Self-esteem in a broad-spectrum approach for
mental health promotion
Michal (Michelle) Mann
, Clemens M. H. Hosman
, Herman P. Schaalma
and Nanne K. de Vries
Self-evaluation is crucial to mental and social
well-being. It inﬂuences aspirations, personal
goals and interaction with others. This paper
stresses the importance of self-esteem as a pro-
tective factor and a non-speciﬁc risk factor in
physical and mental health. Evidence is pre-
sented illustrating that self-esteem can lead to
better health and social behavior, and that poor
self-esteem is associated with a broad range of
mental disorders and social problems, both
internalizing problems (e.g. depression, suicidal
tendencies, eating disorders and anxiety) and
externalizing problems (e.g. violence and sub-
stance abuse). We discuss the dynamics of self-
esteem in these relations. It is argued that
an understanding of the development of self-
esteem, its outcomes, and its active protection
and promotion are critical to the improvement
of both mental and physical health . The
consequences for theory development, program
development and health education research are
addressed. Focusing on self-esteem is consid-
ered a core element of mental health promotion
and a fruitful basis for a broad-spectrum
The most basic task for one’s mental, emotional
and social health, which begins in infancy and con-
tinues until one dies, is the construction of his/her
positive self-esteem. [(Macdonald, 1994), p. 19]
The beliefs and evaluations people hold about
themselves determine who they are, what they can
do and what they can become (Burns, 1982). These
powerful, inner inﬂuences provide an internal
guiding mechanism, steering and nurturing indi-
viduals through life, and governing their behavior.
People’s concepts and feelings about themselves
are generally labeled as their self-concept and
self-esteem. These, together with their ability to
deal with life’s challenges and to control what
happens to them, are widely documented in liter-
ature (Seligman, 1975; Bandura, 1977; Bowlby,
1980; Rutter, 1992; Harter, 1999).
Self-concept is deﬁned as the sum of an
individual’s beliefs and knowledge about his/her
personal attributes and qualities. It is classed as
a cognitive schema that organizes abstract and
concrete views about the self, and controls the
processing of self-relevant information (Markus,
1977; Kihlstrom and Cantor, 1983). Other concepts,
such as self-image and self-perception, are equiv-
alents to self-concept. Self-esteem is the evaluative
and affective dimension of the self-concept, and
is considered as equivalent to self-regard, self-
estimation and self-worth (Harter, 1999). It refers to
a person’s global appraisal of his/her positive or
negative value, based on the scores a person gives
him/herself in different roles and domains of life
(Rogers, 1981; Markus and Nurius, 1986). Positive
Department of Health Education and Promotion,
Maastricht University, Maastricht and
Research Center on Program Development and Effect
Management, The Netherlands
Correspondence to: M. Mann, Department of Health
Education and Promotion (GVO), PO Box 616,
6200 MD Maastricht, The Netherlands;
HEALTH EDUCATION RESEARCH Vol.19 no.4 2004
Theory & Practice Pages 357–372
Health Education Research Vol.19 no.4, Ó Oxford University Press 2004; All rights reserved DOI: 10.1093/her/cyg041
self-esteem is not only seen as a basic feature of
mental health, but also as a protective factor that
contributes to better health and positive social
behavior through its role as a buffer against the
impact of negative inﬂuences. It is seen to actively
promote healthy functioning as reﬂected in life
aspects such as achievements, success, satisfaction,
and the ability to cope with diseases like cancer and
heart disease. Conversely, an unstable self-concept
and poor self-esteem can play a critical role in
the development of an array of mental disorders
and social problems, such as depression, anorexia
nervosa, bulimia, anxiety, violence, substance abuse
and high-risk behaviors. These conditions not only
result in a high degree of personal suffering, but also
impose a considerable burden on society. As will be
shown, prospective studies have highlighted low
self-esteem as a risk factor and positive self-esteem
as a protective factor. To summarize, self-esteem is
considered as an inﬂuential factor both in physical
and mental health, and therefore should be an
important focus in health promotion; in particular,
mental health promotion.
Health promotion refers to the process of enabling
people to increase control over and improve their
own health (WHO, 1986). Subjective control as well
as subjective health, each aspects of the self, are
considered as signiﬁcant elements of the health
concept. Recognizing the existence of different views
on the concept of mental health promotion, Sartorius
(Sartorius, 1998), the former WHO Director of
Mental Health, preferred to deﬁne it as a means by
which individuals, groups or large populations can
enhance their competence, self-esteem and sense of
well-being. This view is supported by Tudor (Tudor,
1996) in his monograph on mental health promotion,
where he presents self-concept and self-esteem as two
of the core elements of mental health, and therefore as
an important focus of mental health promotion.
This article aims to clarify how self-esteem is
related to physical and mental health, both empiri-
cally and theoretically, and to offer arguments for
enhancing self-esteem and self-concept as a major
aspect of health promotion, mental health pro-
motion and a ‘Broad-Spectrum Approach’ (BSA) in
The ﬁrst section presents a review of the empirical
evidence on the consequences of high and low self-
esteem in the domains of mental health, health and
social outcomes. The section also addresses the
bi-directional nature of the relationship between
self-esteem and mental health. The second section
discusses the role of self-esteem in health promotion
from a theoretical perspective. How are differ-
entiations within the self-concept related to self-
esteem and mental health? How does self-esteem
relate to the currently prevailing theories in the ﬁeld
of health promotion and prevention? What are the
mechanisms that link self-esteem to health and
social outcomes? Several theories used in health
promotion or prevention offer insight into such
mechanisms. We discuss the role of positive
self-esteem as a protective factor in the context of
stressors, the developmental role of negative self-
esteem in mental and social problems, and the role of
self-esteem in models of health behavior. Finally,
implications for designing a health-promotion
strategy that could generate broad-spectrum out-
comes through addressing common risk factors such
as self-esteem are discussed. In this context, schools
are considered an ideal setting for such broad-
spectrum interventions. Some examples are offered
of school programs that have successfully contrib-
uted to the enhancement of self-esteem, and the
prevention of mental and social problems.
Self-esteem and mental well-being
Empirical studies over the last 15 years indicate that
self-esteem is an important psychological factor
contributing to health and quality of life (Evans,
1997). Recently, several studies have shown that
subjective well-being signiﬁcantly correlates with
high self-esteem, and that self-esteem shares
signiﬁcant variance in both mental well-being and
happiness (Zimmerman, 2000). Self-esteem has
been found to be the most dominant and powerful
predictor of happiness (Furnham and Cheng, 2000).
Indeed, while low self-esteem leads to maladjust-
ment, positive self-esteem, internal standards and
aspirations actively seem to contribute to ‘well-
being’ (Garmezy, 1984; Glick and Zigler, 1992).
According to Tudor (Tudor, 1996), self-concept,
M. Mann et al.
identity and self-esteem are among the key
elements of mental health.
Self-esteem, academic achievements
and job satisfaction
The relationship between self-esteem and academic
achievement is reported in a large number of studies
(Marsh and Yeung, 1997; Filozof et al., 1998; Hay
et al., 1998). In the critical childhood years, positive
feelings of self-esteem have been shown to increase
children’s conﬁdence and success at school (Coop-
ersmith, 1967), with positive self-esteem being a
predicting factor for academic success, e.g. reading
ability (Markus and Nurius, 1986). Results of a
longitudinal study among elementary school chil-
dren indicate that children with high self-esteem
have higher cognitive aptitudes (Adams, 1996).
Furthermore, research has revealed that core self-
evaluations measured in childhood and in early
adulthood are linked to job satisfaction in middle
age (Judge et al., 2000).
Self-esteem and coping with stress
in combi nation with coping with
The protective nature of self-esteem is particularly
evident in studies examining stress and/or physical
disease in which self-esteem is shown to safeguard
the individual from fear and uncertainty. This is
reﬂected in observations of chronically ill individ-
uals. It has been found that a greater feeling of
mastery, efﬁcacy and high self-esteem, in combi-
nation with having a partner and many close
relationships, all have direct protective effects on
the development of depressive symptoms in the
chronically ill (Penninx et al., 1998). Self-esteem
has also been shown to enhance an individual’s
ability to cope with disease and post-operative
survival. Research on pre-transplant psychological
variables and survival after bone marrow trans-
plantation (Broers et al., 1998) indicates that high
self-esteem prior to surgery is related to longer
survival. Chang and Mackenzie (Chang and Mack-
enzie, 1998) found that the level of self-esteem was
a consistent factor in the prediction of the functional
outcome of a patient after a stroke.
