Introduction

Health can be defined as a state of complete physical, mental and social well-being

and not merely the absence of disease or infirmity. Health can be understood from two broad

aspects - physical and mental health. Physical health means a good body health, which is

healthy because of regular physical activity (exercise), good nutrition, and adequate rest.

Fitness reflects a person's cardiorespiratory endurance, muscular strength, flexibility, and

body composition. Mental health refers to people's cognitive and emotional well-being.

According to WHO, mental health is "a state of well-being in which the individual realizes his

or her own abilities, can cope with the normal stresses of life, can work productively and

fruitfully, and is able to make a contribution to his or her community" (Nordqvist, 2015).

Health promotion enables people to increase control over their own health. It covers a

wide range of social and environmental interventions that are designed to benefit and protect

individual people’s health and quality of life by addressing and preventing the root causes of

ill health, not just focusing on treatment and cure (World Health Organization, 2016).

There are 3 key elements of health promotion:

1. Good governance for health. Health promotion requires policy makers across all

government departments to make health a central line of government policy. This

means they must factor health implications into all the decisions they take, and

prioritize policies that prevent people from becoming ill and protect them from

injuries. These policies must be supported by regulations that match private sector

incentives with public health goals. And through legislation that supports healthy

urbanization by creating walkable cities, reducing air and water pollution, enforcing

the wearing of seat belts and helmets (World Health Organization, 2016).
 2. Health literacy. People need to acquire the knowledge, skills and information to

make healthy choices. They need to have opportunities to make those choices. And

they need to be assured of an environment in which people can demand further policy

actions to further improve their health (World Health Organization, 2016).

3. Healthy cities. Cities have a key role to play in promoting good health. Strong

leadership and commitment at the municipal level is essential to healthy urban

planning and to build up preventive measures in communities and primary health care

facilities. (World Health Organization, 2016).

Health promotion includes empowering individuals and communities and implementing

larger sociopolitical interventions designed to foster health. These additional aspects of health

promotion make it possible for nurses to play a role in reforming healthcare delivery systems,

addressing the health needs of local communities, and improving the health of society overall

(Raingruber, 2017).

Adolescence is a critical life period due to hormonal– behavioral and psychosocial

changes, particularly changes in youth’s lifestyle and their health behaviors. One consequence

is that general health systems become very instable and adolescents tend to experience a

greater level of psychosomatic symptoms, anxiety, or depression, and they tend to report

lower level of subjective health status and life satisfaction. In addition, a deterioration of

psychological health is negatively related to health protecting behavior (e.g., physical activity

or healthy diet) and positively to substance use, which may lead to serious negative health

outcomes in later adult life. This is unfortunate because achieving a stable equilibrium of

protective factors could be a key factor in maintaining adolescents' health. A lower level of

health risk behaviors (binge drinking, illicit drug and sedative use, unsafe sex, and the lack of
exercise and diet control) is among the factors that are associated with adolescents who are

trying to find their meaning in life (Brassai, Piko & Steger, 2011).

The extent to which youth engage in physical activity is of great interest to health and

education professionals. Physical activity is an integral part of healthy lifestyle and has been

associated with many health benefits, including reduced risk of overweight and obesity. The

health benefits of physical activity appear to not only include physical health but also

emotional well-being. For example, children who are more physically active have higher

levels of self-esteem and healthy body image. In addition, physical activity may have benefits

on the academic performance of youth. Physical activity has been shown to increase

concentration levels in students and to have a positive effect upon children’s academic

achievement, academic readiness, and perceptual skills. There is concern that many young

people do not get enough physical activity and are missing out on the associated benefits. The

levels of physical activity begin to decline before high school and continue to drop through

the high school grade levels. The determinants of physical activity (and inactivity) among

young people have been studied to gain insight into factors that explain participation in

physical activity (Page et al, 2005).

