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Pediatric Trichotillomania: Clinical Presentation, Treatment, and Implications for Nursing Professionals
Journal of Pediatric Nursing (2012) 27, 225–232
Pediatric Trichotillomania: Clinical Presentation, Treatment, and Implications for Nursing Professionals1 Christa D. Labouliere MA a,⁎, Eric A. Storch PhD a,b a
University of South Florida, Tampa, FL Rothman Center for Pediatric Neuropsychiatry, St. Petersburg, FL
b
Key words: Trichotillomania; Hair pulling; Mental health; Children; Adolescents
Trichotillomania (TTM), or compulsive hair pulling, is a disorder that typically onsets in childhood. It is mistaken to believe that children will “age out” of this behavior, as pediatric TTM often has a chronic, debilitating course that does not remit without treatment, resulting in considerable psychological and physical impairment. Because most children with TTM will be seen initially by nursing professionals in the practices of dermatologists, pediatricians, gastroenterologists, and other disciplines, raising nurses' awareness of this disorder is of the utmost importance for accurate nursing diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients, nurses' detection and diagnosis of TTM can make a critical difference in the initiation of early intervention. Therefore, the purpose of this article is to provide an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace. © 2012 Elsevier Inc. All rights reserved.
TRICHOTILLOMANIA (TTM) is a disorder characterized by the non-cosmetic, repetitive pulling of hair from any part of one's body, resulting in noticeable hair loss or alopecia. Although the disorder was first identified over a hundred years ago (Hallopeau, 1889), scientific inquiry regarding its etiology and treatment is relatively recent, especially in the realm of pediatric TTM (Bruce, Barwick, & Wright, 2005). This is a concern, as the onset of TTM occurs most typically in childhood (Cohen et al., 1995), the prevalence of TTM is much higher in childhood than in adulthood (point prevalence of approximately 0.5% and lifetime prevalence of 0.6%–3.4%; Bruce et al., 2005; Christenson, MacKenzie, & Mitchell, 1991; Dean, Nelson, & Moss, 1992; Hamdan-Allen, 1991), and most research suggests that earlier intervention is more successful than
1 No previous presentations or publications of this work exist. No extramural funding or commercial financial support aided in the preparation of this article. ⁎ Corresponding author: Christa D. Labouliere, MA. E-mail address: [email protected] (C.D. Labouliere).
0882-5963/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.01.028
treating adults in whom the behavior is already entrenched (Bruce et al., 2005; Sah, Koo, & Price, 2008). The mistaken belief that children will “grow out of it” may be partially responsible for this lack of recognition. However, recent research suggests that pediatric TTM often has a chronic, debilitating course that does not remit without treatment (Bruce et al., 2005; Cohen et al., 1995), resulting in considerable psychological and physical health impairment (Boudjouk, Woods, Miltenberger, & Long, 2000; Flessner, Woods, Franklin, Keuthen, & Piacentini, 2009; Franklin et al., 2008; Hamdan-Allen, 1991; Hanna, 1997; Tay, Levy, & Metry, 2004; Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007). Since most children with TTM will be seen initially by school nurses or nursing professionals working in the offices of dermatologists, pediatricians, gastroenterologists, and other disciplines (Blum, Barone, & Friman, 1993), raising nurses' awareness of the disorder is of the utmost importance for accurate diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients (Berg van den, Kolthof, de Bakker, & van der Zee, 2004; Wilson & Childs, 2006), nurses' detection and diagnosis of TTM can make the critical difference in the
226 initiation of early intervention. With this in mind, the present article provides an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace.
Epidemiology Pediatric TTM is estimated to have a point prevalence of approximately 0.5% (Hamdan-Allen, 1991) and a lifetime prevalence of 0.6%–3.4% in adults, most of whom began pulling as children (N85%; Bruce et al., 2005; Christenson et al., 1991). The disorder is up to seven times more common in children than in adults (Bruce et al., 2005; Dean et al., 1992; Hamdan-Allen, 1991; Tay et al., 2004) and typically has its age of onset either in preschool or in the preadolescent years (Christenson et al., 1991; Clark, Helm, & Bergfeld, 1995; Cohen et al., 1995; Du Toit, van Kradenburg, Niehaurs, & Stein, 2001). In toddlerhood through early childhood, equal numbers of males and females have TTM (Cohen et al., 1995; Swedo & Rapoport, 1991), but by late childhood and adolescence, females are disproportionately affected (Christenson, MacKenzie, & Mitchell, 1994; Flessner et al., 2007; Franklin et al., 2008; Greenberg & Sarner, 1965; King et al., 1995a; Muller, 1990; Reeve, Bernstein, & Christenson, 1992; Swedo & Leonard, 1992). The prevalence of TTM is probably underestimated for several reasons (Sah et al., 2008). Perhaps most critically, medical professionals who are not familiar with the disorder's presentation often fail to recognize or diagnose TTM (Cohen et al., 1995). Compounding this difficulty, children are not always reliable reporters of hair pulling behavior. Hair pulling can sometimes occur entirely outside of the patient's awareness (Christenson et al., 1991; Sah et al., 2008), making it hard for the child to report on antecedents and frequency. In addition, many persons who are aware of pulling are ashamed and secretive about their behavior, leading them to deny hair pulling or hide their alopecia with elaborate hairstyles or head coverings (Papadopoulos, Janniger, Chodynicki, & Schwartz, 2003; Santhanam, Fairley, & Rogers, 2008; Tolin et al., 2007). As such, knowledge of signs suggesting TTM and careful assessment is critical.
Definition TTM is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR) of the American Psychiatric Association (2000) as an impulse control disorder, similar to kleptomania, pyromania, or compulsive skin picking. The DSM-IV-TR requires five criteria for the disorder to be diagnosed: (a) one intentionally
C.D. Labouliere, E.A. Storch and repetitively pulls out his or her hair, resulting in noticeable hair loss; (b) an increasing sense of tension occurs immediately before or when trying to resist pulling; (c) pleasure, gratification, or relief occurs once the hair is pulled; (d) another mental or medical condition does not better account for the behavior; and (e) the behavior causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2000). However, some controversy exists regarding criteria b and c (rising tension and relief or gratification), as many persons with clinically significant hair loss due to pulling do not endorse these experiences (Christenson et al., 1991). In children, who may not be able to verbalize or even cognitively understand such experiences, these criteria are particularly problematic because they imply that a diagnosis of TTM should be withheld even when severe, cosmetically disfiguring hair pulling is evident. Critics of the tension and gratification criteria (Christenson et al., 1991; King et al., 1995a, 1995b; Reeve et al., 1992; Sah et al., 2008; Santhanam et al., 2008) have suggested that these criteria sometimes do not apply in a sizable percentage of adults with TTM and are even more notably absent in most affected children and adolescents. Research has shown that children and adolescents rarely endorse the tension or gratification criteria, with reports citing somewhere between 0% and 25% (King et al., 1995b; Reeve et al., 1992; Santhanam et al., 2008). These studies have shown that younger samples are much less likely to endorse these criteria and that rates increase across development into adolescence and young adulthood (Christenson et al., 1991; King et al., 1995a; Reeve et al., 1992). This suggests that the consciousness of and ability to report on internal states may be more related to cognitive development than an inherent characteristic of the disorder. Therefore, the diagnosis of TTM should still be conferred even in the absence of these criteria if clinically significant hair pulling is occurring and other medical conditions have been ruled out (e.g., alopecia areata, tinea capitis; Diefenbach, Tolin, Crocetto, Maltby, & Hannan, 2005; Watson, Dittmer, & Ray, 2000).
