Catherine Cook‐Cottone and Rebecca K. Vujnovic
Department of Psychology, University at Buffalo, The State University of New York, Buffalo, NY, USA
This chapter focuses on the development of the healthy and successful student with specific attention to the development of healthy eating and physical self‐care behaviors. Since the beginning of public education, school personnel have understood that in order to teach students, they must first be physically and emotionally well. It is not possible to fully achieve academic potential without a solid physical and emotional foundation to support learning. Therefore, in addition to the substantial charge of providing a strong academic education, schools must also address the physical and mental health of their students. Further, some suggest that by providing a healthy structure for physical and mental health, schools help students thrive, reaching their fullest potential in both academic and personal life. It is now well accepted that physical and mental health are deeply intertwined within a reciprocal process that either increases risk and pathology or decreases risk and promotes healing and positive development. Hence, consideration and promotion of physical health is now considered a necessary ingredient in psychological and educational interventions. With this understanding the field of health psychology has grown and along with it the notion of the healthy school (Cook‐Cottone, Tribole, & Tylka, 2013). Research showing the negative effects of stress and the role of nutrition and physical self‐care on both physical and mental health continues to grow. Accordingly, school personnel have become increasingly important in the delivery of health and health psychology interventions in schools (e.g., Cook‐Cottone et al., 2013).
The school setting is the ideal place that impacts all children, delivers effective services, and promotes change from the individual to the systemic levels in a manner that can have a positive impact on academics. Specifically in terms of health promotion, schools can help to address issues critical for enhancing resilience and health, as well as to reduce social class disparities in both physical and mental health, to enhance subjective well‐being (Cook‐Cottone et al., 2013; Shoshani & Steinmetz, 2013; Stephens, Markus, & Fryberg, 2012). A review of the literature suggests that subjective well‐being (i.e., life satisfaction, presence of positive affect, absence of negative emotional experiences, and self‐efficacy) be associated with several positive constructs, including academic achievement (Shoshani & Steinmetz, 2013). Within the school setting, models of change to promote well‐being must address both the individual student characteristics and skills, as well as the larger structural level influences, such as material resources (e.g., access to healthy food, safe places to exercise, and access to quality healthcare; Stephens et al., 2012).
Consistent with the focus on system, community, and school‐level factors in the promotion of health, the World Health Organization (WHO, 2015) defines a health‐promoting school as a school that is constantly strengthening its capacity as a health setting, within which students can live, learn, and work. This is done by fostering health and striving to provide a healthy school environment through the provision of school services, curriculum, collaborative projects within the community, and programs for mental health promotion (WHO, 2015). It is critical to engage key stakeholders (e.g., health and education officials, teachers, parents, health providers, and community leaders) in making the school a healthy place to learn (Cook‐Cottone et al., 2013; WHO, 2015). As such, schools and communities must implement policies and practices that respect individual dignity and well‐being to allow many chances for success. The school, and not simply the students or the family, is striving to improve the health of all students, families, school personnel, and community members (WHO, 2015).
Specific to eating behaviors, there are several ways that students can move toward risk and disorder. The three primary clinical disorders are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) (American Psychiatric Association [APA], 2013). Specifically, AN is marked by a strong drive for and pursuit of thinness, body dissatisfaction, disordered body image, and behavior organized around weight loss (APA, 2013; Cook‐Cottone et al., 2013). Although BN also involves dissatisfaction with the body, BN is characterized by difficulty with self‐regulation that manifests in a cyclic behavioral pattern of bingeing on food and compensatory behaviors intended to either counter the caloric intake through exercise or purging (e.g., vomiting, use of laxative; APA, 2013; Cook‐Cottone, 2015a). BED involves repeated binge episode in which the individual eats much more than typical in a discrete amount of time (APA, 2013). BED is also believed to involve difficulties with emotion and self‐regulation (Cook‐Cottone, 2015; Cook‐Cottone et al., 2013). Although not considered to be a clinical eating disorder, but directly associated with weight, obesity results from a chronic disruption of the energy balance (i.e., energy intake and energy expenditure; Cook‐Cottone et al., 2013; Loos & Bouchard, 2003). It is believed that current societal conditions (e.g., easy access to energy‐dense foods and increased sedentary activities) among Westernized cultures have led to rapid increases in obesity rates (Cook‐Cottone et al., 2013).
