P ro m o t i n g M e n t a l H e a l t h

a n d We l l n e s s in Yo u t h
T h ro u g h P h y s i c a l A c t i v i t y,
N u t r i t i o n , a n d Sl e e p
Daniel K. Hosker, MDa,*, R. Meredith Elkins, PhD
b,c,1
,
Mona P. Potter, MDc,d,1

KEYWORDS
 Mental health  Wellness  Exercise  Sports  Nutrition  Diet  Sleep
 Child and adolescent

KEY POINTS
 From 3 to 5 days of moderate to vigorous aerobic exercise for 45 to 60 minutes confers
benefits to youth physical and mental wellness. Additional benefits are seen with sports
participation.
 Nutritional patterns that are high in a variety of fruits and vegetables, whole grains, sea-
food, and nuts, moderate in low-fat dairy products, low in red meat, and very limited in
processed foods, saturated and trans fats, added sugars, and sodium have been associ-
ated with improved mental health outcomes across the lifespan.
 Following age-appropriate recommendations for sleep duration is associated with im-
provements in mental health and well-being. Engaging in consistent and calming bedtime
routines, creating a restful and comforting sleep environment, and ensuring that children’s
physical and emotional needs are met during the daytime can increase the likelihood of
obtaining adequate sleep duration.
 Seligman’s PERMA (positive emotions, engagement, relationships, meaning, and accom-
plishment) model is a useful construct to approach improving physical activity, eating, and
sleep to yield improved physical and mental wellness in youth.

Disclosures: None.
a
Psychiatry, Massachusetts General Hospital, 32 Fruit St, Boston, MA 02114, USA; b McLean
Anxiety Mastery Program, McLean Hospital, 799 Concord Avenue, Cambridge, MA 02138, USA;
c
Department of Psychiatry, Harvard Medical School, 25 Shattuck St, Cambridge, MA 02115,
USA; d McLean Child and Adolescent Psychiatry Outpatient Services, McLean Hospital, 115 Mill
St, Belmont, MA 02478, USA
1
Present address: 799 Concord Avenue, Cambridge MA 02138.
* Corresponding author. 4 Emerson Place Apartment 1113, Boston, MA 02114.
E-mail address: [email protected]

Child Adolesc Psychiatric Clin N Am - (2018) -–-

https://doi.org/10.1016/j.chc.2018.11.010 childpsych.theclinics.com
1056-4993/18/ª 2018 Elsevier Inc. All rights reserved.
2 Hosker et al

INTRODUCTION

Approximately 1 in every 4 to 5 youth in the United States meet criteria for a mental
disorder with severe impairment before they reach adulthood.1 Improving health
care and implementing practices to decrease vulnerability to psychiatric symptoms
is a vital part of treatment of this population. Conventional first-line treatments such
as cognitive behavior therapy (CBT) and psychopharmacology may be moderately
effective, but too often fail to improve some symptoms, with medications carrying a
risk for serious side effects.2,3 Alternative or augmenting treatment interventions
such as incorporating physical activity, improving nutrition, and optimizing sleep allow
clinicians to fashion a more comprehensive approach to mental health treatment of
youth.
The landscape of youth mental health and wellness is evolving as providers increas-
ingly view interventions through a more holistic lens. Although many research studies
have shown the benefits of physical activity, nutrition, and sleep in youth, few studies
show how these factors interact with emotional health and wellness. The existing
research in this area is largely cross-sectional, which precludes a demonstration of
causality, and is also limited by researchers’ use of heterogeneous protocols and
measurements, small sample sizes, and nonclinical participants. These methodolog-
ical limitations highlight the complexity involved with researching such dynamic vari-
ables and interactions. Given the lack of a robust evidence base, it is difficult to
standardize recommendations, particularly in relation to physical activity and nutrition.
However, the existing research studies suggest that optimizing physical activity, nutri-
tion, and sleep confers numerous benefits for youth mental health and wellness, and
exerts a positive impact on the developmental trajectory of young people vulnerable
to, or struggling with, psychiatric disorders.

PHYSICAL ACTIVITY AND SPORTS

Clinical Relevance and Current Research
A significant body of research shows that being more physically active has significant
benefits for everyone, regardless of age, sex, race, ethnicity, or current fitness level.4
The US Department of Health and Human Services recommends that preschool-aged
children (ages 3–5 years) be physically active throughout the day to enhance growth
and development, and children and adolescents aged 6 to 17 years should engage
in 60 minutes or more of physical activity each day (with 3 days a week including mus-
cle- strengthening and bone-strengthening each), with most of the 60 minutes being of
moderate-intensity or vigorous-intensity aerobic physical activity, to enhance physical
wellness.4 Although this level of physical activity yields improved cardiorespiratory
and muscular fitness, stronger bones, healthier metabolic biomarkers, and more
favorable body composition, only 20% of US high school students meet these guide-
lines.4 A growing body of literature suggests that physical activity also yields mental
health and wellness benefits, although precise recommendations for type, amount,
and frequency remain elusive.
There are small to moderate positive associations between physical activity and
positive mental health traits, including social-emotional and academic functioning in
youth, as summarized in Table 1.
Similarly, improving physical activity can also confer benefits to youth at risk for, or
with, certain psychiatric symptoms and disorders, as summarized in Table 2.
Participation in organized and/or competitive sports offers a unique gateway to
physical activity. Children can engage in sports either as an individual or as a member
of a team, although individual sports have been found to yield fewer psychological
 Promoting Mental Health and Wellness 3

Table 1
Associations between physical activity and social-emotional and academic wellness and
possible clinical implications