To conclude, positive self-esteem is associated
with mental well-being, adjustment, happiness,
success and satisfaction. It is also associated with
recovery after severe diseases.
Identity development and the
sources of negative self-esteem
The evolving nature of self-esteem was conceptu-
alized by Erikson (Erikson, 1968) in his theory on
the stages of psychosocial development in children,
adolescents and adults. According to Erikson,
individuals are occupied with their self-esteem
and self-concept as long as the process of crystal-
lization of identity continues. If this process is not
negotiated successfully, the individual remains
confused, not knowing who (s)he really is. Identity
problems, such as unclear identity, diffused identity
and foreclosure (an identity status based on whether
or not adolescents made ﬁrm commitments in
life. Persons classiﬁed as ‘foreclosed’ have made
future commitments without ever experiencing the
‘crises’ of deciding what really suits them best),
together with low self-esteem, can be the cause
and the core of many mental and social problems
(Marcia et al., 1993).
The development of self-esteem during child-
hood and adolescence depends on a wide variety of
intra-individual and social factors. Approval and
support, especially from parents and peers, and self-
perceived competence in domains of importance
are the main determinants of self-esteem [for
a review, see (Harter, 1999)]. Attachment and un-
conditional parental support are critical during the
phases of self-development. This is a reciprocal
process, as individuals with positive self-esteem
can better internalize the positive view of signiﬁ-
cant others. For instance, in their prospective study
among young adolescents, Garber and Flynn
(Garber and Flynn, 2001) found that negative
self-worth develops as an outcome of low maternal
acceptance, a maternal history of depression and
exposure to negative interpersonal contexts, such as
negative parenting practices, early history of child
maltreatment, negative feedback from signiﬁcant
Self-esteem in a BSA for mental health promotion
others on one’s competence, and family discord and
Other sources of negative self-esteem are
discrepancies between competing aspects of the
self, such as between the ideal and the real self,
especially in domains of importance. The larger the
discrepancy between the value a child assigns to
a certain competence area and the perceived self-
competence in that area, the lower the feeling of
self-esteem (Harter, 1999). Furthermore, discrep-
ancies can exist between the self as seen by oneself
and the self as seen by signiﬁcant others. As implied
by Harter (Harter, 1999), this could refer to con-
trasts that might exist between self-perceived com-
petencies and the lack of approval or support by
parents or peers.
Finally, negative and positive feelings of self-
worth could be the result of a cognitive, inferential
process, in which children observe and evaluate
their own behaviors and competencies in speciﬁc
domains (self-efﬁcacy). The poorer they evaluate
their competencies, especially in comparison to
those of their peers or to the standards of signiﬁcant
others, the more negative their self-esteem. Such
self-monitoring processes can be negatively or
positively biased by a learned tendency to negative
or positive thinking (Seligman et al., 1995).
Outcomes of poor self-esteem
The outcomes of negative self-esteem can be
manifold. Poor self-esteem can result in a cascade
of diminishing self-appreciation, creating self-
defeating attitudes, psychiatric vulnerability, social
problems or risk behaviors. The empirical literature
highlights the negative outcomes of low self-
esteem. However, in several studies there is a lack
of clarity regarding causal relations between
self-esteem and problems or disorders (Flay and
Ordway, 2001). This is an important observation,
as there is reason to believe that self-esteem should
be examined not only as a cause, but also as a
consequence of problem behavior. For example,
on the one hand, children could have a negative
view about themselves and that might lead to
depressive feelings. On the other hand, depression
or lack of efﬁcient functioning could lead to feeling
bad, which might decrease self-esteem. Although
the directionality can work both ways, this article
concentrates on the evidence for self-esteem as a
potential risk factor for mental and social outcomes.
Three clusters of outcomes can be differentiated.
The ﬁrst are mental disorders with internalizing
characteristics, such as depression, eating disorders
and anxiety. The second are poor social outcomes
with externalizing characteristics including aggres-
sive behavior, violence and educational exclusion.
The third is risky health behavior such as drug
abuse and not using condoms.
Self-esteem and internalizing mental
Self-esteem plays a signiﬁcant role in the develop-
ment of a variety of mental disorders. According to
the Diagnostic and Statistical Manual of Mental
Disorders (DSM IV), negative or unstable self-
perceptions are a key component in the diagnostic
criteria of major depressive disorders, manic and
hypomanic episodes, dysthymic disorders, dissocia-
tive disorders, anorexia nervosa, bulimia nervosa, and
in personality disorders, such as borderline, narcis-
sistic and avoidant behavior. Negative self-esteem is
also found to be a risk factor, leading to maladjust-
ment and even escapism. Lacking trust in themselves,
individuals become unable to handle daily problems
which, in turn, reduces the ability to achieve
maximum potential. This could lead to an alarming
deterioration in physical and mental well-being. A
decline in mental health could result in internalizing
problem behavior such as depression, anxiety and
eating disorders. The outcomes of low self-esteem for
these disorders are elaborated below.
Depressed m oods, depression and suicidal
The clinical literature suggests that low self-esteem
is related to depressed moods (Patterson and
Capaldi, 1992), depressive disorders (Rice et al.,
1998; Dori and Overholser, 1999), hopeless-
ness, suicidal tendencies and attempted suicide
M. Mann et al.
(Overholser et al., 1995). Correlational studies
have consistently shown a signiﬁcant negative
relationship between self-esteem and depression
(Beck et al., 1990; Patton, 1991). Campbell et al.
(Campbell et al., 1991) found individual appraisal
of events to be clearly related to their self-esteem.
Low self-esteem subjects rated their daily events as
less positive and negative life events as being more
personally important than high self-esteem sub-
jects. Individuals with high self-esteem made more
stable and global internal attributions for positive
events than for negative events, leading to the
reinforcement of their positive self-image. Subjects
low in self-esteem, however, were more likely to
associate negative events to stable and global
internal attributions, and positive events to external
factors and luck (Campbell et al., 1991). There is
a growing body of evidence that individuals with
low self-esteem more often report a depressed state,
and that there is a link between dimensions of
attributional style, self-esteem and depression
(Abramson et al., 1989; Hammen and Goodman-
Some indications of the causal role of self-esteem
result from prospective studies. In longitudinal
studies, low self-esteem during childhood (Rein-
herz et al., 1993), adolescence (Teri, 1982) and
early adulthood (Wilhelm et al., 1999) was
identiﬁed as a crucial predictor of depression later
in life. Shin (Shin, 1993) found that when
cumulative stress, social support and self-esteem
were introduced subsequently in regression analy-
sis, of the latter two, only self-esteem accounted for
signiﬁcant additional variance in depression. In
addition, Brown et al. (Brown et al., 1990) showed
that positive self-esteem, although closely associ-
ated with inadequate social support, plays a role as
a buffer factor. There appears to be a pathway from
not living up to personal standards, to low self-
esteem and to being depressed (Harter, 1986, 1990;
Higgins, 1987, 1989; Baumeister, 1990). Alterna-
tively, another study indicated that when examining
the role of life events and difﬁculties, it was found
that total level of stress interacted with low self-
esteem in predicting depression, whereas self-
esteem alone made no direct contribution (Miller
et al., 1989). To conclude, results of cross-sectional
and longitudinal studies have shown that low
self-esteem is predictive of depression.
The potentially detrimental impact of low self-
esteem in depressive disorders stresses the signif-
icance of Seligman’s recent work on ‘positive
psychology’. His research indicates that teaching
children to challenge their pessimistic thoughts
whilst increasing positive subjective thinking (and
bolstering self-esteem) can reduce the risk of
pathologies such as depression (Seligman, 1995;
Seligman et al., 1995; Seligman and Csikszentmi-
Other internalizing disorders
Although low self-esteem is most frequently
associated with depression, a relationship has also
been found with other internalizing disorders, such
as anxiety and eating disorders. Research results
indicate that self-esteem is inversely correlated with
anxiety and other signs of psychological and
physical distress (Beck et al., 2001). For example,
Ginsburg et al. (Ginsburg et al., 1998) observed
a low level of self-esteem in highly socially anxious
children. Self-esteem was shown to serve the
fundamental psychological function of buffering
anxiety, with the pursuit of self-esteem as a de-
fensive avoidance tool against basic human fears.
