The study, led by Lindsay E. Young of the University of Southern California together with Alyssa F. Harlow, Evan A. Krueger, and Jessica Barrington-Trimis, draws on the ADVANCE study (“Assessing Developmental Patterns of Vaping, Alcohol, Nicotine, Cannabis Use, and Emotional Wellbeing”), an ongoing prospective cohort of roughly 4,500 students recruited from 11 schools across seven school districts in Los Angeles, Riverside, San Bernardino, Orange, and Imperial counties. For the present analysis, the team followed 3,612 adolescents, whose average age was 15.7 years, across five semiannual survey waves spanning Spring 2022 through Spring 2024—the high school years in which internalizing problems typically consolidate. The sample closely mirrored Southern California’s diversity, with 52.6 percent identifying as Hispanic or Latinx and 35.5 percent as Asian, and it included substantial numbers of sexual minority (19.7 percent) and transgender or gender non-binary (6.2 percent) youth.

At every wave, participants named up to seven of their closest friends in their grade, generating directed friendship matrices for each school. Using these nominations, the researchers constructed “network exposure” variables: the average depression or generalized anxiety T-scores of the peers each adolescent had nominated. Symptom levels were measured with the Revised Child Anxiety and Depression Scale, a 47-item instrument that screens for major depressive disorder and five anxiety disorders, with subscales converted to age- and gender-normed T-scores. On average, participants scored below the borderline clinical thresholds, with mean depression and anxiety T-scores of 53.99 and 45.76 respectively, though individual scores spanned a wide range.

The analytical heart of the study lies in a statistical decomposition that separates two fundamentally different explanations for why friends’ feelings correlate. In linear mixed-effects models, each time-varying predictor is split into a between-person component—how an adolescent’s average exposure compares with the sample average—and a within-person component—how exposure at a given wave deviates from that adolescent’s own typical level. The between-person effect captures stable embedding: an adolescent who is chronically surrounded by distressed peers may simply inhabit a social environment that produces or reflects distress. The within-person effect captures momentary synchrony: a teenager faring worse than usual when their friends are also worse than usual. Critically, the models also adjusted for a battery of confounders, both stable and time-varying, including the number of friends nominated (outdegree), the number of nominations received (indegree), past six-month substance use, experiences of in-person or online bullying, time spent across twelve social media platforms, and fixed demographics including sexual identity, gender identity, race, and ethnicity.

The results were consistent for both outcomes. For depression, within-person effects were statistically significant but small (b = 0.01, 95% CI [0.00, 0.03], p = .045): when adolescents were exposed to more depressed friends than usual, they reported slightly higher depression than was typical for them. The between-person effect was roughly five times larger (b = 0.05, 95% CI [0.01, 0.08], p = .005): adolescents chronically embedded in more depressed peer networks reported meaningfully higher depression across the study period, with predicted T-scores rising from about 53 to 58 across the observed distribution of exposure. Anxiety told the same story. Within-person deviations in exposure to anxious friends predicted deviations in personal anxiety (b = 0.01, p = .038), while chronic exposure carried a somewhat larger stable association (b = 0.06, 95% CI [0.02, 0.09], p = .001). Yet in both cases the network exposure terms added less than a quarter of a percentage point of explained variance—a strikingly modest contribution compared with other risk factors in the models.

Those other factors, in fact, dwarfed the peer effects. Being bullied in the past six months predicted sharp within-person spikes in both depression (b = 2.47, p < .001) and anxiety (b = 2.02, p < .001), and adolescents who were chronically bullied scored, on average, more than eight to ten T-score points higher on both outcomes. Heavier social media use independently predicted elevated symptoms both within and between persons, and adolescents who more often reported recent substance use scored substantially higher on depression (b = 5.77, p < .001). Demographic disparities were also pronounced: sexual minority, questioning, and transgender or non-binary adolescents reported significantly higher depression and anxiety than their heterosexual and cisgender male peers, with depression gaps of six to eight points—effects far exceeding anything attributable to peer exposure.

To determine whether the small concurrent co-variation reflected genuine peer influence, the team ran a supplemental set of Random Intercept Cross-Lagged Panel Models (RI-CLPMs), a technique that separates stable trait-like differences from genuine within-person temporal dynamics. The results were decisive. For both depression and anxiety, exposure to peers’ symptoms did not predict subsequent increases in adolescents’ own symptoms six months later—no social contagion. Instead, the analysis revealed an asymmetric pathway for depression: adolescents whose own depressive symptoms rose subsequently showed increases in the average depression of their peer networks (β = 0.052, p = .030), a pattern more consistent with social selection—distressed adolescents coming to affiliate with distressed peers—than with influence. With cross-lagged effects accounted for, the clustering of internalizing symptoms emerged as overwhelmingly a product of stable between-person differences, a signature of homophily and enduring social sorting rather than moment-to-moment emotional transmission.

