Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS): Pilot test of a school-based positive psychological intervention for adolescents

Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS): Pilot test of a school-based positive psychological intervention for adolescents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS): Pilot test of a school-based positive psychological intervention for adolescents Lisa Kamsickas, Jacquelyn E. Stephens, Kathryn Jackson, Nia Heard-Garris, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4464805/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: This study tested the feasibility and preliminary efficacy of Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS) a positive psychological intervention (PPI), tailored for adolescents and administered in a classroom setting, in boosting CEDARS skill use and emotional well-being. Method: Adolescents (N = 102, 45% female) aged 13-15, in four physical education classes at the same school were randomly assigned by classroom to either receive the CEDARS intervention (n = 59) or engage in the usual class activities (n = 44). Participants completed self-report measures at three time points assessing use of intervention skills, positive and negative affect, depressive symptoms, and perceived stress. Results and Conclusion: Groups differed significantly on race with 57% of the intervention group compared to 75% of the control group identifying as Asian or Pacific Islander. Race-adjusted analyses revealed that both groups improved on intervention skill use, negative affect, depressive symptoms, and perceived stress. The group by time interaction was significant such that the CEDARS group increased skill use from pre- to post- intervention and this difference persisted at follow-up. Contrary to hypotheses, there were also significant group by time interactions indicating that the control group had a steeper decline in depression and perceived stress from pre- to post-intervention. Students reported high acceptability and feasibility and suggested key changes to increase engagement. The current study expands on the existing PPI literature focused on adolescents and highlights the need for larger and more diverse samples, as well as developmentally- and culturally-tailored interventions. Figures Figure 1 Figure 2 Figure 3 Introduction Although experiencing some stress during adolescence is normative, too much stress can have deleterious effects on adolescents’ psychological and physical health, including increasing the likelihood of depression, anxiety, social withdrawal, fatigue, and poor problem-solving [ 1 ] as well as increasing the risk of negative health outcomes [ 2 ]. Adolescence is marked by an objective increase in stressors, as well as increases in subjective perceptions of stress [ 3 ]. Adolescents may be particularly sensitive to stress as they experience an increase in autonomy and undergo rapid developmental changes in biological, emotional, social, relational, and cognitive domains [ 4 ]. Simultaneously, during adolescence the stress response system itself may become more robust, leading to increased risk for psychopathology [ 5 ]. As a result, adolescents are especially vulnerable for developing mental health problems when exposed to stressful life events [ 6 , 7 ]. Coping with stress is a key developmental task of adolescence [ 8 ]. Adolescents who do not have strategies for adaptively managing negative emotions may be even more vulnerable to developing psychopathology [ 9 , 10 ]. As concerns rise over adolescents’ deteriorating mental health [ 11 , 12 ], research on coping and stress reduction has grown rapidly [ 3 , 13 – 15 ]. Adolescents who have effective coping strategies and stress management techniques are less likely to be maladjusted or depressed [ 16 , 17 ],though there is high variability in which coping strategies are effective for whom and for which stressors (i.e., not one size fits all)[ 15 ]. Moreover, while effective coping can successfully buffer against mental health symptoms, coping alone is not enough to prevent or fully attenuate symptoms of psychopathology in adolescence. Critically, research has moved beyond a sole focus on relieving negative symptoms, to also promoting well-being [ 18 , 19 ] particularly through increasing positive emotions [ 20 ]. Previous research has shown an independent contribution of positive affect to reductions in risk behavior and increases in adaptive coping with serious stressful events and chronic disease diagnosis [ 21 , 22 ]. Adolescents who report experiencing more positive emotion use more critical thinking skills, have more cognitive flexibility, perform better at memory encoding, and engage in more creative problem-solving, than adolescents who report experiencing less positive emotion [ 23 ]. The benefits of positive emotions in adolescence may also persist into other life stages. Coffey and Warren [ 24 ] found that higher positive emotions in adolescence predicted greater self-esteem and life satisfaction 13 years later. The cognitive resources and abilities conferred from positive emotion may be particularly impactful during chronic stress [ 25 ]. Given that adolescence is generally associated with greater emotional volatility and more frequent high-intensity negative emotion compared to adults [ 26 ], programs that focus specifically on skills to increase positive emotion, especially during times of stress, may be particularly protective for this age group. Interventions that target positive emotion Positive psychological interventions (PPIs) seek to promote well-being in individuals by bolstering their positive emotions, cognitions, and behaviors [ 27 ]. PPIs have been shown to help individuals better cope with stress and result in decreased depressive and anxiety symptoms and increased well-being [ 28 – 30 ]. These meta analyses also found that multi-component PPIs (i.e., those that include multiple skills) were more effective at improving psychological well-being than those that focus on a single skill (e.g., mindfulness)[ 28 , 30 ]. Benefits of PPIs are well-documented in adults and chronically stressed populations [ 28 ] and researchers have begun examining PPIs in adolescents, particularly in school settings [ 31 – 34 ]. School-based positive psychology interventions for adolescents For adolescents, schools provide an advantageous setting to teach well-being skills because large groups of students can be reached simultaneously, students’ interactions and experiences at school comprise most of their waking time and are therefore an important determinant of their well-being, and improving student mental health and well-being has become an increasing focus for educators and policy makers [ 35 , 36 ]. Many students also may perceive the school setting as a comfortable and secure environment for such interventions, in part because they can gain reassurance and support from their peers [ 37 ]. School programs have a wider reach than individual-based programs (i.e., can reach more students), can have a preventative focus (i.e., students can participate before needing professional mental health intervention), and can teach skills that target multiple domains (i.e., students can implement the skills both at school and at home, maximizing their positive effect) [ 38 ]. Previous school-based PPIs for adolescents have aimed to cultivate hope, gratitude, serenity, resilience, and character strengths, among other skills [ 31 , 34 , 39 ]. Consistent with the broader PPI literature, school-based interventions that incorporate multiple components have demonstrated greater efficacy compared to those that solely focus on a single skill [ 31 , 40 ]. School-based PPIs have been shown to foster well-being for students across different countries, genders, and races [ 32 , 34 ]. However, it is unclear what types of PPIs are most feasible in a school setting and which specific skills are most beneficial for students. In the current study, we aim to address these limitations in prior research by investigating the feasibility and preliminary efficacy of the Coping and Emotion Development for Adolescents to Reduce Stress (CEDARS) intervention, a school-based PPI for adolescents. CEDARS, a 5-session PPI that includes 8 skills: noticing positive events, savoring positive events, gratitude, mindful awareness and nonjudgment, positive reappraisal, identifying personal strengths, setting attainable goals, and acts of kindness (See Fig. 1 ). When taught together, these skills have been found to significantly increase positive emotion and decrease depression levels among adults coping with chronic illnesses and other types of life stressors in multiple studies [ 41 – 43 ]. We hypothesized that acceptability and feasibility would be good-to-high for the intervention. We expected that adolescents in the intervention group would significantly increase their use of the skills taught in the interventions, compared to baseline. We also expected them to report greater positive emotion, and lower negative emotion, perceived stress, and depressive symptoms from baseline to post-intervention, as well as at the one-month follow-up. Method Procedure and Content of the Intervention Ethics approval and consent to participate. All procedures received ethics approval by the UCSF IRB Committee on Human Research. The study was also approved by the San Francisco Unified School District (SFUSD) committee for conducting research in schools. Prior to data collection and during class, researchers explained to students that they were testing a program designed to reduce stress and increase positive emotion. Only students who provided their assent and written consent from a parent were enrolled in the study and completed the assessments, though all students received the intervention as part of classroom instruction. Parent consent forms were provided in English, Chinese, and Spanish according to school district regulations. CEDARS was tailored for adolescents by an interdisciplinary working group that included a pediatrician training as a specialist in adolescent medicine, a high school teacher, a counseling psychologist with extensive experience working with adolescents in school settings, a developmental psychologist, and a social/health psychologist who developed the original intervention (JTM). The team members considered adolescent cognitive, emotional, and social development and the evidence base regarding prevention programs delivered in school settings when deciding how much didactic information to provide, what kind of group activities to use, and how interactive to make the sessions. The CEDARS intervention consisted of one weekly, 50-minute, in-person, classroom-based session held consecutively for five weeks. In each session, trained facilitators taught one to two empirically-supported skills for increasing positive affect. The intervention was structured as follows: Session 1) gratitude and noting daily positive events; Session 2) amplifying positive events and mindfulness; Session 3) positive reappraisal; Session 4) focusing on personal strengths and setting attainable goals; and Session 5) performing small acts of kindness. Each session had a didactic portion in which the positive affect skill(s) for that session were introduced, followed by interactive practice of the skill(s), and finally, discussion of the home practice for the following week. Each week, participants were given a set of practice activities and a workbook to record their daily practice according to the skill(s) they learned that week. A feasibility and acceptability assessment was completed at the end of each intervention session. The intervention and control groups completed questionnaires at baseline (T1), at post-test, after completing the 5-week program (T2), and one month later (T3). Measures Feasibility and acceptability were assessed through weekly feedback surveys asking students to rate how helpful each of that week’s skills had been on a scale from 1 ( not helpful ) to 4 ( very helpful) . In an open-ended format, they were also asked what they like best and least about the last session. Weekly surveys were completed with paper and pencil at the beginning of each session on their perceptions of the prior week’s session. Students were also asked to provide open-ended feedback with suggestions for improvements to the content and delivery of CEDARS in weekly surveys. Intervention skill use was assessed using a composite score of individual skill items, which included each of the eight skills taught in CEDARS (gratitude, positive events, acts of kindness, positive reappraisal, attainable goals, personal strengths, and amplifying), which students rated on a scale from 0 to 6. The individual items were averaged to create the intervention skills composite score for each participant at each time point. The composite score had high reliability (α = .91). Positive and negative emotions were measured using a modified version of the Differential Emotions Scale (DES) [20]. This 25-item scale measured various positive (e.g., amused, awe, content) and negative emotions (e.g., ashamed, sad, embarrassed). Participants rated how often they felt each emotion in the last week on a 5-point scale: 0 ( not at all ) to 4 ( extremely ). The positive and negative items were averaged to create separate negative (α = .87) and positive composites (α = .92). Depressive symptoms over the past week were measured using the Center for Epidemiological Studies Depression scale (CES-D)[44]. Participants were asked to indicate how often they felt a certain way about 20 items on a 4-point scale: 0 ( rarely or less than one day ) to 3 ( most days or 5 through 7 days ). Items were summed to create a total depression score (α = .76). Perceived stress was measured using the 10-item Perceived Stress Scale (PSS-10) [45] in which participants rated their perceived stress on a 5-point scale: 0 ( never ) to 4 ( very often ) (α = .66). Race. National Institutes of Health targeted enrollment categories were used to assess race/ethnicity. A majority of the sample identified as Asian-American or Pacific Islander (AAPI), thus race was dichotomized based on race distribution in the sample using an indicator variable, 1 = students who self-identified as AAPI and 0 = students who identified as any other race. Analytic Strategy We first described the baseline demographic characteristics and key study variables for the sample using means/standard deviations and frequencies/percentages for continuous and categorical variables, respectively; baseline differences between groups were identified using independent sample t- tests and chi-squared tests. To gain insight into acceptability and feasibility of the intervention, we examined responses to the students’ weekly feedback surveys (from the intervention group only). Student responses to open-ended survey questions were included as qualitative data to “triangulate” the quantitative data (i.e., a mixed methods approach; Johnson et al., 2007). To determine preliminary efficacy of the intervention, we conducted a series