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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.
This study aimed to investigate demographic, psychosocial, and intervention-related variables as predictors of overall intervention effects after adolescents’ use of YPF.
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.
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
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.
Physical appearance can be a source of psychological and social distress, especially during adolescence. A heightened focus on appearance and pressures to conform to appearance ideals may negatively affect adolescents’ psychological health in terms of anxiety, depression, and low self-esteem [
A range of congenital and acquired conditions may affect facial and bodily appearances and lead to what is referred to as a visible difference [
Some of the main challenges encountered by many adolescents with a visible difference include experiences of being stared at and questioned about their appearance by others [
Experiences of teasing can negatively influence adolescents’ self-esteem and lead some to choose behavioral avoidance—refraining from engagement in social activities—as a coping strategy for fear of being teased for their difference [
It is generally recognized from adolescent community samples that girls tend to experience lower body esteem than boys [
Psychosocial support for adolescents with a visible difference has typically been based on an eclectic approach and includes a wide range of therapeutic approaches and techniques such as social skills training (SST) as well as techniques based on cognitive behavioral therapy (CBT), psychoeducation, mindfulness, and acceptance and commitment therapy [
Internet-delivered CBT (ICBT), which has shown intervention effects on mental health outcomes that are comparable with those shown by standard face-to-face CBT [
To date, Young Person’s Face IT (YPF) is the only self-guided internet-based intervention using a web-based platform developed for adolescents with a visible difference. YPF was developed at the Centre for Appearance Research based at the University of the West of England, Bristol, United Kingdom, in close collaboration with adolescents with a visible difference and their parents, clinical experts, and health professionals [
The feasibility and acceptability of YPF has been explored in several countries [
The objective of this exploratory study was to contribute to the accumulating body of research on the effectiveness of YPF in promoting adolescents’ adjustment to their visible difference [
This study was conducted at the Centre for Rare Disorders based at Oslo University Hospital and used longitudinal data collected as part of a larger, ongoing mixed methods project and RCT (ClinicalTrials.gov NCT03165331) investigating the effectiveness of the Norwegian version of YPF.
The study was reviewed by the Regional Committee for Medical Research Ethics South East Norway (reference number: 2015/2440) and accepted by the hospital’s Data Protection Office. All participants provided signed consent before enrollment. For participants aged <16 years, consent was also obtained from both primary caregivers.
Participants were recruited nationwide between April 2019 and February 2021 from university hospitals, specialist treatment units, local health care services, and patient organizations, as well as through social media platforms [
Before being randomized to an intervention group receiving YPF or to a waiting list control group in the larger mixed methods project and RCT, participants completed outcome measures (baseline). Participants in the control group received the intervention (YPF) 13 weeks after the intervention group and completed outcome measures before starting the intervention. Participants from both groups completed outcome measures 13 weeks after completing YPF (postintervention measurement). In this study, all participants who had completed YPF (from both the intervention group and the waiting list control group) were included. Outcome measures were administered through a secure web-based data collection platform (Service for Sensitive Data).
We assessed 137 participants for eligibility, of whom 102 (74.5%) were randomized (n=6, 4.4%, were excluded for not meeting inclusion criteria; and n=29, 21.2%, were excluded because they changed their minds or did not respond after initial screening for eligibility). Of these 102 participants, we excluded 31 (30.4%) because of missing postintervention data. Of the 71 participants remaining, 1 (1%) was identified as an outlier, and 1 (1%) did not start the intervention; both were removed from the data set. Participants who were excluded because of missing postintervention data and participants included in the study did not significantly differ in age (
The final sample included 71 participants (n=43, 61% girls) aged 11 to 18 years (mean 13.98, SD 1.74, years) with a wide range of conditions leading to a visible difference. Demographic characteristics are presented in detail in
Demographic characteristics of participants by gender and for the total sample.
