Introduction

Research has examined trauma and the immense impact that it can have not only on mental health, but also physical health. Trauma has been associated with long-term and substantial impact on the physical health of children, youth, and adults who experience abuse and neglect. When inflicted during childhood, trauma is considered a major risk factor for developing health problems and obesity in adulthood (Mamun et al. 2007). One of the most predominant physical health consequences of trauma is overweight and obesity (Abramovitz and Bloom 2003). Some of the mental health insults of childhood trauma, abuse, and neglect include general cognitive impairment and the development of mood, anxiety, attention-deficit hyperactive, substance-abuse, and schizophrenic symptoms and disorders (Robert Wood Johnson Foundation 2011).

A large majority of youth in residential settings have experienced trauma, which substantially influences health factors such as overweight and obesity (Abramovitz and Bloom 2003). Because of trauma, individuals can develop disordered eating behaviors which can turn into adulthood obesity (Mamun et al. 2007). Childhood adversity and stress are strongly associated with chronic medical disorders, health risk behaviors, and mental health disorders—a dangerous trifecta that can markedly impact health, quality of life, and overall well-being (Robert Wood Johnson Foundation 2011). All of these factors contribute to an increased risk for youth in residential settings to have a comorbid physical health problem such as overweight and obesity.

Trauma

Trauma can include physical, sexual, and emotional abuse, neglect, witnessing domestic violence, and events such as natural disasters or car accidents for example. Events that are considered to be traumatic are experiences that provoke intense feelings of fear, powerlessness, hopelessness, and hypervigilance or constant alertness. Trauma can also induce feelings of shame, guilt, rage, isolation, and disconnection and can have a substantial impact on interpersonal relationships (National Center for Trauma-Informed Care, Welcome to the National Center for Trauma-Informed Care, ND). As defined by the Child Trauma Academy (2002), trauma is a “psychologically distressing event that is outside the range of usual human experience, one that induces an abnormally intense and prolonged stress response”. Additionally, the American Psychological Association (APA-2010) has delineated a set of criterion used to define trauma which includes the following: (A) actual or threatened death, serious injury, other threats to one’s physical integrity, (B) witnessing an event that involves death, serious injury, a threat to the physical integrity of another person, and, (C) learning about an unexpected or violent death, serious harm, threat of death or injury experienced by a family member or other close person. Common across all definitions is that a person’s response or reaction to the experience involves intense fear, helplessness, or horror. Lastly, all definitions clearly indicate that both direct and indirect experiences can be traumatic. Indirect experiences can include witnessing or learning about a traumatic experience perpetrated to another individual other than self.

National estimates indicate that one million children are victimized per year and approximately 1,500 will die as a result of abuse or neglect (Hussey et al. 2006). From a national sample of 1,699 children, it was reported that 78 % have experienced or been exposed to multiple, prolonged, and continuous trauma assaults (National Child Traumatic Stress Network [NCTSN] 2003). Perhaps most startling, it has been reported that the rate of PTSD among foster care alumni is twice that of United States (U.S.) war veterans (Pecora et al. 2005). Unlike gender disparities noted in adult populations, such differences are more evenly distributed in child and adolescent populations. It is estimated that approximately 48 % of children that are abused are male and 52 % are female (Hussey et al. 2006).

Experiencing a traumatic event can induce a multitude of stress responses that vary depending on the type of trauma incurred. Type one trauma is often referred to as simple trauma and is characterized by a non-recurrent and unexpected event. Simple trauma can include a single incident rape, a car accident, or a natural disaster for example and typically occurs is later in life. Conversely, type two trauma which typically begins in childhood and is persistent, sustained, continuous, and ongoing. Because of the prolonged and chronic nature, type two is often referred to as complex trauma and is more likely to produce long-standing characterological and interpersonal problems. Moreover, type two trauma is more likely to result in trauma-related disorders including PTSD, dissociative disorders, and substance and alcohol use or abuse. Complex trauma is most frequently perpetrated by individuals within the caregiving system and therefore causes a great deal of ongoing distress that often persists long into adulthood (NCTSN, Types of Traumatic Stress, ND).