This mechanism of defense has become evident in
research with primary (Ginsburg et al., 1998) and
secondary school children (Fickova, 1999). In
addition, empirical studies have shown that bol-
stering self-esteem in adults reduces anxiety
(Solomon et al., 2000).
The critical role of self-esteem during school
years is clearly reﬂected in studies on eating
disorders. At this stage in life, weight, body shape
and dieting behavior become intertwined with
identity. Researchers have reported low self-esteem
as a risk factor in the development of eating
disorders in female school children and adolescents
(Fisher et al., 1994; Smolak et al., 1996; Shisslak
et al., 1998), as did prospective studies (Vohs et al.,
2001). Low self-esteem also seems predictive of the
poor outcome of treatment in such disorders, as has
been found in a recent 4-year prospective follow-up
Self-esteem in a BSA for mental health promotion
study among adolescent in-patients with bulimic
characteristics (van der Ham et al., 1998). The
signiﬁcant inﬂuence of self-esteem on body image
has led to programs in which the promotion of self-
esteem is used as a main preventive tool in eating
disorders (St Jeor, 1993; Vickers, 1993; Scarano
et al., 1994).
To sum up, there is a systematic relation between
self-esteem and internalizing problem behavior.
Moreover, there is enough prospective evidence to
suggest that poor self-esteem might contribute to
deterioration of internalizing problem behavior
while improvement of self-esteem could prevent
Self-esteem, externalizing problems
and other poor social outcomes
For more than two decades, scientists have studied
the relationship between self-esteem and exter-
nalizing problem behaviors, such as aggression,
violence, youth delinquency and dropping out of
school. The outcomes of self-esteem for these
disorders are described below.
Violence and aggressive behavior
While the causes of such behaviors are multiple and
complex, many researchers have identiﬁed self-
esteem as a critical factor in crime prevention,
rehabilitation and behavioral change (Kressly,
1994; Gilbert, 1995). In a recent longitudinal
questionnaire study among high-school adoles-
cents, low self-esteem was one of the key risk
factors for problem behavior (Jessor et al., 1998).
Recent studies conﬁrm that high self-esteem is
signiﬁcantly associated with less violence (Fleming
et al., 1999; Horowitz, 1999), while a lack of self-
esteem signiﬁcantly increases the risk of violence
and gang membership (Schoen, 1999). Results of
a nationwide study of bullying behavior in Ireland
show that children who were involved in bullying
as either bullies, victims or both had signiﬁcantly
lower self-esteem than other children (Schoen,
1999). Adolescents with low self-esteem were
found to be more vulnerable to delinquent behavior.
Interestingly, delinquency was positively associ-
ated with inﬂated self-esteem among these ado-
lescents after performing delinquent behavior
(Schoen, 1999). According to Kaplan’s self-
derogation theory of delinquency (Kaplan, 1975),
involvement in delinquent behavior with delinquent
peers can increase children’s self-esteem and sense
of belonging. It was also found that individuals
with extremely high levels of self-esteem and narcis-
sism show high tendencies to express anger and
aggression (Baumeister et al., 2000). To conclude,
positive self-esteem is associated with less aggres-
sive behavior. Although most studies in the ﬁeld of
aggressive behavior, violence and delinquency are
correlational, there is some prospective evidence
that low self-esteem is a risk factor in the de-
velopment of problem behavior. Interestingly,
low self-esteem as well as high and inﬂated self-
esteem are both associated with the development of
Dropping out from the educational system could
also reﬂect rebellion or antisocial behavior resul-
ting from identity diffusion (an identity status based
on whether or not adolescents made ﬁrm commit-
ments in life. Adolescents classiﬁed as ‘diffuse’
have not yet thought about identity issues or,
having thought about them, have failed to make any
ﬁrm future oriented commitments). For instance,
Muha (Muha, 1991) has shown that while self-
image and self-esteem contribute to competent
functioning in childhood and adolescence, low self-
esteem can lead to problems in social functioning
and school dropout. The social consequences of
such problem behaviors may be considerable for
both the individual and the wider community.
Several prevention programs have reduced the
dropout rate of students at risk (Alice, 1993;
Andrews, 1999). All these programs emphasize
self-esteem as a crucial element in dropout
Self-esteem and risk behavior
The impact of self-esteem is also evident in risk
behavior and physical health. In a longitudinal
study, Rouse (Rouse, 1998) observed that resilient
adolescents had higher self-esteem than their
M. Mann et al.
non-resilient peers and that they were less likely
to initiate a variety of risk behaviors. Positive self-
esteem is considered as a protective factor against
substance abuse. Adolescents with more positive
self-concepts are less likely to use alcohol or drugs
(Carvajal et al., 1998), while those suffering with
low self-esteem are at a higher risk for drug and
alcohol abuse, and tobacco use (Crump et al., 1997;
Jones and Heaven, 1998). Carvajal et al. (Carvajal
et al., 1998) showed that optimism, hope and
positive self-esteem are determinants of avoiding
substance abuse by adolescents, mediated by
attitudes, perceived norms and perceived behav-
ioral control. Although many studies support the
ﬁnding that improving self-esteem is an important
component of substance abuse prevention (Devlin,
1995; Rodney et al., 1996), some studies found no
support for the association between self-esteem and
heavy alcohol use (Poikolainen et al., 2001).
Empirical evidence suggests that positive self-
esteem can also lead to behavior which is
protective against contracting AIDS, while low
self-esteem contributes to vulnerability to HIV/
AIDS (Rolf and Johnson, 1992; Somali et al.,
2001). The risk level increases in cases where
subjects have low self-esteem and where their
behavior reﬂects efforts to be accepted by others or
to gain attention, either positively or negatively
(Reston, 1991). Lower self-esteem was also related
to sexual risk-taking and needle sharing among
homeless ethnic-minority women recovering from
drug addiction (Nyamathi, 1991). Abel (Abel,
1998) observed that single females whose partners
did not use condoms had lower self-esteem than
single females whose partners did use condoms. In
a study of gay and/or bisexual men, low self-
esteem proved to be one of the factors that made it
difﬁcult to reduce sexual risk behavior (Paul et al.,
To summarize, the literature reveals a number of
studies showing beneﬁcial outcomes of positive
self-esteem, and conversely, negative outcomes
of poor self-esteem, especially in adolescents.
Prospective studies and intervention studies have
shown that self-esteem can be a causal factor in
depression, anxiety, eating disorders, delinquency,
school dropout, risk behavior, social functioning,
academic success and satisfaction. However, the
cross-sectional character of many other studies does
not exclude that low self-esteem can also be
considered as an important consequence of such
disorders and behavioral problems.
To assess the implications of these ﬁndings for
mental health promotion and preventive interven-
tions, more insight is needed into the antecedents of
poor self-esteem, and the mechanisms that link self-
esteem to mental, physical and social outcomes.
Mechanisms linking self-esteem
and health behavior
What are the mechanisms that link self-esteem to
health and social outcomes? Several theories used
in health promotion or prevention offer insight into
such mechanisms. In this section we discuss the
role of positive self-esteem as a protective factor in
the context of stressors, the developmental role of
negative self-esteem in mental and social problems,
and the role of self-esteem in models of health
Positive thinking about oneself
as a protective factor in the context
People have a need to think positively about
themselves, to defend and to improve their positive
self-esteem, and even to overestimate themselves.
Self-esteem represents a motivational force that
inﬂuences perceptions and coping behavior. In the
context of negative messages and stressors, positive
self-esteem can have various protective functions.
Research on optimism conﬁrms that a somewhat
exaggerated sense of self-worth facilitates mastery,
leading to better mental health (Seligman, 1995).
Evidence suggests that positive self-evaluations,
exaggerated perception of control or mastery and
unrealistic optimism are all characteristic of normal
human thought, and that certain delusions may
contribute to mental health and well-being (Taylor
and Brown, 1988). The mentally healthy person
appears to have the capacity to distort reality in
Self-esteem in a BSA for mental health promotion
a direction that protects and enhances self-esteem.
