Feasibility and Preliminary Outcomes From a Pilot Study of an

Fam Community HealthVol. 37, No. 1, pp. 19–30Copyright C© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Feasibility and PreliminaryOutcomes From a Pilot Studyof an Integrated Health-MentalHealth Promotion Program inSchool Mental Health Services

Melissa W. George, PhD; Nevelyn N. Trumpeter, MS;Dawn K. Wilson, PhD; Heather L. McDaniel, BA;Bryn Schiele, BA; Ron Prinz, PhD; Mark D. Weist, PhD

The prevalence of unmet health and mental health needs among youth has spurred the growingconsensus to develop strategies that integrate services to promote overall well-being. This pilotstudy reports on the feasibility and outcomes of a theory-driven, family-focused, integrated health-mental health promotion program for underserved adolescents receiving school mental healthservices. Parent and adolescent assessments conducted prior to and following the brief, 6-sessionpromotion program showed significant improvements in family support, youth self-efficacy, healthbehaviors, and mental health outcomes. Clinician reports contributed to a characterization of thefeasibility, acceptability, and future recommendations for the integrated program. Key words:families, health promotion, obesity, school mental health, self-efficacy

CURRENT ESTIMATES indicate that 1 in3 adolescents is overweight, 1 in 6 is

obese, and 1 in 8 is very obese.1,2 Overweightadolescents not only suffer from both cur-rent and future health problems,1 but theyoften experience negative social and emo-tional consequences such as discrimination,diminished social isolation, and mental health

Author Affiliations: Department of Psychology,University of South Carolina, Columbia.

Nevelyn N. Trumpeter was supported by T32 GM081740(PI: R. Prinz); Dawn K. Wilson was supported by fromR01DK06761, R01 DK067615-03S1A1, R01 HD072153(PI: D.K. Wilson)]; Heather L. McDaniel was supportedby R01MH081941-01A2 (PI: M.D. Weist)]; and Mark D.Weist was supported by R01MH081941-01A2 (PI: M.D.Weist).

The authors declare no conflict of interest.

Correspondence: Melissa. W. George, PhD, Depart-ment of Psychology, University of South Carolina,Columbia, SC 29208 ([email protected]).

DOI: 10.1097/FCH.0000000000000012

problems.1,3,4 Obesity is even more prevalentamong those with mental health difficultieswith rates as high as 83%.5,6 Because ado-lescents with mental health problems are atgreater risk for becoming overweight and forthe persistence of obesity into adulthood,7,8

they experience an intensification of the so-cial and health-related difficulties they face.1,7

For example, mental health problems oftenlead to social isolation, a sedentary lifestyle,and physical inactivity, increasing the riskfor obesity and associated chronic conditionssuch as mood instability, low self-esteem, andpoor quality of life.9,10 Therefore, it is nota surprise that there is a growing consensusto address the multifaceted nature of youth’shealth needs, that is, to simultaneously pro-mote both their physical and mental health.11

While there is a call to integrate healthapproaches, there is still an alarminggap between need and effective servicesfor youth with emotional, behavioral, and

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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mailto:[email protected]

20 FAMILY & COMMUNITY HEALTH/JANUARY–MARCH 2014

physical health problems.12-14 As such, thereis a national movement toward integratingmental health promotion, prevention, andtreatment for youth “where they are,” inschools.15,16 Schools are uniquely positionedto provide health and mental health servicesto youth and their families.17,18 Strengthen-ing the capacities of schools to provide high-quality, on-site mental health services andsubsequently support students’ needs is acritical ongoing effort.19 Furthermore, fed-eral agencies call for the expansion of ser-vices for youth in schools with explicit rec-ommendations for integrated health-mentalhealth programming.20 This study presentsthe promising findings of a theory-driven,integrated health-mental health promotionprogram delivered to youth and familiesreceiving school mental health (SMH) ser-vices, developed to help reduce the gapbetween need and treatment for reducingthe nation’s obesity epidemic, while pro-moting health lifestyles choices for youthand families who are not yet overweight orobese.

