Preliminary Randomized Controlled Trial of Habit Reversal Training for Treatment of Hair Pulling in Youth

Abstract

Objectives:

This study evaluated the treatment efficacy of habit reversal training (HRT) relative to treatment as usual (TAU) for children and adolescents aged 7–17 years with a primary diagnosis of trichotillomania (TTM).

Method:

An initial assessment consisting of semistructured interviews and rating scales was conducted. Participants (N = 40, 85% female) meeting diagnostic criteria for TTM were randomized to either 8 weekly sessions of HRT by trained therapists or 8 weeks of TAU. One week after the final HRT session or final TAU week, patients completed a posttreatment assessment, followed by 1- and 3-month follow-up assessments. All assessments were conducted by a trained rater who was blinded to treatment condition.

Results:

The group by time analysis of variance yielded a significant interaction on the National Institute of Mental Health—Trichotillomania Severity Scale Total Score (F _1,38 = 16.47, p < 0.001, η ² _p = 0.30). The mean score decreased from 12.67 ± 4.60 at baseline to 5.62 ± 4.38 at posttreatment in the HRT group (t ₂₀ = 5.99, p < 0.001, d = 1.31), whereas the TAU group changed from 10.42 ± 4.35 to 9.32 ± 4.11 (t ₁₈ = 1.34, p = 0.20, d = 0.31). The Massachusetts General Hospital-Hair Pulling Scale Total Score decreased from 15.14 ± 3.86 at baseline to 7.14 ± 5.54 at posttreatment in the HRT group (t ₂₀ = 6.16, p < 0.001, d = 1.34); the TAU group changed from 14.16 ± 4.51 to 12.26 ± 4.34 (t ₁₈ = 1.50, p = 0.15, d = 0.34). On the Clinical Global Impressions-Improvement, 16/21 participants (76%) were rated as treatment responders in the HRT group versus 4/19 (21%) in the TAU group (χ ² = 12.13, p < 0.001, V = 0.55). At 1-month follow-up, 10–12 treatment responders who completed the assessment maintained improvement. At 3-month follow-up, six of eight maintained improvement.

Conclusions:

HRT can be an effective treatment for TTM in youth.

Introduction

Trichotillomania (TTM) is a disorder characterized by compulsive pulling out of one's own hair; it is associated with noticeable hair loss, distress, and impairment. Typically, hair pulling occurs in a ritualistic pattern, in which individuals often engage in prepulling rituals (feel or play with the hair, search for ones that do not look or feel right, etc.). In addition, many patients with TTM engage in compulsive behaviors after they pull each hair (e.g., biting the hair or root, tactile stimulation of lips or face with the hair, ingestion of hair). TTM is often chronic, with a lifetime prevalence of 0.6%–2.5% (Christenson et al. 1991; Duke et al. 2009). Notably, this prevalence rate may be an underestimate, due to the secretiveness associated with the disorder. Hair pulling symptoms typically have a childhood onset (Flessner et al. 2010) and are often accompanied by other psychiatric disorders (e.g., obsessive–compulsive disorder, attention-deficit/hyperactivity disorder) (Christenson 1995; Labouliere and Storch 2012).

TTM can cause significant interference in functioning (Woods et al. 2006a; Lewin et al. 2009; Panza et al. 2013; Walther et al. 2014). It runs a chronic course if the person does not have treatment (Schumer et al. 2015). Negative health outcomes include skin infections, irritation, bleeding, and eye infections. In cases of oral behaviors and ingestion of hair, individuals may experience dental erosion and/or gastrointestinal symptoms that include abdominal pain and nausea (Duke et al. 2010). Negative psychosocial outcomes include functional impairment, diminished quality of social life, avoidance of activities, academic/work impairment, difficulties with concentration, time spent in concealment, and low self-esteem (Diefenbach et al. 2005; Woods et al. 2006a).

