Toddler and Pre-School Hair Pulling
- Ruth Golomb, M.Ed., LPC
- © Trichotillomania Learning Center, Inc. 2008. All Rights Reserved
EDITORS NOTE: This article is based on a transcription of a presentation Ms. Golomb did at TLC's 2004 National Conference in Houston, TX.
Intervention is possible! The treatment that I use is a variation of the treatment used in our office at the Behavior Therapy Center of Greater Washington. It is also a modification of the book that Sherrie Vavrichek and I wrote called "The Hair Pulling 'Habit' and You: How to Solve the Trichotillomania Puzzle," which has the outline for treatment of children from 9-17. I have altered that approach for very young children.
The first thing we will need to do is to identify behaviors surrounding and including the pulling. In other words, when and where is the child likely to be when engaging in hair pulling? And, what is the child doing when pulling his or her hair? Is the child fixing the hair, pulling hair, pulling hair out and looking at it, pulling the hair out and eating it, pulling the hair out and thumb-sucking, wrapping it around the thumb--what are the stages of pulling? Generally speaking, with small children I rely upon the parents for this information, as small children are not accurate reporters.
The second issue to be addressed is to understand when the behavior is likely to happen. In other words, which environments and which activities are likely to elicit hair pulling. Typically, hair pulling is likely to occur in the bedroom, the car, and at daycare. The activities are often sedentary, such as, listening to a story, lying in bed, or sitting in a car. Again, the parents are important information gatherers.
The third thing we need to do is to develop strategies to use in order to provide sensory input (or a sensory substitute) to be used when the child would otherwise be pulling his/her hair. Often, small children that pull their hair will be thumb-sucking simultaneously or using a pacifier while pulling hair. It's not always this way, but very common. Exploring the texture of their hair or their parents' hair is a very common developmental stage. Most children will go through a period where they will be rubbing their heads or playing with their hair or playing with their parents' hair.
We don't know why some children move to hair pulling and others don't. This is an area for research and currently we just don't know the answer. Interestingly, just because a child is rubbing and playing with his/her hair in excess does not necessarily mean anything diagnostically. It is a normal developmental stage to become fascinated with hair, and various textures. However, we do find that most children that will engage in the hair pulling behavior do tend to do it at somewhat predictable times. I will go through some cases with you and illustrate this further. A lot of times kids will pull their hair when they are getting tired, when they are getting fussy, when they are trying to go to sleep, and sometimes when they are waking up in the morning. It does seem to coincide with times when they would need to be soothed. So the hair pulling seems to provide them with some soothing. So we might think of it as a sensory stimulation or a self-stimulation behavior.
The last area to be considered is to develop a reward system. This helps to create motivation. Children pull their hair because it feels good to them. In order to ask them to stop, there must be something offered that is immediately appealing for them as well as motivating. The reward system is based on rewarding REPLACEMENT behaviors, or as mentioned earlier, sensory substitutes, sensory distractions, and using things that block the ability to pull.
It is really important to try not to say simply "Don't pull" as this is not effective with a very young child. What will be most helpful is to find some appropriate strategies to provide alternate sensory stimulation. But again, with really small children we need to be sensitive to their abilities at this very young age. For a small toddler we don't want to use strategies that can easily go in the mouth. So you need to be very creative.
Some creative ideas include a toy rattle that has interesting texture, a doll with hair, a toy pony with a mane can all be used as sensory strategies. A teething ring, nibbling on raw spaghetti and, depending on the age and stage of your child, gum, lollipops, and chewy fruit candies can be used as oral sensory substitutes. One child I worked with got a little toy kitten that had fur that felt real and she just loved petting that kitten! I recently heard about using a vibrating toothbrush to provide great oral sensory stimulation. A ball that can be squeezed can be used as a distraction. There are all these wonderful blankets out now that have soft interesting textures that can used as well.
Of course you must think ahead and use these strategies strategically. A lollipop in bed, for example, is never a good idea. Use it as a strategy to provide an oral stimulation during an activity where the child would otherwise likely be engaged in pulling hair, thumb sucking, and or eating of the hair.
