ARTICLE

Effects of the COPE

Cognitive Behavioral Skills
Building TEEN Program
on the Healthy Lifestyle
Behaviors and Mental
Health of Appalachian
Early Adolescents
Jacqueline Hoying, MS, RN, NEA-BC,
Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FAANP, FNAP, FAAN,
& Kimberly Arcoleo, PhD, MPH

ABSTRACT Program) on healthy lifestyle behaviors, physical health,

Introduction: Appalachian adolescents have a high preva-
lence of obesity and mental health problems that exceed
national rates, with the two conditions often co-existing.
The purpose of this study was to evaluate the feasibility
and preliminary efficacy of a 15-session cognitive-
behavioral skills building intervention (COPE [Creating
Opportunities for Personal Empowerment] Healthy Lifestyles
TEEN [Thinking, Emotions, Exercise, and Nutrition]
and mental health of rural early adolescents.
Methods: A pre- and posttest pre-experimental design was
used with follow-up immediately after the intervention.
Results: Results support improvement in the students’ anxi-
ety, depression, disruptive behavior, and self-concept scores
after the COPE intervention compared with baseline. Addi-
tionally, healthy lifestyle behavior scores improved before
the intervention compared with after the intervention.

Jacqueline Hoying, Doctoral Candidate/Graduate Research
Associate, College of Nursing, The Ohio State University,
Columbus, OH.
Bernadette Mazurek Melnyk, Associate Vice President for Health
Promotion; University Chief Wellness Officer; Dean and Professor,
College of Nursing; Professor of Pediatrics & Psychiatry, College
of Medicine, The Ohio State University, Columbus, OH.
Kimberly Arcoleo, Associate Professor, College of Nursing;
Associate Dean for Research & Transdisciplinary Scholarship;
Director, Center for Women, Children & Youth; Associate
Professor, Pediatrics, College of Medicine, The Ohio State
University, Columbus, OH.
Bernadette Melnyk has a company, COPE2THRIVE, which
disseminates the COPE program.
Partial funding support was provided by the National Institutes of
Health/National Institute of Nursing Research, grant no.
RO1NRO12171.
Correspondence: Jacqueline Hoying, MS, RN, NEA-BC, College
of Nursing, The Ohio State University, 145 Newton Hall, 1585 Neil
Ave, Columbus, OH 43210; e-mail: Hoying.80@osu.edu.
0891-5245/$36.00
Copyright Q 2016 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
Published online April 10, 2015.
http://dx.doi.org/10.1016/j.pedhc.2015.02.005

