The impact of family functioning on pulling styles among adolescents with trichotillomania (hair pulling disorder)

Journal of Obsessive-Compulsive and Related Disorders 14 (2017) 27–35

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The impact of family functioning on pulling styles among adolescents with trichotillomania (hair pulling disorder)

MARK

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Yolanda E. Murphya, , Christopher A. Flessnera, Erin M. Altenburgerb, David L. Paulsc, Nancy J. Keuthenc a b c

Department of Psychological Sciences, Kent State University, United States Department of Psychology, The Ohio State University, United States Massachusetts General Hospital, United States

A R T I C L E I N F O

A B S T R A C T

Keywords: Trichotillomania Pulling styles Family functioning Adolescents

Despite aversive impact amongst youths, trichotillomania (hair pulling disorder, HPD) literature demonstrates a lack of research in several critical domains including adolescent HPD, HPD pulling styles (i.e. focused and automatic pulling) and family functioning. The present study sought to address these limitations through the examination of (1) family functioning within the context of adolescent HPD, (2) family functioning in relation to adolescent pulling styles, and (3) characteristics of an HPD adolescent sample relative to pulling styles. In total, fifty-seven adolescent-parent dyads (41 adolescents with HPD and 16 matched controls) from a larger investigation were included. Participants completed an assessment battery including diagnostic interviews and self-report measures pertaining to comorbidity, pulling styles and family functioning. Regression analyses indicated that diagnostic status (i.e. HPD adolescent or control) failed to predict family functioning. Family functioning also failed to predict the degree to which adolescents reported engaging in focused or automatic pulling. Examination of sample characteristics indicated both focused and automatic pulling styles to some extent, with a large portion of individuals (compared to prior research) demonstrating solely focused pulling behavior. Implications for these findings, as well as limitations and avenues for further research are discussed.

1. . Introduction Trichotillomania (hair pulling disorder, HPD) is characterized by the recurrent pulling out of one's hair, resulting in hair loss. Although largely understudied in pediatric populations, HPD research suggests a substantial presence of this disorder amongst youths. Though the precise number of youths affected is unknown, past research in adult populations indicates approximately 3.4% of adults to be affected by HPD, with a large portion of individuals exhibiting an adolescent onset (i.e. mean age of 13; Bruce, Barwick, & Wright, 2005; Christenson, Pyle, & Mitchell, 1991). What is more, research in youths with HPD has demonstrated significant physical (e.g. trichobezoars; Harrison & Franklin, 2012) and psychosocial impairment associated with the disorder (e.g. poor social relationships and academic functioning, anxious and depressive symptoms; Lewin et al., 2009; Franklin et al., 2008; Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007). For example, Boudjouk, Woods, Miltenberger, and Long (2000) assessed peer evaluations of adolescents with and without a habit behavior (i.e. tic disorder or HPD) and found that adolescents exhibit-

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Corresponding author. E-mail address: [email protected] (Y.E. Murphy).

http://dx.doi.org/10.1016/j.jocrd.2017.05.002 Received 9 December 2016; Received in revised form 5 May 2017; Accepted 11 May 2017 Available online 12 May 2017 2211-3649/ © 2017 Elsevier Inc. All rights reserved.

ing these behaviors were rated significantly lower in social acceptability compared to adolescents with no habit behavior. In addition, anecdotal evidence amongst adolescents indicates substantial isolation and distress due to hair pulling (e.g. “My parents were so stressed. I felt like a terrible child”; Trichotillomania Learning Center, personal communication, November 5, 2015). Despite such evidence demonstrating aversive impact amongst youths, pediatric research in relation to HPD, is significantly lacking. One area in which this lack of research is most evident is with relation to family functioning. Family functioning refers to a multitude of factors within the family including parental mental health, parenting practices, family dynamics and family cohesion. Considering adolescent's proximity to and dependence on family, it is important to understand how the family environment may contribute to and/or be impacted by disorders with an adolescent onset, such as HPD. What is more, research demonstrates family functioning to be a critical factor in several areas of adolescent development including psychological wellbeing and risk and resilience development (Compas, Hinden, & Gerhardt, 1995; Shek, 2005; Shucksmith,

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focused pulling demonstrates a dramatic increase coinciding with approximately thirteen years of age. This further supports adolescence as a potentially critical period of development within the context of HPD (Flessner, Woods, Franklin, Keuthen, & Piacentini, 2009). However, despite the important implications of these findings (i.e., potential benefit of tailored therapeutic interventions, concurrent impact on the family, etc.), particularly amongst adolescents, scant research has sought to better characterize these pulling styles within youths. Better characterization of these styles may contribute to further hypothesis generation with relation to pulling style behaviors and family functioning (e.g. future research may wish to examine family functioning domains associated with comorbid disorders) and advance comprehensive understanding of adolescent HPD (e.g. associated pulling style comorbidities may provide more support for conceptualization of the styles as affective or habit behaviors; may further clarify adolescent pulling behaviors and appropriate interventions, etc). In sum, a paucity of research within the pediatric HPD literature suggests several domains in need of further inquiry including, (1) family functioning, (2) the relationship between family functioning and automatic and focused pulling, and (3) the improved characterization of pulling styles, particularly during adolescence. Utilizing secondary data analyses, this study looks to alleviate these gaps and expand upon past research. In particular, past research using the current sample (see Keuthen et al., 2013) has assessed family environment in adolescents with HPD as compared to healthy controls, with results indicating increased family conflict, anger, aggression, and parental stress and decreased family support amongst youths with HPD. The current study seeks to expand this line of inquiry (i.e. investigating additional family measures of interest with focus on an adolescent's perspective, etc.) and examine such domains within a pulling style context. As such, the aims of the current study are as follows: (1) examine youth -reported differences in adolescent family functioning (i.e. adolescent report of parenting behaviors via the CRPBI) among adolescents with HPD compared to controls, (2) examine the relationship between parenting behaviors, parenting attitudes, family environment, and pulling styles, and (3) examine characteristics of pulling styles within the current sample (i.e. percentage of focused and automatic pulling, comorbidities, etc.). It is hypothesized that adolescents with HPD will demonstrate decreased family functioning compared to controls. In addition, though exploratory in nature, we hypothesize that adolescents demonstrating worse family functioning will demonstrate increased focused pulling behavior. We predict no relationship between family functioning and automatic pulling.

