Development of new psychometric instruments to measure appearance distress during 1 adolescence: the Adolescent Appearance Distress Scales 2

Measures of adolescent appearance distress have focused on weight and body shape, excluding other aspects of appearance. The absence of a psychometrically sound, general measure of appearance distress has limited evaluation of interventions and curtailed investigation of psychological processes in adolescent appearance adjustment. This paper describes the development of scales assessing adolescent appearance distress to address this dearth of appropriate measures, validated through cross-sectional

design involving 617 adolescents. Two scales were developed, comprising 13 items for 26 younger adolescents and 17 items for older adolescents. Two similar factors were generated 27 for each scale, "fear of negative appearance evaluation" and "salience and investment in 28 appearance." A third factor was identified for older adolescents, "social appearance 29 comparison." Sound psychometric properties were demonstrated. 30

Introduction 33
Physical appearance is a key component of body image and a core feature of identity, 34 communicating to the self and others aspects of health, sexuality, ethnicity and social 35 acceptability. It is no surprise that in studies of adults, self-consciousness of physical 36 appearance (appearance distress) is widespread in both the visibly different ("disfigured") 37 and normative populations (Carr, Harris, & James, 2000). What is less well understood, in 38 part due to inadequacy of current measurement tools, is the extent to which appearance 39 distress impacts on adolescence, and the effectiveness of interventions aimed at ameliorating 40 adolescent appearance distress. This paper seeks to demonstrate the development of age 41 appropriate, theoretically grounded, user-informed measurement scales to support research 42 that addresses this gap in our understanding. 43 From the point of view of socio-cultural theory, a fundamental cause of appearance 44 distress in both adults and in adolescents is the incongruity between reality and unrealistic 45 cultural appearance ideals. Appearance ideals become internalized as personal standard for 46 success (Cafri, et al, 2005). Saturated media coverage of idealized images ensures that an 47 awareness of the Western cultural ideal for men (muscular, low fat, "triangular" shape) and 48 women (an "ideal" standard of being thin, long haired, larger breasted, longer legged) is 49 unavoidable. It is important however to recognize that the specific content of these 50 appearance stereotypes is somewhat culturally determined (cf., for example, Anderson-Fye, 51 2009). Neither set of male or female ideals represent a healthy, or normally attainable 52 appearance. However, a powerful feminist critique has argued that the position for girls and 53 women is even more problematic than for boys and men. These appearance stereotypes have 54 been argues to fulfill particular social functions in relation to women -to "dissipate their 55 emotional and cultural resources, and reduce them to sex objects" (Forbes, Collinsworth, feminine, a personal and social imperative, paramount among her qualities, and requiring 58 substantial modification from natural appearance (Scott, 1997). From a psychological 59 perspective, women have been shown to be more invested in their appearance, more 60 dissatisfied with their appearance, and the subject of pervasive scrutiny from men and other 61 women (Cash, Ancis and Strachan, 1997). This becomes increasingly problematic for 62 adolescents. As they move through puberty and into teenage years, female adolescents in 63 particular will be increasingly aware of and subject to the external social expectations of what 64 it is to negotiate a sexualized, appearance based identity. Thus we suggest that they are at 65 increased risk of developing unhealthy beliefs, emotions and behaviors in relation to their 66 own bodies and appearances. Adolescents are forced to engage with a youth culture which 67 highly values appearance related attributes in a way far less prevalent for children 68 Although it is clear that from at least the age of five, children internalize appearance 70 stereotypes such as "what is beautiful is good", the evidence from developmental 71 perspectives (Harter, 2006) suggests that during adolescence that the internalization of an 72 appearance based identity plays a greater role in the self-concept. Adolescence is often cited 73 as a time of great distress about appearance, and characterized by numerous personal and 74 interpersonal transitions. In particular, the change in the perception of one's self, and the 75 terms under which one evaluates the self, are in flux (Abbott & Barber, 2010;Harter, 2012). 76 of creating aspects of the self that are based on internalized appearance stereotypes prevalent 83 in their wider social environment. At this stage also, adolescents develop an increased 84 preoccupation with the reflected appraisals of others (Rosenberg, 1986), and an increasingly 85 exaggerated sense of being subject to attention or scrutiny from others. We therefore argue 86 that the development of a conception of the self that relies heavily on appearance stereotypes, 87 in tandem with an unsophisticated and exaggerated perception of others' attention, places 88 adolescents at greater risk of negative appearance self-evaluation. 89 By mid-adolescence, there is an increased awareness of conflict between different 90 aspects of the self, but without any developed means of reconciling them. In particular, 91 differences between the actual and ideal self (including actual and ideal appearance) becomes 92 salient, and can elicit difficulty. This is particularly the case for girls, and for appearance 93 based self-discrepancies (Harter, 1998). 94 During older adolescence the ability to shift to an internally driven rather than 95 externally driven locus of self-knowledge is developed. At this stage there is somewhat less 96 reliance on external perspectives of the self for self-knowledge. There is also a greater ability 97 to reconcile conflicting aspects of the self, such as the actual and ideal versions of the self. 98 However, in conflict with this positive trend (for young women particularly) the demands of 99 impossible cultural standards become an increasingly ubiquitous presence, and therefore the 100 consequences of being unable to attain these ideals are potentially more detrimental. 101 Given these developmental changes, we argue that it is sensible to consider 102 adolescence not as a single life stage but as reflecting a process in which the requirements of 103 a prescriptive appearance based society may manifest differently at different ages. Currently, 104 there are no appropriate measures that have been developed and thoroughly evaluated which 105 aim to identify appearance distress in an adolescent population. To this end, we considered 106 two samples, younger and older adolescents. The division between these groups was set at aged 15 years, at a point of transition from younger and middle adolescence to later 108

