Abstract
Body image dissatisfaction shapes well-being across the life course. This study examines associations between parent-reported childhood experiences—adverse (ACEs) and positive (PCEs)—and body image dissatisfaction in adolescents. Using data from the National Survey of Children’s Health, a nationally representative survey of US adolescents, we performed adjusted logistic regressions to assess associations between childhood experiences and body image dissatisfaction. Experiencing 1–2 and 3+ ACEs was associated with body image dissatisfaction compared to experiencing no ACEs (aOR: 1.24, 95% CI: 1.03–1.49; aOR 1.86, 95% CI: 1.39–2.48). PCEs (family resilience and neighborhood support) were associated with lower odds of body image dissatisfaction (aOR 0.57, 95% CI 0.48-0.69; aOR 0.75, 95% CI 0.64–0.86), even in adolescents with ACEs. In adolescents with 3+ ACEs, only family resilience had protective associations against body image dissatisfaction. These findings highlight how relational support may promote positive body image, particularly in adolescents experiencing adversity.
Keywords
Introduction
Body image—an individual’s perception of their physical appearance, shape, and size—shapes psychological well-being, health behaviors, and chronic disease risk (Austin, 2018). Characteristics of positive body image include acceptance of one’s body, confidence with one’s body, appreciation of bodily functions, emphasis on the positive aspects of one’s body, connection with bodily needs, and internalization of positive aspects of one’s body with reframing of negative aspects (Wood-Barcalow et al., 2010). Adolescence is a key transition point from childhood to adulthood; body image dissatisfaction at this stage influences long-term health outcomes (Markey, 2010). Studies have shown that body image dissatisfaction affects almost half of adolescent girls and a quarter of adolescent boys in the United States (US; Wang et al., 2019). Factors influencing adolescent body image development include weight status, internalization of societal norms to one’s own body, and social pressures from family, peers, and society (Voelker et al., 2015). As the prevalence of adolescent obesity increases, weight stigmatization further exacerbates dissatisfaction and its associated detrimental health effects (Pont et al., 2017). Understanding risk and protective factors for body image dissatisfaction can inform strategies for early interventions that promote positive self-image and overall well-being in adolescence and beyond.
Adverse childhood experiences (ACEs), or stressful or traumatic events in early life, are associated with body image dissatisfaction (Akhator-Eneka, 2024; Longobardi et al., 2022). Previous research indicates that the mechanisms through which ACEs lead to body image dissatisfaction and other adverse health outcomes can occur through two dimensions of adversity: threat and deprivation pathways (Sheridan and McLaughlin, 2020). For example, threat-related ACEs (e.g., abuse, exposure to violence) may heighten overall emotional reactivity, leading to high self-monitoring and subsequent concern over physical appearance (Uddin et al., 2024). Deprivation-related ACEs like emotional neglect may interfere with a child’s ability to develop their own self-worth, resulting in their reliance on external sources for validation. These experiences disrupt the body’s stress response during a period of developmental neural plasticity (Sheridan and McLaughlin, 2020), distorting emotional regulation, self-image, and increasing susceptibility to unrealistic body image standards. In contrast to ACEs, researchers have shown that positive childhood experiences (PCEs), defined as supportive relationships that foster resilience, promote multiple domains of childhood health (Han et al., 2023; Huang et al., 2023). More recent studies have established specific PCEs as having protective effects on health outcomes (Huang et al., 2023)—the most well-characterized are family and neighborhood protective factors (Bethell et al., 2019; Duh-Leong et al., 2021; Fuller et al., 2020). In smaller samples, PCEs are associated with positive body image (Crandall et al., 2020). Less is known about whether PCEs have protective associations with dissatisfaction at a population level. Understanding whether PCEs have protective associations, in the setting of ACEs particularly, would inform community and clinical strategies to foster healthy body image among groups at risk for dissatisfaction.
To close these gaps in knowledge, we conducted a study assessing body image dissatisfaction as reported by parents in a US nationally representative sample of adolescents. Our objective was to assess associations between childhood experiences and body image dissatisfaction in adolescents. We hypothesized that (1) ACEs would be associated with higher odds of dissatisfaction; (2) PCEs would be associated with lower odds of dissatisfaction; and (3) PCEs would buffer the negative associations of ACEs.
