What is the best course of action for an 8-year-old child with a history of hair pulling (trichotillomania) and food aversion?

Management of an 8-Year-Old Child with Hair Pulling and Food Aversion

This child requires immediate evaluation to differentiate trichotillomania from body dysmorphic disorder (BDD), followed by comprehensive assessment for food aversion etiology, with first-line treatment being family-based cognitive behavioral therapy (specifically habit reversal training) for the hair pulling and systematic evaluation to distinguish food allergy from food intolerance or behavioral causes for the food aversion.

Critical Diagnostic Differentiation for Hair Pulling

The first priority is determining whether the hair pulling is driven by appearance concerns (BDD) versus non-appearance-related compulsions (trichotillomania):

• In trichotillomania, hair pulling is NOT driven by an attempt to improve appearance, whereas in BDD, hair pulling is specifically intended to improve appearance by removing facial/body hair or specific hairs viewed as unattractive 1
• Ask the child directly: "Why do you pull your hair?" If the answer relates to how the hair looks (too thick, wrong texture, ugly), consider BDD; if unrelated to appearance (tension relief, urges, habit), consider trichotillomania 1
• Trichotillomania typically presents with incomplete alopecia, hairs of variable length, and negative hair pull test along the edges of alopecia 2

Comprehensive Assessment for Hair Pulling

Clinical Examination

• Examine the scalp for patterns of hair loss, inflammation, desquamation, and scarring 2
• Perform dermoscopy to identify yellow dots (active disease), dystrophic hairs with fractured tips (exclamation mark hairs), which can help differentiate from alopecia areata 1
• Document the specific sites of hair pulling (scalp 75%, eyebrows 42%, eyelashes 53%) 2

Psychosocial Evaluation

• Screen for specific stressors: separation from attachment figures, hospitalization, birth of younger sibling, sibling rivalry, moving, school performance problems 2
• Assess for comorbid conditions: depression, anxiety disorders, OCD features (70% of youth with body-focused repetitive behaviors have psychiatric comorbidity) 1
• Evaluate for suicidality, as 11-44% of young people with BDD accessing clinical services have attempted suicide 1
• Obtain collateral information from parents about when/where pulling occurs (typically alone, in relaxed surroundings like bedroom or bathroom) 2

Rule Out Medical Causes

• Obtain mycological examination to exclude tinea capitis 2
• Consider skin biopsy if diagnosis uncertain (shows increased catagen/telogen hairs, pigment casts, empty anagen follicles, perifollicular hemorrhage) 2
• Laboratory tests: CBC, iron, ferritin, transferrin, selenium, zinc, vitamin B12, folic acid, thyroid function 2

Critical Complication Screening

• Ask specifically about trichophagia (hair ingestion), present in 5-30% of patients, which can lead to trichobezoar formation 2, 3
• If trichophagia is present, assess for pallor, nausea, vomiting, anorexia, and weight loss requiring radiologic examination and gastroscopy 2

Food Aversion Assessment

Distinguish Food Allergy from Food Intolerance and Behavioral Causes

Medical history is the foundation but cannot definitively diagnose food allergy alone 1:

• Document specific foods avoided, timing of reactions, and symptoms experienced 1
• Behavioral/mental disorders can cause food aversion including anorexia nervosa, bulimia, and anxiety disorders 1
• Food intolerance (lactose intolerance, gluten sensitivity) causes GI symptoms (bloating, pain, diarrhea) but is NOT allergic 1
• True food allergy involves IgE-mediated reactions with hives, impaired breathing, or eosinophilic GI disorders 1

Physical Examination Priorities

• Assess for signs of malnutrition, growth parameters (height, weight, BMI) 4
• Examine skin for atopic dermatitis (severe eczema in first 6 months increases risk of food allergy 4-fold) 1
• Check for signs of allergic conditions (asthma, allergic rhinitis) as part of the "allergic march" 1

Laboratory Evaluation if Food Allergy Suspected

• Specific IgE testing or skin prick testing for suspected food allergens 1
• Consider oral food challenge under medical supervision for definitive diagnosis 1
• Rule out eosinophilic GI disorders, parasitic infections, gastroesophageal reflux disease 1

Behavioral Assessment for Food Aversion

• Screen for anxiety disorders, OCD features (food-related obsessions/compulsions) 4
• Evaluate for eating disorder criteria: body image concerns, fear of weight gain, restrictive eating patterns 4
• Assess family dynamics and mealtime behaviors 1

Treatment Algorithm

For Trichotillomania (Non-Appearance-Related Hair Pulling)

First-line treatment is family-based cognitive behavioral therapy with habit reversal training (HRT) 5, 6:

• HRT components include awareness training (recognizing pulling urges), competing response training (alternative behaviors), and function-based interventions 5
• Children as young as 8 years can successfully use HRT strategies with strong parental involvement 5
• Treatment typically requires 8+ weekly sessions with significant improvement expected, though complete abstinence may not be achieved 5
• Adjunctive topical treatment: mild shampoo, hydrocortisone butyrate 0.1% solution, methionine supplementation 2

For BDD-Related Hair Pulling

If hair pulling is appearance-driven, treatment differs:

• Cognitive behavioral therapy targeting appearance preoccupations and repetitive behaviors 1
• Consider SSRI medication (though evidence is stronger in adults) 1
• Address comorbid depression and social anxiety which are common 1

For Food Aversion

Treatment depends on underlying cause:

• If food allergy confirmed: strict avoidance of allergen, emergency action plan with epinephrine auto-injector, nutritional counseling 1
• If food intolerance: dietary modification (lactose-free products, gluten-free diet), enzyme supplementation as appropriate 1
• If behavioral/anxiety-related: eating disorder-focused family-based treatment for adolescents, cognitive behavioral therapy addressing food-related fears 4
• If related to sensory issues or rigidity (common in autism spectrum disorder, present in 16% of BDD clinic patients): occupational therapy, gradual exposure, routine establishment 1

Common Pitfalls to Avoid

• Do not assume the child will "age out" of trichotillomania—pediatric TTM often has a chronic course requiring treatment 7
• Do not diagnose food allergy based on history alone—this leads to unnecessarily restrictive diets with adverse nutritional and social consequences 1
• Do not overlook trichophagia—failure to screen for hair ingestion can result in life-threatening trichobezoar complications 2, 3
• Do not miss BDD by assuming all hair pulling is trichotillomania—the treatment approaches differ significantly 1
• Do not delay psychological evaluation—both conditions often have underlying psychosocial stressors requiring family-based intervention 2, 5

Multidisciplinary Coordination

This child requires coordinated care involving:

• Dermatology for initial evaluation and topical management 2
• Child psychology/psychiatry for CBT and family-based therapy 5, 6
• Allergy/immunology if food allergy suspected 1
• Gastroenterology if trichophagia present or eosinophilic GI disorder suspected 1, 2
• Nutrition for dietary counseling regardless of food aversion etiology 1, 4