Hendry, & Glendinning, 1995). This critical period of development simultaneously coincides with average age of HPD onset and lends support to the study of family functioning as a viable area of research among adolescents with HPD. Interestingly, emerging research suggests a presence of dysfunction within the families of youths with HPD. Though scant in number and rarely assessing adolescents exclusively, these studies suggest a link between pediatric HPD (spanning ages ten to seventeen years) and poor parental mental health (e.g. increased parental anxiety), maladaptive parenting practices (e.g. limited independence), weakened family dynamics (e.g. low family cohesion) and a turbulent family emotional climate (e.g. increased family aggression; Boughn & Holdom, 2003; Keuthen, Fama, Altenburger, Allen, & Raff, 2013; Moore et al., 2009; Reeve, Bernstein, & Christenson, 1992). Similarly, qualitative research utilizing case study analyses further indicate increased impairment and disruption amongst the families of youths with HPD (McLaughlin & Nay, 1975; Tay, Levy, & Metry, 2004). Such disruption includes demands of perfectionistic parenting and psychosocial stressors within the family (e.g. separation from an attachment figure, hospitalization of the child or parent, parental marital conflict, etc.). Findings suggest that family functioning may be linked, at least in part, to the onset and course of this disorder (e.g. increased family dysfunction linked to youth HPD diagnosis and worsened quality of life). Despite the evident importance of family functioning within HPD, research within this domain is generally lacking. For example, the majority of recent studies have failed to include youth perspectives in the assessment of family functioning, instead opting for parent report or adult retrospective analyses. Such methodologies are limiting, as the absence of youth report may neglect potentially critical differences in, as well as effects of, family member perceptions (e.g. parent versus youth's perception of family functioning). What is more, due to sample characteristics (e.g. mother-youth dyads) prior research within these domains has failed to assess both maternal and paternal parenting distinctively, limiting a comprehensive understanding of the family dynamics. One available tool commonly used to assess youth report of both maternal and paternal behaviors is the Child Report of Parental Behavior Inventory (CRPBI; Schaefer, 1995). This assessment is used within the current study. Lastly, with regard to limitations, studies have yet to examine whether a relationship exists with respect to family functioning and specific HPD characteristics. One HPD characteristic perhaps of most importance to the family functioning domain is HPD pulling style. Research indicates two distinct styles of pulling exist among youths, termed automatic (i.e. pulling outside of one's awareness) and focused pulling (i.e. intentional pulling in response to an urge, impulse, negative event, or emotion; Flessner, Woods, et al., 2008). Considering the differential functions of pulling styles (i.e. habit behavior versus emotion regulation), it is plausible that disruptions in family behavior may create or foster an emotional environment particularly conducive to focused pulling behavior, however additional research in these domains is critical for determining the validity of such hypotheses. Notably, only a small percentage of youths who hair pull- 4.8% – have been found to engage in solely automatic or focused pulling, supporting the notion that youths most often engage in both forms to some extent (Flessner, Conelea et al., 2008; Flessner, Woods et al., 2008). Interestingly, recent literature has indicated differences amongst HPD pulling styles, both in relation to disorder severity and impairment. For example, in a study of youths 10–17 years old (mean age of 14 years), Flessner, Conelea et al. (2008) and Flessner, Woods et al. (2008) found increased levels of HPD severity amongst high focused pullers compared to low focused pullers. What is more- independent of pulling severity- higher levels of depression symptoms were found amongst high (compared to low) automatic and focused pullers, and higher anxiety symptoms were found amongst high focused pullers. Intriguingly, cross-sectional research indicates that although levels of automatic pulling appear to remain constant throughout the lifespan,

2. Method 2.1. Participants The current study utilized secondary analysis of data obtained by a Northeastern hospital between February 2009 and June 2011. Approval for this study was granted by the institution and university's IRB. Participants described herein were recruited as part of a larger study examining genetic and non-genetic factors related to adolescent and adult HPD. In total, 75 participants were recruited through a northeastern trichotillomania clinic and the Trichotillomania Learning Center Newsletter. For the current study, inclusion within the adolescent HPD group required (a) participant age between 13 and 18 years old, (b) current diagnosis of DSM-IV HPD or chronic hair pulling (as defined by satisfaction of DSM-IV HPD criteria without Criteria B, C or both), (c) no diagnosis of mental retardation, autism spectrum, or psychotic disorders, (d) availability of at least one biological parent for study participation and (e) complete data on all relevant measures. Inclusion within the control adolescent group required (a) participant age between 13 and 18 years old, (b) lack of any DSM-IV diagnoses (c) availability of at least one biological parent for study participation and (d) complete data on all relevant measures. Participants (N=18) failing 28

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to meet inclusion criteria for either group were excluded from present analyses. No significant differences (i.e. ethnicity, age, gender, anxiety and depression scores) were demonstrated between included and excluded participants. Ultimately, fifty-seven adolescent-parent dyads were selected for use including 41 adolescents with HPD and 16 matched controls. Participant demographics are presented in Tables 1 and 2.

