Parental attachment and childhood trauma in adolescents engaged in non‐suicidal self‐injury

In this study, it was aimed to compare parental attachment and childhood traumas in adolescents with NSSI with healthy peers.


| INTRODUCTION
Non-suicidal self-injury (NSSI) is one of the growing public health problems.It is defined as a spectrum of deliberate self-directed injury to one's body that does not involve suicidal intent, excludes socially sanctioned behaviours such as piercing, tattooing, and body modification practices, and results in mild-to-moderate physical harm (Nock & Favazza, 2009).NSSI includes a variety of acts like skin-cutting, hitting, biting, burning, scratching, carving, banging, and scraping (Zetterqvist, 2015).The lifetime prevalence of NSSI varies ranging from 9% to 36% among adolescents (Gholamrezaei et al., 2017;Mannekote Thippaiah et al., 2021).It typically begins in early to middle adolescence and is a common behaviour among adolescents and young adults (Brown & Plener, 2017).Understanding the etiological factors that lead to NSSI is of paramount importance.The literature has identified several risk factors such as previous attempt of self-injury, familial factors such as history of suicide and suicidal behaviour, executive functioning dysfunctions and decision-making dysfunctions, childhood abuse and neglect, suicidal ideation, hopelessness, negative temperament traits, cluster B personality disorders, and media influences (Mummé et al., 2017).Adolescents who engage in NSSI have been reported to have higher rates of negative outcomes, including psychopathology and suicide (Taylor et al., 2018).In recent years, there has been increasing evidence of immune-inflammatory abnormalities in suicidal ideation and behaviour (Serafini et al., 2020).
Similarly, childhood trauma has also been shown to lead to inflammatory abnormalities in later life (Brown et al., 2021).Inflammatory processes may also play a role in adverse clinical outcomes of NSSI such as suicidal behaviour.Studies to understand suicide, perhaps the most important negative outcome of NSSI, have investigated the role of the opioid system and have shown that buprenorphine is effective and safe in reducing suicidal thoughts and NSSI (Serafini et al., 2018).An understanding of NSSI phenomenon and its aetiology will allow clinicians to intervene effectively with adolescents who engage in NSSI and prevent suicidal behaviours.
Clinical studies have discussed multiple associated factors of NSSI include psychological characteristics (such as negative emotionality, deficit in emotion skills, self-derogation), psychiatric disorders, childhood environmental factors and advertises (Klonsky, 2007).Considering psychological factors, the studies have found that early-life traumatic events can influence on need to engage self-injury via managing stress abilities and emotion regulation (Lovell & Clifford, 2016).
A systematic review has shown that childhood maltreatment is a significant risk factor for NSSI (Serafini et al., 2017).Considering Bowlby's Attachment Theory, one of the most important characteristics attributed to psychological well-being is a secure parental attachment (Braga & Gonçalves, 2014).While maternal attachment is related to providing care, comfort, reassurance and a secure base to explore; Attachment to father is more effective than mother in encouraging risk-taking in play, exploration and approach of new social situations, which helps to develop children's confidence and self-esteem (Paquette & Bigras, 2010).Evidence suggests that attachment problems play a fundamental role in NSSI (Molaie et al., 2019) and published studies have yielded that insecure attachment is a risk factor for NSSI (Cassels et al., 2019).
Infants and young children with secure attachments are characterized by higher self-reliance, emotional regulation, social competency, and positive mental health.On the other hand, neglect and maltreatment evokes insecure attachments in infants and children (Gandhi et al., 2016).The present study aimed to evaluate the relationship between NSSI, childhood trauma and attachment to parents.Since most studies examining the related factors with adolescent NSSI in the field were conducted with outpatients, the initial purpose of this study was to evaluate self-injuring behaviours in inpatients.For this purpose, we conducted two groups, based on the history of lifetime self-injury, inpatient adolescents with NSSI (with/without suicide attempt) and a control group.Despite an abundance of studies regarding attachment explanatory model, few empirical studies have examined the relationship between adolescent's attachment to father and NSSI (Jiang et al., 2017).Although studies on the relationship between NSSI and attachment have been conducted in the literature, mostly only attachment to the mother has been evaluated, the evaluation of attachment with both mother and father in this study will contribute to the literature.In addition, the current study investigated the relationship between different types of childhood traumas and NSSI.We hypothesized that; (1) adolescents with NSSI will have less positive parental attachment to both parents, (2) history of childhood traumas will be more common among NSSI group compared to non-NSSI group.Inventory of Statements About Self-injury (skin cutting, followed by head banging or hitting, preventing healing, scraping the skin, drinking hazardous substances, burning the skin, hair plucking, clawing, pricking, biting, and pinching) were asked if they had ever done each of them in their lifetime.Fifty adolescents with lifetime NSSI, aged 14 to 18, were included in the study.Patients who were illiterate or diagnosed with mental retardation, acute psychosis, bipolar disorder, manic episode or autism were excluded from the study.The control group was composed of healthy children from the local community.
For the control group, the ones who reported any NSSI behaviours on the Inventory of Statements About Self-injury (ISAS) Scale and who reported to have applied for psychiatric help previously were excluded.Of the 86 adolescents included in the study for control group, 23 were excluded from the study because they reported NSSI and 7 were excluded because they had previously applied for psychiatric help.Statistical analysis was made with 50 patients with NSSI and 56 healthy controls.

