November 09, 2015

Creating Opportunities for Personal Empowerment (COPE) program has positive effects that last at least a year after completion

Schools can significantly improve the long-term physical and mental health of teens by implementing cognitive behavioral skills-building into already existing high-school health curriculums, according to a study funded by the National Institutes of Health/National Institute of Nursing Research (NIH/NINR) and published in the December issues of the Journal of School Health.

The article reports that 12 months after completing the COPE Healthy Lifestyles Thinking, Emotions, Exercise, Nutrition (TEEN) Program, students had markedly lower body mass index than students who received a more standard health curriculum. Additionally, COPE teens who began the program with extremely elevated depression had symptoms in the normal range after 12 months.

COPE Healthy Lifestyles TEEN teaches adolescents that how they think is directly related to how they feel and behave. It also teaches them how to turn negative beliefs triggered by “activating events” into positive beliefs so that they feel better emotionally and engage in healthy behaviors. The program is based on cognitive behavioral therapy (CBT), with an emphasis on skills-building.

The lead author of the article is COPE creator Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, associate vice president for health promotion, chief wellness officer and dean of the College of Nursing at The Ohio State University. Melnyk is also a professor of pediatrics and psychiatry at Ohio State’s College of Medicine.

“CBT is the gold-standard treatment for depression and anxiety, but it has traditionally been used in one-on-one, hour-long therapy sessions,” said Melnyk, who began developing the program more than 20 years ago as a pediatric and psychiatric nurse practitioner. “With COPE, I’ve created a tool that can be used by any health professional or educator so they can teach cognitive behavior skills to adolescents. This is huge for schools or community centers. We can really make positive impacts on teens’ lives by teaching these skills to them.”

This study was aimed at evaluating the long-term efficacy of COPE. A total of 779 high-school students aged 14 to 16 in the southwestern United States participated in the study. Half attended a control class that covered standard health topics such as road safety, dental care and immunizations. The others were enrolled in the COPE Healthy Lifestyles TEEN program.

Health teachers were provided a full-day workshop on COPE and how to teach the program. The classroom curriculum blends cognitive-behavioral skills sessions with nutrition lessons and 20 minutes of physical activity, such as dancing, walking or kick-boxing movements.

The 12-month follow-up evaluation after the COPE program showed a significant decrease in the proportion of overweight and obese teens. Only 4.8 percent of COPE teens moved into the overweight category compared to 10 percent of the control group, Healthy Teens, who moved to either overweight or obese. None of the COPE teens moved to the obese category.  Further, COPE teens who were on public assistance had a significant decline in body mass percentile following the intervention than teens on public assistance who were on public assistance.

A particularly important finding, Melnyk said, was that COPE students who began the study with severely elevated depressive symptoms had significantly lower depressive scores that fell into the normal range than the Healthy Teens students at 12 months post-intervention.

“Because the majority of adolescents with depression do not receive treatment, and even fewer receive CBT, it is vital that we provide them the tools and ability to engage in positive thinking and employ effective coping,” she said. “The feedback from the teens during the open-ended evaluations included hundreds of comments specifically indicating that the COPE program helped them deal effectively with stress and anger as well as to feel better about themselves.”

This latest article reflects a continuation of positive results from COPE.

In 2013, Melnyk published an article in the American Journal of Preventive Medicine, examining immediate and six-month outcomes of COPE. Those results showed increased physical activity, decreased BMI, higher grades, better scores in cooperation, assertion and academic competence – as rated by teachers – and lower alcohol use.

Melnyk said next steps should include implementation of COPE into health curricula across the country. Because a variety of professionals can learn the program, she hopes to see widespread use in schools, community centers and youth organizations to help teens lead healthier, happier lives and perform better academically.

The NIH/NINR supported this research.

The article notes that overweight/obesity and mental health disorders are significant public health problems that threaten health outcomes and academic performance of United States teens. Approximately 17 percent of U.S. youth is obese and 15 percent is overweight, according to research cited by Melnyk.

Additionally, 15 million U.S. youth have a mental-health problem that interferes with functioning at home or school, but fewer than 25 percent receive treatment, and even fewer receive CBT.

April 30, 2015

On Children’s Mental Health Awareness Day, The Ohio State University Office of the Chief Wellness Officer will host an important discussion that every parent should hear.

“Depression and Anxiety in Children and Teens: What Every Parent Must Know” will be from 10-11 a.m. on May 7 in 168 Newton Hall, located at 1585 Neil Avenue.

The free lecture will be presented by Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, Ohio State’s associate vice president for health promotion, university chief wellness officer and dean of the College of Nursing. Melnyk is a world-renowned authority and author on the topic of child and adolescent mental health and will share strategies for preventing, identifying and seeking help for depressive and anxiety disorders in today’s youth.

