Current treatment practices for children and adults with trichotillomania: consensus among experts

Available online at www.sciencedirect.com Cognitive and Behavioral Practice 17 (2010) 290–300 Current Treatment Practices for Children and Adults With Trichotillomania: Christopher A. Flessner, Bradley/Hasbro Child Research Center/Warren Alpert School of Medicine at Brown University Fred Penzel, Western Suffolk Psychological Services, Huntington, NY Trichotillomania Learning Center–Scientific Advisory Board Nancy J. Keuthen, Massachusetts General Hospital/Harvard Medical School Very little is known regarding the efficacy of pharmacological and psychosocial treatments for children and adults with trichotillomania(TTM). Given this dearth of information, the present investigation sought to examine the treatment practices of members of thenationally recognized Trichotillomania Learning Center–Scientific Advisory Board (TLC-SAB) and practitioners known by members ofthe TLC-SAB to possess extensive experience working with this population. The responses of 67 practitioners to an Internet-based surveywere examined. Our results clearly indicate that cognitive-behavioral treatment (CBT) is the treatment of choice for both children andadults with TTM. In particular, several components of CBT (i.e., awareness training, self-monitoring, competing response training,habit reversal training, and stimulus control) are implemented most often. Selective serotonin reuptake inhibitors (SSRIs, e.g.,citalopram, fluoxetine) and serotonin-norepinepherine reuptake inhibitors (SNRIs, e.g., venlafaxine, duloxetine) were prescribed mostfrequently; however, these results are preliminary given our small sample of prescribing practitioners (n = 11). Taken together, thesefindings are a critical starting point to advancing the understanding of efficacious interventions for the treatment of individuals withTTM. Clinical and research implications, future areas of research, and study limitations are discussed.
TRICHOTILLOMANIA (TTM) is characterized by the ),fluoxetine recurrent pulling out of one's hair resulting in noticeable hair loss and is presently classified as an Impulse Control Disorder in the DSM-IV-TR findings have been mixed regarding efficacy and a recent estimates for TTM range from 0.6% to 3.4%, and the meta-analysis suggested that only clomipramine has demonstrated efficacy greater than placebo ( (hereafter referred to as children), prevalence is less Research examining the efficacy of CBT is slightly more encouraging. In general, CBT for TTM has ) and the gender distribution more balanced ( historically incorporated a variety of techniques, includ- ing awareness training, self-monitoring, aversion, cogni- Treatment options for adults with TTM are limited.
tive strategies, covert sensitization, relaxation training, Generally, results of most pharmacological and cognitive- habit reversal training (HRT), social support, stimulus behavior therapy (CBT) or behavior therapy (BT) control, and more recently, acceptance-based strategies [hereafter referred to as CBT] treatment studies have been hindered by a myriad of methodological limitations, ). Recent adult TTM research suggests that CBT is including small sample sizes, lack of patient randomiza- tion to treatment conditions, and/or reliance on self- report measures. A variety of pharmacological agents pill placebo (Ninan et al.), and supportive have been examined, including clomipramine ). Few studies have sought to compare the efficacy ofvarious components of CBT; however, past research hassuggested that HRT, a package treatment combining competing response training with several techniques 2010 Association for Behavioral and Cognitive Therapies.