Although AN and BN are somewhat rare, affecting less than approximately 1–3% and 5–11% of the population, respectively (APA, 2013), rates suggest that over 20% of students may struggle at some point with clinical‐level disorders associated with eating (Cook‐Cottone et al., 2013). Further, if children and adolescents in the overweight category are included, well over half of the student population could feasibly struggle at some point with food, exercise, and self‐care (Cook‐Cottone, 2013). Thus, collectively, AN, BN, BED, and obesity affect a substantial number of children in schools.
The healthy student approach views each student within the context of his or her individual strengths and challenges and takes into account the influences of the family, school, community, and cultural supports and risk factors. The individual student behaviors are not seen in isolation; thus, the student's struggle for nutritional and physical health and stress management is not viewed as a failure of individual willpower or personal effort. Rather, the student, the school, and the community take ownership of their own responsibility to provide a healthy context from which the individual can make choices that serve their physical and mental health. Accordingly, the self is most effectively conceptualized as a self in which sociocultural context and individual physical and mental health characteristics both play a role in individual positive development, health, and self‐regulation.
More recent models of the self‐integrate physical well‐being and balance the role of cognitions and emotions and the role of sociocultural context (Cook‐Cottone, 2006, 2015a; Cook‐Cottone et al., 2013; Stephens, et al., 2012). The attuned representational model of self (Cook‐Cottone, 2006) demonstrates the role of the internal aspects of self such as cognitive, emotional, and the physical self. The physical self is viewed as a base for emotional and cognitive well‐being. For example, daily nutrition, hydration, and exercise provide a stable physiological framework for emotional stability and positive cognitive functioning. See Cook‐Cottone et al. (2013) and Cook‐Cottone (2015b) for a detailed description of the role of self‐care practices in well‐being.
When self‐care is intact, the aspects of the internal system work in an attuned manner to serve the functioning of the self within the sociocultural context (Cook‐Cottone, 2006, 2015a). Basic structural conditions present within the student's sociocultural contexts (e.g., access to healthy food, school educational practices, school resources and funding, community and larger cultural values and priorities) as well as family influences also play a role in student well‐being and performance (Cook‐Cottone, 2006; Stephens et al., 2012). These processes are viewed as reciprocal, as the student' ability to engage in active self‐care of his or her physical, emotional, and cognitive needs supports the student's ability to manage the challenges presented by sociocultural context. Conversely, the practices, supports, and tools provided within and by those in the sociocultural context (e.g., school program and practices) can enhance the students development of self‐care and self‐regulation tools (Cook‐Cottone, 2006; Cook‐Cottone et al., 2013). The self functions to witness and manage the internal aspects of self within the context of the external aspects of self. The self that presents to the world, school friend, teachers, and family members is an aggregation of the ongoing attunement or aggregated risk manifest by the ongoing dynamics within the self‐system (Cook‐Cottone, 2006; Cook‐Cottone et al., 2013). See Cook‐Cottone (2006) or Cook‐Cottone (2015) for a full description of the model.
In order to increase understanding regarding school health and well‐being promotion within the school setting, the history and foundations of the three‐tier approach to school‐based interventions are described. Next, health promotion approaches, including the promotion of healthy eating and positive mind and body relationships, will be described within the context of the three‐tier approach in schools. To illustrate the approach, mind–body and eating‐related interventions will be presented as examples of service provision within the three‐tier model.
