Middle school and preadolescence is a formative

Patrick Akos, Ph.D., is an assistant professor, School of Education, University of North Carolina at Chapel Hill. E-mail: akos@unc.edu. Dana Heller Levitt, Ph.D., is an assistant professor, Counseling and Higher Education, Ohio University, Athens. Promoting Healthy Body Image in Middle School Middle school and preadolescence is a formative period in development. Students in middle school, in the midst of puberty, begin to establish an individual identity outside the family unit (Berk, 1999). Vast arrays of personal and contextual changes occur simultaneously (Berk; Eccles, Lord, Roeser, Barber, & Jozefowicz, 1997). Part of personal and social development in middle school is the development and continued evolution of one s body image. Physical changes, the mounting importance of peers, and the search for identity are related developmental changes that contribute to one s body image. Physical change in middle school students is varied, as students reach puberty at different times. While boys tend to benefit from early puberty, girls who develop either early or late tend to have difficulties with the timing of physical changes and feeling good about themselves (Brooks-Gunn, Attie, Burrow, Rosso, & Warren, 1989; Faust, 1983). The increasing attention and intimacy of peers amplify physical differences that become evident as bodies change and develop. As preadolescents move away from parental influence, peers play a large role in identity formation. Physical appearance becomes a major factor in peer and opposite sex relations, and students physical development takes center stage. With the changes in physical development, the onset of puberty, peer focus, and the task of identity formation, the development of healthy body image is an important factor for middle school students (Mussell, Binford, & Fulkerson, 2000). The development of identity has not been consistently connected to physical development and body image (Massey-Stokes, 2000; Mussell et al., 2000). School counselors need to be aware of both risk (e.g., gender, low self-esteem, timing of maturation, disordered eating) and protective factors (e.g., healthy self-esteem, positive feelings about physical changes in puberty, accurate information about puberty, healthy eating and exercise patterns) to effectively address developmental issues related to body image. For example, Attie and Brooks-Gunn (1989) emphasized the need to focus developmentally because risk factors like disordered eating typically have their onset during early to middle adolescence and are related to both biological and social changes. In fact, because body dissatisfaction is the single strongest predictor of eating disorder symptomology (Archibald, Graber, & Brooks- Gunn, 1999; Franko & Omori, 1999; Leon, Fulkerson, Perry, & Cudeck, 1993), body dissatisfaction during puberty may predispose the adolescent to develop eating problems in middle to late adolescence (Attie & Brooks-Gunn, p. 76). While increasing protection and decreasing risk are not mutually exclusive (Munoz, Mrazek, & Haggerty, 1996), less research has been directed to protective factors or proactive intervention by school counselors. In some schools, the discussion of body image is often limited solely to didactic instruction from physical education and health teachers. While teachers can and do play an important role, the development of a healthy body image is a protective factor that can be promoted individually and systemically by school counselors. The purpose of this article is to integrate current literature on body image and provide school counseling interventions to promote healthy body image in middle school students. BODY IMAGE IN MIDDLE SCHOOL STUDENTS It is nearly impossible for girls to grow up in Western society today without feeling pressure to adhere to artificially determined appearance norms. Whereas puberty for males is generally more positive, the physical changes girls experience may factor into the increased prevalence among females of body dissatisfaction and weight management behaviors. Girls are generally more influenced by body image, with 28% to 55% wanting thinner bodies compared to 17% to 30% of boys (Ricciardelli & McCabe, 2001). While boys grow bigger and stronger, consistent with the cultural ideal, girls 138 ASCA PROFESSIONAL SCHOOL COUNSELING

struggle with normative weight gain that is the antithesis to the female cultural ideal (Maine, 2000). At ages 10 and 11 years, 80% of girls are convinced that they should be thinner (Friedmann, 1998). These feelings about body image often surface as behaviors that could be damaging to development. In a longitudinal study, 17.8% of 11- to 14-year-old girls reported having gone on a diet within the past 6 months, and 34.5% at the one-year follow-up indicated dieting activity within the past 12 months (Byely, Archibald, Graber, & Brooks- Gunn, 2000). Over one third of adolescent females report aggressive weight control such as chronic dieting, excessive exercise, self-induced vomiting, and abuse of laxatives, diet aids, and water pills (Phelps, Andrea, & Rizzo, 1994). These disturbing behaviors most often begin in middle school, where school counselors may be the only adults who are sensitive to the integration of the various aspects of development. Understanding the physical changes of puberty and the associated behaviors that middle school students exhibit are essential. Additionally, understanding levels of body image is helpful in determining appropriate intervention. The perceptual level involves evaluation of one s body size, and the affective-cognitive level refers