You, Your Child, and Your Child’s PullingBy Fred Penzel, Ph.D.
Speaking to you as both a clinical psychologist and a parent of a child with special needs, I now realize how easy it is to sit back and give other people advice on how to be objective about their child's problems. However, since I have spent the last two years learning to accept my own little boy's difficulties, I believe I may have a few insights to share with you, about what you should learn to accept in order to get a handle on these things.
I could start by telling you to not become very disturbed by your child's hair-pulling, but I won't. I understand that when you see your child uncontrollably doing things that other children aren't doing, especially if it's something you've never seen before, feeling upset is a natural reaction and part of the protectiveness you feel towards them. Alter all, If your child's distress or dysfunction didn't bother you, what would motivate you to get help for them? As a psychologist, I have to stand back and observe. As a parent, I feel a sharp and unique kind of pain when faced with such things.
Feeling upset, and then admitting it, is the place you start from, even though it is an uncomfortable one. Fortunately, It Is something you can eventually move beyond. You do this by recognizing these feelings within yourself; and getting them out in the open by discussing them with others close to you. The goal Is to both accept these feelings as natural, and to accept that your child's problem really exists and is not simply going to vanish on its own. When I first began to tell people about my son, I found that I was unable to talk without feeling as though I would cry. So I talked and I cried. As time passes, I find that I can discuss it without as much pain, although there is still a place deep inside where some pain exists. I suppose that's what acceptance is.
At this point of acceptance, there is a step which you would be wise to avoid. Don't blame yourself or indulge in hours of soul-searching to find out what you did wrong. New studies suggest that TTM is a biologically-based problem and you did not cause it. In my own child's case, we were lucky with this issue, because the old psychoanalytic theories which put the blame squarely on the parents for disorders of my son's type were discredited a number of years ago. Even so, during more illogical moments, I find myself wondering now and then, and that kind of thinking is not helpful.
As a parent and also a psychologist, I suggest that you do not treat your child's hair-pulling as some sort of shameful or disgusting secret, which will put an everlasting blot on your family, and cause others to draw back in horror from you and your child. First of all, this is your beloved child we are talking about -- not someone to feel ashamed of or to have to constantly apologize for. This is how your child was given to you. Also, it could be essentially selfish in nature - worrying about what others will think of you because of your child's problem. You can't control what others think, anyway. My advice is to remind yourself that anyone who rejects you or your child because of their hair-pulling, is not necessarily someone whose opinion you ought to worry about anyway. I like to tell people that my son is my perfect child. Your child is a complete person in his or her own right, with all the strengths and weaknesses of other human beings not just a collection of hairs, eyebrows and eyelashes. To paraphrase Patricia Perkins-Doyle, President of the OC Foundation, "Your child is a person who also happens to have Trich."
Treatment issues bring up a whole new set of realities to accept. First you must accept that you will probably need to get treatment for you child. Trich is generally chronic. This means that, while your child can recover, they will not necessarily be "cured." It also means that they will probably need have to some therapy to help control their symptoms, and keep their hair pulling controlled throughout their lives, through maintenance. If you think that this means you should take your child to a professional, the answer is basically yes. Go where the help is. Again, if you worry more about what others may think, you are letting them run your life.
You will have to deal with the day of the "official diagnosis" by the professional. As a psychologist, I present diagnoses several times a week, but being on the receiving end is another story. It's exactly what you don't want to hear. If the problem has a name, it is suddenly real. When my son was first diagnosed, I was sure that all the professionals were wrong and I felt a lot of anger towards them -- I was still partly in denial. I thought, how dare they tell me my child has-a serious problem? Perhaps you will need to hear the same diagnosis from several different professionals, just as I did. In the end, I was surrounded, and had to surrender my demands that it not be so but I did accept it, if only grudgingly at the time.
Treatment for young people with Trichotillomania usually consists of; or includes, a good behavioral therapy program. Some people think that behavioral therapy is strict and cold and will not focus on their child's feelings or sensitivities. This could not be further from the truth. As a therapy, it cannot succeed without the therapist and your child having a warm and friendly relationship. My own child gets nearly eight hours of behavior therapy daily, goes off to it willingly, and is very affectionate towards his therapists. Speaking as a psychologist, I know that I value the regard my patients and I hold for each other. We not only do behavioral therapy, but we also spend a good part of every session focusing on the patient's life. And, by the way, we definitely do discuss feelings, contrary to the popular myth that says behavior therapists don't.
