It begins so gradually many parents don't even notice it. Your child's odd habit of playing with her hair and even pulling one out once in a while doesn't seem like a big deal. Then you notice she has a small bald spot that seems to be growing. Soon you realize that one bald spot has grown into many and you have entered the often confusing world of trichotillomania.
Trichotillomania (TTM) is currently classified as an impulse-control disorder, but that classification is under review because the disorder also resembles an obsessive-compulsive disorder, an addiction, a habit or a tic disorder. However you classify it, those who suffer from TTM only know that they can't help it.
Ashley Fraser from Columbus, Ohio, was only 8 years old when her parents took her to see her first therapist in an attempt to treat TTM, but the hair pulling had begun long before that day. "I was attending preschool and my teachers began noticing spots of missing hair on my head," says Fraser, now an adult. "They eventually had a conference with my parents to ask why they were 'cutting my hair so oddly.' My parents thought children in the preschool had done this to me. That was the first sign of my trichotillomania."
Knowledge about TTM as a psychological disorder was not widespread at the time Fraser's hair pulling became evident, and the psychologists were baffled. The condition worsened through puberty.
For Frazer, treating TTM as an addiction is the only thing that finally helped her recover from it. Abby Leora Rohrer is a former hair puller and author of the ebook, What's Wrong with Pulling My Hair Out? Breakthrough Secrets and Powerful Answers to End Your Trichotillomania Forever Without Medication, Willpower or Diets (Facilitated Recovery, 2004). Rohrer doesn't claim to be anything other than a recovered TTM sufferer who has, through trial and error, found techniques that help others. She considers TTM to be an addiction, a way for people to cope with toxic or uncomfortable feelings.
"Hair pulling doesn't hurt a compulsive hair puller," Rohrer says. "In fact, most report the behavior as soothing. Hair pullers pull out the hair from their scalp, eyelashes, eyebrows, pubic areas, legs, armpits and create noticeable bald patches. Some hair pullers eat the root [bulb] and even chew and swallow the hair. Some follow other habitual or ritual behaviors such as brushing hair against a cheek, for example. Many pull uncontrollably for hours each day."
Christina Pearson is the executive director of The Trichotillomania Learning Center in Santa Cruz, Calif. She says that at this moment there is no clear-cut answer as to why children develop TTM.
"There are several hypotheses floating around, but not enough empirical data to really answer this question scientifically," Pearson says. "That said, it does seem that the children who develop TTM are, for the most part, quite intelligent, hyper-sensitive to stimuli, easily emotionally overwhelmed and may develop the behavior to help 'regulate' internal states. Patterns of pulling widely vary, but there are some general times that are often triggers for pulling, such as being tired, watching TV, riding in car seats, waking up or going to sleep, etc."
Pearson says it seems as if there may be two types of trichotillomania. "Baby Trich" or "Toddler Trich" seems to be more benign, more self-regulating and diminishes over time. For children who develop pulling before the age of 5, many seem to simply develop out of the need to pull.
"When TTM starts around puberty or pre-puberty, the possibility of long-term chronic TTM is much higher, but again, not a definite," Pearson says.
As far as treatments for children go, Pearson says that cognitive behavioral therapy with a provider familiar with treatment is probably the most accepted form of treatment in the professional community. There are currently no medications that have been approved for TTM by the FDA. So if a doctor prescribes a medication, it is an "off label" use.
"In pharmaceutical studies, no medication has proven that effective for TTM as of yet, although some people do experience some benefit," Pearson says. "The problem is, often when there is initial benefit from a medication, the effect seems to wear off over time."
Various types of treatments for TTM include diet regulation, hypnosis, neurofeedback and psychotherapy. While none of the treatments works for everyone, many receive relief from such treatments.
"The good news is, behavioral strategies have been developed for children ranging from 1 to 2 years old, to older teens," Pearson says. "By contacting Trichotillomania Learning Center and requesting this information, you can either try it on your own with your child or work with a therapist. Most important is a practical, loving approach."
TTM is, in the vast majority of cases, not life threatening, unless there is hair ingestion, in which case a trichobezoar or "hair ball" can form, causing gastric blockage. Pearson stresses that if this is suspected, the child should be evaluated immediately. Though this is fairly rare, it must be considered as a possibly life-threatening problem if the child is ingesting large quantities of hair. Look for hair in the stools and vomit, problems keeping food down, constipation, etc., and if present, immediately take the child in.
"Normally, the biggest danger from TTM is not the loss of hair," Pearson says. "That will grow back; the child is not doing permanent damage. The biggest problem is the loss of self-esteem, feeling out of control, knowing others don't like what you are doing, and yet not being able to stop. So a loving, low-key approach is essential! And again, the good news is, with a good treatment approach, the prognosis is excellent."