Speaking to you as both a clinical psychologist and a parent who has raised 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 many years learning to accept my own son’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 son’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 found myself wondering now and then. That kind of thinking is sim[;y 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, past president of the International OCD 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 Comprehensive Behavioral Therapy (the ComB model). It seeks to do a very thorough behavioral analysis to identify all the potential inputs and triggers that stimulate and contribute to the behavior, and then find replacements for them, modify them, or eliminate them. The goal is to create new learned connections between the urge to pull and new, non-destructive behaviors. 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.
This is not an easy type of therapy. It takes a lot of time and effort, but can be adapted for children. A good description of it was published a while back in In Touch, so I won't go into great detail here. Stubborn daily practice helps ComB treatment to become as automatic as hair-pulling itself, and eventually, it becomes a new way of operating. 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, it can be difficult to explain how it works or why it is important. It's probably better to give younger children a grooup of simpler exercises. I usually recommend giving the child something tactile like a Koosh ball, a foam ball, small textured toys, 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.
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, wanted to see my child behave just like the other children, but I had to wait patiently and take each day as it came along. 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 deal with accompanying problems such as anxiety and depression, however, they generally don’t have a good track record when it comes to reducing the urge to pull. Even when used for these other problems, 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 are much better tolerated, extremely safe and often effective. My own son has been on one of these medications. It has really helped him find his place in life, and so I accept it. I might be cautious in the use of medication, but I would not fear or simply reject it unreasonably.
If a child has clearly made a good effort at therapy, but but has been hampered by anxiety or mood problems, it is time to consider medication. 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 keep your child working on their behavioral therapy. The medication may ease their other issues, but they may still continue at a lower level. Behavioral therapy can help with the BFRB 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, or simply involve play. Your child will have many nice chats and fun times 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