ORIGINAL PAPER

School-based prevention and reduction of depression in adolescents:

A cluster-randomized controlled trial of a mindfulness group program
Filip Raes James W. Griffith Katleen Van der Gucht J. Mark G. Williams

Citation:
Raes, F., Griffith, J. W., Van der Gucht, K., & Williams, J. M. G. (2014). School-based prevention and
reduction of depression in adolescents: A cluster-randomized controlled trial of a mindfulness group
program. Mindfulness, 5, 477-486. doi: 10.1007/s12671-013-0202-1.

___________________________
F. Raes
Faculty of Psychology and Educational Sciences, University of Leuven, Tiensestraat 102, 3000
Leuven, Belgium
e-mail: filip.raes@ppw.kuleuven.be

J. W. Griffith
Department of Medical Social Sciences, Northwestern University, 633 N St Clair, 19th Floor,
Chicago, Illinois 60611, USA
email: j-griffith@northwestern.edu, jameswgriffith@gmail.com

K. Van der Gucht

VZW Mindfulness, Steenstraat 25, 9070 Heusden, Belgium
Current address: Faculty of Psychology and Educational Sciences, University of Leuven,
Tiensestraat 102, 3000 Leuven, Belgium
email: katleen.vandergucht@gmail.com

J. M. G. Williams
Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
email: mark.williams@psych.ox.ac.uk

Abstract
Our objective was to conduct the first randomized controlled trial of the efficacy of a group
mindfulness program aimed at reducing and preventing depression in an adolescent school-based
population. For each of 12 pairs of parallel classes with students (age range 13-20) from five
schools (N = 408), one class was randomly assigned to the mindfulness condition and one class
to the control condition. Students in the mindfulness group completed depression assessments
(the Depression Anxiety Stress Scales) prior to and immediately following the intervention, and
6 months after the intervention. Control students completed the questionnaire at the same times
as those in the mindfulness group. Hierarchical linear modeling showed that the mindfulness
intervention showed significantly greater reductions (and greater clinical significant change) in
depression compared with the control group at the 6-month follow-up. Cohens d was mediumsized (> .30) for both the pre-to-post and pre-to-follow-up effect for depressive symptoms in the
mindfulness condition. The findings suggest that school-based mindfulness programs can help to
reduce and prevent depression in adolescents.

Keywords: mindfulness-based cognitive therapy; mindfulness-based stress reduction;

randomized controlled trial; depression; adolescents

Introduction
Mindfulness refers to a compassionate and nonjudgmental moment-to-moment awareness
of ones experiences. An often-cited definition is that of Kabat-Zinn (1994, p. 4), who describes
mindfulness as the awareness that emerges through paying attention in a particular way: on
purpose, in the present moment, and nonjudgmentally. In the last three decades, interventions
have been developed to teach mindfulness skills to reduce physical and emotional complaints.
Two predominant mindfulness-based approaches, both using mindfulness meditation, are
Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) and Mindfulness-Based
Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002). Other influential approaches
within the family of mindfulness-oriented interventions (Keng, Smoski, & Robins, 2011, p.
1043), such as Dialectical Behavior Therapy (DBT; Linehan, 1993) and Acceptance and
Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) also teach mindfulness but with
less focus on meditation. The success of these mindfulness-based approaches suggests that
mindfulness skills may help to prevent and reduce emotional distress.
In both clinical and non-clinical samples, mindfulness-based interventions have generally
been effective at reducing physical and psychological problems (e.g., anxiety and depression)
and increasing health and well-being (for reviews, see: Hofmann, Swayer, Witt, & Oh, 2010;
Keng et al., 2011). Most studies that provide support for mindfulness-based interventions have
been conducted in adults. Recently, however, there have been more efforts to develop and to
examine the effectiveness of mindfulness-based interventions for children and adolescents
(Burke, 2010; Meiklejohn et al., 2012).
Burke (2010) concludes that there are clear indications now that mindfulness-based
programs with children and youth are feasible and acceptable (e.g., Mendelson et al., 2010).

