Early adolescents’ body dysmorphic symptoms as compensatory responses to parental appearance messages and appearance-based rejection sensitivity

Body Image 23 (2017) 162–170

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Early adolescents’ body dysmorphic symptoms as compensatory responses to parental appearance messages and appearance-based rejection sensitivity Kelly Densham a , Haley J. Webb a,∗ , Melanie J. Zimmer-Gembeck a , Drew Nesdale a , Geraldine Downey b a b

Griffith University, School of Applied Psychology, Australia Columbia University, Department of Psychology, United States

a r t i c l e

i n f o

Article history: Received 16 December 2016 Received in revised form 27 September 2017 Accepted 27 September 2017 Available online 17 October 2017 Keywords: Body dysmorphic disorder BDD Appearance-based rejection sensitivity Appearance teasing Parental modeling Body image

a b s t r a c t Body dysmorphic disorder (BDD) is marked by high distress and behavioral and functional impairments due to preoccupation with perceived appearance anomalies. Our aim was to examine parental correlates of offspring’s symptoms characteristic of BDD, testing both direct associations and indirect associations via appearance-based rejection sensitivity (appearance-RS). Surveys were completed by 302 Australian adolescents (9–14 years) and their parents. Findings indicated parents’ weight and appearance teasing and child-report (but not parent-report) of parental negative attitudes about weight and appearance were uniquely associated with offspring’s heightened BDD-like symptoms, and associations were partially indirect via adolescents’ appearance-RS. Findings support theory that identifies parents as socializers of children’s appearance concerns, and show that BDD-like symptoms may be partly elevated because of the mediating role of appearance-RS. We propose that BDD symptoms could partly emerge as compensatory responses to parents’ appearance messages, and the associated bias to expect and perceive rejection based on one’s appearance. © 2017 Elsevier Ltd. All rights reserved.

1. Introduction Researchers and clinicians are increasingly attending to extreme body image concerns, which are often referred to as symptoms of body dysmorphic disorder (BDD; Albertini & Phillips, 1999) or appearance anxiety (Zimmer-Gembeck, Webb, Farrell, & Waters, 2017). BDD is a pathological condition in which preoccupation with imagined or slight anomalies in appearance cause excessive distress, resulting in behavioral and functional impairments such as excessive grooming and repeated checking of appearance (American Psychiatric Association, 2013). Among adult BDD sufferers, symptoms are typically reported to have emerged during childhood and adolescence (Phillips & Hollander, 2008). Adolescents with BDD tend to be similar to adults in their clinical characteristics, except that adolescents demonstrate poorer insight and even higher rates of suicidal attempts (Phillips et al., 2006). Notably, with a few exceptions (e.g., Mastro, Zimmer-Gembeck,

Webb, Farrell, & Waters, 2016; Webb et al., 2015; Zimmer-Gembeck et al., 2017), there have been few studies of mechanisms or predictors of BDD symptoms in children or adolescents. The aims of the present study were first to examine whether elevated symptoms characteristic of BDD among youth between the ages of 9 and 14 were associated with parents’ weight and appearance teasing of their offspring and parents’ own negative attitudes and behaviors related to weight and appearance. Notably, information about parents’ appearance concerns were gathered from both parents and offspring. Our second aim was to examine whether the association of parents’ teasing and negative attitudes about weight and appearance with BDD-like symptoms was indirect via children’s heightened concerns that rejection in social relationships depends on appearance (known as appearance-based rejection sensitivity [appearance-RS]; Park, 2007). Finally, we sought to examine whether the associations between parent factors and BDD-like symptoms differed between boys and girls. 1.1. Parental influences and BDD

∗ Corresponding author at: School of Applied Psychology and Menzies Health Institute, Griffith University, Gold Coast 4222, Australia. E-mail address: haley.webb@griffithuni.edu.au (H.J. Webb). https://doi.org/10.1016/j.bodyim.2017.09.005 1740-1445/© 2017 Elsevier Ltd. All rights reserved.

Parents are the most important social influence for children (Maccoby, 1992), including in relation to appearance ideals. The

