Does your child obsessively pick or pull at her skin or hair, sometimes to the point of injury? As distressing as this behaviour is to witness, it isn’t uncommon, especially in kids with ADHD, Autism Spectrum Disorder, and other conditions that affect sensory processing. In fact, researchers estimate that approximately three to five percent of the population will experience body-focused repetitive behaviours (BFRBs) during their lifetime, with late childhood to early adolescence being the most typical age of onset.
Though there’s no cure for BFRB, this condition can be managed effectively with a combination of therapy, parenting strategies and, in more extreme cases, medication. Educating yourself about BFRB and taking steps to combat the stigma surrounding it can also greatly improve your child’s quality of life. In this article, we’ll shed some light on what BFRB is, what causes it, and how you can help your child overcome the urge to pick, pull, chew, or scratch at her body.
What Are Body-Focused Repetitive Behaviours?
The term BFRB encompasses any form of chronic, compulsive self-grooming. For a diagnosis of BFRB to be made, a person must demonstrate a recurrent pattern of picking, pulling, scratching, or biting at a specific area. Occasionally pulling off scabs or picking at a sunburn, for instance, doesn’t indicate that a child is experiencing BFRB. Most people will engage in these behaviours in response to a temporary itch or irritation, but only people experiencing BFRB pick or pull at their skin or hair repeatedly when no physical trigger is present.
There are three main types of body-focused repetitive behaviour:
1. Trichotillomania. Trichotillomania is a condition characterized by compulsive hair pulling. People with this condition feel a powerful urge to pluck out their hair, often resulting in partial or total hair loss on the scalp, eyebrows, or eyelashes.
2. Dermatillomania. Also known as skin picking disorder (SPD) or excoriation disorder, dermatillomania involves picking, pulling, squeezing, or scratching at the skin repeatedly, often to the point of self-injury. People with dermatillomania usually focus on one specific area of the body, with the face being the most common area of concern, and they may use tools (such as tweezers) in addition to their hands.
3. Onychophagia. Though nail-biting is a natural behaviour for many people, those with onychophagia take this habit to harmful extremes, often causing damage to the nails, cuticles, and surrounding skin via frequent chewing.
More rarely, BFRB manifests as cheek biting, lip chewing, nose picking, tongue biting, or cutting or chewing the hair.
What Causes Body-Focused Repetitive Behaviours?
In the past, researchers often classified BFRBs as a form of anxiety disorder or obsessive-compulsive disorder. Today, however, we know that these behaviours have complex origins that make them challenging to understand and define. Though some people engage in BFRBs when they feel anxious, many others unconsciously pick, pull, or bite at their bodies while they’re relaxed, distracted, or busy.
One thing virtually all people experiencing BFRB have in common is an inability to control the urge to self-groom. Despite repeated attempts to stop skin-picking, hair-pulling, or nail-biting (and feelings of embarrassment about their blemishes or bald patches), these individuals find themselves continually returning to the problematic behaviour. For this reason, many experts believe that BFRB is related to poor impulse control. Some studies also suggest that BFRBs are more likely to arise in people who have difficulty “filtering out” excess stimuli, possibly as a way of providing sensory relief in overwhelming situations. These factors might explain why BFRBs are more likely to occur in people with ADHD and those on the Autism Spectrum.
Are BFRBs a Type of Self-Harm?
Because many people who struggle with BFRB inadvertently injure themselves, BFRB is often misclassified as a form of self-harm. In reality, however, there’s no direct connection between these two conditions. Some evidence even suggests that people who engage in body-focused repetitive behaviour are less likely to self-harm than the general population.
Body-focused repetitive behaviour differs from self-harm in a few key ways. Those who self-harm often intend to cause themselves pain or injury; for people with BFRB, on the other hand, pain is usually an unintentional consequence of the disorder rather than being a goal in itself. A significant number of BFRB sufferers report disliking the discomfort and changes in appearance associated with their condition.
Furthermore, self-harm is typically performed in response to a trigger, such as interpersonal conflict, as a way of coping with negative emotions. People rarely employ BFRB in this manner; in many cases, sufferers aren’t even aware of their actions. Whereas BFRB is an unconscious attempt to self-soothe (similar to stimming in Autism), self-harm typically stems from a conscious decision to punish or injure oneself. Understanding the difference between these two conditions can help you place your child’s behaviour in its proper context and avoid making incorrect assumptions about her (or his) emotional state.