Variable | Boys | Girls | Total sample | |
Age (years), mean (SD) | 13.89 (1.73) | 14.05 (1.77) | 13.99 (1.74) | |
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Craniofacial condition | 19 (68) | 30 (70) | 49 (69) |
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Condition affecting body form | 4 (14) | 7 (16) | 11 (16) |
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Skin condition | 4 (14) | 4 (9) | 8 (11) |
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Acquired condition | 1 (4) | 1 (2) | 2 (3) |
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Unspecified condition | N/Aa | 1 (2) | 1 (1) |
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High | 12 (44) | 12 (30) | 24 (36) |
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Medium | 8 (30) | 15 (38) | 23 (34) |
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Low | 6 (22) | 7 (17) | 13 (20) |
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Unspecified | 1 (4) | 6 (15) | 7 (10) |
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High | 12 (43) | 16 (40) | 28 (41) |
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Medium | 15 (53) | 17 (42) | 32 (47) |
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Low | 1 (4) | 1 (3) | 2 (3) |
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Unspecified | N/A | 6 (15) | 6 (9) |
aN/A: not applicable.
bParents’ educational level was obtained based on information related to their occupation; for example, an academic position can be expected to correspond to a high educational level, a position within the general support system (eg, school personnel or health care professional) can be expected to correspond to a medium educational level, and a position as a skilled laborer can be expected to correspond to a low educational level.
The Body Esteem Scale for Adolescents and Adults (BESAA), specifically the appearance esteem subscale (appearance esteem subscale of the BESAA [BE-Appearance]), assessed body esteem [
The Social Anxiety Scale for Adolescents (SAS-A) assessed experiences of social anxiety [
The Perceived Stigmatization Questionnaire (PSQ) measured perceptions of stigmatization behaviors [
The Body Image Life Disengagement Questionnaire (BILD-Q) assessed the extent to which appearance-related worries affect engagement or intention to engage in different life activities (eg, “Going to a social event” and “Spend time with friends and family”) [
The EQ-5D-5L questionnaire [
We assessed the frequency of teasing experiences and subsequent distress with 2 items drawn from Project EAT-III [
Engagement was measured in 2 different ways: by the number of sessions completed and by calculating mean time (in minutes) spent on YPF. The YPF program automatically records time spent on each session for each participant. Still, recorded time may not always represent actual time use because participants might forget to log out, which leads to nonvalid measurement of time spent on a particular session. However, each session consists of several subsessions, and time spent is also recorded for each subsession. Therefore, to control for possible errors of total time spent and to obtain a more precise measure of time, we inspected participants’ time use on each subactivity within each session. When unrealistic time use was suspected for any given subactivity within a given session, we calculated a mean based on those subactivities that had representative time use and replaced the suspected time with this mean.
The BESAA, SAS-A, PSQ, and BILD-Q had not been translated into Norwegian before the project. The BESAA, SAS-A, and PSQ were translated following recommended procedures, including back translation [
All analyses were conducted with SPSS software (version 26.0; IBM Corp) and included preliminary and main analyses. Difference scores were calculated based on baseline and postintervention scores for primary and secondary outcomes and used in all analyses to assess the degree of change associated with YPF. Preliminary analyses included inspection of missing data and outliers, as well as a descriptive exploration of participants’ intervention completion, frequency of teasing experiences and related distress, self-rated health states, baseline and postintervention means, and bivariate correlations between prognostic variables and primary and secondary outcomes. The strengths of associations were interpreted using the guidelines formulated by Cohen [
Main analyses were conducted to investigate predictors of intervention effects. This included identification of predictors following recommended procedures [
Rates of missing data for the psychosocial and intervention-related variables were small (baseline depressive and anxiety symptoms: 1% and time spent on YPF: 3%). There were no missing data for the primary and secondary outcomes, except for 1% missing for the BILD-Q on the postintervention measurement. Information about completion of intervention sessions as well as frequency of teasing experiences and teasing-related distress is presented in
Overview of the number of participants who completed each session and time spent on Young Person’s Face IT (YPF), as well as frequency of teasing experiences and teasing-related distress.