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Tripartite Social Influences Model (Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999) is a widely accepted model of the development of body image concerns and eating pathology. According to this model, parents, along with peers and the media, play formative roles in the development of appearance ideals throughout childhood (Shroff & Thompson, 2006) and into adolescence (Webb et al., 2017). Notably, some BDD sufferers report that parents reinforced a focus on appearance during childhood (Neziroglu, Roberts, & Yaryura-Tobias, 2004). Despite the evidence for the important role of parents for child development in general, and in relation to body image beliefs and behavior more specifically, parent factors have not been examined at all in relation to BDD symptoms, with the exception of one descriptive study outlined below (Mastro et al., 2016). 1.1.1. Teasing about weight and looks Research examining specific social risk factors for BDD has identified that in samples of male and female adolescents (Webb et al., 2015) and young adults (Lavell, Zimmer-Gembeck, Farrell, & Webb, 2014), BDD symptoms are associated with higher levels of peer teasing about weight, shape, or appearance more broadly. Yet, teasing by parents may also play a role in early adolescents’ BDD symptoms, given that parents are important sources of information and support (Hair, Moore, Garrett, Ling, & Cleveland, 2008; Steinberg, 2001) and young adolescents still spend a great deal of time with parents (Zeijl, Te Poel, Du Bois-Reymond, Ravesloot, & Meulman, 2000). One study based on the same sample as the present study (Mastro et al., 2016) has examined teasing by parents about “weight or looks” in relation to BDD symptoms in adolescent boys and girls. This study found young adolescents classified as having high BDD symptom levels reported more teasing about weight and appearance by parents, relative to their peers with low BDD symptoms. 1.1.2. Parental negative attitudes Apart from the more direct messages conveyed by teasing about weight and appearance, parents’ attitudes toward their own appearance (including about weight or looks) might result in covert or inadvertent displays that may be influential because they are observed and internalized by offspring (Neziroglu, Khemlani-Patel, & Veale, 2008). While not examined previously in relation to BDD symptoms, parental attitudes have been identified in a review of research as important predictors in the development of appearance ideals and concerns among young boys and girls (Ricciardelli & McCabe, 2001), and daughters’ recollection of their mothers’ concerns about weight and general appearance have been associated with their own concerns about weight and general appearance (Rieves & Cash, 1996). Mother’s (and to a lesser extent, father’s) appearance beliefs and behaviors, including complaints and comments about own weight, weight loss attempts and investment in thinness, have been found to be associated with offspring’s weight loss attempts, body esteem and concerns about weight gain (Smolak, Levine, & Schermer, 1999). Moreover, among adolescent boys and girls, perceptions of more negative parental appearance attitudes and behavior (i.e., parental worry or self-criticism about weight, shape, or muscle tone, and emotional eating) have been prospectively linked to elevated concerns about appearance-RS, which is a social-perceptual processing bias involving expectations of and anxiety about social rejection on the basis of appearance (Webb et al., 2017). Whereas well-intentioned parents may not explicitly communicate pressure for their children to conform to appearance ideals, adolescent perceptions of parents’ implicit messages (i.e., parents’ negative attitudes about their own weight and looks) may nevertheless contribute to the exacerbation of offspring’s appearance concerns (Webb et al., 2017).

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1.1.3. Parent compared to child reports Much of the past research on parental appearance-related attitudes and offspring’s appearance concerns has relied on selfreports from children about both their parents’ behaviors and their own attitudes or behaviors. However, it is known that there are inconsistencies between parent and child perceptions of parents’ appearance-related behaviors. In one study, the greatest disagreements between reports of parents and their adolescents (boys and girls) concerned more indirect or potentially covert behaviors (e.g., parents’ comments about their own weight and engagement in dieting), rather than more overt appearance-related pressure (e.g., encouragement for child to lose weight; Haines, Neumark-Sztainer, Hannan, & Robinson-O’Brien, 2008). Of the covert parent behaviors, it was only child reports, and not parent reports, that were associated with children’s dieting and concerns about weight or body shape. In another study of adolescent boys and girls, it was adolescent perceptions of parents’ maladaptive eating attitudes and behaviors, and not parents’ own reports, that tended to be associated with adolescents’ maladaptive eating attitudes and behaviors (Baker, Whisman, & Brownell, 2000). Thus, discrepancies may exist between what parents believe they are conveying to their children and what children perceive, and it may be that child perceptions are most important for child outcomes. Investigating the association of early adolescents’ symptoms characteristic of BDD with parental negative attitudes about weight, shape and appearance and maladaptive eating behaviors, when reported by parents and their children, provides a novel contribution of the present study, and provides a more detailed picture of the social risk factors.

1.2. Appearance-RS as a mediator and BDD-like symptoms as a compensatory response In extending the Tripartite Model, theorists have more explicitly described the role of individuals’ thoughts and feelings about social relationships and rejection as mechanisms that explain why parental teasing about weight or looks (or other negative appearance-related experiences) can result in elevated BDD symptoms. For example, the cognitive behavioral model of BDD (Veale, 2004) suggests that adverse social experiences during childhood (e.g., teasing or victimization) are linked to internalized negative self-criticism. These social experiences and negative self-criticism result in selective, self-focused attention to specific features of appearance, leading to heightened awareness and exaggeration of undesired aspects. Together, they contribute to body image distortions and BDD symptoms. In support, research findings (Fang et al., 2011; Lavell et al., 2014) have shown that males and females with BDD symptoms demonstrate heightened sensitivity and vigilance to even ambiguous cues of social rejection, and attribute these signs of rejection to their appearance (Park, 2007). This escalating cycle of hyper-vigilance to personal appearance and to social rejection on the basis of appearance identifies a possible direct process through which appearance preoccupation and BDD symptoms develop (Fang et al., 2011; Lavell et al., 2014; Webb et al., 2015). Compensatory responses or self-protective strategies, such as mirror checking, excessive grooming, or camouflaging with cosmetics or clothing are performed to conceal or improve perceived deficits and prevent future victimization or rejection (Veale, 2004). As such, experiences of early social adversity (especially when related to one’s body or appearance more broadly) could precipitate an escalating cycle of appearance hypervigilance, distress, and compulsive behaviors via the development of a social-perceptual processing bias. This bias involves heightened perceptions of rejection from others, and attribution of the perceived rejection to an appearance deficit, and has been referred to as appearance-based rejection sensitivity (Park & Pinkus, 2009).