The type of behavioral therapy I personally favor is called Habit Reversal Training Plus (HRT+). This consists of two parts -- Habit Reversal Training (HRT), and Stimulus Control (SC). No treatment for Trich has been exhaustively researched, but HRT has been researched somewhat more than any of the others, and has given more positive results. I have been using HRT to treat Trich since 1982, and my personal observation is that it has worked well with both my adult and child patients. While I find it a good technique, TTM is a complex problem with many inputs, and requires a more comprehensive treatment -- hence the addition of SC, which rounds things out.
HRT, itself, is not an easy type of therapy. It takes a lot of time and effort, and is probably best suited for children older than ten. A good description of it was published a while back in “In Touch,” so I won't go into great detail here. Basically, patients are taught to relax themselves, breathe from the diaphragm, and perform a muscle tensing exercise with their hands and forearms whenever they get the urge to pull or touch their hair. It takes a short time to learn, but many weeks to master. Stubborn daily practice helps HRT to become as automatic as hair-pulling and eventually, it becomes a harmless substitute. The relaxation and breathing helps center the person and soothes the nervous system, in the place of the soothing effect TTM provides. The muscle tensing makes it impossible to pull at the same time. All together, the approach breaks up the pattern of behaviors that lead to pulling and provides a substitute. Beyond teaching your child this method, the therapist serves as a valuable coach and someone whose approval your child will hopefully work hard for.
For a much younger child, HRT may be too much work for no immediate results. It can be difficult to explain how it works or why it is important. It's probably better to give younger children a simpler exercise. I usually recommend giving the child something tactile like a Koosh ball, a foam ball, a small textured toy, or some Silly Putty to play with or squeeze when they feel like pulling. It may also be necessary to help motivate them to make this change by using rewards. In return for a day or a week without pulling (depending upon the child's age), the child could be allowed to choose from a list of small prizes or desirable activities or privileges that they have helped you put together. I have found this to work the best, although nothing works perfectly all the time.
As I have mentioned, HRT alone, is not enough to do the job, so we employ SC. This is a group of techniques that are used to help the child first identify, and then eliminate, avoid, or change particular activities, environmental factors, emotional states, or circumstances that trigger pulling. The goal is to then create new learned connections between the urge to pull and new, non-destructive behaviors. SC is extremely important and crucial to success in treating TTM. A daily diary of all pulling episodes is kept by the child (sometimes with parental help) and the information is brought in to each therapy session. This information is then used to work on the various triggers, to modify them.
Let's discuss motivation here. In the ideal world, all children would be 100% cooperative and get right to work. While it is true that many children really do want to stop pulling, it is important to recognize that Trichotillomania is a stubborn problem, and your child will be constantly "pulled" in two directions. On the one hand, they will want to stop the behavior that is bringing them unwanted attention and disturbing their lives. On the other hand, TTM can be extremely pleasurable and soothing to an overstimulated nervous system when stress is present, or it can provide stimulation when that same nervous system is stressed in a different way by boredom or inactivity. It can even be an aid to concentration while doing homework. It's portable and always available to the puller. Sometimes TTM doesn't even need a conscious awareness on the part of the puller for it to be performed. It just happens automatically, almost like breathing or blinking.
You also may not want to hear that not every child is motivated to stop pulling no matter how unsightly they may look. This is especially true of young children. Most young ones have not yet developed much social self-consciousness, nor have they yet felt any peer pressure to be like everyone else. It doesn't matter how much you want them to change -- if they aren't motivated, nothing will happen. Threats and punishment are definitely losing propositions and should be avoided at all costs. These negative approaches may actually have the reverse effect of making children pull more, since stress and pressure will drive them to more of the self-soothing that pulling provides. They may also drive your child to simply pull in secret. In addition, it may create a test of wills and make the child pull more out of defiance and anger at the way you are treating them. Your child didn't ask for this problem. Would you punish them for having diabetes?