The authors offer several explanations for why influence effects, widely reported in earlier literature, failed to appear. Peer influence on mood may operate on timescales of days or weeks, faster than semiannual measurement can detect. Average symptom levels in the sample, and in peer networks especially, were low, and emotional states may require sustained, reinforced exposure through strong ties to spread—a logic consistent with complexity contagion theory, which holds that behaviors and states requiring social reinforcement need multiple reinforcing contacts. And because friendship nominations were not held constant across waves, changing network composition may have diluted any influence signal.

Whatever the mechanism, the practical implications are substantial. Because a symptomatic peer network proved to be a stable, persistent feature of adolescents’ social organization rather than a transient state, the researchers argue that clinicians and school counselors should consider assessing the emotional tone of a student’s friend group during intake, even when the individual student’s symptoms appear mild. If an entire friend cluster is struggling, treating one member in isolation is unlikely to be sufficient; classroom- and cohort-level interventions—peer support networks, mental health literacy curricula, and gatekeeper training that teaches peers to recognize distress—are better matched to the data. The findings also underscore that stably elevated symptoms concentrate among already-marginalized youth, who may form networks with others facing the same stressors, compounding risk; identity-conscious, affirming peer support structures are therefore a priority.

The study is not without limitations. It focused on within-school, grade-level friendships, leaving other peer contexts—classmates, extracurricular groups, friends of friends—unexamined. Exposure was measured through outgoing ties, whereas reciprocated friendships may be stronger conduits for co-rumination, the problem-focused conversation style known to mediate internalizing symptom similarity. And the content of friendships themselves was not observed. Future work, the authors suggest, should employ longitudinal social network models to examine the co-evolution of friendship change and emotional change. Still, the central message stands: the well-documented “matching” of adolescent friends’ mental health is primarily a story about who ends up next to whom, not about feelings flowing between them—and interventions that ignore the peer environments and structural conditions in which teenagers are embedded may be treating the wrong target.

The importance of studying body esteem in adolescence cannot be overstated. Adolescence marks a critical developmental period characterized by profound physical, emotional, and social changes. Body image concerns during this stage have been linked with negative outcomes such as eating disorders, depression, and anxiety. To accurately identify and address these issues, researchers must rely on robust measurement tools tailored to the cultural and linguistic context of the populations under study. The BESAA, originally developed within Western contexts, required meticulous adaptation and validation for Chinese adolescents to ensure that its psychometric properties remain sound and that its results are interpretable and actionable.

Understanding the methodological rigor applied in Luo et al.’s examination of the BESAA’s psychometric properties reveals the study’s significant contributions. The research meticulously employed a large, representative sample of Chinese adolescents to test the scale’s reliability, internal consistency, and factor structure. These statistical evaluations are crucial because they verify that the instrument consistently measures the intended constructs of body esteem, including feelings related to appearance, weight, and attribution by others. Confirmatory factor analysis, a technique used to assess whether the data fit an existing theoretical model, confirmed that the BESAA’s three-factor structure remains stable and appropriate within the Chinese cultural milieu.

A particularly intriguing aspect of this psychometric investigation is the cultural adaptation process. Language translation alone is insufficient to capture culturally specific nuances in how body esteem is conceptualized. Luo and colleagues engaged in meticulous forward and backward translation procedures, consulting with experts to ensure semantic and conceptual equivalence. This careful adaptation safeguards against potential biases that may emerge when applying psychological scales across different cultural contexts. Their work underscores the significance of cultural sensitivity in psychological assessment and advocates for localized validation of widely used instruments.

Body esteem encompasses multidimensional constructs. The BESAA measures three subdomains: appearance esteem, weight esteem, and attribution esteem. Each subdomain reflects unique facets of an adolescent’s perception of their body and related social interactions. Appearance esteem evaluates satisfaction with one’s physical look apart from weight. Weight esteem directly concerns feelings about body weight, a parameter heavily influenced by cultural ideals and media portrayals. Attribution esteem measures perceptions of how others evaluate one’s body, incorporating the social dimension of self-image. Luo et al.’s study reaffirmed that these subdomains are discrete yet interconnected components, collectively providing a more holistic and nuanced understanding of body esteem.

