Trichotillomania in Children and Youth
Trichotillomania (pronounced as "trick-o-till-o-mania", commonly called "trich" or also known simply as ‘hair pulling') is a condition where a person has repeated, uncontrollable urges to pull out hair from their scalp, eyelashes, nose hair, ear hair, eyebrows or other body hair. Hair pulling by itself is not harmful -- but it can lead to social problems with others. Many adult individuals with trich report leading perfectly normal lives, with the difference that they happen to have more bald spots than others. In others though, their trichotillomania can cause problems with relationships and function at school, work and home.
The term trichotillomania comes from the Greek words trich (for hair), tillo (pulling) and mania (an impulse).
It is very hard to estimate how common hair pulling occurs, because few individuals with hair pulling seek professional help. However, surveys of college students have shown that 1-2% have had past or current symptoms of trichotillomania (eMedicine.com, 2006). Although the average age of onset for hair pulling is age 13, there are peaks of onset in children at age 5-8 as well as in teenagers at age 13 (DSM-IV-TR, 2000).
Symptoms that the person may have are:
- Irresistible urges to pull out one's hair, to the point that the person develops noticeable hairless or bald spots
- A cycle of rising tension and anxiety, which gets better from hair pulling, which leads to a vicious cycle because the person learns that hair pulling helps them feel better (in the short run)
- Distress and interference with daily life
Hairballs are a rare but potentially serious symptom. Some individuals will play with, nibble or swallow their hairs after they have pulled them. If they swallow enough hair, it leads to a hairball (trichobezoar) in their digestive system. Symptoms of hairballs include: stomach pain, bloated abdomen, weight loss, constipation and/or diarrhea, and hair in the stool. In these cases, it is important that the person see a doctor promptly.
Signs that others may notice include:
- Person starts concealing their head, by wearing hats, kerchiefs, or wigs
- Any changes in social behavior, or decline in marks
Usual triggers include:
- Stressful emotions like anxiety, tension, anger, sadness
- Sedentary activities, e.g. such as reading, talking on the phone, doing schoolwork, or getting ready for bed
If you suspect that your child has problems with hair pulling, start by having your child seen by a medical doctor (such as a family physician or paediatrician). The doctor may recommend more specialized mental health services or professionals such as a psychologist or psychiatrist.
Trichotillomania can be treated with:
1. Cognitive behavior therapy (CBT), which focuses on changing thoughts (cognitions) and behaviors in order to help a person overcome the trichotillomania.
- Awareness training: helping the person become more aware of when s/he is pulling their hair, as it often happens without thinking about it. For example, keeping a hair pulling diary to note when and where it occurs and how strong the urges are.
- Stimulus control: making changes to a person's environment so that it discourages or doesn't support hair pulling.
- Since hair pulling often happens when the person is inactive and alone some helpful strategies might include:
- Being around other people
- Wearing gloves or wearing band aid adhesive strips on one's fingers to make it harder to pull hairs.
- Habit reversal strategies: learning alternate activities to do instead of pulling.
- Examples include: sculpting with clay; hulling sunflower seeds; playing with Koosh ® balls; playing with ‘stress' balls; Chinese exercise/massage balls.
2. Medications such as selective serotonin reuptake inhibitors (SSRIs) are sometimes used for hair pulling. Examples include Fluoxetine (Prozac), Zoloft (Sertraline), Citalopram (Celexa) and Escitalopram (Cipralex).
In general however, medications are used only when other interventions such as CBT have not been successful. This is because studies (in adults) have shown cognitive behavioural therapy to be more effective than medications (Bloch et al., 2007).
Don't be a therapist: first of all, remember that as a parent, relative or friend, you are not that person's therapist. Trying to be a therapist, or telling someone with trichotillomania what to do may backfire if they aren't ready or willing to accept your advice! Instead, ask your child, "How can I support you? How can I be helpful?"
Ensure a healthy body: ensure proper sleep and exercise. Numerous studies have shown that exercise can reduce stress and anxiety (University of Missouri-Columbia, 2003). The Canadian Pediatric Society recommends that children should be active at least 90 minutes per day (Canadian Pediatric Society, 2002).
Firm, consistent parenting: anxious children feel calmer when life is predictable, when they know what is expected of them, and they know what the consequences will be.
Reduce expectations or demands at least initially: excess stress, expectations or demands contributes to anxiety. Typical stresses and problems that children face include: school (academics, teachers, peers, bullying, drugs); home (worries about family finances, fighting or tension between family members); friends and boyfriends/ girlfriends. Help your child figure out what his/her stresses are, and which ones might be overwhelming. Gradually lower those stresses, demands or expectations until they are low enough for the person to cope. And when your child is doing better, those demands and expectations can be gradually raised over time.
Don't blame. Remember that trichotillomania is not the person's fault, and don't simply tell them to stop pulling their hair, because if they could simply stop, then they would!
eMentalHealth.ca has a directory of Ottawa mental health resources, www.eMentalHealth.ca
- The Ottawa Academy of Psychology has a referral service, 613-235-2529, www.ottawa-psychologists.org/find.htm
- The Children's Hospital of Eastern Ontario and the Royal Ottawa Mental Health Centre offer some mental health services. Physicians can contact Mental health Intake (613-737-7600, ext. 2496) for further information. Web: www.cheo.on.ca
Support and Advocacy Groups
- Anxiety Disorders Association of Ontario, Ottawa Chapter, www.anxietydisordersontario.ca
- The Trichotillomania Learning Center, Inc. (TLC), 303 Potrero #51, Santa Cruz, CA 95060, Tel: 831-457-1004, Web: http://www.trich.org
- The National Mental Health Association (USA) has information at http://www.nmha.org/infoctr/factsheets/92.cfm
Books to Read
- Golomb RG, Vavichek SM, The Hair Pulling ‘Habit' and You: How to Solve the Trichotillomania Puzzle (Revised Ed.). Silver Spring, MD: Writer's Cooperative of Greater Washington; 2000. Book for children and teenagers.
- You are Not Alone, by Cheryn Salazar
- What's Happening to My Child? A Guide for Parents of hair Pullers, by Cheryn Salazar
- The Hair Pulling Problem, by Dr. Fred Penzel
Bloch MH, Landeros-Weisenberger A, Dombrowski P, Kelmendi B, Wegner R, Nudel J, Pittenger C, Leckman JF, Coric V (2007). Systematic review: pharmacological and behavioral treatment for trichotillomania. Biological Psychiatry. Oct 15; 62(8):839-46.
Canadian Pediatric Society (2002, July). Healthy active living for children and youth. Retrieved April 4, 2008 from http://www.cps.ca/english/statements/HAL/HAL02-01.htm
American Psychiatric Association 2000. (DSM-IV-TR) Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington, DC: American Psychiatric Press, Inc.
eMedicine.com: Anxiety Disorder: Trichotillomania. Retrieved April 4, 2008 from http://www.emedicine.com/ped/byname/anxiety-disorder--trichotillomania.htm
University Of Missouri-Columbia (2003, July 15). High-Intensity Exercise Best Way To Reduce Anxiety, University Of Missouri Study Finds. ScienceDaily. Retrieved April 4, 2008, from http://www.sciencedaily.com/releases/2003/07/030715091511.htm
Written by the eMentalHealth.ca team and its partners.
Date of Last Revision: Mar 2, 2012