Trauma: Physical and Mental Health Comorbidities

Results from the Adverse Childhood Experiences (ACE) study have shown that chronic childhood stress and trauma can have a substantial effect on health. Persistent stress and the responses to such trauma can include increased heart rate, blood pressure, respiratory rate, and metabolic rate. These are all major contributors to or risk factors of heart disease, hypertension, and other serious health complications (Palaszynski and Nemeroff 2009). Trauma has been associated with increased rates of obesity, diabetes type 2, and eating disorders (Palaszynski and Nemeroff 2009). The impact of complex trauma can affect all domains of health and development including weight and BMI, and the earlier trauma begins the more serious the implications on mental and physical health. By understanding both the physical and mental health impacts of trauma, integrated and comprehensive treatment approaches can be developed for vulnerable at-risk populations with comorbid disorders. The use of health and wellness interventions in conjunction with traditional mental health interventions could prove quite effective in improving not only the physical health, but also the mental health of youth receiving services within a residential setting. Moreover, if implemented during childhood or adolescence, these interventions have the potential to quell the risk of developing serious health problems including obesity, heart disease, and diabetes.

Residential Treatment and Physical and Mental Health Comorbidities

Researchers have pointed to a large gap in research related to the increasingly high numbers of youth in residential settings with comorbid physical and mental health disorders, especially overweight and obesity. It is estimated that approximately 45–80 % of youth with mental health disorders who are living in out-of-home facilities have a physical health disorder (Altshuler and Gleeson 1999). Other estimates reported by the National Institute of Mental Health (NIMH 2009) from the National Comorbidity Survey Replication Study suggest that 45 % of individuals with a mental health disorder have one or more comorbid disorders.

Chipp et al. (2010) examined a sample of youth in a psychiatric residential unit relative to normed population samples on BMI and rates of overweight and obesity. Results from this study showed that the youth in the residential unit had approximately twice the rate of obesity and overweight (46.6 %) as compared to the general population (28.8 %). Similarly, researchers Haw and Bailey (2012) examined BMI and obesity in a sample of inpatient youth using a cross-sectional design. Results indicated that 34.7 % were overweight and 47.4 % were obese. Combined, that is 82.1 % of the youth that were in an unhealthy BMI range. Youth who are overweight or obese have an elevated risk for developing health complications such as diabetes, cardiovascular heart disease, high blood pressure, and other disorders that were once considered “adulthood” health problems (Haw and Bailey 2012).

Federal guidelines have been disseminated to provide direction in developing, implementing, and evaluating physical activity and health education programs for youth. It is recommended that adolescents participate in 60 min or more of daily physical activity consisting of aerobic, muscle strengthening, and bone strengthening activities (Health and Human Services [HHS] 2008 Physical Activity Guidelines for Americans 2008). Guidelines also issue more general statements such as that health benefits are noticeable even without strenuous activity and that any increase from inactivity is a positive change. However, activities that are greater in duration, frequency, and intensity are positively correlated with greater health (HHS, Promoting Better Health for Young People through Physical Activity and Sports 2000, p. 8).

Physical activity is supported as an effective method for improving the health of children, adolescents, and adults. However, researchers have conveyed the idea that single-focused treatments are largely ineffective for improving health and obesity for sustained periods of time (Flodmark et al. 2004). It is therefore recommended that multicomponent programs provided via multidisciplinary treatment teams be utilized to produce the most substantial and long-term impact on health. Such interventions can include mental and behavioral health therapy, psychoeducation, physiological activities, and family-based components. Family-based components are of particular importance for child and adolescent weight loss programs for a variety of reasons including: genetic factors, family support factors, and learned family health behaviors (Flodmark et al. 2004).

While physical activity, dietary behavior, school-based interventions, community-based campaigns, and other interventions designed to improve obesity in youth have been shown to be effective, the most efficacious is likely the intervention that includes multiple dimensions aimed at improving lifestyle. Research studies have examined multicomponent lifestyle interventions that target BMI, physical health, and health behaviors. Results have shown that multicomponent programs are effective in improving the health of youth and provide a basis for future research to examine the use of health and wellness interventions in clinical populations of youth with SEDs living in residential settings (Braet et al. 2004; Margarey et al. 2011; Walker et al. 2002). Lastly, the inclusion of parents in the intervention, group formatting with individualized behavioral counseling, frequent sessions with a long treatment duration, simple techniques, engaging and emphasizing choice and use of reinforcement, self-monitoring, and skills training are all shown to be beneficial in use of interventions for obese children and adolescents (Zametkin et al. 2004).

Methods

Methodological Design and Specific Aims

Using a single group pre-posttest design, the specific aim of the current study was to examine the impact of a multicomponent health and wellness group intervention on BMI and weight with adolescent females, ages 14–18 in an RTC critical care unit. It was hypothesized that the intervention would have positive effects on both the BMI and weight of the participants. More specifically, it is hypothesized that both overweight and obese youth would move toward the healthy BMI range and see a reduction in weight from pre to posttesting. Conversely, it was hypothesized that the health and wellness intervention would impact underweight youth by moving them into the healthy BMI range from pre to posttesting.