Treatment of TTM has been challenging, as evidenced by the chronic nature of the disorder and the significant relapse rate (Cohen et al. 1995; Franklin et al. 2008). Treatment strategies have typically involved behavioral therapies (primarily habit reversal training; HRT) and medication, the latter being the most commonly prescribed treatment (Woods et al. 2006a). Meta-analytic investigations among randomized controlled trials have found a large treatment effect for behavior therapies that utilize HRT, with small to medium effects observed with serotonin reuptake inhibitor medications (Bloch et al. 2007; McGuire et al. 2014b). Thus, behavior therapy incorporating HRT seems to be the most effective treatment for TTM. Currently, HRT is commonly used to treat adults with TTM, as well as tics and other habit disorders such as nail biting and skin picking (Bate et al. 2011; McGuire et al. 2014a). The overall focus of HRT is to provide patients with tools to help manage and reduce hair pulling. The treatment begins with identifying and understanding the feelings and reasons associated with the subject's hair pulling, as well as common triggers. Later sessions involve replacing the hair pulling with a competing response such as clenched fists and clasped hands. An effective competing response, applied in a systematic and consistent way, helps to break habitual hair pulling behaviors and also allows for habituation to the urge. Social support provides reinforcement for application of the strategies, as well as encouragement and help (Woods 2001; Franklin and Tolin 2007).

In the first published trial examining HRT for TTM, 34 adults (10 males and 24 females) were randomly assigned to either HRT or negative practice (Azrin et al. 1980). Participants in the HRT group were twice as likely to reduce frequency of hair pulling, almost stop pulling, and stop pulling completely. Other studies have replicated the effectiveness of HRT for the treatment of TTM in individual (e.g., Rothbaum 1992; Ninan et al. 2000; van Minnen et al. 2003; Rogers et al. 2014) and group formats (Mouton and Stanley 1996). Furthermore, in a study of 25 women and 3 men, Woods et al. (2006b) showed that behavioral treatment that combined HRT with acceptance and commitment therapy (ACT) was significantly more effective than wait-list in improving hair pulling. Keuthen et al. (2012), in a randomized controlled trial of 31 females and 7 males, found that HRT enhanced with dialectical behavior therapy (DBT) was effective in the treatment of TTM. Moreover, the meta-analysis by McGuire et al. (2014b) found that HRT enhanced with DBT or ACT was better than HRT alone; however, enhanced HRT was confounded with greater number of sessions.

Despite the growing evidence for the effectiveness of HRT for treating adults with hair pulling, few controlled trials with children and adolescents have been published (Woods and Houghton 2015). Rapp et al. (1998), in a case series of three adolescents with chronic hair pulling, demonstrated the effectiveness of a simplified version of HRT. Tolin et al. (2007), in an open trial of 22 children who were a subset of a larger study, found that cognitive behavior therapy incorporating HRT was effective in improving hair pulling. In their sample, 77% were considered treatment responders and 64% maintained a positive treatment response after 6 months. A few studies have examined behavior therapy using differential reinforcement for the treatment of hair pulling in very young children. These include a case study (Rahman et al. 2009) and a case series (Park et al. 2012). In the only published randomized controlled trial with 24 children, Franklin et al. (2011) found that behavior therapy incorporating HRT was superior to minimal attention control in reducing the severity of hair pulling symptoms. Seventy-five percent of those receiving behavior therapy with HRT responded to treatment versus 0% of the control arm. Thus, while HRT has growing evidence as an efficacious treatment for adults with TTM, there has been minimal examination of it among youth with TTM. This is surprising as hair pulling symptoms typically develop in childhood and adolescence. Given the paucity of controlled studies and clear developmental differences between youth and adults, further investigation of HRT to reduce hair pulling severity among youth with TTM is warranted.

In this study, we examined the efficacy of HRT for TTM in a randomized controlled trial of children and adolescents. Given the background, our main hypothesis was that HRT would be an effective treatment for improving hair pulling in children and adolescents. Given that there is limited research regarding the long-term therapeutic benefit of HRT for youth with TTM, we examined whether treatment gains persist beyond 1 and/or 3 months. Finally, we briefly examined comorbid anxiety and depressive symptoms in the participants.