Variable | Boys | Girls | Total sample | ||||
Time spent on YPF (minutes), mean (SD) | 187 (128) | 232 (146) | 215 (140) | ||||
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0 | 18 (4) | N/Ab | 1 (1) | |||
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1 | 4 (14) | 4 (9) | 8 (11) | |||
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2 | 1 (4) | 2 (5) | 3 (4) | |||
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3 | N/A | 1 (2) | 1 (1) | |||
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4 | 3 (11) | 2 (5) | 5 (7) | |||
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5 | 2 (7) | N/A | 2 (3) | |||
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6 | N/A | N/A | N/A | |||
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7 | 1 (4) | 3 (7) | 4 (6) | |||
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8 | 16 (57) | 31 (72) | 47 (66) | |||
Frequency of teasing experiences, mean (SD) | 1.57 (0.52) | 1.62 (0.68) | 1.60 (0.62) | ||||
Teasing-related distress, mean (SD) | 1.98 (1.12) | 2.24 (1.29) | 2.13 (1.22) |
aDescribes the number of participants who completed each session (eg, 8 participants completed only the first session, and 47 participants completed all sessions, including the booster session).
bN/A: not applicable.
Baseline and postintervention means for primary and secondary outcomes by gender and for the total sample.
Variable | Boys, mean (SD) | Girls, mean (SD) | Total sample, mean (SD) | |||
|
Baseline | Postintervention | Baseline | Postintervention | Baseline | Postintervention |
BE-Appearancea | 2.69 (0.78) | 2.92 (0.65) | 2.06 (1.01) | 2.41 (0.89) | 2.31 (0.97) | 2.61 (0.84) |
SAS-Ab total | 35.32 (14.33) | 30.11 (9.66) | 48.05 (15.11) | 43.58 (14.42) | 43.03 (15.98) | 38.27 (14.31) |
FNEc | 15.71 (7.62) | 13.14 (4.95) | 21.26 (7.99) | 17.77 (6.38) | 19.07 (8.26) | 15.94 (6.25) |
SAD-Newd | 12.93 (5.70) | 11.39 (4.45) | 18.05 (5.85) | 17.07 (6.31) | 16.03 (6.28) | 14.83 (6.27) |
SAD-Generale | 6.68 (2.82) | 5.57 (1.81) | 8.74 (3.81) | 8.74 (3.15) | 7.93 (3.58) | 7.49 (3.11) |
PSQf total | 1.98 (0.54) | 1.79 (0.38) | 2.04 (0.51) | 1.96 (0.47) | 2.02 (0.52) | 1.89 (0.44) |
AFBg | 2.02 (0.55) | 1.82 (0.49) | 2.02 (0.59) | 2.05 (0.50) | 2.02 (0.57) | 1.96 (0.50) |
CSBh | 2.23 (0.64) | 2.07 (0.55) | 2.33 (0.61) | 2.12 (0.59) | 2.29 (0.62) | 2.10 (0.57) |
HBi | 1.51 (0.69) | 1.31 (0.41) | 1.62 (0.68) | 1.55 (0.56) | 1.58 (0.68) | 1.46 (0.52) |
BILD-Qj | 1.21 (0.30) | 1.11 (0.22) | 1.57 (0.54) | 1.57 (0.58) | 1.43 (0.49) | 1.39 (0.52) |
Self-rated health satisfaction measured with EQ-VASk | 83.75 (15.79) | 88.75 (9.29) | 75.47 (21.26) | 74.88 (19.26) | 78.73 (19.60) | 80.35 (17.39) |
aBE-Appearance: appearance esteem subscale of the Body Esteem Scale for Adolescents and Adults.
bSAS-A: Social Anxiety Scale for Adolescents.