adolescence. 109
Appearance-related distress has often been treated as synonymous with body image 110 dissatisfaction, which in turn is interpreted as dissatisfaction with over/underweight. This 111 work has been vital in understanding the emotional distress and related disordered eating 112 which are both associated with poor body image (Stice, 2003). However, for some 113 adolescents, weight is not the central focus of their appearance distress. In particular, the 114 quality and texture of skin, the size/shape of physical features such as nose, ears, and mouth, 115 the presence of scarring or other physical reminders of trauma or medical intervention can all 116 be cause for distress (Fox, Rumsey and Morris, 2007). 117 Existing measures of this non-weight based appearance distress in adolescents are 118 only available as a subscale within measures that are measuring multiple domains. There is a 119 dearth of psychometric tests to assess other appearance distress in young people (Rumsey & 120 Harcourt, 2007;Smolak, 2004). The lack of either theoretical integration or measurement 121 tools in adolescent health science across different disciplines makes it difficult to identify 122 common and idiosyncratic predictors and interventions for appearance-related distress. 123 Perhaps the most widely used measure in this field for adolescents at present is the 124 Body Esteem Scale (BES; Mendelson, Mendelson, & White, 2001). This includes the most 125 explicit measure of general appearance distress and has the advantage of being 126 psychometrically valid and age-appropriate. However, the principal focus of the BES is still 127 on weight related issues, and the interaction between weight concern, general appearance and 128 other psychological constructs. To use the BES in both general and visibly different 129 populations would necessitate using it collectively with other measurements such as social 130 anxiety, perceived stigmatization, and a more detailed investigation of the role that social 131 experience has on the development of appearance self-consciousness. This may then provide 132 an adequate bank of measures but raises both theoretical and practical challenges for 133 researchers that would be overcome if a single scale were available. Other scales related to 134 well-being specifically developed for use with adolescents typically measure constructs such 135 as general self-esteem (for example, Rosenberg Self-Esteem Scale (Rosenberg, 1965) and 136 the Piers-Harris Children's Self-Concept Scale (Piers, 1969) but do not include items 137 designed to detect general appearance concerns. This lack of appearance specific measures 138 has led researchers to use other more generic indicators of psychosocial well-being to 139 measure general appearance concerns or instead measure general self-esteem, and thus 140 reduce the sensitivity and power of experimental designs. 141 The lack of general appearance scales available for those younger than 18 years old, 142 pragmatically informed our development of two scales for adolescents aged 11 to 15 and 16 143 to 18 years old. In recognition that adolescence is not a homogenous life stage, we sought to 144 develop separate scales taking into account the psychological, physiological, and social 145 differences between early/middle and later adolescence. 146 Therefore the current study aimed to: 147 1. Develop a psychometrically robust measure to assess appearance distress in 148 adolescent populations. 149 2. To identify variation in the structure of appearance distress between early/middle and 150 later adolescence. 3.02; 49.6% female). Sixty seven percent of the sample were living with both parents, 28% 159 with their mother only, 3% with their father only, and 2% reported other/preferred not to say. 160 Reported ethnicity was 90.9%White, 1.1% ,Black African or Caribbean, 0.6%, Bangladeshi, 161 Indian or Pakistani, 0.2% Chinese and 7.2% other.. Four potential participants declined to take part (three < 15 years old, one aged > 16), and 173 were not required to provide a reason; representing a participation rate over 99%. The 174 response rate and recruitment of entire classes ensured that those participating were 175 representative of each entire school. 176

