Narcissus was the character from Greek mythology who fell in love with his own reflection and subsequently suffered one of a variety of tragic deaths, depending on which version of the tale you listen to. In the modern world, the metaphor of Narcissus would have less to do with love and more to do with a deep-rooted anxiety, the sort of social angst that an adolescent feels just before entering his first dance. An iterative process of self-assessment mixed with a generous helping of self-loathing.

Too fat? Too skinny? Too many zits? Dated clothes? Because we incorporate the message that "image" equals "rank in the pecking order," we have become a body-image-obsessed society, seeking a perfection that generally remains just out of reach.

The moral of Narcissus, though, that self-absorption just isn't good for you, still rings true today. Negative self-imagery acquired as a child can persist well into adulthood, and might even in some cases be permanent. The problem is that this doesn't appear to be something we have a choice about. Body image may well be a hard-wired human characteristic with extended implications for social rank, personal happiness and even socioeconomic outcomes.

When self-image goes bad, the consequences are significant. Conditions like anorexia nervosa, in which the body image of the patient drives extreme dieting behaviour, are well-known and sometimes fatal illnesses. Self-image, though, is a spectrum; the definition of any particular point on that spectrum as "illness" is largely socially determined.

What constitutes sick?

Walk into any gym. A small subset of the customers will be trying to sculpt their bodies into shapes that are, truly, quite abnormal by any evolutionary standards. Are people who do this "sick"? Or do they just have a different aesthetic than the norm? What is the difference, after all, between body sculpting and, say, tattooing?

Suppose, though, that the drive to a "better" body has potential risks; if someone has, for example, cardiac issues or joint disease, but won't stop running? Is she "sick" now?

Extend it further: what about anabolic steroids? Does the willing acceptance of serious potential medical risk just to conform to a particular body aesthetic constitute a mental illness? How is this different from the risks "willingly" taken by anorexia victims?

At what point do we declare the obsession with self-image to be a pathological state?

Pathological exercise is a form of body image disorder, in exactly the same category as anorexia or bulimia, yet we don't often recognize it as such because it is much more socially acceptable to be cut and buff than it is to starve yourself to death. Maybe it is true that the consequences of an obsession are reasonable grounds to convict it as disease; if a false body image results in healthy behaviour, who are we to judge?

Body image vs. reality

The problem, of course, is that individuals with poor body image, despite the realities of body shape, are often more unhappy than controls. Further, approaching an ideal body shape or social status in no way guarantees that body worries will disappear. "Popular" and "attractive" are synonyms for adolescents, yet studies have shown that girls identified by peers as "popular" actually had poorer body images than others. The stress and strain surrounding maintenance of social status is significant for adolescents and adults alike.

Once, body or self-image was thought to be acquired and set in the teen years. It now seems to be far more likely that the construction of body image, like most parameters of self, is far more fluid, probably beginning much earlier than previously thought and persisting well into adulthood. As a pediatrician, I certainly see children as young as six years old who consider themselves "fat" (or "stupid" or "bad"), who have, in other words, begun the process of acquiring a "negative self."

Self-image is another example of a memetic process. A "meme" is an idea, and meme theory states that ideas transmit like viruses, replicate in the minds of susceptible individuals (i.e. in "fertile environments") and evolve as they are modified by their hosts. Self-construction is a very complicated concept, but probably consists of an interplay between many ideas, each of which has to get into and persist in the head of the individual. The whole process is likely guided by various factors. Some, like genetic background, are probably biological, and may act by selecting which ideas will flourish in an individual's mind and which will fail. Children who are depressed, for example, probably have more negative memes than those who aren't; depression is at least partially determined by genetic (biological) factors. Other influences on self-construction are more societal, more informatics-based, and relate to the sort of ideas that are out there to be absorbed in the first place.

In children, the memes that create self-image are provided by media, family and peers. While it is not known just how this all comes together, it is clear that for children, especially adolescents, the memes provided by peers and to some extent media can trump those provided by family. Adolescents appear to select someone to compare themselves to, an attribute to compare, then through a complex process decide just how they measure up. If the answer is negative, self-image can take a big hit. While media is a pervasive advertiser that aggressively shapes the way adolescents think, ultimately it is the peer group that has the biggest effect. For a parent, this means that a fundamental contributor to a child's future happiness is outside of the home, and therefore to some extent, outside parental control.