Moreover, this research illuminated gender differences prevalent among Chinese adolescents with respect to body esteem. Consistent with global findings, females in the sample exhibited lower scores in weight esteem and appearance esteem compared to males, possibly reflecting societal pressures related to female physical attractiveness norms. These findings highlight the necessity of gender-sensitive approaches in both research and interventions aimed at improving adolescent mental health. Understanding gender-specific patterns in body esteem opens avenues for tailored prevention programs that can better address the unique challenges faced by boys and girls.

The implications of validating the Chinese BESAA extend well beyond academic interest. It provides practitioners, including psychologists, educators, and public health officials, a reliable instrument to screen for body image disturbances within school and clinical settings. Accurate identification of low body esteem may facilitate earlier interventions, potentially mitigating the progression to more severe psychological disorders. Importantly, assessment tools like the BESAA can serve as outcome measures for evaluating the effectiveness of intervention programs focused on enhancing body positivity and self-acceptance among adolescents.

From a broader perspective, the research conducted by Luo et al. contributes to the ever-growing field of cross-cultural psychology, highlighting how cultural values intersect with youth identity development and self-perception. It emphasizes that while core psychological constructs such as self-esteem are universal, their manifestations and the ways individuals internalize societal feedback differ vastly across societies. This intersectionality mandates dedicated research within various cultural contexts to avoid ethnocentric biases and to generate globally valid psychological theories and applications.

An exciting frontier opened by this validated scale lies in the potential for longitudinal research. By utilizing a standardized and culturally validated tool, future studies can track changes in body esteem over time among Chinese adolescents, identifying critical windows of vulnerability and resilience. Such longitudinal data will illuminate developmental trajectories and the impact of sociocultural dynamics such as the influence of social media, urbanization, and evolving beauty standards. This knowledge could lead to dynamic adaptation of intervention strategies, enhancing their timeliness and effectiveness.

Additionally, the study paves the way for comparative international research. With the Chinese version of the BESAA now psychometrically validated, researchers worldwide have an opportunity to engage in cross-national studies investigating similarities and divergences in adolescent body esteem across cultures. Such comparisons can accelerate our understanding of universal versus culture-specific determinants of body image, enriching global health literature and informing multinational health policies focusing on adolescent well-being.

The intersection of psychometrics and adolescent psychology showcased in Luo et al.’s work also informs technological innovation. Given the rising integration of digital health tools in mental health monitoring, a psychometrically sound and culturally validated BESAA can be embedded in mobile applications and online platforms targeting adolescent users in China. This integration offers scalable, real-time assessments, promoting proactive mental health engagement and reducing stigma associated with conventional clinical interviews.

It is also noteworthy that this study’s timing aligns with shifting global dialogues around body positivity and inclusivity. By establishing a rigorous Chinese version of the BESAA, the research supports these socio-cultural movements, facilitating evidence-based advocacy and policy-making that champions diverse and healthy body images in educational curricula and media portrayals. Such influence underscores the synergy between scientific advancement and societal transformation.

Furthermore, the detailed statistical validation procedures employed ensure that the BESAA is not simply reliable but also practically useful in clinical diagnostics. For example, Cronbach’s alpha coefficients indicated high internal consistency, confirming that the items within each subscale coherently measure the same underlying construct. Test-retest reliability results demonstrated stability over time, a crucial feature for tracking treatment progress. These psychometric properties collectively give researchers and clinicians confidence in the scale’s applicability across various contexts.

In summary, Luo, He, Wang, and colleagues have provided a pivotal contribution by ensuring that the Body Esteem Scale for Adolescents and Adults is both linguistically and culturally attuned to Chinese adolescents. Their study addresses a critical gap in adolescent psychological assessment, equipping the scientific and clinical community with a validated tool capable of informing prevention and intervention strategies. As body esteem emerges as a cornerstone of adolescent mental health, this research facilitates a deeper understanding of the complex interplay between culture, gender, and self-perception, embodying a significant stride forward in global psychological science.

Subject of Research:
Psychometric evaluation and cultural validation of the Chinese version of the Body Esteem Scale for Adolescents and Adults (BESAA) among adolescent populations.

Article Title:
Psychometric properties of the Chinese version of the Body Esteem Scale for Adolescents and Adults (BESAA) among adolescents.

Article References:
Luo, D., He, A., Wang, Q. et al. Psychometric properties of the Chinese version of the Body Esteem Scale for Adolescents and Adults (BESAA) among adolescents. BMC Psychol 13, 602 (2025). https://doi.org/10.1186/s40359-025-02955-y

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