cFNE: fear of negative evaluation (Social Anxiety Scale for Adolescents subscale).
dSAD-New: social avoidance and distress specific to new situations (Social Anxiety Scale for Adolescents subscale).
eSAD-General: social avoidance and distress in general (Social Anxiety Scale for Adolescents subscale).
fPSQ: Perceived Stigmatization Questionnaire.
gAFB: absence of friendly behavior (Perceived Stigmatization Questionnaire subscale).
hCSB: confused and staring behaviors (Perceived Stigmatization Questionnaire subscale).
iHB: hostile behavior (Perceived Stigmatization Questionnaire subscale).
jBILD-Q: Body Image Life Disengagement Questionnaire.
kEQ-VAS: EuroQol visual analog scale.
Generally, significant correlations were moderate to strong (refer to
To test our research question, backward multiple regression analyses were used to identify predictors of changes in body esteem, social anxiety, perceived stigmatization, life disengagement, and self-rated health satisfaction after adolescents’ use of YPF (refer to
For body esteem (BE-Appearance), age (β=.170), frequency of teasing experiences (β=.199), and time spent on YPF (β=.375) were retained in the final model, which was significant (
For perceived stigmatization (PSQ), 4 different models were developed (total scale and 3 subscales). For the total scale (PSQ total), age (β=–.204), gender (β=–.207), frequency of teasing experiences (β=.163), and depressive and anxiety symptoms (β=.245) were retained in the final model, which was significant (
To obtain a better understanding of which adolescents are likely to benefit from YPF, this study explored how demographic (age and gender), psychosocial (baseline frequency of teasing experiences as well as depressive and anxiety symptoms), and intervention-related (time spent on YPF) variables predicted changes in a range of outcomes. The principal findings of the study were that different combinations of demographic, psychosocial, and intervention-related variables predicted intervention effects on primary and secondary outcomes. In general, explained variance was higher in analyses that included primary outcomes than in those that included secondary outcomes. Nonetheless, it is important to note that explained variance overall was relatively low for most of our regression models (ranging from 1.6% to 24.1%), which should be taken into account when interpreting our results. The findings are discussed in more detail in the following sections.
Adolescents who reported greater baseline psychosocial distress in the form of higher frequency of teasing experiences as well as depressive and anxiety symptoms had stronger effect of YPF on primary and secondary outcomes than adolescents with lower levels of psychosocial distress. These results could indicate that adolescents who experience higher levels of psychosocial distress may benefit more from YPF than adolescents who experience relatively lower distress. Indeed, similar to our findings, studies with adolescent community samples have found that higher pretest symptoms of anxiety [
Frequent experiences of different types of teasing in childhood, including teasing about appearance, have been linked to symptoms of social anxiety in adulthood [
This study also found that time spent on YPF predicted stronger intervention effects on primary and secondary outcomes, suggesting that adolescents who spend more time on YPF and thereby engage more with the content of the intervention achieve a higher intervention response. This aligns with the study by Williamson et al [
We found that gender was significantly related to intervention effects because girls had consistently lower changes in primary and secondary outcome scores than boys. This corroborates some of the findings reported in the study by Zelihić et al [
Age did not provide a consistent picture of intervention effects. Whereas higher age predicted higher changes in body esteem, lower age predicted higher changes in perceived stigmatization and self-rated health satisfaction. Generally, studies with adolescent community samples also offer inconsistent results regarding the importance of age in predicting intervention effects of standard CBT and ICBT [
This study has several important implications that may guide the referral of adolescents to YPF. Our results indicate that YPF may have an increased benefit for adolescents who experience high levels of psychosocial and psychological distress because of, for example, appearance-related teasing or high levels of depressive and anxiety symptoms. However, it is important to note that YPF may not benefit all adolescents with a visible difference, and future studies should further investigate which indicators may consistently predict intervention effects. Our results also suggest that time spent on YPF matters for intervention effects, in line with previous testing of YPF [
Adolescents with moderate-to-severe psychological difficulties (eg, clinical depression, eating disorders, or posttraumatic stress disorder) were excluded from this study based on the clinically informed premise that they are likely to require alternative higher-level treatment. However, only 1 participant (with concurrent diagnosis of eating disorder and clinical depression) was excluded on this basis. Given the findings from a recent study that demonstrated that YPF is safe [
This study includes some limitations that need to be addressed. First, the regression models generally showed relatively low explained postintervention variance in most primary and secondary outcomes (range 1.6%-24.1%). In other words, other unknown variables, not included in our study, could contribute to explain adolescents’ overall response to YPF. As such, we encourage future studies to include additional variables (eg, incentives to complete YPF, perceptions of user-interface design, level of family support, previous history of surgery, and psychosocial support). We also need a better understanding of how adolescents’ baseline levels of body esteem, perceived stigmatization, and life disengagement prospectively predict intervention effects of YPF.