Methods
Study design and data source
This was a secondary analysis of the 2022 National Survey of Children’s Health (NSCH), a cross-sectional survey of parents or primary caregivers of US children. Families in the US with at least one child, as identified through the Census Bureau, were invited through mail or the web to participate in a survey about their child’s health. Households with children aged 0–5, 6–11, and 12–17 were provided with an age-based health questionnaire. Those unable to complete the screener in English or Spanish were excluded. For this analysis, the responses of parents of adolescents aged 12–17 (N = 19,028) were utilized, including information on ACEs and PCEs. The 2022 NSCH introduced questions related to body image dissatisfaction for the first time (https://www.census.gov/programs-surveys/nsch/data/datasets.html). Our institutional review board deems studies of public, deidentified data exempt from human subjects review.
Variables
Body image dissatisfaction in the past 12 months was assessed by asking, “How concerned was this child about their weight, body shape, or body size?” Parents could answer with “Very much” “Somewhat” or “Not at all”. We dichotomized “Very much” and “Somewhat” (yes) vs. “Not at all” (no) to capture the presence of any body image dissatisfaction.
The NSCH assesses ACEs across multiple domains—abuse, neglect, household challenges, and discrimination—by asking caregivers about their child’s exposure to these adversities. Specifically, the NSCH asked parents if the child had experienced the following ACEs: parent divorce/separation, death, time in jail/prison, household violence, mental illness, alcohol/drug use, neighborhood violence, and racial, sex-based, and disability-based discrimination. Guided by prior work (Crouch et al., 2024; Santos et al., 2023), ACEs were summed and grouped into three categories: no ACEs, 1-2 ACEs, and 3+ ACEs.
Parents assessed the presence of these PCEs: family resilience and neighborhood support. Family resilience was a composite measure based on four questions: “When your family faces problems, how often are you likely to do each of the following: (1) talk together about what to do, (2) work together to solve our problems, (3) know we have strengths to draw on, (4) stay hopeful even in difficult times.” Neighborhood support was a composite measure based on three questions: “To what extent do you agree with these statements about your neighborhood or community: (1) people in this neighborhood help each other out, (2) we watch out for each other’s children in this neighborhood, and (3) when we encounter difficulties, we know where to go for help in our community.” We coded these two composite measures as dichotomous variables as per the NSCH codebook (CAHMI, 2024).
Covariates
We selected covariates based on prior work examining body image and adolescent health. Adolescent covariates include age (years), sex assigned at birth (male, female), race and ethnicity (White, non-Hispanic Black, non-Hispanic Asian, Hispanic, Other/Multi-Racial non-Hispanic), self-reported diagnoses of anxiety (yes/no) and depression (yes/no), and body-mass-index-for-age category (Underweight [<5th percentile], Healthy Weight [5th–84th percentile], Overweight [85th–94th percentile], Obese [>=95th percentile]). Parent covariates include age (years) and highest education level (Less than high school, high school, some college/technical school, college degree or higher). Household covariates include household income by Federal Poverty Level (0%–99%, 100%–199%, 200%–399%, 400+%) and family marital structure (two parents married, two parents not married, single parent, other family type).
Analysis
We applied survey weights to reflect the full US adolescent (ages 12–17) population. We summarized sample characteristics and used weighted groupwise comparisons to assess sociodemographic differences by body image dissatisfaction. We used weighted adjusted logistic regressions to determine whether experiencing 1–2 or 3+ ACEs was associated with body image dissatisfaction compared to experiencing no ACEs. Regarding PCEs (family resilience and neighborhood support), we used separate adjusted logistic regression models to assess their associations with body image dissatisfaction. As done in prior work examining health outcomes in the simultaneous presence of ACEs and PCEs (Huang et al., 2023), we conducted separate adjusted logistic regressions to assess associations between PCEs and body image dissatisfaction in adolescents experiencing no, 1–2, or 3+ ACEs. Analyses were performed using Stata (version 18.0, College Station, TX, USA).
Results
Our sample included 19,028 adolescents aged 12–17, weighted to represent 26,243,242 US adolescents. Table 1 displays sample characteristics: body image dissatisfaction (33.3%), ACE status (no ACEs: 52.2%, 1–2 ACEs: 35.3%, 3+ ACEs: 12.5%), and PCEs (family resilience: 80.8%, neighborhood support: 54.5%). Participants who were female, had depression or anxiety, had overweight or obesity, whose parents had a high school education, or one or more ACEs were more likely to have body dissatisfaction as reported by a parent (Table 1). Adolescents experiencing family resilience or neighborhood support were less likely to have dissatisfaction (Table 1).