There is also emerging evidence on the efficacy and effectiveness of such interventions for
children and adolescents, both in clinical and in normative or community samples (for reviews,
see Black, 2009; Burke, 2010; Meiklejohn et al., 2012).
The results of an RCT by Biegel, Brow, Shapiro and Schubert (2009), for example,
reported positive effects of MBSR in an adolescent outpatient psychiatric sample, in terms of
decreases in anxiety and depression, and increases in self-esteem. Other promising findings on
the benefits of mindfulness-based approaches for adolescents and children with clinical problems
are reported, for example, for ADHD (e.g., Singh, Singh, Lancioni, Singh, Winton, & Adkins,
2010; van de Weijer-Bergsma, Formsma, de Bruin, & Bgels, 2012) and anxiety (Semple, Reid,
& Miller, 2005).
Preliminary studies examining mindfulness-based approaches in community children and
adolescents suggest that such interventions might also be beneficial for non-clinical individuals
for reducing stress, depression, and anxiety, as well as helping to improve attention and emotion
regulation (see Meiklejohn et al., 2012, for a review). Positive effects have been reported for
school-based mindfulness approaches for elementary- and middle-school-aged children (e.g.,
Napoli, Krech, & Holley, 2005; Schonert-Reichl & Lawlor, 2010; van de Weijer-Bergsma,
Langenberg, Brandsma, Oort, & Bgels, in press) as well as for high-school-aged adolescents
(e.g., Broderick & Metz, 2009; Huppert & Johnson, 2010).
Although the findings to date on mindfulness interventions for children and adolescents
are promising, further empirical work is clearly needed. This is particularly so for community
samples, because existing studies are typically limited either by small sample sizes, lack of
adequate control groups, or nonrandomized designs (Burke, 2010; also see: Keng et al., 2011;

Meiklejohn et al., 2012). Thus, there is a need to advance research on mindfulness for youth
using larger-scale group randomized controlled trials (RCTs).
This article reports the effects of a mindfulness group program on reducing and
preventing depression in adolescents, using a group-RCT design with a large school-based
sample. The mindfulness program was developed specifically for adolescents (Dewulf, 2009, in
press) and integrates components of MBCT (Segal et al., 2002) and MBSR (Kabat-Zinn, 1990).
Method
Participants and Design
Fifty schools were invited to participate. The schools were located in Flanders the
northern, Dutch-speaking region of Belgium. Fifteen schools expressed interest in participating,
but ten were unable to participate due to practical difficulties that mainly had to do with course
timetable incompatibilities. Four of the five schools each offered two or three pairs of parallel
classes, spread over two school years (2009-2010; 2010-2011), resulting in 9 pairs of classes (n =
315). Within pairs, one class was randomized to the mindfulness condition, the other to the (no
intervention) control condition. In the fifth school, classes were too small to be used as
mindfulness or control groups. For that particular school, half of the students of each class was
randomized to the mindfulness condition, the other half to the control condition, which led to an
additional three pairs of mindfulness and control groups (n = 93). This randomization resulted in
a total of 12 pairs of mindfulness and 12 control groups (N= 408; mindfulness n = 201; control n
= 207). Randomization, using an online random number generator, was done by the first author
who did not participate in the assessments and who had no contact with schools, classes, or
students. Participating classes were from Year 3 to 6 in secondary school, a time that is
characterized by the highest percentage of age at onset of first major depressive episode (Zisook

et al., 2007). Year 3 to 6 in Flemish secondary schools, roughly referring to ages 14 to 17,
corresponds to Grades 9 to 12 (or high school) in the American educational system. To be more
precise, there were three pairs of groups from Year 3 (mean age 14), four pairs of groups from
Year 4 (mean age 15), four pairs of groups of Year 5 (mean age 16), and one pair of groups of
Year 6 (mean age 17).Group size ranged from 10 to 24 (M = 16.8; SD = 4.9) for the mindfulness
condition; for the control groups, group size ranged from 12 to 24 (M = 17.3; SD = 4.8), t< 1).
Measures
Depression Anxiety Stress Scales (DASS-21). The DASS-21 (Lovibond & Lovibond,
1995) consists of three 7-item scales designed to assess depression (DASS-21-D), anxiety
(DASS-21-A), and stress symptoms (DASS-21-S). In this study, the depression scale was the
main outcome. Items were scored on a four-point scale, ranging from 1 (did not apply to me at
all) to 4 (applied to me very much, or most of the time), for the past week. Good psychometric
properties are reported for the original as well as the Dutch version that we used (de Beurs, van
Dyck, Marquenie, Lange & Blonk, 2011; Willemsen, Markey, Declercq, & Vanheule, 2011). To
aid in questionnaire interpretation, all subscales of the DASS were converted to percent-ofmaximum-possible (POMP) scores, in which a scale is converted to a 0-100% metric with 0
being the minimum value of the scale and 100 being the maximum possible value of the scale (P.
Cohen, J. Cohen, Aiken, & West, 1999). For the depression scale, a raw score of 14 or above
(POMP score of 33.3) was considered clinically significant. Reliability for this scale was good in
this study; Cronbachs alphas were > .80 across all three time points.
Other measures. We included several measures in this study that are not reported in this
manuscript. For example, we had initially wanted to use the 15-item Five Factor Mindfulness
Questionnaire (Baer, Carmody, & Hunsinger, 2012) as a mindfulness measure, but the internal