The theoretical framework for the in-tegrated health-mental health promotionprogram integrates elements from SocialCognitive Theory,12-14 Self DeterminationTheory,15,21 and Family Systems Theory,16

which posit addressing adolescent self-regulation and self-efficacy (self-confidence)for health and mental health. Difficul-ties with self-regulation, including low self-efficacy, in adolescence are associated witha number of poor health outcomes includ-ing obesity-related health behaviors18-20 anddepression.22 Adolescence is a developmen-tal period characterized by heightened vul-nerability to emotional and behavioral prob-lems due to poor self-regulatory skills,17 sobuilding self-regulatory skills during this pe-riod is important for the prevention and earlyintervention of poor health outcomes. Pro-moting self-regulation and self-efficacy in ado-lescents occurs through practicing specificbehavioral skills, including self-monitoring,goal-setting, and self-evaluation to build self-regulatory capacity and self-efficacy for be-

havior change.23,24 These behavioral skills forself-regulation and self-efficacy are effectivefor changing adolescent obesity-related healthbehaviors in intervention research.20,25,26

Moreover, these skills are fundamental forimproving self-regulation and self-efficacy foradolescent mental health; that is, they are corepractice elements in evidence-based practicein adolescent mental health treatment.27,28

However, families are critical in support-ing adolescent behavior change to promotehealth and mental health. As such, underscor-ing the importance of social context, recentreviews have noted the strong influence offamily systems in health promotion programsand mental health interventions.29-32 Familyenvironments that promote autonomy, com-petence (ie, self-efficacy), and connectednesssupport motivation for behavior change andhealthy functioning.33,34 Indeed, the practiceof specific behavioral skills in a supportivefamily environment is foundational for chang-ing behavior, developing self-regulation, andachieving overall well-being. Specifically, ex-isting research points to authoritative par-enting as essential in providing a support-ive family environment for promoting ado-lescent health and mental health. Authori-tative parenting practices, such as monitor-ing, communication, and autonomy support(eg, shared decision making),35-37 have beenlinked to fewer obesity-related health behav-iors 31,38,39 and emotional and behavioraldifficulties40,41,42 because they promote self-regulation.40,41,43 Some experts have arguedthat involving parents to engage the familysystem is necessary for successful weight lossand health promotion31 as well as in mentalhealth treatment.44

Preliminary evidence supports this the-oretical framework for addressing adoles-cent obesity,45,46 and highlighting the im-portance of improvement in self-efficacy andself-regulation as key for the promotion ofhealth47-51 and adolescent well-being in var-ious psychosocial domains.14,52,53 Moreover,the role of self-efficacy in mediating connec-tions between health behavior and mentalhealth, such as depression, has been shown


Feasibility and Preliminary Outcomes 21

in recent studies addressing multiple healthoutcomes.54-56 Thus, evidence suggests thatessential elements for an integrated health-mental health promotion program for ado-lescents include a family-focused approachthat supports adolescent skill-building for self-regulation and self-efficacy to change obesity-related health behavior and improve mentalhealth.

The purpose of this study was to exam-ine the feasibility, acceptability, and effec-tiveness of an integrated, theory-based obe-sity and mental health promotion programin the contexts of SMH services. The pro-gram focused on positive parenting prac-tices and behavioral skills training for weightloss in youth with mental health issues whowere already referred to receive treatmentthrough SMH services. Specifically, this pro-gram emphasized communication, shared de-cision making, and problem solving (auton-omy support), parental monitoring coupledwith parental warmth (connectedness), andsocial support (emotional and tangible) forbehavior change techniques. These elementsare essential for building youth self-regulationand self-efficacy, the established protectivefactors for physical and mental health prob-lems that we assert are the underlying mech-anisms of change for our integrated health-mental health promotion program. It was hy-pothesized that the program would result inimprovements in adolescent weight change,fruit and vegetable consumption, and overallmental health functioning based on changesin family-level and interpersonal psychosocialvariables, including self-efficacy for regulationand for health behavior change consistentwith our theory of change.