Clinical Presentation TTM is characterized by the non-cosmetic, repetitive pulling of hair from any part of one's body, resulting in noticeable hair loss. Hair pulling behavior occurs along a continuum, ranging from a relatively benign form that produces no significant aesthetic or psychological distress to a more serious disorder that is often disfiguring and leads to great personal suffering. Hair is most commonly pulled from the crown, occipital, or parietal regions of the scalp (Papadopoulos et al., 2003) but may also be pulled from other areas of the body, including the eyelashes, eyebrows, arms, legs, torso, or pubic area (in postpubertal children;
Pediatric Trichotillomania Franklin et al., 2008; King et al., 1995a; Malhoutra, Grover, Baweja, & Bhateja, 2008; Papadopoulos et al., 2003; Santhanam et al., 2008). Most children pull hair from multiple areas (King et al., 1995a; Santhanam et al., 2008; Tay et al., 2004; Tolin et al., 2007), with younger children pulling from fewer areas than older children (Wright & Holmes, 2003). Many children pluck one hair at a time, although some children have been known to pull hair in clumps (Christenson et al., 1991; Stemberger, Thomas, Mansueto, & Carter, 2000). Pulling tends to be more prevalent on the side of the child's dominant hand (Tay et al., 2004), although some children may use either hand (Christenson et al., 1991). Most children only use their hands to pull hairs, although rarely some will use tweezers or other instruments (Walsh & McDougle, 2001). Children may devote a great deal of time (over an hour) per day to hair pulling (Tolin et al., 2007), either in discrete binges or in dozens of brief periods throughout the day. It is common for symptoms to wax and wane over time from periods of intense activity to periods of complete abstinence (often lasting 2 weeks or longer; Tolin et al., 2007). In addition to pulling behavior, more than half of children with TTM engage in rituals involving the hair (Christenson et al., 1991; Papadopoulos et al., 2003; Tay et al., 2004; Walsh & McDougle, 2001), such as playing with, touching, or stroking the hair before pulling; twirling the hair before or after plucking; dropping the hair in a certain manner; storing the hairs; rubbing the hair across the face or mouth; sucking or biting off the hair root; or even ingesting the entire hair (trichophagy, which can lead to serious medical complications; Tay et al., 2004). Many children report that they specifically select hairs that are different from their other hairs in terms of color, thickness, consistency, curly/kinky texture, length, or location (Swedo, 1993; Tay et al., 2004). Unfortunately, this practice is self-perpetuating: The very trauma of pulling a hair can damage the hair root, making the new hair more likely to appear or feel different and therefore more likely to be repulled. Many children report the desire to pull symmetrically, and they may continue to pull hairs until symmetry is achieved or the pattern feels “just right” (Christenson et al., 1991; Walsh & McDougle, 2001). Two subtypes of hair pulling have been noted. The first, “focused pulling,” occurs in a compulsive fashion in response to an urge to pull in order to achieve a symmetrical pattern or to modulate an aversive emotional state such as anxiety, anger, or frustration (Diefenbach, Mouton-Odum, & Stanley, 2002; Flessner et al., 2009). This variant of hair pulling is within conscious awareness and is intentional (Begotka, Woods, & Wetterneck, 2004). Alternatively, “automatic pulling” occurs outside of a person's awareness, often during sedentary, boring, or mindless activities, such as lying in bed, reading a book, or watching television (Flessner et al., 2007). Often, patients with automatic pulling do not realize that they have been engaged in hair pulling until they see the evidential hair lying on the floor nearby or
227 a parent notifies them of the behavior. As discussed in relation to the diagnostic criteria, although most adults endorse focused hair pulling on at least some pulling occasions, most children do not, with older children being more likely to report focused pulling (Christenson et al., 1991; King et al., 1995a; Reeve et al., 1992). Therefore, even if a child does not report hair pulling, parents or other family members should be recruited to ascertain if hair pulling is occurring outside of the child's awareness. The presentation of TTM is somewhat different across development. For young children, this disorder may begin as a habit, similar to nail biting or thumb sucking, but then does not decrease over development as more common habits often do (Franklin et al., 2008). In some cases, hair pulling may commence as a result of anxiety, changes in routine, or psychological or physical trauma, but many children will seemingly have no overt origin of their hair pulling (Roblek, Detweiler, Fearing, & Albano, 1999). As noted earlier, hair pulling in young children is usually completely outside of their awareness, occurring while the child is at rest or performing sedentary activities (Sah et al., 2008). Parents may witness the hair pulling in their children. However, as many young children pull their hair while alone, parents may only see secondary evidence of their child's pulling, such as bald spots on the head or a large number of hairs around the bed or pillows (Sah et al., 2008). Young children typically only pull from one site, usually the scalp (Wright & Holmes, 2003), and do not report rising tension or gratification from pulling (Bruce et al., 2005). The research has shown that this early-onset version of TTM is equally prevalent in both genders (Tay et al., 2004; Whiting, 1999). Early-onset TTM can be more benign (Reeve, 1999; Walsh & McDougle, 2001) and time limited (Swedo & Leonard, 1992; Walsh & McDougle, 2001), and may respond well to behaviorally oriented psychotherapy (Byrd, Richards, Hove, & Friman, 2002; Rahman, Toufexis, Murphy, & Storch, 2009; Watson et al., 2000). Treatment is often recommended to prevent negative psychosocial or physical outcomes (Watson et al., 2000). Hair pulling in preadolescents and young adults is believed more common than in young children, with the most common age of onset being between ages 9 and 13 years (Christenson et al., 1991; Cohen et al., 1995; Tay et al., 2004; King et al., 1995a; Sah et al., 2008). The gender difference in which females preponderate begins to emerge in this age bracket, with between 70% and 90% of cases occurring in females (Christenson et al., 1994; Cohen et al., 1995; Sah et al., 2008). Focused pulling begins to be more readily reported in this age group, although many adolescents and young adults still engage in frequent automatic pulling (Bruce et al., 2005). Hair pulling behavior in this age group tends to be chronic and not remit without treatment. Most adults with TTM report that their hair pulling behavior began in preadolescence or adolescence and continued intermittently into adulthood, despite attempts to cease the behavior on their own (Christenson et al., 1991).