According to Melnyk, one in four American children and teenagers suffers from a mental health disorder that disrupts functioning at home, at school and with peers, yet less than 25 percent of affected children receive mental health treatment.

“If left untreated, mental health problems can lead to chronic illnesses that are more difficult to treat,” explained Melnyk. “Our ultimate goal is to prevent these conditions, but we also want to help parents identify the warning signs of anxiety and depression and give them the proper resources so that they know where to turn for help should their child develop a mental health problem.”

Participants may join via livestream at carmenconnect.osu.edu/mhd-talk. Ohio State users should log into CarmenConnect with their Ohio State account. Others may login as a guest. For detailed login instructions, visit go.osu.edu/carmenconnect-quickstart.

September 10, 2013

Study Suggests Focus on Mental Health Key to Improving Physical Health

Adding a mental health component to school-based lifestyle programs for teens could be key to lowering obesity, improving grades, alleviating severe depression and reducing substance use, a new study suggests.

As a group, high-school students who participated in an intervention that emphasized cognitive behavioral skills building in addition to nutrition and physical activity had a lower average body mass index, better social behaviors and higher health class grades and drank less alcohol than did teenagers in a class with standard health lessons.

Symptoms in teens who were severely depressed also dropped to normal levels at the end of the semester compared to the control group, whose symptoms remained elevated.

Most of the positive outcomes of the program, called Creating Opportunities for Personal Empowerment (COPE) were sustained for six months.

Thirty-two percent of youths in the United States are overweight or obese, and suicide is the third leading cause of death among young people age 14 to 24, according to the Centers for Disease Control and Prevention, yet most school-based interventions don’t take on both public health problems simultaneously or measure the effects of programs on multiple outcomes, said Bernadette Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN, creator of the COPE program, dean of The Ohio State University College of Nursing and lead author of the study.

“This is what has been missing from prior healthy lifestyle programs with teens – getting to the thinking piece. We teach the adolescents that how they think directly relates to how they feel and how they behave,” said Melnyk, also Ohio State’s chief wellness officer.

“This program dropped scores of severely depressed teens almost in half. Less than 25 percent of adolescents who have mental health problems get any help, and here we have an intervention that addresses that suffering and also can prevent or reduce obesity.”

The study is published in the American Journal of Preventive Medicine.

A total of 779 high school students age 14 to 16 in the southwestern United States participated in the study. Half attended a control class that covered standard health topics such as road safety, dental care and immunizations. The others were enrolled in the COPE intervention Melnyk and colleagues were testing for its effectiveness.

Melnyk began developing COPE more than 20 years ago while she was a nurse practitioner at an inpatient psychiatric unit for children and adolescents. The program is based on the concepts of cognitive behavioral therapy, with an emphasis on skills building.

It’s not counseling in the classroom, however: The entire COPE curriculum, a blend of weekly 50-minute behavioral skills sessions, nutrition information and physical activity over the course of 15 weeks, is spelled out for instructors in manuals and PowerPoints. This study was the first to test COPE’s effectiveness when taught by trained teachers in a health classroom setting. In pilot studies, Melnyk and her team have taught the curriculum themselves.

“These are skills that I can teach a variety of professionals how to deliver, and they don’t have to be certified therapists,” said Melnyk, also a professor of pediatrics and psychiatry.

At its core, the COPE program emphasizes the link between thinking patterns, emotions and behavior as well as the ABCs of cognitive behavioral skills building: activator events that trigger negative thoughts, negative beliefs teens may have about themselves based on the triggering event, and the consequences of feeling bad and engaging in negative behavior as a result.

“We teach kids how to monitor for activator events and show them that instead of embracing a negative belief, they can turn that around to a positive belief about themselves,” Melnyk said. “Schools are great at teaching math and social studies, but we aren’t giving teens the life skills they need to successfully deal with stress, how to problem-solve, how to set goals, and those are key elements in this healthy lifestyle intervention."

COPE also includes nutrition lessons on such topics as portion sizes and social eating and 20 minutes of movement – dance, dodgeball, taking a walk, anything to keep the students out of their seats.

Among the participating teens, 68.3 percent self-identified as Hispanic and 51.5 percent were female. More than half began at a healthy weight, with 19 percent considered overweight and 23.4 percent in the obese category for their age. Almost 10 percent of the adolescents reported having anxiety and depression symptoms.

Immediately after the programs ended, COPE students’ outcomes exceeded the control group’s, on average, in several areas: 4,061 more steps per day; a significantly lower average body mass index (BMI); better scores in cooperation, assertion and academic competence – all social skills that are rated by teachers; and lower alcohol use – 12.96 percent of COPE teens compared to 19.94 percent of adolescents in the control class.