Table 1 Demographic characteristics of adolescent HPD and control samples. HPD adolescents N=41 Age (mean yrs., SD) 15.10 (1.48) Gender (n, %) Female 40 (97.6%) Male 1 (2.4%) Ethnicity (n, %) White/European 37 (90.2%) American Black/African American 1 (2.4%) Other 3 (7.3%) MIST-C Score (mean, SD) Automatic Subscale 6.85 (7.19) Focused Subscale 94.95 (32.28) CDI Total Score (mean, 57.17 (13.94) SD) MASC Total Score (mean, 53.49 (18.36) SD) Current Psychiatric Comorbidity (n, %) ADHD combined type 2 (4.9%) ADHD hyperactive type 1 (2.4%) ADHD inattentive type 2 (4.9%) Anorexia nervosa 1 (2.4%) Bulimia nervosa 1 (2.4%) MDD 6 (14.6%) OCD 13 (31.7%) Tourette syndrome 3 (7.3%) Transient tic disorder 1 (2.4%) GAD 9 (22%) Panic disorder w/ 1 (2.4%) agoraphobia Social phobia 6 (14.6%) Specific phobia 8 (19.5%) PTSD 2 (4.9%) Avoidant disorder 1 (2.4%) ODD 1 (2.4%) Enuresis 2 (4.9%)

Control adolescents N=16 15.22 (1.54) 14 (87.5%) 2 (12.5%)

2.2. Measures

16 (100%)

2.2.1. HPD diagnosis, severity, distress and subtype 2.2.1.1. Trichotillomania diagnostic inventory revised (TDI-R). The TDI-R is a revised 6-item, 3 point rating, semi-structured interview designed to assess satisfaction of DSM-IV criteria for HPD or chronic hair pulling (Rothbaum & Ninan, 1994). The TDI-R was administered to both parent and child separately.

0 (0%) 0 (0%) n/a n/a 42.88 (6.16) 41.44 (13.65)

0 0 0 0 0 0 0 0 0 0 0

(0%) (0%) (0%) (0%) (0%) (0%) (0%) (0%) (0%) (0%) (0%)

0 0 0 0 0 0

(0%) (0%) (0%) (0%) (0%) (0%)

2.2.1.2. Trichotillomania scale for children- child/parent report (TSC-C/ P). The TSC-C/P is a 12-item child/adolescent (TSC-C) and parent (TSC-P) self-report measure used to assess HPD symptom severity and distress (Tolin et al., 2008). The TSC-C/P is comprised of two subscales (i.e. symptom severity and distress/ impairment), with 5 and 7 items respectively, rated on a 0–2 scale. Total scores are calculated by summing average scores from each subscale, with higher scores indicating increased severity and distress. Research indicates the TSCC/P to have adequate internal consistency and test retest reliability and good concurrent validity (Tolin et al., 2007). 2.2.1.3. Milwaukee inventory for styles of trichotillomania-child version (MIST-C). The MIST-C is a 25-item child/adolescent self-report designed to assess styles of hair pulling in children and adolescents 10–17 years of age (Flessner et al., 2007). The MIST-C is comprised of two subscales (i.e. focused pulling and automatic pulling) with 21 and 4 items respectively, rated on a 0–9 scale. Scores on each subscale are calculated by adding respective item ratings, producing a dimensional score with higher sores suggesting increasingly “focused” or “automatic” pulling. Available evidence demonstrates the MIST-C to have acceptable internal consistency and good construct and discriminant validity (Flessner et al., 2007).

ADHD: Attention Deficit Hyperactivity Disorder, CDI: Child Depression Inventory, GAD: Generalized Anxiety Disorder, HPD: Hair Pulling Disorder, MASC: The Multidimensional Anxiety Scale for Children, MDD: Major Depressive Disorder, MIST-C: Milwaukee Inventory for Styles of Trichotillomania-Child Version, OCD: Obsessive-Compulsive Disorder, ODD: Oppositional Defiant Disorder, PTSD: Post-traumatic Stress Disorder, SD: standard deviation. Table 2 Demographic characteristics of parents (mothers, fathers) present at initial intake assessment. HPD mothers N=41 Age (mean yrs., 47.49 (4.27) SD) Ethnicity (n, %) White/European 39 (95.1%) American Black/ African 1 (2.4%) American Hispanic/Latino 1 (2.4%) Education (n, %) HS or GED 7 (17.1%) Technical/ 6 (14.6%) Associates Bachelors 18 (43.9%) Graduate degree 10 (24.4%) Marital Status (n, %) Single 3 (7.3%) Married 34 (82.9%) Separated 1 (2.4%) Divorced 3 (7.3%)

HPD fathers N=6

Control mothers N=14

Control fathers N=2

46.67 (4.72)

48 (4.74)

47 (0)

6 (100%)

14 (100%)

2 (100%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%) 0 (0%)

1 (7.1%) 1 (7.1%)

1 (50%) 0 (0%)

4 (66.7%) 2 (33.4%)

6 (42.9%) 6 (42.9%)

1 (50%) 0 (0%)

0 6 0 0

0 (0%) 12 (85.7%) 0 (0%) 2 (14.3%)

0 2 0 0

(0%) (100%) (0%) (0%)

2.3. Comorbid diagnoses and symptoms 2.3.1. Kiddie-SADS-present and lifetime version (K-SADS-PL) The K-SADS-PL is a semi structured diagnostic interview designed to assess current and past psychopathology within children and adolescents (Kaufman et al., 1997). Within the current study, the K-SADS-PL was administered to adolescents individually (i.e. without parent). Past research utilizing the K-SADS-PL has demonstrated good concurrent validity and excellent interrater reliability (Ambrosini, 2000). 2.3.2. The multidimensional anxiety scale for children (MASC) The MASC is a 39 item self-report of child anxiety symptoms. Items are rated on a 0–4 scale and summed to create a total score (March & Parker, 2004). The MASC has demonstrated excellent internal consistency, adequate test-retest reliability and excellent construct validity (March, Parker, Sullivan, Stallings, & Conners, 1997; March, Sullivan, & Parker, 1999).