of mixed-effects and repeated measures ANCOVAs [46], followed by planned contrast analyses. Specifically, we examined group differences in change in the outcome variables (positive affect skill use, positive affect, negative affect, depressive symptoms, perceived stress) over time using mixed-effects ANCOVAs. Race was included as a covariate, given the between condition differences in racial demographics, as well as outcome variables, at baseline (see Table 1). The within-subjects factor was timepoint and the between-subjects factor was the intervention group (either intervention or control). These analyses were followed by within-group repeated-measures ANCOVAs to assess change from baseline (T1) to post-intervention (T2) for the intervention and control group separately. All ANCOVAs were then repeated from baseline (T1) to follow-up (T3) to determine whether effects persisted at the third timepoint. For the intervention group only, we conducted mixed effects repeated measures ANCOVAs for the individual skills that comprised the interventions skills composite (i.e., the skills taught in the intervention), to determine whether specific skills drove any significant associations. Analyses were run using SPSS statistical software version 28.0. Results Preliminary Analyses Of the 103 students who gave assent and whose parents signed informed consent documents, 102 (99%) completed the baseline questionnaires, 97 (94.2%) students completed the T2 questionnaires, and 99 (96%) completed the T3 questionnaires. The average participant age was 14.35 (SD = .52) and the sample was 45% female. The control group was comprised of a significantly higher number of students identifying as Asian-American or Pacific Islander, whereas the intervention group had a significantly higher number of students identifying as non-Hispanic White (Table 1). The control group reported greater depressive symptoms and perceived stress at baseline than the intervention group ( p value s < .05) (Table 2). Feasibility and Acceptability Students rated the sessions with moderate-to-high acceptability and feasibility. Combined across all sessions, students rated the sessions as both helpful (Median = 2.0, M = 1.75, SD = 0.69) and interesting (Median = 2.00, M = 1.68, SD = 0.63), on a scale from 0-3. Session 3, which taught positive reappraisal, was rated highest in helpfulness (Median = 2.0, M = 1.89, SD = 0.70) and interest (Median = 2.00, M = 1.92, SD = 0.73), though none of the session ratings were statistically different from one another ( p > .05). Students identified mindfulness as their favorite skill (33%), followed closely by positive reappraisal (25%), then amplifying positive events (15%). The fewest students preferred identifying personal strengths and setting attainable goals (2% and 5%, respectively). Student Feedback. Overall, students reported enjoying the sessions in the open-ended weekly surveys. They appreciated the engaging format of the sessions and articulated benefits from several of the specific skills. They appreciated aspects of the content as well as structure of the sessions. “I liked talking about what makes me makes me stressed and hearing that everyone else was going through it too.” (Session 1) “I liked it because I could relate to so many of the situations people had when they were stressed.” (Session 1) “It was nice to know that it was beneficial to be positive.” (Session 3) “Realizing that I had a lot more strengths than I thought.” (Session 4) Students’ least liked aspects of the intervention were around their perceived lack of hands-on and engaging activities during the sessions. “We weren't involved enough and it got boring.” (Session 1) “I didn't like that a lot of the material was repeated.” (Session 1) “Talking/lectures for most of the time.” (Session 3) “Sitting there for so long.” (Session 5) Their suggestions included making the sessions more interactive and engaging through the use of games and other activities and tailoring the content even more to their lives. “Games! games! too much lecturing and just sitting and talking” (Session 4) “Relate it more to our lives” (Session 5) “Do more activities…they are fun while just talking and sharing emotions is boring” (Session 5) Within- and Between-Group Change in Outcomes from Pre- to Post-Intervention Given the group difference in proportion of students identifying as AAPI, we control for race in the following analyses. Results from the uncontrolled analyses are in the supplementary table. Intervention skill use. In mixed-factor ANCOVAS between the control and intervention group, controlling for the group difference in participants identifying as AAPI, there was a significant interaction between Time and Group, F (1, 100) = 4.367, p = .04. Specifically, only the intervention group experienced an increase in overall intervention skill use from pre- to post-intervention (Figure 2A). This Time by Group interaction persisted at the follow-up timepoint F (1, 101) = 4.06 ( p = .047) In analyses within the intervention group, the increase in overall positive emotion skill use was not statistically significant, from pre- ( M = 2.31, SD = 1.47) to post-intervention ( M = 2.78, SD = 1.58; F (1, 57) = 1.83, p = .18, ) or to follow-up ( M = 2.77, SD = 1.48), F (1, 57) = 3.81, p = .06. There was no significant change in overall intervention skill use within the control group ( p > .05 for all). Looking separately at use of each of the 8 intervention skills , repeated measures ANCOVAs within the intervention group revealed that amplifying positive events significantly increased from pre- ( M = 1.91, SD = 1.64) to post-intervention ( M = 2.65, SD = 1.94), p = .03, and was maintained at follow-up ( M = 2.51, SD = 1.67), p = .02. Gratitude marginally increased from pre- ( M = 1.88, SD = 1.93) to post-intervention ( M = 2.61, SD = 1.88), p = .108, and remained marginal at follow-up ( M = 2.62, SD = 1.82), p = .07 (Figure 3). Identifying personal strengths, positive reappraisal, noticing positive events, acts of kindness, and attainable goals did not change significantly over time ( p s > .05 for all). Well-being Outcomes Positive emotions. In mixed ANCOVAS including both the control and intervention group, there was a significant effect of time, F (1, 100) = 6.69, p = .01, indicating that both groups improved on positive emotion from pre- to post-intervention (Figure 2B). The interaction between Time and Group, however, was not significant, F (1, 100) = .51, p > .05 (Figure 2B), indicating that there was no difference in change over time between groups. This interaction remained non-significant at the follow-up timepoint ( p > .05). In analyses within the intervention group, there was a marginally significant change in positive emotions at post-intervention, (pre: M = 2.87, SD = .90; post : M = 2.98, SD = .97), F (1, 57) = 3.23, p = .08, which was not sustained at follow-up ( p > .05). Similarly, there was a marginally significant increase in positive emotions for the control group (pre: M = 2.85, SD = 1.00; post : M = 3.02, SD = .95), F (1, 42) = 3.19, p = .08) that was not sustained at follow-up ( p > .05). Negative emotions. In mixed ANCOVAS comparing the control and intervention group, there was a significant effect of time, F (1, 100) = 21.38, p .05 (Figure 2C). This interaction remained non-significant at the follow-up timepoint ( p > .05). In follow-up analyses within the intervention group, there was a significant decrease in negative emotions F (1, 57) = 17.29, p < .001, from pre- ( M = 1.57, SD = .86) to post-intervention ( M = 1.33, SD = .84). This decrease was sustained at follow-up ( M = 1.32, SD = .80), F (1, 57) = 9.97, p = .003. There was a marginally significant decrease in negative emotions for the control group from pre- ( M = 1.58, SD = .79) to post-intervention ( M = 1.47, SD = .70; p = .06) and a significant decrease at follow-up ( M = 1.53, SD = .80), F (1, 42) =5.25, p = .03. Depressive Symptoms. In mixed ANCOVAS comparing the control and intervention group, there was a significant effect of time, F (1, 100) = 6.29, p = .01, such that there was a decrease in depressive symptoms overall, as well as a significant interaction between Time and Group, F (1, 100) = 6.62, p = .01 (Figure 2D). Specifically, contrary to our hypotheses, the control group demonstrated a steeper decline in depressive symptoms than the intervention group. The interaction between Time and Group was not significant from pre-test to follow-up ( p > .05). In follow-up analyses within the intervention group, there was not a significant change in depressive symptoms post-intervention, F (1, 57) =.40, p = .53 though there was a marginally significant decrease at follow-up, F (1, 57) = 3.38, p = .07). The control group experienced a significant reduction in depressive symptoms from pre ( M = 17.07, SD = 9.58) to post-intervention ( M =13.40, SD = 6.49), F (1, 42) = .67, p = .01, that was sustained at follow-up ( M =14.79, SD = 7.25), p = .05. Perceived Stress. In mixed ANCOVAS comparing the control and intervention group, there was a significant effect of time, F (1, 100) = 15.33, p < .001, such that perceived stress decreased overall, as well as a significant interaction between Time and Group, F (1, 100) = 6.57, p = .01 (Figure 2E). Specifically, the control group experienced a steeper decline in perceived stress than the intervention group. The interaction between Time and Group was not significant from pre-test to follow-up ( p > .05). In analyses within the intervention group, there was a significant change in perceived stress from pre- ( M = 15.63, SD = 5.95) to post-intervention ( M =15.21, SD = 6.23), F (1, 57) = 5.74, p .02, which was sustained at follow-up ( M = 14.75, SD = 6.20), F (1, 57) = 6.43, p .01. The control group also experienced a decrease in perceived stress from pre- ( M = 18.98, SD = 5.63) to post-intervention ( M = 16.64, SD = 5.69), F (1, 42) = 6.44, p = .02, but this reduction did not persist to follow-up ( p > .05). Discussion The present study examined feasibility and acceptability, as well as preliminary efficacy of the Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS) intervention, a positive psychological intervention (PPI) tailored for adolescents and administered in a school setting. Results revealed that intervention skill use significantly increased, particularly skills of amplifying positive events and gratitude. As for well-being outcomes, within the CEDARS group there was a significant drop in negative emotions and perceived stress. There were statistically significant time by condition interaction effects for depressive symptoms and perceived stress, indicating that, contrary to hypotheses, the control group experienced steeper declines in these outcomes than the intervention group (although this improvement did not last to T3). This finding may be explained by the difference in baseline levels of depression and perceived stress between the two groups. The control group reported significantly higher baseline levels of both depressive symptoms and perceived stress, and thus had more room for improvement. Students in the intervention group reported good acceptability and feasibility of the CEDARS intervention, with several recommendations for future modifications, including greater attention to developmentally-appropriate tailoring to increase student engagement. Our main hypotheses, that CEDARS would contribute to improvements in affect, stress, and mental health outcomes, compared to the control condition, were partially supported. The intervention significantly decreased negative emotions for the intervention group at post-intervention as well as at follow-up. However, the intervention did not have an effect on positive emotions. Adolescents undergo normative reductions in positive emotions [47], which may partially explain our null findings. They also experience greater emotional volatility, which can include more frequent and intense negative emotions [26, 47] Thus, interventions that effectively reduce negative emotions during this time period are critical. We found that the intervention group improved as a whole on the skills taught in the intervention. Specifically, they showed significant improvement in the use of gratitude and amplifying positive events and these changes were maintained at the follow-up. The benefits of cultivating gratitude as part of positive psychology interventions are well-documented [48, 49], and gratitude is among the most effective PPI skills for positive youth development in adolescents [50]. Savoring (referred to as “amplifying” in this study) is also uniquely beneficial for adolescents: in one study, the ability to maximize or enhance a positive experience was associated with greater feelings about the event one week later and better overall adjustment to adolescence [51]. Even the skills that did not show statistically significant improvement still trended upward after CEDARS participation. To our knowledge, previous studies on school-based PPIs have not identified specific skills that changed the most as a result of the intervention. Future work should test whether these specific skills mediate the relationship between the intervention participation and well-being outcomes. In order to better tailor PPIs to adolescents, it is important to test the specific set of skills that are included in order to maximize the impact of the intervention. In part, our findings show null results for Time x Group interactions, not because the intervention group did not improve, but because both conditions tended to improve from the pre-to post- intervention period. The control group reported significantly higher levels of depressive symptoms and perceived stress at baseline, and their levels tended to remain higher throughout the study period, with the exception of post-intervention depressive symptoms, which also rebounded back to higher levels at the follow-up period. A previous PPI study of middle schoolers also found no significant between-group differences in positive affect, though in contrast to our findings, that study also found null results for negative affect [33]. Prior work in an Israeli adolescent sample found that their school-based PPI reduced overall distress, depressive and anxiety symptoms, and increased feelings of optimism, self-esteem, and self-efficacy [32]. Notably, they employed a “whole-school” approach, where the entire school received the intervention (or control) and the intervention was delivered by classroom teachers, who were also trained in the intervention skills. Interventions with wide-spread administrative support that are woven into the school curriculum are likely to be more effective than those at the classroom- or individual-level. Moreover, the effects of their PPI were shown to extend to war-affected regions of Israel, where the intervention condition showed improvements in well-being, as well as intergroup trust and intergroup compassion. These results indicate that PPIs may be beneficial in normative, as well as tumultuous, settings and further research should continue to examine how