Rise and Shine! Investigating the effectiveness and feasibility of a wellness programme for adolescents in a CAMHS setting

Picture 1

Joanne Kierans and Muiríosa Connolly

 

Abstract

This non-randomised feasibility pilot study aimed to determine whether Rise and Shine, a 4-week wellness programme, is an acceptable and feasible group-based intervention for adolescents attending Child and Adolescent Mental Health Services (CAMHS). Rise and Shine promotes positive habits in relation to a number of areas of wellbeing particularly relevant during the adolescent period, including sleep, physical activity, diet, and consistent morning and night-time routines. Ten participants attending CAMHS for moderate anxiety and/or depressive symptoms were recruited and four completed the Rise and Shine programme. A mixed methods design was employed to obtain rich information on the experience of group participation for both participants and their parents. Moreover, information was sought on efficacy, cost, recruitment and retention, and acceptability to participants and parents. Despite limitations due to the low retention rate and brief measures applied, participants and parents rated the group experience positively and indicated that they would recommend the group to others. Important parameters were uncovered for further evaluation studies of the programme, including the need to spend time promoting the value of group-based interventions to service users during recruitment. Overall, findings suggest that the programme is acceptable and feasible in terms of cost and practicality, and a useful recovery-focused supplement to individual support provided at CAMHS.

Introduction

Adolescence is a demanding developmental stage with rapid physiological growth, new levels of cognitive functioning and affective regulation, and new social roles and relationships to contend with.1 Interacting pressures from sociocultural influences and modern-day lifestyles can lead to mental health problems and engagement in unhealthy behaviour. Recent figures highlight the pervasiveness of mental health problems in adolescence. In a large-scale study of European adolescents, 5.8% met criteria for an anxiety disorder and 10.5% for depressive disorder.2 The My World Survey3 (MWS) national study of youth mental health in Ireland found that significant proportions of the Irish adolescent population presented with above average levels of depression (30%), anxiety (32%), and stress (20%), ranging from mild to severe. Fostering positive health behaviours such as good sleep habits, physical activity and healthy eating during this key stage is particularly important in helping young people manage vulnerabilities to emotion and behaviour dysregulation.4

 

Sleep

Sleep quality has been negatively associated with anxiety and depression in adolescence.5,6 The recommended level in adolescence is between 8 and 10 hours per night.7 However, a significant proportion of young people in Ireland (38%)8and worldwide (53%)9 fail to obtain this level. Although associations appear bidirectional, greater evidence points to sleep disturbance preceding the development of anxiety and depression in childhood and adolescence than the reverse.5

 

Physical Activity

Engagement in regular physical activity is associated with better mental and physical health and wellbeing in adolescence. 10,2 Although the recommended level is at least 60 minutes of moderate to vigorous physical activity daily,11 only a minority (13.6%) of adolescents in Europe appear to reach this level.2 The Health Behaviour in School-Aged Children study12 (HBSC) in Ireland found that 61% of boys and 44% of girls met recommended levels. Engagement was much lower in females and decreased with age; almost 9 out of 10 girls (15-17 years of age) were not achieving recommended levels.

 

Nutrition

The field of research focusing on the relationships between overall dietary quality and mental health is relatively new, but dietary consumption is increasingly recognised as an important contributing factor in the development, management and prevention of specific mental health problems, including depression and attention deficit/hyperactivity disorder.13A healthy diet providing adequate amounts of complex carbohydrates, essential fats, amino acids, vitamins, minerals and water can promote a balanced mood and overall wellbeing.13,14  However, Irish research shows that the amount of fruit and vegetables consumed by young people is relatively low and consumption of foods high in fat, salt and sugar is high.15

 

Wellness Programmes with Young Adolescents

To date, many interventions for young people with mental health difficulties have adopted similar approaches to those for adults, with the main goal of reducing specific clinical symptoms rather than addressing physical, social and occupational behaviours that contribute to overall wellbeing.16,17 However, research demonstrating the value of recovery-focused programmes that aim to promote resilience and engagement in health behaviour is progressing. 18-22

The Sleep Programme is a 5-week group programme aiming to promote positive sleep habits in young people.8 In a recent evaluation with a nonclinical sample, sleep hygiene scores did not show significant improvement, but small increments on domains of sleep habits and sleep quality were evident.8 Many participants reported the need to get more sleep and improve their sleep habits after having attended the Sleep Programme, suggesting its use as a means of enhancing understanding of sleep architecture and hygiene.