The three‐tier model of prevention became a classification system pertinent to the field of prevention and public health, highlighting the importance of promoting and maintaining public health, rather than solely focusing on the prevention of disease (Leavell & Clark, 1953, 1958, 1965). The first tier became known as the primary prevention level, intended for the promotion of health and well‐being and to provide specific protection against onset of disease. The primary prevention level included the implementation of procedures (i.e., immunizations, genetic screening) to identify potential risk and to intercept such risk prior to infection of the disease. Subsequently, secondary prevention was intended for early detection and timely treatment to prevent infection from spreading to others or to limit prolonged disability in the individual. Finally, the tertiary level of prevention was considered for the treatment of symptoms, rehabilitation, and limitations of the consequence of the disease to prevent progression or premature death (Leavell & Clark, 1953, 1958, 1965) Since its establishment, the fields of preventative health, medicine, and the social sciences have adopted this framework, although definitions of these three categories have varied across disciplines (Machlem, 2013). By the 1990s, the field of prevention adopted the terminologies endorsed by the Institute of Medicine (IOM): universal, selective, and indicated (Strein, Kuhn‐McKearin, & Finney, 2014).
At the same time, the field of education increasingly embraced the prevention model framework for several reasons, including the increased development and research documenting the efficacy of evidence‐based interventions, the promotion of well‐being, and the increasing levels of need among students along with the recognition of the limitation of resources and cost‐effectiveness. Further, such a multitier model accommodated recommendations outlined by the National Association of School Psychologists (NASP, 2010) that recommended a ratio of one school psychologist to every 500–700 students, depending on the need within the student population (NASP, 2010). This tremendously high ratio of students to school psychologists highlights the necessity of using a prevention model for the provision of services, as direct service to treat all individuals in need of services would be impossible.
Applied within the school framework, the three‐tier model is incredibly effective for providing services to all students, especially as school personnel are frequently the first line of defense against emerging eating disorders and health problems related to obesity (Cook‐Cottone et al., 2013). The first of the three tiers is Tier 1, the universal level, and is conceptualized as the core instructional or social‐behavioral program. Tier 1 programs are research supported and aim to have an impact on the majority of students by meeting the needs of 80–90% of students. Accordingly, the majority of students, including those who may be at risk for concerns, respond sufficiently to this level of programming (Stoiber, 2014). Tier 2 is the targeted level of supports that are intended to serve a smaller group of students who require increased support to enhance the core programs at the Tier 1 level (Stoiber, 2014). Tier 3 is the intensive level and is the highest level of intensity. Tier 3 is designed to be individualized and strategically aligned with the needs of the individual student being serviced. This level is intended to be implemented for the smallest percentage of students, 1–5% of students who continue to require supports beyond those in the first two tiers (Stoiber, 2014).
Tier 1 approaches for health and well‐being promotion are interventions at the universal level. In general, they are core instructional or social‐behavioral programs that are implemented for all students within the school and likely to be sufficient in meeting the needs of the majority of students (Stoiber, 2014). There is a long‐standing history in the provision of universal programs in education that illustrate the link between physical health and learning. For example, school lunch programs were among the first interventions provided within the school setting to address a foundational health need that was notably interfering with student learning (Cook‐Cottone et al., 2013). Since first initiated, school‐based programs to promote nutrition and physical health have grown substantially. These programs have developed to include large‐scale federally funded school lunch programs, integrate physical and health education, and target all levels of well‐being support from counseling services to family support. Current implementation issues hinge on funding, challenges related to scheduling and time constraints, and finding evidence‐based programs that meet school needs.
Beyond the provision of school lunches, there is emerging evidence that universal practices designed to promote well‐being and health are effective in schools (Cook‐Cottone et al., 2013; Shoshani & Steinmetz, 2013). However, research is in the early stages; much of the evidence is based on pilot studies or short‐term controlled trials as opposed to more rigorous randomized trials. At the universal level, there is a significant need for higher‐quality research with randomized controlled trials and assessment of long‐term outcomes (Serwacki & Cook‐Cottone, 2012; Shoshani & Steinmetz, 2013). A review of available research related to universal programs has identified several key factors across programs that were believed to play a role in student well‐being at the universal level, including the cultivation of positive emotions, gratitude, and hope, goal setting, and development of character strengths (Shoshani & Steinmetz, 2013). These foci can easily be woven into daily curriculum, although some schools integrate such themes more formally through structured social emotional learning (SEL) programs. Overall research on SEL programs indicates that they result in an increase in student well‐being (Ashdown & Bernard, 2012; Durlack, Weissberg, Dynamicki, Taylor, & Schellinger, 2011). Benefits include increased emotional regulation, self‐awareness, stress management, relationship skills, and social awareness and have demonstrated an impact on learning (Ashdown & Bernard, 2012; Durlack et al., 2011). These larger‐scale, often school‐ and district‐wide approaches provide a foundational context for more specific programs that focus on healthy eating and physical health promotion.