Conversely, individuals who are moderately depres-
sed or low in self-esteem consistently display an
absence of such enhancing delusions. Self-esteem
could thus be said to serve as a defense mechanism
that promotes well-being by protecting internal
balance. Jahoda (Jahoda, 1958) also included the
‘adequate perception of reality’ as a basic element of
mental health. The degree of such a defense, however,
has its limitations. The beneﬁcial effect witnessed in
reasonably well-balanced individuals becomes in-
valid in cases of extreme self-esteem and signiﬁcant
distortions of the self-concept. Seligman (Seligman,
1995) claimed that optimism should not be based on
unrealistic or heavily biased perceptions.
The protective role of self-worth is also present
in stress theories, in which positive thinking about
oneself is considered to buffer the impact of
stressors. The transactional model of stress and
coping, as developed by Lazarus and Folkman
(Lazarus and Folkman, 1984), is frequently used as
a theoretical basis of preventive interventions in
mental health. The model emphasizes cognitive
appraisals, which center on the evaluation of harm,
threats and challenges, as well as on the options to
cope with such threats. The transactional character
refers to the cognitive process in which particular
environmental conditions are appraised by a partic-
ular person with certain psychological character-
istics. Self-esteem is considered as one of the factors
that inﬂuence both the perception of threats and the
evaluation of possible coping reactions. Positive
self-esteem and self-conﬁdence can buffer stress by
mitigating the perceived threat and by enhancing the
selection and implementation of efﬁcacious coping
strategies. As Lazarus and Folkman state:
Viewing yourself positively can also be regarded
as a very important psychological resource for
coping. We include in this category those general
and speciﬁc beliefs that serve as a basis for hope
and that sustain coping efforts in the face of the
most adverse condition... Hope can exist only
when such beliefs make a positive outcome seem
possible, if not probable. [(Lazarus and Folkman,
1984), p. 159]
A high level of self-esteem together with strong
social support makes individuals less vulnerable to
stressors (Brown et al., 1990; Rutter, 1992). Self-
esteem can be seen as an internal moderator of
stressors and social support as an external moder-
ator (Caplan, 1974; Hobfool and Walﬁsch, 1984).
On a far more general level, this is reﬂected in
Albee’s (Albee, 1985) formula for the incidence of
emotional illness in society, used as a theoretical
fundament for primary prevention:
Incidence = organic causes and stressors/compe-
tence, coping skills, self-esteem and social support
Actions that increase the size of the numerator will
increase the incidence of dysfunctional behavior
in society and activities that reduce, modify or
eliminate these factors will diminish the incidence
of dysfunction. Efforts that reduce the size of the
denominator will correspondingly increase the
incidence, whereas actions that increase the size
of the denominator, such as self-esteem, will reduce
Identity, se lf-est eem, and the development
of externalizing and internalizing
Erikson’s (Erikson, 1965, 1968) theory on the
stages of psychosocial development in children,
adolescents, and adults and Herbert’s ﬂow chart
(Herbert, 1987) focus on the vicissitudes of identity
and the development of unhealthy mental and social
problems. According to these theories, when a
person is enduringly confused about his/her own
identity, he/she may possess an inherent lack of
self-reassurance which results in either a low level
of self-esteem or in unstable self-esteem and
feelings of insecurity. However, low self-esteem—
likewise inﬂated self-esteem—can also lead to
identity problems. Under circumstances of insecu-
rity and low self-esteem, the individual evolves in
one of two ways: he/she takes the active escape
route or the passive avoidance route (Herbert,
1987). The escape route is associated with exter-
nalizing behaviors: aggressive behavior, violence
and school dropout, the seeking of reassurance
in others through high-risk behavior, premature
M. Mann et al.
relationships, cults or gangs. Reassurance and se-
curity may also be sought through drugs, alcohol or
food. The passive avoidance route is associated
with internalizing factors: feelings of despair and
depression. Extreme avoidance may even result in
Whether identity and self-esteem problems
express themselves following the externalizing
active escape route or the internalizing passive
avoidance route is dependent on personality
characteristics and circumstances, life events and
social antecedents (e.g. gender and parental sup-
port) (Hebert, 1987). Recent studies consistently
show gender differences regarding externalizing
and internalizing behaviors among others in
a context of low self-esteem (Block and Gjerde,
1986; Rolf et al., 1990; Harter, 1999; Benjet and
Hernandez-Guzman, 2001). Girls are more likely
to have internalizing symptoms than boys; boys
are more likely to have externalizing symptoms.
Moreover, according to Harter (Harter, 1999), in
recent studies girls appear to be better than boys in
positive self-evaluation in the domain of behav-
ioral conduct. Self-perceived behavioral conduct
is assessed as the individual view on how well
behaved he/she is and how he/she views his/her
behavior in accordance with social expectations
(Harter, 1999). Negative self-perceived behavioral
conduct is also found to be an important factor
in mediating externalizing problems (Reda-Norton,
1995; Hoffman, 1999).
The internalization of parental approval or
disapproval is critical during childhood and ado-
lescence. Studies have identiﬁed parents’ and peers’
supportive reactions (e.g. involvement, positive
reinforcement, and acceptance) as crucial determi-
nants of children’s self-esteem and adjustment
(Shadmon, 1998). In contrast to secure, harmonious
parent–child relationships, poor family relation-
ships are associated with internalizing problems
and depression (Kashubeck and Christensen, 1993;
Oliver and Paull, 1995).
Self-esteem in health behavior models
Self-esteem also plays a role in current cognitive
models of health behavior. Health education re-
search based on the Theory of Planned Behavior
(Ajzen, 1991) has conﬁrmed the role of self-
efﬁcacy as a behavioral determinant (Godin and
Kok, 1996). Self-efﬁcacy refers to the subjective
evaluation of control over a speciﬁc behavior.
While self-concepts and their evaluations could be
related to speciﬁc behavioral domains, self-esteem
is usually deﬁned as a more generic attitude towards
the self. One can have high self-efﬁcacy for
a speciﬁc task or behavior, while one has a negative
evaluation of self-worth and vice versa. Neverthe-
less, both concepts are frequently intertwined since
people often try to develop self-efﬁcacy in activities
that give them self-worth (Strecher et al., 1986).
Self-efﬁcacy and self-esteem are therefore not
identical, but nevertheless related. The develop-
ment of self-efﬁcacy in behavioral domains of
importance can contribute to positive self-esteem.
On the other hand, the levels of self-esteem and
self-conﬁdence can inﬂuence self-efﬁcacy, as is
assumed in stress and coping theories.
The Attitude–Social inﬂuence–self-Efﬁcacy
(ASE) model (De Vries and Mudde, 1998; De
Vries et al., 1988a) and the Theory of Triadic
Inﬂuence (TTI) (Flay and Petraitis, 1994) are recent
theories that provide a broad perspective on health
behavior. These theories include distal factors that
inﬂuence proximal behavioral determinants (De
Vries et al., 1998b) and specify more distal streams
of inﬂuence for each of the three core determinants
in the Planned Behavior Model (Azjen, 1991)
(attitudes, self-efﬁcacy and social normative be-
liefs). Each of these behavioral determinants is
assumed to be moderated by several distal factors,
including self-esteem and mental disorders.
The TTI regards self-esteem in the same sense as
the ASE, as a distal factor. According to this theory,
self-efﬁcacy is inﬂuenced by personality character-
istics, especially the ‘sense of self’, which includes
self-integration, self-image and self-esteem (Flay
and Petraitis, 1994).