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Psychosocial and Physical Complications Regardless of the age of the child, TTM can result in considerable distress for both the child and the family. Youth with TTM can spend upwards of 30–60 minutes per day pulling hair and experience significant distress regarding their symptoms (Tolin et al., 2007). Children may feel ashamed, guilty, anxious, or depressed over their pulling behavior (Bruce et al., 2005). Bald spots may adversely affect body image, and concerns over appearance and perceived lack of willpower may lead to low self-esteem (Bruce et al., 2005). Likewise, parents and family members may feel considerable frustration and anger over the continued hair pulling behavior. Many may feel reduced competency as a parent or feel unsure of how to properly rear their child without exacerbating the hair pulling behavior (Bruce et al., 2005). Children with TTM often report social and interpersonal impairment that increases with age (Flessner et al., 2009). More than half of children with TTM report avoidance of social situations due to their hair pulling (Franklin et al., 2008), which may be related to the fact that they are consistently more negatively evaluated by their peers (Boudjouk et al., 2000). Most of the youth with TTM report that the disorder also impairs their academic functioning, with more than half reporting interference with studying and more than a third reporting interference severe enough to impair academic achievement (Franklin et al., 2008). In addition to impairment resulting from the disorder itself, TTM is also associated with significant psychiatric morbidity. Research suggests that somewhere between one and two thirds of youth diagnosed with TTM also meet the criteria for at least one other mental disorder, most often anxious, depressive, or internalizing disorders (Hanna, 1997; King et al., 1995a; Lewin et al., 2009; Malhoutra et al., 2008; Reeve et al., 1992; Santhanam et al., 2008; Tolin et al., 2007). Increased rates of anxiety, depression, obsessive– compulsive disorder, and TTM have also been found in firstdegree relatives (Schlosser, Black, Blum, & Goldstein, 1994). Without treatment, TTM and other comorbid conditions can cause substantial impairment in social, academic, and psychological domains and reduced quality of life. In addition to psychosocial risk, TTM also engenders risks to physical health. Children and adolescents with TTM may feel such severe shame over their hair pulling behavior or bald spots that they may try to convince parents to avoid necessary medical attention, such as annual checkups or treatment for illnesses (Papadopoulos et al., 2003). Severe cases of TTM can result in permanent changes in the color or texture of the hair, skin excoriation or infection in the areas of pulling, and muscle strain or repetitive stress injuries from the repeated motions of pulling (Christenson & Crow, 1996; O' Sullivan et al., 1997; O'Sullivan, Keuthen, Jenike, & Gumley, 1996). However, the most serious medical complications resulting from TTM are caused by the associated behavior of hair ingestion (trichophagia), which
C.D. Labouliere, E.A. Storch occurs in approximately 10% of persons with TTM (Christenson et al., 1991). Ingesting hair can lead to the creation of a trichobezoar, or hair ball, which can subsequently lead to abdominal pain, nausea, vomiting, halitosis, anorexia, anemia, constipation, flatulence, gastrointestinal or bowel obstruction, ulceration, and/or perforation, intestinal bleeding, acute pancreatitis, obstructive jaundice, and even death if left untreated (Christenson, 1995; Christenson & Crow, 1996; Hamdan-Allen, 1991; Muller, 1987; Stone, Rush, & Westphal, 1998). As such, swift and accurate diagnosis is critical to forestall these negative physical and psychosocial consequences.
How to Recognize TTM in Your Patients Because TTM is a problem of considerable morbidity in pediatric populations, it would be most beneficial for affected children if their difficulties could be identified soon after onset, before the condition becomes chronic and increasingly impairing. When a child admits to pulling or their parents have witnessed hair pulling behavior, it is relatively easy to diagnose TTM. However, because pulling can occur outside of a child's awareness or away from a parent's notice, how can nurses recognize the signs of TTM without a parent's or child's report? One possible method of assessment available when a parent or child report is not forthcoming is to seek physical evidence of TTM in the most common, visible areas of hair pulling—scalp, eyelashes, and eyebrows. Unlike alopecia areata (the most common differential diagnosis), bald spots resulting from TTM are not bare and patchy. Rather, youth with TTM often have areas of different hair length, with some hairs being full-length and untampered, others broken midshaft, and some like short fuzzy stubble or small dark dots along the skin. Remnants of hair bulbs with the actual hair follicle pulled away may also be visible. Many hairs in the affected area will either have blunt ends from being broken by being pulled or tapered ends indicating new growth. However, overall hair density is normal outside of the affected region and not reduced generally. When pulled, hair should not come out easily, as is more common in other types of alopecias. The site of pulling is often irregularly shaped or may change shape or position between visits (Sah et al., 2008). A common hair loss pattern is referred to as the “Friar Tuck” pattern, where pulling may result in bald spots along the top of the scalp but hair remains long in the lowerback regions of the head where the scalp is more tender and hair is harder to reach. A dermatological evaluation often reveals normally growing hairs among empty hair follicles with little or no scalp inflammation (Bruce et al., 2005), with more hairs in the catagen and telogen phases of growth than would normally be expected (Sah et al., 2008). Perifollicular hemorrhage near the hair bulb or between the outer root and connective tissue sheath (Muller, 1990) or trichomalacia
Pediatric Trichotillomania (e.g., oddly pigmented spiral hairs) is also commonly found (Sah et al., 2008). Although the scalp is the most common location for pulling, it is important to remember that pulling of eyelashes and eyebrows is also frequently found in youth with TTM; as such, it is also important to examine locations other than just the scalp for evidence of hair loss. Depending on the setting, nurses may be presented with differing information with which to assess the existence of TTM. For example, nurses in a school setting may not have direct access to parents or full physical examinations but may be able to examine the most common visible sites for evidence of pulling or utilize teacher's reports of in-class pulling and pulling in relation to certain classroom activities (e.g., oral presentations, free time). Alternatively, nurses in primary care are likely to be able to conduct a thorough physical examination for hair pulling across various bodily locations and can usually incorporate both parent and child reports of pulling behavior and precipitating factors. Nurses working in specialty settings, such as dermatology or gastroenterology clinics, should be especially cognizant that the sequelae of TTM may masquerade as unexplained physical symptoms, such skin irritation or digestive problems. Once a patient is suspected of experiencing TTM, it is important to broach the subject to the child and his or her parents with caution. Some children and parents may deny that baldness could have a psychological origin and insist that hair loss is the result of a physical illness. Empathic listening and providing of sensitive psychoeducation is often needed. It can be helpful to avoid confrontation and explain that pulling likely occurs outside of the child's and parents' awareness, so as to diffuse defensiveness and allay fears that the child or parents are to blame for the condition (Sah et al., 2008). Lastly, after presenting families with appropriate referrals and a menu of possible treatment options, expressing to parents that simple behavioral interventions can greatly improve their child's prognosis is likely to reduce anxiety.