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noted above (e.g., awareness training, self-monitoring), is more effective than at least one other form of behavior general knowledge items from a survey about TTM (e.g., therapy (i.e., massed negative practice; diagnostic criteria, gender differences, whether TTM is a subtype of obsessive-compulsive disorder, etc.). Perhaps due to this general lack of knowledge, 72% of providers HRT was superior to pharmacotherapy with clomipra- thought that pharmacological agents were an effective mine. Preliminary research suggests that components of treatment for TTM, whereas only 54% thought CBT was the HRT package (i.e., awareness training, competing an effective treatment option. Given the paucity of response training, social support, stimulus control) and treatment outcome research in this area, current treat- Acceptance and Commitment Therapy (ACT) may be ment practices of those with expertise in TTM may be an useful elements in the treatment of adults with TTM appropriate starting point for working with both children among those who utilize CBT, it is important to identify A small but growing body of research has examined what practitioners identify as the most important compo- what general practitioners know or believe about the nent(s) to CBT (e.g., HRT, individual elements to HRT treatment of a variety of psychiatric conditions including such as self-monitoring, stimulus control, relaxation training, etc.). This information can be used along with available data from both scientists and practitioners to enhance or modify existing approaches to treatment or develop new treatments. Alternatively, this evidence may no study to date has examined the treatment choices of provide avenues for further research (e.g., dismantling clinicians and clinical researchers with known expertise in studies) to identify those specific components to CBT that the field of TTM treatment. Given the paucity of existing are most important in providing efficacious and effective research, understanding what TTM experts endorse as effective treatment in combination with, or in lieu of, To date, no pharmacological studies have been existing empirical evidence may accelerate the treatment conducted among children with TTM. In contrast, development process and better help those afflicted with however, there is some limited evidence from single Consequently, we sought to examine treatment open-label CBT trial with 22 child pullers ( choices among members of the Trichotillomania Learn- ing Center–Scientific Advisory Board (TLC-SAB), as well suggesting that children may benefit from CBT. In the as clinicians known by members of the TLC-SAB to latter study, 77% and 66% of children were classified as possess expertise in the treatment of children and/or treatment responders at posttreatment and 6-month adults with TTM. Given the myriad of existing CBT follow-up, respectively. However, methodological limita- techniques and different pharmacological agents, we tions (e.g., lack of a control group, absence of an sought to examine which specific components of CBT independent evaluator) highlight the need for caution and, in a preliminary analysis, types of medications, in interpreting these results. It would be useful at this experts view as the treatment(s) of choice.
juncture to obtain a better understanding of the treatment strategies currently being used to help children(and their families) afflicted with this disorder. Inquiry regarding the approaches employed by those with Sixty-seven respondents to an Internet-based survey expertise in treating TTM provides an appropriate were recruited via a link to the TLC's homepage ( starting point for informing the development of more TLC is a nonprofit organization dedicated to efficacious treatments for children with TTM.
providing information, support, and treatment resources Clearly, knowledge is limited regarding the best to TTM sufferers. Potential respondents (clinicians and treatments for children and adults with TTM. However, clinical researchers) were selected upon the basis of their available evidence suggests that CBT currently has the known expertise within the field of TTM treatment.
greatest degree of empirical support for efficacy in the Expertise was defined as either being a member of the treatment of both children and adults with this disorder.
SAB of the TLC, or someone selected by a member of the Unfortunately, however, general practitioners, pediatri- TLC-SAB, who in their opinion would be considered to cians, psychiatrists, psychologists, and other providers are have expertise in the treatment of TTM. The TLC-SAB is composed of psychologists, psychiatrists, professional counselors, geneticists, and animal behaviorists with In fact, Marcks and colleagues found that general knowledge of TTM and, in most cases, contributions to practitioners were able to accurately answer only 61% of the field of TTM treatment. Practitioners with TTM expertise were nominated at an annual SAB meeting and used most frequently (e.g., HRT as a combined treatment via the SAB mailer. Surveys were not sent to individuals if package or individual treatment components such as there was dissension among SAB members regarding competing response training, stimulus control, relaxation their level of expertise. Due to the nature of the study, training, etc.), assessment strategies (e.g., whether the institutional review board approval was not obtained.
practitioner conducted a comprehensive behavioral assess- Participants ranged in age from 28 to 77 years ment), modes of treatment (e.g., individual, group, etc.) (M = 47.5, SD = 10.6). Our response rate for questionnaire and treatment schedules (e.g., weekly, bi-weekly, etc.). It completion was 89.3% (67 respondents/75 surveys sent).
also assessed variability in treatment practices employed as Upon inspection, no duplicate surveys (e.g., surveys a function of TTM severity. Those practitioners authorized containing identical information on all items) were to prescribe medication were asked questions regarding found. We are unable to quantify how many TLC-SAB classes of medications (e.g., SSRIs, SNRIs, etc.), specific members were survey respondents given the anonymous medications (e.g., fluoxetine, naltrexone, clomipramine, nature of this survey. At the time this survey was etc.), and schedules of treatment maintenance for patients developed, there were 18 members of the TLC-SAB; thus, at least 49 survey respondents were not TLC-SABmembers. The majority of respondents endorsed CBT as their theoretical orientation (n = 49, 73.1%). This finding The CPS was linked to the TLC website for a 3-month was not totally unexpected given the predominant CBT period from March to June, 2008. E-mails directing orientation of TLC-SAB members and the likelihood that respondents to the survey link were sent from the TLC colleagues endorsed as TTM experts would share a similar to practitioners on its contact list. Prior to completing the orientation. Respondents reported practicing in a range CPS, respondents were informed of the project's purpose of settings including group private practice (n = 18, (e.g., to better understand the treatment standards of 26.9%), solo private practice (n = 17, 25.4%), medical clinicians and clinical researchers in the field of TTM).