Population and Sample

Youth who are eligible for admittance to the RTC have had several unsuccessful placements prior to referral and are considered to be ‘hard to place’ youth. They have extensive histories of trauma and exhibit self-harming, self-destructive, and aggressive behaviors. Likewise, they also have a history of participating in behaviors that cause danger to self or others and have a history of suicidal tendencies. Youth in the RTC are often diagnosed with SEDs and struggle with symptoms of depression, anxiety, compulsions, phobias, and psychosis. Lastly, RTC youth can experience difficulties being safety maintained in their own home or community environment, have poor self-care and lifestyle behaviors (hygiene, eating, and dressing), display limited ability to self-direct and self-control, and have challenges with social relationships and other interactions with peers (Hillside Family of Agencies 2010). Through convenience sampling, a total sample of seven adolescent females who were receiving services in an RTC critical care program participated in the study.

RTC: Program Description

Under the umbrella of Hillside Family of Agencies, the RTC is located in a largely rural region of New York and is one of the region’s first gender-specific programs. The RTC was developed to address the unique needs of young women with significant trauma histories that have not responded well in previous, more conventional therapeutic programs. In response to a clear need to develop gender-specific programs, the critical care RTC was “Developed in collaboration with funders, parents, and young women, the RTC is one of the first gender-specific residential treatment programs in the state.” (Hillside Family of Agencies 2010) Residents of the holistic RTC program are provided a safe, stable, and structured environment that offers evidence-based treatment approaches, primarily Dialectical Behavior Therapy (DBT).

The RTC program is centered on the following goals for discharge: be safe, be ready for transition to lower level of care (less intense service needs), home, or other permanent resource, have identified medical and mental health providers for follow-up care, and have an educational plan. Additional goals of the program include decreased trauma symptoms, levels of stress, anger, self-inflicted harm, and feelings of negativity. The program is aimed at increasing positive feelings, self-confidence, support and resource systems, healthy outlets, social skills, and family and peer relationships. The RTC emphasizes that residents identify formal and informal community supports and resources to help the transition back into the community post-discharge. Lastly, residents must also be able to demonstrate all major components and skills of DBT in daily living prior to discharge.

The RTC is operated by a multi-disciplinary team that has been extensively trained in DBT, female development and women’s issues, cultural competence, human sexuality, and medical awareness. The multidisciplinary team is comprised of the following: a part-time psychiatrist and psychologist, a full-time program manager, a child care team including socio-therapists, recreation workers, a family advocate, a part-time case manager, and a medical team including a nurse, pediatrician, and dietician. The RTC offers a number of activities including, but not limited to, individual, group, and family therapy, DBT and skills groups, and sexuality and health psychoeducation. Moreover, youth in the RTC participate in journaling activities, yoga classes, nutrition and menu planning groups, community outings and service opportunities, and mindfulness and meditation activities. Target areas of the RTC are listed and defined in Table 1.

Table 1 Program target areas (Hillside Family of Agencies, 2010)
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Health and Wellness Group Intervention

The health and wellness group intervention was implemented within the critical care RTC from 2008 to 2011. Provided by an interdisciplinary team comprised of highly trained specialists (nutrition specialists, nursing, clinicians, dieticians, and physical education teachers), the intervention mission was to “Create an environment which assists the client in healthy lifestyle changes such as: diet, exercise, and wellness education in order to promote a positive lifestyle in combination with achieving a healthy weight” (Hillside Family of Agencies, personal communication, March 10, 2009). Implementation of a multicomponent intervention that targets lifestyle behavior changes requires a team with expertise in multiple areas including behavior change methods, education, psychotherapy and other mental health intervention modalities, as well as recreational and occupational therapy. The primary components of the health and wellness intervention consisted of diet, exercise or physical activity, and medication psychoeducation. To improve the health of residents, manualized protocols were developed to guide staff and youth in recommendations for physical activity and dietary behaviors. These protocols provided the framework for implementation of the health and wellness group intervention.