Characteristics of sample of adolescents (ages 12–17, N = 19,028).
IQR: interquartile range, FPL: federal poverty level, ACEs: adverse childhood experience(s), BMI: body mass index.
Survey weights were utilized to reflect all 26,243,242 adolescents ages 12–17 living in the US.
Reference group for groupwise comparisons.
p < 0.05; ***p < 0.001 indicate significant differences in groupwise comparisons.
As compared to White, non-Hispanic adolescents, Black, non-Hispanic adolescents were less likely to experience body image dissatisfaction.
Table 2 displays how having 1–2 ACEs was associated with higher odds of body image dissatisfaction (aOR: adjusted odds ratio 1.24; 95% CI: confidence interval 1.03–1.49) as compared to experiencing no ACEs. Adolescents who experienced 3+ ACEs were also associated with higher odds of body image dissatisfaction (aOR 1.86; 95% CI 1.39–2.48) as compared to experiencing no ACEs. Conversely, family resilience was associated with half the odds of dissatisfaction (aOR 0.57; 95% CI 0.48–0.69). Likewise, neighborhood support was associated with lower odds of dissatisfaction (aOR 0.75; 95% CI 0.64–0.86).
Body Image Dissatisfaction in the setting of ACEs and PCEs.
aOR: Adjusted odds ratio; CI: Confidence interval.
Analyses were adjusted for child age, sex, race/ethnicity, anxiety, depression, BMI, parent age, education, household income level, and family structure. Survey weights were utilized to reflect all 26,243,242 adolescents ages 12–17 living in the US.
p < 0.05; **p < 0.01; ***p < 0.001.
Associations between PCEs and body image dissatisfaction were largely preserved in adolescents experiencing graded levels of ACEs. Family resilience was associated with lower dissatisfaction among adolescents with zero ACEs (aOR 0.54; 95% CI 0.40–0.75), 1–2 ACEs (aOR 0.66; 95% CI 0.50–0.86), and 3+ ACEs (aOR 0.53; 95% CI 0.37–0.76). Neighborhood support was associated with decreased dissatisfaction at zero ACEs (aOR 0.70; 95% CI 0.56–0.87) and 1–2 ACEs (aOR 0.77; 95% CI 0.63–0.95) but was not significant at 3+ ACEs (Table 2).
Discussion
Our study represented the experiences of 26.2 million US adolescents, as reported by their parents—in this sample, over half of adolescents experienced 1+ ACE, most adolescents experienced 1+ PCE, and one-third experienced body image dissatisfaction. Consistent with our hypothesis, we found that experiencing a higher number of ACEs was associated with higher odds of body image dissatisfaction, and conversely, experiencing PCEs (family resilience and neighborhood support) was associated with lower odds of dissatisfaction. Although family resilience retained a protective association against body image dissatisfaction in adolescents experiencing graded levels of ACEs, neighborhood support was no longer significantly associated with decreased dissatisfaction in adolescents experiencing 3+ ACEs.
Consistent with prior research, baseline characteristics associated with greater body image dissatisfaction included participants of female sex, having depression or anxiety, overweight or obesity, having parents without higher education, and having at least one baseline ACE. Prior literature reflects that female gender (Paxton et al., 2006) and obesity (Voelker et al., 2015) are inversely associated with body image, driven by societal norms regarding body image ideals. Body image dissatisfaction in the setting of obesity likely exacerbates adverse health impacts through disordered eating, extreme dieting, or avoidance of physical activity. Having baseline anxiety or depression may predispose adolescents to maladaptive thought patterns regarding their bodies—and in turn, body image dissatisfaction may further contribute to depressive symptoms (Thorup et al., 2024). Although prior research has not directly associated parental education level to child body image, adult education level has been shown to be inversely related to body image dissatisfaction (Rosenqvist et al., 2024). Parents with a higher educational background may have a more positive self-image overall, and this attitude may influence the development of similar positive attitudes in their children.