center (n = 17, 25.4%), university setting (n = 12, 17.9%), The entire survey took approximately 30 minutes to and “other” (e.g., community mental health center; n = 3; complete. The CPS was developed and data were 4.5%). The majority of respondents (n = 60, 89.6%) collected and stored using surveymonkey.com.1 The first reported directly treating a minimum of 50 clients with author subsequently downloaded these data into a format TTM. Sixty-one percent of respondents (n = 41) reported suitable for analysis using the Statistical Package for the a Ph.D. as their highest degree received, followed by M.D.
Social Sciences, version 16.0 (SPSS-16.0).
(n = 11, 16.4%), Psy.D. (n = 7, 10.4%), and “other” (e.g.,Ed.D., M.A., M.Ed., M.S., or M.S.W.; provides descriptive data regarding respon- dents' preferences for different treatment modalities The CPS was developed by the second author (FP) among children and adults with TTM. Of those respond- based on a review of the available literature regarding ing, CBT was overwhelmingly ranked as the treatment of “current practice” surveys. The Expert Consensus Panel choice for adults and children, respectively. The compo- nents of CBT the respondents used most frequently for utilized as a model for development of our survey. This treatment of TTM (in descending order) were awareness previous landmark survey had collected responses from training, self-monitoring, competing response training, 69 international experts in the field of OCD treatment HRT, and stimulus control, regardless of client age. In the selected by the National Institute of Mental Health. It case of children with TTM, reward systems were also covered a domain of 10 different guidelines relating to frequently employed. Of those respondents endorsing both psychological and pharmacological treatments for HRT, self-monitoring, awareness training, competing OCD, and was the first such survey in that particular field.
response training, and stimulus control procedures were It, in turn, had been based upon the Rand Method that most frequently noted. Other components sometimes was developed as a means of synthesizing expert opinions ascribed to HRT (e.g., relaxation training, social support) and using them to rate the appropriateness of medical Seventy-six percent (n = 51) of respondents indicated that The CPS is a 55-item questionnaire designed to examine they routinely conducted a comprehensive assessment of a variety of domains relevant to the treatment of individuals triggers and consequences associated with pulling prior (both children and adults) with TTM. Domains assessed viathe CPS include treatment modality of choice (e.g., CBT, 1 Surveymonkey.com is an internet-based company designed to aid ACT, psychopharmacology, etc.), components of CBT researchers in development and storage of web-based surveys.
Table 1Treatment Modality and Treatment Component(s) of Choice for Treatment of Children and Adults with TTM Please rate your preference for treatment components you would employ in the treatment of an adult/child with TTM in the range of moderate severity. Rank answers 1 (highest) to 9 (lowest). Choose “N/A” if you would NOT employ this method in any case.
Please rank the following components of CBT in the order you most frequently employ for the treatment of adult/child patients with moderately severe TTM. Rank answer 1 (highest) to 9 (lowest). Choose “N/A” if you would NOT employ this method in any case.
If you, yourself, employ habit reversal training (HRT) as a treatment technique, which components do you routinely include? (check as many as apply).
Motivation (inconvenience review) Display of improvement (seeking out situations previously avoided) Note. Samples for each treatment component vary because responses of “N/A” were coded as missing values. In addition, respondents wereasked to skip items pertaining to populations (e.g., adults, children) that they did not treat.
to treatment. Of those responding “yes” to this item, all for the treatment of children and adults with TTM.