www.jpedhc.org January/February 2016 65

Discussion: COPE is a promising intervention that improves
mental health and healthy lifestyle behaviors and can be in-
tegrated routinely into school-based settings. J Pediatr Health
Care. (2016) 30, 65-72.
KEY WORDS
Appalachian early adolescence, school-based intervention,
physical and mental health outcomes, obesity, healthy life-
style behaviors
Two major public health conditions in disadvantaged
early adolescents ages 11 to 13 years, overweight/
obesity and mental health disorders, are the anteced-
ents for the development of an array of unfavorable
health and academic outcomes (Franks et al., 2010;
I’Allemand-Jander, 2010; Institute of Medicine, 2012;
Ma, Flanders, Ward, & Jemal, 2011). Appalachian
adolescents have a higher prevalence of obesity
(38%) compared with national averages (32%). In
addition, the prevalence of mental health problems
among these teens (19%) exceeds the national
prevalence rate (13%; Costello, Farmer, Angold,
Burns, & Erkanli, 1997; Costello, Mustilo, Erkanli,
Keeler, & Angold, 2003). Furthermore, these two
conditions often co-exist (Polaha, Dalton III, & Allen,
2011; Smith & Holloman, 2011). Even with the high
prevalence of these problems and the substantial time
youth spend in learning environments, few school-
based health promotion interventions targeting obesity
and mental health conditions studies have been con-
ducted to improve outcomes in high-risk teens.
The prevalence of obesity and mental health disor-
ders is even higher in minority youth from lower socio-
economic status families (Steinberg, Sidora-Arcoleo,
Serebrisky, & Feldman, 2012). Several previous studies
have established the short-term benefits of healthy
nutrition and physical activity (PA) interventions on
the consumption of fruit and vegetables, musculoskel-
etal health, body mass index (BMI), and self-concept in
children and early teens (Sallis & Glanz, 2009; Marcus
et al., 2006). A literature search on school-based
healthy lifestyle interventions for early adolescence
specifying the key words obesity, early adolescence,
school-based intervention, mental health, and healthy
behaviors found 11 studies that evaluated the effects
of nutritional education, physical activity, or a combina-
tion of the two interventions. Youth ranged in age from
5 to 18 years, and study intervention duration ranged
from 4 weeks to 24 months (Branscum & Sharma,
2012; Brown & Summerbell, 2009; Cardoso da
Silveira, De Aguiar Carrazedo Taddei, Guerra, & Cuce
Nobre, 2013; Frenn, Malin, & Bansal, 2003; Friedrich,
Schuch, & Wagner, 2012; Gortmaker et al., 1999;
Harris, Kuramoto, Schulzer, & Retallack, 2009;
Johnston et al., 2013; Kater, Rohwer, & Londre, 2002;
Shaya, Gbarayor, & Wang, 2008; Van Lippevelde et al.,
66 Volume 30  Number 1
2012). The results of this evidence review revealed
that nutrition alone is the least effective intervention,
followed by PA alone, with the combination of
nutrition and PA yielding the greatest benefits.
However, these studies did not target simultaneous
improvements in healthy lifestyle behaviors and
mental health. Including mental health promotion as
part of healthy lifestyle interventions is important
because findings from prior research indicate that
overweight youth frequently have issues with
depression, anxiety, and poor self-concept (Au,
2012). Further, adolescents who are depressed often
perceive healthy lifestyle behaviors as being more diffi-
cult to engage in than those who are not depressed
(Melnyk, Small, Morrison-Beedy, et al., 2006).
From this evidence review, it can be concluded that
there are limited published intervention studies
for teens in school settings that simultaneously
target improvement
of healthy lifestyle be- .there are limited
haviors, overweight/
obesity, and mental published
health. Key findings intervention studies
from this review identi- for teens in school
fied positive outcomes
in some studies; how- settings that
ever, methodological simultaneously
flaws resulted in target improvement
several threats to inter-
nal validity, such as in- of healthy lifestyle
strument variation, behaviors,
limited randomized overweight/obesity,
controlled trial (RCTs),
lack of objective mea- and mental health.
sures, inattention to
intervention fidelity, measurement error, short-term
follow-up, nonsustained effects, and lack of manual-
ized intervention protocols.
Melnyk and colleagues (2013) conducted an
RCT with 14- to 16-year-old high school adolescents
(n = 779) that concurrently focused on healthy life-