 

The Present Study

The need to promote positive social, vocational and physical functioning in managing mental health difficulties rather than traditional symptom-resolution approaches is increasingly acknowledged.16 In fact, in response to the emergence of data highlighting the important role of health behaviours for the prevention and treatment of mood disorders, recent policy documents in Australia have made explicit recommendations to address these behaviours as a first step in adult clinical treatment.23 The literature base for these recovery-focused interventions is more established for adult populations, and there are few interventions offered by child and adolescent mental health services that focus on optimising these skills and reducing modifiable risk factors such as poor sleep, diet, and physical inactivity.24 The prevalence of mental health issues and low levels of engagement in health behaviours in adolescence indicates the need for multi-faceted programmes promoting health behaviours and wellness for adolescents presenting to clinical services, based on holistic, recovery-focused wellness models.

The purpose of the present study was to conduct a feasibility pilot study to evaluate the Rise and Shine wellness programme, in terms of its efficacy, acceptability and utility when delivered to adolescents within a CAMHS setting. Rise and Shine is a 4-week multidisciplinary group-based intervention aiming to increase awareness of the relationship between healthy lifestyle behaviours and positive mental health. Utilising a multi-faceted approach, the programme intends to equip participants with tools to promote these health behaviours and develop consistent routines.

 

The evaluation involved examining the applicability of the programme for this population and context in addition to its effect on a number of aspects of physical and psychological wellbeing. By adopting a mixed-methods design and involving participants and their parents, the aim was to capture rich accounts of participants’ experiences and outcomes. Moreover, key information was sought on how the programme can be further improved and refined in terms of content, efficacy, cost, and acceptability to participants and parents.

 

Methodology

 

Participants

Participants eligible for study inclusion were adolescents aged between 13 and 16 years currently attending a CAMHS service for support with moderate mental health difficulties. Seven young adolescents (6 female and 1 male) attended the first session for the Rise and Shine group. From these, 4 participants (3 female and 1 male) completed the programme. All participants were Caucasian and lived in the local area. The primary reasons for participants’ referrals to CAMHS were anxiety, low mood and previous suicidal ideation.

 

Design

Adopting a quasi-experimental, prospective design, there were three points of quantitative data collection: pre-programme, post-programme, and at 5-week follow-up. Qualitative data were obtained from structured interviews with participants and the open-ended questions and discussions with parents.

 

Measures

Parent and participant rating scales

The parent rating scale requires ratings using visual analogue scales from 1 to 10 of how well parents felt their child was functioning across a number of areas of living (e.g. “How is your child’s morning routine?”). After each question, their comments were invited to obtain qualitative feedback. The participant rating scale consisted of a similar format with questions directed to them personally.

The Adolescent Sleep Hygiene Scale (ASHS)

The Adolescent Sleep Hygiene Scale8 is a 33-item self-report measure that assesses sleep practices theoretically important for optimal sleep. Higher scores reflect better success across dimensions of sleep hygiene.

The Paediatric Daytime Sleepiness Scale (PDSS)

The Paediatric Daytime Sleepiness Scale8 is an 8-item self-report measure assessing an individual’s tendency to feel drowsy during waking hours. Higher scores reflect greater levels of daytime sleepiness.

Participant Interviews and Parent Group Discussion

Structured interviews were conducted with participants to explore their experience of the programme, their views on the most useful aspects, what could be improved, and any resulting lifestyle changes. Qualitative feedback was obtained from parents through group discussion in terms of perceived benefits and areas of improvement.

 

The Programme: The Rise and Shine Group

The Rise and Shine programme consisted of four weekly 75-minute sessions and a ‘booster’ session involving parents and participants five weeks later. Each session addressed an area of wellbeing particularly relevant to the early adolescent period, including sleep, physical activity, diet, and the development of consistent morning and bedtime routines. A considerable amount of the content was adapted from The Sleep Programme8 and other online resources.13,25 In addition to focusing on increasing knowledge and implementing useful strategies for these areas of wellbeing, each session involved group-based activities, relaxation, home challenges, and reflections. The content of the programme is further described in Table 1.