Specifically, we hypothesized that familieswith more supportive parenting for healthand mental health will be associated withmore youth self-efficacy for behavior changeand, in turn, associated with improvementsin health behaviors and mental health. Giventhe Changing Lifestyles to Impact Mind andBody’s (CLIMB’s) program attention to im-proving family-level variables (eg, parenting

for autonomy-support, parenting for commu-nication about health) and youth-level vari-ables (eg, monitoring, goal-setting, and reg-ulating health behavior to build self-efficacyfor change) as mechanisms to promote youthchange in health and mental health, we ex-pected improvements in these domains offunctioning from pre- to postprogram assess-ment. Over the 6-week program, we expectedthat we would see the greatest impact of theCLIMB program in changing specific familycommunication patterns about health and im-provements in adolescent health; changes infamily- and adolescent-level variables for men-tal health were expected to take longer tochange which may not be reflected duringthe short 6-week period. Clinicians were inter-viewed after the program was implemented toassess feasibility and acceptability of the pro-gram.

METHODS

Participants

Participants included 10 adolescents (andtheir parents) referred to receive mentalhealth services in a rural, underserved, South-eastern region of the United States that is char-acterized by low income, high poverty, andfew resources (most students [n = 9] receivedfree or reduced lunch). Adolescents attendedmiddle school (grades 6-8) and were referredto a community mental health center for avariety of emotional and behavioral difficul-ties, including conduct problems, depression,and attention problems. Clinicians employedby the community mental health center pro-vided school-based services to these adoles-cents. On average, adolescents had been re-ceiving SMH services for an average of 1 to2 months before beginning the integratedpromotion program. Table 1 summarizes thedemographic characteristics for participants;the majority of participating parents were thebiological mother of the adolescent, half weremarried at the time of the study, and half wereAfrican American.



Table 1. Demographic Characteristics forFamilies Receiving the CLIMB Program inSchool Mental Health Services

M (SD) orN (%)

Adolescent age (years;range 11-15)

13.28 (1.14)

Adolescent gender(females)

4 (40%)

Adolescent race/ethnicityAfrican American 5 (50%)White 5 (50%)

Adolescent weight statusHealthy weight

(5%-85%)7 (70%)

Obese (>95%) 3 (30%)Caregiver relationship

Biological 7 (70%)Adoptive 1 (10%)Grandmother 2 (20%)

Family structureMarried 5 (50%)Single/separated 3 (30%)Widowed 2 (20%)

Receives free/reducedlunch

9 (90%)

Caregiver age (years) 42.20 (9.81)Caregiver gender

(females)10 (100%)

Caregiver race/ethnicityAfrican American 4 (40%)White 4 (40%)American Indian/

Alaskan Native1 (10%)

Other 1 (10%)Caregiver education level

High school 3 (30%)Some college 6 (60%)Associate’s degree 1 (10%)

Caregiver employmentFull-time 3 (30%)Homemaker 4 (40%)Retired/

unemployed/unable to work

3 (30%)

CLIMB: An integrated health-mentalhealth program

The CLIMB program was developed fromempirical support for improving diet andphysical activity and mental health outcomes,integrating essential elements across over-weight/obesity promotion interventions45

and evidence-based practice for child and ado-lescent mental health treatment.28 These es-sential components for improving diet andexercise and for improving mental health in-clude (1) supporting not only the youth di-rectly but also the family context to improvefamily-level skills and supports for youthhealth and mental health, (2) directly provid-ing youth with goal-setting and skill-buildingcapacities, and (3) promoting healthy lifestylechoices to teach youth and families the utilityand importance of achieving and maintaininghealth, mental health, and well-being.

The program materials were provided toclinicians and allowed to be used flexiblyas indicated by the needs of the clinician,youth, and family. Flexibility of the programreflects the ability for clinicians to integratethe modules into the typical treatment ses-sion and to tailor the physical health com-ponents to the individualized target healthgoals (eg, increase fruits and vegetables, de-crease sedentary behavior, increase physicalactivity, decrease junk food). Program materi-als were developed as 6 different content ar-eas that could be integrated into typical SMHservices: (1) foundations of behavior change(health and mental health interrelatedness,self-monitoring), (2) framework for behav-ior change (goal-setting and social support,family empowerment), (3) managing multi-ple systems (family support, environmentalbarriers, and facilitators), (4) youth autonomyand support for health change (health targetbehaviors, communication skills), (5) specifichealth targets (problem-solving strategies forbarriers), and (6) sustaining behavior change(maintenance and prevention relapse strate-gies). These 6 modules comprising CLIMBcould be integrated and provided during a por-tion of the therapy session that clients were



otherwise receiving. Therefore, clinicians notonly focused on the immediate mental healthneeds of the adolescent and family but alsoincorporated the scheduled CLIMB materials,so that all youth received the full 6-moduleCLIMB program.

