Experiences of appearance conversations among young people living with a visible difference.

Stigmatisation surrounding having a visible difference to the face or body may have a marked impact on how young people communicate about appearance. The aim of our study was therefore to explore the experiences of appearance conversations among young people living with a visible difference. Interviews were conducted with 32 young people (mean age 14.1 years; 67.7% girls), with a condition resulting in a visible difference (e.g., craniofacial condition or scarring). Using reflexive thematic analysis, we identified three themes. Importance of Safety and Understanding reflects the importance of feeling safe in order to be able to talk about appearance. Participants described appearance conversations as often originating in their need for emotional support or practical assistance when encountering difficulties (Conversations When in Need of Support), but appearance was also experienced as a sensitive topic that was difficult to talk about (Avoiding Appearance Conversations). Our results highlight the importance of creating spaces where young people with a visible difference feel safe to bring up the topic of appearance when in need of support. Elements that facilitate such conversations include others having knowledge about the condition and having one's feelings and experiences validated instead of minimised.

Predictors of Adolescents' Response to a Web-Based Intervention to Improve Psychosocial Adjustment to Having an Appearance-Affecting Condition (Young Person's Face IT): Prospective Study.

BACKGROUND: Adolescents with a condition affecting their appearance that results in a visible difference can be at risk of psychosocial distress and impaired adjustment. Evidence for the effectiveness of existing interventions in improving psychosocial outcomes is limited, and relevant treatment can be difficult to access. Young Person's Face IT (YPF), a self-guided web-based intervention, has demonstrated potential in reducing social anxiety in adolescents with a visible difference. However, more knowledge is needed about the variables that contribute to variations in intervention effects to identify those who may benefit most from YPF. OBJECTIVE: This study aimed to investigate demographic, psychosocial, and intervention-related variables as predictors of overall intervention effects after adolescents' use of YPF. METHODS: We used longitudinal data collected as part of a larger, ongoing mixed methods project and randomized controlled trial (ClinicalTrials.gov NCT03165331) investigating the effectiveness of the Norwegian version of YPF. Participants were 71 adolescents (mean age 13.98, SD 1.74 years; range 11-18 years; 43/71, 61% girls) with a wide range of visible differences. The adolescents completed primary (body esteem and social anxiety symptoms) and secondary (perceived stigmatization, life disengagement, and self-rated health satisfaction) outcome measures at baseline and postintervention measurement. The predictor variables were demographic (age and gender), psychosocial (frequency of teasing experiences related to aspects of the body and appearance as well as depressive and anxiety symptoms), and intervention-related (time spent on YPF) variables. RESULTS: Two-thirds (47/71, 66%) of the adolescents completed all YPF sessions and spent an average of 265 (SD 125) minutes on the intervention. Backward multiple regression analyses with a 2-tailed P-value threshold of .20 revealed that several variables were retained in the final models and predicted postintervention outcome changes. Body esteem was predicted by age (P=.14) and frequency of teasing experiences (P=.09). Social anxiety symptoms were predicted by gender (P=.12), frequency of teasing experiences (P=.03), depressive and anxiety symptoms (P=.08), and time spent on YPF (P=.06). Perceived stigmatization was predicted by age (P=.09), gender (P=.09), frequency of teasing experiences (P=.19), and depressive and anxiety symptoms (P=.06). Life disengagement was predicted by gender (P=.03), depressive and anxiety symptoms (P=.001), and time spent on YPF (P=.14). Self-rated health satisfaction was predicted by age (P=.008). However, the results were limited by relatively low explained postintervention variance, ranging from 1.6% to 24.1%. CONCLUSIONS: This study suggests that adolescent boys, adolescents who experience higher levels of psychosocial distress related to their visible difference, and adolescents who spend sufficient time on YPF may obtain better overall intervention effects.

Cost-effectiveness analysis of a psychosocial web-based intervention for adolescents distressed by a visible difference: Results from a randomized controlled trial in Norway.

Adolescents with a visible difference to the face or body (e.g., due to a congenital condition, illness, or injury), may be at risk of elevated psychological distress. Young Person's Face IT (YPF), a web-based psychosocial intervention, has displayed effectiveness, but no previous study has specifically evaluated its cost-effectiveness. The aim of our study was to investigate whether YPF could be a cost-effective alternative for psychosocial support to adolescents distressed by a visible difference, relative to care-as-usual (CAU). Within the context of a randomized controlled trial in Norway, 102 participants (43% boys) were allocated to intervention (n = 55) or waiting list control group (n = 47). Mean age was 13.9 years (SD = 1.71; range 11-18), and all self-identified as experiencing distress related to a visible difference. Participants answered questionnaires including measures of health-related quality of life and social anxiety at baseline and 3-month follow-up. A health economic evaluation using the method of cost-utility analysis was performed, including quality-adjusted life-years (QALYs). Results indicated that the incremental cost-effectiveness of YPF was 63,641 Norwegian kroner per QALYs gained, which is well within the acceptability threshold in the Norwegian healthcare sector. Hence, YPF could potentially be considered a cost-effective intervention for adolescents experiencing distress related to a visible difference, but more research is needed that includes comparisons of YPF to other health- and societal resources and long-term follow-ups. Our study also constitutes an addition to research as, compared to interventions for somatic diseases, there is a lack of studies exploring the cost-effectiveness of psychological interventions.

