Pediatric Trichotillomania: Clinical Presentation, Treatment, and Implications for Nursing Professionals1

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Trichotillomania (TTM), or compulsive hair pulling, is a disorder that typically onsets in childhood. It is mistaken to believe that children will “age out” of this behavior, as pediatric TTM often has a chronic, debilitating course that does not remit without treatment, resulting in considerable psychological and physical impairment. Because most children with TTM will be seen initially by nursing professionals in the practices of dermatologists, pediatricians, gastroenterologists, and other disciplines, raising nurses' awareness of this disorder is of the utmost importance for accurate nursing diagnosis and assessment. As the health care providers who spend the greatest amount of time with patients, nurses' detection and diagnosis of TTM can make a critical difference in the initiation of early intervention. Therefore, the purpose of this article is to provide an overview of pediatric TTM, including its epidemiology, clinical presentation, and treatment options, from the perspective of nurses who may interact with such patients in their workplace.

Section snippets

Epidemiology

Pediatric TTM is estimated to have a point prevalence of approximately 0.5% (Hamdan-Allen, 1991) and a lifetime prevalence of 0.6%–3.4% in adults, most of whom began pulling as children (>85%; Bruce et al., 2005, Christenson et al., 1991). The disorder is up to seven times more common in children than in adults (Bruce et al., 2005, Dean et al., 1992, Hamdan-Allen, 1991, Tay et al., 2004) and typically has its age of onset either in preschool or in the preadolescent years (Christenson et al.,

Definition

TTM is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) of the American Psychiatric Association (2000) as an impulse control disorder, similar to kleptomania, pyromania, or compulsive skin picking. The DSM-IV-TR requires five criteria for the disorder to be diagnosed: (a) one intentionally and repetitively pulls out his or her hair, resulting in noticeable hair loss; (b) an increasing sense of tension occurs immediately before or

Clinical Presentation

TTM is characterized by the non-cosmetic, repetitive pulling of hair from any part of one's body, resulting in noticeable hair loss. Hair pulling behavior occurs along a continuum, ranging from a relatively benign form that produces no significant aesthetic or psychological distress to a more serious disorder that is often disfiguring and leads to great personal suffering. Hair is most commonly pulled from the crown, occipital, or parietal regions of the scalp (Papadopoulos et al., 2003) but

Psychosocial and Physical Complications

Regardless of the age of the child, TTM can result in considerable distress for both the child and the family. Youth with TTM can spend upwards of 30–60 minutes per day pulling hair and experience significant distress regarding their symptoms (Tolin et al., 2007). Children may feel ashamed, guilty, anxious, or depressed over their pulling behavior (Bruce et al., 2005). Bald spots may adversely affect body image, and concerns over appearance and perceived lack of willpower may lead to low

How to Recognize TTM in Your Patients

Because TTM is a problem of considerable morbidity in pediatric populations, it would be most beneficial for affected children if their difficulties could be identified soon after onset, before the condition becomes chronic and increasingly impairing. When a child admits to pulling or their parents have witnessed hair pulling behavior, it is relatively easy to diagnose TTM. However, because pulling can occur outside of a child's awareness or away from a parent's notice, how can nurses recognize

Treatment

Depending on the age of the child, several treatment options are available to combat TTM. Simple home remedies, such as placing band-aids on the child's fingers, socks over the child's hands, or a hat on the child's head, may reduce the behavior in some children. However, for those in whom the behavior is more entrenched, behavior modification programs implemented by a behavior therapist or psychologist show the most success (Sah et al., 2008). For very young children with mild TTM, behavior

Implications for Nurses

Considering that nurses interact with children in multiple settings (e.g., school, primary care, hospitals, home visitations) and may be the professionals who spend the greatest amount of time with child patients, nurses may be the persons most equipped to recognize TTM. Care of patients who may present with TTM should be guided by a systematic process of assessment and intervention. Within this framework, it is of utmost importance to establish a calm and safe therapeutic environment in which

Conclusion

TTM adversely affects thousands of children, resulting in seriously negative physical and psychosocial consequences. These children and their parents may not be aware of the cause of their affliction or may feel helpless to change their pulling behavior. As pediatric nurses spend the greatest amount of time with their child patients, they may be one of the first persons able to identify TTM. It is therefore of the utmost importance for nurses to be aware of this condition, to recognize the

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    No previous presentations or publications of this work exist. No extramural funding or commercial financial support aided in the preparation of this article.

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