You may just have to sadly accept that your child is not yet ready to stop pulling for whatever reason. They may say they are not ready, or communicate it by only making half-hearted attempts in therapy. You'll know that you have a better chance of success when your child says, "Mom and Dad, please, I need help." You can't want them to stop more than they do. It won't help. Look at it this way it's not fatal. It's unsightly and disturbing to watch, but there are much worse things that can happen to your child, believe me. If we lived in a society where everyone shaved their heads, it wouldn't even be a problem. Your child can still successfully change someday, if they choose to. They haven't stopped being your wonderful child just because some of their hair is missing and they definitely haven't lost their need for your love, respect and acceptance.
Remember not to nag or constantly check up on them. It is their job to change not yours. You can potentially turn a reasonably motivated child into an annoyed and unmotivated resister. It's never too early for them to start learning the skills they will need for the rest of their lives, but they do need to be ready. Try to believe in them and their own timing. My philosophy has always been that your child will rise to whatever level of expectation you place on them. Expect little and that's what you'll get.
It is irrational and illogical to demand that they stop when you say so. They don't have to want what you want. If you try and force them, everyone will just get upset. I too, would like to see my child behave just like the other children right now, but I have to wait patiently and take each day as it comes. We all want our children to be well, happy and accepted by others and would gladly suffer all of life's ills in their place, but we can't.
One other topic to mention here is medication as a form of treatment. I personally believe that each child should first be given a chance to work behaviorally before you consider the use of medication. There are a number of drugs that can help reduce the urge to pull. However, they are not always helpful, can have annoying side effects, and can sometimes stop working alter a few months for no reason. Many parents are very nervous about psychiatric medications and have visions of their children turning into stunted, drugged-out zombies. On the other hand, although medications are not perfect, they have come a long way from the powerful and sometimes misused drugs of the past. The newer antidepressants used to treat Trichotillomania are much better tolerated, extremely safe and often effective. My own child may one day need medication. I hope he won't but if it would help him find his place in life, I will accept it. I might be cautious of its use, but would not fear or reject it unreasonably.
If a child has clearly made a good effort at therapy, but still feels the urges too strongly, it is time to consider medication. Also some children may refuse the hard work of therapy altogether, but would take a pill or two daily without too much fuss. Be careful not to make the mistake of promising all kinds of success from the medication, or you'll set your child up to be disappointed. There is no "best" or perfect drug only one that works best for a particular individual. Your child may have to spend a few months on each of several drugs, one at a time, to find one that works. You and your child will have to be patient, as it can take drugs several weeks to even begin to work.
If you do find a drug that helps, be sure to get your child right back to working on their behavioral therapy. The medication may take away up to 60%-70% of the urge to pull, but the problem may continue at a lower level. Behavioral therapy can help with the remaining symptoms and your child will have more success fighting a reduced urge. Also, relying on medication alone is taking a chance on a complete relapse should they ever stop taking it. Therapy gives them another line of defense.
Finally, try to be a good consumer. Read up on your child's disorder, and learn about effective treatment. I still sometimes find it difficult to read about my son's disorder, especially if I run across something that doesn't sound very optimistic, but I do it for him. Good treatment for TTM isn't always easy to find, so if you can't find an experienced therapist, at least find one who is willing to learn and work with you. Avoid therapies that are all talk and no action. Your child will have many nice chats and still be missing their hair.
Overall, don't blame yourself or your child, be patient and don't get confused about whose responsibilities are whose. Remember, that it's your responsibility to provide the means to get well and be there with support if your child wants it. It is your child's responsibility to ultimately learn to help themselves if they so desire. Through it all, remember to love your child for the whole person they are.
If you would like to read more about what Dr. Penzel has to say about Trichotillomania, take a look at his self-help book "The Hair-Pulling Problem: A Complete Guide to Trichotillomania," (Oxford University Press, 2003). You can learn more about it at www.trichbook.com.
Fred Penzel, Ph.D. is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and O-C related problems, and is a founding member of the IOCDF Science Advisory Board. He can be reached at email@example.com or through the phone number on his website. Dr. Penzel is the author of “Obsessive-Compulsive Disorders: A Complete Guide To Getting Well And Staying Well,” a self-help book covering OCD and other O-C spectrum disorders.