Meal and Snack Protocol

The primary purpose of the meal and snack protocol was to “help promote the health and well-being of our clients, staff and families by ensuring that compliance is maintained regarding healthy food choices” (Hillside Family of Agencies, personal communication, March 10, 2009). The meal and snack protocol was used to help guide staff and youth in making healthy choices when participating in both on- and off-campus activities. The protocol operationalized key behaviors and concepts to ensure that staff and youth had the same understanding of what was expected when making dietary choices. For example, a meal was operationally defined as the “food served and eaten in one setting” and a snack was defined as “any food eaten between meals”. As part of teaching healthy eating habits, portion or serving size was also defined “as an amount of food served for one person”. Lastly, the meal and snack protocol defined non-caffeinated drinks as “those that did not contain caffeine” and provided a list of such beverages. While caffeinated and high-sugar beverages were rationed, the protocol recommended unlimited water intake unless otherwise directed by the health office.

The meal and snack protocol also provided specific guidelines for off-campus activities, events, and outings. Prior to an off-campus outing where a meal would be purchased, program staff had to obtain prior approval from department supervisors and notify the kitchen staff. By notifying the supervisor and kitchen staff, it was possible to have healthy lunches prepared and bagged for youth participating in the off-campus activities. Though the protocol was designed to create a set of guidelines for meals and snacks, program staff members were instructed to observe, respect, and maintain cultural and religious sensitivity concerning food and eating behaviors.

The protocol also provided guidelines for specific portion and serving sizes that were allowable during off-campus outings. For example, youth were to choose only one item from the following list: a sandwich; a salad; two slices of pizza; two small French fries (orders); or a side dish. After choosing one item from the above, youth were also allowed to have one small dessert (for dinner only) and one small non-caffeinated drink. If dining at a restaurant, youth were able to have one entrée with a side, one small non-caffeinated drink, and one small dessert. Additionally, youth were not permitted to bring food back onto campus from off-campus visits or outings. Buffet-style meals and energy drinks were not permitted.

With regards to recreational outings and events such as movies, spectator sports, and shopping at a mall, youth were allowed to choose one snack from the following list: a small candy item; a small ice cream or frozen yogurt (can have sprinkles, cannot have sundaes or milkshakes); a small serving of popcorn, nachos, soft pretzel, or french fries; a hotdog, hamburger, or slice of pizza. In addition to a snack, youth were allowed one small non-caffeinated drink or hot cocoa. The meal and snack protocol also provided guidelines for on-campus meals and activities such as holiday parties, family gatherings, and unit cookouts. For such meals, youth were able to have one serving size per item. For example, youth were allowed to have one piece of cake for birthday parties (which counted for the allowed dessert for that day) and were also allowed to have a vegetable or fruit tray served within the school setting.

The health and wellness team also made significant changes to daily menus for on-campus meals. For instance, all milk was changed to skim, all bread products were changed to 100 % whole wheat, and ground beef products were changed to 90 % lean 10 % fat ratio. When possible, turkey substitutes were made for items such as bacon, hamburgers, and hotdogs. Serving sizes of fruits and vegetables were increased to one cup/serving per day and the serving of dessert at lunch was eliminated (only provided at dinner). Cereals high in sugar and non-nutrient fats were also eliminated from the menu options.

To improve menu options, campus recipes were developed in collaboration with the Cornell Cooperative Extension and the Healthy, Kid Approved Recipes. Furthermore, the kitchen staff sent all recipes and food labels to a dietary specialist who conducted a nutrient analysis to ensure that meals were low in fat and cholesterol, but high in fiber. Recipes that called for sour cream, creamed soups, cheese, mayonnaise, or salad dressings were modified by substituting high-fat for low-fat ingredients. Serving sizes were actively monitored and reinforced by the kitchen staff members who were responsible for portioning the meals. Of pertinence, an integral component to the health and wellness group intervention was that staff members were held responsible for role modeling. Staff members were also expected to follow the meal and snack protocol at off- and on-campus events and were held accountable through supervision. A copy of the meal and snack protocol can be found in Appendix 1.

Fitness and Activity Protocol

In addition to the meal and snack protocol, the health and wellness team developed a fitness and activity protocol designed to improve levels of physical activity at the RTC. The protocol required all youth to participate in a minimum of 60 min of physical activity for 3 out of 5 weekdays. The protocol also required limited time spent participating in sedentary activities such as watching television or playing video games. Such sedentary activities were replaced by physical activity. Physical activity was operationalized in the protocol as “any form of exercise or movement” whereas activity was defined as “involving physical effort and action”.