Domain of
Benefits Trait Clinical Implications
Social-Emotional  Enhanced self-concepta,5  Improved self-perception and value of
 Increased life skillsa,5 own qualities and abilities
 Improved self-esteema,5  More likely to express confidence in self
 Protective for shy  Increased engagement in novel
childrena,b,5 activities and/or new situations
 By learning to tolerate distress, can
challenge self further, and reap
benefits when overcoming new tasks
Academic  Improved classroom  Improvements in grades and test
behavior, with decreased scores6
disruptive behaviors6  Reduce the likelihood of negative
 Improved academic classroom behaviors6
achievement6  Greater confidence in school-based
 Cognitive and metacognitive tasks
benefits including learning,  Improved ability to attend to academic
memory, attention and daily tasks (eg, homework, quizzes,
management, and tests)6
processing speed4,7–9
a
Associations seen with sports participation.
b
As measured by decreased reports of anxiety symptoms.

benefits, and significantly fewer social benefits than team participation.5 Children who
are active in sports are more likely to be physically active in adulthood, which is crit-
ically important because more physically active adults lead physically and emotionally
healthier lives.5,23
How It Works
The mechanisms of action by which physical activity and sports confer benefits to
different domains of mental health and wellness are multifactorial, but they tend to
be in 2 broad categories: neurobiological and psychosocial. Although the neurobiolog-
ical cannot be separated from the psychosocial, and vice versa, conceptualizing it in
this way can be helpful, as summarized in Table 3.
Clinical Assessment
Before recommending physical activity or sports as part of a therapeutic intervention,
it is important to clarify what the child is already doing, the child’s activity preferences,
and potential obstacles to being physically active. The answers to these questions
may prompt further inquiry if, for example, the clinician suspects that the child is exer-
cising too much in the context of an eating disorder or too little because of ongoing
medical issues. Sample questions to help in the assessment of children’s physical ac-
tivity are listed in Table 4. It is important to ask these of the parent and child if possible,
because there can be discrepancies that are important to address. These questions
can be modified to be asked directly of the child as the clinical context allows.
Recommendations for Physical Activity
Clinicians should consider prescribing physical activity as a way of promoting both
physical and emotional health in youth, especially given the increasing evidence
4 Hosker et al

Table 2
Associations between physical activity and psychiatric disorders

Depression and  Protective effect against depression across age, gender, and
suicidality geographic regions across the world10
 Treatment effect sizes similar to that of antidepressant and CBT
therapy for depressive symptoms in children and adolescents2,11–13
 Lower odds of sadness, suicidal ideation, or suicidal attempts in high
school studentsa,14
 Reduction in suicidal ideation and attempts in bullied high school
studentsa,15
 Decreased suicidal ideation and intention in adolescents involved
with team sportsb,g
 Decreased hopelessness, depression, and suicidality among college
students16
 Inverse bidirectional association between depressive symptoms and
physical activity (ie, increased physical activity precedes decreased
depressive symptoms, and increased depressive symptoms precede
decreased physical activity)17
ADHD  Improvements in core ADHD symptoms (inattention, hyperactivity,
and impulsivity)c,3
 Improved social, motor, behavioral, and emotional functioningd,18
 Physical activity in adolescence may decrease ADHD symptoms in
early adulthood19
Anxiety  May improve symptoms of anxiety in children and adolescents6
 Decreased social anxiety with lowered social isolation5,g
Substance use  Lower levels of alcohol, cigarette, and marijuana use among high
school studentse,20
Psychosis and  Decreased physical activity and poorer cardiorespiratory fitness have
antipsychotic use been seen in adolescents who develop a psychotic illness21
 Lower measures of adiposity and improved insulin resistance in
children treated with a second-generation antipsychoticf,22

Abbreviation: ADHD, attention-deficit/hyperactivity disorder.

a
In high school students who exercised 4 to 5 d/wk compared with those who exercised 0 to
1 d/wk.
b
Benefits were lost when they discontinued playing sports.
c
Effects seen primarily with aerobic exercise.
d
Effects seen in medicated and unmedicated children with ADHD.
e
Although team sports were associated with higher levels of alcohol and smokeless tobacco use,
physical activity mitigated some of the effects between team sports and alcohol use. Physical activ-
ity and being on a team were both shown to decrease cigarette and marijuana use.20
f
Seen in children who met a minimal recommendation for daily physical activity compared with
those who did not.
g
Associations seen with sports participation.

regarding the negative health impact of sedentary behaviors, with US children spending
approximately 7.7 h/d (55% of their monitored waking time) being sedentary.4
As discussed earlier, it is difficult to draw conclusions regarding optimal types or
“doses” of physical activity for mental health benefits given the overall heteroge-
neous nature of the research and lack of methodologically rigorous studies. Howev-
er, common trends among the data across mental health and wellness domains
suggest that to obtain the mental health benefits, physical activity in youth should
involve:
 At least 45 to 60 minutes of physical activity each day2,4,10,14,18
 From 3 to 5 days a week of moderate to vigorous aerobic activity2,4,10,14,18
 Promoting Mental Health and Wellness 5

Table 3
Means by which physical activity and sports may confer benefits to youth mental wellness

Conceptual
System Mechanism of Action
Neurobiological  Modify inflammatory and oxidative stress responses10
 Promote neurogenesis, synaptogenesis, myelination, and angiogenesis to
aid brain development through neurotrophic factors (such as BDNF)2,3,10,24
 Modulate monoamines (serotonin, dopamine, norepinephrine),
endorphins, and endocannabinoids2,3,10,24
 HPA axis regulation2
Psychosocial  Behavioral activation with positive reinforcement2
 Satisfy basic psychological needs for social connectedness and autonomy24
 Mastery of a skillset2,24
 Promote confidence through achievement2,24
 Exposure to difficult situations and using distress tolerance
 Increasing overall self-efficacy and self-concept2

Abbreviations: BDNF, brain-derived neurotropic factor; HPA, hypothalamic-pituitary-adrenal.

