TTM in young children

Credit Sue Price for Notes, TLC Conference Session

This was originally an email sent to me - notes from a TLC Conference. 

"Trichotillomania in Young Children" 
(presented at TLC Conference April 2002) 

**(If you don't already know what TLC is, it is the Trichotillomania
Learning Center - and the only Not-for Profit Association for
Trichotillomania. Their Website is www.trich.org 
They have encouraged me and others to post and distribute our notes from
the TLC Retreat sessions, in order to help as many people as possible!)
I recommend that you look through their site ... the Calendar section
lists events and Support Groups (who know they may be in your area). 

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Here are my notes from a talk at the TLC conference last month. The
formatting didn't transfer over so well. 

"Trichotillomania in Young Children" 
(presented at TLC Conferce April 2002)

Harry Wright, MD, MBA  
University of South Carolina 
______________________________________ 

**The first part of the talk was background on ttm: epidemiology,
prevalence, diagnosis and classification in the DSM-IV, co-morbid
disorders, ttm and the OCD spectrum. 

**Characteristics of Early and Later Onset Trichotillomania, from
Winchel, "Psychiatric Annuals" 1992. Early Onset is infant, toddler and
preschool; Later Onset is late childhood and adolescence. 

**Early Onset ttm tends to be mild and often self-limited; duration
several weeks to several months; frequency of males and females similar;
suggested association with increased developmental and family
psychopathology; usually responds to simple intervention. 

**Later Onset tends to be severe and chronic, duration of years to
decades; more frequent among females; apparent high lifetime incidence
of mood and anxiety disorders; often not responsive to intervention. 

**While later onset ttm is classified as an impulse control disorder,
childhood onset ttm has often been conceptualized as an anxiety
disorder. In fact it would be difficult to document DSM IV criteria B
and C for ttm in infants, toddlers and preschool children. (B and C are
the criteria about the increasing tension before pulling, and pleasure
or relief after pulling) 

**Dr. Wright found 19 cases in the literature of ttm in children 6 or
younger.   His report was on 20 children he has studied and treated at
USC. 

! 
Comparisons: 
! 
Age Range:                    
2.0- 6.0 from the literature;  
1.16 - 4.08 in his report 
! 
Average age of presentation:  
4.0 in the literature;                
2.63 in his report 
! 
Percent female:                
65% in the literature;        
80% in his report. 

! 
**He noted that even at this age when the incidence is the same between
the genders, you still see many more girls brought in for treatment.
With boys, parents often just shave his head. But with girls, parents
want them to have pretty hair, and thus are more likely to be distressed
and seek treatment for girls. 

! 
Summary of data on the young children he studied (N = 20) 
! 
Presenting Problems:
Hair Pulling             20     100%
Self Abuse*             11       55%   
*(includes head banging, scratching, picking) 

Speech Problem   10       50% 
Attacking Others     6       30%
Anxious                     6       30%
Temper Tantrums     5       25%
Sleep Problems       3       15%
Aggressive              4         20% 

!
! 
Pediatric Medical Diagnoses:
Ottitis Media            4       20%
Failure to Thrive       4       20%
Asthma                     4       20%
Seizure                     2       10% 

!
! 
DSM-IV Diagnoses (in addition to ttm):
Anxiety Disorders        10   50%
Selective Mutism          1       5% 
Reactive Attachment Disorder           3  15%
Communication/Language Disorders 7   35% Pervasive Developmental
Disorder   4   20% 
Mental Retardation       3     15% 
Pica                             2   10% 

Parent-Child Relational Problems  2  10% 

!
! 
**He had a slide summarizing characteristics of the 20 children in his
slide. Most were what has already been presented. In addition ... 
! 
Average age of presentation   31 months 
! 
Average age of onset            25 months 
! 
Family history mental illness*  60%
*(mostly depression and/or anxiety) 

! 
Treatment 
! 
**Numerous treatment approaches have been described for ttm including
psychodynamic, behavioral, psychopharmacologic. There are no reports of
specific interventions for early onset ttm. 

**The treatment approach for the 20 toddlers and preschoolers presented
in this report involved behavioral and family intervention focused on
decreasing the child's anxiety and the family's stress. He feels that is
the most effective treatment for that age. Pscyhopharmacologic
intervention was used for one child. 

! 
Conclusions 
! 
** ttm in young children maybe better classified as an anxiety disorder. 
! 
**DSM-IV criteria B and C are only endorsed by a minority of hair
pullers under age 12 years and rarely by those under 6 years. 
! 
**Even in this very young population referral to clinical setting for
hair pulling may be biased toward females. 
! 
** The age of onset of hair pulling may be bimodal with peaks between
1&3 years, and 8&13 years. The onset is frequently 1-3 years prior to
presentation for assessment and treatment. 
! 
** Young children pull almost exclusively from the scalp. 
! 
** Disruptive Behavior and Anxiety Disorders are common in young hair
pullers. 
! 
**Treatment should focus on decreasing child and family anxiety and
stress. 
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