consistency for this measure was too low to be trusted Cronbachs =.47). We suspect that this
was because this measure was not developed for secondary school students. Thus, we do not
report this measure. We also included a Mood Disorders Questionnaire (Van der Does,
Barnhofer, & Williams, 2003), which is an experimental questionnaire that is intended to yield a
yes/no diagnosis of major depressive disorder. However, the sensitivity and specificity of this
measure are not well known at this time in English or Dutch. Thus, we did not use this
questionnaire as an endpoint.
Procedure
All students gave written assent or informed consent if they were already legal adults. For
those below age 16, passive parental informed consent was also obtained using a letter in which
they are asked to complete and return an attached form if they do not want their child to
participate. Students in the mindfulness condition attended the mindfulness program during
school hours for eight weeks, replacing religious studies, physical education, or another
academic course, depending on the classs timetable. One school was a boarding school, so the
mindfulness sessions were organized on a weekday evening. Each mindfulness session lasted
100 minutes. Students were not graded on any aspect of the mindfulness course. Participants in
the control groups followed their regular school program; no intervention or attention was
provided to them. Mindfulness and control groups of each pair were conducted at the same time.
Students in the mindfulness groups completed the questionnaire before the mindfulness program
(baseline; T1), after the mindfulness program (post-intervention; T2), and at a 6-month follow-up
point (T3). Control students completed the questionnaire at the same times as those in the
mindfulness group. All assessments were administered during regular school hours by the third
author who was not involved as a mindfulness trainer in any of the groups. Students were

provided with help-seeking contacts (e.g., helpline numbers, mental health centers) at each
assessment point. The ethical committee of the University of Leuven approved the study.
Mindfulness Intervention
The intervention was a mindfulness group training specifically developed for adolescents
(Dewulf, 2009, in press). It integrated elements of MBCT (Segal et al., 2002) and MBSR (e.g.,
Kabat-Zinn, 1990). The program was delivered by an instructor in eight weekly 100-minute
sessions, and included guided experiential mindfulness exercises (e.g., mindfulness of breathing,
breathing space, body scan), sharing of experience of these exercises; reflections in small groups,
inspiring stories; psycho-education (e.g., stress, depression, self-care), and review of homework.
Homework assignments were 15 minutes of mindfulness practice each day, suggested reading,
and weekly tips on how to bring mindfulness into daily life. Each session focused on a specific
theme, and some exercises are repeated throughout the program. Sessions thematically focus on
Attention to the breath and the moment (Session 1), Attention to the body and pleasant
moments (Session 2), Attention to your inner boundaries and to unpleasant moments (Session
3), Attention to stress and space (Session 4), Attention to thoughts and emotion (Session 5),
Attention to interpretations and communication (Session 6), Attention to your attitudes and
your moods (Session 7), and Attention to yourself and your heartfulness (Session 8).
Participants in this program received the book Mindfulness voor jongeren [Mindfulness for
adolescents] (Dewulf, 2009) for reviewing the material at home. For formal practice, the book
comes with a double CD with mindfulness exercises and several sitting meditations. Participants
were also encouraged to apply mindfulness throughout their daily lives. They received a
workbook for making notes on their home practice; these notes are then used as input for
discussion during the next group session.