The Precede–Proceed model of Green and
Kreuter (Green and Kreuter, 1991) for the planning
of health education and health promotion also
recognizes the role of self-esteem. The model
directs health educators to specify characteristics
Self-esteem in a BSA for mental health promotion
of health problems, and to take multiple determi-
nants of health and health-related behavior into
account. It integrates an epidemiological, behav-
ioral and environmental approach. The staged
Precede–Proceed framework supports health edu-
cators in identifying and inﬂuencing the multiple
factors that shape health status, and evaluating
the changes produced by interventions. Self-esteem
plays a role in the ﬁrst and fourth phase of the
Precede–Proceed model, as an outcome variable
and as a determinant. The initial phase of social
diagnosis, analyses the quality of life of the target
population. Green and Kreuter [(Green and Kreuter,
1991), p. 27] present self-esteem as one of the
outcomes of health behavior and health status, and
as a quality of life indicator. The fourth phase of
the model, which concerns the educational and
organizational diagnosis, describes three clusters
of behavioral determinants: predisposing, enabling
and reinforcing factors. Predisposing factors pro-
vide the rationale or motivation for behavior, such
as knowledge, attitudes, beliefs, values, and per-
ceived needs and abilities [(Green and Kreuter,
1991), p. 154]. Self-knowledge, general self-
appraisal and self-efﬁcacy are considered as
To summarize, self-esteem can function both as
a determinant and as an outcome of healthy behavior
within health behavior models. Poor self-esteem
can trigger poor coping behavior or risk behavior
that subsequently increases the likelihood of certain
diseases among which are mental disorders. On the
other hand, the presence of poor coping behavior
and ill-health can generate or reinforce a negative
Self-esteem in a BSA to mental health
promotion a nd prevention in schools
Given the evidence supporting the role of self-
esteem as a core element in physical and mental
health, it is recommended that its potential in future
health promotion and prevention programs be
The design of future policies for mental health
promotion and the prevention of mental disorders is
currently an area of active debate (Hosman, 2000).
A key question in the discussion is which is more
effective: a preventive approach focusing on
speciﬁc disorders or a more generic preventive
Based on the evidence supporting the role of self-
esteem as a non-speciﬁc risk factor and protective
factor in the development of mental disorders and
social problems, we advocate a generic preventive
approach built around the ‘self’. In general,
changing common risk and protective factors (e.g.
self-esteem, coping skills, social support) and
adopting a generic preventive approach can reduce
the risk of the development of a range of mental
disorders and promote individual well-being even
before the onset of a speciﬁc problem has presented
itself. Given its multi-outcome perspective, we
have termed this strategy the ‘BSA’ in prevention
Self-esteem is considered one of the important
elements of the BSA. By fostering self-esteem, and
hence treating a common risk factor, it is possible to
contribute to the prevention of an array of physical
diseases, mental disorders and social problems
challenging society today. This may also, at a later
date, imply the prevention of a shift to other
problem behaviors or symptoms which might occur
when only problem-speciﬁc risk factors are ad-
dressed. For example, an eating disorder could be
replaced by another type of symptom, such as
alcohol abuse, smoking, social anxiety or de-
pression, when only the eating behavior itself is
addressed and not more basic causes, such as poor
self-esteem, high stress levels and lack of social
support. Although there is, as yet, no published
research on such a shift phenomenon, the high level
of co-morbidity between such problems might
reﬂect the likelihood of its existence. Numerous
studies support the idea of co-morbidity and
showed that many mental disorders have over-
lapping associated risk factors such as self-esteem.
There is a signiﬁcant degree of co-morbidity
between and within internalizing and externalizing
problem behaviors such as depression, anxiety,
substance disorders and delinquency (Harrington
et al., 1996; Angold et al., 1999; Swendsen and
Merikangas, 2000). By considering the individual
M. Mann et al.
as a whole, within the BSA, the risk of such an
eventuality could be reduced.
The BSA could have practical implications.
Schools are an ideal setting for implementing BSA
programs, thereby aiming at preventing an array of
problems, since they cover the entire population.
They have the means and responsibility for the
promotion of healthy behavior for such a common
risk and protective factor, since school children are
in their formative stage. A mental health promotion
curriculum oriented towards emotional and social
learning could include a focus on enhancing self-
esteem. Weare (Weare, 2000) stressed that schools
need to aim at helping children develop a healthy
sense of self-esteem as part of the development of
their ‘intra-personal intelligence’. According to
Gardner (Gardner, 1993) ‘intra-personal intelli-
gence’ is the ability to form an accurate model of
oneself and the ability to use it to operate effectively
in life. Self-esteem, then, is an important component
of this ability. Serious thought should be given to the
practical implementation of these ideas.
It is important to clearly deﬁne the nature of
a BSA program designed to foster self-esteem
within the school setting. In our opinion, such
a program should include important determinants of
self-esteem, i.e. competence and social support.
Harter (Harter, 1999) stated that competence and
social support, together provide a powerful expla-
nation of the level of self-esteem. According to
Harter’s research on self-perceived competence,
every child experiences some discrepancy between
what he/she would like to be, the ‘ideal self’, and
his/her actual perception of him/herself, ‘the real
self’. When this discrepancy is large and it deals
with a personally relevant domain, this will result in
lower self-esteem. Moreover, the overall sense of
support of signiﬁcant others (especially parents,
peers and teachers) is also inﬂuential for the
development of self-esteem. Children who feel that
others accept them, and are unconditionally loved
and respected, will report a higher sense of self-
esteem (Bee, 2000). Thus, children with a high
discrepancy and a low sense of social support
reported the lowest sense of self-esteem. These
results suggest that efforts to improve self-esteem in
children require both supportive social surround-
ings and the formation and acceptance of realistic
personal goals in the personally relevant domains
In addition to determinants such as competence
and social support, we need to translate the theo-
retical knowledge on coping with inner self-
processes (e.g. inconsistencies between the real
and ideal self) into practice, in order to perform
a systematic intervention regarding the self. Harter’s
work offers an important foundation for this. Based
on her own and others’ research on the development
of the self, she suggests the following principles to
prevent the development of negative self-esteem and
to enhance self-worth (Harter, 1999):
(1) Reduction of the discrepancy between the real
self and the ideal self.
(2) Encouragement of relatively realistic self-
(3) Encouraging the belief that positive self-
evaluations can be achieved.
(4) Appreciation for the individual’s views about
their self-esteem and individual perceptions on
causes and consequences of self-worth.
(5) Increasing awareness of the origins of negative
(6) Providing a more integrated personal con-
struct while improving understanding of self-
(7) Encouraging the individual and his/her signif-
icant others to promote the social support they
give and receive.
(8) Fostering internalization of positive opinions
Examples of school health promotion
programs t hat foster self-esteem
Haney and Durlak (Haney and Durlak, 1998) wrote
a meta-analytical review of 116 intervention studies
for children and adolescents. Most studies indicated
signiﬁcant improvement in children’s and adoles-
cents’ self-esteem and self-concept, and as a result
of this change, signiﬁcant changes in behavioral,
personality, and academic functioning. Haney and
Self-esteem in a BSA for mental health promotion
Durlak reported on the possible impact improved
self-esteem had on the onset of social problems.
However, their study did not offer an insight into
the potential effect of enhanced self-esteem on
Several mental health-promoting school pro-
grams that have addressed self-esteem and the
determinants of self-esteem in practice, were
effective in the prevention of eating disorders
(O’Dea and Abraham, 2000), problem behavior
(Flay and Ordway, 2001), and the reduction of
substance abuse, antisocial behavior and anxiety
(Short, 1998). We shall focus on the ﬁrst two
programs because these are universal programs,
which focused on ‘mainstream’ school children.
The prevention of eating disorders program ‘Every-
body’s Different’ (O’Dea and Abraham, 2000) is
aimed at female adolescents aged 11–14 years old.
It was developed in response to the poor efﬁcacy of
conventional body-image education in improving
body image and eating behavior. ‘Everybody’s
Different’ has adopted an alternative methodology
built on an interactive, school-based, self-esteem
approach and is designed to prevent the develop-
ment of eating disorders by improving self-esteem.
The program has signiﬁcantly changed aspects of
self-esteem, body satisfaction, social acceptance
and physical appearance. Female students targeted
by the intervention rated their physical appearance,
as perceived by others, signiﬁcantly higher than
control-group students, and allowed their body
weight to increase appropriately by refraining from
weight-loss behavior seen in the control group.
These ﬁndings were still evident after 12 months.
This is one of the ﬁrst controlled educational
interventions that had successfully improved body
image and produced long-term changes in the
attitudes and self-image of young adolescents.
The ‘Positive Action Program’ (Flay and Ordway,
2001) serves as a unique example of some BSA
principles in practice. The program addresses the
challenge of increasing self-esteem, reducing prob-
lem behavior and improving school performance.