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Taken together, parental teasing and negative attitudes about weight and general appearance would be expected to result in elevated BDD symptoms via an appearance-RS mediational pathway. In support of this proposed pathway, researchers have found the association between peer teasing about weight or appearance and BDD symptoms in early adolescents (Webb et al., 2015) and young adults (Lavell et al., 2014) was partially mediated by appearance-RS. Both studies suggest that biased processing of social information regarding rejection, and attributing rejection to an appearance deficit, is a crucial link between appearance socialization processes and BDD symptoms. In the current study, it was anticipated that appearance-RS would, in part, explain the association of parents’ weight and appearance teasing and parents’ personal attitudes about their weight or looks with early adolescents’ symptoms characteristic of BDD. 1.3. Gender The association of parental teasing or maladaptive attitudes about weight and looks with appearance-RS and BDD symptoms may differ for girls compared to boys. BDD affects approximately 2.8% of adolescent girls and only 1.7% of boys (Mayville, Katz, Gipson, & Cabral, 1999), and in a community sample of adolescents, the majority of those identified with high BDD symptom levels were girls (Mastro et al., 2016). Appearance-RS is higher for girls than boys (Calogero, Park, Rahemtulla, & Williams, 2010; Webb et al., 2017), and while girls are susceptible to internalization of the thinness ideal (Thompson & Stice, 2001), boys tend to aspire to lean muscularity (Hargreaves & Tiggemann, 2006). In regard to interactions with parents, both mothers and fathers have been shown to provide more feedback about physical appearance to their daughters than their sons (Schwartz, Phares, Tantleff-Dunn, & Thompson, 1999). Despite these pervasive gender differences in the levels of these variables, previous research has found the association between peer teasing about weight or appearance and BDD symptoms did not differ between adolescent boys and girls (Webb et al., 2015). Similarly in another study, the associations of perceived parent teasing about weight or looks and parent negative attitudes about weight, shape or muscle tone with adolescent appearance-RS did not differ according to gender (Webb et al., 2017). Gender moderation was not assessed in a study of peer teasing about weight and BDD symptoms in a sample of adults (Lavell et al., 2014). Taken together, it is clear there are differences in the experiences of males and females in terms of the appearance culture to which they are exposed, as well as their weight and appearance ideals and concerns, yet associations of perceptions of appearance messages with BDD symptoms and appearance-RS do not consistently differ according to gender. In view of this, the present study included both boys and girls, and examined gender differences in symptoms characteristic of BDD and appearance-RS, as well as in the direct and indirect associations of parent appearance messages with BDD symptoms, via appearance-RS. 1.4. The present study Theoretical models assert that childhood and early adolescence are critical phases during which maladaptive ideals and concerns about body shape, weight and appearance are shaped by social experiences (Shroff & Thompson, 2006; Veale, 2004; Webb et al., 2015). However, there has been little investigation of the role of parents’ attitudes about weight and general appearance in relation to early adolescents’ BDD symptoms. Moreover, evidence suggests that appearance-RS at least partially explains why teasing about weight and general appearance is associated with heightened BDD symptoms (Lavell et al., 2014; Webb et al., 2015), but this has not been examined in a model of parent teasing about weight and

appearance. Our aim was to test a unique model linking parents’ appearance-focused messages with offspring’s symptoms characteristic of BDD via appearance-RS. It was hypothesised that overt and more covert exposure to maladaptive appearance-focused messages by parents, including parent teasing about weight or looks and negative attitudes about weight, shape, muscle tone or general looks, would be linked with higher BDD-like symptoms. Moreover, it was anticipated that these associations would be mediated via appearance-RS. Both parent- and child-reports of parental appearance attitudes were collected and discrepancies between them were examined. Gender differences in BDD-like symptoms and appearance-RS, and in model paths from parent factors to appearance-RS and BDD-like symptoms were also examined. Given evidence that the mean onset of BDD symptoms ranges from 12 to 17 years (Albertini & Phillips 1999; Bjornsson et al., 2013), the present study focused on a community sample of young adolescents, in order to capture the period of development when BDD symptoms are likely to emerge. 2. Method 2.1. Participants Participants were 302 students (53% female) from three Australian schools (grades 5, 6 or 7). Participants were 9.7–14.0 years old (Mage = 12.0, SD = 0.9), and were predominantly white/Caucasian (78.5%), and Asian (15.6%). Utilizing the Centers for Disease Control and Prevention (CDC) BMI percentile calculator for children and teens, which takes into account gender and age, BMI percentiles were calculated. Based on the CDC weight status classifications, most participants (77.5%) were in the healthy BMI range (i.e., 5th to <85th percentile). A small proportion of participations were underweight at less than the 5th percentile (7.6%). The remaining participants were classified as overweight (11.1%) or obese (3.8%), being between the 85th and 95th percentile, and greater than the 95th percentile, respectively. Participants were drawn from the first wave (the only wave when data from parents were also collected) of a larger, ongoing longitudinal study (N = 393) and included only those students who also had a parent participate. Participating parents were predominantly female (85.7%), aged 29.1 years to 67.3 years (Mage = 45.4, SD = 5.1), and married or in a long term relationship (86.5%). A smaller proportion reported being single (1%) or divorced/separated (12.5%). Participating parents reported that the child’s mother had completed education from 1st to 8th grade (1%), 9th to 12th grade (19%), vocational training or some university (26%), or a university degree (54%). Participating parents reported that the child’s father had completed education from 1st to 8th grade (2%), 9th to 12th grade (18%), vocational training or some university (30%), or a university degree (50%). Of the possible sample of students (N = 927), 42.4% participated in the study. Most non-participating students (41.9%) failed to return consent forms, and a small proportion of parents (15.7%) actively declined participation. No students declined to participate. A further 10% of the sample (n = 91) were excluded from present analyses because a parent did not complete the parent questionnaire. 2.2. Procedure After approval from the university’s Human Research Ethics Committee, schools in South East Queensland were contacted about the study via email, and the first three schools to agree to participate were accepted into the study. Students were provided with parent consent forms, a parent questionnaire to take home, and an envelope in which to return these completed forms to the school. The