context, including geopolitical differences, influence PPI outcomes. Our sample primarily identified as Asian-American and Pacific Islander, an underexamined population in adolescent intervention studies in the U.S., which tend to focus on White youth [52] and there were significant between group differences with 56.9% identifying as AAPI in the intervention group and 75% in the control. Although we statistically controlled for this difference in the analyses, it was likely insufficient to account for the impact on the effects of the intervention. There is evidence that there are higher rates of depression in Asian-Americans than the general U.S. population [53]. Thus, cultural-contextual factors may have played a role; in future iterations of this intervention, greater attention should be paid to cultural tailoring for the intended population [54]. For example, following the ecological validity model (EVM), emphasizing group benefits of the intervention rather than individual benefits may be more culturally resonant for groups from more collectivist cultures [54, 55]. In larger samples, testing moderators related to racial and ethnic-minoritized group-related stressors (e.g., discrimination/racism, immigration or generational status) would also be informative. We also recommend further tailoring our (and other) PPIs for the unique demands of adolescence. As noted by Yeager and colleagues note [56] , adolescents, beginning in middle school and continuing through high school, benefit less from interventions than younger children. Indeed, traditional intervention methods that have shown to be efficacious for younger children or adults may not translate to delivery for adolescence. Specifically, adolescents may be especially sensitive to material that doesn’t relate enough to their lives or engage them enough. They are also more strongly influenced by the attitudes and behaviors of their peers, which could be beneficial or detrimental, depending on the group. Our intervention was conducted in a class setting, which exacerbates the effects of peer pressure (for better and for worse) and emotional contagion [57], to which adolescents are particularly susceptible. Interventionists and researchers should pay attention not only to what is said (i.e., the content), but also how it is said (i.e., delivery), in order for adolescents to be most receptive to the intervention content. This hypothesis is consistent with other literature suggesting that teacher competency in conveying and embodying the coping skills is a critical element for successful school based social emotional programs [58]. These principles were also reflected in our student quotes – students overwhelmingly suggested more hands-on, engaging, and life-relevant activities. Leveraging technology that adolescents already use (e.g., smartphones, apps, video content) could also improve adherence and efficacy for PPIs with this target group [59], as well as improve the reach of interventions more generally [60]. A major limitation of our study is the lack of randomization at the person-level. Instead, students were randomly assigned by classroom, so that each class could be taught the skills – it is not feasible for students within a single class to receive different instruction, which is a potential limitation to in-school interventions. As a result, our study showed significantly different baseline levels for a number of variables, including race, depressive symptoms, and perceived stress. These baseline differences contribute to the likelihood of biased estimates, and therefore, we cannot conclude that any changes in outcome were due to the intervention instead of other factors. We included AAPI race (which was associated with depressive symptoms and perceived stress) as a covariate in our analyses due to the baseline difference. Future studies should include sufficient power to conduct subgroup analyses and test potential mechanisms of effects to better understand vs. control for meaningful differences linked to participant racial identity. Overall, this study, in combination with other research on school-based PPIs for adolescents, suggests that PPIs tailored for adolescents are feasible and acceptable for adolescents and have the potential to benefit their well-being. Our findings show that adolescents are more receptive to certain PPI skills and are also particularly sensitive to intervention messaging and delivery. PPIs, especially when offered in school settings, offer unique opportunities to target adolescents’ psychosocial needs and develop their coping skills to buffer against negative consequences of stress and negative emotion [32]. However, developmentally- and culturally-tailored intervention designs will be paramount to increasing efficacy and feasibility of school-based PPIs. Declarations Funding: UCSF Osher Center, William J Bowes Research Fund & the Sarlo Family Foundation Conflicts of interest/Competing interests : N/A Data availability (data transparency). Upon request of the corresponding author Code availability Upon request of the corresponding author Authors' contributions Conceptualization: Duncan, Moskowitz, Vo, Bussolari; Methodology: Duncan, Moskowitz, Vo, Bussolari, Chang; Formal analysis and investigation: Ducan, Moskowitz, Vo, Bussolari, Chang, Kamsickas, Stephens, Jackson; Writing - original draft preparation :Kamsickas, Scheps, Jackson, Moskowitz; Writing - review and editing: Stephens, Heard-Garris, Vo, Bussolari, Moskowitz, Duncan; Funding acquisition: Moskowitz & Duncan References Sisk, L.M. and D.G. Gee, Stress and adolescence: vulnerability and opportunity during a sensitive window of development. Current Opinion in Psychology, 2022. 44 : p. 286-292. Chiang, J.J., et al., Psychological stress during childhood and adolescence and its association with inflammation across the lifespan: A critical review and meta-analysis. Psychological Bulletin, 2022. 148 (1-2): p. 27. Seiffge‐Krenke, I., K. Aunola, and J.E. Nurmi, Changes in stress perception and coping during adolescence: The role of situational and personal factors. Child development, 2009. 80 (1): p. 259-279. Romeo, R.D., The teenage brain: The stress response and the adolescent brain. Current directions in psychological science, 2013. 22 (2): p. 140-145. Leussis, M.P. and S.L. Andersen, Is adolescence a sensitive period for depression? Behavioral and neuroanatomical findings from a social stress model. Synapse, 2008. 62 (1): p. 22-30. Andersen, S.L. and M.H. Teicher, Stress, sensitive periods and maturational events in adolescent depression. Trends in neurosciences, 2008. 31 (4): p. 183-191. Holder, M.K. and J.D. Blaustein, Puberty and adolescence as a time of vulnerability to stressors that alter neurobehavioral processes. Frontiers in neuroendocrinology, 2014. 35 (1): p. 89-110. Ginsburg KR and A. SM., The 7 Cs: An interdisciplinary model that integrates positive youth development, resilience-building strategies, and trauma-sensitive practices. , in Reaching Teens: Strengths-Based, Trauma-Sensitive, Resilience-Building Communication Strategies Rooted in Positive Youth Development, , Ginsburg KR and M. SBR, Editors. 2020, American Academy of Pediatrics: Itasca, IL. Compas, B.E., P.G. Orosan, and K.E. Grant, Adolescent stress and coping: Implications for psychopathology during adolescence. Journal of adolescence, 1993. 16 (3): p. 331-349. Silk, J.S., et al., Resilience among children and adolescents at risk for depression: Mediation and moderation across social and neurobiological contexts. Development and psychopathology, 2007. 19 (3): p. 841-865. Bor, W., et al., Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Australian & New Zealand journal of psychiatry, 2014. 48 (7): p. 606-616. Twenge, J.M., Why increases in adolescent depression may be linked to the technological environment. Current opinion in psychology, 2020. 32 : p. 89-94. Aldridge, A.A. and S.C. Roesch, Coping with daily stressors: Modeling intraethnic variation in Mexican American adolescents. Hispanic Journal of Behavioral Sciences, 2008. 30 (3): p. 340-356. Dumont, M. and M.A. Provost, Resilience in adolescents: Protective role of social support, coping strategies, self-esteem, and social activities on experience of stress and depression. Journal of youth and adolescence, 1999. 28 (3): p. 343-363. Perzow, S.E., et al., Individual differences in adolescent coping: Comparing a community sample and a low-SES sample to understand coping in context. Journal of youth and adolescence, 2021. 50 (4): p. 693-710. Hampel, P. and F. Petermann, Perceived stress, coping, and adjustment in adolescents. Journal of adolescent health, 2006. 38 (4): p. 409-415. Rodríguez-Naranjo, C. and A. Caño, Daily stress and coping styles in adolescent hopelessness depression: Moderating effects of gender. Personality and Individual Differences, 2016. 97 : p. 109-114. Sheldon, K.M. and L. King, Why positive psychology is necessary. American psychologist, 2001. 56 (3): p. 216. Trompetter, H.R., E. De Kleine, and E.T. Bohlmeijer, Why does positive mental health buffer against psychopathology? An exploratory study on self-compassion as a resilience mechanism and adaptive emotion regulation strategy. Cognitive therapy and research, 2017. 41 : p. 459-468. Fredrickson, B.L., et al., What good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001. Journal of Personality and Social Psychlogy, 2003. 84 : p. 365-376. Folkman, S. and J.T. Moskowitz, Stress, Positive Emotion, and Coping , in Current Directions in Psychological Science . 2000. p. 115-118. Moskowitz, J.T., et al., Illness appraisals and depression in the first year after HIV diagnosis. PloS one, 2013. 8 (10): p. e78904. Gilbert, K.E., The neglected role of positive emotion in adolescent psychopathology. Clinical psychology review, 2012. 32 (6): p. 467-481. Coffey, J.K. and M.T. Warren, Comparing adolescent positive affect and self-esteem as precursors to adult self-esteem and life satisfaction. Motivation and emotion, 2020. 44 (5): p. 707-718. Folkman, S. and J.T. Moskowitz, Positive affect and the other side of coping. American Psychologist, 2000. 55 (6): p. 647-654. Bailen, N.H., L.M. Green, and R.J. Thompson, Understanding emotion in adolescents: A review of emotional frequency, intensity, instability, and clarity. Emotion Review, 2019. 11 (1): p. 63-73. Schueller, S., T. Kashdan, and A. Parks, Synthesizing positive psychological interventions: Suggestions for conducting and interpreting meta-analyses. International Journal of Wellbeing, 2014. 4 (1). Carr, A., et al., Effectiveness of positive psychology interventions: a systematic review and meta-analysis. The Journal of Positive Psychology, 2020: p. 1-21. Bolier, L., et al., Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC public health, 2013. 13 (1): p. 1. Sin, N.L. and S. Lyubomirsky, Enhancing well-being and alleviating depressive symptoms with positive psychology intervention: A practice-friendly meta-analysis. Journal of Clinical Psychology, 2009. 65 : p. 467-487. Platt, I.A., et al., The hummingbird project: a positive psychology intervention for secondary school students. Frontiers in Psychology, 2020. 11 : p. 542643. Shoshani, A. and S. Steinmetz, Positive psychology at school: A school-based intervention to promote adolescents’ mental health and well-being. Journal of Happiness Studies, 2014. 15 : p. 1289-1311. Suldo, S.M., J.A. Savage, and S.H. Mercer, Increasing middle school students’ life satisfaction: Efficacy of a positive psychology group intervention. Journal of happiness studies, 2014. 15 : p. 19-42. Waters, L., A review of school-based positive psychology interventions. The Australian Educational and Developmental Psychologist, 2011. 28 (2): p. 75-90. Seligman, M.E., et al., Positive education: Positive psychology and classroom interventions. Oxford review of education, 2009. 35 (3): p. 293-311. Wyn, J., et al., MindMatters, a whole-school approach promoting mental health and wellbeing. Australian & New Zealand Journal of Psychiatry, 2000. 34 (4): p. 594-601. McKeague, L., et al., Exploring the feasibility and acceptability of a school‐based self‐referral intervention for emotional difficulties in older adolescents: qualitative perspectives from students and school staff. Child and adolescent mental health, 2018. 23 (3): p. 198-205. García-Carrión, R., B. Villarejo-Carballido, and L. Villardón-Gallego, Children and adolescents mental health: A systematic review of interaction-based interventions in schools and communities. Frontiers in psychology, 2019. 10 : p. 389201. Quinlan, D.M., et al., How ‘other people matter’in a classroom-based strengths intervention: Exploring interpersonal strategies and classroom outcomes. The Journal of Positive Psychology, 2015. 10 (1): p. 77-89. Roth, R.A., S.M. Suldo, and J.M. Ferron, Improving middle school students' subjective well-being: Efficacy of a multicomponent positive psychology intervention targeting small groups of youth. School Psychology Review, 2017. 46 (1): p. 21-41. Moskowitz, J.T., et al., Positive psychological intervention effects on depression: Positive emotion does not mediate intervention impact in a sample with elevated depressive symptoms. Affective Science, 2023. 4 (1): p. 163-173. Moskowitz, J.T., et al., Randomized controlled trial of a positive affect intervention for people newly diagnosed with HIV. Journal of Consulting and Clinical Psychology, 2017. Vol 85 (5): p. 409-423. Moskowitz, J.T., et al., Randomized Controlled Trial of a Facilitated Online Positive Emotion Regulation Intervention for Dementia Caregivers. Health Psychology, 2019. 38 (5): p. 391-402. Radloff, L.S., The CES-D scale a self-report depression scale for research in the general population. Applied psychological measurement, 1977. 1 (3): p. 385-401. Cohen, S., Perceived stress in a probability sample of the United States , in The social psychology of health. The Claremont Symposium on Applied Social Psychology , S. Spacapan and S. Oskamp, Editors. 1988, Sage Publications, Inc: Thousand Oaks, CA. p. 31-67. O'Connell, N.S., et al., Methods for analysis of pre-post data in clinical research: a comparison of five common methods. Journal of biometrics & biostatistics, 2017. 8 (1): p. 1. Griffith, J.M., et al., Affective development from middle childhood to late adolescence: Trajectories of mean-level change in negative and positive affect. Journal of Youth and Adolescence, 2021. 50 : p. 1550-1563. Cregg, D.R. and J.S. Cheavens, Gratitude interventions: Effective self-help? A meta-analysis of the impact on symptoms of depression and anxiety. Journal of Happiness Studies, 2021. 22 : p. 413-445. Davis, D.E., et al., Thankful for the little things: A meta-analysis of gratitude interventions. Journal of counseling psychology, 2016. 63 (1): p. 20. Khanna, P., K. Singh, and S. Dua, Role of gratitude in positive adolescent development , in Adolescence in India: Issues, Challenges and Possibilities . 2022, Springer. p. 423-451. Gentzler, A.L., et al., Young adolescents’ responses to positive events: Associations with positive affect and adjustment. The Journal of Early Adolescence, 2013. 