Effective implementation of school and district‐wide interventions requires an organization around a set of principles, which facilitates communication and aligns efforts. Cook‐Cottone et al. (2013) present an approach to the healthy student, which includes three essential components: (a) intuitive eating and nutrition, (b) healthy physical activity, and (c) mindfulness, self‐care, and emotion regulation. It is important that the overall focus is on promoting health, rather than avoiding obesity (Cook‐Cottone et al., 2013). To do this schools must adopt a transcontextual approach in which adults within schools, families, and the community work together to provide a healthy environment (Cook‐Cottone et al., 2013). This approach helps the entire community “walk the walk” of healthy eating, physical exercise, and mindful self‐care. The entire school community is encouraged to embrace a focus on overall health over weight and weight loss. This community must also create a zero‐tolerance policy for teasing and bullying, especially related to weight. Additionally, students, teachers, and families should be provided with opportunities to learn about nutrition. Nutrition education should also be included in health class and other appropriate sections of the curriculum. Farm‐to‐school programs and school farm program can enhance student knowledge of food sourcing, agriculture, botany, and nutrition. Further, through collaboration between school lunch providers and food vendors, the school should provide an environment full of healthy food choices with minimal exposure to unhealthy, competing foods (i.e., foods that have little nutritional value and are offered as a purchasing option during meal times, outside of, or as part of the school meal program; Cook‐Cottone et al., 2013). Finally, opportunities for physical activity and access to water throughout the school day are also critical for supporting and promoting overall health (Cook‐Cottone et al., 2013).
One approach that can be applied at the universal level and is aligned with the positive psychology paradigm is the Health at Every Size (HAES) program. The HAES program is based on supporting a fundamental understanding of the body, suggesting that an individual is more likely to treat his or her body with respect and care, as well as provide his or her body with good nutrition and exercise, if an individual likes their body (Mukai, Kambara, & Sasaki, 2013). Research suggests that when the body is experienced with a sense of shame, an individual may be more likely to engage in self‐neglect and self‐destructive eating behaviors and is less likely to engage in physical exercise, nutrition, and self‐care (e.g., Duarte, Pinto‐Gouveia, & Ferreira, 2014). The HAES principles include (a) a respect and acceptance of the body (all body types, shapes, and sizes), (b) a focus on making physical activity enjoyable, (c) a decreased focus on food (i.e., not using food as an external reward for achievement or behavior or as a way of celebrating achievement), and (d) a decreased focus on weight and body shaming. These HAES general principles can be readily applied to the school setting (Cook‐Cottone et al., 2013). For example, there is no need to weigh students in school when they are routinely monitored by their primary healthcare provider or during their individual school physical (Cook‐Cottone et al., 2013). For some students, the school weighing day is the beginning of their eating disorder story. This policy has been criticized not only for the risk it induces but also for the frequent lack of connection with any intervention to address variations in body mass index. Finally, schools should help students focus on being present, active, and living fully in their present body no matter its shape or size (Cook‐Cottone et al., 2013). There are several programs that have been shown effective in promoting healthy eating behavior and a positive relationship with the body: Planet Health (Austin et al., 2012; Gortmaker et al., 1999), New Moves (Neumark‐Sztainer et al., 2010), Healthy Buddies (Stock et al., 2007), and Learning Gardens.
It is important to note that mindfulness and mindful self‐care strategies are also central to the healthy student approach and schools are increasingly integrating them into their daily classroom practices and social and emotional learning programs. Mindful practice and self‐care are ways of being present in your mind and body that allows for a shift from externally oriented stimuli and standards to an ongoing presence with your own experience. Specifically, mindfulness includes formal mindful practices such as meditation, yoga, and systematic relaxation, as well as an increase in mindful awareness throughout the day. For example, a student could eat lunch, practice his or her instrument, do math, and read mindfully. Although more rigorous research is needed, mindful practices, yoga, and mindful awareness are believed to reduce risk for eating disorder behavior and increase student well‐being (Cook‐Cottone et al., 2013; Greenberg & Harris, 2012; Scime & Cook‐Cottone, 2008; Serwacki & Cook‐Cottone, 2012). For an expanded review of school‐wide interventions, see Cook‐Cottone et al. (2013). Overall, within the context of honoring and respecting bodies of all shapes and sizes, the district‐wide focus is on respect for the body and the body's wisdom to know when and what to eat, healthy physical exercise, and mindful practice and self‐care.