or nearly all respondents reported that this included Results suggested that individual therapy was ranked as assessing internal/external triggers associated with pull- the most frequently employed treatment format for both ing (100%, n = 51), activities/situations avoided due to adults (M = 1.19, SD = 0.67) and children (M = 1.27, pulling (100%, n = 51), whether they pulled while alone SD = 0.65), although individual plus concurrent family or around others (100%, n = 51), selection of particular therapy was also a popular treatment format for children hairs to pull (98.0%, n = 50), what they do with their hair (M = 2.06, SD = 1.23). Results indicated that 11 to 15 after they pull (98.0%, n = 50), use of implements to pull sessions was the most frequently employed number of (96.1%, n = 49), awareness of pulling (96.1%, n = 49), and sessions for both children and adults with TTM. Similarly, shame associated with pulling (94.1%, n = 48).
weekly, in-office sessions with homework were ranked the provides descriptive data regarding style, highest regarding frequency of sessions for treatment of number, and frequency of sessions most often employed Table 2Style, Number, and Frequency of Sessions Employed for the Treatment of Children and Adults with TTM Please rate, in terms of effectiveness, treatment formats you employ for providing CBT to an average adult/child patient with TTM. Rank answers from 1 (highest) to 5 (lowest). Choose “N/A” if you would not employ this method in any case.
Please rate EACH of the following selections in terms of reasonableness of the number of CBT sessions typically required to treat the average uncomplicated adult/child TTM patient. Rank answer from 1 (highest) to 6 (lowest).
Please rate the therapeutic effectiveness of EACH of the following treatment schedules for an initial trial of CBT in an average adult/child patient with TTM in the range of moderate severity. Ranks answers from 1 (highest) to 8 (lowest) Weekly Office therapy sessions with homework for patient to her own/her own Every other week office sessions with homework for patient to her own/her own Self-help book plus weekly telephone follow-up only to assign and monitor Self-help book plus every other week telephone follow-up to assign and Self-help website plus weekly telephone follow-up only to assign and Self-help website plus every other week telephone follow-up to assign Referral for Pharmacological Treatment as a Function cable to all survey respondents) and (b) pharmacological interventions used most often for the treatment of TTM Respondents were asked how many weeks they would (applicable only to those respondents able to prescribe allow of poor or no response to CBT alone prior to referring medication). Results clearly suggest that SSRIs were the an adult or child with TTM for medication. Respondents most commonly employed medication. Within this class of indicated that for patients with mild to moderate TTM, they medications, citalopram and fluoxetine (both ranked would wait before medication referral a median of 10 (for highest), escitalopram, and sertraline were used frequently adults) and 12 (for children) weeks with poor response to and ranked highly by most experts. In descending order, CBT and 8 weeks (for both adult and child) with no antipsychotics, SNRIs, and opiate blockers2 were also response to CBT. Similarly, respondents indicated that they frequently employed more often than other classes of would wait before medication referral a median of 10 weeks medications. Of note, tricyclic antidepressants (e.g., with poor response to CBT and 7 weeks with no response toCBT for both adults and children with moderate to severeTTM. provides data regarding the method oftreatment experts would be most likely to try first to treat 2 The CPS was developed with the expectation that tricyclic varying degrees of TTM severity. Again, CBT was the antidepressants would be considered one of the primary pharmacolo-gical treatments of choice for TTM alongside SSRIs, antipsychotics, and SNRIs. Consequently, in an attempt to minimize burden to respondents, provides descriptive data regarding (a) reasons follow-up questions were only developed for tricyclic antidpressants to refer patients for pharmacological intervention (appli- rather than opiate blockers (which were ranked higher).
Table 3Most Appropriate Method(s) for Initiating Treatment Among Children and Adults of Varying Degrees of Severity with TTM For ADULTS with mild to moderate TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone Combined CBT and medication begun together For ADULTS with moderate to severe TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone Combined CBT and medication begun together For PREPUBESCENT CHILDREN with mild to moderate TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating Combined CBT and medication begun together For PREPUBESCENT CHILDREN with moderate to severe TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating Combined CBT and medication begun together For ADOLESCENTS with mild to moderate TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone Combined CBT and medication begun together For ADOLESCENTS with moderate to severe TTM, please rank from 1 (highest) to 5 (lowest) the most appropriate method to use for initiating treatment.