to attitudes held towards one s body (Pesa, Syre, & Jones, 2000). PERCEPTUAL LEVEL Like many adults, preadolescents believe that acceptance and popularity are correlated with a desirable body shape and type (Gable & Kearney, 1998). There is widespread desire among preadolescents to lose weight or attain a different body type to be liked and accepted by the same and opposite sex peers (Ricciardelli & McCabe, 2001). Middle school students, in search of an identity, are often critical about personal self-image. Many preadolescents become thin fat people (Bruch, 1973, p. 91), holding misconceptions and misinterpretations of excess weight as grotesquely fat. The fat spurt (normative accumulation of skin thickness and fat) is one of the most dramatic physical changes associated with puberty (Brooks-Gunn & Warner, 1988). These normative changes often lead students to damaging attitudes about their body. The attitudes and subjective opinions about weight, more than actual weight, are predictive of dieting behavior and disturbances in body image (Phelps, Sapia, Nathanson, & Nelson, 2000). For example, prepubescent girls who perceive themselves as underweight are most satisfied with body image (Simmons & Blyth, 1987). Even as self-perception may be skewed, social learning theory suggests that family and peers can intensify and even validate the sociocultural emphasis on slenderness (Byely et al., 2000). When feeling that they do not measure up to the ideal body image against which they compare themselves through photographs, scales, media, high profile women, and their friends, young girls experience high levels of self-hatred that can follow them into womanhood (Hesse-Biber, 1996; Maine, 2000). AFFECTIVE-COGNITIVE LEVEL Both boys and girls in middle school connect feelings to physical development. A strong correlation exists between body satisfaction and self-concept in sixth grade boys (Folk, Pedersen, & Cullari, 1993). Those that do experience dissatisfaction tend to oscillate between a preference for a thinner ideal image and a heavier, more muscular image (Cohane & Pope, 2001). In turn, most girls at some point feel fat, worry about weight, or develop ambivalent feelings about food (Friedmann, 1998). Both boys and girls experience negative feelings about their bodies. Such negative feelings are a source of negative emotions about oneself as a whole (Pesa et al., 2000) and are closely linked to self-esteem (Brumberg, 1997; Friedmann; Gabel & Kearney, 1998; Maine, 2000; Pesa et al., 2000; Phelps et al., 2000). Other emotional features include depression, anxiety, mood swings, low self-esteem associated with weight cycling, and self-hatred of one s body fat (Bruch, 1973; Johnston, 1996; Toray & Cooley, 1997). Beyond students feelings about their own bodies, the physical changes that occur among middle school students lead them to search for ways to express feelings. Girls in particular talk about feeling fat as a means of expressing emotions they do not know how to describe or experiences that make them feel unsafe (Friedmann). The principles of body-conscious society trickle into the mindsets of middle school students and allow feeling fat to be an acceptable means of emotional expression, when in fact the feelings experienced may have little to do with body image itself. As body image dissatisfaction becomes more prominent, general dissatisfaction with other aspects such as social and school achievement also increases (Ricciardelli & McCabe, 2001). A poor body image is often associated with a history of teasing (Ricciardelli & McCabe), and previous experiences may only serve to complicate this already difficult time of pubertal changes. It is also significant to note that body image, more than internalized perfectionism or feelings of ineffectiveness, serves as a longitudinal predictor of eating problems (Attie & Brooks-Gunn, 1989). Given the deleterious consequences of a negative body image among preadolescents, it is essential to consider the 6:2 DECEMBER 2002 ASCA 139

Physical changes girls experience may factor into the increased prevalence among females of body dissatisfaction and weight management behaviors. role of school counselors in promoting a healthy body image. PROMOTING HEALTHY BODY IMAGE: SCHOOL COUNSELING INTERVENTIONS It is incumbent upon those who promote healthy body image in the school environment to consider their own attitudes and behaviors about body image. It is not only peers who endorse prejudicial attitudes towards fat children, but also parents, teachers, and school counselors (Loewy, 1998). Influential adults in middle school students lives should have an awareness of self that allows them to avoid inadvertently projecting body dissatisfaction onto students in their homes, communities, and schools. The attitudes endorsed and portrayed by key personnel are critical in building healthy body image in students. Particularly within the realm of body image, schools should develop an environment of acceptance and safety that promotes personal health and strength, so that all students are given the most optimal chance to succeed. In creating this environment at school, it is hoped that it will extend into the community through the voice of students. Promoting attitudes of strength, health, and acceptance of all body types relates to the healthy selfesteem of students (O Dea & Abraham, 2000). For example, a program addressing self-esteem was effective in decreasing body image dissatisfaction among its participants without directly addressing body satisfaction (O Dea & Abraham). As selfesteem is often associated with beneficial student outcomes, it seems