Table 4
Example questions of parents when assessing physical activity in youth in the context of a
mental health evaluation

Example Questions
Type  What types of activities or sports does your child participate in?
 Are these activities mostly aerobic (eg, running, swimming, soccer) or
anaerobic (eg, push-ups/sit-ups, weight lifting, tug-of-war)?
Frequency  How many days in a week does your child exercise or play sports?
 What does your child do during “spare time”?
 How consistently is the child exercising or staying physically active? (eg, spurts
every so often, only during a sports season)
Duration  How many minutes does your child exercise on average each day/week?
 Do you have any worries that your child exercises too much? If yes, why do you
think so?
Intensity  When your child is exercising or playing sports, is the intensity most
comparable with walking, jogging, or running?
 Does your child usually end up sweating?
 Is your child breathing hard during some, most, or all of the activity?
Preferred  What is your child’s favorite way to be physically active?
exercise  Does your child prefer to play sports alone or on a team?
 What have you seen your child enjoy most while engaged in physical activity?
Obstacles to  Is there anything keeping your child from being more physically active?
physical  Are there any medical concerns regarding your child being more physically
activity active?
 Does your child have appropriate strength and motor coordination?
 Any concerns for bullying when your child is playing/practicing physical
activities?
 What other activities compete with time for physical activities? (eg, screen
time, hanging out)
Supporting  How has physical activity altered your child’s nutrition?
questions  How has physical activity affected your child’s sleep?
 Do you believe that your child is able to appropriately recover from the
physical activity?
6 Hosker et al

 Understanding that it might take at least 8 weeks of engagement before recog-

nizing most benefits, although short-term benefits may be seen after as little as 1
bout of physical activity2,4,10,14,18
Fortunately, these guidelines align with the physical activity recommendations for
youth from the US Department of Health and Human Services. Table 5 summarizes
clinical considerations when increasing physical activity and selecting appropriate ac-
tivities for youth, adopted from the US Department of Health and Human Services’
Physical Activity Guidelines for Americans, 2nd edition.4
The most important role a provider can play is to guide the exploration for an appro-
priate and enjoyable physical activity for a child, especially in younger children, in
whom physical activity can be introduced as “play,” and establishing an active lifestyle
may yield benefits throughout a lifetime. Similarly, encouraging a child’s participation
in organized sports can be helpful in the right context, and may provide mental health
benefits beyond increased physical activity alone. By fostering a best-fit activity, clini-
cians can yield improved compliance in the subset of youth who may otherwise have
ambivalence or disinterest preventing them from participating. To further address
ambivalence regarding participation, clinicians can use motivational interviewing tech-
niques focusing on the goals, values, and interests of the child.

NUTRITION SCIENCE
Clinical Relevance and Current Research
A global obesity epidemic (United States currently ranked #1 in childhood obesity
rates [12.7%]) has called attention to the need for intervention in multiple domains,
including diet and nutrition.25 Emerging evidence argues the case for nutritional
awareness not only for its effects on physical health, but also because of its relation-
ship with mental health and well-being. Much of the investigation historically has
focused on the role of individual nutrients on mental health. For example, magne-
sium,26 zinc,27 and omega-3 fatty acids28 have been studied in relation to anxiety
and depression.
However, recent focus has broadened the scope to considering dietary patterns.
Data that support an association between unhealthy patterns of eating and poor
mental health (eg, depression, anxiety), as well as healthy patterns of eating and
improved mental health, are emerging for all stages of life. Table 6 summarizes major
findings, including 1 adult randomized control trial, the Supporting the Modification of
lifestyle In Lowered Emotional States (SMILES) trial.41

How It Works
Multiple pathways have been proposed in the association between diet and mental
health, including (but not limited to) inflammation,42 oxidative stress,43 and changes in
brain structure.44 For example, unhealthy diet patterns have been associated with lower
left hippocampal volume in animal and human studies, as well as the reverse for adults
with healthy diet patterns, possibly mediated via brain-derived neurotropic factor.29,45
In addition, although in early stages, there has been growing interest in the gut
microbiome (the approximately 100 trillion microorganisms that exist in the gastroin-
testinal tract) and its relationship with mental health.46 The gut microbiome has
been noted to be a virtual organ, producing metabolites that influence the host in
many ways, with emerging evidence showing cross-influence with multiple systems,
including neurobehavioral, metabolic, immune, and endocrine systems.47 Although
most data regarding the microbiota gut-brain connection currently come from animal
models, human studies are emerging.46,48,49
 7
Table 5
Clinical considerations when increasing and selecting physical activities for youth