Method

Participants

Participants included 40 youth between the ages of 7 and 17 years (85% female), who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association 1994) criteria for a primary diagnosis of TTM. The target sample size was based on a power analysis indicating that N = 40 would be sufficient to identify a moderate or greater effect size (ES). In addition, given the difficulty in recruiting adolescents with TTM, this allowed us to complete the study in a reasonable amount of time. Exclusion criteria included the presence of bipolar or psychotic disorder, autism spectrum disorder, borderline intellectual functioning, or recent change (i.e., 8 weeks for antidepressant and 4 weeks for antipsychotic) in psychotropic medication (ascertained by clinician assessment, review of records, and caregiver report).

Measures

All clinician-administered measures were administered by a blinded, trained independent evaluator (IE) who was not involved in treatment or aware of randomization assignment. Although trained IEs can accurately rate outcomes regardless of awareness of condition in psychotherapy trials (Lewin et al., 2012), numerous precautions to prevent unblinding of the IE were taken. These included ensuring that the IE did not have any other study-related tasks, instructing all study personnel to not discuss the study in front of the IE, and using the back door of the clinic to escort participants to therapy rooms. We also took steps to monitor the integrity of ratings (i.e., training raters to criteria and ongoing supervision).

Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman and Albano 1996)

The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (ADIS-IV-C/P) are clinician-administered, structured interviews that were developed from DSM-IV diagnostic criteria. Diagnoses reflect endorsement of symptoms as well as a severity rating of at least 4 or higher, consistent with large clinical trials.

Massachusetts General Hospital Hair Pulling Scale (Keuthen et al. 1995)

The seven-item Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) assesses the number of hair pulling urges, the intensity of the urges, the ability of the patients to distract themselves from the urge to pull their hair, the number of hair pulling incidents, attempts to resist hair pulling, the ability to resist hair pulling, and feeling uncomfortable about hair pulling. Individual items are rated for severity from 0 (no symptoms) to 4 (extreme symptoms). The MGH-HPS is commonly used across studies and has strong psychometric properties (McGuire et al. 2012), and exhibited poor-to-good internal consistency between pretreatment and posttreatment assessments (α = 0.69–0.87).

National Institute of Mental Health—Trichotillomania Severity Scale (Swedo et al. 1989)

The National Institute of Mental Health—Trichotillomania Severity Scale (NIMH-TSS) is a clinician-administered semistructured interview to assess the severity of hair pulling behaviors over six questions. Responses on the items are summed to produce a total score that ranges from 0 (no symptoms) to 25 (severe symptoms). The NIMH-TSS has demonstrated excellent inter-rater reliability and good test–retest reliability (Franklin et al. 2011). In the current study, the internal consistency was fair at both pretreatment and posttreatment assessments (α = 0.71–0.73).

Clinical Global Improvement (Guy 1976)

The Clinical Global Improvement (CGI) is a seven-point rating of treatment response anchored by 1 (“very much improved) and 7 (“very much worse”). Youth being rated by the IE as 1 (“very much improved”) and 2 (“much improved”) are considered “treatment responders.”

Trichotillomania Diagnostic Interview (Rothbaum and Ninan 1994)

This is a clinician-administered semistructured interview to assess several aspects of the patient's hair pulling (i.e., building tension to pull, relief from pulling, hair loss, and resistance to impulses).

The Service Assessment for Children and Adolescents (Stiffman et al. 2000)

The Service Assessment for Children and Adolescents (SACA) assesses for services used for emotional issues. It inquires about 25 specific service settings grouped into three areas: inpatient, outpatient, and school based.

Children's Depression Inventory (Kovacs 1981)

The Children's Depression Inventory (CDI) is a 27-item self-report measure of cognitive, affective, and behavioral symptoms of depression for ages 7–17 years. It measures symptoms for the past 2 weeks and provides an overall score and scores for the following subscales: Negative Mood, Interpersonal Problems, Ineffectiveness, Anhedonia, and Negative Self-esteem. The CDI total score exhibited good internal consistency in the present sample (α = 0.81–0.89).