With very young children what works best is to identify strategies that block the ability to pull, because parents cannot always be present to identify when the child is in a trigger situation and potentially pulling. I often suggest using little gloves with little kids. Character or cartoon band-aids placed over their thumbs work out really well to block the ability to pull, and kids usually love them! For older kids, I encourage using something called rubber fingertips. Clerical workers use them and they have some texture on the outside. Slightly older kids (4-6 year-olds) love these fingertips because they feel good and they are kind of "cool-looking" to them. Finding a variety of things that allow the child to block the ability to pull is important.
The next step is to develop a plan that includes a reward system. It is truly possible to work with small children and encourage them to do what you are asking of them, but they must experience an immediate reward for this to be successful. Developing a good reward system, however, can be tricky. Often reward systems do not work because they were set up ineffectively. Rewards seem easy and straightforward, but they are far from it! It is very important for little children to be rewarded immediately following performing the behavior that you've asked them to do. Small rewards that can be given "on the spot" work best, such as stickers.
Other parents I have worked with have gone to the dollar store or party store and picked up little trinkets that you might get at birthday parties in a goody bag. You can get a few of these and put them in a bag and the child can have a little grab-bag toy as a reward. Remember, toddlers cannot go all day in order to get a reward.
What needs to be done is to identify the times when the child is likely to pull, for example while watching a video. A plan for the child could be to wear "TV. gloves," play with a squishy ball, and possibly even use a baby brush to brush her own hair while watching the video. If after 10 minutes the child is still wearing the gloves and playing with the other items, she will get a sticker or a grab-bag toy or it may make sense to give a reward at the end of the video. However, if the child takes her gloves off after 15 minutes, then a reward after 30 minutes is too long.
The other aspect that's really crucial for success is that the plan must be revised often. Little children are very clever, and they will frequently foil your efforts to establish a working system. If you have a small child that pulls his/her hair, it's important that you commit yourselves to coming in to therapy on a regular basis. I would be hopeful that it would be on a short-term basis, but you should have a regularly scheduled appointment time. Unfortunately, in a one-shot consultation you are going to get an overall idea, and you can even develop a plan. But you won't have an opportunity to revise that plan with the assistance of a therapist, and changes can be very tricky. The following shows two cases that will help illustrate what I've been talking about.
Case One: Sally
One person I worked with recently was a little girl I am going to call Sally. She was one year and 11 months old when her parents came to see me. The parents had actually seen another therapist approximately 3 months prior to seeing me. They had seen the therapist twice in the hopes that they would get enough pointers to help the child stop pulling. They were not able to really utilize fully the ideas that the prior therapist had given them. We first talked about the idea of coming in regularly and being open to revising the plan and making sure they were prepared for that from the beginning. I wanted to be clear with them that it was important to commit from the very beginning, which they agreed to do.
Sally had been pulling her hair and creating small bald patches for the past few months. She also ate the hair. She would take fuzz out of the carpet and eat it. She was using a pacifier at the time and would always rub the hair around the pacifier or rub the pacifier on the floor to pick up the fuzz and then put it in her mouth. So the pacifier was a tool that she was using in order to gain hair, or sometimes carpet fuzz, to eat. When the parents came to see me, they had been trying deal with this behavior by telling Sally "No, don't do that!" and trying to do it sternly. What they quickly discovered was that this approach really didn't work for them. As you may well know, saying "no" to your very young child of 2, 3, or 4, or sternly saying, "Don't do that," is often not going to work, so I needed to help the parents develop a different method of helping their child to stop pulling her hair.