Clinicians received in-person training,weekly training support via phone, a clini-cian resource guide, and youth and familyworkbooks to provide the program materi-als to families/students; weekly group train-ing calls also served as fidelity checks regard-ing the specific program content delivered inthe previous session. Clinicians provided ses-sions with families, including meeting at thefamilies’ homes for at least 1 session. Mate-rials were developed to be implemented indifferent session types and depending on themodule clinicians were instructed to deliverthe material in 1 of 3 session types: youth-only sessions at school, family sessions eitherat school or over the phone if families couldnot attend the session at school, and fam-ily sessions in the home. Session type wasdetermined by the particular module beingused. For example, one of the modules fo-cused on environmental barriers and facilita-tors of change and clinicians were asked todeliver this module as a family session in thehome.

Procedure

The study was reviewed and dually ap-proved by the institutional review boards forthe mental health center and sponsoring uni-versity. After completion of parental consentand youth assent, parents and adolescentscompleted questionnaire measures at base-line before the CLIMB program was imple-mented, and again after the 6 modules hadbeen delivered in services. Interviews wereconducted with clinicians to collect feedbackon the feasibility and acceptability of imple-menting CLIMB into existing services, includ-ing barriers to implementation, areas of im-provement, and perceived usefulness of skillsand modules.

Measures

Adolescent height was measured using aShorr Height Board, and weight was mea-sured with a SECA 880 digital scale. Twomeasures of height and weight were col-lected, and the average score used in an-thropometric calculations. Body mass index(BMI) percentiles and the standardized BMI(zBMI = weight (lb)/[height (in)]2 × 703)were calculated using recent Centers for Dis-ease Control and Prevention growth refer-ence curves.57 Parents and adolescents com-pleted an assessment battery of family andyouth functioning. As summarized in Table 2,parents and adolescents reported on primarystudy outcomes and adolescent health andmental health outcomes, reporting fruit andvegetable consumption and overall adoles-cent mental health difficulties. Specific di-mensions of family functioning, including par-ent support for psychosocial needs and forhealth behavior, perception of family sup-port for health, and parent communicationabout health were measured. Assessments ofthe mechanisms specified in our theory ofchange were also included; these psychoso-cial variables included adolescent self-efficacyfor emotional regulation and self-efficacy forhealth. After program implementation, inter-views of the clinicians assessed program fea-sibility and acceptability.

Analytic plan

Given the small sample size and the pilotnature of this study, descriptive data analy-ses were conducted and contributed to onlythe most conservative interpretations of thesedata. Correlations were calculated for familysupport, youth self-efficacy, and youth out-comes to consider the associations acrossdomains of support for physical and mentalhealth, highlighting the importance of theserelations after the delivery of the program.Paired sample t tests of pre- and postassess-ment data were calculated to assess changein family and youth variables from T1 andT2. Finally, feasibility and acceptability of the



Table 2. Measurement Information for All Study Variables Assessed Before and After

Construct Measure Reporting Response Psychometrics

Parenting Supportfor YouthPsychosocialNeeds

ParentingPractices Scale

Parent 0 = nonau-thoritativeto 3 = au-thoritative

Internal consistency forfactors α = .72-.82;factor structureconfirmed acrosssamples; currentsample: α = .62

Parenting Supportfor Health

Parenting Eatingand ActivityScale

Parent 0 = never to 4= always

Internal consistency forfactors α = .73-.87;current sample:α = .94

AdolescentPerception ofFamily Supportfor Health

Support forExercise andDiet Scales

Adolescent 0 = none to 4= everyday

Adequate test-retestreliability, internalconsistency, validityin family healthinterventions; currentsample: α = .81

ParentCommunicationabout Health

Parent-AdolescentCommunica-tion aroundHealthBehaviorsScale

Parent How often: 0 =never to 3 =many times;how did itgo: 0 = donot discussto 3 = talkopenly