Treatment Depending on the age of the child, several treatment options are available to combat TTM. Simple home remedies, such as placing band-aids on the child's fingers, socks over the child's hands, or a hat on the child's head, may reduce the behavior in some children. However, for those in whom the behavior is more entrenched, behavior modification programs implemented by a behavior therapist or psychologist show the most success (Sah et al., 2008). For very young children with mild TTM, behavior modification strategies such as increased positive reinforcement for behaviors incompatible with pulling (i.e., sitting on hands, playing with a koosh ball), verbal instructions by parents not to pull, reduction of parental reinforcement for pulling (i.e.,
229 attention), or the implementation of a token economy may help decrease pulling (Blum et al., 1993). For those children with more severe TTM, habit reversal training (HRT) methods have been demonstrated efficacious (Roblek et al.; 1999; Stanley, 1999). HRT (Azrin & Nunn, 1973) begins by teaching awareness of the behavior through a combination of self-monitoring and assistance from observers in the environment (most often parents, siblings, or teachers) who can unobtrusively and kindly point out the behavior when it is outside the child's awareness. Children and parents should view relapses as learning opportunities that allow identification of triggers and barriers to successful behavior change. The awareness training component often includes (a) identifying in which situations or at what time of day pulling is most common; (b) how to identify hair pulling once the behavior is initiated (i.e., by movement of the arms and hands near the head); and (c) how to detect when pulling may occur (if any premonitory urges or contextual cues exist; Azrin & Nunn, 1973). Next, the child is instructed to engage in a competing response anytime there is a risk for hair pulling. For example, if a child is likely to pull while watching television or reading, he or she will engage in a behavior incompatible with hair pulling, such as squeezing a stress ball, clenching the hands into fists, or putting the hands behind the back. A good competing response will make it difficult for a child to engage in hair pulling (i.e., the hands will be away from the hair and/or engaged in an alternate activity), produce increased awareness of the behavior by tightening an alternate set of muscles than those used in pulling (i.e., instead of bringing arms up, pushing them into a downward position), and will be able to be maintained for several minutes until the risk for pulling has passed (Azrin & Nunn, 1973). In addition, the response should be relatively socially inconspicuous, so that it can be used across settings (i.e., home, school, etc.) without fear of embarrassment or ridicule. The child is instructed to engage in the competing response for approximately 3 minutes following an urge to pull or after an instance of pulling. In this manner, awareness of the behavior and its triggers is heightened, the episode of pulling is aborted, and the association between pulling and certain contexts is weakened. For children with significant anxiety or focused pulling for affect regulatory purposes, cognitive–behavioral strategies, alternate coping skills, or relaxation training may also be implemented (Stanley, 1999). This habit reversal approach has been found to be highly effective in reducing or eradicating TTM (Sah et al., 2008; Stanley, 1999) and may be preferable to psychopharmacological approaches as a first-line of defense, given lack of empirical support for the latter and improved tolerability for the former. If HRT does not produce suitable reductions in hair pulling or significant comorbid psychiatric conditions such as depression or anxiety disorders are present, adjunctive treatment using cognitive–behavioral therapy and/or pharmacological therapy with a selective serotonin reuptake inhibitor (SSRI) may be indicated. However, only limited
230 effectiveness of this medication class for pediatric TTM has been noted, and SSRIs have showed no clear efficacy among adults with TTM (Bloch et al., 2007). As such, adjunctive medication should only be considered if other more empirically supported behavioral methods have not produced desired results (Sah et al., 2008) or in the presence of comorbid conditions where such medications are indicated.
Implications for Nurses Considering that nurses interact with children in multiple settings (e.g., school, primary care, hospitals, home visitations) and may be the professionals who spend the greatest amount of time with child patients, nurses may be the persons most equipped to recognize TTM. Care of patients who may present with TTM should be guided by a systematic process of assessment and intervention. Within this framework, it is of utmost importance to establish a calm and safe therapeutic environment in which nonjudgmental and empathetic discussion of symptoms can be maintained. Unless hair pulling is disclosed initially by the child or parents, all potential medical causes for hair loss should be ruled out by dermatological examination and laboratory work. Once it is determined that psychological causes are likely to blame for alopecia, a thorough assessment of symptoms, locations of pulling, presence or absence of premonitory urge, antecedents and consequences of pulling, and any impairment in social, emotional, or academic functioning obtained from multiple informants is critical. Any discrepancy between informants should not be viewed necessarily as errors but rather as potential hypotheses to be tested. For example, if a parent reports pulling but the child does not, it is possible that the pulling behavior is occurring outside of the child's awareness. A particular focus should be placed on events, situations, or emotional states that directly precede episodes of hair pulling, as these instances may provide clues for prevention and intervention. Since identifying “triggers” can be difficult with young children, children with poor insight, or children who pull outside of their awareness, the utilization of multiple informants and self-monitoring techniques is crucial. In addition, since family influences often play a strong role in the maintenance or elimination of TTM, nurses should pay careful attention to interactions among children, parents, and siblings to determine if family members are unwittingly accommodating, reinforcing, or modeling the hair pulling behavior. Lastly, it is important to screen for other possible psychological problems, as TTM can often be comorbid with other anxiety or mood disorders. Once a thorough assessment has been completed, nurses can also play a decisive role in treatment planning and implementation. If the behavior is infrequent, not disfiguring, or otherwise relatively benign, nurses may themselves educate the family regarding simple behavior modification
C.D. Labouliere, E.A. Storch strategies; alternatively, if the patient has a more complex presentation (e.g., extensive or disfiguring TTM; TTM that is severely interfering with social, emotional, or academic functioning; or TTM with comorbid psychological conditions), nurses may facilitate referrals to a primary care provider, psychiatric nursing professional, or a local child psychologist or psychiatrist trained in habit reversal and cognitive–behavioral techniques for more extensive assessment and intervention. Nurses who work in settings where TTM presents more frequently may wish to seek additional formal training in these methods to better serve their child patients.
Conclusion TTM adversely affects thousands of children, resulting in seriously negative physical and psychosocial consequences. These children and their parents may not be aware of the cause of their affliction or may feel helpless to change their pulling behavior. As pediatric nurses spend the greatest amount of time with their child patients, they may be one of the first persons able to identify TTM. It is therefore of the utmost importance for nurses to be aware of this condition, to recognize the physical evidence that suggests TTM, and to be able to provide appropriate psychoeducation and treatment information to families. Most parents and children will be relieved to hear that there is no physical problem and that the hair will eventually grow back normally with the implementation of minimally invasive behavioral treatments. As such, the pediatric nurse can be an advocate in ceasing the considerable morbidity associated with pediatric TTM.
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232 Watson, T. S., Dittmer, K. I., & Ray, K. P. (2000). Treating trichotillomania in a toddler: Variations on effective treatments. Child and Family Behavior Therapy, 22, 29−40. Whiting, D. A. (1999). Traumatic alopecia. International Journal of Dermatology, 38(Suppl. 1), 34−44.