| Study procedures
All participants were informed of the study protocol and those who volunteered to participate were included in the study.A standard form was used to collect demographic data (age, sex, the education level of the child, parental age and education status).How to fill in the forms was explained by the researchers to the adolescents who independently completed the questionnaires in a silent room.The study protocol was reviewed and approved by the institutional ethical committee.

| Inventory of statements about selfinjury (ISAS)
ISAS is a two-section scale developed by Klonsky and Glenn (2009).
The first section (behaviours) evaluates the lifetime frequency of 12 NSSI behaviours that is intentional and not suicidal.In this section, participants are asked how many times they perform each behaviour.
Those endorsing one or more NSSI behaviours are directed to answer the second section of the scale.The second section assesses 13 potential functions of NSSI.The functions have two dimensions as autonomic functions and social functions.Autonomous functions include 5 subscales: affect regulation, anti-suicide, marking distress, selfpunishment, and anti-dissociation.Social functions have 8 subscales: interpersonal boundaries, interpersonal influence, revenge, sensation seeking, peer bonding, toughness, autonomy, self-care (Klonsky & Glenn, 2009).Turkish validity and reliability of the scale has been made by Bildik et al. (2012).

| The parental bonding instrument (PBI)
The PBI was developed by Parker et al. to retrospectively evaluates the relationship pattern established with the parents in terms of the individual's perception (Parker et al., 1979).It is filled in separately for the mother and father.The scale has two subscales: care and control/ overprotection.In the original form of the scale, an increase in the care dimension and a decrease in the overprotection/control dimension indicate perceived positive parental behaviours.However, in the Turkish validity and reliability study, all items were arranged in the same direction in terms of meaning-the score increase reflects positive parental attachment.Therefore, an increase in both subscales in the Turkish form indicates positive attachment (Kapçı & Küçüker, 2006).In the Turkish validity and reliability study, similar to its original form, a two-factor structure was determined, but it was divided into care/control and overprotection (Kapçı & Küçüker, 2006).

| Child trauma questionnaire (CTQ-28)
The CTQ was developed by Bernstein and Fink to evaluate the history of trauma in adolescents with psychiatric disorders (Bernstein et al., 1994).It is a self-report tool designed to assess five types of childhood trauma: emotional abuse, emotional neglect, physical abuse, physical neglect, and sexual abuse.The higher score indicating higher abuse and neglect experiences (Bernstein et al., 1994;Şar et al., 2012).Turkish validity and reliability of the scale has been made by Şar et al. (2012).
All of the mean CTQ-28 subscales scores were significantly higher for patients than for controls.Both the mean mother-and fatherrated PBI care/control and PBI overprotection scores were significantly lower in the patient group compared to controls.Questionnaire and inventory scores of the adolescents with NSSI and the controls are summarized in Table 1.
The correlations of the ISAS scores with the CTQ-28 and PBI scores in adolescents with NSSI were evaluated in the patient group.

Correlations among psychometric questionnaires was given in
Table 2.
In the patient group, the frequency of having a history of suicide attempt was 62%.The association between having a history of suicide attempt and questionnaire and inventory scores was also assessed in the patient group.Analyses showed that ISAS Interpersonal Boundaries (z = 2.18, p = .030),ISAS Sensation Seeking (z = 2.43, p = .015)and CTQ-28 Emotional Neglect (z = 2.22, p = .026)scores were higher in the suicide attempters compared to non-attempters.Among the parental bonding subscales, the scores of those who attempted suicide only in the mother care/control subscale were significantly lower than those who did not (z = À2.40,p = .016).In terms of other scale scores, there was no difference between those who attempted suicide and those who did not.
Linear regression analyses (forward conditional) were also used to evaluate the relationships between the ISAS Autonomic Functions and Social Functions scores and the CTQ-28 and PBI scores in the patient group.We included the questionnaire and inventory scores that significantly correlated with the ISAS Autonomic Functions and ISAS Social Functions scores as independent variables.The analyses showed that only mother PBI Care/control and sexual abuse score

