Trichotillomania or compulsive hair pulling occurs in people of all ages. Much, though still not enough, has been written recently about adult hair pullers, so this article will focus on childhood trichotillomania. While professional treatment for children engaged in the pulling of hairs from the scalp, eyebrows, or eyelashes may ultimately prove necessary, this article will provide some suggestions for parents who are attempting to cope with the early appearance of this behavior in their young child.

For the past eight years we at Behavior Therapy Associates have done extensive work with adults and children suffering from trichotillomania. Over this time we have observed some notable differences in hair pulling between children and adults. Dr. Susan Swedo, an NIMH researcher, believes that early childhood hair pulling (i.e. onset occurring before age 5) may not represent the same clinical disorder as hair pulling that begins during and beyond adolescence (Swedo, 1991). She suggests that many cases of childhood onset hair pulling may be outgrown. Therefore, for preschoolers, this is worth keeping in mind when considering parental or professional intervention.

In children, it appears that tactile stimulation (e.g., feeling the texture of the hair, rubbing the hair between a finger and thumb, or running the fingers along the hair shaft), oral stimulation (e.g., biting the hair bulb, eating the hair, sucking on hair, or "playing" with the hair in the mouth), or stimulation of the skin (e.g., rubbing the hair along the cheek, nose or lip) can be important components of the hair pulling habit. For many children these behaviors provide sensory stimulation which apparently has a self-quieting effect similar to that achieved by rocking, thumb sucking, rubbing a favorite blanket or stroking a stuffed animal.

It is possible that some adult hair pullers began pulling and continue to pull for similar reasons. Years of practice, however, permit the habit to evolve into a highly ingrained behavior pattern with complex and idiosyncratic emotional, postural, sensory and situational determinants. Over time, secondary effects of hair pulling can negatively impact mood, self-esteem and social confidence, further complicating the clinical picture.

Young children who pull typically do not experience the same degree of self-consciousness as pre-adolescent children, adolescents and adult sufferers and thus, may be free from shame and other socially-inspired effects of hair pulling. While the majority of adult hair pullers report lowered self-esteem, a diminished sense of attractiveness, a sense of isolation and a feeling of being odd or peculiar for having this habit (Mansueto, 1991) these effects may be entirely absent in the young hair puller. While hair pulling may be indicative of stress in the child, this is not always the case, and should not automatically be assumed so. Although acute environmental and interpersonal stressors can certainly contribute to the incidence of hair pulling, this effect seems more evident in hair pullers at puberty and beyond. Also, there is no evidence that hair pulling is symptomatic of a "deep-seated" problem.

Although young children tend not to experience the same degree of detrimental secondary effects as older pullers, this does not mean that they are immune to such effects. These children often do have some sense of being different, usually derived from parental attention for hair pulling, the comments of other adults, and the reactions of their peers. These can negatively affect the child's emotions and behavior. Left unaddressed, it is possible, but not certain that these feelings can lead to the more severe emotional side effects experienced by many adults with trichotillomania.

So what can parents do when they discover that their young child has been pulling out hair? First and foremost, don't panic! Many parents, particularly if they are individuals who have struggled with hair pulling themselves, tend to be quite sensitive about their children's interest in their own hair. It is very common for children to be curious about different textures and to explore their heads, hair, and bodies by touch. Remember, for some children hair pulling is a brief childhood phase associated with self exploration and self quieting, and will not develop into a clinical problem. However, if a child has done substantial damage, or expresses a wish to stop hair pulling, or if the pulling of hair persists beyond pre-school age and seems to be incorporated into increasing numbers of activities and situations, here are some general approaches a parent might consider.

Adopt a non-punitive, non-critical attitude toward the hair pulling. Observe your child's hair pulling habits. Determine which activities and what situations seem to increase the likelihood that there will be a pulling episode. In other words, when is your child most vulnerable to pulling? In most cases, sedentary activities will set the occasion for pulling episodes. Some of these activities include watching T.V., reading, studying, listening, riding in the car, daydreaming, settling down, and trying to fall asleep. Often children can be helped to establish alternative non-damaging routines while involved in situations that would typically trigger a pulling episode.

You may want to explore with the child a variety of "toys" that may interest your child and distract him/her from hair. Some examples include koosh balls, nerf balls, stuffed animals, pieces of velcro, felt or velvet, etc. The list is only limited by one's own imagination! Introduce one toy at a time in situations where the child is vulnerable. Be positive and encouraging. Help your child incorporate handling and playing with the toy into the activities and situations where they are vulnerable. For example, if your child has typically pulled while watching T.V., you might introduce a "T.V. toy" and encourage your child to play with it while watching T.V. Provide lots of praise for these alternative behaviors until the pattern is changed. This process could take from a few days to much longer but even a diligent effort may in fact, not succeed. Be patient and be careful not to nag. It is perfectly acceptable to drop the effort for a time and reintroduce it later. If you suspect that your child's hairstyle and length may be contributing to the problem, it may help to experiment with a different style, particularly one that keeps the hair away from face and fingers. Remember this is a complex behavior pattern, the causes of which are as yet unknown and the treatment of which continues to be experimental. If you need additional support and/or guidance, don't hesitate to seek the assistance of a qualified therapist.

Although little has been written about treatment outcome for childhood trichotillomania, the work at our clinic suggests that the prognosis is quite good. Early intervention can be successful in reducing or eliminating hair pulling in most children. A systematic, learning-based intervention, introduced before there are significant emotional side effects, allows children to gain healthy perspectives of themselves while developing positive self-esteem. In addition, teaching children about their own unique needs and helping them to acquire coping skills within a positive and encouraging atmosphere provides an opportunity for them to learn valuable lessons about gaining mastery over their own lives and behavior. As stated earlier, a low profile, "wait and see" approach may suffice for pre-schoolers. However, for some school-age children, early intervention can help to ensure that young hair pullers are protected from the potentially devastating problems associated with adult trichotillomania.



References
Mansueto, C. (1991) Trichotillomania in Focus OCD Newsletter #5, 10-11.
Swedo, S. (1991) Childhood Trichotillomania update OCD Newsletter #5, 4.




Ruth Goldfinger Golomb, M.Ed.
and Charles S. Mansueto, Ph.D.
Behavior Therapy Center of Greater Washington D.C.
Reprinted from InTouch, Volume 2, Issue 8, 1994


Both Dr. Golomb and Dr. Mansueto can be reached at Behavior Therapy Center of Greater Washington DC, Silver Spring, MD at (301) 593-4040