Clinical
Consideration Clinical Example/Recommendations
Increasing Physical Start early  Encourage play at home and in the neighborhood
Activity  Provide time for structured and unstructured
physical activity in and out of school
 Promote activities the child can enjoy for a
lifetime (eg, swimming, cycling)
Start low, go slow  Risk of injury is directly related to the gap
between usual level of activity and a new level of
activity. Keep the gap small, allowing the body to
adapt
 Use the child’s level of fitness to guide the level of
effort expected
 First, increase the number of minutes (duration)
of an activity, then the number of days
(frequency), then increase from moderate to
vigorous intensity
 Can add light-intensity to moderate-intensity
activities (eg, short walk) to weekly routine
 Increase activity by small amounts every week or
two for youth (considering age, level of fitness,
and level of experience)
 Keep activities enjoyable
 Vary activities to avoid muscle overuse injuries
Medical clearance  Although medical clearance should not be
necessary for most children, periodic monitoring
and collaboration with relevant providers may be
appropriate for children with known medical
conditions that may be adversely affected by
rigorous exercise3,4
Replace sedentary  Replace TV watching after school with sports
behavior with participation
activity when  Encourage walking or biking when possible
possible instead of driving
 Limit and replace screen time with family
activities and outside games
Choosing a Preschool-aged  Moderate intensity
Physical Activity children  Tag, playing on playground, riding a tricycle or
by Age and bicycle; games requiring catching, throwing, or
Aerobic Intensitya kicking
 Vigorous intensity
 Running, skipping, dancing, jumping,
gymnastics, swimming
School-aged  Moderate intensity
children  Brisk walking, riding a bicycle, hiking,
swimming, games that require catching and
throwing
 Vigorous intensity
 Running, riding a bicycle, jumping rope, cross-
country skiing, sports (eg, soccer, basketball,
tennis)
Adolescents  Moderate intensity
 Brisk walking, riding a bicycle, recreational
activities (eg, kayaking, hiking, swimming)
 Vigorous intensity
 Running, riding a bicycle, martial arts, vigorous
dancing, sports (eg, soccer, basketball, tennis)

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8 Hosker et al

Table 5
(continued )
Clinical
Consideration Clinical Example/Recommendations
Special During the  Female youth may need additional support and
Considerations transition to encouragement to maintain beneficial levels of
adolescence, physical activity
physical activity  This may be provided by health professionals,
in girls decreases parents, coaches, teachers, peers, and so forth
significantly
compared with
boys (this
disparity persists
into adulthood)
Children and  Youth with disabilities should partner with a
adolescents with health care or physical activity professional to
disabilities are understand appropriate types and amounts of
more likely to be physical activity for them to assist in decreasing
inactive than inactivity
those without
disabilities
a
Because the evidence for mental health and wellness benefits in youth are most supported from
aerobic activities, these are presented here.
Adapted from US Department of Health and Human Services. Physical activity guidelines for
Americans. 2nd edition. Washington, DC: US Department of Health and Human Services; 2018.

Although there is a heritable component to people’s microbiota compositions, envi-

ronmental factors such as diet, stress, and medications are thought to have a larger
influence.47,50,51 Animal models have shown that an anxious phenotype can be trans-
ferred via gut microbiota, and manipulation of the gut microbiota (eg, with probiotics or
antibiotics) can influence depression-like behaviors.49
Application of knowledge of the gut-brain relationship is a work in progress. Diver-
sity of gut microbiota (rather than the concentration of any particular microorganism
species) seems to be an indicator of a healthy gut.47 Probiotics are marketed for their
possible role in increasing “good bacteria,” and therefore potentially benefitting
mental health; however, the role of particular microbiota has yet to be fully elucidated,
leaving many questions about the particular application of probiotics in the treatment
of mental health problems.47,48

Clinical Assessment
Many factors contribute to food choice, including (but not limited to) biological need/
appetite, taste preference/sensory stimulation, family/peer/social/cultural influence,
habit/routine, cost/access/availability, mood/emotions/craving, health attitudes, and
weight awareness. Given the impact on physical and mental health, clinicians are
encouraged to evaluate for food insecurity (lack of consistent access to adequate
food). The who, what, when, why, and where of eating patterns can offer opportunities
to recognize processes that are going well and help bring attention to areas in need of
intervention. Given the potential impact of the family system on the eating patterns of
children, thorough assessment incorporates nutritional patterns of the family sys-
tem.52 Sample questions and associated recommendations for parents are listed in
Table 7 to assist in this assessment. These questions can be modified to be asked
directly of the child as the clinical context allows.
 Promoting Mental Health and Wellness 9

Table 6
Association between dietary pattern and mental/emotional health across the life span

Stage of Life Mental Health Outcomes

Prenatal and early  High adherence to unhealthy diet during pregnancy associated
life with increased risk of child externalizing problems29–31
 Children with high level of unhealthy diet or low level of healthy
diet postnatally had higher levels of both internalizing and
externalizing problems by 5 y old32
Childhood and  A review of 20 studies across 11 countries found support for an
adolescence association between unhealthy diet and increased odds of mental
health difficulties and between healthy dietary patterns and better
mental health33
Prospective studies:
 Jacka and colleagues,34 2011: a study of nearly 3000 Australian
adolescents, predominantly from higher socioeconomic
backgrounds
 Better diet quality at baseline predicted better mental health at
follow-up even after adjustment for mental health at baseline
 Improvements in diet quality were associated with improved
mental health score at 2-year follow-up, whereas reductions in
diet quality were associated with declining psychological
functioning
 Mental health at baseline did not predict diet quality at 2-year
follow-up
 McMartin and colleagues,35 2012: 3757 fifth graders in Nova Scotia
participated as part of the Children’s Lifestyle and School
performance Study (CLASS) survey
 Diet quality was not significantly associated with visits to a health
care provider for internalizing disorder
 Dietary variety may reduce the risk of developing internalizing
disorders
 One-third of children with the highest fish consumption had
lower rates of being diagnosed with internalizing disorder
 Jacka and colleagues,36 2013: evaluated >2000 students from
ethnically diverse and socially deprived backgrounds and included
a wide range of potentially confounding variables
 Cross-sectional study found an association between unhealthy
diet and mental health difficulties
 Prospective study found that unhealthy and healthy diet scores
did not significantly predict mental health status at 3-year
follow-up, although patterns of associations were in the same
direction as the cross-sectional analysis
 Trapp and colleagues,37 2016: 746 adolescents participated as part
of the Western Australian Pregnancy Cohort (Raine) Study
 Western (unhealthy) dietary pattern at 14 y old was positively
associated with greater externalizing behaviors at 17 y old in girls
 No other statistically significant associations were observed after
full adjustment of confounders
 Winpenny and colleagues,38 2018: 603 adolescents participated as
part of the ROOTS study (United Kingdom), participants were from
higher socioeconomic status categories, adjustments made for
sociodemographic, anthropometric, behavioral, and psychological
factors in longitudinal analysis
 There were no prospective associations between healthy diet at
14 y of age and depressive symptoms at 17 y of age after
controlling for covariates