C.D. Labouliere, E.A. Storch Wilson, A. D., & Childs, S. (2006). Effects of interventions aimed at changing the length of primary care physicians' consultation. Cochrane Database of Systematic Reviews, 1. Wright, H., & Holmes, G. (2003). Trichotillomania (hair pulling) in toddlers. Psychological Reports, 92, 228−230.
Pediatric Trichotillomania: Clinical Presentation, Treatment, and Implications for Nursing Professionals1 Christa D. Labouliere MA a,⁎, Eric A. Storch PhD a,b a
University of South Florida, Tampa, FL Rothman Center for Pediatric Neuropsychiatry, St. Petersburg, FL
b
Key words: Trichotillomania; Hair pulling; Mental health; Children; Adolescents
Trichotillomania (TTM), or compulsive hair pulling, is a disorder that typically onsets in childhood. It is mistaken to believe that children will “age out” of this behavior, as pediatric TTM often has a chronic, debilitating course that does not remit without treatment, resulting in considerable psychological and physical impairment. Because most children with TTM will be seen initially by nursing professionals in the practices of dermatologists, pediatricians, gastroenterologists, and other disciplines, raising nurses' awareness of this disorder is of the utmost importance for accurate nursing diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients, nurses' detection and diagnosis of TTM can make a critical difference in the initiation of early intervention. Therefore, the purpose of this article is to provide an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace. © 2012 Elsevier Inc. All rights reserved.
TRICHOTILLOMANIA (TTM) is a disorder characterized by the non-cosmetic, repetitive pulling of hair from any part of one's body, resulting in noticeable hair loss or alopecia. Although the disorder was first identified over a hundred years ago (Hallopeau, 1889), scientific inquiry regarding its etiology and treatment is relatively recent, especially in the realm of pediatric TTM (Bruce, Barwick, & Wright, 2005). This is a concern, as the onset of TTM occurs most typically in childhood (Cohen et al., 1995), the prevalence of TTM is much higher in childhood than in adulthood (point prevalence of approximately 0.5% and lifetime prevalence of 0.6%–3.4%; Bruce et al., 2005; Christenson, MacKenzie, & Mitchell, 1991; Dean, Nelson, & Moss, 1992; Hamdan-Allen, 1991), and most research suggests that earlier intervention is more successful than
1 No previous presentations or publications of this work exist. No extramural funding or commercial financial support aided in the preparation of this article. ⁎ Corresponding author: Christa D. Labouliere, MA. E-mail address: [email protected] (C.D. Labouliere).
0882-5963/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.pedn.2011.01.028
treating adults in whom the behavior is already entrenched (Bruce et al., 2005; Sah, Koo, & Price, 2008). The mistaken belief that children will “grow out of it” may be partially responsible for this lack of recognition. However, recent research suggests that pediatric TTM often has a chronic, debilitating course that does not remit without treatment (Bruce et al., 2005; Cohen et al., 1995), resulting in considerable psychological and physical health impairment (Boudjouk, Woods, Miltenberger, & Long, 2000; Flessner, Woods, Franklin, Keuthen, & Piacentini, 2009; Franklin et al., 2008; Hamdan-Allen, 1991; Hanna, 1997; Tay, Levy, & Metry, 2004; Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007). Since most children with TTM will be seen initially by school nurses or nursing professionals working in the offices of dermatologists, pediatricians, gastroenterologists, and other disciplines (Blum, Barone, & Friman, 1993), raising nurses' awareness of the disorder is of the utmost importance for accurate diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients (Berg van den, Kolthof, de Bakker, & van der Zee, 2004; Wilson & Childs, 2006), nurses' detection and diagnosis of TTM can make the critical difference in the
226 initiation of early intervention. With this in mind, the present article provides an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace.
Epidemiology Pediatric TTM is estimated to have a point prevalence of approximately 0.5% (Hamdan-Allen, 1991) and a lifetime prevalence of 0.6%–3.4% in adults, most of whom began pulling as children (N85%; Bruce et al., 2005; Christenson et al., 1991). The disorder is up to seven times more common in children than in adults (Bruce et al., 2005; Dean et al., 1992; Hamdan-Allen, 1991; Tay et al., 2004) and typically has its age of onset either in preschool or in the preadolescent years (Christenson et al., 1991; Clark, Helm, & Bergfeld, 1995; Cohen et al., 1995; Du Toit, van Kradenburg, Niehaurs, & Stein, 2001). In toddlerhood through early childhood, equal numbers of males and females have TTM (Cohen et al., 1995; Swedo & Rapoport, 1991), but by late childhood and adolescence, females are disproportionately affected (Christenson, MacKenzie, & Mitchell, 1994; Flessner et al., 2007; Franklin et al., 2008; Greenberg & Sarner, 1965; King et al., 1995a; Muller, 1990; Reeve, Bernstein, & Christenson, 1992; Swedo & Leonard, 1992). The prevalence of TTM is probably underestimated for several reasons (Sah et al., 2008). Perhaps most critically, medical professionals who are not familiar with the disorder's presentation often fail to recognize or diagnose TTM (Cohen et al., 1995). Compounding this difficulty, children are not always reliable reporters of hair pulling behavior. Hair pulling can sometimes occur entirely outside of the patient's awareness (Christenson et al., 1991; Sah et al., 2008), making it hard for the child to report on antecedents and frequency. In addition, many persons who are aware of pulling are ashamed and secretive about their behavior, leading them to deny hair pulling or hide their alopecia with elaborate hairstyles or head coverings (Papadopoulos, Janniger, Chodynicki, & Schwartz, 2003; Santhanam, Fairley, & Rogers, 2008; Tolin et al., 2007). As such, knowledge of signs suggesting TTM and careful assessment is critical.
Definition TTM is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSMIV-TR) of the American Psychiatric Association (2000) as an impulse control disorder, similar to kleptomania, pyromania, or compulsive skin picking. The DSM-IV-TR requires five criteria for the disorder to be diagnosed: (a) one intentionally
C.D. Labouliere, E.A. Storch and repetitively pulls out his or her hair, resulting in noticeable hair loss; (b) an increasing sense of tension occurs immediately before or when trying to resist pulling; (c) pleasure, gratification, or relief occurs once the hair is pulled; (d) another mental or medical condition does not better account for the behavior; and (e) the behavior causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2000). However, some controversy exists regarding criteria b and c (rising tension and relief or gratification), as many persons with clinically significant hair loss due to pulling do not endorse these experiences (Christenson et al., 1991). In children, who may not be able to verbalize or even cognitively understand such experiences, these criteria are particularly problematic because they imply that a diagnosis of TTM should be withheld even when severe, cosmetically disfiguring hair pulling is evident. Critics of the tension and gratification criteria (Christenson et al., 1991; King et al., 1995a, 1995b; Reeve et al., 1992; Sah et al., 2008; Santhanam et al., 2008) have suggested that these criteria sometimes do not apply in a sizable percentage of adults with TTM and are even more notably absent in most affected children and adolescents. Research has shown that children and adolescents rarely endorse the tension or gratification criteria, with reports citing somewhere between 0% and 25% (King et al., 1995b; Reeve et al., 1992; Santhanam et al., 2008). These studies have shown that younger samples are much less likely to endorse these criteria and that rates increase across development into adolescence and young adulthood (Christenson et al., 1991; King et al., 1995a; Reeve et al., 1992). This suggests that the consciousness of and ability to report on internal states may be more related to cognitive development than an inherent characteristic of the disorder. Therefore, the diagnosis of TTM should still be conferred even in the absence of these criteria if clinically significant hair pulling is occurring and other medical conditions have been ruled out (e.g., alopecia areata, tinea capitis; Diefenbach, Tolin, Crocetto, Maltby, & Hannan, 2005; Watson, Dittmer, & Ray, 2000).