6 Ways to Help Your Child Manage BFRB
People with BFRB often experience a significant amount of shame and self-blame due to their condition. Giving your child the support she needs to manage her urge to self-groom can improve her confidence, prevent disfigurement and other complications, and reduce the risk of experiencing isolation, depression, and other psychological challenges related to BFRB. Some effective strategies for helping kids cope with BFRB are as follows:
1. Avoid blaming yourself for your child’s condition.
Unlike self-harm, BFRB doesn’t appear to be associated with early childhood stress, trauma, or neglect. As such, you shouldn’t assume that your child’s actions stem from something you did “wrong” as a parent. Not only is this unlikely to be the case, but blaming yourself could make your child feel worse about her condition. After all, no child wants to be the cause of a parent’s distress.
2. Understand that your child can’t “just stop” picking.
Don’t nag, punish, or criticize your child for engaging in BFRB. These tactics aren’t an effective means of controlling BFRB, and they’ll almost certainly increase the shame and stigma your child already feels about her condition. Aside from letting your child know that you’re there for her if she wants to talk, try to avoid drawing attention to her BFRB altogether. In addition to not making comments directly, respect her boundaries by not telling friends or relatives about her condition without her consent.
3. Look for situations that trigger your child’s BFRB.
For most kids with BFRB, there are specific activities, situations, or stimuli that increase the likelihood of experiencing an episode of skin-picking, hair-pulling, or nail-biting. Usually, BFRBs occur during sedentary activities, such as watching TV or reading, where the child’s hands are free.
These habits may also become more prevalent during times when your child is trying to focus, especially if she has ADHD. For some individuals with ADHD, the release of dopamine that accompanies BFRBs increases the sense of reward associated with completing a task, making it easier to stay on track. Some kids may simultaneously use these behaviours as a way to “drown out” distractions in the background.
Sensory triggers can play a role in provoking BFRBs, too. Some kids are more likely to pull their hair if it’s long or loose, for instance, or pick their skin if they already have blemishes. Cutting hair short (or tying it back), preventing sunburn and dry skin, treating adolescent acne, and other comfort-enhancing measures may therefore have a useful therapeutic role in managing BFRB.
4. Try redirecting your child’s urge to self-soothe.
Part of the reason BFRBs are so hard to control is that they fill a psychological need for the individual experiencing them. (E.g., relieving tension, promoting concentration, or creating feelings of intense satisfaction.) As such, controlling BFRB begins with giving your child another, less harmful way of addressing her needs, such as a fidget toy. For best results, let your child pick a toy that’s appealing to her, then suggest when you would like her to use it (for instance, while watching TV). Praise your child to reinforce the new behaviour and remain patient; it often takes several weeks or months for a child to adapt to using a fidget toy in place of skin-picking or hair-pulling.
For older kids and adolescents, tactile hobbies – like knitting or crochet – may also be useful for limiting BFRB. In addition to keeping the hands occupied, these activities stimulate the production of dopamine by producing tangible items your child can use and feel proud of.
5. Give your child tools to manage confidence issues associated with BFRB.
One of the hardest parts of living with BFRB is dealing with negative comments from friends, acquaintances, and strangers. Over time, these remarks can take a significant toll on a child’s self-esteem and potentially contribute to other mental health issues, such as anxiety, depression, and isolation.
To prevent these unwanted outcomes, equip your child with strategies for handling social stigma and finding support in the community. To address negative or impolite comments from friends, your child might try educating them about her condition, for example. If the comment is coming from a stranger, ignoring it might be the best course of action.
To further alleviate any feelings of alienation your child is experiencing, encourage her to join a support group for people with BFRB. The TLC Foundation has a useful online search tool you can use to find BFRB support groups in your area.
Cosmetic aids can also go a long way towards reducing self-consciousness, especially for adolescents. Providing wigs for a teen with trichotillomania, for instance, will cover bald patches while simultaneously blocking hair-pulling behaviour. Similarly, acrylic nails can be used to create a “shield” over bitten, brittle natural nails.
6. Seek professional help.
Though some cases of early childhood BFRB clear up on their own, most people with BFRB don’t get better without medical treatment. Currently, the most effective treatment for BFRB is cognitive-behavioural therapy (CBT), which should be administered by a trained child psychologist or licensed therapist with experience in treating BFRB. CBT helps kids recognize their triggers, figure out what needs they’re trying to address through BFRB, and learn alternative coping strategies.
No medication has been reliably proven to eliminate BFRB symptoms. In rare cases, however, medication may be recommended for teens and young adults who have comorbid conditions (such as anxiety or depression) that may be making their BFRB worse. Lifestyle changes and certain supplements (notably N-acetylcysteine and inositol) may also help reduce BFRB symptoms in some individuals.
For most people affected by BFRB disorders, management is a lifelong process. Nonetheless, early intervention, consistent treatment, and support create significant improvement – and even remission – in the vast majority of cases. Even if you can’t cure your child’s BFRB, getting her the help she needs to control her symptoms will allow her to live a full, satisfying life.
