Happy Being Me in the UK: A controlled evaluation of a school-based body image intervention with pre-adolescent children

This study evaluated an adapted version of ‘Happy Being Me’, a school-based body image intervention, with girls and boys aged 10–11 years. Forty-three children participated in a three-week intervention, and 45 children formed a control group. Both groups completed measures of body satisfaction, risk factors for negative body image, eating behaviors, self-esteem, and intervention topic knowledge, at baseline, post-intervention, and 3-month follow-up. For girls, participation in the intervention resulted in significant improvements in body satisfaction, appearance-related conversations, appearance comparisons, eating behaviors and intervention topic knowledge at post-intervention, although only the change in body satisfaction was maintained. There was also a signiﬁcant decrease in internalization of cultural appearance ideals from baseline to follow-up. For boys, participation in the intervention resulted in signiﬁcant improvements in internalization and appearance comparisons at post-intervention; however, neither of these changes were sustained at follow-up. There were no improvements in the control group over time.


Introduction
Body dissatisfaction develops during childhood and typically 40-50% of 6-12 year olds report being unhappy with the way they look (Smolak, 2011).Poor body image among children and adolescents can have severe health-related implications, including reduced exercise behavior (Grogan, 2006), unhealthy eating behaviors (Tremblay & Lariviere, 2009), and mental health problems such as depression (Xie, Unger, Gallaher, Anderson Johnson, Wu, & Chu, 2010).Therefore there is a need for early intervention to reduce the onset of negative body image among young people (Neumark-Sztainer, Levine, Paxton, Smolak, Piran, & Wertheim, 2006;Paxton, 2000).In a recent British Government report, early intervention was hailed as an opportunity to "significantly improve mental and physical health, educational attainment and employment" (Allen, 2011, p. 14).
Due to their ability to reach large groups of young people from differing backgrounds and experiences, many school-based body image interventions have been evaluated, with varying levels of success (Paxton, 2002).These programs have applied a diverse range of methodologies including psycho-education (Baranowski & Hetherington, 2001), media literacy (Richardson, Paxton, & Thomson, 2009), and dissonance-based activities (Stice, Shaw, Burton, & Wade, 2006).Although some of these programs have led to improvements in thin-ideal internalization (e.g., Stice, Chase, Stormer, & Appel, 2001), disordered eating (e.g., Dalle Grave, De Luca, & Campello, 2001), and media literacy (e.g., Richardson et al., 2009); many have failed to improve body image (e.g., Dalle Grave et al., 2001;Nicolino, Martz, & Curtin, 2001;Richardson et al., 2009).Furthermore, despite evidence suggesting that body image concerns often develop in childhood (Cohane & Pope, 2001;Wood, Becker, & Thompson, 1996), the majority of school-based interventions have overlooked risk factor reduction in pre-adolescent girls and boys, focusing instead upon adolescents who may have already formed body image concerns.
Stice, Shaw, and Marti (2007) conducted a meta-analysis of eating disorder prevention programs, including those that assessed improvements in body image.They found that interventions were more successful with adolescents aged over 15 when compared to those with younger people.It was suggested that younger participants may lack the cognitive ability to participate fully in many of the existing intervention programs.However, in light of the growing evidence for the early onset of negative body image, it seems imperative to develop interventions to address these issues at an earlier age (Holt & Ricciardelli, 2008).
A comprehensive review of the literature reported that risk factors for negative body image are, in general, either related to individual attributes or external social/environmental factors.It has been proposed that a reduction in such risk factors may 'break' the developmental sequence and thus prevent the onset of negative body image in later life (Jacobi, Hayward, de Zwann, Kraemer, & Agras, 2004).