33 (5): p. 663-683. Pina, A.A., A.J. Polo, and S.J. Huey, Evidence-based psychosocial interventions for ethnic minority youth: The 10-year update. Journal of Clinical Child & Adolescent Psychology, 2019. 48 (2): p. 179-202. Kim, H.J., et al., Depression among Asian-American adults in the community: Systematic review and meta-analysis. PloS one, 2015. 10 (6): p. e0127760. Bernal, G., M.I. Jiménez-Chafey, and M.M. Domenech Rodríguez, Cultural adaptation of treatments: A resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 2009. 40 (4): p. 361. Perera, C., et al., No implementation without cultural adaptation: a process for culturally adapting low-intensity psychological interventions in humanitarian settings. Conflict and health, 2020. 14 : p. 1-12. Yeager, D.S., R.E. Dahl, and C.S. Dweck, Why interventions to influence adolescent behavior often fail but could succeed. Perspectives on Psychological Science, 2018. 13 (1): p. 101-122. Herrando, C. and E. Constantinides, Emotional contagion: A brief overview and future directions. Frontiers in psychology, 2021. 12 : p. 712606. Kuyken, W., et al., Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial. BMJ Ment Health, 2022. 25 (3): p. 99-109. Baños, R.M., et al., Online positive interventions to promote well-being and resilience in the adolescent population: A narrative review. Frontiers in psychiatry, 2017. 8 : p. 222668. Griffiths, K.M. and H. Christensen, Internet‐based mental health programs: A powerful tool in the rural medical kit. Australian Journal of Rural Health, 2007. 15 (2): p. 81-87. Tables Table 1 Baseline Characteristics and Differences between Groups Characteristic CEDARS (N=58) Mean or % (SD) Control (N=44) Mean or % (SD) t -statistic p -value Age (years) 14.31 (0.54) 14.41 (0.50) .95 .35 Gender (Female) 52% 59% .74 .47 Ethnicity Asian American, or Pacific Islander 56.9% 75.0% 2.02 .047* White (non-Hispanic) 20.7% 4.5% 2.35 .02* More than one race 11.9% 9.1% .45 .66 Hispanic/Latino 5.1% 4.5% .13 .90 Black 0% 4.5% 1.66 .10 Other 5.1% 2.3% .73 .47 Language Other Than English Spoken at Home 72.4% 75% 1.22 .22 * p <.05 Table 2 Baseline Descriptive Statistics and Group Differences on Key Outcome Variables Outcome CEDARS (N=58) Mean (SD) Control (N=44) Mean (SD) t -statistic p -value Intervention Skills 2.31 (1.47) 2.57 (1.61) .84 .40 Positive Emotion 2.87 (0.90) 2.85 (1.00) .10 .92 Negative Emotion 1.21 (0.66) 1.42 (0.61) 1.65 .10 Depressive Symptoms 13.46 (8.56) 17.07 (9.58) 2.01 .047* Perceived Stress 15.63 (5.95) 18.98 (5.63) 2.89 .01* * p <.05 Additional Declarations No competing interests reported. Supplementary Files CEDARSSupplementalTable.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Sep, 2024 Reviewers agreed at journal 03 Sep, 2024 Reviews received at journal 24 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviews received at journal 25 Jun, 2024 Reviewers agreed at journal 05 Jun, 2024 Reviewers invited by journal 28 May, 2024 Editor assigned by journal 28 May, 2024 Submission checks completed at journal 28 May, 2024 First submitted to journal 23 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Duncan","email":"","orcid":"","institution":"University of Wisconsin—Madison","correspondingAuthor":false,"prefix":"","firstName":"Larissa","middleName":"G.","lastName":"Duncan","suffix":""}],"badges":[],"createdAt":"2024-05-23 06:57:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4464805/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4464805/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58225646,"identity":"2d0b6ecf-5c0d-41c1-bdfa-f3bb18550961","added_by":"auto","created_at":"2024-06-12 17:49:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41247,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSchematic overview of the CEDARS Intervention\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4464805/v1/aea58030d4c32b781dfed967.jpg"},{"id":58224767,"identity":"dead6059-6fa2-4c49-9a54-e2383a65ab38","added_by":"auto","created_at":"2024-06-12 17:41:36","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":106385,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eWell-being Outcomes by Condition and Timepoint\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote:\u003c/em\u003e Figures control for Asian-American/Pacific Islander status.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4464805/v1/d6616a71a643161878f3dff5.jpg"},{"id":58224764,"identity":"e43d1cc6-1022-4e0b-a1fc-280682781fcf","added_by":"auto","created_at":"2024-06-12 17:41:36","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":16374,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eChange in Specific Intervention Skills Over Time Within the Intervention Group\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: Only statistically significant associations are depicted. * \u003cem\u003ep\u003c/em\u003e \u0026lt; .05, ** \u003cem\u003ep\u003c/em\u003e \u0026lt; .01\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4464805/v1/747e2f4b51fb7b6f19e1a52e.jpg"},{"id":58226664,"identity":"909d9d4a-421a-4a25-80ea-5730ca194991","added_by":"auto","created_at":"2024-06-12 18:05:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":924062,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4464805/v1/c6b18ab5-1b47-4e2f-bfa1-3b0cb88339b2.pdf"},{"id":58226094,"identity":"5a8566b9-aab3-492f-8e65-d6da39060f23","added_by":"auto","created_at":"2024-06-12 17:57:36","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17461,"visible":true,"origin":"","legend":"","description":"","filename":"CEDARSSupplementalTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-4464805/v1/4043a622a89eb7b4b6123750.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS): Pilot test of a school-based positive psychological intervention for adolescents","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlthough experiencing some stress during adolescence is normative, too much stress can have deleterious effects on adolescents\u0026rsquo; psychological and physical health, including increasing the likelihood of depression, anxiety, social withdrawal, fatigue, and poor problem-solving [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] as well as increasing the risk of negative health outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Adolescence is marked by an objective increase in stressors, as well as increases in subjective perceptions of stress [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Adolescents may be particularly sensitive to stress as they experience an increase in autonomy and undergo rapid developmental changes in biological, emotional, social, relational, and cognitive domains [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Simultaneously, during adolescence the stress response system itself may become more robust, leading to increased risk for psychopathology [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As a result, adolescents are especially vulnerable for developing mental health problems when exposed to stressful life events [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Coping with stress is a key developmental task of adolescence [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Adolescents who do not have strategies for adaptively managing negative emotions may be even more vulnerable to developing psychopathology [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs concerns rise over adolescents\u0026rsquo; deteriorating mental health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], research on coping and stress reduction has grown rapidly [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Adolescents who have effective coping strategies and stress management techniques are less likely to be maladjusted or depressed [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e],though there is high variability in which coping strategies are effective for whom and for which stressors (i.e., not one size fits all)[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, while effective coping can successfully buffer against mental health symptoms, coping alone is not enough to prevent or fully attenuate symptoms of psychopathology in adolescence.\u003c/p\u003e \u003cp\u003eCritically, research has moved beyond a sole focus on relieving negative symptoms, to also promoting well-being [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] particularly through increasing positive emotions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Previous research has shown an independent contribution of positive affect to reductions in risk behavior and increases in adaptive coping with serious stressful events and chronic disease diagnosis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Adolescents who report experiencing more positive emotion use more critical thinking skills, have more cognitive flexibility, perform better at memory encoding, and engage in more creative problem-solving, than adolescents who report experiencing less positive emotion [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The benefits of positive emotions in adolescence may also persist into other life stages. Coffey and Warren [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found that higher positive emotions in adolescence predicted greater self-esteem and life satisfaction 13 years later. The cognitive resources and abilities conferred from positive emotion may be particularly impactful during chronic stress [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Given that adolescence is generally associated with greater emotional volatility and more frequent high-intensity negative emotion compared to adults [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], programs that focus specifically on skills to increase positive emotion, especially during times of stress, may be particularly protective for this age group.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eInterventions that target positive emotion\u003c/h2\u003e \u003cp\u003ePositive psychological interventions (PPIs) seek to promote well-being in individuals by bolstering their positive emotions, cognitions, and behaviors [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. PPIs have been shown to help individuals better cope with stress and result in decreased depressive and anxiety symptoms and increased well-being [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These meta analyses also found that multi-component PPIs (i.e., those that include multiple skills) were more effective at improving psychological well-being than those that focus on a single skill (e.g., mindfulness)[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Benefits of PPIs are well-documented in adults and chronically stressed populations [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and researchers have begun examining PPIs in adolescents, particularly in school settings [\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSchool-based positive psychology interventions for adolescents\u003c/h2\u003e \u003cp\u003eFor adolescents, schools provide an advantageous setting to teach well-being skills because large groups of students can be reached simultaneously, students\u0026rsquo; interactions and experiences at school comprise most of their waking time and are therefore an important determinant of their well-being, and improving student mental health and well-being has become an increasing focus for educators and policy makers [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Many students also may perceive the school setting as a comfortable and secure environment for such interventions, in part because they can gain reassurance and support from their peers [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. School programs have a wider reach than individual-based programs (i.e., can reach more students), can have a preventative focus (i.e., students can participate before needing professional mental health intervention), and can teach skills that target multiple domains (i.e., students can implement the skills both at school and at home, maximizing their positive effect) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious school-based PPIs for adolescents have aimed to cultivate hope, gratitude, serenity, resilience, and character strengths, among other skills [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Consistent with the broader PPI literature, school-based interventions that incorporate multiple components have demonstrated greater efficacy compared to those that solely focus on a single skill [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. School-based PPIs have been shown to foster well-being for students across different countries, genders, and races [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, it is unclear what types of PPIs are most feasible in a school setting and which specific skills are most beneficial for students.\u003c/p\u003e \u003cp\u003eIn the current study, we aim to address these limitations in prior research by investigating the feasibility and preliminary efficacy of the Coping and Emotion Development for Adolescents to Reduce Stress (CEDARS) intervention, a school-based PPI for adolescents. CEDARS, a 5-session PPI that includes 8 skills: noticing positive events, savoring positive events, gratitude, mindful awareness and nonjudgment, positive reappraisal, identifying personal strengths, setting attainable goals, and acts of kindness (See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). When taught together, these skills have been found to significantly increase positive emotion and decrease depression levels among adults coping with chronic illnesses and other types of life stressors in multiple studies [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. We hypothesized that acceptability and feasibility would be good-to-high for the intervention. We expected that adolescents in the intervention group would significantly increase their use of the skills taught in the interventions, compared to baseline. We also expected them to report greater positive emotion, and lower negative emotion, perceived stress, and depressive symptoms from baseline to post-intervention, as well as at the one-month follow-up.\u003c/p\u003e \u003c/div\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cstrong\u003eProcedure and Content of the Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics\u0026nbsp;approval and\u0026nbsp;consent\u0026nbsp;to participate.\u003c/em\u003e All procedures received ethics approval by the UCSF IRB Committee on Human Research.