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10 Hosker et al

Table 6
(continued )
Stage of Life Mental Health Outcomes
Adulthood  A systematic review and meta-analysis of 13 cross-sectional and
cohort studies concluded that healthy diet pattern was significantly
associated with reduced odds of depression, but no statistically
significant association was observed between unhealthy (Western)
diet and depression (trend toward positive association)39
 A meta-analysis of 22 studies investigated the association between
a Mediterranean-style diet and brain diseases and determined that
higher adherence to the Mediterranean-style diet was associated
with reduced risk for depression and cognitive decline40
Randomized controlled trial
 Jacka and colleagues,41 2017, Supporting the Modification of
lifestyle In Lowered Emotional States (SMILES) trial: included 67
adults diagnosed with depression; 31 in dietary support group and
25 in social support control group for 12 weeks
 The dietary support group received 7 60-min individual
ModiMedDiet counseling sessions: diet rich in vegetables, fruit,
and whole grains, with an emphasis on increased consumption of
oily fish, extravirgin olive oil, legumes, and raw unsalted nuts,
and moderate consumption of red meat and dairy
 The dietary support group showed significantly greater
improvement in depressive symptoms between baseline and
week 12 compared with the control group (32.3% vs 8%),
number NNT based on remission score was 4.1 (95% CI of NNT,
2.3–27.8)
 All effects were independent of any changes in BMI, self-efficacy,
smoking rates, and/or physical activity

Abbreviations: BMI, body mass index; CI, confidence interval; NNT, needed to treat.

Recommendations for Nutrition

The 1990 National Nutrition Monitoring and Related Research Act states that every
5 years the US Department of Agriculture (USDA) and Department of Health and Hu-
man Services must jointly publish dietary guidelines based on a preponderance of
current scientific and medical knowledge. The 2015 to 2020 Dietary Guidelines for
Americans marks the eighth edition and presents several changes from previous
versions, including a change from MyPyramid to MyPlate (www.ChooseMyPlate.
gov) as the guiding structure for nutritional decision making. The recommendations
have increasingly acknowledged the importance of cultural needs as well as
financial constraints. With emerging evidence, there are evolving updates for certain
recommendations, including those for dietary cholesterol, fats, and calorie
restriction:
 Loosening recommendations to limit dietary cholesterol (eg, eggs), but with
caution because of frequent correlation between high cholesterol and high satu-
rated fats in food.
 Reframing fats: not all fats are bad (eg, instead of avoiding all fats, move to
reducing intake of saturated fatty acids by replacing them with monounsaturated
fatty acids; eg, olive oil, nuts, avocados).
 Intermittent fasting and calorie restriction might have potential benefits in some
adults; however, this is not recommended in children and adolescents given en-
ergy and growth requirements at this stage.
 11
Table 7
Components of a nutritional assessment in the context of a mental health evaluation

Category Sample Questions Recommendations

What are they Are they:  Shift focus from what not to eat to
eating?  Eating a variety of nutrient-dense what to eat (eg, gradually replace
foods? candy/sweets with fruit, refined
 Limiting processed foods that are grain [eg, white bread] with whole
high in added sugars, sodium, and grain, butter with olive oil, potato
saturated fat (eg, potato chips, fast chips with kale chips or sweet
food pizzas, white bread)? potato fries)
 Choosing water rather than juice  Limit/avoid artificial
and soda? sweeteners53,54 (eg, choose water
 Showing any restrictions, rather than diet soda)
aversions, or patterns of picky  If a child shows a pattern of picky
eating? eating, consider offering a choice
 Taking vitamins and/or between healthy food options
supplements? (that the child might have helped
pick in the store) in small,
manageable portions in the
context of an enjoyable
environment in which all family
members are eating the same meal
(www.choosemyplate.gov)
 Aim to obtain nutrients from food
rather than supplements when
possible (eg, drinking smoothies
that include combinations of fruit,
vegetables, and nuts, plus
additional options of spices, oils,
and seeds)
 Include prebiotic (eg, bananas,
garlic, onion) and probiotic foods
(eg, fermented foods, yogurt) in
the diet
Why are they Is the purpose of eating:  Consider the role of mindful
eating?  For nourishment/energy? eating: making deliberate food
 For enjoyment, craving? choices and fully paying attention
 To manage emotion, stress, to the food55
boredom, or to provide comfort?  Develop a list of healthy
alternatives for comfort eating. In
a study of college students there
was no significant difference in
resolution of negative feelings
between groups that ate (1)
comfort food, (2) liked-but-not-
comforting food, or (3) plain
granola bars56
With whom are  What is the frequency and quality  Aim for at least 5 family meals per
they eating? of family meals? week (does not necessarily have to
 What is being modeled (eg, in the be dinner)57
household)?  Aim to make meals enjoyable
experiences, choosing topics of
conversation that foster
engagement and interest
 Encourage parents to increase
awareness of their eating pattern
and the impact it has not only on
themselves but also on their
children

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12 Hosker et al

Table 7
(continued )
Category Sample Questions Recommendations
When do they  How often are they eating  Problem-solve limitations to eating
eat? breakfast? breakfast, because associations
 How about snacks? exist between having breakfast
 What is the daily eating schedule? and improved student psychosocial
and academic functioning58
 Deliberately plan snack content
and timing to manage energy
needs of the child
 Develop a list of acceptable healthy
snacks and keep them readily
available:
Create a kids’ snack drawer/
cabinet that offers easily
accessible healthy snacks; have
fruits and vegetables precut
and available for munching in
a bowl on the counter/kitchen
table
Where do they  Are they eating at the kitchen/  Maximize eating in spaces that
eat? dining room table? promote mindful eating (eg, eat
 How often are they eating in front snacks at the kitchen table instead
of TV/screens? of in front of TV/computer/phone)
 How often are they eating at fast
food restaurants?