The three instructors, two men and one woman, were experienced mindfulness trainers;
two of them were psychologists; one was a medical doctor. One of them, D. Dewulf, developed
the mindfulness intervention and is the founder and chairman of the Institute for Attention and
Mindfulness (I AM). The other two completed their mindfulness training at I AM. They had
extensive experience with delivering the program to adults and adolescents and also have an
ongoing personal mindfulness meditation practice. The three instructors regularly met eight
times during the course of the first mindfulness groups to discuss their experience with the
sessions and to evaluate and to maximize or ensure close adherence to the protocol, but no
formal adherence measure was used.
Statistical Analysis
For each of the three DASS-subscales, if fewer than 20% of the items were missing (i.e.
not more than one item missing), the score was prorated. Ten participants did not provide
sufficient data on the DASS-21-D to compute baseline scores. Those participants who did not
complete the pre-intervention assessment were excluded from analyses. Our analysis plan was a
follows: We first compared the mindfulness versus control groups to ensure that they were
comparable at baseline; we predicted that there would be no meaningful differences. We next
used hierarchical linear modeling (e.g., Raudenbush & Bryk, 2002) to examine the differential
trajectories of depression. Hierarchical linear modeling allowed us to determine individual
trajectories in individual change while accounting for the fact that individuals within groups
might show dependencies by virtue of the fact that they are in the same group. Cases with
missing data at T2 or T3 were still included in the analyses, which still allows for estimation of
change over time with full maximum likelihood estimation. We hypothesized that mindfulness
would result in larger reductions in depression at T2 and T3 above and beyond gender and school

as covariates, relative to the control condition. We also used Cohens d statistic (Cohen, 1988) to
calculate within-group effect sizes. In addition, we examined the clinical significance of the
effects using a normative cutoff point for our primary outcome measure (DASS-21-D).
Results
Participants flow
Figure 1 presents the flowchart of the recruitment and retention of participants in the trial.
None of the students from the classes involved in the project declined to participate.
Four participants had missing data at the T1 in the mindfulness condition versus one in the
control group. Table 1 presents the percentage of missing data across the follow-ups. The main
reason for missing data were participants being absent from school on the day of testing. No
students formally withdrew from the study. There were significantly higher rates of missing data
for the control group versus the mindfulness group at T2 (12% vs. 6%; Table 1), but rates of
missing data were not significantly different at T3 (16% vs. 14%; Table 1). The average age in
the sample was 15.4 years (SD = 1.2, range 13-20). In terms of year in school, 20% were in their
third year of secondary school (typically age 14), 40% were in their fourth year, 29% were in
their fifth year, and 10% were in their sixth year.
Pre intervention Comparisons
Table 1 shows comparisons of the mindfulness versus control groups at baseline. Clinical
significance of depression was assessed using the DASS-21-D scores of moderate depression or
greater (Lovibond & Lovibond, 1995). Rates of clinically-significant depression are shown in
Table 2. No significant differences were observed between the two groups at baseline.
Intervention Outcome

Hierarchical linear modeling was used to conduct the analyses of the DASS-21-D. The
model is presented in Table 3 and the overall results presented in Figure 1. We first examined a
null model, in HLM parlance, to estimate intraclass correlations (ICCs) for level-2 and level-3
variability. These ICCs represent the proportion of variance in the dependent variable (DASS21-D) that are accounted for by level-2 (subject level, e.g., gender), and level-3 (e.g., school)
factors. The ICCs for levels 2 and 3 were
.35 and .08 respectively.
Level 1 of the model contained the within-subject relationship between time point and the
DASS-21-D. Time point was dummy coded such that one dummy variable measured the change
from baseline to T2 (post-intervention), and another variable measured the change from baseline
to T3 (see Table 3). Level 2 of the model contained the regression of the level-1 parameters on
gender, which was the only participant-level variable that we examined. At level 2, error terms
were included for the two level-1 slopes as dependent variables to capture participant-toparticipant differences that might exist for the relationship between time point and depression. At
level 3, group was used as the identifier to capture differences across groups; experimental
condition and school were used as covariates. School was represented by four dummy variables.
At level 3 the dependent variables were the level 2 regression parameters. Gender and school
were not our main variables of interest. Gender is often related to depression, so it was entered to
reduce potential nuisance variance. School was entered to represent the nested structure of the
data.
Table 3 presents hierarchical model that we tested. Table 4 presents the results for each
parameter in the model. To test our main hypotheses, we used DASS-21-D as the dependent
variable in the regression; the coefficients and standard errors for parameters G101 and G201