Procedure

Following a discussion of the programme and eligibility criteria with the CAMHS multidisciplinary team (MDT), an information pack was posted to the parents/guardians of 21 young adolescents containing programme information, a parental consent form and an adolescent assent form. Those who returned signed consent forms were then contacted by the lead researcher by phone and provided with further information.

A parent information session took place one week before the group commenced. Pre-programme evaluation measures were administered, followed by introductions, and a detailed overview of each group session. The key role parents would play in promoting healthier lifestyle behaviours and in supporting their child throughout the group was highlighted. Session 1 of the Rise and Shine programme took place the following week. Similar to the parent information session, pre-programme evaluation measures were administered before introductions, icebreakers and information regarding the content of subsequent group sessions were provided.

All subsequent sessions began with an icebreaker activity and a reflection of the previous week, and ended with setting weekly home challenges and relaxation. A flipchart was used throughout to take notes, illustrate points and generate discussion. Games were included that encouraged learning in relation to the topics covered, for example, playing ‘Headbandz’ with images of food to generate discussion on food groups and nutritional content, and games that encouraged movement and quick thinking to stimulate their bodies and minds (Figure 1). Session 4 took place in the morning and emphasised the importance of a healthy start to the day. Participants prepared healthy and tasty breakfasts, such as fruit smoothies, wholegrain toast and cereal. Post-programme measures were administered at the end of Session 4.

Throughout the following week, the structured interviews with participants were conducted. A booster session took place five weeks later for parents and participants, summarising the key elements of the programme and reflecting on the experience. Once more, participants and parents completed the set of measures at the end of this session. All were thanked for participating in the programme and evaluation. Sessions were facilitated by a psychologist in clinical training (the lead researcher), a senior clinical psychologist, and an occupational psychologist, all of whom were part of the MDT in CAMHS.

Table 1

Data Analysis

Adhering to Patton’s26 method of process evaluation, both quantitative and qualitative change as a result of the programme was of interest. Multiple perspectives were sought as both parents and participants were involved in the evaluation. However, due to the small sample size and inadequate power, quantitative analyses were not permitted. However, descriptive statistics were generated and graphically presented in order to observe trends and possible changes in the examined variables.

The qualitative data was analysed using Patton’s26 suggested method of content analysis for process evaluation. The aim was to focus on the process as well as the evaluative feedback in order to determine how changes (if any) as a result of the programme were produced. This involved exploring, interpreting and reporting themes within the data that reflected the young adolescents’ personal views and experiences of the group. Interview discussions were transcribed verbatim from audiotape shortly after each interview took place. The initial coding phase involved a label being attached to all elements of interest in the text and these codes were then grouped together and organised within a master-coding template based on the questioning route of the interview schedule. Conceptually-related codes were combined and renamed to represent a refined theme that encompassed a broad but specific pattern in the data.

Figure 1

 

Results

 

Participation and Retention Rates

From the 21 adolescents recruited, 10 consented to participate, demonstrating a low-moderate recruitment rate (48%). Reasons for declining included unavailability of the child or parent on the specified dates and lack of readiness or interest from the child. Of the 10 who agreed to participate, 7 parents attended the parent session and 7 adolescents attended the first group session. Four adolescents completed all group sessions, demonstrating a moderate retention rate (57%). Reasons for non-completion included the time commitment and prioritising school work.

 

Quantitative Analysis

Parent Ratings

Observation of scores indicated that parents rated improvements in their child’s functioning on all outcome variables following participation in the Rise and Shine group, and this effect was maintained at follow-up (Figures 2 & 3).

 

Figure 2: Mean scores for parent ratings of daily lifestyle activities at pre-group, post-group, and follow-up

Figure 2

 

Figure 3: Mean scores for parent ratings of psychological functioning at pre-group, post-group, and follow-up

Figure 3

Participant Ratings

Examination of variables reflecting participants’ daily living activities show that their morning routine, night-time routine, sleep, diet, and physical activity all appeared to show an improvement upon completing the group (Figure 4). However, levels appeared to revert close to baseline at follow-up and improvement was only maintained for sleep quality. Technology use was unchanged post-group and levels increased at follow-up. Improvements in ratings of psychological functioning were apparent post-group and were maintained at follow-up (Figure 5). Overall sleep ratings and sleep hygiene did not change as a result of completing the group and appeared to reduce slightly at follow-up (Figure 6). Daytime sleepiness declined across the three time periods. However, as there was an insufficient sample size to undertake more rigorous statistical analyses, no inferences to wider population conditions can be drawn.