Tier 2 approaches are targeted level supports that are intended to serve a smaller group of students who require increased support to enhance the core programs at the Tier 1 level programs (Stoiber, 2014). Tier 2 programs often target a specific risk group (e.g., elite athletes) or students already showing risk factors (e.g., dieting, body dissatisfaction) without manifesting full diagnostic criteria. There are many different types of programs that range from those that focus on physical exercise, or are solely focused on nutrition and eating or mood regulation and distress tolerance, to integrated programs that include both yoga and didactic skills training (e.g., media literacy, assertiveness, emotion regulation; see Cook‐Cottone et al. (2013) for a review of school‐based programs).
Here, two examples are provided as illustrations of a Tier 2 approach. First, Martinsen et al. (2014) designed and studied an eating disorder prevention intervention for elite high school athletes that addressed self‐confidence, motivation, growth and development, and sports nutrition as related to health, eating disorders, and performance. Results indicated that those in the intervention group showed no onset of clinical eating disorder, whereas control group members showed significant increases in eating disordered behavior. Other programs have focused on students who are referred to the intervention due to suspect increased risk. Programs such as Girls Growing in Wellness and Balance: Yoga and Life Skills to Empower use yoga, and a risk‐based curriculum can be used as a Tier 2 intervention for girls at risk for eating disorders. This program has been found, in controlled trials, to reduce body dissatisfaction, increase self‐care, and decreased drive for thinness (Cook‐Cottone, Kane, Keddie, & Haugli, 2013; Scime & Cook‐Cottone, 2008; Serwacki & Cook‐Cottone, 2012). However, there is still much work needed before there is a strong evidence base supporting a variety of Tier 2 interventions. Specifically relevant for school settings are issues such as dosage of the intervention may matter. For example, how much yoga, mindfulness, or prevention curriculum is needed to create change (Cook‐Cottone, 2013)? Notably, dissonance‐based programs in which students are led through a process of media literacy, psychoeducation on the thin ideal, activities designed to help students internalize a healthy body weight perspective and counter the thin ideal have also found to be effective (Rohde et al., 2014).
Once a student is showing symptoms of a disorder, there should be considered for a Tier 3 level of intervention. Tier 3 is the highest level of intensity and is designed to be intensive, individualized, and strategically aligned with the student's individual needs (Stoiber, 2014). Screening and assessment can help identify those students who are in need of more intensive interventions. The SCOFF is a brief five‐item screening instrument that can be very helpful. The questions are the following: (S) “Do you make yourself sick (vomit) because you feel comfortably full?” (C) “Do you worry that you have lost control over how much you eat?” (O) “Have you recently lost more than one stone (i.e., 15 pounds) in a 3‐month period?” (F) “Do you believe yourself to be fat when others say you are thin?” (F) “Would you say the food dominates your life?” (Solmi, Hatch, Hotopf, Treasure, & Micali, 2015) Other behaviors of concern include eating in the absence of hunger, emotional eating, body dissatisfaction, and distortions in or over concern with body image (Cook‐Cottone et al., 2013). For a more detailed review of screening and assessment tools for disordered eating, refer to Cook‐Cottone et al. (2013), Berg and Peterson (2013), and Palmer (2014).
Following screening and assessment, if it is determined that the student is at risk for disordered eating, a referral should be made to an eating disorder specialist. Treatment may be done either on an inpatient or outpatient basis depending on the level of symptomatology and the patient's health status (Cook‐Cottone et al., 2013). Those with clinical‐level eating disorders require comprehensive and multifaceted care (American Academy of Pediatrics [AAP], 2003). The treatment of disordered eating utilizes a multidisciplinary team that specializes in the treatment of eating issues that includes a medical doctor specializing in eating disorders, a mental health specialist, and a nutritionist (Cook‐Cottone et al., 2013). See Cook‐Cottone and Vujnovic (2015) for a review of evidence‐based interventions for children and adolescents with eating disorders.