Is it safe? Exploring positive and negative outcome changes following a web-based intervention for adolescents distressed by a visible difference (YP Face IT).

Despite the importance of making sure that psychological interventions are safe, research including both positive and negative effects of novel internet-delivered support is scarce. The aim of our study was to explore whether, and in what way, a new intervention for adolescents distressed by a visible difference (YP Face IT; YPF, Norwegian version) led to positive and/or negative outcome changes. Participants were 79 adolescents (62.00% girls; Mage = 13.84, SD = 1.73), with a visible difference. All had access to the YPF programme and answered questionnaires assessing social anxiety and body esteem pre- and post-intervention. Analyses included calculations of statistical as well as clinically significant and reliable changes. Results showed that fewer participants reported clinical levels of social anxiety and low body esteem after access to YPF. Results also indicated that participants who had a positive pre- to post-intervention change had lower levels of perceived self-worth pre-intervention, and spent more time on the intervention than those with a negative pre- to post change. Three participants showed a clinically significant negative and reliable change in social anxiety or body esteem from pre- to post-intervention. However, based on an examination of these participants' characteristics, preliminary findings support the safety of YPF.

Reducing social anxiety in adolescents distressed by a visible difference: Results from a randomised control trial of a web-based intervention.

A visible difference to the face or body may challenge adolescents' adjustment and engagement in life activities, where some require psychosocial support. However, evidence is limited for whether existing interventions for this adolescent group reduce social or appearance-related distress. We therefore conducted a parallel-group, randomised control trial to evaluate the effectiveness of Young Person's Face IT, a self-guided web-based psychosocial intervention developed for adolescents with a visible difference who experience distress. Adolescents (N = 189, aged 11-18) from two countries (Norway and the Netherlands), were randomly allocated to an intervention group or care as usual (CAU). Outcomes were body esteem, social anxiety, perceived stigmatisation, and life disengagement. Compared with CAU, participants who completed Young Person's Face IT showed reductions in social anxiety symptoms (ηp2 = 0.06). No significant improvements were found for the other outcomes. This study endorses web-based psychosocial support in reducing social anxiety in adolescents distressed by a visible difference. Future studies are needed to confirm the effectiveness of Young Person's Face IT and to explore potential long-term effects.

Adolescents and parents' perception of Young Person's Face IT: An online intervention for adolescents struggling with conditions affecting their appearance.

Objective: A visible difference in appearance caused by a congenital or acquired condition can negatively affect adolescents' psychosocial well-being. Young Person's Face IT (YPF) is an online intervention based on cognitive behavioural therapy and social skills training, developed to help adolescents who struggle with adjusting to a visible difference. The objective of the present study was to explore adolescents' and parents' perceptions of the intervention's relevance and usefulness in supporting young people with appearance-related psychosocial concerns. Methods: Participants were adolescents (N = 76, aged 11-18) and parents (N = 15), recruited in a larger randomised controlled trial aiming at evaluating YPF. This qualitative study with descriptive data includes adolescents' ratings on YPF's usefulness, and interview data from adolescents and parents on their experiences with YPF. The interviews were analysed using a thematic approach. Results: Results indicated that YPF was experienced as useful and relevant. Interviews showed that adolescents felt validated through the programme's content, discovered that other young people had similar experiences and felt that YPF could contribute to changing self-perceptions for the better. However, results could not confirm whether perceived usefulness led to the development and use of new social skills in real-life situations. Conclusion: This study offers new perspectives on the relevance and usefulness of YPF in supporting adolescents with appearance-related psychosocial concerns. Findings suggest that updates and modifications are required so that YPF stays relevant and useful for adolescents in need of support. Trial registration number: NCT03165331.

Recruiting hard-to-engage groups to online psychosocial interventions: Experiences from an RCT study targeting adolescents with a visible difference.