 

Figure 4: Mean scores for participant ratings of daily lifestyle activities at pre-group, post-group, and follow-up

Figure 4

 

Figure 5: Mean scores for participant ratings of psychological functioning at pre-group, post-group, and follow-up

Figure 5

 

Figure 6: Mean scores for participant ratings of sleep variables at pre-group, post-group, and follow-up.

Figure 6

 

Qualitative Analysis

 

Parent Qualitative Feedback

Qualitative data obtained from the parent rating sheets and the group discussion were analysed. One parent thought the group was too short but, overall, parents felt topics were relevant and useful in providing their children with knowledge and increasing their focus.

“Very good group, great topics and engaged her very well. Information was clear and relevant.”

Improvements were noted in a number of areas, such as their child now taking responsibility to set an alarm and rise independently in the morning. All parents reported improvements in physical activity; with increased participation for some and increased knowledge and motivation for others. Technology use was an area that still required improvement, although one parent reported an improvement since participation in the group.

“It’s much better. She’ll put her phone up at ten and be in bed for half ten”

 

In terms of psychological functioning, mood appeared more stable overall and anxiety levels were reported to have decreased. It was felt that the group was beneficial in helping participants manage the stress of the Junior Certificate mock exams.

 

Participant Interviews

From the content analysis, three overarching themes emerged from the dataset. Experiential aspects of participating in the group were merged to produce the ‘group experience’ theme; ‘self-motivation’ reflects personal accounts of efficacious aspects of the group; and ‘programme feedback’ reflects comments regarding programme content and delivery.

Group experience

The experience of the group brought both challenges and rewards for participants. Most presented with symptoms of anxiety and would generally find group participation difficult. One participant appeared surprised at how much she enjoyed previously feared activities:

Louise: Em well I did liked it, I liked the group. My first thoughts were, like when we were doing the icebreakers I was like ‘Oh my God!’ But as we got into it I properly joined in and I thought the group was very good.

 

When asked about the home challenges, it was noted that they were feasible and useful in encouraging daily reflection.

Nicola: Well I found it hard at first but then I decided to get into it and I found it easier. Actually surprisingly easy.

 

Parent involvement was noticeable for all participants; a number of parents appeared to benefit from reflecting on their own level of functioning in those areas and actively participated in activities with their child.

Eva:My mom would help me with the sheets and we could see what time we went to bed and stuff

Nicola:My mom said it made her think she never walks so she’s going to do more walking and I will too.

Self-Motivation

In relation to the programme content, one participant noted that the learning was enjoyable as the topic was relevant and interesting. The format of interspersing the material with games helped him to retain the information.

Chris: But I do care about this because if you find it interesting and fun you do care.

 

Participants’ insight in terms of the need to be ready and willing to make successful and sustained lifestyle changes was evident. It was apparent that they had personally applied acquired information and considered changes that could be made.

Louise: Em… well my diet is a lot better anyway. And I think it is more like the knowledge has helped me so I keep thinking about all the different things now.

 

They were aware that this was a more effective means of making lifestyle changes than being told what they should do by their parents.

Chris: If it’s a challenge… eh a challenge to change a habit which I’m just not willing to do at the moment like they’d try and force me to do that challenge and like that wouldn’t, I wouldn’t be gaining anything by doing it. I’d just be getting a lot more angry and upset.

 

A number of lifestyle changes had been made by participants as a result of participating in the group, and these changes reflected every area of wellbeing that the course covered.

Louise: Yeah. Because like I would never have breakfast before and I would just go to school but since the group now I’m like ‘OK you have to have breakfast.’ Yeah, it’s good especially for exam time and stuff you need the energy.

 

Programme Feedback

Data that related to feedback regarding programme delivery and content were pooled together under the headings of ‘useful aspects’ and ‘areas for improvement.’ The subthemes and illustrative examples are presented in Table 3.

 

Table 3

Discussion

 

This preliminary investigation examined whether the Rise and Shine wellness programme could positively impact the wellbeing of adolescents experiencing moderate mental health difficulties. Furthermore, it sought to evaluate the feasibility of delivering the programme within a CAMHS setting. A mixed-methods design was employed in evaluating the programme to obtain feedback and detailed accounts of the process from all stakeholders involved.