Clinical Presentation TTM is characterized by the non-cosmetic, repetitive pulling of hair from any part of one's body, resulting in noticeable hair loss. Hair pulling behavior occurs along a continuum, ranging from a relatively benign form that produces no significant aesthetic or psychological distress to a more serious disorder that is often disfiguring and leads to great personal suffering. Hair is most commonly pulled from the crown, occipital, or parietal regions of the scalp (Papadopoulos et al., 2003) but may also be pulled from other areas of the body, including the eyelashes, eyebrows, arms, legs, torso, or pubic area (in postpubertal children;
Pediatric Trichotillomania Franklin et al., 2008; King et al., 1995a; Malhoutra, Grover, Baweja, & Bhateja, 2008; Papadopoulos et al., 2003; Santhanam et al., 2008). Most children pull hair from multiple areas (King et al., 1995a; Santhanam et al., 2008; Tay et al., 2004; Tolin et al., 2007), with younger children pulling from fewer areas than older children (Wright & Holmes, 2003). Many children pluck one hair at a time, although some children have been known to pull hair in clumps (Christenson et al., 1991; Stemberger, Thomas, Mansueto, & Carter, 2000). Pulling tends to be more prevalent on the side of the child's dominant hand (Tay et al., 2004), although some children may use either hand (Christenson et al., 1991). Most children only use their hands to pull hairs, although rarely some will use tweezers or other instruments (Walsh & McDougle, 2001). Children may devote a great deal of time (over an hour) per day to hair pulling (Tolin et al., 2007), either in discrete binges or in dozens of brief periods throughout the day. It is common for symptoms to wax and wane over time from periods of intense activity to periods of complete abstinence (often lasting 2 weeks or longer; Tolin et al., 2007). In addition to pulling behavior, more than half of children with TTM engage in rituals involving the hair (Christenson et al., 1991; Papadopoulos et al., 2003; Tay et al., 2004; Walsh & McDougle, 2001), such as playing with, touching, or stroking the hair before pulling; twirling the hair before or after plucking; dropping the hair in a certain manner; storing the hairs; rubbing the hair across the face or mouth; sucking or biting off the hair root; or even ingesting the entire hair (trichophagy, which can lead to serious medical complications; Tay et al., 2004). Many children report that they specifically select hairs that are different from their other hairs in terms of color, thickness, consistency, curly/kinky texture, length, or location (Swedo, 1993; Tay et al., 2004). Unfortunately, this practice is self-perpetuating: The very trauma of pulling a hair can damage the hair root, making the new hair more likely to appear or feel different and therefore more likely to be repulled. Many children report the desire to pull symmetrically, and they may continue to pull hairs until symmetry is achieved or the pattern feels “just right” (Christenson et al., 1991; Walsh & McDougle, 2001). Two subtypes of hair pulling have been noted. The first, “focused pulling,” occurs in a compulsive fashion in response to an urge to pull in order to achieve a symmetrical pattern or to modulate an aversive emotional state such as anxiety, anger, or frustration (Diefenbach, Mouton-Odum, & Stanley, 2002; Flessner et al., 2009). This variant of hair pulling is within conscious awareness and is intentional (Begotka, Woods, & Wetterneck, 2004). Alternatively, “automatic pulling” occurs outside of a person's awareness, often during sedentary, boring, or mindless activities, such as lying in bed, reading a book, or watching television (Flessner et al., 2007). Often, patients with automatic pulling do not realize that they have been engaged in hair pulling until they see the evidential hair lying on the floor nearby or
227 a parent notifies them of the behavior. As discussed in relation to the diagnostic criteria, although most adults endorse focused hair pulling on at least some pulling occasions, most children do not, with older children being more likely to report focused pulling (Christenson et al., 1991; King et al., 1995a; Reeve et al., 1992). Therefore, even if a child does not report hair pulling, parents or other family members should be recruited to ascertain if hair pulling is occurring outside of the child's awareness. The presentation of TTM is somewhat different across development. For young children, this disorder may begin as a habit, similar to nail biting or thumb sucking, but then does not decrease over development as more common habits often do (Franklin et al., 2008). In some cases, hair pulling may commence as a result of anxiety, changes in routine, or psychological or physical trauma, but many children will seemingly have no overt origin of their hair pulling (Roblek, Detweiler, Fearing, & Albano, 1999). As noted earlier, hair pulling in young children is usually completely outside of their awareness, occurring while the child is at rest or performing sedentary activities (Sah et al., 2008). Parents may witness the hair pulling in their children. However, as many young children pull their hair while alone, parents may only see secondary evidence of their child's pulling, such as bald spots on the head or a large number of hairs around the bed or pillows (Sah et al., 2008). Young children typically only pull from one site, usually the scalp (Wright & Holmes, 2003), and do not report rising tension or gratification from pulling (Bruce et al., 2005). The research has shown that this early-onset version of TTM is equally prevalent in both genders (Tay et al., 2004; Whiting, 1999). Early-onset TTM can be more benign (Reeve, 1999; Walsh & McDougle, 2001) and time limited (Swedo & Leonard, 1992; Walsh & McDougle, 2001), and may respond well to behaviorally oriented psychotherapy (Byrd, Richards, Hove, & Friman, 2002; Rahman, Toufexis, Murphy, & Storch, 2009; Watson et al., 2000). Treatment is often recommended to prevent negative psychosocial or physical outcomes (Watson et al., 2000). Hair pulling in preadolescents and young adults is believed more common than in young children, with the most common age of onset being between ages 9 and 13 years (Christenson et al., 1991; Cohen et al., 1995; Tay et al., 2004; King et al., 1995a; Sah et al., 2008). The gender difference in which females preponderate begins to emerge in this age bracket, with between 70% and 90% of cases occurring in females (Christenson et al., 1994; Cohen et al., 1995; Sah et al., 2008). Focused pulling begins to be more readily reported in this age group, although many adolescents and young adults still engage in frequent automatic pulling (Bruce et al., 2005). Hair pulling behavior in this age group tends to be chronic and not remit without treatment. Most adults with TTM report that their hair pulling behavior began in preadolescence or adolescence and continued intermittently into adulthood, despite attempts to cease the behavior on their own (Christenson et al., 1991).