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parent questionnaire was completed by one of the child’s parents, in parents’ own time, taking approximately 20 min. Participating students completed the questionnaire during normal class time, which contained additional measures not included in this study, and took approximately 45 min to complete. A trained researcher measured participant height and weight. Each student received a small gift upon completion of the questionnaire. 2.3. Measures 2.3.1. BDD symptoms Symptoms characteristic of BDD were measured using the 10item Appearance Anxiety Inventory (AAI; Veale et al., 2014), which was developed to assess the cognitive and behavioral aspects of BDD. This measure aligns with BDD symptomology as indicated by the DSM-5, which includes obsessional thoughts and repetitive behaviors. An example item is “I try to camouflage or alter aspects of my appearance”. A 5-point scale was used to report frequency of BDD symptoms (0 = Never, 4 = Always or Almost Always). Summing all items formed the total score, which has a possible range of 0–40. Cronbach’s ˛ was .89. The AAI has been used previously with young adolescents, and demonstrated convergent validity with self-perceptions and comorbidities of BDD (Mastro et al., 2016). 2.3.2. Appearance-RS The Adolescent Appearance-RS Scale (AA-RS; Webb, ZimmerGembeck, & Donovan, 2014) was used to measure appearance-RS. Participants imagine themselves in 10 hypothetical scenarios (e.g. “You are leaving the house to go to school when you notice a big pimple on your face”). Participants indicate on a 6-point scale the extent to which they are anxious or concerned about being rejected based on their appearance (e.g. “How concerned/anxious would you be that others would think you were less attractive because of the way you look?”) (1 = Not concerned, 6 = Very concerned) and their expectation of appearance-related rejection in the imagined scenario (e.g. “Do you think other people would find you unattractive?”) (1 = No!!, 6 = Yes!!). Multiplying anxious concern and expectation of appearance-related rejection scores for each item and then averaging the 10 item scores formed a total score. The possible range of scores was 1–36, with higher scores indicating greater appearance-RS. Cronbach’s ˛ was .92. The AA-RS has demonstrated sound reliability and including a convergent yet distinct relationship with body dissatisfaction (Webb et al., 2014). 2.3.3. Child-reported parent weight and appearance teasing An item modified from the Weight Teasing Subscale of the Perceptions of Teasing Scale (POTS; Thompson, Cattarin, Fowler, & Fisher, 1995) was used to measure child perceptions of appearance teasing by parents. The item was “Do your parents tease you about your weight and looks?” Participants indicated the frequency of this behavior (1 = never, 5 = always) and the degree to which they found this behavior upsetting (1 = not upset, 5 = very upset). The frequency rating was multiplied by the distress rating to obtain a total score. The possible range for the total parental weight and appearance teasing score was 1–25, with higher scores indicating greater perceived teasing by parents. The original scale has demonstrated validity in measuring appearance teasing in children (Jensen & Steele, 2010), and parent weight and appearance teasing as measured by the modified scale has, as expected, been previously shown to be higher among young people at-risk, compared to those not at risk, for BDD (Mastro et al., 2016). 2.3.4. Parental negative weight and appearance attitudes and behaviors The 4-item Attitude and Behavior Scale (ABS; Baker et al., 2000) was used to measure both child- and parent-reports of parental

