and independent studies show that PATHS program is a successful example of whole-school generalization, enhances classroom climate and significantly contributes to children's emotion recognition and self-regulation, improves relationships with others, and

To test intervention effects, hierarchical linear models were estimated, nesting children within classrooms. In school study, analyses were conducted for subgroups of children within the sample. Each of the child behaviors included in this study was dichotomized to specify whether a child was above or below average in terms of her/his functioning at the pre-intervention assessment. Latent class analysis was applied to nine indicators to determine whether children were relatively high or low risk. In this analysis, 223 children had the highest probability of being in the most elevated risk group. Those children had highest likelihood for lower scores on prosocial behavior, control of emotions, and school-related performance. In the same time, the same kids had a highest chance for high results on problem list (inattentiveness, hyperactivity, opposition, aggression, difficulties with peers, and inhibited/sad behavior). Analysis showed that 335 children had maximum chance of being in the low-risk subclass, which was characterized by above average scores on the positive behaviors and

In preschool study, analyses were done in two stages: the first stage aiming to see changes in intervention sample across time and the second stage to compare scores with comparison condition. The first stage of preschool analyses shows insignificant change score for emotional symptoms of −.14, p < .0001, *d* = .41; ICC = .02, *p* = ns. Second-stage analyses show differences among children who were in comparison and PATHS condition: there was statistically significant difference in rates of change for emotional symptoms, β = −.33, *p* = < .05, *d* = .56; ICC = .27, *p* < .05. The magnitude of this difference in rates of change was over one-half of one

In school study, the pre-intervention level of functioning on the outcome and child sex were included as covariates. Among the children who were relatively high risk, there were no sta-

Among the children who were relatively low risk, there was a small to moderate effect for emotion regulation and a marginally statistically significant difference in withdrawn/ depressed behavior but no changes for high-risk group. To examine the robustness of effects among the low-risk children, latent class analysis was used again to determine whether children exhibited any problems. In this analysis, 81 children had the highest probability of being in the low risk with social difficulties subgroup, which was characterized by below average scores on prosocial behavior and emotion regulation and above average scores on withdrawn/depressed behavior. The other 254 children had the highest probability of being in the low risk without social difficulties subgroup, which was characterized by above average scores on all the positive behaviors and below average scores on all the negative

tistically significant differences between intervention and control group children.

**3.3. Results in Croatia: effects of PATHS on internalized symptomatology**

diminishes externalizing problems [70, 71].

132 Health and Academic Achievement

below average scores on the negative behaviors.

behaviors.

standard deviation. Results for school study are shown in **Table 2**.

**Table 2.** School PATHS effects on emotion regulation and withdrawn behavior for the complete sample and subgroups of schoolchildren.


**Table 3.** Prevention programs found promising/effective for internalized problems prevention.

Among the children who were relatively low risk with social difficulties, there were statistically significant differences on emotion regulation and withdrawn/depressed behavior. Intervention effects of this magnitude shown in **Table 3** would be considered moderate to large. Among the children who were low risk without social difficulties, there was a small effect on emotion regulation but no effect on withdrawn behavior.

#### **3.4. Discussion of results**

Both of the presented studies of PATHS curriculum in Croatia indicate participation of children in universal, social-emotional curriculum that promotes emotion recognition and relationships with others and self-esteem and self-control can diminish emotional symptoms, withdrawal, depressed symptoms, and worry, even for young children from 3 to 6. Also, data clearly shows that the decrease of risks for development of internalized problems is not uniform for all children: benefits vary depending upon sets of negative behaviors or lack in social or learning skills.

**Acknowledgements**

**Conflict of interest**

manuscript.

**Author details**

**References**

2008.04.007

1469-7610.2006.01682.x

Miranda Novak\* and Josipa Mihić

contributed to the chapter by conducting analyses.

\*Address all correspondence to: miranda.novak@erf.hr

Geneva: World Health Organization; 2012

980-989. DOI: 10.1016/j.jaac.2010.05.017

and Rehabilitation Sciences, University of Zagreb, Croatia

Studies mentioned in this chapter were financed by the Unity through Knowledge Fund, Republic of Croatia, and the local authorities of three Croatian regions. Josipa Basic, retired full professor of Faculty of Education and Rehabilitation Sciences, University of Zagreb, Croatia, was the project leader; Celene Domitrovich, now at Department of Psychiatry, Georgetown University, USA, was the coleader. Robert L. Nix, University of Wisconsin, Madison, USA,

Prevention of Internalized Problems of Children and Youth in Academic Setting

http://dx.doi.org/10.5772/intechopen.75590

135

Authors certify they have no financial or nonfinancial interest in the subject matter of this

Department of Behavioral Disorders, Prevention Research Laboratory, Faculty of Education

[1] World Health Organization. Adolescent's Mental Health: Mapping Actions of Non-Governmental Organizations and Other International Development Organizations.

[2] Lack CW, Green AL. Mood disorders in children and adolescents. Journal of Pediatric Nursing: Nursing Care of Children and Families. 2009;**24**(1):13-25. DOI: 10.1016/j.pedn.

[3] Jane Costello E, Erkanli A, Angold A. Is there an epidemic of child or adolescent depression? Journal of Child Psychology and Psychiatry. 2006;**47**(12):1263-1271. DOI: 10.1111/j.

[4] Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J. Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry. 2010;**49**(10):

Analyses conducted for subgroups of children show that effectiveness depends upon child's capacity and needs. For children that are low risk but seem to have smaller issues in relating to others and lower social skills as well as lower learning behaviors, it is plausible to conclude that mental health promotion intervention like PATHS is very useful. For that group of children that need additional but not clinical support, improvement of classroom climate, boost of social competencies, and focus on feelings, such classroom intervention gives promising results. For that subgroup, improvement of emotion regulation and decline in withdrawal happened within a year of program implementation. Our results for high-risk children subsample show that they need additional care and support, probably more attention within indicated prevention approach or even clinical support. Nevertheless, within comprehensive policy addressing mental and emotional well-being of children, Croatian example shows that universal strategies are helpful and should be considered when planning prevention of internalized symptoms.