Second, there is a lack of cross-condition or condition-specific measures developed for adolescents with a wide range of visible differences that are sensitive to different stages of adolescence or aspects other than those related to body image that may influence adolescents’ adjustment [
Third, assessing the degree of clinically important change is vital to understand how a treatment may affect a particular group of individuals [
Fourth, a larger sample size would have increased statistical power and made it possible to use more stringent statistical analyses by, for example, exploring interaction effects in our subgroups. Nonetheless, given the lack of research on web-based interventions for adolescents with a visible difference, we believe that our study provides support for the evidence base regarding the effectiveness of YPF.
Finally, we were not able to systematically control for possible negative influences of the COVID-19 pandemic on the intervention effects of YPF, mainly because participants were enrolled in the study before, during, and after COVID-19–related lockdowns and restrictions, which also differed from districts in Norway. Emerging number of studies have found that the pandemic had a significant negative impact on the mental health of many adolescents, including increased levels of social anxiety [
This study explored predictors of the intervention effects of YPF, a web-based psychosocial intervention designed to promote adolescents’ adjustment to having a visible difference. We specifically examined how demographic, baseline psychosocial, and intervention-related variables prospectively explained postintervention improvements in body esteem, social anxiety, perceived stigmatization, life disengagement, and self-rated health satisfaction. Our results suggest that boys and adolescents with higher levels of psychosocial distress may have increased intervention effects of YPF. Our results also suggest that time spent on YPF plays a role in the intervention effects. In sum, although more studies are needed to further investigate the intervention effects of YPF and similar intervention programs, our study advances the understanding of how web-based psychosocial support may benefit adolescents who may experience challenges with adjusting to the impact of having an appearance-affecting condition.
Descriptive characteristics related to each of the 5 health dimensions from the EQ-5D-5L questionnaire by gender and for the total sample.
Bivariate correlations (Pearson r and 2-tailed
Bivariate correlations (Pearson r and 2-tailed
Selection of predictor variables using backward multiple regression.
absence of friendly behavior (Perceived Stigmatization Questionnaire subscale)
appearance esteem subscale of the Body Esteem Scale for Adolescents and Adults
Body Esteem Scale for Adolescents and Adults
Body Image Life Disengagement Questionnaire
cognitive behavioral therapy
confused and staring behaviors (Perceived Stigmatization Questionnaire subscale)
EuroQol visual analog scale
fear of negative evaluation (Social Anxiety Scale for Adolescents subscale)
hostile behavior (Perceived Stigmatization Questionnaire subscale)
internet-delivered cognitive behavioral therapy
Perceived Stigmatization Questionnaire
randomized controlled trial
social anxiety and distress in general (Social Anxiety Scale for Adolescents subscale)
social avoidance and distress specific to new situations (Social Anxiety Scale for Adolescents subscale)
Social Anxiety Scale for Adolescents
social skills training
Young Person’s Face IT
None declared.