Although specific recommendations are likely to continue to change as knowledge

and understanding of the interaction between food and the mind/body increase, a
theme in current recommendations is to focus on a healthy eating pattern that is:
 High in fruits and vegetables (variety), whole grains, seafood, nuts, and legumes
 Moderate in low-fat dairy products
 Low in red and processed meat
 Very limited in processed foods, saturated fats and trans fats, added sugars, and
sodium (unhealthy diet pattern)
As with changes in physical activity, improvement in dietary pattern can be chal-
lenging to accomplish quickly. Engaging the patient and family in motivational inter-
viewing to help assess readiness to change (and first focusing on improving
motivation to change if needed), identifying goals that are both appealing and
manageable, and breaking goals down into small, incremental steps can increase
the likelihood of success.59 Opportunities for improved nutritional patterns through
the who, what, when, why, and where of eating should be considered as part of psy-
chiatric assessment and treatment planning and are included in Table 7.

SLEEP SCIENCE
Clinical Relevance and Current Research
Along with diet and exercise, sleep is an essential activity that plays a crucial role in
emotional and physical development, health, and well-being. Quality sleep is asso-
ciated with positive health and emotional outcomes in youth, including, but not
limited to, improvements in attention, learning, academic performance, memory,
 Promoting Mental Health and Wellness 13

cognition, behavior, and emotion regulation, as well as enhanced self-esteem, self-

acceptance, levels of optimism, and overall quality of life.60–62 In contrast, a wealth
of evidence attests to the relationship between inadequate sleep and poorer health
and emotional well-being in youth, including greater levels of self-criticism,
internalizing symptoms, risk-taking behaviors, risk for suicidality and psychiatric
illness, in addition to a host of negative effects on physical health and cognitive
capabilities.60,61,63–65
Adequate sleep has been defined as the number of hours of daily sleep that an in-
dividual requires to function optimally and feel well rested.66 Regrettably, most youth
are not obtaining adequate sleep. Moreover, the likelihood that children will obtain
adequate sleep decreases with age.64 A survey of US students showed that nearly
60% of middle school students and nearly 75% of high school students endorsed
short sleep duration on school nights (defined as <9 hours for children aged 6–12
years, or <8 hours for adolescents aged 13–18 years).67 Similar results were found
in a more recent study of high school students, with 71.9% reporting less than 8 hours
of sleep per night.65 In addition, this study found that the odds of engaging in risky be-
haviors (eg, risky driving, substance use, aggressive behaviors) increased as hours of
sleep decreased.65 Crucially, the strongest association was identified between sleep
and mood and/or self-harm; youth who slept less than 6 hours per night were 3 times
more likely to report suicidal behavior.65
Several factors contribute to poor sleep in youth, including electronic media expo-
sure; caffeine consumption; early school start times; chronic medical conditions;
neurologically based sleep disorders (eg, obstructive sleep apnea, restless legs syn-
drome); and pressures to achieve good grades, participate in extracurricular activ-
ities, and maintain an active social life.64 Notably, youth from families of a lower
socioeconomic status, as well as racial and ethnic minority youth, are at higher
risk for insufficient sleep.68,69 Sleep disruptions are frequently identified in children
with psychiatric disorders, including attention-deficit/hyperactivity disorder, mood
and disorders, and autism spectrum disorders.63 The relationship between sleep
and psychiatric illness is often bidirectional, whereby sleep disruptions are a symp-
tom of a psychological disorder and the resulting poor sleep compounds and inten-
sifies the condition.63,70

How It Works
Sleep architecture throughout most of childhood, adolescence, and adulthood con-
sists of 2 stages: non–rapid eye movement sleep (NREM) and rapid eye movement
sleep (REM), which are characterized by distinct electroencephalographic patterns
and physiologic features. NREM sleep progresses through 3 stages of increasingly
deep sleep and is considered necessary for rest and restoration. REM sleep follows
stage 3 of NREM sleep, and is characterized by bouts of rapid eye movements, the
suppression of muscle tone, and increases in brain activity, during which dreaming
occurs. REM sleep is associated with dreaming, and is thought to play a role in
the consolidation of memory and is crucial for the healthy development of the central
nervous system. Children and adults enter sleep at stage 1 of NREM sleep and prog-
ress through NREM and REM cycles, which lengthen across development from 45 to
60 minutes in infancy to 90 to 110 minutes in childhood and adulthood, with brief pe-
riods of waking in between cycles. The amount of sleep necessary per 24-hour
period peaks in neonates and decreases across childhood and adolescence.71
Table 8 outlines consensus guidelines from the American Academy of Sleep Medi-
cine detailing the recommended amount of sleep in childhood and adolescence by
age group.
14 Hosker et al

Table 8
Recommended minimum and maximum hours of sleep recommended per age group within a
24-hour period

Age Group Recommended Amount of Sleep per 24-h Period (h)

Infants 4–12 mo 12–16 (including naps)
Children 1–2 y 11–14 (including naps)
Children 3–5 y 10–13 (including naps)
Children 6–12 y 9–12
Teenagers 13–18 y 8–10

Adapted from Paruthi S, Brooks LJ, D’Ambrosio C, et al. Recommended amount of sleep for pedi-
atric populations: a consensus statement of the American Academy of Sleep Medicine. J Clin Sleep
Med 2016;12(6):785–6.