Individual factors that can predict risk behaviors among students include parental

support on issues related to school, students’ perceptions of the school and of their peers as

agents for acquiring and altering knowledge, approaches, and behaviors, time spent with

friends, and loneliness. School level factors refer mainly to components of a health promotion

policy that includes: agenda setting, school rules, intervention, student involvement, and

parental involvement. The school system influences students by constituting a universal and

normative framework to which youth belong until the age of 18. The role of the school in
providing a formal education has been the focus of much research; however, school is also an

important framework from the health perspective and can serve as a platform for advancing

health issues, potentially affecting students' health attitudes and behaviors (Tesler, Harel-

Fisch, & Baron-Epel, 2016).

According to proposed models of health promotion and education, the school principal

plays a crucial role in integrating intervention programs and implementing health changes

throughout the school. Hence, the school principal's perceptions, management, and policies

have a direct effect on the development and design of a viable health-behavior culture to be

adopted by students and teachers alike. Health promotion policies in schools vary according

to the needs of the particular institution; a school may focus on bullying phenomenon,

emphasize issues of mental well-being or prioritize proper eating habits and the consumption

of healthful foods. Based on our case study of Bonnie, individual level of health approach is

essential since the adolescent is at the early stages of psychological illness. However this

individual may be integrated with environmental and social health promotion levels as well as

organizational. This is necessary so as to achieve the optimum results that will see her regain

her energy and go back to playing the dodge ball. Beginning with the individual level, will be

helpful in understanding the personal state of Bonnie. This will help in evaluating the best

strategies to approach her case (Tesler, Harel-Fisch, & Baron-Epel, 2016).

Prevention requires a paradigm shift from traditional disease models, in which

symptoms are treated when they emerge, to a proactive focus on mental health and on

maximizing protective factors while reducing risk factors for mental illness. In our case, we

will focus on depression prevention efforts that aim to promote mental health and prevent the

onset of depressive disorder in adolescents (Gladstone, Beardslee & O’Connor, 2011).

 Adolescent depression is a prevalent and disabling condition resulting in emotional

suffering and social and educational dysfunction. The SMART objective of this article is to

care for Bonnie’s depression situation. This situation is suboptimal and could be improved

through the development and use of quality indicators

In understanding and tackling the case of Bonnie presented above, you will need

several health promotion activities to be incorporated in the depression control approaches.

First, Bonnie’s parents need to stay aware of her functioning. Implementing preventive

interventions in schools is suitable for several reasons. First, depression in children and

adolescents is an important problem from a public health perspective: the prevalence of

depression is estimated at 2.5% in children and 8.3% in adolescents with high recurrent rates,

often leads to poor psychosocial and academic outcomes, and is associated with an increased

risk for other mental disorders. Furthermore, clinically relevant depressive symptoms

(subthreshold symptoms) that do not meet criteria for major depressive disorders are found in

up to 30% of the adolescent (Cuijpers et al., 2014).

The hallmarks of teenage depression are changes in function getting unusually poor

grades, discontinuing activities that have always been enjoyed, or avoiding friends. “You also

want to look for certain persistent situations. If you see a depressed mood or a sad or irritable

teen for a day or two, that’s probably okay, but if that kind of sign or symptom occurs with

sleep problems, eating problems, or fatigue, and it persists nearly every day for a few weeks,

that’s when you want to seek professional help. This might involve booking consultation

services with a psychiatrist. However, most teenagers view therapy as uncool, so they are

unlikely to seek out treatment for teenage depression on their own (Vann, 2010).
 Psychotherapy, also called psychological counseling or talk therapy, is a general term

for treating depression by talking about depression and related issues with a mental health

provider. Different types of psychotherapy can be effective for depression, such as cognitive

behavioral therapy or interpersonal therapy. Psychotherapy may be done one-on-one, with

family members or in a group. Through regular sessions, your teen can: learn about the causes

of depression, learn how to identify and make changes in unhealthy behaviors or thoughts,

explore relationships and experiences, find better ways to cope and solve problems, set

realistic goals, regain a sense of happiness and control, help ease depression symptoms such

as hopelessness and anger and adjust to a crisis or other current difficulty (Mayo Clinic Staff,

2016).