(see Table 3) were respectively, -6.0 (3.1) and -6.8 (3.3). The p value for parameter G101 was p
= .050, but the observed t statistic (t = 1.958, 391 df) was very slightly below the critical value
needed for statistical significance. Parameter G201, however, was significant at p < .05, which
indicates that, as predicted, the mindfulness intervention had more of an impact on changes in
depression than the control group at T3. The mindfulness group had lower levels of depression at
T2 and T3 relative to baseline, whereas little change was observed in the control group (see
Table 1). The effect of the mindfulness intervention did not significantly interact with gender.
Another way to think about G101 and G201 are as cross-level interactions of condition and time
these parameters capture the effect of treatment condition on the changes from baseline in
depression. Although they were not the main focus of the study, the G201 parameters were also
negative and significant at p < .05 when the anxiety scale and stress scale were used as
dependent variables.
Because gender and school were not hypothesized to influence the efficacy of treatment,
we also compared the full model in Tables 3 and 4 to a simplified model that did not contain the
parameters for gender and school. The deviance statistic for the simplified model (11 parameters)
was 9330.0; for the full model (Tables 3 and 4; 41 parameters), the deviance statistic was 9288.5.
Despite our large sample, the difference between these two models was not statistically
significant, 2 (df = 30) = 41.5, ns. This suggests that these additional variables did not have a
significant effect as a group. Among the other 34 t tests produced by the model (not counting our
2 hypothesized effects), there were, however, 4 individual t tests that were significant as shown
in Table 4. Because the block of variables was not significant, and because it is not surprising to
see some significant tests when testing a large block, these were not interpreted further and no
additional modifications were made to the model.

To further examine the magnitude of the effect of the mindfulness intervention we used
repeated measures t tests as well as Cohens d effect sizes (Cohen, 1988). We compared the
differences from T2 and T3, respectively, from baseline. In the mindfulness group, for the
reduction from baseline to T2 in DASS-21-D, there was a significant decrease in depression, t
(181) = 4.4, p < .001, Cohens d was .32. For the reduction from baseline to T3, there was also a
significant reduction, t (166) = 4.0, p < .001,Cohens d was .31. In terms of J. Cohens (1988)
conventions, these are small to medium-sized reductions. No significant changes over time were
observed in the control condition, ts < 1.2, ns.
Clinical Significance: Clinical Cutoff Depression Symptoms (DASS-21-D). Table 2
shows the number and percentage of students scoring above the clinical cutoff on the DASS-21D at baseline (T1), post-intervention (T2), and at follow-up (T3). At T2 and at T3 a significantly
smaller percentage of students in the mindfulness group scored above the clinical cutoff,
compared to the control condition.
Focusing only on participants (n = 88) who scored above the clinical cutoff at baseline,
one sees that at T3, in the control condition a significantly larger percentage of these students
were still scoring above the cutoff, as compared to the mindfulness condition. In the control
condition 46% had recovered versus 73% in the mindfulness condition. We also examined
whether these changes exceeded the reliable change index (RCI; Jacobson & Truax, 1991)3 and
whether participants moved from above to below the cutoff. We calculated the RCI using the
formula from Jacobson and Truax (1991, p. 14); we used the SD from the DASS-21-D at T1 in
the calculations; we used .80, which is Cronbachs from the T1 DASS-21-D, as the reliability
estimate. The RCI was 4.7 in raw units, 22.2 in Percent of Maximum Power units. Of the control