style behaviors, physical health, and mental health.
The study tested the efficacy of the COPE (Creating
Opportunities for Personal Empowerment) Healthy
Lifestyles TEEN (Thinking, Emotions, Exercise, Nutri-
tion) Program. The 15-week cognitive-behavioral
skills-building (CBSB) program was compared with
an attention control group (Healthy Teens) that
taught 15 weekly health topics unrelated to COPE
(e.g., motor vehicle safety and skin care). Immedi-
ately after the intervention, adolescents who
received the COPE intervention had a significantly
greater number of steps per day, lower BMI, and
higher social skills and academic performance
compared with their peers in Healthy Teens. Addi-
tionally, teens in the COPE group with extremely
elevated depression scores at baseline had
Journal of Pediatric Health Care
FIGURE. Creating Opportunities for Personal Empowerment (COPE) conceptual model.
Adapted with permission from Melnyk, 2014; Melnyk et al., 2007.
significantly lower depression scores than their
counterparts. A lower level of alcohol use also was
reported in the COPE group compared with the con-
trol group. Findings at the 6-month postintervention
follow-up indicated that adolescents in the COPE
group had a lower mean BMI than control adoles-
cents, and the proportion of overweight teens
decreased in the COPE group compared with an in-
crease in overweight teens in the control group
(Melnyk et al., 2013).
Given the positive effects of the COPE Healthy Life-
style TEEN program with middle adolescents, the over-
arching research question in this study was whether the
COPE intervention could demonstrate similar positive
effects for Appalachian teens in early adolescence.
The literature review indicated a need for this research
because of a gap in published intervention studies
simultaneously targeting improvement of healthy life-
style behaviors, overweight/obesity, and mental health
for teens in early adolescence in Appalachian middle
school settings.
www.jpedhc.org
THEORETICAL FRAMEWORK
Cognitive theory (CT) is the foundation on which the
COPE Healthy Lifestyles Program is based and utilized
in this study (Beck, 1964, 1976). The essence of CT
emphasizes that how a teen thinks affects his or her
feelings and behaviors. This concept is referred to as
the thinking-feeling-behaving triangle (Beck, Rush,
Shaw, & Emery, 1979). The Figure illustrates the con-
ceptual model used in the study. The emphasis of this
model is on changing automatic negative thoughts/be-
liefs to have a positive effect on emotional and behavior
change. Previous studies (Lusk & Melnyk, 2011; Melnyk
et al., 2013) have validated effectiveness with anxious
and depressed adolescents utilizing CT and this
conceptual model, but not with an Appalachian early
adolescent population. For this study, it was posited
that the early adolescent’s self-concept and subsequent
beliefs result in positive or negative behaviors that par-
allel the direction of his or her cognitive thoughts and
feelings. The purpose of this pilot study was to evaluate
the feasibility, acceptability, and preliminary efficacy of
January/February 2016 67
the COPE Healthy Lifestyles TEEN program on the
healthy lifestyle behaviors, physical health, and mental
health of rural early adolescents in middle school.
METHODS
Design
A pilot study was conducted using a one-group pre-
and posttest pre-experimental design with data
collected prior to intervention introduction and imme-
diately after the COPE Healthy Lifestyles TEEN 15-
session intervention. Demographic information was
collected from the parents and adolescents. The main
outcomes variables included healthy lifestyle behav-
iors, anxiety, depression, self-concept, and BMI.
Setting and Sample
A convenience sample of 102 8th-grade students be-
tween the ages of 13 and 14 years who were enrolled
in a required health education class in an Appalachian
junior high school in the Midwest was recruited to
participate in the pilot study. The Appalachian middle
school was identified through an interested principal
and the academic university’s liaison. During the first
week of the semester, members from the research
team used a recruitment script that introduced the study
and sent home an informational packet including a
parent/guardian letter explaining the study with con-
sent and assent forms. The study was approved by
The Ohio State University Institutional Review Board
and conducted from August 2013 through May 2014.
All participants and their parents provided assent/con-
sent prior to their participation. Inclusion criteria were