'Happy Being Me' and Risk Factors for Negative Body Image
Body image interventions can be effective in addressing body image concerns among younger adolescents in a school setting.'Happy Being Me' was designed to target specific risk factors associated with negative body image (internalization of cultural appearance ideals, appearance-related conversations, appearancerelated comparisons, and appearance-related teasing), while also incorporating a self-esteem component (Richardson & Paxton, 2010).In a previous evaluation with 12-13 year old Australian girls, results revealed a reduction in risk factors for negative body image and disordered eating behavior, an improvement in self-esteem, and an increased awareness of intervention topic; both at postintervention and 3-month follow-up (Richardson & Paxton, 2010).
Exposure to media images portraying idealized thin and muscular individuals is commonly associated with the onset of body image concerns (Levine & Murnen, 2009).In children, research has shown that negative body image can occur when an individual does not attain their desired, ideal appearance goal (Clark & Tiggemann, 2008;Jones, Vigfusfottir, & Lee, 2004).In response, it has been suggested that raising awareness of unrealistic cultural-beauty ideals (Richardson et al., 2009) and reducing internalization of such ideals may help to reduce the onset of negative body image.Evidence suggests that body ideals may differ according to gender.Typically, girls desire a thinner body; whereas boys usually wish to have a muscular physique with minimal body fat (Grogan, 2008;Lawler & Nixon, 2011).These gender-specific differences require consideration when developing intervention content for girls and boys.
Appearance-related conversations are also a risk factor for body image concerns.Adolescent girls frequently engage in appearance-related conversations with family, peers, and friends (Jones, 2004).Exposure to these conversations has been shown to increase thin-ideal internalization and body dissatisfaction (Clark & Tiggemann, 2006).Although fewer studies have investigated the impact of appearance-related conversations on boys' body image concerns, negative appearance-related conversations have been associated with an increased drive for muscularity (Jones & Crawford, 2006) and higher levels of body image dissatisfaction among adolescent boys (Jones & Crawford, 2005).
Appearance comparison, defined by Schutz, Paxton, and Wertheim (2002) as the tendency to evaluate one's appearance by comparing it with the appearance of another, has been identified as a further risk factor for negative body image.Studies conducted with girls consistently reveal an association between appearance comparison and body dissatisfaction (Keery, van den Berg, & Thompson, 2004;Mitchell, Petrie, Greenleaf, & Martin, 2012).The research on social comparisons among boys is less consistent and, in part, highlights the gender specific nature of risk factors for body image disturbance.The majority of evidence suggests that males engage in appearance comparisons and the tendency to engage in such comparisons is positively associated with muscularity dissatisfaction (Smolak & Stein, 2006).However, Jones (2004) reported that appearance comparison was not a significant predictor of muscularity-related body dissatisfaction.Research suggests that boys engage in comparisons based specifically on muscularity and these inconsistencies have been attributed in part to the measures used to operationalize constructs such as appearance comparison (McCreary & Saucier, 2009).
Appearance-related teasing from family, peers, and friends is associated with an increased likelihood of experiencing negative body image among adolescents (Helfert & Warschburger, 2011;Menzel, Schaefer, Burke, Mayhew, Brannick, & Thompson, 2010;Thompson et al., 2007).Parental and sibling teasing is a significant predictor of negative body image among adolescent girls (Keery, Boutelle, van den Berg, & Thompson, 2005).Notably, a three-year longitudinal study of boys' body dissatisfaction revealed that appearance-related teasing was the only significant risk factor for body dissatisfaction, while other outcome variables of pubertal development, body mass index (BMI), and figure management (i.e., trying to lose weight to look thinner or gain weight to look larger) were not (Barker & Galambos, 2003).
There is evidence that 'Happy Being Me' is an effective intervention and can address such factors among adolescent girls (Richardson & Paxton, 2010).However, in light of the evidence demonstrating that boys of all ages are also affected by body image concerns, it would be useful to be able to implement the intervention in mixed-sex schools.Furthermore, although the risk factors associated with the onset of negative body image appear to be broadly similar for girls and boys (Presnell, Bearman, & Stice, 2004); further exploration of gender-specific risk factors is required.The exclusion of boys from school-based body image interventions is not unique to 'Happy Being Me'.Historically, such interventions have been developed for, and conducted with, girls.In a review of primary school-based interventions by Holt and Ricciardelli (2008), only five of the 13 studies reviewed addressed programs that targeted both girls and boys.

Current Study
Given the evidence for the early onset of negative body image concerns among girls and boys, and in response to the dearth of literature investigating the effectiveness of intervention programs designed to combat body image concerns in pre-adolescent girls and boys, there is a clear need to develop school-based body image programs that are inclusive and can be implemented successfully in mixed-sex primary (i.e., elementary) schools.
To address this gap, this study aimed to evaluate an adaptation of 'Happy Being Me' among a sample of pre-adolescent girls and boys aged 10-11 years.This is the first known examination of this intervention with children of this age, and the first to include boys.It was hypothesized that girls and boys who completed the intervention would report improved body satisfaction, self-esteem and intervention topic knowledge compared to the control group.It was also hypothesized that children in the intervention group would report reduced internalization of cultural appearance ideals, appearance-related conversations, appearance comparisons, appearance-related teasing, and disordered eating tendencies compared with the control group.

Participants
Following institutional ethical approval and active informed consent from all parents and children, 88 children (46 boys, 42 girls; 100% Caucasian) aged 10-11 years from two community primary schools located in Southern England volunteered to participate in the study.A quasi-experimental design was utilized; based upon curriculum issues, teachers allocated one class of children from each school to the intervention program and one to the control condition.This design was chosen to avoid classroom disruption and to reduce potential uncontrolled differences between schools