The types of problem behavior in question were
delinquent behavior, ‘misdemeanors’ and objection
to school rules (Flay and Ordway, 2001). This
program concentrates on self-concept and self-
esteem, but also includes other risk and protective
factors, such as positive actions, self-control, social
skills and social support that could be considered as
determinants of self-esteem. Other important deter-
minants of self-esteem, such as coping with internal
self-processes, are not addressed. At present, the
literature does not provide many examples of BSA
studies that produce general preventive effects
among adolescents who do not (yet) display
behavioral problems (Greenberg et al., 2000).
To conclude, research results show beneﬁcial
outcomes of positive self-esteem, which is seen to
be associated with mental well-being, happiness,
adjustment, success, academic achievements and
satisfaction. It is also associated with better re-
covery after severe diseases. However, the evolving
nature of self-esteem could also result in negative
outcomes. For example, low self-esteem can be
a causal factor in depression, anxiety, eating
disorders, poor social functioning, school dropout
and risk behavior. Interestingly, the cross-sectional
characteristic of many studies does not exclude
the possibility that low self-esteem can also be
considered as an important consequence of such
disorders and behavioral problems.
Self-esteem is an important risk and protective
factor linked to a diversity of health and social
outcomes. Therefore, self-esteem enhancement can
serve as a key component in a BSA approach in
prevention and health promotion. The design and
implementation of mental health programs with
self-esteem as one of the core variables is an
important and promising development in health
The authors are grateful to Dr Alastair McElroy for
his constructive comments on this paper. The
authors wish to thank Rianne Kasander (MA) and
M. Mann et al.
Chantal Van Ree (MA) for their assistance in the
literature search. Financing for this study was
generously provided by the Dutch Health Research
and Development Council (Zorg Onderzoek Neder-
Abel, E. (1998) Sexual risk behaviors among ship and shore
based Navy women. Military Medicine, 163, 250–256.
Abramson, L.Y., Metalsky, G.I. and Alloy, L.B. (1989)
Hopelessness depression: a theory based subtype of de-
pression. Psychological Review, 96, 358–372.
Adams, M.J. (1996) Youth in crisis: an examination of adverse
risk factors effecting children’s cognitive and behavioral–
emotional development, children ages 10–16. Dissertation
Abstracts International A: Humanities and Social Sciences,
Ajzen, I. (1991) The theory of planned behavior. Organizational
and Human Decision Processes, 50, 179–211.
Albee, G.W. (1985) The argument for primary prevention.
Journal of primary prevention, 5, 213–219.
Alice, E. (1993) Mediating at risk factors among seventh and
eighth grade students with speciﬁc learning disabilities using
a holistically based model. Dissertation, Nove University.
Andrews, E.J. (1999) The effects of a self-improvement program
on the self-esteem of single college mothers. Dissertation
Abstracts International A: Humanities and Social Sciences,
Angold, A., Costello, E.J. and Erkanli, A. (1999) Comorbidity.
Journal of Child Psychology and Psychiatry, 40, 57–87.
Bandura, A. (1977) Social Learning Theory. Prentice-Hall,
Englewood Cliffs, NJ.
Bandura, A. (1986) Social Foundations of Thought And Action:
A Social Cognitive Theory. Prentice-Hall, Englewood Cliffs,
Baumeister, R.F. (1990) Suicide as escape from self. Psycho-
logical Review, 97, 90–113.
Baumeister, R.F., Bushman, B.J. and Campbell, W.K. (2000)
Self-esteem, narcissism and aggression: does violence result
from low self-esteem or from threatened egotism? Current
Directions in Psychological Science, 9, 26–29.
Beck, A., Steer, R.A., Epstein, N. and Brown, G. (1990) Beck
Self Concept Test. Psychological Assessment, 2, 191–197.
Beck, A.T., Brown, G.K., Steer, R.A., Kuyken, W. and Grisham,
J. (2001) Psychometric properties of the Beck Self-Esteem
Scales. Behavior Research and Therapy, 39, 115–124.
Bee, H.L. (2000) The Developing Child, 9th edn. Allyn & Bacon,
Benjet, C. and Hernandez-Guzman, L. (2001) Gender differ-
ences in psychological well-being of Mexican early adoles-
cents. Adolescence, 36, 47–65.
Block, J. and Gjerde, P.F. (1986) Distinguishing between
antisocial behavior and under control. In Olweus, D., Block,
J. and Radke-Yarrow, M. (eds), Development of Antisocial
and Prosocial Behavior: Research, Theories and Issues.
Academic Press, New York, pp. 117–206.
Bowlby, J. (1980) Attachment and Loss III: Loss Sadness and
Depression. Hogarth Press, London.
Broers, S., Hengeveld, M.W., Kaptein, A.A., Le-Cessie, S., van
de Loo, F. and de Vries, T. (1998) Are pretransplant
psychological variables related to survival after bone marrow
transplantation? A prospective study of 123 consecutive
patients. Journal of Psychosomatic Research, 45, 341–351.
Brown, G.W., Biﬂuco, A. and Andrews, B. (1990) Self esteem
and depression 3. Aetiological issues. Social Psychiatry and
Psychiatry Epidemiology, 25, 235–243.
Burns, R. (1982) Self Concept—Developing and Education.
Dorset Press, Dorchester.
Campbell, J.D., Chew, B. and Scrathley, L. (1991) Cognitive and
emotional reactions to daily events: the effects of self esteem
and self complexity. Journal of Personality and Social
Psychology, 59, 473–505.
Caplan, N. (1974) Who’s to blame? Psychology Today, 8,
Carvajal, S.C., Clair, S.D., Nash, S.G. and Evans, R.I. (1998)
Relating optimism, hope and self-esteem to social inﬂuences
in deterring substance use in adolescents. Journal of Social
and Clinical Psychology, 17, 443–465.
Chang, A.M. and Mackenzie, A.E. (1998) State self-esteem
following stroke. Stroke, 29, 2325–2328.
Coopersmith, S. (1967) The Antecedents of Self Esteem.
Freeman, San Francisco, CA.
Crump, R., Lillie-Blanton, M. and Anthony, J. (1997) The
inﬂuence of self esteem on smoking among African American
school children. Journal of Drug Education, 27, 277–291.
De Vries, H. and Mudde, A.N. (1998) Predicting stage transitions
for smoking cessation applying the Attitude–Social inﬂuence–
Efﬁcacy Model. Psychology and Health, 13, 369–385.
De Vries, H., Dijkstra, M. and Kuhlman, P. (1988a) Self-
efﬁcacy: the third factor besides attitude and subjective norm
as predictor of behavioral intentions. Health Education
Journal, 3, 273–282.
De Vries, H., Mudde, A.N., Dijkstra, A. and Willemsen, M.C.
(1998b) Differential beliefs, perceived social inﬂuences and
self-efﬁcacy expectations among smokers in various motiva-
tional phases. Preventive Medicine, 27, 681–689.
Devlin, S.D. (1995) Drug use in rural America: what you can do
about it. Conference Proceedings of the American Council of
Rural Special Education. ACRES, Las Vegas, NV.
Dori, G.A. and Overholser, J.C. (1999) Depression, hopelessness
and self-esteem: accounting for suicidality in adolescent
psychiatric inpatients. Suicide and Life Threatening Behavior,
Erikson, E.H. (1965) Childhood and Society. Norton, New York.
Erikson, E.H. (1968) Youth, Identity and Crisis. Norton, New
Evans, D.R. (1997) Health promotion, wellness programs,
quality of life and the marketing of psychology. Canadian
Psychology, 38, 1–12.
Fickova, E. (1999) Personality dimensions and self esteem
indicators relationship. Studia Psychologica, 41, 323–328.
Filozof, E., Albertin, H., Jones, C., Sterne, S., Myers, L. and
McDermott, R. (1998) Relationship of adolescent self esteem
to selected academic variables. Journal of School Health, 68,
Self-esteem in a BSA for mental health promotion
Fisher, M., Pastore, P., Schneider, M., Pegler, C. and Napolitano,
B. (1994) Eating attitudes in urban and suburban adolescents.
International Journal of Eating Disorders, 16, 67–74.
Flay, B.R. and Ordway, N. (2001) Effects of the positive action
program on achievement and discipline: two matched- control
comparisons. Prevention Science, 2, 71–89.