(0%) (100%) (0%) (0%)

2.3.3. Children's depression inventory (CDI) The CDI is a 27-item self-report used to assess depressive symptoms in youths aged 6–17 years old. Research utilizing the CDI demonstrates good to excellent internal consistency, reliability, and adequate validity (Doerfler, Felner, Rowlison, Raley, & Evans, 1988; Smucker, Craighead, Craighead, & Green, 1986; Stockings et al., 2015).

HPD: Hair Pulling Disorder, HS: high school, GED: General Education Diploma, SD: standard deviation.

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Table 3 Correlation matrix for examined covariates in case vs. control analyses. Variable

1

1. Father Acceptance-Rejection p-value 2. Father Autonomy-Psychological Control p-value 3. Father Lax-Firm Control p-value 4. Mother Acceptance-Rejection p-value 5. Mother Autonomy- Psychological Control p-value 6. Mother Lax-Firm Control p-value 7. Depressive Symptoms p-value 8. Anxiety Symptoms p-value 9. Age

2

3

4

5

6

7

8

9

−.237 .076

.061 .652 .099 .464

.571 .000 −.147 .275 −.248 .063

−.112 .406 .477 .000 .411 .001 −.296 .025

−.298 .024 .490 .000 .255 .055 −.167 .215 .204 .129

−.296 .025 .386 .003 .137 .309 −.233 .081 .323 .014 .248 .063

−.007 .958 .234 .080 .034 .800 .046 .736 −.004 .974 −.058 .669 .544 .000

−.167 .214 .175 .194 .272 .041 −.040 .769 .111 .410 .259 .051 .200 .136 −.134 .320

TSC: Trichotillomania Scale for Children- Child/Parent Report.

study staff trained to reliability on interviews) administered both structured and semi structured interviews. Parents and children were interviewed separately. Consensus of participant diagnoses were achieved utilizing best estimates procedures by two doctoral-level clinicians. Contingent upon time remaining, self-reports were subsequently completed on site by parents and adolescents or were taken home to complete and return within two weeks. All participants received monetary compensation for their time.

2.4. Family functioning 2.4.1. Family environment scale (FES) The FES is a 90-item self-report designed for individuals 11 years or older and assesses three dimensions of family environment (i.e. relationships, personal growth, and system maintenance; Moos, 1990). Items comprise ten distinct subscales of true-false questions assessing family cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural orientation, active recreational orientation, moral-religious emphasis, organization and control. Prior research indicates the FES to have concurrent, construct and predictive validity (Moos, 1990). Based upon prior research within the present sample (Keuthen et al., 2013), data analyses of HPD pulling styles and the family environment were conducted only amongst FES subscales previously demonstrating significant differences between HPD participants and controls (i.e. Conflict, Independence, and Family Relationship Index). Within the FES, Conflict refers to the amount of openly expressed anger and conflict among family members. Independence refers to the extent to which family members are perceived as assertive and self-sufficient. The Family Relationship Index (FRI) is a composite of the Cohesion, Expressiveness and Conflict subscales and is used as a measure of family support.

2.6. Data analytic plan 2.6.1. Power analysis Based upon findings of prior research examining family functioning among adolescents with HPD (Keuthen et al., 2013), a priori calculations indicated a total sample size of 48 to produce at least a medium to large effect size. As such, the present sample (N=57) is deemed sufficient to detect medium to large effects if present. 2.6.2. Cases vs. controls analyses Linear regression analyses were utilized to investigate relationships between HPD diagnostic status (i.e. case versus controls) and parental behaviors. Prior to conducting analyses, statistical assumptions of linear regressions were verified. Based upon prior HPD research, potential covariates were examined and controlled for where appropriate. Covariates examined included comorbidity (i.e. depression and anxiety symptoms), and age. Based on significant correlations with independent variables (parental behaviors, p < .05), the following covariates were used: depression (for father and mother autonomy-psychological control and father acceptance- rejection) and age (for father lax-firm control). Covariates that did not indicate significant correlations (p > .05) with independent variables were not included in case versus control analyses (See Table 3).

2.4.2. Attitudes toward my child rating checklist (ATMCRC) The ATMCRC is a 10-item parental self-report used to assess parent's feelings about their child/adolescents’ hair pulling behavior and perceptions of child's competence and need for support (Moore et al., 2009). Items are rated on a 0–5 scale and points are summed to create a total score. 2.4.3. Child report of parental behavior inventory (CRPBI) The CRPBI is a child and adolescent self-report consisting of 10-item scales assessing 26 concepts related to parental behaviors (e.g. ignoring, possessiveness, lax discipline; Schaefer, 1995). Items are rated on a 0–3 scale and summed for a total score. Major family dimensions assessed by this measure include (1) Acceptance versus Rejection, (2) Psychological Autonomy versus Psychological Control, and (3) Firm versus Lax Control. Research utilizing the CRPBI demonstrates that the measure exhibits high reliability (Schludermann & Schludermann, 1970).