Multidimensional Anxiety Scale for Children (March et al. 1997)

The Multidimensional Anxiety Scale for Children (MASC) is a 39-item parent-report questionnaire that assesses anxiety severity. Items are rated on a four-point scale from 0 (never true) to 3 (often very true). Items are summed to produce a total score. The MASC total score exhibited excellent internal consistency in the present sample (α = 0.91–0.92).

Procedures

This study was approved by the relevant institutional review board. Informed written consent was obtained from parents or legal guardians, followed by written assent from the youth participant. All participants completed a screening assessment to establish initial study eligibility. A pretreatment assessment was completed 1 week after screening at which time the ADIS-IV-C/P and outcome measures were administered. Thereafter, patients were randomized in a 1:1 manner to HRT or treatment as usual (TAU). Those randomized into the HRT arm participated in eight 50-minute weekly HRT sessions. One week after the final HRT session, patients completed a posttreatment assessment. Patients randomized into the TAU arm had 8 weeks of usual care (see below for further detail) and completed a posttreatment session during the 9th week. Treatment responders were then asked to complete 1 and 3-month follow-up assessments.

Treatment

HRT condition

All subjects received 8 weekly therapy sessions lasting 50 minutes each based on the protocol outlined by Woods (2001). Each session included a discussion of goals, review of homework and past material, discussion of new information or tasks, therapist-assisted practice, and homework for the coming interval. The overall focus of treatment was to provide patients with tools to manage and reduce hair pulling. The treatment protocol consisted of (1) awareness training; (2) competing response training; and (3) social support. Other issues that were relevant to the participant (anxiety, depression, family issues, school issues, etc.) were addressed in sessions as appropriate as long as these issues remained secondary to TTM.

TAU condition

Participants randomized to the TAU condition were instructed to continue receiving their prior interventions as recommended by their providers (e.g., psychotherapy or pharmacological interventions). Treatment changes (e.g., medication increase, starting psychotherapy) were not prohibited and were monitored using the SACA. Thus, treatment continued as it would in standard practice. Following the 8-week interval, those randomized to TAU were offered HRT without cost.

Analytic plan

There were no missing data on the NIMH-TSS and MGH-HPS. Although one CDI and four MASC forms were incomplete at the posttreatment assessment, the remaining missing data were minimal on the CDI and MASC (<10%) and missing at random (Little's Missing Completely at Random test, p > 0.05). Missing data were addressed using expectation maximization, which utilizes a two-step iterative process based on the likelihood estimation of obtaining missing values (Peugh and Enders 2004). This approach provides accurate and efficient estimates for replacing missing data at the item level when <15% of item-level data are missing (Enders 2003, 2010). Descriptive statistics were used to characterize the sample. Chi-square (χ ²) and t-tests examined pretreatment group differences for categorical and continuous characteristics, respectively. Two-way repeated measure analysis of variance (ANOVA) compared differences in continuous TTM measures, with χ ² used to compare outcome on categorical measures (CGI-Improvement). The two treatment groups (HRT and TAU) and the two time points (pretreatment and posttreatment) were entered into the ANOVA to identify a significant interaction between treatment group and time, with significance levels reflecting the Greenhouse–Geisser correction for sphericity. The ES for continuous measures was calculated using Cohen's d, with Cramér's V used for categorical comparisons. Maintenance of treatment gains for HRT responders was reassessed at a 1- and 3-month follow-up assessment, using paired t-tests and χ ² tests for continuous and categorical comparisons, respectively. As youth who were assigned to the TAU group also received HRT, an open-trial analysis was conducted, in which outcome data were collapsed across treatment arms (21 HRT, 17 TAU). Paired samples t-tests were performed to compare pretreatment and posttreatment scores for all youth who received HRT (n = 38).

Results

Baseline characteristics

Participant characteristics are detailed in Table 1. Participants mostly had mild impairment (n = 26, 65%) on the NIMH-TSS, with minimal impairment (n = 7, 17.5%) and moderate/severe impairment (n = 7, 17.5%) also represented. There were no statistically significant differences between randomly assigned groups on demographic or clinical characteristics (p > 0.05, see Table 1).