CBT alone Combined CBT and medication begun together Note. Respondents were asked to skip items pertaining to populations (e.g., adults, prebuscent children, adolescents) that they did not treat.
clomipramine) were not ranked within the top half of would complete a median of two trials of different medications prescribed. However, within this class, clomi- medications from the same class before recommending pramine was clearly the medication of choice.
a trial of medication from a different class. In addition, Respondents indicated that 4 and 12 weeks were the results suggested that 12 weeks was the median duration median lower and upper limits for the period of time of time for an adequate trial of the respondent's initial practitioners would allow before increasing the dosage for choice of medication (administered at the highest an “average” patient with TTM experiencing little or no dosage) before the respondent would change medication response to treatment. Respondents indicated that they or suggest adding an augmenting drug. Antipsychotics Table 4Approaches to the Pharmacological Treatment of Adults and Children with TTM Please rate EACH of the following (from 1-7) in terms of the order of importance as a reason to refer a patient with TTM for psychopharmacological treatment. Choose “N/A” if you would NOT employ this method in any case. ⁎⁎ A high level of family, work, or environmental stress Assume you have decided that a medication trial is indicated. Please rate your preference for EACH of the following medication classes to use as a single-drug approach (monotherapy) for treatment of TTM. Choose “N/A” if you would NOT employ this method in any case. ⁎⁎ Antihypertensive (e.g., guanfacine, Clonidine) Mood stabilizers (e.g., lithium, anticonvulsants) Norepinephrine-Dopamine Reuptake Inhibitors(e.g, .Buproprion) Other medication (e.g., Clomipramine, “I would use any medication”) Rank EACH medication within the _________ class you would use in the acute treatment of TTM. Choose “N/A” if you would NOT employ this method in any Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) For patients who have NOT shown a sufficient response to a particular medication, and where TTM is present without comorbidities, please rank the following choices of medications you might use to augment the first medication. Choose “N/A” if you would NOT employ this method in any case. ⁎⁎ Antihypertensive (e.g., guanfacine, Clonidine) Mood stabilizers (e.g., lithium, anticonvulsants) Other antidepressants (e.g., buproprion, trazodone, mirtazapine) Note. Sample size varies because responses of “N/A” were coded as missing values. In addition, respondents unable to prescribe medicationwere asked to skip items specific to the classes or specific medications he/she would be likely to use.
represented the respondents' top choice for an augment- competing response training, HRT, and stimulus control were the most frequently employed treatment compo- provides descriptive data regarding course of nents and should be considered the core components of pharmacological treatment. Results indicate that a CBT for individuals with TTM at this time. In contrast to maintenance visit schedule of 1 to 2 months was most the available empirical literature, tricyclic antidepressants appropriate for highly improved TTM patients, with 3 to were utilized seldom by our sample of practitioners able to 5 months and every 6 months ranked as second and third prescribe medication (n = 11). Among those using tricyc- options. Conversely, maintenance visit schedules of 1 to lics, clomipramine was the most utilized tricyclic. Collec- 3 weeks (first) or 1 to 2 months (second) were clearly tively, these findings provide important information for viewed as most appropriate for those patients with only the development of more efficacious interventions for the treatment of both children and adults with TTM.
Additional results with respect to medication use among practitioners are mixed. Given that only a small The current study is the first to query experienced TTM subset of respondents was able to prescribe medication, clinicians and clinical researchers regarding recom- extreme caution is warranted in interpreting our medica- mended treatment techniques and their specific compo- tion findings. Our preliminary findings, however, suggest nents. Evidence from the current study clearly indicates that four classes of medications (e.g., SSRIs, SNRIs, opiate that those with expertise in the treatment of TTM view blockers, and antipsychotics) were used most frequently as CBT to be the first line treatment for both children and monotherapy. However, the efficacy of only one SSRI adults. This finding is in line with preliminary evidence (e.g., fluoxetine) and one opiate blocker (e.g., naltrex- one) has ever been tested for the treatment of TTM in a larger, though still small, body of adult TTM research Fluoxetine was tied with citalopram as the first ). Again, given that our pool of respondents SSRI of choice, yet the efficacy of citalopram for the consisted of TLC-SAB members and those endorsed by treatment of TTM has never been examined in a them as TTM experts, it is not surprising that CBT was the controlled fashion. Furthermore, tricyclic antidepressants orientation endorsed by the majority of respondents. Our were not highly regarded as a medication class for use study found that self-monitoring, awareness training, among those with TTM, though in a recent meta-analysis, Table 5Descriptive Data regarding Course of Pharmacological Treatment Please rank the appropriateness of EACH of the following medication maintenance visit schedules for a highly improved patient who has just responded to a course of medication (WITH concurrent CBT) and who plans to remain on medication.