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Psychosocial and Physical Complications Regardless of the age of the child, TTM can result in considerable distress for both the child and the family. Youth with TTM can spend upwards of 30–60 minutes per day pulling hair and experience significant distress regarding their symptoms (Tolin et al., 2007). Children may feel ashamed, guilty, anxious, or depressed over their pulling behavior (Bruce et al., 2005). Bald spots may adversely affect body image, and concerns over appearance and perceived lack of willpower may lead to low self-esteem (Bruce et al., 2005). Likewise, parents and family members may feel considerable frustration and anger over the continued hair pulling behavior. Many may feel reduced competency as a parent or feel unsure of how to properly rear their child without exacerbating the hair pulling behavior (Bruce et al., 2005). Children with TTM often report social and interpersonal impairment that increases with age (Flessner et al., 2009). More than half of children with TTM report avoidance of social situations due to their hair pulling (Franklin et al., 2008), which may be related to the fact that they are consistently more negatively evaluated by their peers (Boudjouk et al., 2000). Most of the youth with TTM report that the disorder also impairs their academic functioning, with more than half reporting interference with studying and more than a third reporting interference severe enough to impair academic achievement (Franklin et al., 2008). In addition to impairment resulting from the disorder itself, TTM is also associated with significant psychiatric morbidity. Research suggests that somewhere between one and two thirds of youth diagnosed with TTM also meet the criteria for at least one other mental disorder, most often anxious, depressive, or internalizing disorders (Hanna, 1997; King et al., 1995a; Lewin et al., 2009; Malhoutra et al., 2008; Reeve et al., 1992; Santhanam et al., 2008; Tolin et al., 2007). Increased rates of anxiety, depression, obsessive– compulsive disorder, and TTM have also been found in firstdegree relatives (Schlosser, Black, Blum, & Goldstein, 1994). Without treatment, TTM and other comorbid conditions can cause substantial impairment in social, academic, and psychological domains and reduced quality of life. In addition to psychosocial risk, TTM also engenders risks to physical health. Children and adolescents with TTM may feel such severe shame over their hair pulling behavior or bald spots that they may try to convince parents to avoid necessary medical attention, such as annual checkups or treatment for illnesses (Papadopoulos et al., 2003). Severe cases of TTM can result in permanent changes in the color or texture of the hair, skin excoriation or infection in the areas of pulling, and muscle strain or repetitive stress injuries from the repeated motions of pulling (Christenson & Crow, 1996; O' Sullivan et al., 1997; O'Sullivan, Keuthen, Jenike, & Gumley, 1996). However, the most serious medical complications resulting from TTM are caused by the associated behavior of hair ingestion (trichophagia), which
C.D. Labouliere, E.A. Storch occurs in approximately 10% of persons with TTM (Christenson et al., 1991). Ingesting hair can lead to the creation of a trichobezoar, or hair ball, which can subsequently lead to abdominal pain, nausea, vomiting, halitosis, anorexia, anemia, constipation, flatulence, gastrointestinal or bowel obstruction, ulceration, and/or perforation, intestinal bleeding, acute pancreatitis, obstructive jaundice, and even death if left untreated (Christenson, 1995; Christenson & Crow, 1996; Hamdan-Allen, 1991; Muller, 1987; Stone, Rush, & Westphal, 1998). As such, swift and accurate diagnosis is critical to forestall these negative physical and psychosocial consequences.
How to Recognize TTM in Your Patients Because TTM is a problem of considerable morbidity in pediatric populations, it would be most beneficial for affected children if their difficulties could be identified soon after onset, before the condition becomes chronic and increasingly impairing. When a child admits to pulling or their parents have witnessed hair pulling behavior, it is relatively easy to diagnose TTM. However, because pulling can occur outside of a child's awareness or away from a parent's notice, how can nurses recognize the signs of TTM without a parent's or child's report? One possible method of assessment available when a parent or child report is not forthcoming is to seek physical evidence of TTM in the most common, visible areas of hair pulling—scalp, eyelashes, and eyebrows. Unlike alopecia areata (the most common differential diagnosis), bald spots resulting from TTM are not bare and patchy. Rather, youth with TTM often have areas of different hair length, with some hairs being full-length and untampered, others broken midshaft, and some like short fuzzy stubble or small dark dots along the skin. Remnants of hair bulbs with the actual hair follicle pulled away may also be visible. Many hairs in the affected area will either have blunt ends from being broken by being pulled or tapered ends indicating new growth. However, overall hair density is normal outside of the affected region and not reduced generally. When pulled, hair should not come out easily, as is more common in other types of alopecias. The site of pulling is often irregularly shaped or may change shape or position between visits (Sah et al., 2008). A common hair loss pattern is referred to as the “Friar Tuck” pattern, where pulling may result in bald spots along the top of the scalp but hair remains long in the lowerback regions of the head where the scalp is more tender and hair is harder to reach. A dermatological evaluation often reveals normally growing hairs among empty hair follicles with little or no scalp inflammation (Bruce et al., 2005), with more hairs in the catagen and telogen phases of growth than would normally be expected (Sah et al., 2008). Perifollicular hemorrhage near the hair bulb or between the outer root and connective tissue sheath (Muller, 1990) or trichomalacia
Pediatric Trichotillomania (e.g., oddly pigmented spiral hairs) is also commonly found (Sah et al., 2008). Although the scalp is the most common location for pulling, it is important to remember that pulling of eyelashes and eyebrows is also frequently found in youth with TTM; as such, it is also important to examine locations other than just the scalp for evidence of hair loss. Depending on the setting, nurses may be presented with differing information with which to assess the existence of TTM. For example, nurses in a school setting may not have direct access to parents or full physical examinations but may be able to examine the most common visible sites for evidence of pulling or utilize teacher's reports of in-class pulling and pulling in relation to certain classroom activities (e.g., oral presentations, free time). Alternatively, nurses in primary care are likely to be able to conduct a thorough physical examination for hair pulling across various bodily locations and can usually incorporate both parent and child reports of pulling behavior and precipitating factors. Nurses working in specialty settings, such as dermatology or gastroenterology clinics, should be especially cognizant that the sequelae of TTM may masquerade as unexplained physical symptoms, such skin irritation or digestive problems. Once a patient is suspected of experiencing TTM, it is important to broach the subject to the child and his or her parents with caution. Some children and parents may deny that baldness could have a psychological origin and insist that hair loss is the result of a physical illness. Empathic listening and providing of sensitive psychoeducation is often needed. It can be helpful to avoid confrontation and explain that pulling likely occurs outside of the child's and parents' awareness, so as to diffuse defensiveness and allay fears that the child or parents are to blame for the condition (Sah et al., 2008). Lastly, after presenting families with appropriate referrals and a menu of possible treatment options, expressing to parents that simple behavioral interventions can greatly improve their child's prognosis is likely to reduce anxiety.