condition, 36% were reliably improved at follow-up versus 62% of the mindfulness condition,
(1) = 4.87, p < .05.
For those starting below the DASS-21-D cutoff (n = 305), a larger percentage of control
participants were above the clinical cutoff at both T2, (1) = 8.89, p < .01, and at T3, (1) =
5.54, p < .05. Looking at both an increase that exceeded the RCI and moving from below to
above the cutoff, 13% of the controls had more depression at T2 versus 1% of the mindfulness
condition, (1) = 16.71, p < .05; from baseline to follow-up, 18% of the control condition had
more depression at T3 versus 9% in the mindfulness condition, (1) = 4.39, p < .05.
Discussion
These results show that a mindfulness program, as compared with a control condition,
was able to result in lower levels of depression at a 6-month follow-up in adolescents. Moreover,
these results appear to be clinically significant when examining the effect size from the DASS21-D. The effects for depressive symptoms from baseline to post-intervention and from baseline
to follow-up were small to medium (both Cohens d were > .30). These values correspond to an
approximate r value of .15, which is similar to the average pre-to-post (r = .15) and average preto-follow-up effect (r = .11) reported for depression prevention programs for youth in a recent
meta-analytic review (Stice, Shaw, Bohon, Marti, & Rohde, 2009).
Further, in the mindfulness condition a significantly smaller percentage of students scored
above the clinical cutoff at follow-up than in the control condition, reflecting a combination of a
curative and preventive effect of the intervention: A greater proportion of depressed students (i.e.
scoring above the clinical cutoff at baseline) were reliably recovered at follow-up (i.e. scoring
now below the clinical cutoff) in the mindfulness condition; and a smaller proportion of nondepressed students (i.e. scoring below the clinical cutoff at baseline) reliably deteriorated at

follow-up (i.e. scoring now above the clinical cutoff). Our results, thus, extend earlier findings
on the positive effects of mindfulness-based interventions for depressive symptoms in clinical
samples (see Hofmann et al., 2010) to a community sample (of adolescents). Also, our findings
add to the growing body of research that mindfulness-based programs can be successfully
integrated in education (see Meiklejohn et al., 2012)
There are several limitations and caveats to note about this study. There was a
disproportionately high percentage of females versus males in this study (see Table 1). Although
we did not find a significant gender condition interaction (see parameters G111 and G211 in
Table 4), we may have lacked sufficient power to detect such effects. Future studies should
aggressively recruit large subsamples from both genders (and potentially other subgroups) to
determine definitively whether treatment efficacy interacts with other participant characteristics.
In terms of methodological limitations, we did not assess the fidelity of the intervention
by recording (e.g., videotaping) the sessions and having the sessions coded. We did not measure
any psychotherapy process variables (e.g., how much homework was completed, what specific
topics were discussed), and our control group did not receive any active ingredient of
psychotherapy (e.g., attention, supportive listening). Thus, the mechanism by which the
mindfulness intervention was effective is unclear.
With regard to our assessments, our measure of depression was a self-report
questionnaire. A superior methodology would have been to use a psychometrically strong,
clinician-administered interview. Unfortunately, in this study, it was not logistically possible to
administer an in-depth clinical interview to our sample of over 400 participants. Future studies
should seek to replicate our findings using interview-based assessments. Finally, we stress once
more that we only had a no-treatment control, so we cannot rule out the effect of non-specific

aspects of the mindfulness intervention (e.g., attention). Thus, future studies should include
active control groups as much as possible. Assuming that future studies show that mindfulness
can be effective for preventing depression, other studies could then examine the mechanisms of
change so that these future interventions could target these mechanisms. Potential mechanisms or
key processes in this respect might be, for example, cognitive reactivity (e.g., Kuyken et al.,
2010; Raes, Dewulf, Van Heeringen, & Williams, 2009), self-compassion (Kuyken et al., 2010),
and experiential acceptance (Keng et al., 2011) .
In summary, the current study, to our knowledge, is the first group-RCT to examine the
effects on depression of a mindfulness-based intervention for adolescents in a community
setting. Previous research had found that mindfulness interventions could be adapted to younger
populations, but evidence for the efficacy was limited by weak study designs (e.g., low sample
sizes, no randomization). Our results provide evidence in support of the efficacy of a
mindfulness-based approach to reduce depression symptoms in adolescents. This effect was
statistically and clinically significant and appears to reflect a combination of a curative and
preventive effect.

Acknowledgements
This research was supported by a grant from the Foundation Go for Happiness. Dr.
Griffith was supported by the Research Foundation-Flanders (FWO; GP.035.11N). We sincerely
thank David Dewulf, Inge De Leeuw and Lieven Vercauteren, and the schools and students of
Belgium who participated in this project. We would also like to acknowledge the assistance
provided by Tineke Vandenbroucke and Margot Bastin. And a special thanks to Jan Toye and
Ghita Kleijkers for their sincere and motivating interest.

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Figure 1. Flowchart of the recruitment and retention of participants in the trial.