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe study was also approved by the San Francisco Unified School District (SFUSD) committee for conducting research in schools. Prior to data collection and during class, researchers explained to students that they were testing a program designed to reduce stress and increase positive emotion. Only students who provided their assent and written consent from a parent were enrolled in the study and completed the assessments, though all students received the intervention as part of classroom instruction. Parent consent forms were provided in English, Chinese, and Spanish according to school district regulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCEDARS was tailored for adolescents by an interdisciplinary working group that included a pediatrician training as a specialist in adolescent medicine, a high school teacher, a counseling psychologist with extensive experience working with adolescents in school settings, a developmental psychologist, and a social/health psychologist who developed the original intervention (JTM). The team members considered adolescent cognitive, emotional, and social development and the evidence base regarding prevention programs delivered in school settings when deciding how much didactic information to provide, what kind of group activities to use, and how interactive to make the sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe CEDARS intervention consisted of one weekly, 50-minute, in-person, classroom-based session held consecutively for five weeks. In each session, trained facilitators taught one to two empirically-supported skills for increasing positive affect. The intervention was structured as follows: Session 1) gratitude and noting daily positive events; Session 2) amplifying positive events and mindfulness; Session 3) positive reappraisal; Session 4) focusing on personal strengths and setting attainable goals; and Session 5) performing small acts of kindness. Each session had a didactic portion in which the positive affect skill(s) for that session were introduced, followed by interactive practice of the skill(s), and finally, discussion of the home practice for the following week. Each week, participants were given a set of practice activities and a workbook to record their daily practice according to the skill(s) they learned that week. A feasibility and acceptability assessment was completed at the end of each intervention session. The intervention and control groups completed questionnaires at baseline (T1), at post-test, after completing the 5-week program (T2), and one month later (T3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFeasibility and acceptability\u003c/em\u003e were assessed through weekly feedback surveys asking students to rate how helpful each of that week\u0026rsquo;s skills had been on a scale from 1 (\u003cem\u003enot helpful\u003c/em\u003e) to 4 (\u003cem\u003every helpful)\u003c/em\u003e. In an open-ended format, they were also asked what they like best and least about the last session. Weekly surveys were completed with paper and pencil at the beginning of each session on their perceptions of the prior week\u0026rsquo;s session. Students were also asked to provide open-ended feedback with suggestions for improvements to the content and delivery of CEDARS in weekly surveys.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntervention skill use\u0026nbsp;\u003c/em\u003ewas assessed using a composite score of individual skill items, which included each of the eight skills taught in CEDARS (gratitude, positive events, acts of kindness, positive reappraisal, attainable goals, personal strengths, and amplifying), which students rated on a scale from 0 to 6. The individual items were averaged to create the intervention skills composite score for each participant at each time point. \u0026nbsp;The composite score had high reliability (\u0026alpha;\u0026nbsp;= .91).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePositive and negative emotions\u003c/em\u003e were measured using a modified version of the Differential Emotions Scale (DES)\u0026nbsp;[20]. This 25-item scale measured various positive (e.g., amused, awe, content) and negative emotions (e.g., ashamed, sad, embarrassed). Participants rated how often they felt each emotion in the last week on a 5-point scale: 0 (\u003cem\u003enot at all\u003c/em\u003e) to 4 (\u003cem\u003eextremely\u003c/em\u003e). The positive and negative items were averaged to create separate negative (\u0026alpha;\u0026nbsp;= .87) and positive composites (\u0026alpha;\u0026nbsp;= .92).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDepressive symptoms\u003c/em\u003e over the past week were measured using the Center for Epidemiological Studies Depression scale\u0026nbsp;(CES-D)[44]. Participants were asked to indicate how often they felt a certain way about 20 items on a 4-point scale: 0 (\u003cem\u003erarely or less than one day\u003c/em\u003e) to 3 (\u003cem\u003emost days or 5 through 7 days\u003c/em\u003e). Items were summed to create a total depression score (\u0026alpha;\u0026nbsp;= .76).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePerceived stress\u003c/em\u003e was measured using the 10-item Perceived Stress Scale (PSS-10)\u0026nbsp;[45]\u0026nbsp;in which participants rated their perceived stress on a 5-point scale: 0 (\u003cem\u003enever\u003c/em\u003e) to 4 (\u003cem\u003every often\u003c/em\u003e) (\u0026alpha;\u0026nbsp;= .66).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRace.\u003c/em\u003e National Institutes of Health targeted enrollment categories were used to assess race/ethnicity. A majority of the sample identified as Asian-American or Pacific Islander (AAPI), thus race was dichotomized based on race distribution in the sample using an indicator variable, 1 = students who self-identified as AAPI and 0 = students who identified as any other race.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalytic Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe first described the baseline demographic characteristics and key study variables for the sample using means/standard deviations and frequencies/percentages for continuous and categorical variables, respectively; baseline differences between groups were identified using independent sample \u003cem\u003et-\u003c/em\u003etests and chi-squared tests. To gain insight into acceptability and feasibility of the intervention, we examined responses to the students\u0026rsquo; weekly feedback surveys (from the intervention group only). Student responses to open-ended survey questions were included as qualitative data to \u0026ldquo;triangulate\u0026rdquo; the quantitative data\u0026nbsp;(i.e., a mixed methods approach; Johnson et al., 2007).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo determine preliminary efficacy of the intervention, we conducted a series of mixed-effects and repeated measures ANCOVAs [46], followed by planned contrast analyses. Specifically, we examined group differences in change in the outcome variables (positive affect skill use, positive affect, negative affect, depressive symptoms, perceived stress) over time using mixed-effects ANCOVAs. Race was included as a covariate, given the between condition differences in racial demographics, as well as outcome variables, at baseline (see Table 1). The within-subjects factor was timepoint and the between-subjects factor was the intervention group (either intervention or control). These analyses were followed by within-group repeated-measures ANCOVAs to assess change from baseline (T1) to post-intervention (T2) for the intervention and control group separately. All ANCOVAs were then repeated from baseline (T1) to follow-up (T3) to determine whether effects persisted at the third timepoint. For the intervention group only, we conducted mixed effects repeated measures ANCOVAs for the individual skills that comprised the interventions skills composite (i.e., the skills taught in the intervention), to determine whether specific skills drove any significant associations. Analyses were run using SPSS statistical software version 28.0.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePreliminary Analyses\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 103 students who gave assent and whose parents signed informed consent documents, 102 (99%) completed the baseline questionnaires, 97 (94.2%) students completed the T2 questionnaires, and 99 (96%) completed the T3 questionnaires. The average participant age was 14.35 (SD = .52) and the sample was 45% female. The control group was comprised of a significantly higher number of students identifying as Asian-American or Pacific Islander, whereas the intervention group had a significantly higher number of students identifying as non-Hispanic White (Table 1). The control group reported greater depressive symptoms and perceived stress at baseline than the intervention group (\u003cem\u003ep value\u003c/em\u003es \u0026lt; .05) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeasibility and Acceptability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents rated the sessions with moderate-to-high acceptability and feasibility. Combined across all sessions, students rated the sessions as both helpful (Median = 2.0, \u003cem\u003eM\u003c/em\u003e = 1.75, \u003cem\u003eSD\u003c/em\u003e = 0.69) and interesting (Median = 2.00, \u003cem\u003eM\u003c/em\u003e = 1.68, \u003cem\u003eSD\u003c/em\u003e = 0.63), on a scale from 0-3. Session 3, which taught positive reappraisal, was rated highest in helpfulness (Median = 2.0, \u003cem\u003eM\u0026nbsp;\u003c/em\u003e= 1.89, \u003cem\u003eSD\u003c/em\u003e = 0.70) and interest (Median = 2.00, \u003cem\u003eM\u003c/em\u003e = 1.92, \u003cem\u003eSD\u003c/em\u003e = 0.73), though none of the session ratings were statistically different from one another (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05). Students identified mindfulness as their favorite skill (33%), followed closely by positive reappraisal (25%), then amplifying positive events (15%). The fewest students preferred identifying personal strengths and setting attainable goals (2% and 5%, respectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudent Feedback.\u0026nbsp;\u003c/strong\u003eOverall, students reported enjoying the sessions in the open-ended weekly surveys. They appreciated the engaging format of the sessions and articulated benefits from several of the specific skills. They appreciated aspects of the content as well as structure of the sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I liked talking about what makes me makes me stressed and hearing that everyone else\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ewas going through it too.\u0026rdquo; (Session 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I liked it because I could relate to so many of the situations people had when they were stressed.\u0026rdquo; (Session 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It was nice to know that it was beneficial to be positive.\u0026rdquo; (Session 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Realizing that I had a lot more strengths than I thought.\u0026rdquo; (Session 4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStudents\u0026rsquo; least liked aspects of the intervention were around their perceived lack of hands-on and engaging activities during the sessions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We weren\u0026apos;t involved enough and it got boring.\u0026rdquo; (Session 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I didn\u0026apos;t like that a lot of the material was repeated.\u0026rdquo; (Session 1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Talking/lectures for most of the time.\u0026rdquo; (Session 3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sitting there for so long.\u0026rdquo; (Session 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTheir suggestions included making the sessions more interactive and engaging through the use of games and other activities and tailoring the content even more to their lives. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Games! games! too much lecturing and just sitting and talking\u0026rdquo; (Session 4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Relate it more to our lives\u0026rdquo; (Session 5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Do more activities\u0026hellip;they are fun while just talking and sharing emotions is boring\u0026rdquo; (Session 5)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWithin-\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and Between-Group Change in Outcomes from Pre- to Post-Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the group difference in proportion of students identifying as AAPI, we control for race in the following analyses. \u0026nbsp;Results from the uncontrolled analyses are in the supplementary table. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention skill use.\u0026nbsp;\u003c/strong\u003eIn mixed-factor ANCOVAS between the control and intervention group, controlling for the group difference in participants identifying as AAPI, there was a significant interaction between Time and Group, \u003cem\u003eF\u003c/em\u003e(1, 100) = 4.367,\u0026nbsp;\u003cem\u003ep\u003c/em\u003e = .04. Specifically, only the intervention group experienced an increase in overall intervention skill use from pre- to post-intervention (Figure 2A). This Time by Group interaction persisted at the follow-up timepoint \u003cem\u003eF\u003c/em\u003e(1, 101) = 4.06 (\u003cem\u003ep\u003c/em\u003e = .047)\u003c/p\u003e\n\u003cp\u003eIn analyses within the intervention group, the increase in overall positive emotion skill use was not statistically significant,\u0026nbsp;from pre- (\u003cem\u003eM\u003c/em\u003e = 2.31, \u003cem\u003eSD\u003c/em\u003e = 1.47) to post-intervention (\u003cem\u003eM\u0026nbsp;\u003c/em\u003e= 2.78, \u003cem\u003eSD\u003c/em\u003e = 1.58;\u0026nbsp;\u003cem\u003eF\u003c/em\u003e(1, 57) = 1.83, \u003cem\u003ep\u003c/em\u003e = .18, ) or to follow-up (\u003cem\u003eM\u003c/em\u003e = 2.77, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 1.48), \u003cem\u003eF\u003c/em\u003e(1, 57) = 3.81, \u003cem\u003ep\u003c/em\u003e = .06. There was\u0026nbsp;no significant change in overall intervention skill use within the control group (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05 for all).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eLooking separately at use of each of the 8 intervention skills\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003erepeated measures ANCOVAs within the intervention group revealed that amplifying positive events significantly increased from pre- (\u003cem\u003eM\u003c/em\u003e = 1.91, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 1.64) to post-intervention (\u003cem\u003eM\u003c/em\u003e = 2.65, \u003cem\u003eSD\u003c/em\u003e = 1.94), \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .03, and was maintained at follow-up (\u003cem\u003eM\u003c/em\u003e = 2.51, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 1.67), \u003cem\u003ep\u003c/em\u003e = .02. Gratitude marginally increased from pre- (\u003cem\u003eM\u003c/em\u003e = 1.88, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 1.93) to post-intervention (\u003cem\u003eM\u003c/em\u003e = 2.61, \u003cem\u003eSD\u003c/em\u003e = 1.88),\u003cem\u003e\u0026nbsp;p\u003c/em\u003e = .108, and remained marginal at follow-up (\u003cem\u003eM\u003c/em\u003e = 2.62, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 1.82), \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .07 (Figure 3). Identifying personal strengths, positive reappraisal, noticing positive events, acts of kindness, and attainable goals did not change significantly over time (\u003cem\u003ep\u003c/em\u003es \u0026gt; .05 for all).