In determining change in aspects of wellbeing, parents reported small improvements in their child’s functioning and this was maintained at follow-up, although formal statistical analyses of these changes were not undertaken due to the small sample size. Similarly, participants rated improvements in their wellbeing post-group but these improvements were not maintained at follow-up for diet, physical activity and morning routines. More sessions and less time before the booster session may be required in order to consolidate the observed post-group changes. As the majority of participants were sitting their Junior Certificate mock exams during the five-week latency period, extra stress during this time is also an important factor to consider. Interestingly, perceived technology use had increased at the booster session from pre- and post-group levels and was reported by all parents as an issue. Indeed, technology use and academic pressure have both been cited as factors impacting adolescent sleep quality,18 and may be important topics to specifically address in future applications of the Rise and Shine programme.

 

Participants’ rated improvements that were maintained at follow-up for sleep, night-time routines, and psychological functioning variables. However, as the data was limited to descriptive statistics, no generalisations can be made and findings must be interpreted with caution. Nevertheless, trends look promising and coincide with previous research highlighting the association between sleep quality and psychological functioning.5,19 Moreover, daytime sleepiness appeared to decline across the three time periods indicating that participants felt more alert during the day, possibly due to making changes in other areas of their daily living as a result of participating in the programme.

The qualitative data further elucidated observed trends, as parents discussed the group favourably. Participants also discussed many benefits of the group. Connections were made with other group members, and in turn, participants gained the confidence to engage in activities and contribute to discussions. The home challenges were also adhered to, encouraging personal reflections in relation to recommendations for optimal wellbeing. Participants reported a number of lifestyle changes as a result of participating in the group and seemed genuinely surprised to find the experience enjoyable. The experiential aspects of the programme – intrinsic motivation, reflective practice, and behaviour modification – were successful in fostering a sense of autonomy for participants in relation to their wellbeing and in considering health behaviours. The group-based format and collaborative parental involvement were paramount for these effects, coinciding with previous research on such programmes.21 Indeed, participants reported that changes are more likely to be effective when they are not enforced by parents, indicating the benefit of their supportive role. Valuable feedback was also obtained from participants on useful aspects of the group and areas for improvement.

Strengths & Limitations

Innovative features of the Rise and Shine programme include: i) collectively discussing key information, ii) identifying and challenging barriers to change, iii) nurturing decision-making abilities, iv) supporting and respecting autonomy within a peer-supportive environment, v) involving parental support, and vi) providing opportunities to practice strategies at home. Moreover, it was clinically useful to see participants’ functionality within a group environment and to feedback to their keyworkers. The evaluation coincides with recommendations relating to evidence-based practice27and CAMHS Standard Operating Procedures,28 such as welcoming feedback from service users and acquiring the best available evidence to address clinical need. The engagement of the CAMHS MDT was a further strength, with psychology and occupational therapy collaboratively working from an integrated, holistic, recovery-based model. Indeed, its cross-disciplinary nature and relevance to overall mental health suggests that the programme could be facilitated by staff across the MDT.

This preliminary investigation also carries a number of limitations. The small sample size and brief rating scales greatly limits its ability to derive meaningful data. As inferential analysis was not permitted, the trends observed can only be used to describe the population under study. Unfortunately, retention rates were low-to-moderate reflecting the clinical realities of participation in group interventions. In surmising reasons for non-completion, further work in promoting the value of group interventions to service users and their parents may be warranted. This could include greater effort in promoting the value of group-based interventions to service users at the recruitment stage and providing testimonials from participants who have completed such programmes. The brief measures were selected with participant burden and participation in mind, restricting the depth of analysis and generalisability. Replication in other CAMHS settings would be beneficial with larger samples, incorporation of objective standardised outcome measures, and comprehensive interviews to permit greater interpretive-level analyses. Moreover, the evaluation did not include a control group and, although the reliability of the findings was increased through the prospective design, future work needs to explore randomising participants to intervention versus treatment as usual. Greater retention and randomisation would permit the power required for adequate quantitative analysis and the ability to generalise to wider adolescent clinical populations. An indication of inter-rater reliability could also increase the reliability of the qualitative data.