| DISCUSSION
In this study, we found that adolescents with NSSI have more negative characteristics than their peers without NSSI in terms of all childhood traumas and attachment to both parents.In addition, we found that the maternal attachment-care/control subscale and sexual abuse had a significant relationship with both the autonomous and social functions of the NSSI.
The NSSI method used may vary.In a review, it was reported that cutting, hitting, and burning were the most common NSSI methods (Klonsky, 2007).Similarly, in our study the most commonly used methods were cutting, hitting the head, and preventing wound healing.NSSI is thought to be associated with both intrapersonal and interpersonal factors (Jutengren et al., 2011;Rodav et al., 2014).The most emphasized reasons for NSSI in the studies are affect regulation, dissociation prevention, suicide prevention, interpersonal boundary setting, interpersonal interaction, self-punishment, and sensation seeking (Klonsky, 2007).In a recent meta-analysis, internal factors, particularly emotion regulation, were the most common NSSI function, while interpersonal factors were less frequent (Taylor et al., 2018).Similar to the current literature, the most common causes in our study were emotion regulation, marking distress, selfpunishment, revenge and self-care.(Braga & Gonçalves, 2014).In the context of these models the parental attachment relationships has become to a subject of interest.
Attachment theory explains how attachment insecurity develops and interferes with emotional regulation, social adjustment, and mental health (Mikulincer & Shaver, 2007).Studies have shown that there is a relationship between insecure attachment styles and NSSI (Gratz et al., 2002;Kimball & Diddams, 2007;Levesque et al., 2010;Molaie et al., 2019).Attachment to mother and father may affect psychological outcomes differently (Freeman et al., 2010).However, studies evaluating paternal attachment with NSSI are limited.While some studies show the relationship between NSSI frequency and both maternal and paternal attachment (Di Pierro et al., 2012;Gratz et al., 2002); others have shown that perceptions of relationship with fathers are a better predictor of NSSI than with mothers (Hallab & Covic, 2010;Hilt et al., 2008).In our study, both mother and father attachment characteristics of adolescents with NSSI were more negative than their healthy peers in all dimensions.Although insecure attachment is common in NSSI, it is not clear how insecure attachment causes NSSI in young people.Intrapersonal factors such as emotional regulation, academic stress and depression, and interpersonal factors such as parenting and peer relationships may also play an important role (Nock & Prinstein, 2004).These variables may play a mediator role in the relationship between insecure attachment and NSSI.Insecure attachment styles, on the other hand, can hinder socioemotional development and the development of effective coping strategies and problem-solving skills needed in challenging situations (Mikulincer et al., 2003).The relationship of the NSSI to a wide range of functions, including emotion regulation, self-punishment, or distress communication (Edmondson et al., 2016;Klonsky, 2007), may mediate its relationship to attachment.
In our study, we found that all types of childhood traumas, were more common in those with NSSI compared to those without NSSI.In a systematic review of studies conducted in different age groups, childhood maltreatment was found to be a risk factor for NSSI (Ford & G omez, 2015).Also, NSSI was associated with higher abuse history in adolescent students in a longitudinal study (Garisch & Wilson, 2015).There are different findings in the literature regarding the relationship between types of maltreatment and NSSI in adolescence.In a study evaluating the specificity of childhood maltreatment (child physical, sexual, emotional abuse and emotional, physical neglect), as factors associated with NSSI in a sample of inpatient adolescents, results indicated that only child emotional abuse was directly associated with NSSI (Thomassin et al., 2016).In the study by Glassman et al., there was strong relations between emotional and sexual abuse with NSSI (Glassman et al., 2007).These findings of the literature support the association between childhood trauma and NSSI but there are differences regarding maltreatment types.Different results in studies may be due to variables such as retrospective questioning T A B L E 2 Correlations of the ISAS scores with the CTQ-28 and PBI scores in adolescents with NSSI.  of trauma, differences in personal trauma perception, and protective factors from trauma.In our study, we found trauma scores higher in patients with NSSI than in those without.We also found significant results regarding the effect of especially sexual abuse on NSSI functions.In the study of Glassman et al. (2007), similar to our study, small-to-moderate relationships were found between childhood traumas, especially sexual abuse, and NSSI, while another study found no evidence for the predictive role of sexual abuse in NSSI (Swannell et al., 2012).Various studies have shown that there is an indirect relationship between childhood traumas and NSSI, and mediator variables play a role (Shenk et al., 2010;Zetterqvist et al., 2014).Differences between studies may be due to the effect of mediator variables.
Follow-up studies on the direct and indirect effects of childhood traumas on NSSI development and functions will contribute to a better understanding of the subject.