2.6.3. HPD pulling styles analyses Additional linear regression analyses were employed to examine possible relationships between level of HPD pulling styles, family environment, parental behaviors and parental attitudes. Of note, considering the dimensional nature of HPD pulling styles when measured with the MIST-C, participant pulling scores within the current regression analyses were assessed along two continuums (e.g. increasingly focused pulling and increasingly automatic pulling) rather than assignment to an exclusive automatic or focused pulling group. Similar to prior analyses, statistical assumptions of regression were tested and covariates (i.e. comorbidity, age, HPD symptom severity and HPD distress) were assessed and included as appropriate. Specifically,

2.5. Procedure Prior to study participation, informed consent was obtained from all participants. Parent and adolescent dyads attended one study session lasting approximately 3–4 h, during which independent evaluators (i.e. 30

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characteristics of the current HPD sample were examined, including percentage of high/low focused and automatic pullers and comorbidities with additional DSM-IV psychiatric disorders. To facilitate examination of these characteristics, participant MIST-C scores were used in a median split procedure, subsequently classifying adolescents into four groups (i.e. high focused-high automatic, high focused-low automatic, low focused-low automatic, low focused-high automatic). Notably, this methodology was only used for analyses of pulling style characteristics and has been used within prior research assessing both adult and youth pulling styles (Flessner, Conelea et al., 2008; Flessner, Woods et al., 2008). Within the current sample, adolescents scoring greater than or equal to 98 on the focused subscale and greater than or equal to 4 on the automatic subscale were classified as “high focused-high automatic pullers”. Participants scoring greater than or equal to 98 on the focused subscale and less than 4 on the automatic scale were classified as “high focused-low automatic”. Participants scoring less than 98 on the focused subscale and less than 4 on the automatic subscale were classified as “low focused-low automatic”. Whereas, participants scoring less than 98 on the focused subscale and greater than or equal to 4 on the automatic subscale were classified as “low focused-high automatic”.

Table 4 Regression summary for CRPBI controls vs. cases analyses. Variable

B

β

S.E

Father Acceptance-Rejection Step 1 Depressive Symptoms −.227 .099 Step 2 Depressive Symptoms −.251 .113 Group Classification 1.564 3.436 Father Autonomy- Psychological Control Step 1 Depressive Symptoms .305 .098 Step 2 Depressive Symptoms .296 .112 Group Classification .665 3.426 Father Lax-Firm Control Step 1 Age 1.160 .553 Step 2 Age 1.170 .558 Group Classification .866 1.825 Mother Acceptance-Rejection Step 1 Group Classification −3.991 2.473 Mother Autonomy- Psychological Control Step 1 Depressive Symptoms .243 .096 Step 2 Depressive Symptoms .211 .110 Group Classification 2.087 3.338 Mother Lax-Firm Control Step 1 Group Classification −.485 2.077

ΔR2

p

.003

.025 .025 .076 .030 .651

.001

.003 .003 .013 .011 .847

.078

.004

.041 .041 .112 .041 .637

.045

n/a

R2

.088 −.296 .091 −.328 .067 .149 .386 .149 .373 .028 .074 .272 .274 .062

−.213 .104 .323 .111

.006

.001

n/a

.280 .091

−.031

.112 .112

3. Results

.014 .014 .042 .059 .534

3.1. Cases versus control analyses Regression results for case versus control analyses (i.e. CRPBI) are presented in Table 4. Notably, group classification (i.e. HPD diagnostic status) did not significantly predict adolescents’ perception of parental behavior, including paternal behaviors of acceptance-rejection (after controlling for depression; β=.067, p=.651), autonomy-psychological control (after controlling for depression; β=.028, p=.847), or lax-firm control (after controlling for age; β=.062, p=.637). Prediction of similar maternal behaviors were also unsupported including those of acceptance-rejection (β=−.213, p=.112), autonomy-psychological control (after controlling for depression; β=.091, p=.534) and laxfirm control (β=−.031, p=.816). Given non-significant findings in these regressions, parental behaviors were not included in subsequent pulling style analyses.

.816 .816

Table 5 Correlation matrix for examined covariates in pulling style analyses. Variable 1. Focused Pulling p-value 2. Automatic Pulling p-value 3. Depressive Symptoms p-value 4. Anxiety Symptoms p-value 5. Age p-value 6. TSC Total Score

1

2

3

4

5

6

.182 .254

.535 .000 .236 .138

.600 .000 .229 .150 .572 .000

.291 .065 .044 .786 .362 .020 .008 .959

.468 .002 .128 .23 .512 .001 .132 .410 .243 .125

3.2. HPD pulling style analyses Regression analyses (i.e. FES, ATMCRC) examining the relationship between family functioning and levels of HPD pulling style are presented in Tables 6 and 7 respectively. Contrary to predicated hypotheses, family environment, specifically family conflict (for automatic pulling: β=.089, p=.581; for focused pulling: β=−.117, p=.381) independence (for automatic pulling: −.166, p=.299; for focused pulling: β=.193, p=.106) and relationship index (for automatic pulling: β=−.047, p=.771; for focused pulling: β=.227, p=.104) failed to predict levels of automatic or focused pulling. Additionally, results demonstrated that mother's attitudes towards their child (for automatic pulling: β=.063, p=.696; for focused pulling: β=−.037, p=.771) did not predict levels of automatic or focused pulling behavior.