Table 1.

Demographic and Clinical Characteristics for Participants Across and Within Groups at Baseline

Characteristics	Entire sample (N = 40) N (%)	HRT group (N = 21) N (%)	TAU group (N = 19) N (%)	χ²	ES
% Female	34 (85%)	18	16	0.02	0.02
White (non-Hispanic)	31 (78%)	15	16	0.94	0.15
Comorbid psychiatric disorders
Depressive disorders^a	7 (18%)	5	2	1.22	0.18
Anxiety disorders^b	23 (58%)	11	12	0.47	0.11
OCD	1 (3%)	1	0	0.93	0.15
ADHD	7 (18%)	3	4	0.32	0.09
ODD	4 (10%)	3	1	0.90	0.15
Current medication use
SSRI medications	8 (20%)	2	6	3.03	0.28
Psychostimulants	6 (15%)	3	3	0.02	0.02
Atomoxetine	3 (8%)	0	3	3.59	0.30
Alpha-2 agonist	3 (8%)	1	2	0.48	0.11
N-acetylcysteine medication	1 (3%)	0	1	1.13	0.17
Antipsychotic medication	1 (3%)	0	1	1.13	0.17

	Mean (SD)	Mean (SD)	Mean (SD)	t	ES
Age	11.85 (3.14)	11.76 (3.32)	11.95 (3.01)	−0.19	0.06
Age TTM onset	8.30 (3.73)	8.83 (3.72)	7.71 (3.76)	0.95	0.30
TTM severity
MGH-HPS	14.68 (4.16)	15.14 (3.86)	14.16 (4.51)	0.74	0.23
NIMH-TSS total score	11.60 (4.57)	12.67 (4.60)	10.42 (4.35)	0.58	0.50
Comorbid symptom severity
MASC total raw score	40.25 (17.76)	41.09 (19.73)	39.33 (15.77)	0.31	0.10
CDI total raw score	8.48 (5.86)	9.06 (6.64)	7.84 (4.96)	0.	0.21
Global severity
CGI-severity	2.95 (0.93)	2.95 (0.87)	2.95 (1.03)	0.02	0.00

Depressive disorders included major depressive disorder or dysthymia.

Anxiety disorders included generalized anxiety disorder, separation anxiety disorder, specific phobia, social phobia.

HRT, habit reversal training; TAU, treatment as usual; ES, effect size; TTM, trichotillomania; MGH-HPS, Massachusetts General Hospital Hair-pulling Scale; NIMH-TSS, National Institute of Mental Health—Trichotillomania Severity Scale; MASC, Multidimensional Anxiety Scale for Children; CDI, Children's Depression Inventory; CGI, Clinical Global Improvement; OCD, obsessive compulsive disorder; ADHD, attention-deficit/hyperactivity disorder; ODD, oppositional defiant disorder; SSRI, selective serotonin reuptake inhibitor; SD, standard deviation.

Acute treatment outcomes from randomized controlled trial

While youth in the HRT group received eight sessions of HRT, youth in the TAU group received the following interventions: medication management (n = 5, 26%), therapy (n = 4, 21%), other school interventions (i.e., 504 plan, group with guidance counselor, n = 3, 16%), school-based therapy (n = 1, 5%), and religious counseling (n = 1, 5%). Ten youth (52%) in the TAU group reported receiving no treatment during the course of the acute study.