(a) students and parents of any gender, ethnicity/race,
or socioeconomic status who speak and comprehend
English and (b) students enrolled in the 8th-grade
health class. Overall, 29 students (28%) consented to
participate in the study and 24 (83%) of those enrolled
completed the pre- and postintervention measures.
One student moved out of the school district, one stu-
dent decided not to complete the study, and three stu-
dents were absent on the postintervention data
collection day.
Intervention Conditions
The COPE program is a 15-session CBSB program
based on CT principles that uses 12 empirically based
concepts (McCarty & Weisz, 2007) to modify or restruc-
ture faulty thinking and dysfunctional beliefs. The
fundamental premise for the intervention program—
that is, how a person thinks affects his or her feelings
and behaviors (Beck, 2011)—was introduced in session
1 (Melnyk, 2014). Threaded throughout the sessions
was the teaching of the ABC’s (Activator event, Belief
that follows, and Consequence of the belief). Individual
cognitive reappraisal practice occurred as the students
identified their ABC events and then were taught to re-
frame their thinking, thereby eliciting a more positive
68 Volume 30  Number 1
emotion and healthier behavior. Session 2 involved
practicing positive thinking, self-talk, and mindfulness
to promote increased self-esteem. Session 3 focused
on individual goal-setting, identifying a four-step prob-
lem-solving method and how to overcome potential
barriers. Session 4 discussed stress and healthy coping.
Students were taught in session 5 how to think more
positively and deal with emotions in healthy ways. Per-
sonality and effective communication were covered in
session 6, and sleep management and energy balance
was the focus for session 7. Sessions 8-15 focused on
physical activity (including proper stretching,
warming-up and cooling-down, and how to take
one’s heart rate), nutrition (such as reading labels and
the stop light diet), and healthy choices. Case-based ex-
amples are used throughout to highlight the concepts
and enhance behavior skills learning. Skills-building
homework assignments and log completion (goal
setting, mood, and activity logs) were required weekly.
The health teacher who delivered the intervention
received an 8-hour day of training that included (a)
background on the theoretical framework and
cognitive-behavioral skills building, (b) a review of
each of the COPE sessions with accompanying home-
work activities, (c) role plays for skill building with
the teens, and (d) a review of the documentation to
complete in the intervention diary after each classroom
session. The training was completed by the first author,
who had been trained in the COPE intervention by the
creator of the COPE program. Twenty minutes of phys-
ical activity to encourage movement and build confi-
dence in being able to be active was incorporated
into each COPE session. The research team rated 25%
of the teacher-delivered intervention using a previously
developed observation instrument for intervention
fidelity (Melnyk et al., 2009).
Measures
Demographics
Information was collected on age, race/ethnicity, gender,
parent’s employment status and income, parent’s marital
status, family structure (e.g., one-vs. two-parent house-
hold), and highest level of parental education.
Healthy Lifestyle Behaviors Scale
The Healthy Lifestyle Behaviors Scale is a 15-item
instrument (Melnyk & Small, 2003) that assesses behav-
iors about maintaining a healthy lifestyle (e.g., ‘‘I exer-
cised regularly’’). Participants respond to each item on a
Likert-type scale ranging from 0 (none of the time) to 3
(all of the time). Total scores range from 0 to 45, with
higher values indicating greater healthy lifestyle behav-
iors. Face validity was established with 10 adolescents,
and content validity was established with eight adoles-
cent health experts (Melnyk et al., 2006). Cronbach’s a
in this sample of teens was 0.80.
Journal of Pediatric Health Care
Depressive symptoms, anxiety, and self-concept (hopelessness). The school counselor was notified the
The Beck Youth Inventory, 2nd edition (BYI-II) is a 100- same day for follow-up with the student. For any stu-
item instrument for youth ages 7 to 18 years (Beck, dent who had a depression T score of $ 70, a letter
Beck, Jolly, & Steer, 2005). The BYI-II commercial prod- was sent home to the parents within 24 hours providing
uct measures five constructs: depressive symptoms, notification of depression risks and referral resources.