TSC: Trichotillomania Scale for Children- Child/Parent Report.

focused pulling demonstrated significant (p < .05) correlations with CDI (depression), MASC (anxiety), and TSC (HPD severity and distress) total scores. Consequently, these variables were included as covariates in all focused pulling analyses. Automatic pulling demonstrated no significant correlations (p > .05), therefore covariates were not used in automatic pulling analyses (See Table 5). As noted previously, data analyses examining HPD pulling styles and the family environment were conducted only amongst FES subscales previously demonstrating significant differences between HPD participants and controls (i.e. Conflict, Independence, and Family Relationship Index; Keuthen et al., 2013). Regressions in relation to HPD pulling styles and parental behaviors were conducted only amongst subscales demonstrating significant differences or trends (i.e., p < .10) within prior regression analyses (see cases vs control analyses). Lastly, a final set of regressions were ran to determine potential relationship between HPD pulling styles and parental attitudes (i.e. ATMCRC).

3.3. HPD pulling style characteristics Examination of sample characteristics indicated that no adolescents within the current sample could be classified as entirely automatic (i.e. MIST-C automatic subscale score of 1 or more and focused subscale score of 0), however 22% (n=9) of the sample were classified as solely focused pullers (i.e. score of 1 or more on MIST-C focused subscale and 0 on automatic subscale). What is more, 34.1% (n=14) of the sample were classified as “high focused-high automatic”, 17.1% (n=7) as “high focused-low automatic”, 24.4% (n=10) as “low focused-low

2.6.4. HPD pulling style characteristics In efforts to better characterize adolescent pulling styles, several 31

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and one of only two studies in the past fifteen years to utilize adolescent report (as opposed to retrospective adult report or parent report) of family environment. Contrary to study hypotheses, diagnostic status failed to predict parental behaviors. Similarly, family functioning failed to predict the degree to which adolescents reported engaging in automatic or focused pulling. What is more, examination of the current sample demonstrated both automatic and focused pulling behaviors, with a large portion of individuals demonstrating solely focused pulling – particularly in comparison to previously published work utilizing internet sampling procedures (Flessner, Conelea et al., 2008; Flessner, Woods et al., 2008). What follows is a discussion of these findings and their potential for impacting future investigation in, and increasing overall understanding of, adolescent HPD. Results presented herein suggest that diagnostic status (i.e. case versus controls) failed to predict youth report of parental behaviors. These findings are in contrast to past research indicating poorer functioning amongst families of child and adolescent hair pullers when compared to controls. Discrepancies between past and present research may reflect idiosyncrasies to the family measures used herein. Specifically, past research utilizing current youth report demonstrated significant differences between cases and controls when using the Family Environment Scale (Keuthen et al., 2013), however the present study examines potential differences using the CRPBI. Though the CRPBI is advantageous over the FES in its distinction of perceived maternal and paternal behaviors, differences between these measures may be critical in the assessment of HPD family environment. For example, both the FES and CRPBI examine family support, however content of items used to assess this construct differ by measure. Specifically, while the FES assesses support through a composite of items on the cohesion, expressiveness and conflict subscales, the CRPBI assesses support through items relating to acceptance and rejection. Given lack of research examining convergent validity between these two measures, it is plausible that support assessed by the FES and CRPBI is critically distinct, in that support assessed by the FES is more relevant to the family of a child with HPD. Notably, such conjecture may modify potential hypotheses for future research. Specifically, within the current study it was hypothesized that adolescents with HPD would demonstrate worse family functioning compared to controls. As current findings did not support this hypothesis, it may be that maladaptive family functioning is limited to specific domains, rather than generally poor functioning (e.g. worse family functioning within domains of family cohesion, expressiveness and conflict rather than domains such as acceptance and rejection). Future research should consider which domains may be most critical to families with HPD and should perhaps explicitly define constructs of interest (e.g. to determine whether similar constructs are studied across studies). Relatedly, both the CRPBI and FES measure domains of control. Given lack of significance for this domain in both past and present research, it is plausible that results reflect a genuine lack of distinction- in relation to control- between families of hair pullers and those of healthy controls. Understandably, hypotheses regarding results herein are merely conjectural. Further investigation of these domains within additional samples is critical in the rejection or corroboration of such hypotheses. Beyond measure distinctions, lack of significance within the current study may also suggest that critical components of families of children with HPD have been overlooked. For example, past research utilizing retrospective analyses, have indicated a disproportionately higher report of family violence amongst women with HPD compared to family violence reported within the general population (Boughn & Holdom, 2003). Though such findings are intriguing, research has yet to study these domains within additional HPD literature. Similarly, additional impaired domains implicated within the families of adolescents with HPD, yet lacking replication research, include parental mental health and family role performance. Researchers may consider further investigation of these areas within the families of adolescents with HPD. Such investigation may perhaps be enhanced

Table 6 Regression summary for FES pulling style analyses. Variable

B

β

S.E

Focused Pulling & Family Independence Step 1 Depressive Symptoms .092 .383 Anxiety Symptoms .926 .252 TSC Total Score 13.275 4.806 Step 2 Depressive Symptoms .113 .375 Anxiety Symptoms 1.014 .252 TSC Total Score 13.068 4.698 Family Independence .396 .239 Focused Pulling & Family Conflict Step 1 Depressive Symptoms .092 .383 Anxiety Symptoms .926 .252 TSC Total Score 13.275 4.806 Step 2 Depressive Symptoms .228 .414 Anxiety Symptoms .918 .253 TSC Total Score 13.397 4.822 Family Conflict −.305 .344 Focused Pulling & Family Relationship Index Step 1 Depressive Symptoms .092 .383 Anxiety Symptoms .926 .252 TSC Total Score 13.275 4.806 Step 2 Depressive Symptoms .407 .419 Anxiety Symptoms .833 .252 TSC Total Score 14.097 4.720 Family Relationship Index .244 .146 Automatic Pulling & Family Independence Step 1 Family Independence −.076 .072 Automatic Pulling & Family Conflict Step 1 Family Conflict .051 .092 Automatic Pulling & Family Relationship Index Step 1 Family Relationship Index −.011 .038