Table 2 presents the results and ESs from the repeated measures ANOVA. The group by time ANOVA yielded a significant interaction on the NIMH-TSS Total Score, with a large difference between groups at the posttreatment assessment (d = 0.87). The HRT group exhibited a very large significant decrease on the NIMH-TSS Total Score from baseline to posttreatment (t ₂₀ = 5.99, p < 0.001, d = 1.31). Meanwhile, the TAU group exhibited only a moderate decrease on the NIMH-TSS Total Score from baseline to posttreatment (t ₁₈ = 1.34, p = 0.20, d = 0.31). Similarly, a significant interaction was also observed on the MGH-HPS Total Score, with a large difference between groups at the posttreatment assessment (d = 1.02). Specifically, the HRT group exhibited a very large significant decrease on the MGH-HPS Total Score from baseline to posttreatment (t ₂₀ = 6.16, p < 0.001, d = 1.34). Comparatively, the TAU group exhibited only a moderate decrease on the MGH-HPS Total Score from baseline to posttreatment (t ₁₈ = 1.50, p = 0.15, d = 0.34). Meanwhile on the CGI-Improvement, 16 of the 21 participants (76%) were rated as treatment responders in the HRT group compared to only 4 of the 19 participants (21%) in the TAU group (χ ² = 12.13, p < 0.001, V = 0.55). When examining co-occurring psychopathology, an ANOVA found no significant interaction for anxiety symptom severity, with minimal difference between groups at posttreatment (d = 0.39). Although the HRT group (t ₁₇ = 2.52, p < 0.02, d = 0.60) exhibited a moderate decrease in anxiety relative to the TAU group (t ₁₇ = −0.27, p = 0.79, d = 0.06), it was not statistically significant. Similarly, an ANOVA revealed no significant interaction for depression severity, with minimal difference between groups at posttreatment (d = 0.15). Neither the HRT group (t ₁₉ = 1.88, p = 0.08, d = 0.42) nor the TAU group (t ₁₇ = −0.43, p = 0.67, d = −0.10) exhibited significant changes in depressive symptoms over the course of treatment.

Table 2.

Acute Treatment Outcomes From the Randomized Controlled Trial Comparing Habit Reversal Training and Treatment-As-Usual

	Habit reversal training (N = 21)		Treatment-as-usual (N = 19)
Measure	Pretreatment Mean (SD)	Posttreatment Mean (SD)	Pretreatment Mean (SD)	Posttreatment Mean (SD)	F-test	p	η² _p
TTM symptom severity
NIMH-TSS total score	12.67 (4.60)	5.62 (4.38)	10.42 (4.35)	9.32 (4.11)	F _1,38 = 16.47	<0.001	0.30
MGH-HPS total score	15.14 (3.86)	7.14 (5.54)	14.16 (4.51)	12.26 (4.34)	F _1,38 = 11.29	<0.002	0.23
Co-occurring symptom severity
MASC raw total score^a	41.09 (19.73)	33.67 (18.58)	39.33 (15.77)	39.78 (19.07)	F _1,34 = 3.31	0.08	0.09
CDI raw total score^b	9.06 (6.64)	7.25 (7.43)	7.84 (4.96)	8.32 (6.73)	F _1,37 = 2.26	0.14	0.06

Missing posttreatment MASC scores from four youth.

Missing posttreatment CDI scores from one youth.

TTM, trichotillomania; NIMH-TSS, National Institute of Mental Health Trichotillomania Impairment Scale; MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; MASC, Multidimensional Anxiety Scale for Children; CDI, Child Depression Inventory; SD, standard deviation.

Durability of treatment gains at follow-up

Twelve of the sixteen acute treatment responders (75%) completed the 1-month follow-up assessment. At this assessment, 10 of the 12 youth continued to exhibit a treatment response (83%). Paired t-tests revealed that there was no significant change between posttreatment and 1-month follow-up on TTM symptom severity on the NIMH-TSS Total Score (t ₁₁ = 0.00, p = 1.00, d = 0.00) or the MGH-HPS Total Score (t ₁₁ = −1.48, p = 0.17, d = −0.43). Similarly, there was no significant change in anxiety (t ₇ = −0.88, p = 0.41, d = −0.31) or depressive symptom severity (t ₁₀ = −0.74, p = 0.48, d = 0.22). Meanwhile, only 8 of the acute 16 treatment responders (50%) completed the 3-month follow-up assessment. At this assessment, six of the eight youth continued to exhibit a positive treatment response (75%). Paired t-tests revealed that there was no significant change between posttreatment and 3-month follow-up on TTM symptom severity on the NIMH-TSS Total Score (t ₇ = −0.46, p = 0.67, d = −0.16) or the MGH-HPS Total Score (t ₇ = −1.05, p = 0.33, d = −0.37). Similarly, there was no significant change in anxiety (t ₆ = −0.53, p = 0.62, d = −0.20) or depressive symptom severity (t ₆ = −0.93, p = 0.39, d = 0.35).