The first thing that I suggested to the parents was for them to take the child to the doctor just to make sure that her bowels were okay and that the stomach was not hurting. Any time that a child is ingesting a whole hair you just want to make sure they are physically healthy. (Hair can collect in the intestines and cause a blockage.) The next thing that I asked the parents to do was to observe the child's behavior and determine when she was pulling. The parents were already largely aware of the pulling behaviors, but it is important to gather information for a period of time. They spent one week observing the pulling and determined the child was pulling her hair prior to naptime, at naptime, prior to bedtime, at bedtime, and in the morning as she was waking up. She would also pull her hair when she was listening to a story, watching a video, and riding in the car. The environments were typically the home, pre-school, and the car.
So we developed a plan for Sally. (I say "we" because treatment is an important collaboration between the parents and, in this case, me.) We decided that she was going to wear bedtime gloves. The parents found little tiny Easter gloves, fancy little gloves for girls. The parents made a big deal about them, about how wonderful the new gloves were going to be, and the child loved it. She had these fancy little gloves that the parents clearly associated with bedtime and referred to them as Sally's "bedtime gloves." Putting on the gloves became her special nighttime activity. The other activity that was added to the nighttime routine was to have the mom brush or comb Sally's hair more often, generally when Sally was listening to her bedtime story. The mom would brush her hair and then hand the brush to Sally and encourage her to brush her own hair. They left a brush in the crib so Sally could brush her hair at night. They also had special toys in a little basket that she could only use when she was watching TV. She also wore cute little band-aids on her thumbs at the same time.
Then we talked about the rewards. The parents settled on stickers, grab-bag trinkets, and huge lollipops for watching TV. Not only were lollipops a little reward for having done reasonably well during the day, but were also used as a sensory substitute. While she was watching a video she could suck on a lollipop while she had her band-aids on and her toys in her hand.
Every morning when Sally left her room, the parents looked for strands of hair in the crib. If they did not see strands of hair they would say "Ah, that's great! You are using your strategies, you wore your nighttime gloves and you did a great job!" And they would give the child a grab-bag toy.
We found out after a week that Sally loved these strategies but wasn't really able to stop pulling because she was still using the pacifier (wrapping the hair around it and sucking the hairy pacifier). So we decided at that time to eliminate the pacifier. The mom made up an elaborate story about giving the pacifier to the "pacifier fairy." After they gave the pacifier to the pacifier fairy Sally stopped most of her hair pulling. However, it was hard for Sally to settle down when trying to go to sleep because she was so used to the pacifier. So the parents cut holes in the gloves to allow thumb sucking. This did not work because Sally was able to pull her hair and wrap it around her thumb. She wasn't getting any rewards in the morning, but was getting rewards during the day. Clearly parts of the plan were not working.
I had the parents buy new gloves and eliminated all the sucking, both pacifier and thumb- sucking. The mom would come in the morning to check the crib, and there was no hair. Sally, who was a little more verbal than the average two-year-old at that stage, was able to say "No hair! OK!" And then she was ready for her grab-bag toy. This worked very well for about a month. After they committed themselves to the idea that Sally was not going to have a pacifier or a thumb to suck, it took about a week, and she was able to fall asleep and have no trouble. But the parents committed themselves to being miserable for a few nights. So we talked about other ways of soothing--patting on the back, making sure that she had other toys, other things to play with, encouraging her to do other things.
The second glitch came up when the family went on vacation and soon discovered that they forgot the gloves, the grab-bag toys, basically all of the strategies that they were working on at home. Lo and behold, the child started pulling when they were on vacation. We talked about how important it was to plan ahead and pack those things in the bag first so as to make sure to remember those important strategies. And when they came back they had to re-establish their routine. This worked very well.
The third glitch arose when family friends came to visit. The family was pretty structured and routine-oriented, but they really made a conscious decision not to be too rigid when they had their friends come over. Well, Sally got over-tired, out of sorts, completely out of her routine and started pulling again. We talked about what happened and how to moderate her routine and schedule when friends and family come in town, during holidays, and when they go on vacation.
Another important event was when a new brother joined the family. Things went really well for the first couple of months because that's an exciting time. People are coming in and giving big sister presents; Sally's getting a lot of attention. Then after a few months reality sets in-that baby's not going away, and there aren't many people coming to visit and giving her presents. She hung in there for a while, but baby brother also developed acid reflux, was a cranky, uncomfortable baby, and didn't sleep well. Mom and Dad got exhausted and the big sister got tired of the baby crying all the time and getting all of the attention, so she began to pull her hair again.