The BMI improvements in COPE teens held for six months, and a trend toward lower alcohol use among COPE teens was maintained. In addition, 97.3 percent of COPE teens who started at a healthy weight remained in that category six months later, while only 2.7 percent moved to the overweight category. In comparison, of teens in the control group who started at a healthy weight, 91.2 percent remained in that category, with 7.3 percent progressing to overweight and 1.5 percent moving to the obese category.

Melnyk noted that it’s not possible to tease out exactly which component of the program has the most profound effect on teens, but it is likely to be the combination of all of them together.

“I believe it has to be the combination,” she said. “You’ve got to have a nutrition piece to teach them how to eat healthier and resist unhealthy eating to make themselves feel better. And they’ve got to be more active. But a very key piece is the mental health and cognitive piece.”

Two school systems and a YMCA chapter in Ohio have adopted COPE. Melnyk plans to continue testing the program in schools in other areas of the country.

The National Institute of Nursing Research supported this research.

Co-authors include Diana Jacobson, Stephanie Kelly, Michael Belyea, Gabriel Shaibi, Leigh Small, Judith O’Haver and Flavio Marsiglia of Arizona State University.

NIH/NINR Press Release

Contact: Bernadette Melnyk, 614-292-4844; Melnyk.15@osu.edu

Written by Emily Caldwell, 614-292-8310; Caldwell.151@osu.edu

May 29, 2013

Study Points to Need for Interventions That Address Neighborhood Poverty

Living in a poor neighborhood as an adolescent is linked to an increased risk of getting the sexually transmitted infection (STI) chlamydia in young adulthood, according to new research.

Ohio State University researchers analyzed data from a large national study that tracked youths over time. The analysis suggested that children who lived in poor neighborhoods during their teenage years had an almost 25-percent greater risk of having chlamydia in their early 20s – even if they themselves weren’t poor – than did teenagers living in wealthier settings.

The effect of living in an impoverished neighborhood on the risk for later infection was unaffected by other known STI risk factors, such as depression, having multiple sex partners or beginning sexual activity at a very young age.

“There is a long-term effect of living in poverty on the risk for sexually transmitted infections in young adulthood, above and beyond behavioral issues,” said Jodi Ford, PhD, RN, lead author of the study and assistant professor of nursing at Ohio State. “We have a lot of interventions trying to address sexual risk behaviors, but few target neighborhood poverty and disadvantage. And this work shows that living in a poor neighborhood can have a long-term effect on health.”

Ford conducted the research with Christopher Browning, professor of sociology at Ohio State. The study was published in a recent issue of the  Journal of Urban Health. Ford and Browning accessed data from the National Longitudinal Study of Adolescent Health to conduct the analysis. The sample they studied included data from three separate interviews of 11,460 youths who participated in the national project. When they were first interviewed, the average age of the children studied was 15.6 years; by the time of the third interview, these same participants were between 18 and 27 years old.

The prevalence of chlamydia among the young adults surveyed was 4.6 percent – relatively low compared to what national data suggests, Ford said. That could be because the national longitudinal study from which she drew her sample took place in schools, meaning it did not capture portions of the population who had dropped out prior to the beginning of the Adolescent Health study.

Chlamydia is a bacterial infection that can affect both men and women, but can cause scarring and infertility issues in women if the infection persists. An estimated 2.86 million infections occur annually, according to the Centers for Disease Control and Prevention, but many are not reported because most people do not have symptoms and do not seek testing.

“Adolescents and young adults are the most likely to experience chlamydia infection in the United States. This study strengthens the evidence that to fully address the sexual health needs of this population, STI prevention efforts should also acknowledge the effects of neighborhood poverty,” Ford said.

The researchers considered four characteristics from U.S. Census data from corresponding years to determine whether the youths lived in poor neighborhoods as teenagers: proportion of households below poverty, proportion of households on public assistance, total unemployment rate and proportion of female-headed households with children.

By applying statistical modeling to the data, Ford determined that young adults who lived in a neighborhood with higher concentrations of poverty during their adolescence had higher odds of testing positive for chlamydia in their early 20s compared to their more advantaged peers.

The researchers also examined whether risky sexual behaviors or depression occurring during the transition from adolescence to young adulthood explained the relationship between adolescent poverty and chlamydia risk, but the findings were not significant. This means the significant effect of exposure to neighborhood poverty during adolescence on chlamydia risk during young adulthood was not because of an increased likelihood of sexual risk-taking behaviors or depression.

his analysis of data on a broad level does not address the reasons behind how living in an impoverished area can affect health later in life. The work is part of Ford’s ongoing investigation of how neighborhoods can influence risk for depression, infectious disease and other health problems in vulnerable populations.

She continues to use data from the Adolescent Health project, which was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development

This study was funded by a Robert Wood Johnson Foundation Nurse Faculty Scholar grant.

