Trichotillomania (TTM) is a chronic impulse-control disorder in which the individual pulls out one's hair to the point of alopecia. TTM is estimated to affect 1% - 3.5% of late adolescents and young adults [1
]; rates among younger children are largely unknown [2
]. Sufferers of TTM across the developmental spectrum may experience medical complications such as skin irritation, infections and repetitive use hand injuries [3
]; those who ingest the hairs after pulling are at risk for gastrointestinal complications stemming from trichobezoars (i.e., hairballs); [4
]), which have been documented in patients as young as four [6
]. Psychiatric comorbidity is apparently common, and includes anxiety disorders, mood disorders, substance use disorders, eating disorders [6
], and personality disorders in adults [8
] and anxiety and disruptive behavior disorders in youth [9
]. Notably, TTM onset in childhood or adolescence appears to be the norm, and TTM onset typically precedes that of most comorbidities [10
]. Accordingly, a major priority in TTM psychopathology and treatment research is to recruit younger samples since clinical trials have enrolled children with TTM as young as seven, so we know that they can participate, if not do well, with Habit and Reversal Training (HRT) [11
]. The goal of improving our understanding of TTM closer in time to its onset will perhaps, by extension, reduce future functional impairment and prevent the development of debilitating comorbid disorders.
Despite the fact that TTM is a pediatric onset disorder associated with significant morbidity, comorbidity, and functional impairment in adults [12
], very few TTM psychopathology research studies have actually included adolescents or children, and there are as yet no published randomized controlled trials (RCTs) of any psychopharmacological interventions for youth with TTM. Initial findings for cognitive-behavioral therapy were encouraging [13
], but questions pertaining to the role of developmental factors in TTM psychopathology and treatment response have yet to be examined. With respect to similarities and differences in TTM presentation across development, very little is known about symptom presentation in young children, but it appears that the scalp is the most common pulling site in both adults and older children and adolescents [7
]. Pulling tends to be both automatic (i.e., outside awareness) and focused (i.e., in response to identifiable affective triggers) within each individual, rather than exclusively one form or the other [16
] although it appears that there is a greater preponderance of automatic pulling in younger samples. The concept of urge plays an important role, as most participants in TTM studies to date have reported tension or some other unpleasant sensation that precedes pulling [12
]. Whether urges are present or can be reliably described by younger patients with TTM is unknown, although one study among youth and adults with tic disorders [18
] found that while adults were able to identify and verbalize both the premonitory urge to tic and the relief experienced after indulging that impulse, children under age 10 were unable to describe the premonitory urge reliably. Perhaps young children have not yet developed the expressiveness skills and emotional awareness [19
] required in behavior therapy for TTM, so it is unclear if young children would actually benefit from such treatments. Further, as Freeman et al.'s [19
] research demonstrated among young children with OCD, very young participants may lack the insight, motivation, and developmental capacity to follow a treatment protocol on their own, so the protocol may need to be altered to better suit these developmental needs and to set the treatment in the context of the family.
Following from Freeman et al.'s [19
] work, we wish to examine whether the developmental issues described above necessarily preclude the use of child-focused HRT in the treatment of young children with TTM. For the reasons outlined above, we believe that HRT designed for older children and adolescents with TTM will yield the same gains in treatment outcome when applied to young children. Further, given that there are no prior published randomized trials for any treatment for pediatric TTM and that there is a paucity of information available about TTM psychopathology and treatment outcome in younger children with TTM, data in the current report are being used solely for the purposes of hypothesis generation.