Trichotillomania Basics

A child with trichotillomania feels the urge to pull out hair from the scalp or other parts of the body. In this guide you will learn how trichotillomania is diagnosed and treated in children.

Trichotillomania: What Is It

Trichotillomania is a disorder characterized by the urge to pull out hair from the scalp or other parts of the body, including the eyelashes, brows, genitals, back, arms and legs. Children are more likely to pull hair out from the scalp. Some with the disorder say pulling hair makes them feel good, but not everyone with trichotillomania pulls out hair intentionally. Kids often pull unconsciously, and may not even remember doing so. Others develop rituals, removing hairs of certain textures or colors, or hair from specific locations, although this is less likely in children. Some people with trichotillomania also compulsively eat their hair after pulling it out.

Trichotillomania: What to Look For

Signs a child might have this disorder include rapid or asymmetrical hair loss, hair on the floor and pillows, and having hands constantly near the head. Wearing hats or other cover-ups and constantly checking mirror reflections may also be signs of the disorder. Some children describe feeling a release of tension after pulling out their hair, although those who pull unconsciously won’t experience this sensation. When asked, many children deny pulling out their hair (and, indeed, may really not remember ever doing it). Some kids with trichotillomania have rituals surrounding their hair pulling and may play with the hair afterwards, rolling or bending it, or putting it to their lips. Because severe hair pulling has an effect on a child’s appearance, it can be damaging to self-esteem and may interfere with social life and performance in school. Onset commonly occurs around 12 years of age, but it can appear in much younger children.

Trichotillomania: Risk Factors

Girls are more likely to have trichotillomania than boys. The disorder is more common in children who have OCD, and those whose first-degree relatives have OCD. Hair pulling may be done to alleviate discomfort or anxiety; it also tends to be a cyclical problem because hair often itches as it regrows, making children more likely to continue pulling their hair to avoid discomfort.

Trichotillomania: Diagnosis

Trichotillomania is diagnosed in children who have established a recurrent behavior of hair pulling that is causing them significant distress. To meet the criteria for the disorder they must have made repeated attempts to decrease or stop the behavior. Before receiving a diagnosis, children are often tested for scalp infections, alopecia, or spot baldness, and any other possible medical explanation. Trichotillomania is more difficult to diagnose in very young children.

There are two types of trichotillomania:

  • In automatic hair pulling, the individual may not even realize she is doing it until after the fact. For example, she could be zoning out watching TV, then look down and realize that the couch is full of hair she has pulled.
  • In focused hair pulling, the child is doing it very intentionally because it feels good. Often, focused hair pullers will wait until they are in private to engage in the behavior.

Trichotillomania: Treatment

Psychotherapeutic: Trichotillomania is treated primarily through behavioral therapy. Cognitive behavioral therapy (CBT), which helps children become more aware of their hair pulling, is very helpful. Through a form of CBT called habit reversal therapy, children are taught to recognize the emotions and triggers involved in their hair pulling. Sometimes something as simple as wearing loud, dangling bracelets can make kids more self-aware. When they feel the urge, they learn to substitute another motion or activity instead.

Some doctors recommend tricks that make hair pulling more difficult. For example, wearing bandages around the fingers and nails can make it harder to pull out hair, as does wearing hair pulled back or under a hat. For kids who enjoy the sensation of playing with the hair after it has been pulled, rolling a paper clip or playing with a textured pencil topper can help re-create the desired sensation and keep the hands distracted. Some kids in treatment carry kits around with bandages, paper clips, hair ties and other items that will help them.

For focused pulling in particular, the treatment includes the cognitive work of changing the way the person responds to negative emotions. Teaching them better coping skills for the distress, and helping them tolerate negative emotions without pulling, will help them achieve the goal of maintaining their hair.

Pharmacological: Medication is usually not the first choice in treating trichotillomania, although children may be prescribed antidepressants like SSRIs while they participate in behavioral therapy.