24 classes/groups randomized
to the MFS or CON condition
(n = 408)a

12 classes/groups randomized
to the
MFS condition (n = 201) a

12 classes/groups randomized
to the
CON condition (n = 207) a

Pre intervention
Completed n = 197
Missing n = 4 (2%)

Completed n = 206
Missing n = 1 (<1%)

Post intervention
Completed n = 185
Missing n = 16 (8%)

Completed n = 185
Missing n = 22 (11%)

6 month Follow up
Completed n = 170
Missing n = 31 (15%)

Completed n = 175
Missing n = 32 (16%)

Note. For 4 schools classes were randomized. For 1 school, because of classes being too small,
individuals were randomized (for more details, see Participants and Design).

Running head: RCT OF MINDFULNESS AT SCHOOL

25

Table 1. Baseline and outcome characteristics (N = 393)

Baseline Characteristics

Mindfulness

Control

Gender

131 female / 63 male

68% / 33%

194

119 female / 80 male

60% / 40%

199

T1 DASS-21-D
T1 DASS-21-A
T1 DASS-21-S

M (SD) of POMP scores

19.4 (16.6)
22.2 (17.5)
34.9 (18.5)

N
194
194
194

M (SD) of POMP scores

21.2 (19.2)
22.2 (16.3)
34.9 (19.1)

n
199
199
199

Outcome data
T2 DASS-21-D
T3 DASS-21-D

M (SD) of POMP scores

14.1 (14.6)
12.9 (17.3)

N
182
167

M (SD) of POMP scores

22.2 (21.4)
21.0 (21.3)

n
175
168

Missing data
12 (6%)*
27 (14%)

Missing data
24 (12%)*
31 (16%)

Note: In some cases percentages do not sum to 100% exactly due to rounding error. POMP scores are percent-of-maximum-possible scores; each DASS
subscale was rescaled to a 0-100% metric with the minimum of the scale at 0% and the maximum at 100%. DASS = Depression Anxiety Stress Scales
(DASS-21) for depression (D), anxiety (A), and stress (S). The percentages of data lost (i.e., missing data) are presented above next to each follow-up time
point. * = p < .05 for the differences between the mindfulness and control groups: At T2, rates of missing data were different on the DASS-21-D.

Running head: RCT OF MINDFULNESS AT SCHOOL

26

Table 2
Number and percentage of students scoring above the clinical cutoff for depression symptoms (as assessed with the DASS-21-D) at baseline,
post-intervention, and follow-up.
Condition

All
Control
Mindfulness

Pre (T1)

Post (T2)

FU (T3)

47 24%
41 21%

47 27%*
28 15%

52 31%*
26 16%

Clinical Cases at T1 only

Control
47
Mindfulness
41

22 55%
18 51%

21 54%*
9 27%

New Clinical Cases

Control
Mindfulness

25 19%*
10 7%

31 24%*
17 13%

(0)
(0)

Note. * p < .05 for difference between mindfulness versus control group.

Running head: RCT OF MINDFULNESS AT SCHOOL

27

Table 3
Hierarchical Linear Model of DASS-21-D

Level-1 Model
Y = P0 + P1(T2) + P2(T3) + E
Level-2 Model
P0 = B00 + B01(GENDER)
P1 = B10 + B11(GENDER) + R1
P2 = B20 + B21(GENDER) + R2
Level-3 Model
B00 = G000 + G001(CONDITION) + G002(X1) + G003(X2) + G004(X3) + G005(X4) + U00
B01 = G010 + G011(CONDITION) + G012(X1) + G013(X2) + G014(X3) + G015(X4)
B10 = G100 + G101(CONDITION) + G102(X1) + G103(X2) + G104(X3) + G105(X4)
B11 = G110 + G111(CONDITION) + G112(X1) + G113(X2) + G114(X3) + G115(X4)
B20 = G200 + G201(CONDITION) + G202(X1) + G203(X2) + G204(X3) + G205(X4)
B21 = G210 + G211(CONDITION) + G212(X1) + G213(X2) + G214(X3) + G215(X4)

Note. E, R1, R2, and U00 are error terms. Gender was dummy coded (female = 0, male = 1). T2 and T3 are dummy variables for the differences
from baseline. X1-X4 are dummy variables for the five difference schools. Condition is mindfulness versus control, dummy coded (mindfulness
= 1, control = 0). G101 and G201 are the main effects of condition on T2 and T3, respectively. G111 and G211 are the interaction effects of
condition and gender on change from baseline to T2 and T3, respectively. Group was included as the identifier variable at level 3, so group-togroup variability is captured as error at that level. The notation used is that of the HLM software.