Materials 177
Development of the Adolescent Appearance Distress Scale. Our methodological 178 epistemology was iterative, with close attention paid to face validity. The initial item pool 179 was generated through multiple convergent methods (cf. Streiner and Norman, 2008). Three 180 sources of data were used for the item pool generation. The first was by expert consensus. 181 Experts were an internationally renowned team of academics and clinicians who conduct research with and deliver interventions to young people with appearance distresss and 183 clinicians based in a university Centre for Appearance Research, with many years of 184 experience publishing and/or working face-to-face in appearance psychology with adults 185 and adolescents. A literature search was also conducted to identify any gaps in academic 186 knowledge, using "appearance" and its synonyms combined with "adolescence" and its reconstructive surgery settings). Items were not therefore gender or condition specific. 202 Following initial item pool development a user-involvement event, led by experienced 203 researchers, was held to refine and test the acceptability of the items. Thirty adolescents from 204 a different school but who were representative of the study sample, gave feedback. Items 205 were removed or added to the item pool, and where necessary language was amended and 206 items were clarified. Participants also advised which response format they preferred and as a 207 consequence a "not sure" category was added. 208 Based on expert and user input, the preliminary Adolescent Appearance Distress items. The response format was a 6-point likert scale ("very unlike me", to "very like me"). 212

Social Anxiety Scale for Children -Revised (SASC-R; La Greca & Stone, 1993). 214
SASC-R is an 18-item self-report measure with three subscales: Fear of negative evaluation, 215 social avoidance and distress in new situations, and generalized social avoidance and distress. 216 The authors report Cronbach's α = .78. 217

Body-Esteem Scale (BES; Mendelson, Mendelson, & White, 2001). The BES is a 218
23 item self-report measure that assesses participants' attitudes and feelings about their 219 bodies and appearance. The instrument contains three subscales: BE-Weight (weight 220 satisfaction), BE-Appearance (general feelings about appearance), and BE-Attribution 221 (judgment from others about appearance). The authors report Cronbach's α = .89. 222