Contact: Jodi Ford, 614-292-6862, Ford.553@osu.edu

Written by Emily Caldwell, 614-292-8310, Caldwell.151@osu.edu

March 13, 2013

Mentored kids lose weight, move more than those taught by adults

An obesity intervention taught by teen mentors in Appalachian elementary schools resulted in weight loss, lower blood pressure and healthy lifestyle changes among the younger students learning the curriculum, according to a new study. In contrast, children taught the same lessons by adults in a traditional classroom saw no changes in their health outcomes.

The results of the eight-week clinical trial conducted by The Ohio State University researchers suggest that school systems could consider using teen mentors to instruct younger children in select health-related programs.

In the study, all instructors taught lessons from a program called “Just for Kids!” that was developed by the University of California, San Francisco. For one hour after school each week, teen mentors met one-on-one with students in a large gym setting while another group of students was taught in a classroom by school system employees, such as librarians or administrative staff.

When the program ended, only the teen-mentored group showed a greater increase in physical activity and marginal decreases in body mass index (BMI) and diastolic blood pressure. Kids led by teens also showed slight increases in nutrition knowledge and plans to change their behavior. Children taught by adults showed no improved health outcomes.

Though the study was conducted in Appalachian Ohio, where research suggests people prefer an informal way of receiving information, teen mentors have the potential to help influence health behaviors of younger children in any school district, researchers said.

“Not only would this help schools deliver a curriculum, but this study supports the idea that this mentoring approach is a better way to impact younger kids, and it creates an infrastructure to improve health without it having to come from a classroom,” said Laureen Smith, PhD, RN, FAAN, associate professor of nursing at Ohio State and lead author of the study. “I focused on diet and nutrition, but there’s no reason this can’t be used to address other health issues that a school identifies. In order for this to be successful, there has to be good training and good support to the teens. But the right teens with the right help and support can make a big difference.”

The research is published online and will appear in a future print issue of the Journal of School Nursing.

In all, 160 schoolchildren in the third and fourth grades participated in the intervention, along with 32 teen mentors and five adult teachers. The study took place at three public schools in the same county, and teen mentors attended high schools affiliated with the participating elementary schools.

Each one-hour session with the curriculum included 45 minutes of structured activities and 15 minutes of noncompetitive physical activity. Weekly topics included keeping the body healthy, the importance of exercise, food groups, portion control, emotional eating, food cravings and building more activity into daily life.

Though “Just for Kids!” targets obesity, the researchers told the children the program promoted being healthier and making healthy choices. Among the third and fourth graders, 29.7 percent were obese based on a BMI ranking above the 95th percentile for their age group. Another 18.9 percent were overweight, 51.4 percent were normal weight and 0.7 percent were underweight. The kids ranged from 8 to 11 years old.

Smith collected baseline information on a number of measures and repeated assessments after the eight-week study. In addition to BMI and blood-pressure readings, health measures included dietary behaviors, physical activity, attitudes about healthy eating and exercising and intention to or having confidence in their ability to eat better and move more.

After the intervention, only the teen-mentored group showed a greater increase in physical activity and marginal decreases in BMI and diastolic blood pressure, the pressure in arteries as the heart fills with blood. Children mentored by teens also had a larger positive change in intention to eat healthfully than the adult teacher group and a marginal increase in nutritional knowledge.

Retention had an impact on student outcomes, Smith noted. The overall retention rate was 92 percent, and attending more sessions was associated with a greater increase in nutritional knowledge in both groups, and with an uptick in physical activity in kids mentored by teens.

“The findings reaffirmed what I suspected, that the teens impacted physical activity for the kids rather than their nutrition," Smith said. "That makes sense because most kids don’t have a whole lot of control over what they eat. They rely on parents to provide food at home and otherwise rely on what the school provides."

While individual teachers and mentors did not affect the kids’ outcomes, the school they attended did make a difference; children’s gains in intention and perceived support to eat better were highest in the school that had the most disadvantages based on such economic indicators as parental unemployment and student eligibility for free and reduced lunches.

The nature of the intervention – using members of the community to deliver information rather than having “outsiders” identify a problem and try to fix it – could make it attractive to “any school that’s under-resourced, or any school, really,” Smith said. And the results are not a knock on adult teachers.

“Younger kids look at older kids in their peer group as role models. Teens provide younger children perceived psychological safety and a social network,” she said. “And this is helpful to adults. Using teen mentors removes some pressure on the staff and teachers of a school to reach students and have an impact on their health.”

Smith, also director of the Appalachian Translational Research Network with Ohio State's Center for Clinical and Translational Science, is continuing the work to further analyze how teen mentors yield these results and to gauge the effects of mentoring on the teens themselves.

This work was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health & Human Development.

Smith conducted the study with Christopher Holloman of Ohio State’s College of Nursing.

Contact: Laureen Smith, 614-292-4578, Smith.5764@osu.edu

Written by Emily Caldwell, 614-292-8310, Caldwell.151@osu.edu