Online interventions have the potential to reach individuals who are otherwise difficult to engage due to stigma and sensitive topics. However, these individuals also tend to be hard to recruit in clinical trials, a crucial step in order to provide evidence-based interventions. This highlights a need for more information about efficient recruitment strategies for difficult-to-engage groups. The present study aimed to share the systematised experiences of recruiting adolescents with a visible difference to an online psychosocial intervention RCT. With the intention to recruit 160 participants (age 12-17), recruitment efforts were nationwide and included multiple arenas (e.g., hospitals, schools, social media), and methods (e.g., in-consultation, targeted letters, posters). Ultimately, 102 participants were recruited, and results showed that recruitment involving patient organisations, hospital departments, and specialised resource centres were most successful in reaching participants. The most efficient recruitment strategy was targeted letters sent home to eligible patients/members, as 78% of the participants were recruited this way. Media and social media recruitment efforts yielded comparatively few participants. No participants were recruited through schools and educational health care services, primary health care services, or municipal and regional authorities. Our results are discussed in relation to barriers with recruiting difficult-to-engage groups to RCTs, providing useful recruitment tools to future similar studies. For instance, future studies are recommended to utilise targeted approaches over general population approaches. Also, results from recruitment efforts should routinely be reported, as this ultimately will provide more general strategies for effective recruitment and support studies in reaching recruitment goals.

Translation and psychometric evaluation of the Experience of Embodiment Scale in a Swedish community sample of young women and men.

This report describes a Swedish translation and psychometric evaluation of the Experience of Embodiment Scale (EES; Piran, Teall, & Counsell, 2020), an instrument for assessing a wide range of positive and negative experiences of living in the body. A community sample (N = 545) of Swedish young women (56%) and men (Mage = 24.4; SD = 0.52) completed the Swedish translation of the EES. To explore its construct validity, participants also completed measures of body esteem, disordered eating, internalization of appearance ideals, drive for muscularity and leanness, body mass index, life satisfaction, self-esteem, and psychological distress. Exploratory factor analyses (performed separately for women and men) revealed structures of the Swedish EES similar to those displayed during the development and first evaluations of the scale in North America. However, among men, the factors of agency and sexual desire combined to form one factor. On total scale level, the Swedish EES showed good internal consistency (McDonald's ω = .95 for women; ω = .94 for men), convergent validity, and incremental validity. Overall, the present findings support the Swedish version of the EES and the EES's cross-national use to assess the construct of embodiment, as well as its use among men.

Disordered eating through the lens of positive psychology: The role of embodiment, self-esteem and identity coherence.

Applying a positive psychology perspective, this study aimed to identify potential intra-individual factors that might protect against the development of disordered eating in a community sample of young women and men (N = 510; 56 % women; Mage = 24.3). Based on existing literature, the study included the general resilience factors of self-esteem and identity coherence as well as two dimensions of positive embodiment (positive body connection and comfort, and agency and functionality). All factors were negatively correlated with disordered eating among women and men. Hierarchical regression analyses indicated that positive embodiment, specifically positive body connection, was a significant predictor of lower degrees of disordered eating symptoms in both women and men, followed by self-esteem. The overall prediction model accounted for 42.6 % in the variation of disordered eating symptoms for women and 23.9 % for men. Prevention and treatment interventions promoting health factors that protect against the development of eating disorders are much needed. The present study informs such efforts by emphasizing the promotion of positive embodiment.

"It's tough because I see that it's upsetting her ": A qualitative exploration of parents' perceptions of talking with their adolescents about having a visible difference.

Many adolescents live with a visible difference that affects their lives in profound ways, but studies investigating parents' perceptions of raising appearance issues during conversations with their adolescent are lacking. As part of a larger study exploring the effectiveness of a web-based intervention (YP Face IT), semi-structured interviews were conducted with 18 parents of adolescents with a visible difference. Thematic analysis revealed four overarching themes: (1) Conversational settings; (2) Understanding adolescents' feelings and thoughts; (3) Providing parental guidance and encouragement; and (4) When the dialogue becomes difficult. Results showed that parents resorted to specific settings when instigating conversations about appearance, such as when their adolescents expressed a need for emotional care, were perceived to be upset, or whilst managing their condition. The choice of setting was also important as some parents generally felt uncomfortable raising appearance issues with their adolescent, for fear of fueling appearance concerns. Results further suggest that open communication can enable parents to stay informed about their adolescent's psychosocial adjustment to a visible difference. These results stress the need to make available support to facilitate open communication about appearance-related topics between parents and adolescents.

Systematic review of body image measures.

This systematic review synthesizes and critically appraises measurement properties of influential body image measures. Eight measures that met the definition of an assessment of body image (i.e., an individual's cognitive or affective evaluation of their body or appearance with a positive or negative valence), and scored high on systematic expert priority ranking, were included. These measures were: the Body Appreciation Scale (original BAS and BAS-2), the Body Esteem Scale for Adolescents and Adults, the Body Shape Questionnaire, the Centre for Appearance Research Valence Scale, the Drive for Muscularity Scale, two subscales of the Eating Disorders Examination Questionnaire, one subscale of the Eating Disorder Inventory 3, and two subscales of the Multidimensional Body Relations Questionnaire. Articles assessing these scales' psychometric properties (N = 136) were evaluated for their methodological quality using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist, and a best evidence synthesis was performed. The results supported the majority of measures in terms of reliability and validity; however, suitability varied across populations, and some measurement properties were insufficiently evaluated. The measures are discussed in detail, including recommendations for their future use in research and clinical practice.