anxiety symptoms, anger, disruptive behavior, and This same procedure was followed during week 15
self-concept via 20 statements for each subscale. The with postintervention data collection.
statements reference thoughts, feelings, and behaviors
related to emotional and social impairment. Partici- Data Analysis
pants respond to each item on a Likert-type scale Descriptive statistics summarized the demographic
(never, sometimes, often, always) with raw scores con- characteristics of the sample. Paired t-tests were
verted to T scores for age and sex based on population computed to examine change from baseline to immedi-
norms. A T score of < 55 is average; 55-59 is considered ately after the intervention, and additional analyses
mildly elevated; 60-69 is moderately elevated; and 70+ were completed for students who had elevated anxiety
is extremely elevated. Content and construct validity scores. Effect sizes were calculated for each of the
are well established, with high correlation of the five outcome variables. Internal consistency reliability was
subscales scores ($ 0.70). Internal consistency has calculated with Cronbach’s a for the five subscales of
been calculated by sex with overall Cronbach’s a the BYI-II before and after the intervention, respec-
ranging from 0.87 to 0.92 (Thastum, Ravn, Sommer, & tively—depression (0.94, 0.91), anxiety (0.98, 0.95),
Trillingsgaard, 2009; Lusk & Melnyk, 2011; Melnyk disruptive behavior (0.99, 0.82), anger (0.98, 0.99),
et al., 2009). and self-concept (0.94, 0.91)—as well as the Healthy
Lifestyle Behaviors Scale (0.90, 0.97).
BMI
BMI was measured using the adolescent’s height and RESULTS
weight to assess obesity/overweight status. A BMI Sample Characteristics
based on sex and age that is greater than the 85th The mean age of the adolescents enrolled was 13.6 years
percentile indicates overweight, and a BMI greater (SD = 0.56). The mean weight of the adolescents was
than the 95th percentile indicates obesity (Ogden 141.71 lb (SD = 42.15), with a range from 58 to 256.75
et al., 2010). A standard protocol of removing shoes lb. The baseline mean BMI for the adolescents was
and any layers of clothing beyond one layer was fol- 23.37 (SD = 6.54), and the mean BMI percentile was
lowed prior to taking the measurements in a private of- 75.36 (SD = 28.08). The adolescents’ mean BMI after
fice. Individual measurements were shared with each the intervention was 24.80 (SD = 8.06). The study
teen. Height and weight were measured with a Seca included 14 males (48%) and 15 females (52%). The sam-
220 stadiometer/scale (Seca, Hanover, MD). ple was 100% White, and 48% of the participants were
receiving public assistance. At baseline, 14 students
Teen and parent program evaluation were normal weight, 5 were overweight (> 85th percen-
At posttest data collection, participants were asked the tile), and 9 were obese (> 95th percentile). Overall, at
following questions: Was the format of the program baseline, the group reported lower than average scores
acceptable to you? Was the program helpful? How was on the BYI-II subscale of self-concept and average scores
it/was it not helpful? Would you recommend the program for depression, anxiety,
to a friend? Parents also were asked about the helpfulness anger, and disruptive .after the
of the program for their teens. The program evaluation behavior (see Table 1). intervention,
identifies the feasibility and acceptability of the 15- The sample also
week COPE intervention with a different population reported moderate adolescents in the
and age group than from previous studies. This study healthy lifestyle behav- COPE group had
evaluated Appalachian adolescents in the 8th grade. iors at baseline. improved self-
Procedure Outcomes concept, were less
After a formal consent procedure was performed, base- Analyses anxious, had less
line demographics and height and weight measure- Paired sample t-tests disruptive behavior,
ments were obtained and preintervention instruments evaluating change
were completed during the first week of the study. Stu- from before to after and had increased
dents’ BYI-II responses were immediately reviewed by the intervention indi- engagement in
a nurse or mental health counselor for any student who cated that after the practicing healthy
answered ‘‘sometimes’’ or higher on question 4, ‘‘I wish intervention, adoles-
I were dead’’ (suicidal ideation) and/or who answered cents in the COPE lifestyle
‘‘always’’ on question 20, ‘‘I think my life will be bad’’ group had improved behaviors.