We found that higher ACE exposure was associated with greater odds of body dissatisfaction, aligning with a well-established evidence base demonstrating the harmful impact of ACEs on psychological well-being (Mosley-Johnson et al., 2019). This supports prior literature positing that psychological consequences of trauma could potentially lead to difficulty in resolving internal conflicts between societal expectations, self-perception, and acknowledgement of their body as strong, capable and healthy (Akhator-Eneka, 2024). ACEs represent a wide range of traumas—abuse, discrimination, material hardship—which may have heterogeneous impacts on body image.
Conversely, family resilience, a positive childhood experience, was associated with lower odds of dissatisfaction, even in adolescents with the highest level of ACEs, reinforcing prior work highlighting the importance of family relationships (Gonçalves et al., 2020). Family resilience provides consistent support and nurtures a strong sense of belonging in children (Masten and Monn, 2015), which likely buffers the effects of ACEs. Studies examining PCEs and obesity posit that PCEs may improve impulse control for binge eating, and that family resilience may attenuate the stress response after an ACE (Crouch et al., 2022; Heerman et al., 2022; Mellar et al., 2025). Our findings support this body of work on a population level, providing insights into these trends on a societal level. Future qualitative methods should attempt to elucidate how these experiences of family resilience intersect with healthy body image and healthy lifestyle behaviors.
Our measure of neighborhood support did not have protective associations with body dissatisfaction at the highest ACE level. Overall, neighborhood support, particularly when measured by the parent, may not align with the adolescent’s perspective, and will not capture the neighborhood’s ability to address an adolescent’s emotional and psychological needs. Our measure also queried specifically about proximate local communities. Adolescents may primarily develop their social support communities beyond their immediate surroundings. In fact, researchers have already shown how online communities can have a negative impact on body image, particularly around disordered eating (Wang et al., 2018) or a positive impact through body-positive online communities (Rodgers et al., 2020). Our findings highlight the need for future studies to examine distinct types of adolescent social support networks and their influence on body image dissatisfaction.
Study strengths include the large representative sample size, allowing our findings to have generalizability and relevance at the US population level. Additionally, as this was the first time body image dissatisfaction was assessed in the NSCH, this analysis is one of the first known studies to date to analyze factors associated with body image dissatisfaction within this sample.
There are several limitations to this dataset and overall study. First, the NSCH patient population is predominantly composed of families who self-identified as White, with high educational background and high socioeconomic status, and many were from married, two-parent households. The NSCH’s cross-sectional design limits the ability to interpret causality in our associations, and as the data relies on parents’ self-reported data, there is increased risk of recall bias and informant bias. Past research on concordance between parent and adolescent reports of behaviors and feelings (Berg-Nielsen et al., 2003; Go et al., 2022) has posited that factors such as parent stress and degree of involvement can lead to misestimation of a child’s report of the same question (Berg-Nielsen et al., 2003; Go et al., 2022). The NSCH does not assess if adolescents are from a sexual and gender minority group, communities at increased risk for both body image dissatisfaction and ACEs (Jones et al., 2016; Solberg et al., 2024). Finally, we also relied on a single item outcome measure, limiting depth, nuance, and reliability in our measurement of body image dissatisfaction. As body image dissatisfaction measures continue to be developed and validated (Kling et al., 2019), future studies should interview adolescents directly using a more robust measure of body image dissatisfaction (Cuzzolaro et al., 2006), as well as directly assess their experiences of ACEs and PCEs.
This study established associations between ACEs, PCEs, and body image dissatisfaction, and found that PCEs largely retained a protective association with body image in the setting of ACEs. These novel findings, representing one of the first times that body image dissatisfaction has been assessed in this large US representative sample, affirm the need to integrate considerations of an adolescent’s social and relational context when developing strategies to promote healthy body image. Understanding how ACEs and PCEs shape body image during adolescence—a critical transition period to adulthood—inform strategies to understand risk for body image dissatisfaction and trauma-informed preventive strategies to improve long-term mental and physical health outcomes.
Footnotes
Acknowledgements
This work was supported by the Sala Elbaum Pediatric Research Scholars Program. The funders/sponsors had no role in the design or conduct of the study.
Ethical considerations
The NYU institutional review board deems this study of public, deidentified data exempt from human subjects review.
Consent to participate
Not applicable.
Consent for publication
Not applicable.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Sala Elbaum Pediatric Research Scholars Program.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.