Unfortunately, there's no specific diet that's been proven to relieve depression. Still,

while certain eating plans or foods may not ease your symptoms or put you instantly in a

better mood, a healthy diet may help as part of your overall treatment. Our bodies normally

make molecules called free radicals, but these can lead to cell damage, aging, and other

problems. Carbohydrates are linked to the mood-boosting brain chemical, serotonin. For

Bonnie, there is need to choose her carbs wisely. Limit her from taking sugary foods and opt

for smart or “complex” carbs (such as whole grains) rather than simple carbs (such as cakes

and cookies). Fruits, vegetables, and legumes also have healthy carbs and fiber. Foods like

turkey, tuna, and chicken have an amino acid called tryptophan, which may help her make

serotonin. Let her eat something with protein several times a day, especially when she needs

to clear her mind and boost her energy (Goldberg, 2016.)

Exercise is the most important place to start. Numerous well-designed studies have

found exercise to be effective in elevating mood and reducing symptoms of depression. As for
anxiety, many research studies have also found an improvement in anxiety symptoms with

increased physical activity, especially mindful movement, such as yoga, tai chi, and qigong.

Exercise stimulates the body to produce serotonin and endorphins, which are chemicals in the

brain (neurotransmitters) that alleviate depression. But that only partially explains the positive

impacts of exercise on depression. Participating in various activities such as dodge ball as she

used to will help her: increase self-esteem, boost self-confidence, create a sense of

empowerment and enhance social connections and relationships (Lawson and Towey, 2015).

Lastly, Teenagers tend to go to sleep later and get less sleep than other age groups,

and given the featured research, this could potentially be playing a role in their risk of mood

problems, including depression. Teenagers with positive and social friends, who were active

in their school communities and who cared about their school performance got more sleep

each night.8 Those with more involved parents also had better sleep habits at night. In

general, social relational factors outperform developmental factors in determining youths'

sleep patterns, particularly pointing to the importance of parental, peer, and school ties in

promoting healthy sleep behaviors (Mercola, 2013).

The Penn Resiliency Program (PRP) was developed in 1990 by a group of researchers

at the University of Pennsylvania. The goals of PRP are to prevent and reduce depressive

symptoms by building resilience, teaching effective problem solving, and promoting

optimistic thinking and adaptive coping skills. These goals are accomplished with PRP’s

manual-based curriculum consisting of 12 90-minute sessions designed for girls and boys

ages 10-14 and delivered in groups of about 10-12 youth (Gillham et al, 2012).

The content of the program consists of two modules: cognitive-behavioral and social

problem solving. Participants are taught how their negative beliefs affect their emotions and
behavior. They learn cognitive restructuring techniques that help them to identify their

negative beliefs and to challenge them by examining the evidence, thus building their

capacity to more accurately evaluate situations. Participants also learn effective coping

mechanisms and techniques for decision-making, assertiveness, negotiation, and relaxation.

These skills are introduced and practiced through skits, group discussions and activities,

hypothetical examples, cartoons, stories, games, and worksheets. In addition, the youth are

encouraged to do brief homework assignments and write journal reflections between sessions

(Gillham et al, 2012).

PRP is designed to be school-based and is most often implemented as an after school

program or during regular school time. However, the program can also be implemented in a

primary care setting. The program serves both as a universal (targeting a whole population)

and as a secondary/indicated (targeting high-risk youth) intervention. Program facilitators

includes PRP developers and other members of the research team, including graduate and

post-graduate psychology students, as well as school personnel and experiences mental health

practitioners who receives intensive training in the approach and ongoing supervision

(Gillham et al, 2012).

Child and adolescent psychiatry deals with individuals undergoing rapid

developmental change in physical, cognitive, affective, communicative, and interpersonal

spheres. All children deserve respect for their autonomy rights, but young and older youths

exist at very different stages of maturation. Thus, it can safely be assumed that the average

16-year-old, because of a less developed intellectual apparatus, has far less of an inkling of

the ultimate consequences of his behaviors on his near- and intermediate-term future than

does the 19-year-old. Second, it is likely that parents are better able to exert authority over
their young school-aged children than they can over their teenagers, who are physically

bigger and often more self-sufficient and semiautonomous. Therefore, apparently similar

clinical situations demand that CAPs tailor their techniques to different degrees of

developmental attainments (Sondheimer, 2010).