So how can parents help their children establish and maintain a positive self and body image? Research is sadly lacking. However, my advice is to begin early in childhood, to inoculate your child with positive memes, so that by the time adolescence arrives, he or she is armed and ready.

Common truths of parenting apply here. For the first six or seven years of a child's life, there is no more important evaluator than a parent. Having time to parent well, providing a positive role model, and minimizing criticism while rewarding and reflecting the positive aspects of your child will build confidence and self-esteem. Dedicated time now pays big dividends down the road.

Sports may enhance a positive self-image, but there are a number of potential pitfalls. Success at some sports requires a specific body shape (gymnasts, figure skaters and ballerinas beware). Because of this, kids who aren't the ideal shape may draw negatives instead of the positives from participating. Organized sports may offer your child an opportunity to be accepted by peers, and therefore to be less exposed to the negative comments and bullying that so powerfully degrade self-image. It is important, however, to emphasize the individual objectives and accomplishments of players. This can sometimes be difficult in team sports such as hockey, soccer and basketball because so much of the emphasis is on goal scoring. Individual sports, like track, running and (my favourite) competitive swimming offer the child the chance to win even when she loses: even if your son doesn't win the race, he can win by setting a best personal time. For a child, competing against self guarantees success, and success at a sport implies at least some degree of satisfaction with body image.

Selection of a sport should be individualized by parents. It is important to start early, say by four or five years of age, to try lots of different sports, and to let your child's successes and inclinations guide you as to whether any one particular sport is right for him. Don't push! Let your child find his or her own way.

Notice just how difficult this process is for children of low-income families. Sport participation is increasingly expensive, and there just isn't that much help out there. The current offering from government, an income-tax deduction for some of the costs of sports programs, is very helpful for those of us who earn a living (and probably don't need the benefit), but useless for those parents too poor to pay much tax in the first place. More needs to be done.

Activity tops dieting

Major impacts on body image in childhood occur because of medically related issues. Children with asthma, for example, can have symptoms that punish them for being active. If you wheeze and cough when you run, you are likely to self-select away from running. You might perceive yourself as being unfit, and eventually this might become true. The vast majority of asthmatic children can exercise just as much as they want. If they wheeze, they should be treated more aggressively so that exercise-induced symptoms don't occur, but in general, they should not be pulled from sports they love because of their lungs (that's in general, talk to your child's doctor about the details in your case). Good control of the asthma is the issue, not cessation of exercise.

Children who are obese are also a special case. Here the challenge is to address the very real health risks of childhood obesity without inducing self-hatred (or eating disorders) in the process. Many different approaches exist for this; mine is to avoid aggressive dieting and focus on exercise. Again, I like swimming and other individual sports, because they offer rewards to the child almost immediately, and if coached properly burn a lot of calories. Nothing hooks a kid like success; if your child gets faster each time she is measured, she will know that she is succeeding. An emphasis on personal bests, heart rate and overall fitness should replace an emphasis on weight, diet and body shape. Teach your child to be delighted with his capabilities and his improvement, and not to focus on his body type.

Finally: bullying. Research into the risk factors for body-image disorder in childhood repeatedly demonstrates how critically important peer relations and opinions are for a child's self image. Bullying in school age and adolescent children may be as detrimental to the psychosocial development of a child as abuse at home. Schools and parent groups have stepped up on this issue over the last two decades, and no-tolerance programs are having an effect. If you are the parent of a kid who is being bullied, your primary role is that of unceasing advocate for the safety and health of your child. Most teachers and principals are well informed on this issue and can be very effective in managing it; don't quit until you get your child's needs met.

There are all sorts of measures that can be used to assess the success of a child; we often look at school marks, or sports performance, or accomplishments in other areas like music and the arts. We emphasize skill set, intelligence, and social capability, all of which are clearly important characteristics of a successful child. But sometimes I think we risk missing the point, that all these measures are really just mechanisms by which true success is achieved. A successful child is one who is happy, and happiness springs from within, from a satisfaction with and confidence regarding self. As parents, teachers and caregivers, we could, and should, put more emphasis on this outcome.

Brett Taylor is an associate professor of pediatrics and emergency medicine at Dalhousie University. He works as an emergency paediatrician and researcher at the IWK Health Centre in Halifax. He is in the process of obtaining a Masters in Health Informatics, also through Dalhousie. His website for parents is available at www.thevirtualpediatrician.com.

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