Open trial examination

Table 3 presents the results from the open trial analyses of the 38 youth who received HRT. Youth exhibited large reductions in TTM symptom severity (d = 1.21–1.38), with more modest reductions in co-occurring anxiety and depression (d = 0.35 − 0.55). On the CGI-Improvement, 31 youth (82%) were considered to exhibit a treatment response to HRT.

Table 3.

Open Label Pretreatment and Posttreatment Scores for the Thirty-Eight Youth Who Received Habit Reversal Training

Measure	Pretreatment Mean (SD)	Posttreatment Mean (SD)	Paired T-test	p	ES
TTM symptom severity
NIMH-TSS total score	11.21 (4.60)	5.08 (3.74)	7.45	<0.001	1.21
MGH-HPS total score	13.84 (4.37)	6.92 (4.71)	8.49	<0.001	1.38
Co-occurring symptom severity
MASC raw total score^a	39.37 (19.22)	33.50 (17.14)	3.12	0.004	0.55
CDI raw total score^b	8.85 (7.16)	7.15 (6.24)	2.03	0.05	0.35

Missing posttreatment MASC scores from six youth.

Missing posttreatment CDI scores from five youth.

TTM, trichotillomania; NIMH-TIS, National Institute of Mental Health Trichotillomania Impairment Scale; MGH-HPS, Massachusetts General Hospital Hair Pulling Scale; MASC, Multidimensional Anxiety Scale for Children; CDI, Child Depression Inventory; SD, standard deviation.

Discussion

We report on the preliminary efficacy of HRT relative to TAU in children and adolescents with TTM. Consistent with Franklin et al. (2011), HRT was associated with significantly reduced TTM symptoms across both patient- and clinician-rated assays with large ESs relative to TAU. Overall, 76% of participants responded to treatment, which was superior to TAU and consistent with findings among adults with TTM (e.g., van Minnen et al. 2003; Woods et al. 2006b) and the limited available data among youth. When considering those youth who received HRT following TAU, the response rate increased to 82%. Responders to acute treatment maintained their gains over a 1-month interval. Although only a subsample of this group was available for the 3-month follow-up assessment, most (6/8) continued to maintain gains. However, that 25% failed to retain responder status suggests the need for ongoing booster sessions to support gains after acute treatment is concluded. This study is the second controlled study to support the efficacy of HRT among youth with TTM. Notably, treatment of pediatric TTM has posed a significant challenge with few established efficacious pharmacotherapy options (Bloch et al. 2007, 2013). Thus, these further data supporting HRT hold promise for addressing this impairing condition.

No differences in child-reported anxiety and depressive symptoms were found. This may reflect the focused nature of HRT on TTM symptoms while not addressing comorbid conditions that commonly present (Cohen et al. 1995; Woods et al. 2006a; Duke et al. 2010). In the presence of such comorbidities, clinicians would be well advised to consider incorporating other evidence-based interventions (e.g., cognitive-behavioral therapy for anxiety or depressive disorders). It is also worth noting that our sample did not exhibit particularly elevated anxiety and depressive symptoms, which has been found by others (Rozenman et al. 2016); thus, it may have been difficult to obtain further reductions in already low symptom states.