Identity and the body: Trajectories of body esteem from adolescence to emerging adulthood.

Although Erikson (1968) originally conceptualized identity development as a process of becoming at home in one's body, little work has been done linking identity development and research on the body. This study examines how trajectories of the development of body esteem over time are related to young people's sense of identity and psychological functioning in a longitudinal sample from age 10 to 24 (N = 967). Using group-based trajectory modeling, three cubic subgroups were determined for each of the three types of body esteem: appearance, weight, and attribution. These groups demonstrated significant variations in the ways in which body esteem changes over time. These trajectory groups importantly differed in relationship to gender, identity coherence, identity confusion, and psychological functioning. Results are discussed in terms of the need to use a sociocultural perspective to explore the body's relation to identity development and the importance of disaggregating mean-level findings using person-centered approaches to determine high-risk groups. (PsycINFO Database Record

"This body is me": Discovering the ways in which the body is salient in people's identities.

Although previous research has revealed associations between negative body image and identity problems, there are sound theoretical reasons to assume much greater diversity in relations between body image and identity. The aim of the present qualitative study was to explore the ways people find the body salient to their identities. Young adults (N=121; 51% women) were interviewed, and four main themes were found: identification with the body, body functionality in identity-relevant tasks, appearance and identity in social interactions, and identity-relevant bodily engagement. Both positive and negative ways in which the body is salient in identity were described and descriptions included functionality, embodied experiences, and social environments. Gender differences were not found with one exception: more women than men described experiences of identifying with their bodies. These novel results have implications for the understanding of the interconnection between body image and identity and may open avenues for continued research.

Swedish women's perceptions of and conformity to feminine norms.

The relatively high gender equality in the Swedish society is likely to exert an influence on gender role construction. Hence, the present research aimed to investigate Swedish women's perceptions of and conformity to feminine norms. A mixed methods approach with two studies was used. In Study 1, young Swedish women's gender role conformity, as measured by the Conformity to Feminine Norms Inventory 45 (CFNI-45), was compared to the results from previously published studies in Canada, the United States, and Slovakia. Overall, Swedish women displayed less conformity than their foreign counterparts, with the largest difference on the subscale Sexual fidelity. In Study 2, focus group interviews with young Swedish women added a more complex picture of feminine norms in the Swedish society. For instance the results indicated that Swedish women, while living in a society with a strong gender equality discourse, are torn between the perceived need to invest in their appearances and the risk of being viewed as non-equal when doing so. In sum, despite the fact that traditional gender roles are less pronounced in Sweden, gender role conformity is still a pressing issue. Since attending to the potential roles of feminine norms in women's lives previously has been proposed to be useful in counseling and therapeutic work, the present research also offers valuable information for both researchers and practitioners. [Correction added on 5 May 2017, after first online publication in April 2017: An incorrect Abstract was inadvertently captured in the published article and has been corrected in this current version.].

Young men's endorsement and pursuit of appearance ideals: The prospective role of appearance investment.

Appearance investment has been proposed as a risk factor for the development of body dissatisfaction. Despite this, few studies have explored men's investment in their appearance. The aim of the present study was therefore to examine appearance investment as a prospective predictor of young men's endorsement and pursuit of appearance ideals. A community sample of 187 young men participated in a study at ages 21 and 24. Hierarchical multiple regressions revealed that appearance investment, as hypothesized, was a prospective predictor of increases in leanness orientation, media-ideal internalization, and muscularity behaviors. However, appearance investment did not predict increases in muscularity dissatisfaction. The present findings highlight the importance of including appearance investment in sociocultural models of the development of men's body image, and suggest that appearance investment may be an important target variable to consider when designing body dissatisfaction prevention and intervention programs tailored to young men.

Appearance-related cyberbullying: a qualitative investigation of characteristics, content, reasons, and effects.

The aim of this study was to explore 15-year-old adolescents' experiences of appearance-related cyberbullying. Twenty-seven adolescents participated in four focus groups. The adolescents in this study perceived that it is common to be targeted in appearance-related cyberbullying, especially for girls, and that appearance-related cyberbullying is considered to be a potent strategy when attempting to hurt girls. Girls often received comments about being fat, while among boys, it was common to receive comments about looking or seeming "gay." According to the adolescents, an important reason for engaging in appearance-related cyberbullying was to attain higher social status in the peer group. The girls and boys reacted differently to appearance-related cyberbullying. Boys tended to act out or take no offence, while girls experienced lower self-esteem and feelings of depression. Findings in this study contribute to research on cyberbullying as well as to research on girls' body esteem development.