ΔR2

p

.034

.000 .812 .001 .009 .000 .764 .000 .009 .106

.010

.000 .812 .001 .009 .000 .585 .001 .009 .381

.549

.035

.000 .812 .001 .009 .000 .338 .002 .005 .104

.028

n/a

.299 .299

.008

n/a

.581 .581

.002

n/a

.771 .771

R2

.514 .040 .527 .378 .549 .049 .577 .372 .193 .514 .040 .527 .378 .525 .098 .522 .382 −.117 .514 .040 .527 .378 .176 .474 .402 .227

−.166

.089

−.047

n/a: not applicable, TSC: Trichotillomania Scale for Children- Child/Parent Report. Table 7 Regression summary for ATMCRC pulling style analyses. Variable

B

S.E

β

Focused Pulling & Mother's ATMCRC Total Score Step 1 Depressive Symptoms .092 .383 .040 Anxiety Symptoms .926 .252 .527 TSC Total Score 13.275 4.806 .378 Step 2 Depressive Symptoms .065 .399 .028 Anxiety Symptoms .949 .267 .540 TSC Total Score 13.108 4.900 .374 ATMCRC Total Score −.155 .530 −.037 Automatic Pulling & Mother's ATMCRC Total Score Step 1 ATMCRC Total Score .059 .150 .063

ΔR2

p

.516

.001

.000 .812 .001 .009 .000 .872 .001 .011 .771

.004

n/a

R2

.514

.696 .696

ATMCRC: Attitudes Toward My Child Rating Checklist, TSC: Trichotillomania Scale for Children- Child/Parent Report.

automatic” and 24.4% (n=10) as “low focused-high automatic”. See Table 8 for additional information regarding comorbidities.

4. Discussion The current study sought to examine family environment relative to youth report and HPD pulling styles. To our knowledge this is the first study to examine family environment within the pulling style context 32

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Table 8 Characteristics of HPD Sample.

# of participants (%) Current Psychiatric Comorbidity ADHD Combined Type ADHD Hyperactive Type ADHD Inattentive Type Anorexia Nervosa Bulimia Nervosa MDD OCD Tourette Syndrome Transient Tic Disorder GAD Panic disorder w/agoraphobia Social Phobia Specific phobia PTSD Separation Anxiety Disorder Avoidant Disorder ODD Enuresis

High Focused-High Automatic

High Focused-Low Automatic

Low Focused-Low Automatic

Low Focused-High Automatic

14 (34.1%)

7 (17.1%)

10 (24.4%)

10 (24.4%)

1 0 1 0 0 5 6 1 1 4 1 3 4 0 0 1 0 0

0 0 0 0 1 1 3 1 0 2 0 0 2 0 0 0 0 0

1 0 0 1 0 0 3 0 0 2 0 1 1 2 0 0 0 1

0 1 1 0 0 0 1 1 0 1 0 2 1 0 0 0 1 1

(7.1%) (0%) (7.1%) (0%) (0%) (35.7%) (42.9%) (7.1%) (7.1%) (28.6%) (7.1) (21.4%) (28.6%) (0%) (0%) (7.1%) (0%) (0%)

(0%) (0%) (0%) (0%) (14.3%) (14.3%) (42.9%) (14.3%) (0%) (28.6%) (0%) (0%) (28.6%) (0%) (0%) (0%) (0%) (0%)

(10%) (0%) (0%) (10%) (0%) (0%) (30%) (0%) (0%) (20%) (0%) (10%) (10%) (20%) (0%) (0%) (0%) (10%)

(0%) (10%) (10%) (0%) (0%) (0%) (10%) (10%) (0%) (10%) (0%) (20%) (10%) (0%) (0%) (0%) (10%) (10%)

ADHD: Attention Deficit Hyperactivity Disorder, GAD: Generalized Anxiety Disorder, MDD: Major Depressive Disorder, ODD: Oppositional Defiant Disorder, PTSD: Post-traumatic Stress Disorder.

levels of focused pulling throughout the adolescent period. From a clinical perspective, these characteristics may provide critical information for interventions specific to adolescent HPD populations. For example, considering demonstrated presence of both focused and automatic pulling to some extent, a substantial number of adolescents with HPD may benefit from a combined therapeutic approach focusing on both habitual (e.g. Habit Reversal Therapy) as well as potential emotional components of pulling behavior (e.g. Acceptance and Commitment Therapy or Dialectical Behavioral Therapy). In addition, comorbidities indicated within the current study, suggest that clinicians may benefit from the assessment and treatment of additional symptoms of therapeutic concern (e.g. depression, general anxiety, obsessivecompulsive symptoms, etc.). Notably, compared to prior research (Flessner, Conelea et al., 2008; Flessner, Woods et al., 2008), analyses within the current sample indicate an increased number of solely focused, as well as high focused pullers. Considering scant studies assessing pulling styles exclusively amongst adolescents, it is unclear whether current sample characteristics are common to or unusual to the adolescent HPD population, thus warranting continued research assessing characteristics of such populations. Given noted differences between high/low focused and automatic pulling (e.g. differences in comorbidity, HPD severity, etc.), differences in sample makeup (as compared to prior pediatric HPD research) may have contributed to the present study's findings and suggest the need for reanalysis amongst multiple, larger samples of youths. While this study contributes to the small body of research assessing HPD family environment and provides potential avenues of future research within this domain, there are several limitations of note. First, family environment within this study was solely assessed utilizing selfreport measures. Though frequently utilized amongst the research literature (Derisley, Libby, Clark, & Reynolds, 2005; Moore et al., 2009; Peris et al., 2012), such methods are inherently susceptible to self-serving biases and distortions of self-perception. What is more, meta-analytic studies within the pediatric anxiety literature demonstrate larger effect sizes amongst observational methods compared to questionnaire or interview techniques (McLeod, Wood, & Weisz, 2007). While research has yet to examine effect size differences within the HPD literature, it is plausible that such discrepancies apply herein as well. Thus, future research may wish to include additional methods (e.g. observational data) complimenting self-report data. A second limitation of this investigation is breadth of family domains assessed.