Clinical Assessment
Despite recommendations that sleep assessment be part of child well-visits, sleep is
not regularly addressed in pediatric primary care.72 It is therefore essential that mental
health providers recognize the links between sleep and emotional well-being, and
continuously assess and address sleep issues in the course of their work with youth.
This assessment includes recognizing that both too little and too much sleep are asso-
ciated with poorer outcomes.61 Tools to assess pediatric sleep include clinical inter-
views, sleep diaries, and sleep questionnaires, such as the parent-report Children’s
Sleep Habits Questionnaire73 or the adolescent-report School Sleep Habits Survey.74
Clinicians should also assess environmental factors related to sleep quality and can be
influential in assisting families to implement evidence-based behavioral recommenda-
tions to improve sleep. Table 9 highlights potential areas of inquiry for parents or
guardians to facilitate assessment of sleep hygiene and environmental factors. These
questions can be modified to be asked directly of children as clinical context allows.
Recommendations for Sleep
Guidelines from the American Academy of Pediatrics detailed earlier can inform age-
based recommendations for sleep duration, recognizing that the sleep needs of indi-
vidual children may vary depending on the unique genetic, behavioral, medical,
emotional, and environmental factors at play. In addition to recommendations about
the duration of sleep, there are several environmental factors that should be consid-
ered, outlined in Table 9. In short, parents of children and adolescents should estab-
lish regular bedtimes and wake times to facilitate age-based recommendations for
sleep duration. Implementing a consistent, predictable, and calming bedtime routine
is particularly beneficial for children aged 12 years and younger.60,75 Most research
supports recommendations that sleep should occur:
 Independent of parental presence
 In a cool (16 –19 C [60 –67 F]), dark, comfortable, quiet room reserved primarily
for sleeping60
 With minimal exposure to electronics, particularly in the evenings, and all elec-
tronic devices should be removed from children’s rooms
In addition, sleep is optimized when children maintain a healthy diet, participate in
regular physical activity, and have their emotional needs met during the day.60
Some children require more targeted interventions to improve their sleep. Emerging
evidence suggests that cognitive behavioral and mindfulness-based treatments may
 15
Table 9
Sample questions to assess sleep hygiene in the context of a mental health evaluation and
related recommendations

Example Questions Recommendations

Sleep Duration  How long does the child sleep  Adjust bedtimes and wake times to
each night? allow for age-appropriate sleep
 When is the child’s bedtime duration (see guidelines discussed
during the week? On earlier)
weekends?  If it typically takes time for the child to
 How long does it take for the fall asleep, set an earlier bedtime to
child to fall asleep at night? permit the recommended amount of
 Is the child napping? If yes, sleep (eg, a 13-y-old who wakes at 6 AM
how frequently and for how for school and takes 30 min to fall
long? asleep should go to bed by 9:30 PM at
 What is the child usually doing the latest to ensure 8 h of nighttime
while waiting to fall asleep? sleep)
(eg, listening to music, thinking  Keep bedtimes and wake times as
about tomorrow, thinking consistent as possible on weeknights
about past events) and weekends
 Is the child experiencing  Avoid daytime naps for children 6 y of
nighttime awakenings? If yes, age and older, unless the child is ill.
how frequently and for Daytime naps for older children make
how long? it less likely that they will sleep at night
 Encourage diaphragmatic breathing
(belly breathing), progressive muscle
relaxation, or other breathing-based
relaxation strategies to facilitate sleep
onset
 For nighttime awakenings that last
longer than 15 min, get out of bed and
do a quiet activity (eg, reading,
coloring) in dim light for 10 min, and
then return to bed. This technique
helps to reinforce that bed is
associated only with sleep
Routines  What is the child’s daytime  Predictability during the day can help
routine? (ie, meal times, school optimize nighttime sleep
attendance, participation in  Engaging in a consistent and calming
extracurricular activities) bedtime routine can improve sleep;
 How consistent are the initiating the routine eventually cues
child’s daytime and nighttime the body that it is time for sleep via
schedules? classic conditioning
 Does the child have a  Restrict caffeine intake beginning in
wind-down or nighttime the afternoon
routine? (ie, shower, brush  Avoid exercising 3 h before bedtime
teeth, read a book, lights  Avoid eating <2 h before bed, and
out) limit liquid intake
 Is the child’s bed used for  Take a warm shower or bath before
activities other than sleep, bed to relax. The change in body
such as homework, watching temperature from the warm water to
TV, using the phone? the cool air also facilitates cooling of
the body, which improves sleep
 Listen to slow, relaxing music for
45 min before bedtime
 The bed should be reserved only for
sleep; avoid doing other activities on
or in bed to reinforce the association
between the bed and sleep

(continued on next page)

16 Hosker et al

Table 9
(continued )
Example Questions Recommendations
Sleep  Where does the child sleep in  Whenever possible, sleep should occur
Environment the home? independently (ie, in the child’s own
 Does the child sleep alone? room) and in a dark room
With siblings? With parents?  Consider using white noise machines
 What is the child’s sleep or fans to block sounds that may cause
environment like? (eg, bright, wakefulness
noisy, comfortable, free of  Sleep is optimized when the bedroom
electronics) temperature is 16 –19 C [60 –67 F] (ie,
the room should feel mildly chilly
when you get out of bed)
 Reduce exposure to blue light (ie, LED,
florescent lights, screens) before bed;
shift electronics to nighttime settings
in the evening if they must be used
before bed
 Whenever possible, avoid exposure to
screens entirely for 1–2 h before
bedtime. Keep electronics away from
the bed or bedside to avoid
interruptions from notifications
 Prevent viewing the clock by turning
the clock face away or removing it
entirely, because clockwatching can
increase anxiety about not getting
enough sleep