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negative weight and appearance attitudes and engagement in maladaptive eating behavior. Parents completed the ABS about themselves, and children completed it to describe their parents. Children were advised to leave items blank if not applicable (i.e., if they did not have contact with a second parent). Eating attitudes (2 items) and eating behaviors (2 items) were measured. An example parent item is “I am critical about my weight, shape, size or muscle tone” (1 = Never, 5 = Always). An example child item is “When sad or angry, my Mum/Dad eats more” (1 = Never, 5 = Always). Children reported mother and father attitudes and behaviors separately and a total score was obtained by averaging responses across items pertaining to each parent (range = 1–5). Where children completed only one set of items (i.e., items pertaining to mother or father), an average score for the completed items was taken as the total score. One child left mother items blank, and 7 children left father items blank. Higher scores indicated more negative parent attitudes and behaviors. Cronbach’s ˛ was .74 for child-reported ABS and .83 for parent-reported ABS. The validity of the ABS is supported by theory-consistent associations between parental ABS and children’s maladaptive eating attitudes and behaviors, however, associations were only found when parental ABS was child-reported (Baker et al., 2000). 2.3.5. Body mass index Height and weight were measured by trained researchers and used to calculate body mass index (BMI; weight kg/height m2 ). 2.4. Overview of statistical analyses Two participants were excluded due to missing data on one or more entire measures. Correlations were first calculated to evaluate associations between all measures. Independent groups t-tests were conducted to examine gender differences in appearance-RS and symptoms characteristic of BDD. A paired t-test examined differences in child- and parent-reported parental negative weight and appearance attitudes. PROCESS (Hayes, 2013) was used to test indirect effects. PROCESS is a macro available for SPSS or SAS that can be used to compute the indirect effect of an independent variable (X) on a dependent variable (Y), through a mediator (M). The indirect effect is calculated as the product of pathways from X to M (pathway ‘a’), and from M to Y (pathway ‘b’), with mediation supported through rejection of the null hypothesis that the indirect effect (pathway ‘ab’) is zero. PROCESS implements the bootstrap confidence interval to test the inference about the indirect effect. A bootstrap confidence interval for the indirect effect relies on resampling the observed dataset with replacement, thousands of times, and estimating the model and resulting indirect effect ‘ab’, pooling the results across the samples. The sampling distribution of ‘ab’ is built from resampling, and a confidence interval for the indirect effects is constructed using percentiles of that distribution (Hayes & Rockwood, 2017). For an overview of the practice of mediation and moderation, including using PROCESS, see Hayes and Rockwood (2017). In the present study, PROCESS was used to determine whether parent teasing (X1) and child- and parent-reported parental weight and appearance attitudes (X2 and X3) were indirectly associated with symptoms characteristic of BDD (Y) via appearance-RS (M). Given evidence of higher body dissatisfaction and BDD symptom levels among adolescents with a larger BMI (Botta, 1999; Mastro et al., 2016; Paxton, Eisenberg, & Neumark-Sztainer, 2006), researcher-measured BMI was included as a covariate. However, conditional indirect effects were first examined (i.e., moderated mediation) using PROCESS to assess whether gender moderated the pathways from parent teasing and child- and parent-reported parental appearance attitudes to appearance-RS and BDD-like

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Fig. 1. Proposed model.

symptoms. PROCESS Model 8 was employed for moderated mediation analyses, enabling assessment of the moderation effect on the association of the independent variables with (1) the mediator and (2) the dependent variable (see Fig. 1). Mean centring for products was utilized, and five thousand bootstrapped samples were formed for bias corrected bootstrap confidence intervals. 3. Results 3.1. Descriptive statistics, correlations between all variables, and comparison of reporters Ms, SDs, and correlations between all variables can be found in Table 1. BDD-like symptoms were positively associated with appearance-RS, and both BDD-like symptoms and appearance-RS were positively associated with parent teasing, child-reported (but not parent-reported) parental appearance attitudes, and BMI. To determine whether girls reported more symptoms characteristic of BDD and appearance-RS than boys, independent samples ttests were conducted. Levene’s Test of Equality of Variances was significant (p < .05), thus equal variances were not assumed for both BDD-like symptoms and appearance-RS. Girls reported significantly higher BDD-like symptoms, t(273.70) = −5.04, p <.001, d = 0.57, and appearance-RS, t(268.98) = −4.73, p < .001, d = 0.54, than boys. The effect sizes for these gender differences were moderate. There was a significant positive correlation between childreported and parent reported parental weight and appearance attitudes. A paired sample t-test indicated that parents selfreported significantly more negative weight and appearance attitudes than was perceived by their offspring, t(301) = −14.62, p < .001, d = 0.85. The effect size for this difference was large. 3.2. Associations of parent factors with BDD-like symptoms Moderated mediation analyses were first conducted to assess whether the pathways from parent factors to appearance-RS and BDD-like symptoms were moderated by gender. Gender was not found to moderate the associations of parent teasing (interaction t[295] = 1.53, p = .13), child-reported parental attitudes (interaction t[295] = 0.87, p = .39) or parent-reported parental attitudes (interaction t[295] = 1.14, p = .26) with appearance-RS. Gender also did not moderate the associations of parent teasing (interaction t[294] = 1.01, p = .31), child-reported parental attitudes (interaction t[294] = 1.08, p = .28), or parent-reported parental attitudes (interaction t[294] = −1.14, p = .25) with BDD symptoms. Given the absence of significant gender moderation, the mediation model (PROCESS Model 4) was then assessed without gender. These analyses assessed the direct and indirect (i.e., via appearance-RS) associations of parent teasing, child- and parent-reported weight and appearance attitudes with symptoms

characteristic of BDD. BMI was entered as a covariate. As shown in Table 2, the model explained (adjusted R2 ) 12.9% of the variance in appearance-RS. Parent teasing and child-reported negative parental appearance attitudes, but not parent-reported negative appearance attitudes, were associated with higher appearance-RS. BMI was also uniquely associated with appearance-RS, whereby appearance-RS was higher among adolescents with higher relative to lower BMI. The model explained (adjusted R2 ) 48.6% of the variance in BDDlike symptoms. Appearance-RS, parent teasing and child-reported negative parental appearance attitudes, but not parent-reported negative appearance attitudes, were directly and positively associated with symptoms characteristic of BDD. BDD-like symptom level was associated with BMI, whereby symptoms were higher in adolescents with higher relative to lower BMI. There was also a significant indirect association of parent teasing with BDD-like symptoms via appearance-RS (ˇ = .13), and a significant indirect association of child-reported parent attitudes with BDD-like symptoms via appearance-RS (ˇ = .09). As such, 59% of the total effect (ˇ = .22) of parent teasing on symptoms characteristic of BDD was indirect via appearance-RS, whereas 31% of the total effect (ˇ = .30) of parent attitudes on symptoms was indirect via appearance-RS.