We developed a nighttime routine for the baby and mom that worked very well. Then we talked about not reinforcing Sally when she would get up in the middle of the night and discussed developing a new routine for her. She loves stories, pictures, and anything visual. So the parents made a huge chart for her with pictures-pictures of somebody reading a story, and pictures of putting gloves on (before listening to the story) -all of the strategies that had been previously used successfully. The chart was made with Velcro so that after every little activity was done for the evening routine the child could move a little Velcro piece from one side of the chart to the other. Bath is done; move the piece. Gloves are on; move the piece and so on. The child LOVED the chart and that provided new structure for her; the parents committed again to working the baby's schedule so that mealtime, naps and bedtime would not be disruptive to the family.
I've been in touch with this family several times over the past twelve months. Sally has been pull-free for about eighteen months. With a young family there are still some disruptions. The mom went back to work after maternity leave; vacations, holidays, and daycare changes came up and Sally has handled all of this very well and has moved through being pull-free. The parents check in with me periodically and keep me updated.
Case Two: Abby
This next patient is a slightly older child whose situation will illustrate some complexities that come up. This child-I'm going to call her Abby-is a six-year-old who is in first grade. She is the middle of three children, with an older sister of nine and a younger nine-month-old sister. Abby sucks her thumb and pulls her hair. She pulls while she's falling asleep, watching TV, riding in the car, during transitions, and sometimes at school. She also sometimes pulls when she is upset and crying. Abby also has tics: a shoulder roll and a tic where she brushes her hair away from her face. Again, I asked the parents to identify the behaviors with Abby's pulling, to the best of their ability. But in this case, I was also able to talk to Abby and ask her about her behaviors.
Abby was pretty articulate and able to discuss her hair-pulling behaviors. Her mom would fill in whatever was left out. We determined the environments and activities where Abby was likely to pull. We also found that Abby was unaware of some of her pulling. Therefore we developed a treatment plan that addressed the pulling that we could be aware of and decided, due to the uncertainty about other times when she might be pulling, to play it safe and have her wear band-aids on her thumbs all day. Wearing the band-aids blocked the ability to pull during the day as well as raise her awareness about her pulling. At night she would wear gloves. In addition to that, I encouraged the parents to buy a lot of different sensory toys that they could work with. She got some Koosh balls and a stretchy doll and silly putty. In addition, since Abby really likes to write, I suggested that she keep what we called a journal. We had her keep a pretty little book that she could write in every day about her use of strategies-for example, what worked for her and what didn't work. For a six-year-old, this boils down to writing "good," or putting a smiley face in. For some kids, this is an important feature of self-monitoring and independence.
The parents then instituted a reward system. She would get rewards for putting the band- aids on in the morning, wearing them at school and coming home with them on her thumbs. She'd also get a reward for putting the gloves on at night and waking up with the gloves still on. We quickly discovered that coming home from school with band-aids on was a problem. At lunchtime she would wash her hands and the band-aids would fall off. We adjusted by sending a box of band-aids to school with the teacher. The teacher developed a plan with Abby so that Abby was able to retrieve band-aids when she needed them. In addition, Abby put extra band-aids in her little pencil case in her folder and would get a "reward" point for putting band-aids on before she went to school and another point or a little reward for having the band-aids on when she came home from school.
Abby was reporting 100% success with everything but you could see with casual observation that there was still significant hair loss and not a lot of regrowth. Her mom told me, "Abby's lying to us."
I hear this a lot from parents and I think it's extremely important to identify this phenomenon correctly. Most kids who have trich-young kids and older kids-are really good children. They don't like having this behavior and they don't like disappointing their parents. They also don't like feeling like they're bad kids. Abby started feeling badly about herself when she was reporting that she had pulled. So she stopped reporting it. In her mind this solved the problem! However, what then began to happen was the mom did not trust Abby's self reports and accused her of lying. Now, for Abby, this didn't feel very good either, but she had been reporting success and did not want to admit to anything less.