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWell-being Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003ePositive emotions.\u0026nbsp;\u003c/strong\u003eIn mixed ANCOVAS including both the control and intervention group, there was a significant effect of time, \u003cem\u003eF\u003c/em\u003e(1, 100) = 6.69, \u003cem\u003ep\u003c/em\u003e = .01, indicating that both groups improved on positive emotion from pre- to post-intervention (Figure 2B). The interaction between Time and Group, however, was not significant, \u003cem\u003eF\u003c/em\u003e(1, 100) = .51, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05 (Figure 2B), indicating that there was no difference in change over time between groups. This interaction remained non-significant at the follow-up timepoint (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003eIn analyses within the intervention group, there was a marginally significant change in positive emotions at post-intervention, (pre: \u003cem\u003eM\u003c/em\u003e = 2.87, \u003cem\u003eSD\u003c/em\u003e = .90; post\u003cem\u003e: M\u003c/em\u003e = 2.98, \u003cem\u003eSD\u003c/em\u003e = .97), \u0026nbsp;\u003cem\u003eF\u003c/em\u003e(1, 57) = 3.23, \u003cem\u003ep\u003c/em\u003e = .08, which was not sustained at follow-up (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05). Similarly, there was a marginally significant increase in positive emotions for the control group (pre: \u003cem\u003eM\u003c/em\u003e = 2.85, \u003cem\u003eSD\u003c/em\u003e = 1.00; post\u003cem\u003e: M\u003c/em\u003e = 3.02, \u003cem\u003eSD\u003c/em\u003e = .95), \u003cem\u003eF\u003c/em\u003e(1, 42) = 3.19, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= .08) that was not sustained at follow-up (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNegative emotions.\u0026nbsp;\u003c/strong\u003eIn mixed ANCOVAS comparing the control and intervention group, there was a significant effect of time, \u003cem\u003eF\u003c/em\u003e(1, 100) = 21.38, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, such that negative emotions decreased for both groups, but a nonsignificant interaction between Time and Condition, \u003cem\u003eF\u003c/em\u003e(1, 100) = 1.70, \u003cem\u003ep\u003c/em\u003e \u0026gt; .05 (Figure 2C). This interaction remained non-significant at the follow-up timepoint (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003eIn follow-up analyses within the intervention group, there was a significant decrease in negative emotions \u003cem\u003eF\u003c/em\u003e(1, 57) = 17.29, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, from pre- (\u003cem\u003eM\u003c/em\u003e = 1.57, \u003cem\u003eSD\u003c/em\u003e = .86) to post-intervention (\u003cem\u003eM\u003c/em\u003e = 1.33, \u003cem\u003eSD\u003c/em\u003e = .84). This decrease was sustained at follow-up (\u003cem\u003eM\u003c/em\u003e = 1.32, \u003cem\u003eSD\u003c/em\u003e = .80), \u003cem\u003eF\u003c/em\u003e(1, 57) = 9.97, \u003cem\u003ep\u003c/em\u003e = .003. There was a marginally significant decrease in negative emotions for the control group from pre- (\u003cem\u003eM\u003c/em\u003e = 1.58, SD = .79) to post-intervention (\u003cem\u003eM\u003c/em\u003e = 1.47, SD = .70; \u003cem\u003ep\u003c/em\u003e= .06) and a significant decrease at follow-up (\u003cem\u003eM\u003c/em\u003e = 1.53, SD = .80), \u003cem\u003eF\u003c/em\u003e(1, 42) =5.25, \u003cem\u003ep\u003c/em\u003e = .03.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepressive Symptoms.\u0026nbsp;\u003c/strong\u003eIn mixed ANCOVAS comparing the control and intervention group, there was a significant effect of time, \u003cem\u003eF\u003c/em\u003e(1, 100) = 6.29, \u003cem\u003ep\u003c/em\u003e = .01, such that there was a decrease in depressive symptoms overall, as well as a significant interaction between Time and Group, \u003cem\u003eF\u003c/em\u003e(1, 100) = 6.62, \u003cem\u003ep\u003c/em\u003e = .01 (Figure 2D). Specifically, contrary to our hypotheses, the control group demonstrated a steeper decline in depressive symptoms than the intervention group. The interaction between Time and Group was not significant from pre-test to follow-up (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003eIn follow-up analyses within the intervention group, there was not a significant change in depressive symptoms post-intervention, \u003cem\u003eF\u003c/em\u003e(1, 57) =.40, \u003cem\u003ep\u003c/em\u003e = .53 though there was a marginally significant decrease at follow-up, \u003cem\u003eF\u003c/em\u003e(1, 57) = 3.38, \u003cem\u003ep\u003c/em\u003e = .07). The control group experienced a significant reduction in depressive symptoms from pre (\u003cem\u003eM\u003c/em\u003e = 17.07, SD = 9.58) to post-intervention (\u003cem\u003eM\u003c/em\u003e =13.40, \u003cem\u003eSD\u003c/em\u003e = 6.49), \u003cem\u003eF\u003c/em\u003e(1, 42) = .67, \u003cem\u003ep\u003c/em\u003e = .01, that was sustained at follow-up (\u003cem\u003eM\u003c/em\u003e =14.79, \u003cem\u003eSD\u003c/em\u003e = 7.25), \u003cem\u003ep\u003c/em\u003e = .05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Stress.\u0026nbsp;\u003c/strong\u003eIn mixed ANCOVAS comparing the control and intervention group, there was a significant effect of time, \u003cem\u003eF\u003c/em\u003e(1, 100) = 15.33, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, such that perceived stress decreased overall, as well as a significant interaction between Time and Group, \u003cem\u003eF\u003c/em\u003e(1, 100) = 6.57, \u003cem\u003ep\u003c/em\u003e = .01 (Figure 2E). Specifically, the control group experienced a steeper decline in perceived stress than the intervention group. The interaction between Time and Group was not significant from pre-test to follow-up (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e\n\u003cp\u003eIn analyses within the intervention group, there was a significant change in perceived stress from pre- (\u003cem\u003eM\u003c/em\u003e = 15.63, SD = 5.95) to post-intervention (\u003cem\u003eM\u003c/em\u003e =15.21, SD = 6.23), \u003cem\u003eF\u003c/em\u003e(1, 57) = 5.74, \u003cem\u003ep\u003c/em\u003e\u0026nbsp; .02, which was sustained at \u0026nbsp;follow-up (\u003cem\u003eM\u003c/em\u003e = 14.75, \u003cem\u003eSD\u003c/em\u003e = 6.20), \u003cem\u003eF\u003c/em\u003e(1, 57) = 6.43, \u003cem\u003ep\u003c/em\u003e\u0026nbsp; .01. The control group also experienced a decrease in perceived stress from pre- (\u003cem\u003eM\u003c/em\u003e = 18.98, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 5.63) to post-intervention (\u003cem\u003eM\u003c/em\u003e = 16.64, \u003cem\u003eSD\u0026nbsp;\u003c/em\u003e= 5.69), \u003cem\u003eF\u003c/em\u003e(1, 42) = 6.44, \u0026nbsp;\u003cem\u003ep\u003c/em\u003e = .02, but this reduction did not persist to follow-up (\u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study examined feasibility and acceptability, as well as preliminary efficacy of the Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS) intervention, a positive psychological intervention (PPI) tailored for adolescents and administered in a school setting. Results revealed that intervention skill use significantly increased, particularly skills of amplifying positive events and gratitude. As for well-being outcomes, within the CEDARS group there was a significant drop in negative emotions and perceived stress. There were statistically significant time by condition interaction effects for depressive symptoms and perceived stress, indicating that, contrary to hypotheses, the control group experienced steeper declines in these outcomes than the intervention group (although this improvement did not last to T3). This finding may be explained by the difference in baseline levels of depression and perceived stress between the two groups. The control group reported significantly higher baseline levels of both depressive symptoms and perceived stress, and thus had more room for improvement. Students in the intervention group reported good acceptability and feasibility of the CEDARS intervention, with several recommendations for future modifications, including greater attention to developmentally-appropriate tailoring to increase student engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur main hypotheses, that CEDARS would contribute to improvements in affect, stress, and mental health outcomes, compared to the control condition, were partially supported. The intervention significantly decreased negative emotions for the intervention group at post-intervention as well as at follow-up. However, the intervention did not have an effect on positive emotions. Adolescents undergo normative reductions in positive emotions\u0026nbsp;[47], which may partially explain our null findings. They also experience greater emotional volatility, which can include more frequent and intense negative emotions\u0026nbsp;[26, 47]\u0026nbsp;Thus, interventions that effectively reduce negative emotions during this time period are critical.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe found that the intervention group improved as a whole on the skills taught in the intervention. Specifically, they showed significant improvement in the use of gratitude and amplifying positive events and these changes were maintained at the follow-up. The benefits of cultivating gratitude as part of positive psychology interventions are well-documented\u0026nbsp;[48, 49], and gratitude is among the most effective PPI skills for positive youth development in adolescents\u0026nbsp;[50]. Savoring (referred to as \u0026ldquo;amplifying\u0026rdquo; in this study) is also uniquely beneficial for adolescents: in one study, the ability to maximize or enhance a positive experience was associated with greater feelings about the event one week later and better overall adjustment to adolescence\u0026nbsp;[51].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Even the skills that did not show statistically significant improvement still trended upward after CEDARS participation. To our knowledge, previous studies on school-based PPIs have not identified specific skills that changed the most as a result of the intervention. Future work should test whether these specific skills mediate the relationship between the intervention participation and well-being outcomes. In order to better tailor PPIs to adolescents, it is important to test the specific set of skills that are included in order to maximize the impact of the intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn part, our findings show null results for Time x Group interactions, not because the intervention group did not improve, but because \u003cem\u003eboth\u003c/em\u003e conditions tended to improve from the pre-to post- intervention period. The control group reported significantly higher levels of depressive symptoms and perceived stress at baseline, and their levels tended to remain higher throughout the study period, with the exception of post-intervention depressive symptoms, which also rebounded back to higher levels at the follow-up period. A previous PPI study of middle schoolers also found no significant between-group differences in positive affect, though in contrast to our findings, that study also found null results for negative affect\u0026nbsp;[33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrior work in an Israeli adolescent sample found that their school-based PPI reduced overall distress, depressive and anxiety symptoms, and increased feelings of optimism, self-esteem, and self-efficacy\u0026nbsp;[32]. Notably, they employed a \u0026ldquo;whole-school\u0026rdquo; approach, where the entire school received the intervention (or control) and the intervention was delivered by classroom teachers, who were also trained in the intervention skills. Interventions with wide-spread administrative support that are woven into the school curriculum are likely to be more effective than those at the classroom- or individual-level. Moreover, the effects of their PPI were shown to extend to war-affected regions of Israel, where the intervention condition showed improvements in well-being, as well as intergroup trust and intergroup compassion. These results indicate that PPIs may be beneficial in normative, as well as tumultuous, settings and further research should continue to examine how context, including geopolitical differences, influence PPI outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur sample primarily identified as Asian-American and Pacific Islander, an underexamined population in adolescent intervention studies in the U.S., which tend to focus on White youth\u0026nbsp;[52]\u0026nbsp;and there were significant between group differences with 56.9% identifying as AAPI in the intervention group and 75% in the control. Although we statistically controlled for this\u0026nbsp;difference in the analyses, it was likely insufficient to account for the impact on the effects of the intervention. There is evidence that there are higher rates of depression in Asian-Americans than the general U.S. population\u0026nbsp;[53]. Thus, cultural-contextual factors may have played a role; in future iterations of this intervention, greater attention should be paid to cultural tailoring for the intended population\u0026nbsp;[54]. For example, following the ecological validity model (EVM), emphasizing group benefits of the intervention rather than individual benefits may be more culturally resonant for groups from more collectivist cultures\u0026nbsp;[54, 55]. In larger samples, testing moderators related to racial and ethnic-minoritized group-related stressors (e.g., discrimination/racism, immigration or generational status) would also be informative.\u003c/p\u003e\n\u003cp\u003eWe also recommend further tailoring our (and other) PPIs for the unique demands of adolescence. As noted by Yeager and colleagues note\u0026nbsp;[56]\u0026nbsp;, adolescents, beginning in middle school and continuing through high school, benefit less from interventions than younger children. Indeed, traditional intervention methods that have shown to be efficacious for younger children or adults may not translate to delivery for adolescence. Specifically, adolescents may be especially sensitive to material that doesn\u0026rsquo;t relate enough to their lives or engage them enough. They are also more strongly influenced by the attitudes and behaviors of their peers, which could be beneficial or detrimental, depending on the group. Our intervention was conducted in a class setting, which exacerbates the effects of peer pressure (for better and for worse) and emotional contagion\u0026nbsp;[57], to which adolescents are particularly susceptible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterventionists and researchers should pay attention not only to \u003cem\u003ewhat\u003c/em\u003e is said (i.e., the content), but also \u003cem\u003ehow\u003c/em\u003e it is said (i.e., delivery), in order for adolescents to be most receptive to the intervention content. This hypothesis is consistent with other literature suggesting that teacher competency in conveying and embodying the coping skills is a critical element for successful school based social emotional programs\u0026nbsp;[58]. These principles were also reflected in our student quotes \u0026ndash; students overwhelmingly suggested more hands-on, engaging, and life-relevant activities. Leveraging technology that adolescents already use (e.g., smartphones, apps, video content) could also improve adherence and efficacy for PPIs with this target group\u0026nbsp;[59], as well as improve the reach of interventions more generally\u0026nbsp;[60].