Brief Fear of Negative Evaluation scale (FNEB; Leary, 1983). The FNEB was 223
included for 16-18 year olds. The scale contains 12 items, and assesses social-evaluative 224 anxiety (e.g., distress, avoidance, expectations). The FNEB was specifically developed for 225 use in those aged >16 years old and was therefore not suitable for the younger participants. 226 The authors report Cronbach's α = .90. 227 We hypothesized that the SASC-R and FNEB would correlate positively with the 228 In agreement with the participating schools, consent was either passive (opt-out) or 231 active (opt-in) depending on age. As the study was considered to pose minimal risk to well-232 being (by both adolescents in the PPI event and by senior teaching staff at the participating 233 schools), opt-out parental consent was implemented for participants aged 11-15 years old. Bartlett's test of sphericity indicated no problem with sphericity of the data (χ² = 2127.7, df = 264 91, p<.001). Two components with eigenvalues >1 were observed. A scree plot of 265 eigenvalues also showed a clear "elbow" at this point, therefore a two component solution 266 was the best fit for the data. Component one was defined as "fear of negative appearance 267 evaluation" and component two as "salience and investment". 268 Only items loaded at >.5 on either of the components (Matsunaga, 2010) were 269 retained, resulting in 13 items, Table 1.  Demographic factors. There was no significant correlation between age and 291 AADS-Y scores (r =.07, p =.26). As would be expected, there was a highly statistically 292 significant difference between the scores of males and females. The mean score for boys was 293 37.1 (SD = 12.5), significantly lower than the mean score for girls, 54.4 (SD = 11.2), t (336) 294 = 12.6, p < .001. 295

Adolescent Appearance Distress Scale-Older 296
Cases with >10% missing data were removed (n = 39), resulting in a sample of 258 297 Demographic factors. There was no significant correlation between age and AADS-332 0 scores (r=.07, p=.248). There was a highly statistically significant difference between the 333 scores of males and females. The mean score for boys was 48.1 (SD = 14.5), whilst the mean 334 score for girls, 60.1 (SD=17.2), t (217) =5.54, p < .001. 335 Readability. The final items in each scale were assessed for readability to reflect the 336 appropriate reading level, using the Flesch-Kincaid Ease in Microsoft Word. The overall 337 reading ease score for the younger version was 89 ("very easy") and for the older version 77 338 ("fairly easy") and therefore both were suitable for their target ages. factors for each scale, "fear of negative appearance evaluation" and "salience and investment 344 in appearance". In addition, the scale for older adolescents generated a third factor, "social 345 appearance comparison." As has been frequently observed elsewhere there was a significant 346 difference by gender on levels of appearance distress, with girls scoring higher than boys in 347 both age groups (Feragen, Kvalem, Rumsey, & Borge, 2010). As far as we are aware, the 348 AADS-Y and the AADS-O are the first to measure appearance distress and self-349 consciousness specifically for adolescents outside weight and shape dissatisfaction. items that characterize this factor placed social gaze, and the resultant fear of being judged 353 negatively, at its core. Within this factor, the AADS-O includes three items that tap distress 354 and uncertainty around sexual attractiveness that are not included in the AADS-Y. 355 Within the "salience and investment" construct, principal component analysis 356 revealed not only the focus on appearance (salience) but also utilization of strategies adopted 357 to alter appearance (investment). "Social comparison" the third factor that is only present in 358 the AADS-O -was "social comparison." This suggests a developmental shift in the older age 359 group, reflecting how older adolescents may place and assess themselves in a social context, 360 as their social comparison skills become progressively more advanced with age (Harter, 361 2012). Therefore social comparison information becomes more salient as adolescents make 362 more frequent use of others as their reference point for social desirability. 363 Differences in the items that represented the same factor in younger and older age 364 groups corroborates how appearance distress may manifest in distinctive ways for different 365 stages of adolescence, this further justifies the need for age specific scales. An constructs that may underpin adjustment to appearance difference across diagnostically 382 distinct appearance-altering conditions. The AADS may then provide a psychometrically 383 valid scale that would enable multiple or rare conditions to be studied concurrently. 384 Limitations of this study include the pragmatic use of chronological age as a cut-off 385 for developmental stage. Age is a somewhat blunt instrument for defining developmental 386 stage and cannot take into account early and late maturation, which are of particular 387 relevance in appearance distress (Rogol, Clark, & Roemmich, 2000