This frequently happens at certain stages in therapy with children. It was time to talk with the mom alone. I asked the mom to take a step back and look at the function of the "lying." As we talked, the mom began to understand that Abby was intending to present a very positive picture of herself in order to maintain a good feeling about who she is. In order to do this, she didn't want to say anything negative about herself. I suggested an approach that was initially challenging for the mom, but she was willing to try it. The system was to reward Abby for telling the truth no matter what. So if Abby came and told her that she pulled her hair, Abby got a little reward for telling the truth. Mom would say "I know this is really hard for you so I'm very proud that were able to tell me."
Now of course what happened is that Abby started to report pulling a bit more often. Mom became disturbed because she thought "Oh my gosh, now we're increasing the hair-pulling!" But it only happened for a couple of days. Abby didn't really want to pull her hair, but needed an avenue to be able to talk to her parents about her struggles and feel good about herself. We were then able to increase the use of the strategies as well increase mom's involvement in reminding Abby to wear band-aids and gloves. At that point, the behavior subsided very quickly and Abby stopped pulling completely.
Structuring the appointments from the very beginning of treatment will greatly assist a positive outcome. Abby's parents wanted to come in once a month and see how this would work. Rather than struggle with the schedule, I allowed them to try this, but suggested that if it does not work, we would have to commit to regular meetings that would be closer together. They tried monthly appointments for two months and quickly realized it didn't work very well. They'd come in one week and start the program. It worked really well for about a week and then the second week it would begin to fall apart. By the third week things were not working so well. And during the fourth week the family had forgotten what they were supposed to be doing. Due to a busy after-school schedule, we settled on them coming in every two weeks. Abby really liked coming in. She was able to talk to me about what she was doing. I also became her advocate and was able to talk to her mom on Abby's behalf. Coming to therapy was a very positive experience for her and that helped everybody.
They came in every other week for about six months. During this period of time Abby stopped pulling her hair. As mentioned earlier, we had a lot kinks to work out with the treatment, but that's what therapy is for!
There is a lot of hope with treating pre-school and toddler hair pulling! The kids respond very well to early intervention and it can be a very positive experience for the whole family. It's important to remember a few key points, however. First, become aware of all of the pulling behaviors. Devise interventions that are age-appropriate and fit the ability and temperament of the child and the family. Be flexible!! Change the approach, strategies, or even the focus of the treatment as needed. And most important, try to relax. Kids pick up on their parents' discomfort. Being a parent is a very challenging, demanding role in the best of circumstances. Being a parent of a child who is hair pulling is even more challenging. If you are having difficulty balancing things, you are not alone! However, if you are anxious, depressed, or tremendously stressed, it is very important for you to get more support. It is crucial for you to take care of yourself FIRST. Treatment can be fascinating, engaging, and a wonderful learning opportunity. You and your child can learn about his/her temperament, sensory needs, and strategies that really work so that hair pulling is not a part of your future!
Ruth Goldfinger Golomb, LCPC, is a senior clinician, supervisor, and co-director of the doctoral training program at the Behavior Therapy Center of Greater Washington, where she has worked since the mid 1980's. Ms. Golomb specializes in treatment of anxiety disorders in children and adults. She has conducted numerous workshops and seminars, and participated as an expert in panel discussions covering many topics including Tourette Syndrome, Obsessive Compulsive Disorder, Trichotillomania, and managing anxiety disorders in the classroom. In addition to publishing articles for professional journals and newsletters, Ms Golomb is co-author of "The Hair Pulling 'Habit' and You: How to Solve the Trichotillomania Puzzle" a book describing the comprehensive treatment of trichotillomania in children and "Stay Out of My Hair," a book aimed to help parents of children with trichotillomania. Ms. Golomb is member of the Science Advisory Board for The Trichotillomania Learning Center.
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