Although treatment is likely to occur outside of the school setting, adequate support in the school setting can be a critical part of the treatment and recovery process. Support of the treatment of disordered eating can be most effectively done within the context of a prevention‐oriented school atmosphere already promoting zero tolerance of in‐school advertising, body teasing, and encouraging healthy nutritional behaviors and opportunities for positive physical activity (e.g., soccer, yoga classes, track, swimming; Cook‐Cottone et al., 2013). If a student requires hospitalization or day treatment, providing support for the student's transition back to school is vital to recovery maintenance (Manley, Rickson, & Standeven, 2000). Student needs may include supportive counseling, medical monitoring, release from physical education classes, meal monitoring, and communication with the treatment team and family (Cook‐Cottone et al., 2013). Special academic accommodations may be necessary, which include adjusted workload, alternative assignments for some physical education requirements, extended time on assignments and tests, tutoring for missed coursework, copies of class notes, and access to quiet study locations (Cook‐Cottone et al., 2013; Manley et al., 2000). Given the medical complications sometimes involved in more chronic or severe cases, the school nurse may play an important role (Cook‐Cottone et al., 2013). In‐school counseling can nicely augment outpatient treatment team efforts via relaxation work, supportive and reflective listening, and short‐term, solution‐focused or problem‐solving approaches for in‐school issues. In addition, the treatment team therapist may have specific objectives with which he or she would like supported within the school setting (Cook‐Cottone et al., 2013). Other areas of school support for those with disordered eating include supporting student during meals, alternative assignments in physical education and health classes, and flexibility and support with academic assignments and attendance (Cook‐Cottone et al., 2013).
Physical and mental health provides the foundation for student learning. Today, schools have increasing responsibility for the provision of education beyond academics and are now charged with supporting overall well‐being, not only for their students but also for families, school staff, and members of the larger community. One important deterrent to health is the increasing prevalence of eating disorders and obesity, with over half of the student population potentially struggling with food, exercise, and self‐care. Addressing well‐being and health in the school setting is best conceptualized in a three‐tier approach, focusing not on the avoidance of the disorder itself, but on providing a level of programming to all students to support health and wellness within the school community. At the Tier 1 universal level, programs target all students and are usually implemented at the larger school or district‐wide levels, focusing on healthy eating and physical health promotion. At the Tier 2 selective level, programs are intended to be implemented only to a smaller group of students and often target a specific risk group or students already showing risk factors. At this level, programming is varied and focuses on the students' needs. Thus, programs for use at Tier 2 might include those that focus on physical exercise, nutrition and eating, or mood regulation and distress tolerance. Tier 2 programs with a more broad focus integrate both yoga and didactic skills training to support well‐being. Finally, at the Tier 3 indicated level, treatment is likely to occur outside of the school setting, making coordination and support for treatment in the school setting essential. Students may require accommodations to support treatment progress and maintenance, and communication with treatment providers is important. Overall, schools provide an important setting for supporting health and well‐being in the school and community.
Catherine Cook‐Cottone, PhD, is a licensed psychologist, registered yoga teacher, professor at SUNY at Buffalo, and co‐editor in chief of Eating Disorders: The Journal of treatment and Prevention. She is founder and president of Yogis in Service, Inc., a not‐for‐profit organization. Her research specializes in embodied self‐regulation (i.e., yoga, mindfulness, and self‐care) and psychosocial disorders (e.g., eating disorders, trauma). She has written 6 books and over 60 peer‐reviewed articles and book chapters.
Rebecca K. Vujnovic, PhD, is a licensed psychologist and nationally certified school psychologist. She is director of the University at Buffalo, State University of New York School Psychology Program. She maintains a private practice specializing in youth with attention and anxiety disorders. She has authored a workbook to support the management of anxiety through mindfulness strategies anxiety and has published 4 book chapters and 12 research articles.