\u003c/p\u003e\n\u003cp\u003eA major limitation of our study is the lack of randomization at the person-level. Instead, students were randomly assigned by classroom, so that each class could be taught the skills \u0026ndash; it is not feasible for students within a single class to receive different instruction, which is a potential limitation to in-school interventions. As a result, our study showed significantly different baseline levels for a number of variables, including race, depressive symptoms, and perceived stress. These baseline differences contribute to the likelihood of biased estimates, and therefore, we cannot conclude that any changes in outcome were due to the intervention instead of other factors. We included AAPI race (which was associated with depressive symptoms and perceived stress) as a covariate in our analyses due to the baseline difference. Future studies should include sufficient power to conduct subgroup analyses and test potential mechanisms of effects to better understand vs. control for meaningful differences linked to participant racial identity.\u003c/p\u003e\n\u003cp\u003eOverall, this study, in combination with other research on school-based PPIs for adolescents, suggests that PPIs tailored for adolescents are feasible and acceptable for adolescents and have the potential to benefit their well-being. Our findings show that adolescents are more receptive to certain PPI skills and are also particularly sensitive to intervention messaging and delivery. PPIs, especially when offered in school settings, offer unique opportunities to target adolescents\u0026rsquo; psychosocial needs and develop their coping skills to buffer against negative consequences of stress and negative emotion [32]. However, developmentally- and culturally-tailored intervention designs will be paramount to increasing efficacy and feasibility of school-based PPIs.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e UCSF Osher Center, William J Bowes Research Fund \u0026amp; the Sarlo Family Foundation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e: N/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e (data transparency). Upon request of the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e Upon request of the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConceptualization:\u003c/em\u003e Duncan, Moskowitz, Vo, Bussolari; \u003cem\u003eMethodology:\u003c/em\u003e Duncan, Moskowitz, Vo, Bussolari, Chang; \u003cem\u003eFormal analysis and investigation:\u003c/em\u003e Ducan, Moskowitz, Vo, Bussolari, Chang, Kamsickas, Stephens, Jackson; \u003cem\u003eWriting - original draft preparation\u003c/em\u003e:Kamsickas, Scheps, Jackson, Moskowitz; \u003cem\u003eWriting - review and editing:\u003c/em\u003e Stephens, Heard-Garris, Vo, Bussolari, Moskowitz, Duncan; \u003cem\u003eFunding acquisition:\u003c/em\u003e Moskowitz \u0026amp; Duncan\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSisk, L.M. and D.G. Gee, \u003cem\u003eStress and adolescence: vulnerability and opportunity during a sensitive window of development.\u003c/em\u003e Current Opinion in Psychology, 2022. \u003cstrong\u003e44\u003c/strong\u003e: p. 286-292.\u003c/li\u003e\n\u003cli\u003eChiang, J.J., et al., \u003cem\u003ePsychological stress during childhood and adolescence and its association with inflammation across the lifespan: A critical review and meta-analysis.\u003c/em\u003e Psychological Bulletin, 2022. \u003cstrong\u003e148\u003c/strong\u003e(1-2): p. 27.\u003c/li\u003e\n\u003cli\u003eSeiffge‐Krenke, I., K. Aunola, and J.E. Nurmi, \u003cem\u003eChanges in stress perception and coping during adolescence: The role of situational and personal factors.\u003c/em\u003e Child development, 2009. \u003cstrong\u003e80\u003c/strong\u003e(1): p. 259-279.\u003c/li\u003e\n\u003cli\u003eRomeo, R.D., \u003cem\u003eThe teenage brain: The stress response and the adolescent brain.\u003c/em\u003e Current directions in psychological science, 2013. \u003cstrong\u003e22\u003c/strong\u003e(2): p. 140-145.\u003c/li\u003e\n\u003cli\u003eLeussis, M.P. and S.L. Andersen, \u003cem\u003eIs adolescence a sensitive period for depression? Behavioral and neuroanatomical findings from a social stress model.\u003c/em\u003e Synapse, 2008. \u003cstrong\u003e62\u003c/strong\u003e(1): p. 22-30.\u003c/li\u003e\n\u003cli\u003eAndersen, S.L. and M.H. Teicher, \u003cem\u003eStress, sensitive periods and maturational events in adolescent depression.\u003c/em\u003e Trends in neurosciences, 2008. \u003cstrong\u003e31\u003c/strong\u003e(4): p. 183-191.\u003c/li\u003e\n\u003cli\u003eHolder, M.K. and J.D. Blaustein, \u003cem\u003ePuberty and adolescence as a time of vulnerability to stressors that alter neurobehavioral processes.\u003c/em\u003e Frontiers in neuroendocrinology, 2014. \u003cstrong\u003e35\u003c/strong\u003e(1): p. 89-110.\u003c/li\u003e\n\u003cli\u003eGinsburg KR and A. SM., \u003cem\u003eThe 7 Cs: An interdisciplinary model that integrates positive youth development, resilience-building strategies, and trauma-sensitive practices.\u003c/em\u003e, in \u003cem\u003eReaching Teens: Strengths-Based, Trauma-Sensitive, Resilience-Building Communication Strategies Rooted in Positive Youth Development,\u003c/em\u003e, Ginsburg KR and M. SBR, Editors. 2020, American Academy of Pediatrics: Itasca, IL.\u003c/li\u003e\n\u003cli\u003eCompas, B.E., P.G. Orosan, and K.E. Grant, \u003cem\u003eAdolescent stress and coping: Implications for psychopathology during adolescence.\u003c/em\u003e Journal of adolescence, 1993. \u003cstrong\u003e16\u003c/strong\u003e(3): p. 331-349.\u003c/li\u003e\n\u003cli\u003eSilk, J.S., et al., \u003cem\u003eResilience among children and adolescents at risk for depression: Mediation and moderation across social and neurobiological contexts.\u003c/em\u003e Development and psychopathology, 2007. \u003cstrong\u003e19\u003c/strong\u003e(3): p. 841-865.\u003c/li\u003e\n\u003cli\u003eBor, W., et al., \u003cem\u003eAre child and adolescent mental health problems increasing in the 21st century? A systematic review.\u003c/em\u003e Australian \u0026amp; New Zealand journal of psychiatry, 2014. \u003cstrong\u003e48\u003c/strong\u003e(7): p. 606-616.\u003c/li\u003e\n\u003cli\u003eTwenge, J.M., \u003cem\u003eWhy increases in adolescent depression may be linked to the technological environment.\u003c/em\u003e Current opinion in psychology, 2020. \u003cstrong\u003e32\u003c/strong\u003e: p. 89-94.\u003c/li\u003e\n\u003cli\u003eAldridge, A.A. and S.C. Roesch, \u003cem\u003eCoping with daily stressors: Modeling intraethnic variation in Mexican American adolescents.\u003c/em\u003e Hispanic Journal of Behavioral Sciences, 2008. \u003cstrong\u003e30\u003c/strong\u003e(3): p. 340-356.\u003c/li\u003e\n\u003cli\u003eDumont, M. and M.A. Provost, \u003cem\u003eResilience in adolescents: Protective role of social support, coping strategies, self-esteem, and social activities on experience of stress and depression.\u003c/em\u003e Journal of youth and adolescence, 1999. \u003cstrong\u003e28\u003c/strong\u003e(3): p. 343-363.\u003c/li\u003e\n\u003cli\u003ePerzow, S.E., et al., \u003cem\u003eIndividual differences in adolescent coping: Comparing a community sample and a low-SES sample to understand coping in context.\u003c/em\u003e Journal of youth and adolescence, 2021. \u003cstrong\u003e50\u003c/strong\u003e(4): p. 693-710.\u003c/li\u003e\n\u003cli\u003eHampel, P. and F. Petermann, \u003cem\u003ePerceived stress, coping, and adjustment in adolescents.\u003c/em\u003e Journal of adolescent health, 2006. \u003cstrong\u003e38\u003c/strong\u003e(4): p. 409-415.\u003c/li\u003e\n\u003cli\u003eRodr\u0026iacute;guez-Naranjo, C. and A. Ca\u0026ntilde;o, \u003cem\u003eDaily stress and coping styles in adolescent hopelessness depression: Moderating effects of gender.\u003c/em\u003e Personality and Individual Differences, 2016. \u003cstrong\u003e97\u003c/strong\u003e: p. 109-114.\u003c/li\u003e\n\u003cli\u003eSheldon, K.M. and L. King, \u003cem\u003eWhy positive psychology is necessary.\u003c/em\u003e American psychologist, 2001. \u003cstrong\u003e56\u003c/strong\u003e(3): p. 216.\u003c/li\u003e\n\u003cli\u003eTrompetter, H.R., E. De Kleine, and E.T. Bohlmeijer, \u003cem\u003eWhy does positive mental health buffer against psychopathology? An exploratory study on self-compassion as a resilience mechanism and adaptive emotion regulation strategy.\u003c/em\u003e Cognitive therapy and research, 2017. \u003cstrong\u003e41\u003c/strong\u003e: p. 459-468.\u003c/li\u003e\n\u003cli\u003eFredrickson, B.L., et al., \u003cem\u003eWhat good are positive emotions in crises? A prospective study of resilience and emotions following the terrorist attacks on the United States on September 11th, 2001.\u003c/em\u003e Journal of Personality and Social Psychlogy, 2003. \u003cstrong\u003e84\u003c/strong\u003e: p. 365-376.\u003c/li\u003e\n\u003cli\u003eFolkman, S. and J.T. Moskowitz, \u003cem\u003eStress, Positive Emotion, and Coping\u003c/em\u003e, in \u003cem\u003eCurrent Directions in Psychological Science\u003c/em\u003e. 2000. p. 115-118.\u003c/li\u003e\n\u003cli\u003eMoskowitz, J.T., et al., \u003cem\u003eIllness appraisals and depression in the first year after HIV diagnosis.\u003c/em\u003e PloS one, 2013. \u003cstrong\u003e8\u003c/strong\u003e(10): p. e78904.\u003c/li\u003e\n\u003cli\u003eGilbert, K.E., \u003cem\u003eThe neglected role of positive emotion in adolescent psychopathology.\u003c/em\u003e Clinical psychology review, 2012. \u003cstrong\u003e32\u003c/strong\u003e(6): p. 467-481.\u003c/li\u003e\n\u003cli\u003eCoffey, J.K. and M.T. Warren, \u003cem\u003eComparing adolescent positive affect and self-esteem as precursors to adult self-esteem and life satisfaction.\u003c/em\u003e Motivation and emotion, 2020. \u003cstrong\u003e44\u003c/strong\u003e(5): p. 707-718.\u003c/li\u003e\n\u003cli\u003eFolkman, S. and J.T. Moskowitz, \u003cem\u003ePositive affect and the other side of coping.\u003c/em\u003e American Psychologist, 2000. \u003cstrong\u003e55\u003c/strong\u003e(6): p. 647-654.\u003c/li\u003e\n\u003cli\u003eBailen, N.H., L.M. Green, and R.J. Thompson, \u003cem\u003eUnderstanding emotion in adolescents: A review of emotional frequency, intensity, instability, and clarity.\u003c/em\u003e Emotion Review, 2019. \u003cstrong\u003e11\u003c/strong\u003e(1): p. 63-73.\u003c/li\u003e\n\u003cli\u003eSchueller, S., T. Kashdan, and A. Parks, \u003cem\u003eSynthesizing positive psychological interventions: Suggestions for conducting and interpreting meta-analyses.\u003c/em\u003e International Journal of Wellbeing, 2014. \u003cstrong\u003e4\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eCarr, A., et al., \u003cem\u003eEffectiveness of positive psychology interventions: a systematic review and meta-analysis.\u003c/em\u003e The Journal of Positive Psychology, 2020: p. 1-21.\u003c/li\u003e\n\u003cli\u003eBolier, L., et al., \u003cem\u003ePositive psychology interventions: a meta-analysis of randomized controlled studies.\u003c/em\u003e BMC public health, 2013. \u003cstrong\u003e13\u003c/strong\u003e(1): p. 1.\u003c/li\u003e\n\u003cli\u003eSin, N.L. and S. Lyubomirsky, \u003cem\u003eEnhancing well-being and alleviating depressive symptoms with positive psychology intervention: A practice-friendly meta-analysis.\u003c/em\u003e Journal of Clinical Psychology, 2009. \u003cstrong\u003e65\u003c/strong\u003e: p. 467-487.\u003c/li\u003e\n\u003cli\u003ePlatt, I.A., et al., \u003cem\u003eThe hummingbird project: a positive psychology intervention for secondary school students.\u003c/em\u003e Frontiers in Psychology, 2020. \u003cstrong\u003e11\u003c/strong\u003e: p. 542643.\u003c/li\u003e\n\u003cli\u003eShoshani, A. and S. Steinmetz, \u003cem\u003ePositive psychology at school: A school-based intervention to promote adolescents\u0026rsquo; mental health and well-being.\u003c/em\u003e Journal of Happiness Studies, 2014. \u003cstrong\u003e15\u003c/strong\u003e: p. 1289-1311.\u003c/li\u003e\n\u003cli\u003eSuldo, S.M., J.A. Savage, and S.H. Mercer, \u003cem\u003eIncreasing middle school students\u0026rsquo; life satisfaction: Efficacy of a positive psychology group intervention.\u003c/em\u003e Journal of happiness studies, 2014. \u003cstrong\u003e15\u003c/strong\u003e: p. 19-42.\u003c/li\u003e\n\u003cli\u003eWaters, L., \u003cem\u003eA review of school-based positive psychology interventions.\u003c/em\u003e The Australian Educational and Developmental Psychologist, 2011. \u003cstrong\u003e28\u003c/strong\u003e(2): p. 75-90.\u003c/li\u003e\n\u003cli\u003eSeligman, M.E., et al., \u003cem\u003ePositive education: Positive psychology and classroom interventions.\u003c/em\u003e Oxford review of education, 2009. \u003cstrong\u003e35\u003c/strong\u003e(3): p. 293-311.\u003c/li\u003e\n\u003cli\u003eWyn, J., et al., \u003cem\u003eMindMatters, a whole-school approach promoting mental health and wellbeing.\u003c/em\u003e Australian \u0026amp; New Zealand Journal of Psychiatry, 2000. \u003cstrong\u003e34\u003c/strong\u003e(4): p. 594-601.\u003c/li\u003e\n\u003cli\u003eMcKeague, L., et al., \u003cem\u003eExploring the feasibility and acceptability of a school‐based self‐referral intervention for emotional difficulties in older adolescents: qualitative perspectives from students and school staff.\u003c/em\u003e Child and adolescent mental health, 2018. \u003cstrong\u003e23\u003c/strong\u003e(3): p. 198-205.\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a-Carri\u0026oacute;n, R., B. Villarejo-Carballido, and L. Villard\u0026oacute;n-Gallego, \u003cem\u003eChildren and adolescents mental health: A systematic review of interaction-based interventions in schools and communities.\u003c/em\u003e Frontiers in psychology, 2019. \u003cstrong\u003e10\u003c/strong\u003e: p. 389201.\u003c/li\u003e\n\u003cli\u003eQuinlan, D.M., et al., \u003cem\u003eHow \u0026lsquo;other people matter\u0026rsquo;in a classroom-based strengths intervention: Exploring interpersonal strategies and classroom outcomes.\u003c/em\u003e The Journal of Positive Psychology, 2015. \u003cstrong\u003e10\u003c/strong\u003e(1): p. 77-89.\u003c/li\u003e\n\u003cli\u003eRoth, R.A., S.M. Suldo, and J.M. Ferron, \u003cem\u003eImproving middle school students\u0026apos; subjective well-being: Efficacy of a multicomponent positive psychology intervention targeting small groups of youth.