A randomized controlled trial examining the efficacy of behavior therapy for pediatric trichotillomania was recently completed with 24 participants (ages 7 to 17). The broad age range raised a question about whether young children, older children, and adolescents would respond similarly to intervention. In particular, it is unclear whether the younger children have the cognitive capacity to understand concepts like “urges” and whether they are able to introspect enough to be able to benefit from awareness training, which is a key aspect of behavior therapy for trichotillomania. Check the end of this report for a link to download this open access article.
Background
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); [4,5]), which have been documented in patients as young as four [6].
Methods
Participants were recruited into a randomized controlled trial examining the efficacy of behavior therapy for pediatric TTM that was conducted at the University of Pennsylvania’s School of Medicine. Primary inclusion criteria for that study were: 1) ages 7 -17 inclusive; 2) diagnosis of TTM; 3) symptom duration of at least six months; and 4) participant and at least one parent fluent in English.
Participants were randomly assigned to receive either behavior therapy (N = 12) or minimal attention control (N = 12), which was included to control for repeated assessments and the passage of time. Primary outcome measures were the independent evaluator-rated NIMH-Trichotillomania Severity Scale, a semi-structured interview often used in trichotillomania treatment trials, and a post-treatment clinical global impression improvement rating (CGI-I). Behavior therapy was conducted in accordance with a manual developed in the context of a treatment development grant; this manual has now been published [7].
Results
The correlation between age and change in TTM symptoms (NIMH-TSS total score at week 0-8) for all 24 participants in the RCT was -.16, which was not significant statistically (p = .48) and not supportive of an expected association between age and change in TTM symptom severity over time regardless of treatment received.
In light of the small sample size, the mean symptom severity scores at weeks 0 and 8 for younger and older patients randomized to behavioral therapy were also plotted. Visual inspection of these data indicated that although the groups appeared to have started at similar levels of severity for children ≤ 9 years old vs. children ≥ 10 years old; the week 8 data show that the three younger children did at least as well as if not slightly better than the nine older children and adolescents.
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Conclusions
The purpose of the current report was to explore whether developmental factors influenced change in TTM symptoms in a pediatric sample randomly assigned to receive either behavior therapy or a comparison condition designed to control for the effects of time and repeated assessments. Findings indicated that there was a small, negative, and insignificant relationship between participants’ age and change in TTM symptoms over the course of the acute phase of the trial. Treatment outcomes for both groups who received behavioral therapy evidenced large effects sizes and a positive treatment response. Thus, behavior therapy for pediatric trichotillomania appears to be efficacious even in young children.
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Download/Citation/Material adapted from:
Martin Franklin, Aubrey Edson, & Jennifer Freeman (2010). Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome. Child and Adolescent Psychiatry and Mental Health, 4:18.
References
[1] Christenson GA, Pyle RL, Mitchell JE: Estimated lifetime prevalence of trichotillomania in college students. Journal of Clinical Psychiatry 1991 , 52:415-417.
[2] Tolin DF, Franklin ME, Diefenbach GJ, Anderson E, Meunier SA: Pediatric trichotillomania: Descriptive psychopathology and an open trial of cognitive-behavioral therapy. Cognitive Behaviour Therapy 2007 , 36:129-144.
[3] du Toit PL, van Kradenburg J, Niehaus DHJ, Stein DJ: Characteristics and phenomenology of hair-pulling: An exploration of subtypes. Comprehensive Psychiatry 2001 , 42:247-256.
[4] Bouwer C, Stein DJ: Trichobezoars in trichotillomania: Case report and literature overview. Psychosomatic Medicine 1998 , 60:658-660.
[5] Swedo SE, Leonard HL: Trichotillomania: An obsessive compulsive spectrum disorder? Psychiatric Clinics of North America 1992 , 15:777-790.
[6] Lanoue JL, Arkovitz MS: Trichobezoar in a four-year-old-girl. New England Journal of Medicine 2003 , 348(13):1242.
[7] Franklin ME, Tolin DF: Treating trichotillomania: Cognitive-behavioral therapy for hairpulling and related problems. New York, New York: Springer Science + Business Media; 2007.
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