Behavior: Ask the experts


Behavior questions and answers



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Q I recently saw a 10-year-old girl at an initial consultation for trichotillomania. Her habit apparently started six months ago. She was seen by a psychologist shortly after it began and was treated with behavioral modification therapy, but showed little improvement.

She has since pulled out all the hair on her head and is now pulling out whatever grows back. A trial of medications has been recommended. Her mother is concerned, however, because she has heard about medical problems arising from the medications.

The mother has searched the Internet and found possible organic pathologies that could cause her daughter's symptoms, including vitamin and amino acid deficiencies and thyroid imbalance. The girl's thyroid function was tested at the mother's request and was normal. The family history is negative for trichotillomania or other psychiatric disorders of this type, including obsessive-compulsive disorder and tics. The girl looks healthy otherwise and seems pleasant and well-adjusted in spite of her hair loss. What can I do for this child?

Clifford Yut, MD
The Woodlands, Tex.

A Trichotillomania is an underreported condition, and it is a difficult problem to treat. Some questions to consider when you interview a youngster with trichotillomania are: Is this child troubled by her hair loss? What is the secondary gain for her? Increased attention? And how motivated is she to master this habit?

Basic therapies include cognitive behavioral habit reversal therapy, medication (clomipramine), and hypnosis. Several small studies have compared cognitive therapy with medication. One study showed that behavioral interventions and hypnosis were more acceptable to patients than medication.1 Another study showed that behavioral therapy was superior to medication.2

In my experience, cognitive behavioral treatments can vary widely, depending on the training and experience of the therapist. I suggest that this family—given their concern about medication—seek out a second opinion from a cognitive behavioral specialist in their community. If cognitive behavioral therapy does not help, they could consider hypnosis—with medication as a last resort.

Leonard Rappaport, MD

DR. RAPPAPORT is associate chief, division of general pediatrics, Children's Hospital of Boston.


Q The mother of a 5-year-old girl in my practice has sought my advice because she says her daughter is "not kind to others." The girl is the third of four children. Her mother is bright and committed to her children; she gave up her career to stay home with them. She tells me her daughter is very different from the others. The mother says that the girl's nasty words and unpleasant behavior are aimed especially at her but can also include her siblings. Interestingly, the child's father does not seem to be a target. Her kindergarten teacher has noticed a bit of unpleasant behavior but says it has not been a real problem at school. The girl's behavior never involves physical aggression.

I have suggested that the mother spend a period of time each day alone with the little girl and that she try to point out to the child when she does rough things or says something rude or mean. I have also encouraged the mother to acknowledge her daughter's kind, gentle actions. The mother says this has not worked. If anything, it has made the girl even more unpleasant.

The girl has no obvious medical condition that might be making her feel unwell and takes no medication. What can I advise the mother?

Fayette Engstrom, MD
Easton, Md.

A A few focused questions are useful before recommending behavior management for the child and providing supportive counseling for the mother. You could ask: When did the behavioral concerns begin? Did any significant events or changes occur in the family or other areas of the child's life before the onset of the unpleasant behavior? How old was the girl when her younger sibling was born? What is her father's involvement with the children? Has there been any marital discord or other family stressors? And does this daughter remind the mother of anyone, even herself, or someone else in her family?

A description of the child's temperament and her behavior at school also may be revealing. The fact that her "nasty" behavior is directed toward her mother and siblings but is not a significant problem at school or with her father may provide an important clue to understanding this child's behavior. If she interacts with her classmates in a positive manner and is able to develop friendships, the specific focus of her behavior suggests she may need pediatric intervention.

Unkind words and actions may represent attention-seeking behavior in a home environment where she feels emotionally neglected. With three other children to care for, particularly if one is an infant or has special needs, the mother may not realize that her daughter's needs are not being met. If this is the case, one-on-one time with her daughter may be instrumental in modifying the child's behavior. This time should be a scheduled time and it should never be interrupted, even if the period is only 15 minutes every other day. During the allotted time, the child should be allowed to direct the play. The mother should not recall misbehavior or punish the child. She should ignore nastiness (unless physical harm is inflicted) and praise kind behavior.

Another possible cause of the child's behavior is that she is troubled by stressors at home or school and is more comfortable revealing her anger and frustration to those she trusts to love her unconditionally—her mother and siblings. If this situation is suspected, family meetings (perhaps an underused pediatric resource) can allow each member an opportunity to talk about personal concerns. The parents can model the way to express feelings properly without resorting to unkind words. When appropriate, the mother and siblings can discuss with the girl how her nasty comments and actions hurt them. If there is marital discord or a history of serious life stressors, individual or marriage counseling may be beneficial.

Finally, you might consider, "What are the normal tasks of psychosocial development for a 5-year-old girl?" This is the stage in gender identification when a young girl typically develops a stronger emotional connection with her father and decreases her previous close attachment to her mother. It is a time of emotional conflict for some children—especially if either parent is inattentive, emotionally unavailable, or depressed.

Parents often appreciate an explanation of this developmental stage by the pediatrician. Increased father-daughter time may be more effective than time with the mother right now. Another useful approach is to allow the child to be in charge of certain decisions (such as what clothes to wear to school, what cereal to buy, or what video to watch), which encourages initiative and promotes self-esteem.

Martin T. Stein, MD (with Eustratia Hubbard, MD)

DR. STEIN is professor of pediatrics at the University of California at San Diego School of Medicine.


1. Ninan PT, Rothbaum BO, Marsteller FA, et al: A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. J Clin Psychiatry 2000;61(1):47

2. Elliott AJ, Fuqua WR: Acceptability of treatments for trichotillomania: Effects of age and severity. Behav Modif 2002;26(3):378


Behavior: Ask the experts. Contemporary Pediatrics 2003;3:33.

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