appropriate to implement interventions that promote healthy self-esteem and body image. School counselors must be creative and address perceptions, affect, wellness, and health behaviors to promote healthy body image. School counselors can conceptualize and create interventions for the promotion of healthy body image at both individual and systemic levels. INDIVIDUAL COUNSELING A great deal of research addresses treatment when working with clients with eating disorders (Bruch, 1973; Fairburn & Garner, 1988; Gore, VanderWal, & Thelen, 2001; Levine & Smolak, 2001). As agents of change, school counselors may integrate these treatment strategies from a wellness and/or proactive stance. One useful method is the interpersonal therapy approach, focusing on developmental changes and social experiences that may trigger disordered eating behaviors (Gore et al.). This approach helps students develop alternative ways to handle problems and to practice new behaviors. This perspective may be useful with less clinical manifestations of body image dissatisfaction and disordered eating due to its emphasis on increasing self-esteem and feelings of personal competence (Phelps et al., 2000). By targeting help to students with eating disturbances, the importance of body shape and feelings are connected with underlying stories, meanings, and overall well-being (Friedmann, 1998; Mazzeo, 1999; Ricciardelli & McCabe, 2001). Research has suggested that physical self-esteem and personal competence are protective factors that buffer the development of symptomology of eating disorders (Phelps et al.). Interview tools, such as Cooper and Fairburn s (1987) Eating Disorder Examination, that assess the importance of shape can help the counselor identify concerns to be addressed through interpersonal therapy. Action-oriented activities may also be beneficial in individual counseling. Students may be helped to envision themselves as strong, regardless of body shape, by including activities in counseling that allow them to feel good about themselves and their bodies. Encouraging physical activities such as bike riding or roller-blading enables students to experience the physical strengths of their bodies and the positive feeling of movement. Wearing favorite clothes or getting a new haircut often allow students to feel comfortable with themselves and recognize how they feel inside their bodies when experiencing different external elements. Combined with relaxation techniques such as guided imagery, students may become more desensitized to events that elicit negative body feelings (Gore et al., 2001). While learning these techniques, students can also explore some of the developmental perspectives on body image during individual sessions. Suggested general topics include: educational information on body image, investigation of factors contributing to body satisfaction and dissatisfaction, general coping skills training, knowledge about the impact of culture and society on beliefs and attitudes, and activities to promote self-acceptance (Gabel & Kearney, 1998; Gore et al., 2001). Counselors themselves can promote admiration, appreciation, and acceptance of all body shapes through their individual work (Loewy, 1998). Aspects beyond individual counseling should also be considered and incorporated into broader-scale intervention and prevention efforts. Within a developmental context, sociocultural, familial, and peer issues should be considered alongside body image concerns, self-deficits, and means of fostering selfesteem (O Dea, 2000). 140 ASCA PROFESSIONAL SCHOOL COUNSELING

GROUP COUNSELING In many ways, group counseling may have more potential than individual work for promoting a healthy body image. Counselors can provide students with opportunities to engage in activities and practice new behaviors with peers (Friedmann, 1998; Levine & Smolak, 2001). Peers can often be the source of negative feelings towards the body, yet their influences may also work positively. Middle school students are particularly susceptible to the impressions and opinions of their peers. It may be possible for a group of students to capitalize on influences and modify susceptibility to external peer group pressure and body image norms (O Dea & Abraham, 2000). Students in body image enhancement groups have an opportunity to build support systems and facilitate connections with one another (Friedmann, 1998). It is important for counselors themselves to address potential countertransference issues when working with this population to ensure that role modeling works positively, as they can serve as models for body image health. Not only do students receive multiple models for competency, but they also are spared from the ordinary isolation due to the secretive and shameful nature of behaviors associated with negative body image and disordered eating (DeLucia-Waack, 1999). Providing structure to group counseling interventions gives students a focused means of talking about ways to promote their own and others body image. Several approaches (Friedmann, 1998; O Dea & Abraham, 2000; Rhyne-Winkler & Hubbard, 1994) suggest structures that incorporate education, insight, and action. For example, Rhyne-Winkler and Hubbard suggested separate groups for overweight and normal weight students. While the first may focus on healthy exercise and eating and self-esteem, the second may be structured around goal setting, body image, anger, and assertiveness. In both groups, emotions associated with eating, self-esteem, and body image are core themes. The importance of affect is stressed in all of these approaches, fostering self-esteem and thereby reducing body