4. Discussion Our first aim was to examine weight and appearance teasing by parents, as well as parents’ negative attitudes about their personal weight, shape, muscle tone and general looks, as correlates of early adolescents’ BDD-like symptoms. Information about parents’ attitudes were collected from both parents and their offspring, to provide a fuller picture of the social risk factors for symptoms characteristic of BDD in young people. Our additional aims were to examine whether the associations between parent factors and BDD-like symptoms were indirect via increased sensitivity to appearance-related rejection, and whether associations differed between boys and girls. The aims were founded on theory that identifies parents as one socializing agent in relation to offspring’s weight and appearance attitudes and concerns (Shroff & Thompson, 2006; Thompson et al., 1999); the evidence for links between teasing about weight or looks and BDD-like symptoms (Lavell et al., 2014; Webb et al., 2015); and the cognitive behavioral model of BDD, which proposes early adversity and resulting social cognitive processes as explanations for BDD (Veale, 2004). In support of these theories and extending past research, we found adolescent perceptions of parents’ teasing and negative attitudes about weight and appearance were associated with their early adolescents’ elevated BDD-like symptoms. Associations were also indirect by means of appearance-RS, providing preliminary support for the proposal that BDD symptoms may reflect a compensatory response to parents’ appearance messages via heightened concerns about appearance-

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Table 1 Ms, SDs, and correlations between all variables (N = 302).

1. BDD-like symptoms 2. Appearance-RS 3. Child-reported parent teasing 4. Child-reported parent attitudes 5. Parent-reported parent attitudes 6. BMI 7. Gendera Total M Total SD Girls, M Girls, SD Boys, M Boys, SD a * ** *** †

1

2

3

4

5

6

– .65*** .29*** .38*** .10 .30*** .27*** 8.17 7.44 10.06† 8.45 6.00 5.33

– .28*** .24*** .10 .23*** .26*** 10.81 7.50 12.6† 8.64 8.76 5.26

– .10 .04 .20** .11 3.31 2.82 3.60 2.91 2.98 2.69

– .19** .26*** .06 2.05 0.69 2.08 0.69 2.00 0.68

– .13* .01 2.90 0.89 2.91 0.87 2.89 0.92

– −.01 18.47 3.00 18.45 2.87 18.49 3.17

Boys = 1, Girls = 2. p < .05. p < .01. p < .001. significant gender difference p < .001.

Table 2 Direct effects of all measures on BDD symptoms and appearance-RS, and indirect effects of parent teasing and attitudes on BDD via ARS. Model paths

Direct effects on appearance-RS Child-reported parent teasing → ARS Child-reported parent attitudes → ARS Parent-reported parent attitudes → ARS BMI → ARS Direct effects on BDD symptoms Child-reported parent teasing → BDD Child-reported parent attitudes → BDD Parent-reported parent attitudes → BDD Appearance-RS → BDD BMI → BDD Indirect effects on BDD symptoms via Appearance-RS Child-reported parent teasing → BDD Child-reported parent attitudes → BDD Parent-reported parent attitudes → BDD

B

SE(B)

F(4, 297) = 12.14, p < .001, R2 adj = .14 0.63 0.15 0.62 1.87 0.35 0.46 0.32 0.14 F(5, 296) = 57.90, p < .001, R2 adj = .49 0.24 0.11 2.27 0.48 -0.06 0.35 0.55 0.04 0.24 0.11 0.35 1.03 0.19

0.10 0.37 0.25

95% CI B

ˇ

Lower

Upper

0.34 0.65 −0.56 0.04

0.92 3.08 1.26 0.60

.24*** .17** .04 .13*

0.02 1.33 −0.76 0.46 0.03

0.47 3.22 0.63 0.64 0.46

.09* .21*** -.01 .55*** .10*

0.15 0.33 -0.27

0.57 1.78 0.70

.14* .10* .03

Note: CI = confidence interval. * p < .05. ** p < .01. *** p < .001.

based social rejection. The patterns of association were the same for boys and girls.