An activity plan was built into the youth’s recreation schedule. Treatment plans for physical activity interventions should begin with making a commitment. In other words, a contract for activities, duration, frequency, and energy expended should be collaboratively developed with a knowledgeable staff or adult. Once a contract has been developed, the next step is to examine or assess current levels of physical activity and lifestyle behaviors, which can help to identify goals that are both specific and realistic. While current behaviors are assessed and new goals are developed, it is important to assess the availability of necessary resources, information, and support systems that can be utilized to help achieve the pre-determined goals. Lastly, it is vital to monitoring progress on a continual basis via an activity log or food diary (HHS, Promoting Better Health for Young People through Physical Activity and Sports, 2000).

Once per week, youth went on an off-campus trip to the local YMCA to participate in physical activity for at least 1 h excluding travel time. Off-campus recreational and fitness activities could be restricted as a consequence of various behaviors. However, when an off-campus activity such as a trip to the YMCA was restricted, youth were still expected to participate in an alternative physical activity. In other words, restricted physical activity could not be used as a consequence for behavior, rather only the off-campus outing to the YMCA. In addition, the recreational service plan could be modified and restrictions could be placed on activity based on medical necessity with alternative activities planned and developed by both the recreational therapists and the nursing department staff. Much like the guidelines in the meal and snack protocol, the fitness and activity protocol emphasized staff accountability and role modeling of protocol guidelines at all times.

The fitness and activity protocol were informed by guidelines set forth by both the HHS and CDC. Accordingly, youth are more likely to participate in physical activity interventions if people have the freedom to choose activities. For youth populations, it is important to have competent, knowledgeable, and supportive adults that can help teach the necessary skills to participate in activities and perform them correctly, and it is also critical that cultural norms are supported when developing a physical activity intervention or treatment plan (HHS, Promoting Better Health for Young People through Physical Activity and Sports, 2000). A copy of the fitness and activity protocol can be found in Appendix 2.

Family Involvement

As indicated in research, family involvement in the treatment process is one of the most critical components to predicting the success of youth in mental health services (Frensch and Cameron 2002). One of the major components to the health and wellness group intervention was family engagement and education. For example, the RTC disseminated the Health Express newspaper to educate and inform families about healthy lifestyle behaviors including diet and activity. Families were invited to treatment council meetings, which served as another vehicle to disseminate information and education regarding the health and wellness group intervention. Treatment meetings targeted transferability of skills and behaviors so that families could practice healthy lifestyle habits at home with the youth following discharge. Finally, families received letters explaining the types of changes to the nutrition and meal planning at the RTC. The letter read: “…We are asking for your support in following this diet, and are strongly encouraging you to try implementing this diet in your homes and whenever you take your child off campus…” (Hillside Family of Agencies, Personal Communication, March 2009).

Multidimensional interventions concurrently and simultaneously include components such as psychological, physiological, and family-based factors related to health. Family-based components are critical to include in child and adolescent weight loss programs for a variety of reasons including genetics, support systems, role modeling, and learned behaviors (Flodmark et al. 2004). Family engagement and participation in interventions can also improve sustainability of outcomes over time as skills are transferred to and reinforced in the primary living environment.

Psychoeducation

In addition to the health and wellness protocols, youth participated in a healthy lifestyle and behavior psychoeducation group. Youth were educated on the recommended daily amount of physical activity, healthy portion and serving sizes, and health consequences related to poor and risky lifestyle behaviors (e.g. obesity, heart disease, diabetes). Lastly, guided by behavior change theories, behavior change strategies and techniques were taught through psychoeducation methods.

Psychoeducation is one of the primary modalities utilized in prevention interventions. Outcomes can include increased knowledge, self-esteem, self-image, and improvement in eating behaviors and physical activity. In a systematic review of health, physical activity, and dietary focused interventions, results indicate that prevention efforts produced significant improvements in knowledge from pretesting to posttesting (Holt and Ricciardelli 2008).

Resources

A variety of internal and external resources was utilized to support the implementation of the health and wellness group intervention. One major external resource was the local YMCA, which provided an opportunity for youth to participate in off-campus physical activities at least 1 time per week. Other community resources included the Live Well/Play Hard Program and Turn Off Week Initiative, which is designed to reduce or completely eliminate the use of television and other sedentary activities for at least 1 week (Healthy Children 2010). As part of a grant, the Eat Well/Play Hard Program provided resources that included free bicycle helmets, Dance USA, Wii, break dancing lessons, and jump ropes. Also under grant funding, RTC staff members were provided with training that was focused on healthy lifestyle and behaviors. Youth participated in cooking and nutrition education classes once per week as part of the grant. Education included dissemination of newsletters, presentations, classes with parents and guardians, and participation in community projects. Some examples of community projects included partaking in farmers’ markets and health fairs. To improve access and opportunities for on-campus activity, bike trails, walking paths, and gardens were built.