Adequate reliability inother family healthinterventions; currentsample: α = .80

AdolescentSelf-Efficacy forEmotionalRegulation

AffectiveSelf-regulatoryEfficacy Scale

Adolescent 1 = not well atall to 5 =very well

Internal consistency at α

= .75; factor analysissupports separatefactor from overallefficacy; currentsample: α = .88

AdolescentSelf-Efficacy forHealth

Self-Efficacy forExercise andDiet BehaviorScale

Adolescent 1 = a littlesure to 3 =very sure

Modest test-retestreliabilities α =.43-.65; internalconsistency α =.85-.93; currentsample: α = .97

Adolescent MentalHealthDifficulties

Strengths andDifficultiesQuestionnaire

Parent 0 = not true to2 = certainlytrue

Parent report reliabilityfor this scale is α =0.73; current sampleα = .61

Adolescent DailyFruit andVegetable Intake

Fruit &VegetableIntakeScreening

Adolescent 0 = noservings to 4= 4 or moreservings

Test-retest reliability ICC= .68, kappa = 56%;validity with foodrecord Spearman’s r= 0.23, P < .01



program were evaluated on the basis of clin-ician interviews. Clinician interviews weretranscribed and coded for themes. Themeswere defined as any statement or idea thatwas mentioned by 2 or more individuals.

RESULTS

Sample demographics and correlations

Demographic variables and correlations areshown in Tables 1 and 3. Correlations forprimary study variables indicate that parent-ing support for psychosocial needs and forhealth behaviors were positively associated atT1 (r = 0.64; P < .05) and T2 (r = 0.78;P < .05). At T1, there was a positive associ-ation between parenting support for healthand communication about health (r = 0.70; P< .05). Adolescent perception of family sup-port for health was positively associated withself-efficacy for health (r = 0.84; P < .01) andfruit and vegetable consumption (r = 0.71;P < .05). Postassessment (T2), however, sup-ported associations between family and ado-lescent variables across health and mentalhealth. Parenting support for psychosocialneeds was associated with adolescent percep-tions of family support for health (r = 0.79; P< .05). With regard to adolescent outcomesat T2, adolescent perception of family supportfor health was associated with fewer mentalhealth difficulties (r =−0.71; P < .05). Adoles-cent self-efficacy for health was positively cor-related with regulatory self-efficacy (r = 0.77;P < .05) and fruit and vegetable consumption(r = 0.73; P < .05). There was marginal sup-port for fewer mental health difficulties beinglinked to regulatory self-efficacy (r = −0.65;P < .10) and fruit and vegetable consumption(r = −0.67; P < .10).

Physical and mental health outcomes

Preliminary outcomes of the promotionprogram suggest that there were positivechanges in many of the family and youth pro-cesses from pre- to postassessment. As shownin Table 3, which presents the mean and stan-dard deviation for each variable at T1 and T2,

there was a significant increase in parentingsupport for health (t(7) = 1.95; P <.05) andadolescent perception of family support (t(6)= 2.44; P < .05). As hypothesized, there wasan increase in self-efficacy between T1 andT2 for adolescent’s self-efficacy for health be-havior change (t(6) = 2.01; P < .05). More-over, when considering physical and mentalhealth outcomes there was a significant im-provement in mental health difficulties (t(7) =1.95; P < .05) with overall symptoms decreas-ing over the course of the program. Therewas an increase in obesity-related health be-haviors as adolescents reported an increase inthe number of daily fruit and vegetable serv-ings consumed (t(6) = 2.76; P < .05).

Considering the individual adolescentweight change from T1 and T2, while therewas not a significant difference, notably, 3of the 8 adolescents assessed for height andweight lost an average of 7.58 lb. The differ-ence between T1 and T2 weight for all ado-lescents is shown in Figure 1. To describe theadolescents who lost weight, 2 of them werein the “healthy weight” range and the otherwas considered “obese” consistent with theCenters for Disease Control and Prevention58

recommendations for youth based on ageand gender; 2 of the adolescents were male.Consistent with our hypotheses that familychanges would first occur in improving com-munication about health, we further investi-gated this at T2 to characterize adolescentswho lost weight. Differences in parent-childcommunication about health were further ex-amined in relation with those students wholost weight and those who did not. Figure 1displays weight difference pre to post for fami-lies who scored high in communication abouthealth (above the mean) versus those whoscored low in communication about health.None of the adolescents whose parents re-ported low levels of communication abouthealth lost weight.