Please rank the appropriateness of EACH of the following medication maintenance visit schedules for a partially improved patient who has just responded to a course of medication (WITH concurrent CBT) and who plans to remain on medication.
clomipramine was the only medication tested in a placebo- CBT demonstrating the greatest utility. Additionally, given controlled study to show superiority to placebo for the heterogeneity of TTM, clinicians and researchers should also examine the utility of matching a broad range note, safety concerns regarding the use of clomipramine, of treatment components to the specific TTM symptom particularly among children, may explain this discrepancy between available empirical evidence and the prescribing practices of respondents to the CPS. Also, since the meta- Furthermore, additional research is clearly needed to analysis of Bloch and colleagues and development of this examine the efficacy of various pharmacological interven- survey, N-acetyl cysteine (NAC) has demonstrated a robust tions for TTM. Results from the current study suggest that it response in a placebo-controlled study of adults with TTM may be worthwhile to also examine the efficacy of other classes of medications, such as antipsychotics and SNRIs, were made available after the CPS was developed and with placebo-controlled studies. Again, as noted earlier, our placed online, and will likely influence the choice of small sample size restricts interpretation of our data on pharmacological agents in the future.
medication treatment practices. Lastly, researchers should Several clinical and research implications arise from the further explore combined treatment approaches (e.g., present study's findings. First, CBT should be the first line of medication + CBT) as done in the study of sertraline and treatment for both children and adults with TTM. Again, this finding is not totally unexpected given the overwhelm- Despite the important clinical implications noted ingly strong CBT orientation of respondents to this survey.
above, several limitations to the current study are As such, it is important to emphasize the specific CBT noteworthy. First, the current sample (n = 67) is quite strategies employed by these respondents. Our findings small and prohibits more comprehensive analyses suggest that self-monitoring, awareness training, competing examining differences in treatment practices across response training, HRT, and stimulus control are the most (e.g., psychology vs. psychiatry) and/or within (Ph.D.
commonly used components to CBT for children and vs. Psy.D. vs. “other”) disciplines. However, it is our adults with TTM. Although these components are used belief that the present sample adequately reflects most often by current practitioners with expertise in the clinicians and clinical researchers with expertise in treatment of TTM, researchers should continue to examine the treatment of TTM who (1) frequently conduct the development of better therapeutic interventions. In research and/or (2) are known to members of the fact, it is very likely that additional CBT components, as yet TLC-SAB as clinicians experienced in the treatment of untested or undeveloped, may be necessary for more TTM. Future research may wish to examine current efficacious treatment of this disorder. It may also be practices for treatment of TTM across a more particularly helpful to employ dismantling studies to obtain representative sample of practitioners across diverse a more comprehensive analysis of those components of theoretical orientations and levels of expertise. Second, because data were not collected via a face-to-face Sertraline, behavior therapy, or both? Journal of Clinical Psychiatry,67, 1086–1092.
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Dougherty, D. D., Loh, R., Jenike, M. A., & Keuthen, N. (2006). Single Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled modality versus dual modality treatment for trichotillomania: evaluation of acceptance and commitment therapy plus habit reversal as a treatment for trichotillomania. Behavior Research and M.D., Barbara Rothbaum, Ph.D., Douglas W. Woods, Ph.D., and Harry Address correspondence to Christopher A. Flessner, Ph.D., Rhode We would like to express our appreciation for the Trichotillomania Island Hospital, Department of Child and Adolescent Psychiatry, Learning Center's assistance in data collection and financial support for this Bradley Hasbro Children's Research Center, 1 Hoppin St., Suite 204, Coro West, Providence, RI 02903; e-mail: .
In addition to CAF, FP, and NJK, Trichotillomania Learning Center (TLC)-Scientific Advisory Board (SAB) members providingfeedback for the current study include Darin D. Dougherty, M.D., MSc, Ruth Golomb. M.Ed., Charles Mansueto, Ph.D., Carol Novak, M.
D., Suzanne Mouton-Odum, Ph.D, John Piacentini, Ph.D., Dan Stein,

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