4.1. Parental attitudes and behaviors as correlates of adolescents’ BDD-like symptoms In the present study, early adolescents who reported greater weight and appearance teasing by parents also reported higher symptoms characteristic of BDD and appearance-RS, even controlling for BMI. These findings extend one previous study that also found adolescents with a high level of BDD symptoms to experience more teasing about weight and appearance by parents, relative to their peers with a lower BDD symptom level (Mastro et al., 2016). When researchers have examined peer teasing about weight or appearance (Webb et al., 2015) and retrospective reports of weight teasing by peers among young adults (Lavell et al., 2014), similar results have been reported. Our findings also align with research on clinical BDD samples (Buhlmann, Cook, Fama, & Wilhelm, 2007), whereby individuals with BDD retrospectively recalled more appearance-related teasing (by an unspecified source) in comparison to non-BDD controls. Additionally, Buhlmann et al. (2007) found that more frequent reports of general appearance teasing during childhood and ado-

lescence was uniquely associated with greater severity in BDD symptoms. This study was the first to examine parental factors other than weight and appearance teasing, and not using retrospective reporting, in relation to early adolescents’ BDD-like symptoms. As hypothesized, child perceptions of their parents’ negative attitudes about weight, shape, muscle tone and general appearance were uniquely and positively associated with children’s BDD-like symptoms and appearance-RS, even after controlling for parents’ weight and appearance teasing and BMI. This finding is consistent with previous research on appearance-RS and body dissatisfaction, whereby appearance-focused messages that do not explicitly convey direct pressure to conform to appearance ideals (e.g., exposure to peer appearance conversations or parental negative appearance attitudes) were found to be significant correlates of young adolescents’ appearance concerns (Webb et al., 2014, 2017).

4.1.1. Parents’ report of their appearance attitudes We also gathered reports about weight and appearance attitudes from parents themselves. Consistent with one previous study (Haines et al., 2008), we found that parents reported significantly more negative weight and appearance attitudes compared to what their children perceived. We also found that child and

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parent reports were significantly positively correlated. Yet, parents’ reports were not associated with adolescent BDD-like symptoms or appearance-RS. Thus, we found adolescents’ perceptions of parents’ attitudes to be relevant to their symptoms and appearance-RS, but such associations did not extend to parents’ actual reports of their own attitudes. Other studies have found similar results for other measures of adolescent or young adult appearance attitudes and dieting behavior (Wood Baker et al., 2000; Haines et al., 2008; Taylor, Wilson, Slater, & Mohr, 2011). Relatedly, a previous study of adolescents found self-reported, but not peer-reported, peer victimization to be positively associated with BDD symptoms in young adolescents (Webb et al., 2015). As such, it appears that perceptions of appearance victimization and modeling by significant others may be particularly important for adolescent BDD symptoms and appearance-RS. On the other hand, due to the cross sectional design of the present study, these findings might also reflect the negative social perceptual biases inherent to those with elevated BDD symptoms and appearance-RS. In particular, young people with elevated symptoms levels may simply perceive more negative messages in their social environment. Further research employing prospective designs and multiple reporters is required to unpack these results.

4.1.2. Appearance-RS as a mediator and BDD-like symptoms as a compensatory response Results indicated that perceptions of parents’ teasing and negative attitudes about weight and looks were found to be directly associated with early adolescents’ elevated preoccupation with appearance deficits and engagement in compulsive behaviors (i.e., BDD-like symptoms), as well as indirectly associated via increased appearance-RS. Such evidence, when considered along with previous research on peer teasing about weight and appearance (Lavell et al., 2014; Webb et al., 2015; Zimmer-Gembeck et al., 2017), might indicate that exposure to appearance teasing, by parents or peers, prompts heightened vigilance to, and concerns about, signs of interpersonal rejection on the basis of appearance. Increasing preoccupation with appearance deficits and engagement in repeated behaviors intended to improve or conceal perceived flaws, which are the symptoms of BDD, may follow as attempts to prevent negative social judgement. Given this pathway, we expect that BDD symptoms could be compensatory responses to appearance-RS, which are aimed at deflecting others’ attention away from appearance and reducing the possibility that future rejection will occur because of appearance. However, when these behaviors do not reduce (a) the focus on physical appearance and judgements about appearance within the family or peer group, or (b) personal concerns about weight and appearance, or result in even more worry and concern about appearance, BDD symptoms are likely to escalate over time. This leads adolescents further down a pathway to appearance-related or socioemotional forms of psychopathology. For example, BDD symptoms, such as excessive grooming and appearance checking, may initially begin as responses enacted to compensate or alleviate appearance-related rejection concerns, but these may become chronic and obsessional over time when initial behaviors are not sufficient to abate concerns. It is notable that parent teasing and negative attitudes about weight and general appearance had direct associations with BDDlike symptoms when controlling for appearance-RS, suggesting that not all BDD symptoms may be a reaction or compensatory response to concerns about rejection because of appearance. It may be that parental appearance attitudes and comments about appearance (critical or otherwise) reinforce adolescents’ internalization of societal values around the importance of achieving weight and appearance ideals, prompting increasing preoccupation with and attempts to improve physical appearance (Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004).