Qualitative results

Interviews with clinicians supported bothease of integrating the program and benefits



Table 3. Descriptive Statistics for Paired Samples t tests of Family and Adolescent ChangeAcross the CLIMB Program

Change Variable Pre Post

Parenting support for psychosocial needs 1.88 (0.99) 2.25 (0.89)Parenting support for healtha 47.88 (13.85) 53.88 (6.01)Adolescent perception of family supporta 18.14 (6.99) 21.86 (6.36)Parent-child communication about health 17.14 (5.61) 19.57 (2.51)Adolescent self-efficacy for emotional regulation 40.14 (12.01) 41.57 (7.50)Adolescent self-efficacy for healtha 35.14 (14.26) 44.43 (11.86)Adolescent mental health difficultiesa 18.88 (4.91) 16.13 (3.48)Adolescent daily fruit and vegetable consumptiona 2.63 (0.92) 3.88 (1.46)

aP < .05; 1-tailed t-test.

for working with their youth and families.As summarized in Table 4, the participatingclinicians reported that the program elementswere consistent with and easily integratedinto their service delivery; for example–“itwas great that a lot of the strategies matchedup with the services that we already pro-vide.” Clinicians indicated that the focus onphysical health goals made it easier to engageand talk with families; for example–“it rein-forced to the families that, at least once every6 weeks, they need to have a family sessionto go over their child’s progress.” Providing afocus on health made it easier to build a ther-

-10

-8

-6

-4

-2

0

2

4

6

8

10

Change in Weight Pre-Post CLIMB Program

High Communica�on Low Communica�on

Figure 1. Difference in adolescent weight (lb) frompre- to postprogram as a function of parent-childcommunication about health.

apeutic relationship; for example–“overall,CLIMB enabled me to establish deeper re-lationships with my clients because I knewmore about their overall health.” Moreover,clinicians identified that the program pro-vided tangible goals for changing adolescentbehavior, making it easier for adolescents tosee change in behavior resulting in improvedself-efficacy.

The clinicians identified areas of improve-ment for the delivery of the program as well.They recommended more training before thebeginning of the program and more of an em-phasis on the delivery of physical health ma-terials. Specific to changes in program con-tent, the clinicians suggested modificationsto ensure age appropriateness and to reducethe materials provided. Also, regarding im-provements in changes to the program, theclinicians recommended that (1) all materialsshould be Internet accessible, (2) additionalstrategies for enhancing family involvementshould be included, (3) group sessions wouldpromote peer accountability, and (4) an ad-ditional summer component would supportadolescents when school is not in session.Overall the CLIMB program was well-receivedby clinicians and provided a number of advan-tages for service delivery, the therapeutic rela-tionship, family involvement, and adolescentbehavior change.



Table 4. Feasibility, Acceptability, andEffectiveness Themes From ClinicianInterviews About the CLIMB Program

Theme Description

Feasible Easily integrated intoservice delivery

Consistent with servicedelivery

Acceptable Strategies matched upwith existingservices

Made it easier toengage families

Enabled deeperrelationships withclients

Effective Afforded tangible goalsfor changingbehavior

Made it easier foradolescents to seeimprovements inself-efficacy

Recommendations More training onphysical health andstrategies for familyengagement

Provide materials viathe Internet

Modify programmaterials to ensuredevelopmentallyappropriate

Increase modules toreduce programmaterials in each

Build in peer-supportcomponent

Continue providingprogram over thesummer months

DISCUSSION

Preliminary findings in this pilot study sug-gest the potential feasibility and promiseof a brief, integrated health promotion ap-