Implications & Conclusion

Notwithstanding the aforementioned limitations, preliminary findings suggest that the group was beneficial anddemonstrates the feasibility of replication in other CAMHS settings. The positive psychology and holistic focus on social, vocational, and physical functioning coincides with the increased recognition of the need for recovery-focused approaches over traditional symptom-resolution models.16,23 Cost-effective group interventions suitable for clinical settings have implications for addressing the problem of lengthy waiting lists in primary and secondary mental health services, and in the long-term, effective use of limited resources. Initial findings look promising for Rise and Shine in supplementing the prevention and treatment of adolescent mental health problems.

Authors

Joanne Kierans, PhD. Psychologist in Clinical Training, University of Limerick & HSE Midwest. Email: joanne.kierans@hse.ie

Dr. Muiríosa Connolly, Senior Clinical Psychologist, HSE Midwest. Email: muiriosa.connolly@hse.ie

To receive the latest edition of Clinical Psychology Today free to your inbox twice a year, simply subscribe by emailing clinicalpsychologytoday@gmail.com . For details on submitting an article see our noticeboard here .

References

  1. Spruijt-Metz D. Adolescence, affect and health. Studies in adolescent development, London: Psychology Press; 1999.
  2. McMahon EM, Corcoran P, O’Regan G, Keeley H, Cannon M, Carli V, et al. Physical activity in European adolescents and associations with anxiety, depression and well-being. European Child & Adolescent Psychiatry [Internet]. 2017; 26,111–122. Available from: http://dx.doi.org/10.1007/s00787-016-0875-9 10.1007/s00787-016-0875-9
  3. Dooley B, Fitzgerald A. My World Survey: National study of youth mental health in Ireland [Internet]. Dublin: Headstrong – The National Centre for Youth Mental Health, 2012. Available from: https://researchrepository.ucd.ie/handle/10197/4286
  4. Irish Department of Health & Children. A Vision for Change: Report of the Expert Group on Mental Health Policy [Internet]. Dublin: Stationary Office, 2006. Available from: https://www.hse.ie/eng/services/publications/mentalhealth/mental-health—a-vision-for-change.pdf
  5. Lovato N, Gradisar M. A meta-analysis and model of the relationship between sleep and depression in adolescents: Recommendations for future research and clinical practice. Sleep Medicine Reviews [Internet]. 2014; 18, 521–529. Available from: http://dx.doi.org/10.1016/smrv.2014.03.006
  6. McMakin DL, Alfano CA. Sleep and anxiety in late childhood and early adolescence. Current Opinion in Psychiatry [Internet]. 2015; 28, 483–489. Available from http://dx.doi.org/10.1097/YCO.0000000000000204
  7. National Sleep Foundation. Teens and sleep, 2019 [Internet]. Available from: https://www.sleepfoundation.org/articles/teens-and-sleep
  8. Comerford R, Creedon F, Loughran P, Murphy L, O’Halloran J. The sleep programme: Promoting positive sleep habits with young people [Internet]. Crosscare, 2018.Available from: http://hdl.handle.net/10147/622900[accessed: 07 Dec 2018].
  9. Gradisar M, Gardner G, Dohnt, H. Recent worldwide sleep patterns and problems during adolescence: A review and meta-analysis of age, region, and sleep. Sleep Medicine [Internet]. 2011; 12, 110–118. Available from: http://dx.doi.org/10.1016/j.sleep.2010.11.008.
  10. McPhie ML, Rawana JS. The effect of physical activity on depression in adolescence and emerging adulthood: a growth curve analysis. Journal of Adolescence [Internet]. 2015; 40, 83–92. Available from: http://dx.doi.org/1016/j.adolescence.2015.01.008
  11. Irish Heart Foundation & the National Youth Council of Ireland. (2010) Healthy eating, active living: A resource for those working with young people in youth work settings, 2010 [Internet]. Available from: http://www.youthhealth.ie/sites/youthhealth.ie/files/u5/HealthyActive-march10.pdf
  12. Gavin A, Keane E, Callaghan M, Molcho M, Kelly C, NicGabhainn S. The Irish Health Behaviour in School-aged Children Study 2014 [Internet]. Department of Health and National University of Ireland, Galway, 2015. Available from: https://health.gov.ie/wp-content/uploads/2015/12/HBSC2014web2.pdf