There are several study limitations to consider when interpreting results. First, an active, standardized control condition (e.g., supportive therapy, relaxation therapy, and pharmacotherapy) has advantages relative to TAU. Although a significant number of youth (48%) received some form of intervention during TAU, treatment was unstandardized and potentially not maximized nor evidence-based for many youth. A larger sample size may have allowed us to examine differences between three groups: the HRT group, TAU who were receiving some form of treatment, and TAU who were receiving no treatment (essentially a wait-list). This heterogeneity in the TAU group makes the statistical test we conducted a little less robust. Second, due to the modest sample size, we had adequate power to detect main effects but were not able to reliably examine treatment moderators or predictors (within the open trial) to understand factors that may be related to attenuated outcome. Third, although our sample had good external validity (e.g., presence of multiple comorbidities, modest racial/ethnic diversity), most participants were females, which is consistent with adult TTM trials (Bloch et al. 2007). Fourth, some differences that were not statistically significant in this sample (Table 1) may be significantly different in the population, something that a larger sample may be able detect. Fifth, the internal consistency reliabilities of some of the measures were lower than ideal. Finally, our follow-up interval was short and a significant number of youth were lost to assessment especially at the 3-month follow-up.

Collectively and considering these limitations, these data add meaningfully to a modest literature supporting the efficacy of HRT for TTM in children and adolescents. Given that this study, although preliminary in nature, was conducted by a research group independent from Franklin et al. (2007), HRT—when considered with adult TTM findings—may be considered a possibly efficacious intervention for youth TTM (Hollon et al. 2002). At this juncture, a large-scale study is needed to examine treatment outcomes relative to an active control condition to conclusively determine efficacy, as well as treatment mediators and moderators to identify factors that may contribute to better versus attenuated outcomes, as well as understand core intervention mechanisms. Should HRT continue to demonstrate efficacy, HRT dissemination efforts outside of specialty clinics will be needed.

Conclusions

HRT can be an effective form of treatment for hair pulling in youth. Three-quarters of the patients in this study responded to treatment. Data on the maintenance of treatment gains at 1 and 3 months poststudy are encouraging. However, the lack of identified effective alternate treatments for nonresponders continues to present a challenge. There is evidence that other types of therapies, such as ACT or DBT, may enhance the effectiveness of HRT among adults with TTM (Woods et al. 2006b; Keuthen et al. 2012; McGuire et al. 2014b), with further evaluation needed in youth.

Clinical Significance

We report results from the second preliminary randomized clinical trial evaluating the effectiveness of HRT for the treatment of pediatric TTM, a chronic and impairing condition with limited treatment options to date. This study provides evidence that a relatively short behavioral intervention can affect significant symptom change. Given that TTM runs a chronic course, there is some possibility that addressing hair pulling during childhood and adolescence may mitigate the course of the disorder.

Footnotes

Acknowledgments

We acknowledge the contributions of Cary Jordan, Amanda Collier, and Erika Crawford.

Disclosures

Dr. O.R. has received research support from Psyadon, Inc., Neurocrine Biosciences, and AstraZeneca PLC. He has received consulting fees from Bracket Global, LLC. All have been for unrelated projects. Dr. E.A.S. receives research support from NIH, Agency for Healthcare Research and Quality, International OCD Foundation, and All Children's Hospital Research Foundation. He has received royalties from Elsevier Publications, Springer Publications, American Psychological Association, Wiley, Inc., and Lawrence Erlbaum. He is a consultant for Prophase, Inc. and Rijuin Hospital, China. Dr. E.A.S. is on the Speaker's Bureau and Scientific Advisory Board for the International OCD Foundation. He receives research support from the All Children's Hospital Guild Endowed Chair. Dr. J.M. receives grant funding from the Tourette Association of America and National Institutes of Health. Dr. A.B.L. receives research support from All Children's Hospital Research Foundation, the Centers for Disease Control and Prevention, and the International OCD Foundation. He is on the speaker's bureau for the Tourette Association of America and the International OCD Foundation. He has received travel support from Tourette Association of America, American Psychological Association, Anxiety and Depression Association of America, NIMH, and Rogers Memorial Hospital. He has received consulting fees from Bracket and Prophase, Inc. He receives book royalties from Springer and has received honoraria from Oxford University Press, Children's Tumor Foundation, James Cook University, and the University of Central Oklahoma. Dr. A.B.L. is on the Scientific & Clinical Advisory Board for the International OCD Foundation and the Board of Directors for the Society for Clinical Child and Adolescent Psychology and the American Board of Clinical Child and Adolescent Psychology.

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