Suicide attempt is common with NSSI and a history of NSSI is a strong predictor completed suicide (Hawton et al., 2003;Muehlenkamp & Gutierrez, 2007).Similarly, more than half of the NSSI patients in our study had attempted suicide.And those who attempted suicide had significantly lower scores on the mother care/ control subscale of PBI compared to those who did not.In the literature, it has been shown that adolescents who attempt suicide have worse attachment to their parents compared to their non-suicidal peers (Saffer et al., 2015;Sheftall et al., 2013).In our study, the fact that NSSI patients who attempted suicide had worse attachment to their mothers could be interpreted as the fact that positive attachment with the mother could protect these patients from suicide attempts, and more research is needed on this subject.
Factors such as early close relationships, parental care or neglect are likely to affect both attachment and exposure to traumatic experiences and trauma outcomes.In our study, there was a significant relationship between the autonomic and social functions of the NSSI and some childhood trauma subtypes and the care and control subdimensions of maternal attachment.However, in the regression analyzes, only the maternal attachment care/control and sexual abuse 3 subscale had a significant effect on both the autonomic and social functions of the NSSI.These results suggest that secure attachment with the mother may be protective for both the intrapersonal and interpersonal functions of the NSSI.It is known that attachment can be flexible and change over time (Hallab & Covic, 2010).In this context, interventions for dysfunctional parental attachment may be protective against NSSI.
The study has some important limitations.First of all, we did not evaluate the psychiatric diagnoses and focused only on the presence of NSSI.In addition, the fact that the control group consisted of healthy subjects prevents us from evaluating the effect of the presence of psychopathology on our results.Therefore, in future studies, it would be useful to compare clinical samples with NSSI with clinical samples without NSSI and adolescents with NSSI who did not present to the clinic.Also the small sample size, the inability to make comparisons between the genders, and the inability to establish a cause-effect relationship due to the cross-sectional design are the limitations of our study.Therefore, further studies with larger sample sizes are needed.Despite the limitations; the strength of our study was to evaluate the attachment and childhood traumas, which are two important factors in early childhood experiences that may be associated with NSSI, and to investigate the attachment separately for both mothers and fathers.In addition, in order to exclude the presence of NSSI in the control group, it was important to ask about the presence of NSSI methods one by the help of a scale.Because when asked with more than one item, it was reported that NSSI was found at a higher rate than when asked with a single question (Muehlenkamp & Gutierrez, 2007).Also our study was one of the rare studies in this area for having a sample consists of inpatients, but of course at the same time this can also prevent the generalization of the findings.
In conclusion, although the generalizability of the results is limited, this study indicates that problems related to paternal attachment as well as maternal attachment are more common in NSSI cases, but the relationship between attachment and NSSI stems from maternal attachment.Therefore, it suggests that studies to strengthen motherchild attachment may be valuable for the prevention and treatment of NSSI.
T A B L E 3 Results of linear regression (forward conditional) related to the ISAS autonomic functions scores of adolescents with NSSI.
Study groupsThis case-control study was conducted in the inpatient clinic of Bakirkoy Prof. Dr. Mazhar Osman Training and Research Hospital for Psychiatry and Neurology, Department of Child and Adolescent Psychiatry.This service is closed and admits patients with indications such as suicide risk, homicide risk, acute psychotic and manic attacks, and treatment refusal.First of all, the participants were explained what NSSI is and what behaviours it covers.Next, NSSI methods in Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software.Descriptive statistical methods (Frequency, Percentage, Mean, Standard deviation) were examined and Kolmogorov-Smirnov distribution test was used to examine the normal distribution.Categorical variables were compared using Pearson's Chi-square test.Since the data did not show normal distribution, the Mann-Whitney U test were used for group comparisons and Spearman's correlation analysis for intercorrelations between continuous parameters.Linear regression analyses (forward conditional model) were performed to evaluate the effects of childhood trauma and parental bonding related to NSSI social and autonomic functions in the patient group.The results with reliabilities of .95 or greater were interpreted and p-values <.05 were considered as significant.However, to take into account the risk of type I error due to a multiple testing effect, p values were adjusted by the Benjamini-Hochberg procedure with .05false discovery rate for correlation analyses.
had a relationship with both ISAS Autonomic Functions and ISAS Social Functions scores.Additionally, Physical Neglect score had a relationship only ISAS Social Function score.The results of the regression analyzes are shown in Tables 3 and 4 in detail.