  13. Mental Health Foundation. Food for thought: Mental health and nutrition briefing, 2017 [Internet]. Available from: https://www.mentalhealth.org.uk/sites/default/files/food-for-thought-mental-health-nutrition-briefing-march-2017.pdf
  14. Irish Heart Foundation. Healthy eating: To reduce your risk of heart disease and stroke, 2018 [Internet]. Available from: https://irishheart.ie/publications/healthy-eating/
  15. Irish Universities Nutrition Alliance. National Teens’ Food Survey, 2008 [Internet]. Available from: http://www.iuna.net
  16. Gehue LJ, Scott E, Hermens DF, Scott J, Hickie I. Youth Early-intervention Study (YES) – group interventions targeting social participation and physical well-being as an adjunct to treatment as usual: study protocol for a randomized controlled trial. Trials [Internet]. 2015; 16, 333–341. Available from: http://dx.doi.org/10.1186/s13063-015-0834-7.
  17. Jacob KS. Recovery model of mental illness: A complementary approach to psychiatric care. Indian Journal of Psychological Medicine [Internet]. 2015; 37(2), 117–119. Available from:http://dx.doi.org/10.4103/0253-7176.155605.
  18. Blake MJ, Waloszek JM, Schwartz O, Raniti M, Simmons JG, Blake L, et al. The SENSE study: Post intervention effects of a randomized controlled trial of a cognitive-behavioral and mindfulness-based group sleep improvement intervention among at-risk adolescents. Journal of Consulting & Clinical Psychology [Internet]. 2016; 84(12), 1039–1051. Available from: http://dx.doi.org/10.1037/ccp0000142.
  19. Blake MJ, Snoep L, Raniti M, Schwartz O, Waloszek JM, Simmons JG, et al. A cognitive-behavioral and mindfulness-based group sleep intervention improves behavior problems in at-risk adolescents by improving perceived sleep quality. Behavior Research & Therapy [Internet]. 2017; 99, 147–156. Available from: http://dx.doi.org/10.1016/j.brat.2017.10.006.
  20. Blake MJ, Blake LM, Schwartz O, Raniti M, Waloszek JM, Murray G, et al. Who benefits from adolescent sleep interventions? Moderators of treatment efficacy in a randomized controlled trial of a cognitive-behavioral and mindfulness-based group sleep intervention for at-risk adolescents. Journal of Child Psychology & Psychiatry [Internet]. 2018; 59(6), 637–649. Available from: http://dx.doi.org/10.1111/jcpp.12842.
  21. Chamberland K, Sanchez M, Panahi S, Provencher V, Gagnon J, Drapeau V. The impact of an innovative web-based school nutrition intervention to increase fruits and vegetables and milk and alternatives in adolescents: a clustered randomized trial. International Journal of Behavioral Nutrition and Physical Activity [Internet]. 2017; 14(1), 140-151. Available from: http://doi.org/10.1186/s12966-017-0595-7.
  22. Flynn D, Joyce M, Weihrauch M, O’Malley C. DBT STEPS-A: Inter-agency collaboration to promote positive mental health in adolescents. International Journal of Integrated Care [Internet]. 2017; 17(5), A452. Available from: http://doi.org/10.5334/ijic.3772
  23. Malhi GS, Bassett D, Boyce P, Bryant R, Fitzgerald PB, Fritz K, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian and New Zealand Journal of Psychiatry [Internet]. 2015; 49(12):1087–206. Available from: doi:10.1177/0004867415617657.
  24. Corepal R, Tully MA, Kee F, Miller SJ, Hunter RF. Behavioural incentive interventions for health behaviour change in young people (5–18 years old): a systematic review and meta-analysis. Preventive Medicine [Internet]. 2018; 110, 55–66. Available from: https://doi.org/10.1016/j.ypmed.2018.02.004.
  25. The food pyramid and the eat well guide, 2016. Available from: https://www.safefood.eu/Healthy-Eating.aspx
  26. Patton MQ. How to use qualitative methods in evaluation. Newbury Park, CA: Sage; 1987.
  27. Health Service Executive. Evidence based health care, 2018 [Internet]. Available from:https://www.hse.ie/eng/about/who/healthwellbeing/knowledge-management/health-intelligence-work/evidence-based-health-care/
  28. Health Service Executive. (2015) Child and adolescent mental health services standard operating procedure [Internet]. Dublin: Health Service Executive, 2015. Available from: https://www.lenus.ie/handle/10147/558480