Data Collection and Analyses

BMI was measured by RTC staff at multiple intervals including admission and discharge. For children and adolescents, BMI is calculated using measurements of height and weight, which is then mapped onto age- and gender-specific growth charts (CDC, About BMI for Children and Teens 2011). BMI can also be reported in a variety of ways including a range or category (underweight, healthy weight, obese, or overweight; healthy/unhealthy), percentile, and a continuous number (HHS, Calculate Your Body Mass Index, ND). Table 2 lists the corresponding BMI range with BMI percentile range. Multiple studies have used the BMI to examine obesity levels among children and adolescents (Gortmaker et al. 1999; Hawley et al. 2006). Because of the small sample size and inability to determine statistical significance, descriptive statistics were used to analyze changes in BMI range and weight loss from pre to posttesting.

Table 2 Center for Disease Control: BMI-for-age weight status range and the corresponding percentiles ranges
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Results

The final sample consisted of seven females from the RTC between the ages of 14–18. The average age was 16.4 and the average length of stay was calculated at 15.57 months ranging from 8 to 20 months. Youth had anywhere between one and four different SEDs and or personality disorders. Sample demographics and diagnostic data are listed in Table 3.

Table 3 Demographic characteristics
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The results post-intervention are listed in Table 4. Compared to the 85.7 % (6/7) of females at pretesting who fell within the obese BMI range, only three individuals were in the obese range at posttesting. At posttesting, two individuals had moved into the healthy BMI range and two participants were in the overweight BMI range. Participant one was in the underweight BMI range at pretesting and moved into the healthy range at posttesting. The average weight loss, in pounds, was 7.83 pounds, with a low of two pounds lost and a high of 19 pounds lost (excludes participant number one).

Table 4 Post-intervention BMI number, range, weight loss, and triglycerides
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Discussion and Implications

Findings from this study indicate that a health and wellness group intervention is a promising intervention to improve the health of adolescents in residential settings. All participants in this analysis lost weight from pre to posttesting (with the exception of the participant who was in the underweight range at pretesting). The current study adds information to the knowledge base of interventions that can improve the health of youth living in residential settings with histories of trauma and physical health comorbidities. These initial findings provide the support to warrant a large-scale study that implements a health and wellness group in residential settings. While not a statistically strong design, this study underscores the need for future research to examine health and wellness group effects on not only physical health, but also mental, emotional, behavioral, and social health.

It is also important to consider that this type of intervention requires not only an individual change, but also and perhaps more important, a culture change. Both residents and staff in the RTC played a critical role in the health and wellness intervention. It was of utmost importance that the intervention was not solely focused on weight loss, but rather primarily focused on bolstering healthy living behaviors, positive self-perceptions, self-image, and self-esteem through role-modeling, encouragement, support, and acceptance.

Limitations

One of the primary limitations of the current study was the small sample size which limited the ability to run inferential analyses on significant differences from pre to posttesting. Larger sample sizes would not only allow for significance testing, but also for analyses to determine who the health and wellness intervention worked best for by examining potential predictor, mediating, and moderating variables. Additionally, the methodological design, or the use of a single group pre-posttest design, allowed for limited ability to infer direct causality that the intervention was solely responsible for the changes noted in BMI range and weight over time from pre to posttesting.

Future Research

Future research could benefit from conducting larger scale, methodologically stronger studies that examine health and wellness interventions Research indicates that, theoretically, the use of physical activity interventions can improve mood, affect, confidence, and social well-being (Taylor et al. 2009). Health and wellness interventions could have a substantial impact on the outcomes of vulnerable populations with comorbid disorders, histories of trauma, and SEDs. By improving overall levels of well-being, it could be hypothesized that service delivery outcomes would be improved (e.g. a shortened length of stay, less re-admissions/hospitalizations which lowers cost of care, and lower intensity services needed at time of discharge). Future research could examine if any mediating or moderating variables, such as mental health diagnoses, influence the relationship between the intervention and the outcomes of interest. Moreover, future research would benefit from not only increasing sample size, but also expanding to both genders, across age ranges, and other types of mental health service settings such as day treatment services and or outpatient services. Beyond testing for improvements in physical health, health and wellness interventions should be tested for a variety of outcomes including mental, behavioral, social, and emotional health-all components that are encompassed within overall health and well-being.