\u003c/em\u003e School Psychology Review, 2017. \u003cstrong\u003e46\u003c/strong\u003e(1): p. 21-41.\u003c/li\u003e\n\u003cli\u003eMoskowitz, J.T., et al., \u003cem\u003ePositive psychological intervention effects on depression: Positive emotion does not mediate intervention impact in a sample with elevated depressive symptoms.\u003c/em\u003e Affective Science, 2023. \u003cstrong\u003e4\u003c/strong\u003e(1): p. 163-173.\u003c/li\u003e\n\u003cli\u003eMoskowitz, J.T., et al., \u003cem\u003eRandomized controlled trial of a positive affect intervention for people newly diagnosed with HIV.\u003c/em\u003e Journal of Consulting and Clinical Psychology, 2017.\u003cstrong\u003e Vol 85\u003c/strong\u003e(5): p. 409-423.\u003c/li\u003e\n\u003cli\u003eMoskowitz, J.T., et al., \u003cem\u003eRandomized Controlled Trial of a Facilitated Online Positive Emotion Regulation Intervention for Dementia Caregivers.\u003c/em\u003e Health Psychology, 2019. \u003cstrong\u003e38 \u003c/strong\u003e(5): p. 391-402.\u003c/li\u003e\n\u003cli\u003eRadloff, L.S., \u003cem\u003eThe CES-D scale a self-report depression scale for research in the general population.\u003c/em\u003e Applied psychological measurement, 1977. \u003cstrong\u003e1\u003c/strong\u003e(3): p. 385-401.\u003c/li\u003e\n\u003cli\u003eCohen, S., \u003cem\u003ePerceived stress in a probability sample of the United States\u003c/em\u003e, in \u003cem\u003eThe social psychology of health. The Claremont Symposium on Applied Social Psychology\u003c/em\u003e, S. Spacapan and S. Oskamp, Editors. 1988, Sage Publications, Inc: Thousand Oaks, CA. p. 31-67.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Connell, N.S., et al., \u003cem\u003eMethods for analysis of pre-post data in clinical research: a comparison of five common methods.\u003c/em\u003e Journal of biometrics \u0026amp; biostatistics, 2017. \u003cstrong\u003e8\u003c/strong\u003e(1): p. 1.\u003c/li\u003e\n\u003cli\u003eGriffith, J.M., et al., \u003cem\u003eAffective development from middle childhood to late adolescence: Trajectories of mean-level change in negative and positive affect.\u003c/em\u003e Journal of Youth and Adolescence, 2021. \u003cstrong\u003e50\u003c/strong\u003e: p. 1550-1563.\u003c/li\u003e\n\u003cli\u003eCregg, D.R. and J.S. Cheavens, \u003cem\u003eGratitude interventions: Effective self-help? A meta-analysis of the impact on symptoms of depression and anxiety.\u003c/em\u003e Journal of Happiness Studies, 2021. \u003cstrong\u003e22\u003c/strong\u003e: p. 413-445.\u003c/li\u003e\n\u003cli\u003eDavis, D.E., et al., \u003cem\u003eThankful for the little things: A meta-analysis of gratitude interventions.\u003c/em\u003e Journal of counseling psychology, 2016. \u003cstrong\u003e63\u003c/strong\u003e(1): p. 20.\u003c/li\u003e\n\u003cli\u003eKhanna, P., K. Singh, and S. Dua, \u003cem\u003eRole of gratitude in positive adolescent development\u003c/em\u003e, in \u003cem\u003eAdolescence in India: Issues, Challenges and Possibilities\u003c/em\u003e. 2022, Springer. p. 423-451.\u003c/li\u003e\n\u003cli\u003eGentzler, A.L., et al., \u003cem\u003eYoung adolescents\u0026rsquo; responses to positive events: Associations with positive affect and adjustment.\u003c/em\u003e The Journal of Early Adolescence, 2013. \u003cstrong\u003e33\u003c/strong\u003e(5): p. 663-683.\u003c/li\u003e\n\u003cli\u003ePina, A.A., A.J. Polo, and S.J. Huey, \u003cem\u003eEvidence-based psychosocial interventions for ethnic minority youth: The 10-year update.\u003c/em\u003e Journal of Clinical Child \u0026amp; Adolescent Psychology, 2019. \u003cstrong\u003e48\u003c/strong\u003e(2): p. 179-202.\u003c/li\u003e\n\u003cli\u003eKim, H.J., et al., \u003cem\u003eDepression among Asian-American adults in the community: Systematic review and meta-analysis.\u003c/em\u003e PloS one, 2015. \u003cstrong\u003e10\u003c/strong\u003e(6): p. e0127760.\u003c/li\u003e\n\u003cli\u003eBernal, G., M.I. Jim\u0026eacute;nez-Chafey, and M.M. Domenech Rodr\u0026iacute;guez, \u003cem\u003eCultural adaptation of treatments: A resource for considering culture in evidence-based practice.\u003c/em\u003e Professional Psychology: Research and Practice, 2009. \u003cstrong\u003e40\u003c/strong\u003e(4): p. 361.\u003c/li\u003e\n\u003cli\u003ePerera, C., et al., \u003cem\u003eNo implementation without cultural adaptation: a process for culturally adapting low-intensity psychological interventions in humanitarian settings.\u003c/em\u003e Conflict and health, 2020. \u003cstrong\u003e14\u003c/strong\u003e: p. 1-12.\u003c/li\u003e\n\u003cli\u003eYeager, D.S., R.E. Dahl, and C.S. Dweck, \u003cem\u003eWhy interventions to influence adolescent behavior often fail but could succeed.\u003c/em\u003e Perspectives on Psychological Science, 2018. \u003cstrong\u003e13\u003c/strong\u003e(1): p. 101-122.\u003c/li\u003e\n\u003cli\u003eHerrando, C. and E. Constantinides, \u003cem\u003eEmotional contagion: A brief overview and future directions.\u003c/em\u003e Frontiers in psychology, 2021. \u003cstrong\u003e12\u003c/strong\u003e: p. 712606.\u003c/li\u003e\n\u003cli\u003eKuyken, W., et al., \u003cem\u003eEffectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial.\u003c/em\u003e BMJ Ment Health, 2022. \u003cstrong\u003e25\u003c/strong\u003e(3): p. 99-109.\u003c/li\u003e\n\u003cli\u003eBa\u0026ntilde;os, R.M., et al., \u003cem\u003eOnline positive interventions to promote well-being and resilience in the adolescent population: A narrative review.\u003c/em\u003e Frontiers in psychiatry, 2017. \u003cstrong\u003e8\u003c/strong\u003e: p. 222668.\u003c/li\u003e\n\u003cli\u003eGriffiths, K.M. and H. Christensen, \u003cem\u003eInternet‐based mental health programs: A powerful tool in the rural medical kit.\u003c/em\u003e Australian Journal of Rural Health, 2007. \u003cstrong\u003e15\u003c/strong\u003e(2): p. 81-87.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBaseline Characteristics and Differences between Groups\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eCharacteristic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003eCEDARS (N=58)\u003c/p\u003e\n \u003cp\u003eMean or %\u003c/p\u003e\n \u003cp\u003e(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003eControl (N=44)\u003c/p\u003e\n \u003cp\u003eMean or %\u003c/p\u003e\n \u003cp\u003e(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e-statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e14.31\u003c/p\u003e\n \u003cp\u003e(0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e14.41\u003c/p\u003e\n \u003cp\u003e(0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eGender (Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e52%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e59%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eAsian American, or Pacific Islander\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e56.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e75.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e.047*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eWhite (non-Hispanic)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e20.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e2.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e.02*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eMore than one race\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e11.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eHispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e5.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e4.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e1.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e5.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e2.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.3915857605178%\" valign=\"top\"\u003e\n \u003cp\u003eLanguage Other Than English Spoken at Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.06472491909385%\" valign=\"top\"\u003e\n \u003cp\u003e72.4%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.446601941747574%\" valign=\"top\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.592233009708737%\" valign=\"top\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.50485436893204%\" valign=\"top\"\u003e\n \u003cp\u003e.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026lt;.05\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBaseline Descriptive Statistics and Group Differences on Key Outcome Variables\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eCEDARS (N=58)\u003c/p\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003cp\u003e(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.115384615384617%\" valign=\"top\"\u003e\n \u003cp\u003eControl\u0026nbsp;(N=44)\u003c/p\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003cp\u003e(SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e-statistic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.26923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eIntervention Skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e2.31\u003c/p\u003e\n \u003cp\u003e(1.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.115384615384617%\" valign=\"top\"\u003e\n \u003cp\u003e2.57\u003c/p\u003e\n \u003cp\u003e(1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003e.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.26923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003ePositive Emotion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e2.87\u003c/p\u003e\n \u003cp\u003e(0.90)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.115384615384617%\" valign=\"top\"\u003e\n \u003cp\u003e2.85\u003c/p\u003e\n \u003cp\u003e(1.00)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.26923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eNegative Emotion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e1.21\u003c/p\u003e\n \u003cp\u003e(0.66)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.115384615384617%\" valign=\"top\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003cp\u003e(0.61)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.26923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eDepressive Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e13.46\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(8.56)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.115384615384617%\" valign=\"top\"\u003e\n \u003cp\u003e17.07\u003c/p\u003e\n \u003cp\u003e(9.58)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.26923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e.047*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003ePerceived Stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e15.63\u003c/p\u003e\n \u003cp\u003e(5.95)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.115384615384617%\" valign=\"top\"\u003e\n \u003cp\u003e18.98\u003c/p\u003e\n \u003cp\u003e(5.63)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003e2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.26923076923077%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e.01*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*\u003cem\u003ep\u003c/em\u003e\u0026lt;.05\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diedu","sideBox":"Learn more about [Discover Education](https://www.springer.com/journal/44217)","snPcode":"44217","submissionUrl":"https://submission.nature.com/new-submission/44217/3","title":"Discover Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4464805/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4464805/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study tested the feasibility and preliminary efficacy of Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS) a positive psychological intervention (PPI), tailored for adolescents and administered in a classroom setting, in boosting CEDARS skill use and emotional well-being.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdolescents (N = 102, 45% female) aged 13-15, in four physical education classes at the same school were randomly assigned by classroom to either receive the CEDARS intervention (n = 59) or engage in the usual class activities (n = 44). Participants completed self-report measures at three time points assessing use of intervention skills, positive and negative affect, depressive symptoms, and perceived stress.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults and Conclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGroups differed significantly on race with 57% of the intervention group compared to 75% of the control group identifying as Asian or Pacific Islander. Race-adjusted analyses revealed that both groups improved on intervention skill use, negative affect, depressive symptoms, and perceived stress. The group by time interaction was significant such that the CEDARS group increased skill use from pre- to post- intervention and this difference persisted at follow-up. Contrary to hypotheses, there were also significant group by time interactions indicating that the control group had a steeper decline in depression and perceived stress from pre- to post-intervention. Students reported high acceptability and feasibility and suggested key changes to increase engagement. The current study expands on the existing PPI literature focused on adolescents and highlights the need for larger and more diverse samples, as well as developmentally- and culturally-tailored interventions.\u003c/p\u003e","manuscriptTitle":"Coping and Emotional Development for Adolescents to Reduce Stress (CEDARS): Pilot test of a school-based positive psychological intervention for adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-12 17:41:31","doi":"10.21203/rs.3.rs-4464805/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-30T04:38:43+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"49671994829454286061768124535461324008","date":"2024-09-03T18:40:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-24T19:22:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318140701929225220139488297470103721079","date":"2024-08-10T16:33:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-25T23:49:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216148253112679732441505342541085739024","date":"2024-06-05T14:50:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-28T16:43:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-28T05:45:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-28T05:44:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Education","date":"2024-05-23T06:55:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diedu","sideBox":"Learn more about [Discover Education](https://www.springer.com/journal/44217)","snPcode":"44217","submissionUrl":"https://submission.nature.com/new-submission/44217/3","title":"Discover Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"626dc13f-e738-4fab-9215-53c410e76296","owner":[],"postedDate":"June 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-11-26T16:08:30+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-12 17:41:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4464805","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4464805","identity":"rs-4464805","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}