Autism and hair pulling

This response is by psychologist Cathryn Lehman, of the Center for Autism and Developmental Disorders, at the University of Pittsburgh Medical Center. The medical center is one of 13 sites in the Autism Speaks Autism Treatment Network.

My daughter is 16, on the spectrum and non-verbal. Sometimes she starts pulling her own hair out. Often it’s when she’s angry or upset. Sometime it’s out of nowhere. I’ve tried a bandana, hand fidgets. Currently she has a completely bald spot, despite getting a very short haircut. Her teachers says to ignore it, since it’s for attention. But if I ignore her, she will pull out more hair and bring it to me for a reaction. I need some suggestions.

Hello, and thank you for your question. I appreciate that challenging behaviors such as hair pulling can feel overwhelming for parents. It can be extremely stressful to see your child hurting herself. Her hair pulling and bald spots can also lead to social exclusion from her peers. So I’m glad you’re seeking help.

While I’m happy to offer some perspective and tips, I strongly encourage you to discuss your daughter’s hair pulling with her physician and a behavioral therapist who has experience working with children or young adults with autism. They’re in the best position to help you determine why your daughter is pulling her hair out and find appropriate ways for her to express frustration and anger, as well as ask for attention.

For general guidance, also see the Autism Speaks Challenging Behaviors Tool Kit.

Trichotillomania and autism

Start by ruling out underlying conditions. It’s important for your daughter’s doctor to evaluate her for any physical or mental health issues that might be contributing to her hair pulling. The most obvious might be trichotillomania, which involves a recurrent and irresistible urge to pull out hair from the body.

This compulsive behavior can cause great distress and embarrassment, and many people with the condition tend to hide their hair loss. By contrast, your description of your daughter’s hair pulling suggests that she’s doing it to get a reaction – at least some of the time.

Find what’s driving the behavior of pulling out hair

Once your daughter’s physician has ruled out medical causes, the next step is to determine the function, or purpose, of this behavior. You mention that your daughter is nonverbal, which adds to the challenge of understanding what’s behind the behavior.

Some of the most common reasons for challenging behaviors include attention (positive or negative), escape or avoidance (of a stressful situation, discomfort or an unwanted task), sensory needs, or wanting to get something.

In our clinic, we often determine what’s behind a self-harming or other problem behavior with a functional behavior analysis. This is a systematic way to assess what happens immediately before a behavior occurs (the antecedent) and what happens right after the behavior (the consequence or reaction). It’s a little like keeping a diary with a record sheet that looks something like this:

The behavior, in this case, is hair pulling. Let’s say you noticed that you asked your daughter to do her homework (antecedent) right before she began pulling out her hair (the behavior). You jot that down. Under consequence, you write what happened next. For example, did she get out of doing her homework because you got upset about the hair pulling? Or perhaps you realized that she was anxious, helped her calm down, and she stopped the hair pulling and completed her homework. The point is not to judge right or wrong, but to look for patterns.

If you pick up that your daughter is seeking attention with the hair pulling, then her teacher is correct that you don’t want to encourage it with a reaction. At the same time, you want to provide your daughter with another behavior – one that doesn’t hurt anyone – to signal her needs and wants.

Strategies to help your child stop pulling hair out

Here are three strategies, based on the principles of Applied Behavior Analysis, that may help:

1. Catch your daughter being “good.” (e.g. not pulling her hair out) Reinforce her appropriate behavior with praise (“What nice, quiet hands.”) and a small reward. You know your daughter best. Would she respond best to a hug? A small toy or treat? How about a token on a reward board, with the promise of a favorite activity with you after she earns five tokens?
2. Praise and reward her for engaging in a substitute activity. You had the right idea with the hand fidgets you mentioned. You want to reinforce an activity that keeps her hands away from her hair. Praise, attention and/or other rewards may be the key to making this strategy work when it hasn’t before. Within reason, you might try different kinds of hand fidgets to keep her attention. A web search will bring up dozens.
3. Praise and reward her for using an appropriate behavior you’ve discussed in advance. For example, you might teach your daughter to ask for attention either verbally or with a visual support such as a picture card that says, “Let’s play.”

For more on using visual supports, download the Autism Speaks Visual Supports and Autism Spectrum Disorder Tool Kit.

Preventing harm

Until your daughter stops hair pulling, I would suggest working with a behavior therapist to find ways to block her from hurting herself and creating bald spots. You mentioned that you tried a bandana. Other options might include a hat or helmet. Try a combination of consistency and minimal attention (avoid eye contact and emotional expression) while you gently but firmly place the bandana, hat or helmet in place.

Then return to the strategies described above for encouraging appropriate behavior and provide plenty of positive attention for each small effort and step in the right direction on her part.

In our experience, it’s important to use these strategies consistently. If her hair pulling gets an emotional reaction from you – even a fraction of the time – she is much more likely continue, or even increase the behavior, in an effort to keep getting that reaction.

Thank you again for your question.

Additional resources and advice posts by Dr. Lehman:

• Autism and difficulty gauging time: Strategies for a common challenge
• Find the ATN center nearest you
• Contact the Autism Response Team

Editor’s note: The above information is not meant to diagnose or treat and should not take the place of personal consultation, as appropriate, with a qualified healthcare professional and/or behavioral therapist.