proach to address youth’s multifaceted healthand mental health needs. This initial pilotstudy showed positive changes in adoles-cent obesity-related health behaviors includ-ing fruit and vegetable intake, overall men-tal health difficulties, adolescent self-efficacyfor health behaviors, and family social sup-port. A theory-based, family-focused, inte-grated health promotion program to addressobesity and mental health issues provided ina natural service delivery setting (eg, SMH ser-vices) to youth experiencing mental healthchallenges, and subsequent comorbid obesity-related health problems, would representa substantial advance in child and adoles-cent health-mental health treatment. Schoolmental health clinicians were trained onthe CLIMB program and supported throughweekly calls to integrate the program materi-als through youth and family workbooks andresource materials. The CLIMB content in-corporated health-mental health promotion,strategies for supportive parenting and so-cial support, and behavioral techniques (goal-setting, monitoring, and self-evaluation) tobuild youth self-efficacy for behavior changeand self-regulation as these are fundamentalunderlying mechanisms for health and men-tal health. The goal of the pilot study wasto assess the overall feasibility of deliveringthis integrated health-mental health programin existing services, including clinician’s ac-ceptability of this program and its relevance totheir provision of youth’s mental health treat-ment. Moreover, we intended to support thepotential for this program to improve fam-ily and parenting support, build youth self-efficacy, and increase youth physical healthbehaviors and decrease mental health difficul-ties.

This pilot study suggests, consistent withour aims, that the program has the poten-tial to improve family and parenting support,youth self-efficacy, and youth physical andmental health. Specifically, over the course ofthe 6-session program, changes in family pro-cesses, youth self-efficacy, and physical andmental health were noted. Parents reportedincreases in their use of parenting strategies



that support adolescents’ physical health, andadolescents reported an increase in their fam-ily support for health behaviors. The CLIMB’sability to improve family support for youth’shealth behavior change is critically impor-tant, given that social context, and especiallythe role of the family context, has been im-plicated as critical in interventions that tar-get prevention and control of obesity-relatedbehaviors.45,46 Recent evidence, for example,indicated that family-based weight loss inter-ventions are effective at health outcomes in-cluding daily fruit intake, physical activity,and sedentary behavior45,46 and, more specif-ically, that parent-adolescent communicationinfluences sedentary behavior.46

While there was no apparent support forsubstantially addressing authoritative parent-ing for psychosocial needs over the courseof the program, there was a significant corre-lation between parenting for health and psy-chosocial needs at the end of the program.Similarly, while there was support for changein self-efficacy for health behaviors, there wasnot an increase in self-efficacy for emotionalself-regulation. Yet, self-efficacy for health atthe end of the program was associated withregulatory self-efficacy at post as well. The ob-served relationships in self-efficacy across thephysical health and mental health domains areconsistent with recent reviews that suggestself-efficacy as a link between physical andmental health outcomes as it might general-ize across domains.54 Demonstrating improve-ments in adolescents’ fruit and vegetable serv-ings consumption and mental health difficul-ties over the course of the program is also no-table, as the goal of the integrated promotionprogram is to improve both physical healthand mental health for youth. Simultaneously,addressing youth’s complex health needs andseeing progress in multiple domains of health

can help alleviate not only negative socialand emotional consequences that youth withmental health difficulties often face but ad-dress their increased risk for obesity. Attend-ing to these mental and physical health needsin a comprehensive program may yield moreoptimal psychosocial functioning, as experi-encing mental and physical health concernssignificantly increases youth’s risk for socialisolation, diminished occupational and finan-cial success, and chronic physical and mentalhealth problems.

1,3,4,9,10

Clinicians delivering the CLIMB programalso supported the integration of the ap-proach into the mental health services theywere providing suggesting the utility of the ap-proach. Moreover, clinicians identified manyadvantages of the program in improving facetsof their service delivery, the therapeutic rela-tionship with their clients, engagement andinvolvement of families in services, and evenin improving their client’s behavior change.However, further work is needed to bettertrain clinicians on the delivery of physical ac-tivity and diet information. While the smallsample and pilot nature of this work yieldscaution, and without an experimental de-sign, no causal conclusions about the currentpilot project can be made, the study doessuggest feasibility, acceptability, and prelim-inary impact of this integrated health-mentalhealth promotion program for adolescents inschools. The study capitalizes on the realitythat while health and mental health issues inadolescents (and all people) are intertwined,most promotion programs do not match thisreality. Our approach capitalizes on the signif-icant advantage of SMH staff, who are perhapsthe only staff in schools with dedicated timeand opportunities to interact intensively withstudents and families, to integrate health pro-motion into mental health services.59

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