www.jpedhc.org January/February 2016 69

 TABLE 1. Effects of Creating Opportunities for Personal Empowerment (COPE) on study outcomes
after the 15-session intervention
Instrument n Pretest mean (SD) Posttest mean (SD) t value p value Effect size
Beck BYI-II subscales
Self-concept 24 43.25 (9.02) 46.04 (10.25) 2.04 .053* 0.29+
Anxiety 24 18.33 (14.22) 14.00 (12.74) 1.50 .146 0.32+
Depression 24 10.42 (10.06) 9.58 (12.74) .728 .474 0.07
Anger 24 15.17 (12.42) 14.46 (15.10) 0.225 .824 0.05
Disruptive behavior 24 7.80 (12.15) 4.36 (4.19) 1.53 .139 0.38+
Healthy Lifestyle Behaviors Scale 24 52.38 (12.94) 57.46 (11.88) 2.47 .021* 0.41+

Note. BYI-II = Beck Youth Inventory, 2nd edition. Significant values are in bold.
+ = small to medium effect size.
*p < .05.

self-concept, were less anxious, had less disruptive
behavior, and had increased engagement in practicing
healthy lifestyle behaviors, as illustrated in Table 1.
One adolescent with moderate to severe elevated
anxiety decreased to below-average anxiety after the
COPE intervention. Another teen with moderate to se-
vere anger decreased to below-average anger after
the COPE intervention. A subgroup analysis was
completed on adolescents with BMI percentiles > 85%
(overweight/obese), who constituted 50% of the total
sample (Table 2). Compared with the overall group,
this subgroup of overweight and obese teens who
received the COPE intervention demonstrated in-
creases in self-concept and decreases in anxiety,
depression, and anger.
Participating Student Comments on the COPE
Evaluation
Of the students who were enrolled in the study, 92%
found COPE to be beneficial and 75% would recom-
mend the COPE program to other students. Ninety-two
percent of the COPE teens identified learning new skills
and reported the top three skills acquired as: (a) coping
positively with stress; (b) utilizing positive self-talk and
positive thinking; and (c) dealing with emotions in
healthy ways. Additionally, 92% of the students reported
using techniques taught on coping positively with stress,
63% reported using positive self-talk/positive thinking,
and 46% were actively using techniques to deal with
emotions in healthy ways. Many positive comments
were made by the students who participated in the
COPE program evaluation after the intervention. These
comments included ‘‘I learned how to deal with my
stress and anger in a healthy way,’’ ‘‘I learned how relax-
ation techniques can help,’’ and ‘‘It [COPE] helps you un-
derstand about life.’’
Participating Parent Comments on the COPE
Evaluation
Sixteen participating parents completed the COPE pro-
gram evaluation (67% response rate). Of those parents,
94% found COPE to be beneficial and 88% would
recommend COPE to other parents/friends. Sixty-
three percent of the parents observed positive changes
in their child’s behavior as a result of the COPE pro-
gram, and 19% stated that their own parental behavior
had changed as a result of the COPE program. The
top behaviors parents observed in their teens were
healthier nutritional choices, increased exercise, and
increased positive thinking. One parent stated: ‘‘His
anger, when he gets mad now he goes to his room
instead of yelling at me.’’ This parent noted his/her
own behavior change: ‘‘Not to yell, just walk away for
a few, and then talk about it later.’’

TABLE 2. Results for adolescents in the Creating Opportunities for Personal Empowerment (COPE)
group with a body mass index > 85%
Instrument n Pretest mean (SD) Posttest mean (SD) t value p value Effect size
Beck BYI-II subscales
Self-concept 14 40.18 (8.86) 44.91 (9.48) 4.34 .001* 1.31+++
Anxiety 14 15.27 (6.02) 11.36 (10.54) 1.68 .124 0.51++
Depression 14 9.82 (8.33) 8.27 (12.02) 0.739 .477 0.22+
Anger 14 16.27 (8.86) 14.09 (9.14) 2.50 .032* 0.75++
Disruptive behavior 14 5.45 (6.27) 4.37 (5.08) 1.13 .286 0.33+
Healthy Lifestyle Behaviors Scale 14 52.64 (10.90) 54.09 (10.13) 5.27 .609 0.20+
Note. BYI-II = Beck Youth Inventory, 2nd edition. Significant values are in bold.
+ = small effect size; ++ = medium effect size; +++ = large effect size.
*p < .05.