It is important to note that our proposal of BDD symptoms as a compensatory response to social circumstances is preliminary only, as the cross-sectional design precludes conclusions about a causal pathway. It is also possible that the results are explained by young people with elevated appearance-RS and BDDlike symptoms possessing a bias toward perceiving higher levels of weight and appearance teasing and negative appearance attitudes in their social environment (Zimmer-Gembeck et al., 2013; Zimmer-Gembeck, Nesdale, Fersterer & Wilson, 2014). Moreover, there may be other mediators of this indirect association between parent factors and BDD symptoms. It is possible that genetic factors play a role, whereby the same genes that influence parental negative attitudes and behaviors related to weight and appearance could also influence the development of BDD symptoms in youth. Drawing from the cognitive behavioral model (Veale, 2004), another possibility is that appearance–focused interactions with parents may encourage perceptions of self as an esthetic object (i.e., self-consciousness and self-focused attention to one’s appearance as imagined from an observer perspective), or undue social appearance comparisons, both of which have been proposed as perpetuating mechanisms of BDD (Veale, 2004). Continued research examining individual cognitive biases and processes that may underlie appearance preoccupation and compulsive concealment and grooming characteristic of BDD is essential, and may highlight multiple mechanisms that would be amenable to intervention. 4.2. Gender As found in previous studies of BDD symptoms (Mastro et al., 2016; Mayville et al., 1999) and appearance-RS (Webb et al., 2014, 2017), BDD symptoms and appearance-RS were found to be higher among adolescent girls than boys. Despite these gender differences, the identified linkages between perceptions of appearance messages from parents and BDD-like symptoms did not differ between boys and girls. This finding aligns with previous research that also failed to find gender differences in associations between peer teasing about weight and appearance and adolescent BDD symptoms (Webb et al., 2015), and in associations of parent, peer and media factors with appearance-RS (Webb et al., 2017). However, these findings contrast with broader evidence that parents’ appearance comments and modeling are more consistently associated with weight concerns and weight loss attempts among daughters than sons (Smolak et al., 1999). It may be that associations with social risk factors with appearance-RS and BDD symptoms are similar among adolescent boys or girls. On the other hand, this finding should be interpreted considering measurement limitations (described further below). 4.3. Limitations and future directions Generalizability and design issues may be limitations in the current study. First, as previously mentioned, the cross-sectional design of the study precludes conclusions regarding the directionality of associations. Longitudinal research is needed to investigate the role of parent appearance teasing and modeling on changes in adolescent appearance-RS and BDD symptoms over time. Second, the generalizability of the current results may be limited by the sample demographics, whereby the sample comprised adolescents from three urban schools from South East Queensland, with the majority white Australian. Moreover, the AAI (Veale et al., 2014) was used to assess BDD symptoms due to its sound psychometric properties and efficiency in large samples. However, the AAI has not yet been validated as a clinical diagnostic tool. As such, the present study focuses on symptoms that are characteristic of BDD only, and may not be a valid indicator of clinical BDD symptoms. Finally, measurement limitations should be noted. Parent weight/shape teasing

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was measured using a single item, so the reliability of the measure could not be assessed. In addition, some measures, such as that which assessed parents’ teasing about appearance, might not sufficiently reflect male appearance ideals (i.e., drive for muscularity), potentially resulting in poorer validity among males, and an inability to detect gender effects. That the same measures were used in prior research that also failed to find gender differences (i.e., Webb et al., 2015, 2017), leads to the recommendation that measures be substituted or modified in future to more accurately assess male appearance ideals, enabling greater confidence in detecting gender effects.

4.4. Implications for intervention and conclusion Taken together, the findings of the current study suggest that perceptions of parents’ teasing and negative attitudes about weight and appearance may be important to understanding young adolescents’ BDD symptoms and appearance-RS. Any teasing about appearance, whether clearly negative or meant to be neutral (or light-hearted) in tone, could direct more attention and focus to appearance, and prompt adolescents’ heightened concerns about meeting appearance standards. Witnessing parents’ focus on appearance may also provide social learning opportunities (Bandura, 1977), whereby learning can occur through the observation of influential figures (i.e., parents, peers and media personalities) without direct reinforcement. Although the study was cross-sectional in design, the findings also suggest that these associations were partially indirect via a social-perceptual processing bias, whereby greater exposure to negative appearance messages within the family were associated with heightened anticipation of and worry about appearance-based rejection, which was, in turn, associated with higher BDD symptoms. Given these results, intervention programs for adolescents with weight or appearance concerns, and elevated BDD symptoms in particular, should involve family members in order to identify behaviors that may need to be addressed to reduce appearance as a focal point within the family. These recommendations align with existing family-based treatment programs for appearance-related disorders, such as family-based treatment for anorexia nervosa, which emphasizes the active and positive role parents play in intensive outpatient treatment (le Grange & Lock, 2005). These findings also emphasize the need for practitioners to add components to familybased approaches to more directly address social-perceptual biases among adolescents (e.g., see Hurst & Zimmer-Gembeck, 2015 for a CBT extension to family-based treatment of anorexia). In particular, cognitive reframing could be valuable in order to address heightened perceptions of appearance pressures in the social environment, elevated concerns and reactions to appearance-based social rejection, and the cognitive symptoms of BDD. In summary, adolescents’ BDD-like symptoms are related to a complex of direct and subtle social experiences with parents. Prospective research is needed to test our proposal that BDD symptoms may be partly compensatory and enacted in response to social perceptual concerns about appearance standards, meeting these standards, and the heightened concern about rejection that adolescents may overly anticipate because of their appearance concerns.

Acknowledgements This project was funded by an Australian Research Council Discovery Grant (DP130101868). The authors would like to thank the associate investigators, Allison Waters and Lara Farrell, and research assistants that contributed to the larger research project from which this paper was derived.

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