Running head: RCT OF MINDFULNESS AT SCHOOL

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Table 4
Final estimation of fixed effects: with DASS-21-D as the dependent variable
Fixed Effect

Coefficient

SE

t(df)

Description of effect

G000
G001
G002
G003
G004
G005

24.0
-0.4
-3.3
6.0
-5.8
-5.0

3.0
2.8
4.5
4.4
4.3
4.1

7.9 (18) ***

0.1(18)
0.7(18)
1.3(18)
1.4(18)
1.2(18)

Intercept
Cond. on baseline DASS
School on baseline DASS
School on baseline DASS
School on baseline DASS
School on baseline DASS

G010
G011
G012
G013
G014
G015

-5.4
-4.5
6.9
0. 7
5.7
0.7

5.9
3.5
7.2
6.6
6.8
6.9

0.9(1049)
1.3(1049)
1.0(1049)
0.1(1049)
0.8(1049)
0.1(1049)

Gender on baseline DASS

Cond. Gender on baseline DASS
SchoolGender on baseline DASS
SchoolGender on baseline DASS
SchoolGender on baseline DASS
SchoolGender on baseline DASS

G100
G101
G102
G103
G104
G105

-1.1
-6.0
3.6
-6.6
9.0
0.7

3.3
3.1
5.0
5.3
4.4
4.2

0.3(391)
2.0(391)
0.7(391)
1.2(391)
2.1(391)*
0.2(391)

Change from baseline to T2

Cond. on T2 change in DASS
School on T2 change in DASS
School on T2 change in DASS
School on T2 change in DASS
School on T2 change in DASS

G110
G111
G112
G113
G114
G115

-1.8
0.6
1.2
8.3
-4.4
7.3

8.9
5.3
11.0
10.1
10.0
10.3

0.2(391)
0.1(391)
0.1(391)
0.8(391)
0.4(391)
0.7(391)

Gender on T2 change in DASS

Cond.Gender on T2 change in DASS
SchoolGender on T2 change in DASS
SchoolGender on T2 change in DASS
SchoolGender on T2 change in DASS
SchoolGender on T2 change in DASS

G200
G201
G202
G203
G204
G205

-2.9
-6.8
2.1
-5.2
7.9
0.2

3.5
3.3
5.3
5.8
4.7
4.5

0.8(391)
2.1(391)*
0.4(391)
0.9(391)
1.7(391)
0.1(391)

Change from baseline to T2

Cond. on T3 change in DASS
School on T3 change in DASS
School on T3 change in DASS
School on T3 change in DASS
School on T3 change in DASS

G210
G211
G212
G213
G214
G215

26.5
3.0
-32.3
-18.5
-22.1
-22.4

10.8
5.7
12.9
12.1
11.9
12.1

2.5(391)*
0.5(391)
2.5(391)*
1.5(391)
1.9(391)
1.8(391)

Gender on T3 change in DASS

Cond.Gender on T3 change in DASS
SchoolGender on T3 change in DASS
SchoolGender on T3 change in DASS
SchoolGender on T3 change in DASS
SchoolGender on T3 change in DASS

For P0
For B00

For B01

For P1
For B10

For B11

For P2
For B20

For B21

Note. t statistics are absolute values. Degrees of freedom (df) are approximate. * p <. 05; *** p < .001. The
five schools are coded with four dummy variables. Cond. = experimental condition (mindfulness vs. control).
Parameters that were hypothesized to be significant and negative are in bold; these parameters, G101 and G201
are the effects of experimental condition on change from baseline and T2 and T3, respectively.

Running head: RCT OF MINDFULNESS AT SCHOOL

29

Figure 1
Depression Anxiety Stress Scales (DASS)-21 Depression Scale over T1 (baseline), T2 (posttreatment), and T3 (follow-up). The DASS is in percent-of-maximum-possible (POMP) scores,
which range from 0-100%. Only complete cases, with non-missing data at T1, T2, and T3, are
included in the figure.