Flay, B.R. and Petraitis, J. (1994) The theory of triadic inﬂuence:
a new theory of health behavior with implications for
preventive interventions. Advances in Medical Sociology, 4,
Fleming, J., Mullen, P.E., Sibthorpe, B. and Bammer, G. (1999)
The long-term impact of childhood sexual abuse in Australian
women. Child Abuse and Neglect, 23, 145–159.
Furnham, A. and Cheng, H. (2000) Lay theories of happiness.
Journal of Happiness Studies, 1, 227–246.
Garber, J. and Flynn, C. (2001) Predictors of depressive
cognitions in young adolescents. Cognitive Theory and
Research, 25, 353–376.
Garmezy, N. (1984) The study of stress and competence in
children: a building block for developmental psychopathol-
ogy. Child Development, 55, 97–111.
Gilbert, S.E. (1995) Violence in schools: why and what can we
do about it? Journal of Health Care, 6, 205–208.
Ginsburg, G.S., La Greca, A.M. and Silverman, W.K. (1998)
Social anxiety in children with anxiety disorders: relation with
social and emotional functioning. Journal of Abnormal Child
Psychology, 26, 175–185.
Glick, M. and Zigler, E. (1992) Premorbid competence and the
courses and outcomes of psychiatric disorders. In Rolf, J.,
Masten, A.S., Cicchetti, D., Nuechterlein, K.H. and Wein-
traub, S. (eds), Risk and Protective Factors in the Develop-
ment of Psychopathology. Cambridge University Press,
Cambridge, pp. 497–513.
Godin, G. and Kok, G. (1996) The Theory of Planned Behavior:
a review of its applications to health-related behaviors.
American Journal of Health Promotion, 11, 87–98.
Greenberg, M.T., Domitrovich, C. and Bumbarger, B. (2000)
Preventing Mental Disorders in School-age Children: A
Review of the Effectiveness of Prevention Programs. Pre-
vention Research Center for the Promotion of Human
Development, College of Health and Human Development,
Pennsylvania State University, University Park, PA.
Hammen, C. and Goodman-Brown, T. (1990) Self schemes and
vulnerability in speciﬁc life stress in children at risk for
depression. Cognitive Theory and Research, 14, 215–227.
Haney, P. and Durlak, J.A. (1998) Changing self-esteem in
children and adolescents. A meta analytic review. Journal of
Clinical Child Psychology, 27, 423–433.
Harrington, R., Rutter, M. and Fombonne, E. (1996) De-
velopmental pathways in depression: multiple meanings,
antecedents and points. Development and Psychopathology,
Harter, S. (1986) Processes underlying the construction,
maintenance and enhancement of the self-concept in children.
In Suls, J. and Greenwald, A.G. (eds), Psychological Perspec-
tives on the Self. Lawrence Erlbaum, Hillsdale, NJ, vol. 3,
Harter, S. (1990) Causes, correlates and functional role of global
self worth: a life span perspective. In Kollgian, J. and
Sternberg, R. (eds), Perceptions of Competence and In-
competence across Life Span. Yale University Press, New
Haven, CT, pp. 67–98.
Harter, S. (1999) The Construction of the Self. A Developmental
Perspective. Guilford Press, New York.
Hay, I., Ashman, A.F. and van Kraayenoord, C.E. (1998)
Educational characteristics of students with high or low self
concept. Psychology in the Schools, 35, 391–400.
Herbert, M. (1987) Living with Teenagers. Basil Blackwell,
Higgins, E.T. (1987) Self discrepancy; theory relation self and
affect. Psychological Review, 94, 319–340.
Higgins, E.T. (1989) Self discrepancy theory: what patters of self
beliefs cause people suffer? In Berkowitz, L. (ed.), Advances
in Experimental Social Psychology. Academic Press, New
York, vol. 22, pp. 23–63.
Hobfool, S.E. and Walﬁsch, S. (1984) Coping with a threat to
life: a longitudinal study of self concept, social support and
psychological distress. American Journal of Community
Psychology, 12, 87–100.
Hoffman, M.L. (1999) Examining sex differences in adolescent
adjustment: the effect of competence on gender role in
differences in psychopathology. Dissertation Abstracts in-
ternational: Section B: Science and Engineering, 59(9-B),
Horowitz, L.A. (1999) The relationship of childhood sexual
abuse to revictimisation: mediating variables and develop-
mental processes. Dissertation Abstracts International B:
Sciences and Engineering, 60(4-B), 1855.
Hosman, C.M.H. (ed.) (2000) Naar een Geestelijke Gezonde
Samenleving: Inleiding in de Preventieve Geestelijke Gezond-
heidszorg [Towards a Mentally Healthy Community: In-
troduction in Prevention in Mental Health]. Kluwer,
Jahoda, M. (1958) Current Concepts of Positive Mental Health.
Basil Books, New York.
Jessor, R., Turbin, M.S. and Costa, F.M. (1998) Risk and
protection in successful outcomes among disadvantaged
adolescents. Applied Developmental Science, 2, 194–208.
Jones, S. and Heaven, P. (1998) Psychosocial correlates of
adolescent drug-taking behavior. Journal of Adolescence, 21,
Judge, T.A., Bono, J.E. and Locke, E.A. (2000) Personality and
job satisfaction: the mediating role of job characteristics.
Journal of Applied Psychology, 85, 237–249.
Kashubeck and Christensen. (1993) Parental alcohol use, family
relationship quality, self-esteem end depression in college.
Journal of College Student Development, 36, 431–343.
Kihlstrom, J.F. and Cantor, N. (1983) Mental representations of
the self. In Berkowitz, L. (ed.), Advances in Experimental
Social Psychology. Academic Press, San Diego, CA, vol. 17,
Kressly, J.C. (1994) Middle level advisory: targeting potential
violence before tragedy strikes. Schools in the Middle, 3,
Lazarus, R.S. and Folkman, S. (1984) Coping and adaptation. In
Gentry, W.D. (ed.), The Handbook of Behavioral Medicine.
Guilford, New York, pp. 282–325.
Macdonald, G. (1994) Self esteem and the promotion of mental
health. In Trent, D. and Reed, C. (eds), Promotion of Mental
Health. Avebury, Aldershot, vol. 3, pp. 19–20.
M. Mann et al.
Marcia, J.E., Waterman, A.S., Matteson, D.R., Archer, S.L. and
Orlofsky, J.L. (1993) Ego Identity: A Handbook for Psycho-
social Research. Springer, New York.
Markus, H. (1977) Self schemata and processing information
about the self. Journal of Personality and Social Psychology,
Markus, H. and Nurius, P. (1986) Possible selves. American
Psychologist, 41, 954–969.
Marsh, H.W. and Yeung, A.S. (1997) Causal effects of academic
self-concept on academic achievement: structural equation
models of longitudinal data. Journal of Educational Psychol-
ogy, 89, 41–54.
Miller, P.M., Kreitman, N.B., Ingham, J.G. and Sashidharan,
S.P. (1989) Self esteem, life stress and psychiatric disorder.
Journal of Affective Disorders, 17, 65–75.
Muha, D.G. (1991) Dropout prevention and group counseling.
High School Journal, 74, 76–80.
Nyamathi, A. (1991) Relationships of resources to emotional
distress, somatic complaints and high risk behaviors in drug
recovery and homeless minority women. Research in Nursing
and Health, 14, 269–277.
O’Dea, J.A. and Abraham, S. (2000) Improving the body image,
eating attitudes and behaviors of young male and female
adolescents: a new educational approach that focuses on self-
esteem. International Journal of Eating Disorders, 28, 43–57.
Oliver, J.M. and Paull, J.C. (1995) Self-esteem and self-efﬁcacy;
perceived parenting and family climate; and depression
in university students. Journal of Clinical Psychology, 51,
Overholser, J.C., Adams, D.M., Lehnert, K.L. and Brinkman,
D.C. (1995) Self esteem deﬁcits and suicidal tendencies
among adolescents. Journal of American Academy Child and
Adolescent Psychiatry, 34, 919–928.
Patterson, G.R. and Capaldi, D.M. (1992) Mediational model for
boys depressed mood. In Rolf, J., Masten, A.S., Cicchetti, D.,
Nuechterlein, K.H. and Weintraub, S. (eds), Risk and
Protective Factors in Development of Psychopathology.