70 Volume 30  Number 1 Journal of Pediatric Health Care

DISCUSSION
Study findings indicate that incorporating the 15-week
CBSB COPE Healthy Lifestyles TEEN program into a
required health education course for 8th-grade students
is acceptable and was well received by Appalachian
students. The results suggest that the intervention pro-
gram had a positive effect on self-concept, anxiety
and depressive symptoms, and healthy lifestyle behav-
iors. Additionally, overweight/obese adolescents re-
ported greater gains in self-concept, lower anxiety
symptoms, and greater reduction in anger symptoms.
Because the COPE program was one semester in length,
the difference in BMI of the students before and after
the intervention was not statistically significant. It may
be too soon to expect a reduction in overall BMI; how-
ever, the healthy lifestyle behaviors of the students
improved, indicating that they were more physically
active. Furthermore, the results showed that it is
feasible to deliver the program within the context of a
middle school health education course. Previous
RCTs with high school students by Melnyk and
colleagues (2009, 2013) have demonstrated the
efficacy of combining CBSB with exercise and healthy
eating behavior components in an evidence-based
15-week COPE intervention. This was the first pilot
study with an Appalachian group of 8th-grade middle
school students that also demonstrated positive effects
of the COPE program. Overall, participating adoles-
cents reported that they found the intervention sessions
enjoyable and would recommend the program to their
friends and peers. An
intervention contain- A greater effect size
ing a robust CBSB was noted with
component to improve
healthy lifestyle behav- overweight/obese
iors may be key in teens who
decreasing depressive demonstrated
and anxiety symptoms
while improving higher depressive
self-concept (Lusk & and anxiety
Melnyk, 2011), which symptomatology
should result in health-
ier choices and lifestyle before the
behaviors. A greater intervention.
effect size was noted
with overweight/obese teens who demonstrated
higher depressive and anxiety symptomatology before
the intervention. Emphasizing CBSB may be essential
in achieving positive outcomes with this high-risk
population.
Study limitations include a one-group pre-experi-
mental design with no attention control group and
assessment of short-term outcomes. Furthermore, the
study sample consisted of 100% White Appalachian stu-
dents, and the sample size was only 25% of the total po-
tential participants, which limits generalizability and an
www.jpedhc.org
ability to draw strong conclusions. Another limitation
was teacher intervention fidelity. On at least one occa-
sion, the study team observed a decrease in interven-
tion fidelity that required immediate suggested
corrective action. Further research is needed to study
both the short- and long-term outcomes of the interven-
tion to determine whether the short-term positive ef-
fects found in this study with early adolescents in
Appalachian middle schools can be sustained over a
longer period.
IMPLICATIONS FOR CLINICAL PRACTICE
The middle school years are often stressful for students,
especially for Appalachian youth who are from an un-
derserved area and are subject to health disparities.
The COPE program utilized with high school adoles-
cents was tested on middle school teens in early adoles-
cence in Appalachia with similar results. Important to
this particular age group are depression and anxiety
screening, along with reducing current obesity trends.
Pediatric health care clinicians in a variety of settings,
including schools and clinics, are in an excellent posi-
tion to emphasize the importance of mental and phys-
ical health and methods to support healthy lifestyle
choices, which could include CBSB techniques: recog-
nizing the thinking-feeling-behaving triangle, refram-
ing negative self-talk and thinking, practicing positive
self-talk, setting goals and problem-solving utilizing
the four-step process, stress and coping, dealing with
emotions in healthy ways, and the value of physical ac-
tivity and nutrition to encourage and elicit healthy life-
style behavior practices in adolescents. It is important to
translate evidence-based interventions into real-world
environments to prevent the growing incidence of
overweight/obesity and improve mental health out-
comes in adolescents. The COPE Healthy Lifestyle
TEEN program provides a resource for training health
care providers to deliver an evidence-based interven-
tion that supports adolescent mental and physical
health. The findings from this pilot study support a
full-scale RCT to determine both the short- and long-
term efficacy of COPE with Appalachian middle school
students.
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