Abbreviation: LED, light-emitting diode.

be effective in addressing problems associated with poor sleep in at-risk youth.76

When sleep problems do not respond to standard behavioral interventions, children
should be referred for appropriate treatment.
Physical Activity, Nutrition, and Sleep Within a PERMA Framework
Because regular physical activity, balanced nutrition, and quality sleep are associated
with improved well-being across the lifespan, it may be helpful for clinicians to adopt a
framework that highlights the role of each lifestyle factor in optimizing well-being; one
such framework is the PERMA model of mental well-being created by Martin Selig-
man, PhD.15 This approach proposes that mental well-being is a multifactorial
construct that includes the following elements15:
 P: positive emotions
 E: engagement
 R: relationships
 M: meaning
 A: accomplishments
The model further proposes a positive association between each of these elements
and overall well-being. Clinicians may find it useful to consider PERMA elements dur-
ing assessment and treatment to encourage children and adolescents to meet recom-
mendations for physical activity, balanced nutrition, and sleep. Table 10 offers
example questions to address these PERMA factors in relation to each lifestyle factor.
These questions can be modified to be asked of the parent as needed.
Table 10
Sample questions applying the PERMA wellness model to assess physical activity, nutrition, and sleep in the context of a mental health evaluation

Sample Questions
PERMA Factor15 Physical Activity Nutrition Sleep
Positive emotion  What types of physical activity make you  Which meals make you feel content?  What is something you do before you go
feel excited? Happy? Energized? Happy? Energized? Connected to others? to bed that helps you to feel calm?
 What positive emotions do you feel when  What are some of your favorite foods?  What positive emotions do you feel when
you have finished working out?  What positive emotions do you feel when you lie down in your bed to sleep at night?
 How does exercising with other people, or you enjoy a nutritious meal? Is this any  How you feel when you wake up after a
playing a team sport, make you feel? different from when you make less healthy good night’s sleep?
choices?
Engagement  Which physical activities or sports best  Do you prepare meals yourself or with  Do you look forward to sleeping? When
capture your interest? others? What are some of the benefits of you lie down, do you enjoy how your
 What do you like about participating in both? pillow and covers feel? Do you let go of
team sports? How about individual sports?  Where do you like to eat? Do you enjoy your thoughts about the day to enjoy
 Does competition help you push yourself, going to restaurants, or do you prefer being in your bed?
or impair your performance? eating meals at home?  What is a relaxing activity that you do
 What do you like to do while you are before bed? Do you like to read a book,

Promoting Mental Health and Wellness

cooking? Do you listen to music, turn on listen to calming music, or take a hot bath?
the TV, talk to others? Or do you practice  Is your bed the most comfortable place for
mindfulness while cooking? you to sleep? Do you have several places
where you feel so comfortable that it is
easy for you to fall and stay asleep?
 What is it like for you to do breathing
exercises as you try and fall asleep?
Relationships  Is there anyone with whom you like to  Who do you eat your meals with? Who do  How do you say goodnight to your family
exercise? you enjoy eating with the most? members before bed?
 What team sports do you like to play?  What sorts of things do you talk about  Do you feel safe and protected while you
What is it like for you to be part of a sports when you eat meals with others? sleep?
team?  How do you use meals to help build or  Are there any books or songs that you
 How does exercising with other people support your relationships? Do you go out share with others before bed?
make you feel? Do you find that you push to dinner with friends, catch up with
yourself more when you exercise with a classmates over lunch in the cafeteria, or
partner? make meals with your family?

(continued on next page)

17
 18
Hosker et al
Table 10
(continued )
Sample Questions
PERMA Factor15 Physical Activity Nutrition Sleep
Meaning  What do you value about being physically  Why does eating healthily matter to you?  What is something that you have in your
active? Why is it important to you?  Are there special meals that you and your sleep environment/bedroom that is
 How do you feel about yourself when you family make during holidays or other significant to you? A favorite stuffed
are physically active on a regular basis? special occasions? animal? A picture of loved ones by your
 What does winning or losing at a  What foods have meaning to you? Do any bed?
competitive physical activity mean to you? foods remind you of happy times,  Do you value your sleep? Does it make you
How does winning or losing affect you? holidays, or special people? feel better?
 Do you value and think or talk about your
dreams?
Accomplishments  Tell me about something that you  Do you feel a sense of pride when you  Do you notice any relationship between
accomplished that was physically make healthy food choices instead of your sleep and your school performance
challenging. How did you surprise unhealthy ones? (eg, paying attention in class)?
yourself?  What is it like for you to prepare and eat a  How does sleep affect how effective you
 What is it like for you when you are part of well-balanced meal? are at getting things done the next day?
a team that wins or performs well?
 How do you think your schoolwork is
affected by getting exercise? How about
your social life?
 Promoting Mental Health and Wellness 19

SUMMARY

The benefits conferred by physical activity, balanced nutrition, and quality sleep to
youth physical well-being have generally been accepted. Emerging evidence con-
tinues to shed light on their benefits for youth mental health and wellness as well,
including psychiatric disorders. These benefits seem to occur through multifactorial
effects on neurobiological and psychosocial development. Integrating ongoing as-
sessments and interventions related to these lifestyle domains within clinical practice
promotes positive mental as well as physical health in youth, including enhancing
treatment of psychiatric disorders and their impacts on functioning.

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