Cambridge University Press, Cambridge, pp. 141–163.
Patton, W. (1991) Relationship between self image and depres-
sion in adolescents. Psychological Reports, 68, 687–688.
Paul, J.P., Stall, R. and Davis, D.F. (1993) Sexual risk for HIV
transmission among gay/bisexual men in substance-abuse
treatment. AIDS Education and Prevention, 5, 11–24.
Penninx, B.W., van Tilburg, T., Boeke, A.J.P., Deeg, D.J.,
Kriegsman, D.M. and van Eijk, J.T. (1998) Effects of social
support and personal coping resources on depressive symp-
toms: different for various chronic diseases? Health Psychol-
ogy, 17, 551–558.
Poikolainen, K., Tuulio-Henrikkson, A., Aalto-Setaelae, T.,
Marttunen, M. and Loennqvist, J. (2001) Predictors of alcohol
intake and heavy drinking in early adulthood: a 5-year follow-
up of 15–19-year-old Finnish adolescents. Alcohol and
Alcoholism, 36, 85–88.
Reda-Norton, L.J. (1995) Elementary school predictors of
adolescent adjustment problems. Dissertation Abstracts
International B: Science and Engineering, 56(5-B), 2904.
Reinherz, H.Z., Giaconia, R.M., Pakiz, B., Silverman, A.B., Farst,
A.K. and Lefkowitz, E.S. (1993) Psychosocial risk for major
depression in late adolescence. Journal of American Academy
for Child and Adolescent Psychiatry, 32, 1155–1163.
Reston, V. (1991) HIV Prevention Education for Exceptional
Youth: Why HIV Prevention Education is Important. Ofﬁce of
Educational Research and Improvement, Washington, DC.
Rice, K.G., Ashby, J.S. and Slaney, R.B. (1998) Self-esteem as
a mediator between perfectionism and depression: A structural
equations analysis. Journal of Counseling Psychology, 45,
Rodney, H.E., Mupier, R. and Crafter, B. (1996) Predictors of
alcohol drinking among African American adolescents:
Implications for violence prevention. Journal of Negro
Education, 65, 434–444.
Rogers, T.B. (1981) A model of the self as an aspect of the
human information processing system. In Canton, N. and
Kihlstrom, J.F. (eds), Personality, Cognition and Social
Interaction. Erlbaum, Hillsdale, NJ, pp. 193–214.
Rolf, J. and Johnson, J. (1992) The challenges of Aids. In Rolf,
J., Masten, A.S., Cicchetti, D., Nuechterlein, K.H. and
Weintraub, S. (eds), Risk and Protective Factors in De-
velopment of psychopathology. Cambridge University Press,
Cambridge, pp. 384–404.
Rolf, J., Masten, A.S., Cicchetti, D., Nuechterlein, K.H. and
Weintraub, S. (1990) Risk and Protective Factors in the
Development of Psychopathology. Cambridge University
Rouse, K.A. (1998) Longitudinal health endangering behavior
among resilient and nonresilient early adolescents. Journal of
Adolescent Health, 23, 297–302.
Rutter, M. (1992) Psychosocial resilience and protective
mechanisms. In Rolf, J., Masten, A.S., Cicchetti, D.,
Nuechterlein, K.H. and Weintraub, S. (eds), Risk and
Protective Factors in the Development of Psychopathology.
Cambridge University Press, Cambridge, pp. 181–214.
Sartorius, N. (1988) Health Promotionstrategies:Keynote Address.
Canadian Journal of Public Health, 79(Suppl. 2), s3–s5.
Scarano, G.M., Gina, M., Kaodner, M. and Cynthia, R. (1994) A
Description of the continuum of eating disorders: implications
for intervention and research. Journal of Counseling and
Development, 72, 356–361.
Schoen. (1999) The etiology of violence and the voice of the
perpetrator. Dissertation Abstracts International B: Science
and Engineering, 60(2-B), 0875.
Seligman, M.E.P. (1975) Helplessness. Freeman, San Francisco,
Seligman, M.E.P. (1995) What You Can Change and What You
Can’t. Knopf, New York.
Seligman, M.E.P. and Csikszentmihalyi, M. (2000) Positive
psychology: an introduction. American Psychologist, 55, 5–14.
Seligman, M.E.P., Reivich, K., Jaycox, L. and Gillham, J. (1995)
The Optimistic Child. Houghton Mifﬂin, Boston, MA.
Shadmon, O. (1998) Family and non-family supports as
contributors to adjustment in school-aged children with
employed mothers. Dissertation Abstracts International B:
Science and Engineering, 59(2-B), 0898.
Shin, K.R. (1993) Factors predicting depression among Korean-
American women in New York. International Journal of
Nursing Studies, 30, 415–423.
Shisslak, C.M., Crago, M., Gray, N., Estes, L.S., McKnight, K.,
Parnaby,O.G., Sharpe, T., Bryson, S., Killen, J. and Barr-Taylor,
C. (1998) The prevention of eating disorders. Studies in eating
disorders. In Vandereycken, W. and Noordenbos, G. (eds), The
McKnight Foundation Prospective Study of Risk Factors for the
Self-esteem in a BSA for mental health promotion
Development of Eating Disorders. An International Series.New
York University Press, New York, vol. xii, pp. 56–74.
Short, J.L. (1998) Evaluation of a substance abuse prevention
and mental health promotion program for children of divorce.
Journal of Divorce and Remarriage, 28, 139–155.
Smolak, L., Levine, M.P. and Schermer, F. (1998) A controlled
evaluation of an elementary school primary prevention
program for eating problems. Journal of Psychosomatic
Research, 44, 339–353.
Solomon, S., Greenberg, J. and Pysczynski, T. (2000) Pride and
prejudice: fear of death and social behavior. Current
Directions in Psychological Science, 9, 200–204.
Somali, A., Kelley, J., Heckman, T., Hackl, K., Runge, L. and
Wright, C. (2001) Life optimism, substance use and AIDS-
speciﬁc attitudes associated with HIV-risk behaviour among
disadvantaged inner city women. Journal of Women’s Health
and Gender-based Medicine, 9, 1101–1110.
St Jeor, S.T. (1993) The role of weight management in the health
of women. Journal of the American Dietetic Association, 93,
Strecher, V.J., DeVillis, B.M., Becker, M.H. and Rosenstock,
I.M. (1986) The role of self-efﬁcacy in achieving health
behaviour change. Health Education Quarterly, 31, 73–92.
Swendsen, J.D. and Merikangas, K.M. (2000) The comorbidity
of depression and substance use disorders. Clinical Psychol-
ogy Review, 20, 173–189.
Taylor, S. and Brown, J. (1988) Illusions and well-being: a social
psychological perspective on mental health. Psychological
Bulletin, 103, 193–210.
Teri, L. (1982) Depression in adolescence: its relationship to
assertion and various aspects of self image. Journal of Clinical
Child Psychology, 11, 101–106.
van der Ham, T., van der Strien, D.C. and van Engelan, H. (1998)
Personality characteristics predict outcomes of eating disor-
ders in adolescents: a 4-year prospective study. European
Child and Adolescent Psychiatry, 7, 79–84.
Vickers, M.J. (1993) Understanding obesity in woman. Journal
of Obesity and Gynecology, 22, 17–23.
Vohs, K.D., Voelz, Z.R., Pettit, J.W., Bardone, A.M., Katz, J.
and Abramson, L.Y. (2001) Perfectionism, body dissatisfac-
tion and self-esteem: an interactive model of bulimic symptom
development. Journal of Social and Clinical Psychology, 20,
Weare, K. (2000) Promoting Mental and Social Health: A
Whole School Approach. Routledge, London.
WHO (1986) Discussion document on the concept and principles
of health promotion. Health Promotion, 1, 73–76.
Wilhelm, K., Parker, G., Dewhurst-Savellis, J. and Asghari, A.
(1999) Psychological predictors of single and recurrent major
depressive episodes. Journal of Affective Disorders, 54,
Zimmerman, S.L. (2000) Self-esteem, personal control, opti-
mism, extraversion and the subjective well-being of midwest-
ern university faculty. Dissertation Abstracts International B:
Sciences and Engineering, 60(7-B), 3608.
Received on April 10, 2001; accepted on March 30, 2003
M. Mann et al.