Treatment Depending on the age of the child, several treatment options are available to combat TTM. Simple home remedies, such as placing band-aids on the child's fingers, socks over the child's hands, or a hat on the child's head, may reduce the behavior in some children. However, for those in whom the behavior is more entrenched, behavior modification programs implemented by a behavior therapist or psychologist show the most success (Sah et al., 2008). For very young children with mild TTM, behavior modification strategies such as increased positive reinforcement for behaviors incompatible with pulling (i.e., sitting on hands, playing with a koosh ball), verbal instructions by parents not to pull, reduction of parental reinforcement for pulling (i.e.,
229 attention), or the implementation of a token economy may help decrease pulling (Blum et al., 1993). For those children with more severe TTM, habit reversal training (HRT) methods have been demonstrated efficacious (Roblek et al.; 1999; Stanley, 1999). HRT (Azrin & Nunn, 1973) begins by teaching awareness of the behavior through a combination of self-monitoring and assistance from observers in the environment (most often parents, siblings, or teachers) who can unobtrusively and kindly point out the behavior when it is outside the child's awareness. Children and parents should view relapses as learning opportunities that allow identification of triggers and barriers to successful behavior change. The awareness training component often includes (a) identifying in which situations or at what time of day pulling is most common; (b) how to identify hair pulling once the behavior is initiated (i.e., by movement of the arms and hands near the head); and (c) how to detect when pulling may occur (if any premonitory urges or contextual cues exist; Azrin & Nunn, 1973). Next, the child is instructed to engage in a competing response anytime there is a risk for hair pulling. For example, if a child is likely to pull while watching television or reading, he or she will engage in a behavior incompatible with hair pulling, such as squeezing a stress ball, clenching the hands into fists, or putting the hands behind the back. A good competing response will make it difficult for a child to engage in hair pulling (i.e., the hands will be away from the hair and/or engaged in an alternate activity), produce increased awareness of the behavior by tightening an alternate set of muscles than those used in pulling (i.e., instead of bringing arms up, pushing them into a downward position), and will be able to be maintained for several minutes until the risk for pulling has passed (Azrin & Nunn, 1973). In addition, the response should be relatively socially inconspicuous, so that it can be used across settings (i.e., home, school, etc.) without fear of embarrassment or ridicule. The child is instructed to engage in the competing response for approximately 3 minutes following an urge to pull or after an instance of pulling. In this manner, awareness of the behavior and its triggers is heightened, the episode of pulling is aborted, and the association between pulling and certain contexts is weakened. For children with significant anxiety or focused pulling for affect regulatory purposes, cognitive–behavioral strategies, alternate coping skills, or relaxation training may also be implemented (Stanley, 1999). This habit reversal approach has been found to be highly effective in reducing or eradicating TTM (Sah et al., 2008; Stanley, 1999) and may be preferable to psychopharmacological approaches as a first-line of defense, given lack of empirical support for the latter and improved tolerability for the former. If HRT does not produce suitable reductions in hair pulling or significant comorbid psychiatric conditions such as depression or anxiety disorders are present, adjunctive treatment using cognitive–behavioral therapy and/or pharmacological therapy with a selective serotonin reuptake inhibitor (SSRI) may be indicated. However, only limited
230 effectiveness of this medication class for pediatric TTM has been noted, and SSRIs have showed no clear efficacy among adults with TTM (Bloch et al., 2007). As such, adjunctive medication should only be considered if other more empirically supported behavioral methods have not produced desired results (Sah et al., 2008) or in the presence of comorbid conditions where such medications are indicated.
Implications for Nurses Considering that nurses interact with children in multiple settings (e.g., school, primary care, hospitals, home visitations) and may be the professionals who spend the greatest amount of time with child patients, nurses may be the persons most equipped to recognize TTM. Care of patients who may present with TTM should be guided by a systematic process of assessment and intervention. Within this framework, it is of utmost importance to establish a calm and safe therapeutic environment in which nonjudgmental and empathetic discussion of symptoms can be maintained. Unless hair pulling is disclosed initially by the child or parents, all potential medical causes for hair loss should be ruled out by dermatological examination and laboratory work. Once it is determined that psychological causes are likely to blame for alopecia, a thorough assessment of symptoms, locations of pulling, presence or absence of premonitory urge, antecedents and consequences of pulling, and any impairment in social, emotional, or academic functioning obtained from multiple informants is critical. Any discrepancy between informants should not be viewed necessarily as errors but rather as potential hypotheses to be tested. For example, if a parent reports pulling but the child does not, it is possible that the pulling behavior is occurring outside of the child's awareness. A particular focus should be placed on events, situations, or emotional states that directly precede episodes of hair pulling, as these instances may provide clues for prevention and intervention. Since identifying “triggers” can be difficult with young children, children with poor insight, or children who pull outside of their awareness, the utilization of multiple informants and self-monitoring techniques is crucial. In addition, since family influences often play a strong role in the maintenance or elimination of TTM, nurses should pay careful attention to interactions among children, parents, and siblings to determine if family members are unwittingly accommodating, reinforcing, or modeling the hair pulling behavior. Lastly, it is important to screen for other possible psychological problems, as TTM can often be comorbid with other anxiety or mood disorders. Once a thorough assessment has been completed, nurses can also play a decisive role in treatment planning and implementation. If the behavior is infrequent, not disfiguring, or otherwise relatively benign, nurses may themselves educate the family regarding simple behavior modification
C.D. Labouliere, E.A. Storch strategies; alternatively, if the patient has a more complex presentation (e.g., extensive or disfiguring TTM; TTM that is severely interfering with social, emotional, or academic functioning; or TTM with comorbid psychological conditions), nurses may facilitate referrals to a primary care provider, psychiatric nursing professional, or a local child psychologist or psychiatrist trained in habit reversal and cognitive–behavioral techniques for more extensive assessment and intervention. Nurses who work in settings where TTM presents more frequently may wish to seek additional formal training in these methods to better serve their child patients.
Conclusion TTM adversely affects thousands of children, resulting in seriously negative physical and psychosocial consequences. These children and their parents may not be aware of the cause of their affliction or may feel helpless to change their pulling behavior. As pediatric nurses spend the greatest amount of time with their child patients, they may be one of the first persons able to identify TTM. It is therefore of the utmost importance for nurses to be aware of this condition, to recognize the physical evidence that suggests TTM, and to be able to provide appropriate psychoeducation and treatment information to families. Most parents and children will be relieved to hear that there is no physical problem and that the hair will eventually grow back normally with the implementation of minimally invasive behavioral treatments. As such, the pediatric nurse can be an advocate in ceasing the considerable morbidity associated with pediatric TTM.
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