dissatisfaction. Through games, role plays, and activities that encourage putting sociocultural and media messages about the importance of appearance in perspective, students are empowered to feel good about themselves while at the same time contributing to the self-esteem of their peers. The goal is to continue to promote an environment of health and well being irrespective of appearance. SYSTEMIC INTERVENTIONS IN THE SCHOOL School counselors maximize efforts to promote development by using systemic interventions. While group counseling offers one method of utilizing peers to promote development, peer influence occurs through daily interactions. Forty percent to 50% of girls in middle school discuss weight and get weight control ideas from friends (Desmond, Price, Gray, & O Connell, 1986; Levine & Smolak, 1992). Intrapersonal issues such as body image are quickly transformed into interpersonal issues. Recognizing this influence, school counselors can utilize classroom guidance curriculum and coordinate programs that capitalize on peer influence for positive effects. An opportunity for classroom guidance exists with exploratory or health and physical education classes. Most middle school physical education and health curriculum include physical fitness (cardiovascular, strength, endurance, and flexibility), sexual education, and wellness. Health class also affords school counselors the opportunity to integrate psychoeducational classroom guidance lessons on healthy body image. It is imperative that health teachers and school counselors address the changes occurring in puberty in connection with emotional and perceptual processes with students to avoid the negative connotations with body image. Along with these issues, topics relating to body image including self-esteem, locus of control, approval-seeking behavior, nutrition and appropriate exercise, and perfectionism can also be discussed in this setting (Rhyne-Winkler & Hubbard, 1994). Classroom guidance affords counselors a psychoeducational opportunity where peer sharing and dialogue occur as well as a chance for collaboration with teachers. Within this context, accurate information can be disseminated, student norms can be influenced, and physical education teachers can reinforce lessons to promote a healthy body image. Peer culture can also be influenced through programs coordinated and led by the school counselor. Peer mentoring may be an appropriate medium to address body image with older students as useful role models. This may be especially relevant for middle school girls just starting puberty. Research has demonstrated that girls often have more difficulty with the transition to middle school, partly due to puberty (Chung, Elias, & Schneider, 1998), which is a major stimulus toward unhealthy body image. Peer mentors, who demonstrate a healthy body image (not necessarily cultural ideals), can be a way to help students develop norms toward healthy body image. Consultation and collaboration with school per- 6:2 DECEMBER 2002 ASCA 141

One of the most dramatic physical changes associated with puberty is the fat spurt (normative accumulation of skin thickness and fat). sonnel is another systemic way for school counselors to promote healthy body image. Rhyne- Winkler and Hubbard (1994) suggested in-service education for teachers. Making school staff aware of normal developmental issues and the importance of body image can create a staff sensitive to development in all students. At the same time, it allows school counselors an opportunity to build allies in promoting healthy body image. For example, potential significant allies include school staff involved in dietary choices. Often nutritional guidelines are set by district policy, and nutrition experts help dictate the composition of lunch. School counselors and nutritionists may be able to collaborate with each other to offer lunch alternatives to systemically promote healthy bodies. Perhaps more influential, school counselors could consult with administrators to provide alternatives to fattening and unhealthy snacks often found in cafeteria vending machines. School counselors may be able to recommend healthier alternatives such as bottled water and pretzels. Similarly, middle schools often use food and candy incentives for students. School counselors can promote healthy snacks by providing examples in their own work. Another opportunity to collaborate or advocate with administrators and teachers is with behavior related to body image. In order to promote healthy body image in students, school counselors can encourage teachers and administrators to view verbal harassment to student s physical appearance as a serious offense. The middle school locker room is one setting where students may be particularly vulnerable. This type of opportunity provides teachable moments for teachers and administrators to talk about body image and development. School counselors can also work with teachers and administrators to help recognize students for athletic and physical accomplishments such as improvement in fitness testing or participation in athletics or activities in and outside of the school. The materials in the library may also be another source of body image influence for students. Fifty percent of high school girls report using magazines for ideas about weight control (Desmond et al., 1986). Potentially, school counselors can work with library specialists to ensure that appropriate and healthy guides exist for nutrition and exercise. The school can make a statement about its stance on media images through selectivity in the magazines made available to students. While school