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.
Published by Elsevier Ltd. All rights reserved.
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.
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.
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.
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.
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
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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,
A year in the vegetable garden Problem Solving Every season brings its own problems and each year can be different from another. This is part of the joy of gardening. However there are several problems which can occur each year but with careful propagation and planting these can be avoided. As vegetables are to be eaten it is advisable to use as few chemical sprays as pos
Insect-Resist Treatments 0f Wool Carpets Larvae of some insects may eat wool and other animal fibres (mohair, cashmere etc) and they may cause damage to stored textiles and carpets. These insects (Clothes Moth, House Moth, and Carpet Beetle) are unique in their ability to live on wool, but are not restricted to this diet. They may feed on a wide variety of dry materials with a high protein