However, from the legal perspective (as distinct from the ethical), similar rules apply

to all children up to age 18 years. Parents must consent to treatment; children may assent or

dissent. When guardian and child agree, care can proceed smoothly; when they disagree,

resorting to fundamental ethical considerations is required. Because safety of the child is

paramount (beneficence and nonmaleficence principles), guardian and/or child opposition to

psychiatric intervention is disregarded in the event of imminent danger. When, as illustrated

above, parents’ consent and children dissent, these same principles are used as a basis for

reasoning, but because of developmental dissimilarities they will be applied differently (the

justice principle) (Sondheimer, 2010).

Thus in the case of Bonnie, the exercise of parental will is sufficient to result in her

attendance. By contrast, in the case of the older youths, it is far better for the CAP to suggest

an initial visit alone by the child’s parent, both to discuss the presenting complaint and its

context and to explore legitimate approaches that may help turn the 16-year-old from

opposition to direct discussion with the psychiatrist to agreement. As well, the parent’s

capacity to create a firm structure for the child should undoubtedly receive attention.

Confidentiality is a frequent concern in work with children, because guardians (be they

individuals or agencies) commonly initiate care for the youngsters. The guardians legitimately

expect feedback from the child psychiatrist if only to attempt improved care for the children

(Sondheimer, 2010).
 During the initial evaluation of new patients, the physician should ask about a history

of psychiatric disorders. The patient should be asked about a history of suicidal ideation and

suicide attempts. Similarly, all new patients should be screened for alcohol abuse using the

CAGE questionnaire. A brief mental status examination should be recorded in the chart. Any

patient who shows evidence of depressed mood, anxiety or substance abuse should be asked

about recent stressors and suicidal ideation and undergo a full evaluation for the presence of

affective or anxiety disorders (Gliatto and Rai, 1999).

Assessing the effectiveness of therapeutic interventions is important for determining

which therapies are the most beneficial, and for which types of disorders and/or individuals.

Researchers who assess therapy are interested in areas such as whether or not counseling is

effective, under what conditions it is effective, and what outcomes are considered effective

such as symptom reduction, behavior change, or quality-of-life improvement (Boundless,

2016).

When assessing the effectiveness of therapy, researchers often rely on mixed-method

designs, which means using both quantitative and qualitative designs. Unfortunately, a

number of theoretical models used in therapy, such as interviews and observations, lack

quantitative data to support their effectiveness and rely solely on qualitative data. Ideally,

therapies should use mixed methods to provide both quantitative and qualitative data. Each

type of data provides different forms of information, together providing a fuller evaluation of

the therapy (Boundless, 2016).

Quantitative methods include randomly controlled clinical trials, correlational studies

over the course of counseling, and laboratory studies about specific counseling processes and

outcome variables. One way of gathering quantitative data is through the use of inventories.
These types of inventories can be given at the beginning of treatment when a client enters

therapy and then again at some point near the end. The differences in scores can then be

examined to determine if the quality of life has improved, if the distressing symptoms have

decreased, and other factors that indicate the effectiveness of the therapeutic approach

(Boundless, 2016).

Qualitative methods may involve conducting, transcribing, and coding interviews;

transcribing and/or coding therapy sessions; analyzing single counseling sessions or

counselling cases; or using observations made and reported by the therapist. Qualitative data

can provide subjective information that cannot be measured or effectively captured by

quantitative methods. Many psychotherapists believe that the nuances of psychotherapy

cannot be captured by quantitative, questionnaire-style observation, and prefer to rely on their

own qualitative clinical experiences and conceptual arguments to support the type of

treatment they practice (Boundless, 2016).

In conclusion, different researchers have found out that some finding used in previous

researchers are biased since psychotherapies appear to help depressed youths for the short

term, but are no longer significantly favorable at 6-month follow-up. If a youth follows the

assigned procedure for treatment they can be cured and go back to their normal lives.
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