counselors may not be able to change popular culture and media influences on a large scale, the school context affords various systemic opportunities to promote healthy bodies and healthy body image. As school context aligns to promote healthy body image, families are another important system of influence. FAMILY CONSULTATION Counselors may try approaches to help with body image with a modicum of success, but without the support of parents, efficacy is weakened (Gore et al., 2001). Outside of the school context, school counselors can work to include the family in the promotion of a healthy body image. It may start with including parents on school committees (e.g., PTA, School Counseling Advisory Board) to create awareness of developmental issues and opportunities to promote health or healthy body image. This step of inclusion of family may stimulate help beyond the school context. Parental messages are important influences on body image (Byely et al., 2000). Parents have a strong impact on the self-image and self-esteem of their children, including perceptions and attitudes about weight (Loewy, 1998). While modeling of parents dieting behavior and attitudes about body image takes place in adolescence, such intentional proactive modeling is rare at the middle school stage (Byely et al.). It is often difficult for parents to address seemingly adult issues with children leaving elementary school. School counselors can consult with parents and advocate for parents to provide purposeful modeling as students enter middle school. Helpful information about body image may be disseminated at PTA meetings or orientation materials sent home to parents of new middle school students. Another opportunity to communicate with parents about body image is through health and sexual education curriculum. Often committees that determine sex education curriculum include parents, school staff, and community members. School counselors can promote healthy body image by including body image as a relevant factor in the sex education curriculum. These extensions to parents can also be made outside of the school building. COMMUNITY COLLABORATION AND ADVOCACY School counselors often refer students and their parents to community resources to help meet basic needs, but there are often opportunities to promote healthy development in collaboration with city or county health and fitness programs or city parks. Many cities and counties have parks and recreation programs offered through a community organization for school-aged children. School counselors can facilitate access and awareness of these activities by posting flyers and making announcements about the activities during the school day. This is especially significant in middle school, where new sixth graders often are not able to participate in school- 142 ASCA PROFESSIONAL SCHOOL COUNSELING

sponsored athletics or clubs. School counselors may also be able to facilitate community programs to be held at the school. Perhaps school counselors can collaborate to offer fitness and nutrition seminars on site that are particularly geared to middle school students or city/county officials may run a less competitive intramural program specifically for those students not involved school activities. Beyond parks and recreation activities, communities may offer educational opportunities about health, nutrition, or eating disorders. School counselors may be able to bring in relevant speakers or facilitate awareness and access to these programs. IMPLICATIONS FOR SCHOOL COUNSELORS The issue of body image among middle school students does not appear to be diminishing, as preadolescents are increasingly influenced by media, sociocultural, peer, and family pressures. Such pressure may be externally focused, as with students who believe they must achieve a certain appearance in order to be popular, successful, or accepted among peers. Similarly, school counselors may encounter students who exhibit body image dissatisfaction because they lack the ability to express feelings about the developmental changes in preadolescence. In either case, promotion of healthy body image at individual, group, and systemic levels may serve as a protective factor for common disruptions (e.g., self-esteem, school and social competence) associated with puberty and the transition into middle school. To facilitate the personal and social development of middle school students, promoting a healthy body image is a relevant outcome goal for middle school counseling programs. The research literature on school counselor intervention, the developmental needs of preadolescents, and body image direct counselors to be proactive. In promoting a healthy body image in middle schools students, middle school counselors should be aware of the following implications: A healthy body image may serve as a protective factor in preadolescent development and prevent disordered eating Middle school counselors have a unique opportunity to promote normal and optimal development as it relates to puberty and body image School counselors must be self-aware of their own body image and the model it portrays The school environment can be an element of change to promote healthy body image Rather than targeting eating disorders, middle school counselors should focus individual and group interventions on the development and promotion of a healthy body image Systematic collaboration with resources such as peers, teachers, staff, parents, and community organizations are needed to sustain a focus on healthy body image. References Archibald, A., Graber, J., & Brooks-Gunn, J. (1999). 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