What is Trichotillomania?
Trichotillomania (sometimes referred to as TTM or “trich”) is a disorder involving the repeated urge/behavior of pulling out one’s own hair. In DSM-IV, trichotillomania is characterized as an impulse control disorder (rather than, for example, an Anxiety Disorder, a Tic Disorder, or an Addiction). The word is derived from the Greek stem “Tricho,” meaning hair. The disorder was first described in 1889 by a French physician. The hair pulling is significant and results in bald spots. It is estimated to occur in 1 to 2% of the population. The average age of onset for Trichotillomania is 12, however, it sometimes is observed among children as young as 1. Among adults, at least about two-thirds of those with Trichotillomania are female, however, among very young children, Trichotillomania appears to occur with equal frequency among girls and boys. Also, Trichotillomania among children tends to be more benign than among adults. There is often an increase in hair pulling observed when there is an increase in stress.
Trichotillomania can be very difficult to stop, and the hair pulling can become chronic. In fact, even when the condition is brought under control, it is not referred to as being “cured,” but rather it is referred to as being “in hibernation.” There are techniques available to manage Trichotillomania among adults (e.g., behavioral, cognitive-behavioral therapy, support groups, medication, hypnosis, biofeedback), however, for children, there are fewer options. We may consider behavioral or “cognitive-behavioral” intervention options for very young children along the spectrum of A.T.I.P.:
Trying to avoid (or prevent) Trichotillomania among young children may involve creative solutions. For example, if a 2 year-old pulls his hair out during the night, his parent may choose to sew socks on the sleeves of his sleeper. If the hair pulling occurs in response to certain stressful situations, then those situations should be avoided. In certain extreme cases where a child’s health is compromised (e.g., when the child not only pulls but then eats his own hair), some parents have found it necessary to avoid the hair pulling by taking physical measures, such as giving the child an exceptionally short hair-cut or placing baby-oil in the child’s hair). If avoidance seems impossible or impractical, you may choose another option.
With a child who is cognitively ready, try reasoning and explaining that hair pulling is not healthy and will lead to an unusual appearance. With a younger hair puller, “teaching” may refer to rewarding periods when there is no hair pulling (a technique known as a “Differential Reinforcement of Other” or “DRO” schedule).
“Planned Ignoring” (which is the same as “ignoring” but it sounds a lot nicer) is a viable option for “mild” or “occasional” Trichotillomania, as long as the parent closely monitors the hair-pulling over time to ensure that it does not get worse and become excessive. Additionally, if ignoring is to be used, it should be done in for a limited amount of time, while the pediatrician, dermatologist, and/or gastroenterologist closely watches the child’s health.
It may seem cruel to “punish” when a child demonstrates Trichotillomania, however remembering our definition of “punishment” we know that our intention would simply be to decrease the negative behavior in an immediate, consistent, powerful, and humane manner. Use of “time-out” or the brief containment of the child’s hands may be utilized as a consequence when the hair pulling becomes a threat to the child’s health/safety.