through the use of current youth report, interviews and/or observations. Contrary to our hypotheses, family environment and maternal attitudes towards their child failed to predict the degree to which adolescents engaged in automatic or focused pulling. Such findings may suggest no impact of family functioning on pulling styles. Alternatively, it is equally plausible that this relationship does exist, however within the current study such relationships may be masked due to strength of associations between pulling style, anxiety and depressive symptoms. Given the lack of previous research examining family functioning and pulling styles, it is difficult to accurately determine whether the sample size utilized herein is sufficient to detect an effect within this particular study aim. Therefore, future research may wish to reexamine these domains within larger samples to increase probability of detecting relationships of smaller scale. What is more, results herein may also reflect limitations of pulling style assessment. In particular, recent research amongst adult pulling styles has indicated the need for a revised Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A; Alexander et al., 2016; Keuthen et al., 2015). Though the MIST-C demonstrates good construct and discriminant validity (Flessner et al., 2007), similar modifications within the child specific measure may be beneficial in providing an increasingly refined approach to pediatric pulling style assessment. Thus, future research evaluating the MIST-C is warranted. Further, future research may wish to investigate the relationship between additional implicated domains (e.g. family violence, role performance, parental mental health) and disparate pulling styles within the families of adolescents with HPD. Given the proportion of the present sample reporting entirely focused pulling, researchers may also wish to examine domains relating to the development of emotion regulation skills within youths, yet currently unstudied in the HPD literature (e.g. parental attachment, expressed emotion, marital conflict, parental beliefs regarding emotions; Morris, Silk, Steinberg, Myers, & Robinson, 2007). The existing conceptualization of focused pulling as an emotion regulation-based behavior suggests that investigation of these domains within the pulling style context may highlight critical etiological and or maintaining mechanisms of focused pulling. Similar to previous findings amongst HPD populations, adolescents within the current sample demonstrated both automatic and focused pulling, with the majority of participants exhibiting high levels of both. In part, such findings corroborate prior research indicating increased 33

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Though the current study addresses the issue of scant research within the families of youths with HPD, future research in this area may benefit from the inclusion of additional family domains related to HPD (e.g. family violence, role performance, parental mental health) and emotion regulation (e.g. parental attachment, expressed emotion, marital conflict, parental beliefs regarding emotions). Third, case versus control analyses may be limited by the sample size utilized. Power analyses indicated the current sample as sufficient for detecting a medium to large effect for group comparison analyses (i.e. HPD adolescents vs. controls), however utilization of larger samples, particularly with respect to a control/comparison group, may increase the probability of revealing smaller yet meaningful effects (e.g. father laxfirm control, mother acceptance-rejection, mother autonomy-psychological control). Related to sample use, though this study utilizes a sample corresponding to mean onset of HPD (i.e. adolescent onset, specifically 13 years of age), a common definition of adolescence includes children as young as eight years old. As such, a fourth limitation of this study includes restriction of age range. Future samples in this domain may wish to include younger girls to expand sample size and consider potential differing impacts of age. Lastly, participants within the current sample were mainly White adolescents from families of higher education backgrounds (i.e. majority of parents holding a bachelor's degree or higher). Understandably, such restrictions may inhibit generalizability to youths of differing ethnicity and socioeconomic status, as current families’ capacity to find and participate in a study may inherently suggest a higher level of functioning (e.g. some families of poorer functioning may experience stressors including lower socioeconomic status, which may limit means or resources to travel to or participate in studies). What is more, generalizability to race may be of particular importance given recent research demonstrating high levels of hair pulling and related affect amongst African American women (Neal-Barnett & Stadulis, 2006; Neal-Barnett, Statom, & Stadulis, 2011). Consequentially additional research assessing family HPD environment in multiple contexts is warranted. In sum, analyses of the current study demonstrated that diagnostic status did not predict family functioning nor did family functioning predict HPD pulling styles. Findings, though contrary to predicated hypotheses, have potential for enhancing future avenues of research. For example, the current study highlights critical caveats to be considered in further examination of the family environment within the families of youths with HPD (e.g. utilization of a wide range of HPD relevant family measures, examination of additional family and emotion regulation domains, reanalysis amongst multiple, larger samples of youths, etc.). Additional investigation within these domains will ultimately contribute to a more comprehensive understanding of adolescent HPD overall and an increased understanding of the similarities and differences amongst HPD pulling styles. Role of funding sources Collection of this data was supported by a grant from the Greater Kansas City Foundation. Dr. Christopher Flessner receives research support from the TLC Foundation for Body-Focused Repetitive Behaviors Precision Medicine Initiative. The TLC Foundation had no involvement in study design, collection analysis, interpretation of data, writing of the report, or decision regarding article submission. References Alexander, J. R., Houghton, D. C., Twohig, M. P., Franklin, M. E., Saunders, S. M., NealBarnett, A. M., & Barnett, S. N. (2016). Compton Factor analysis of the milwaukee inventory for subtypes of trichotillomania-adult version. Journal of ObsessiveCompulsive Disorders, 11, 31–38. Ambrosini, P. J. (2000). Historical development and present status of the schedule for affective disorders and schizophrenia for school-age children (K-SADS). Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), 49–58.

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