Understanding Compulsive Behaviors in Children: Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors
Dec 22, 2024
Compulsive behaviors in children, such as trichotillomania (hair-pulling), skin picking (dermatillomania), and other body-focused repetitive behaviors (BFRBs), can be distressing for both children and their parents. While these behaviors are often misunderstood, they are relatively common and can affect children’s self-esteem, emotional well-being, and daily life.
In this article we will discuss what these behaviors are, why they occur, and how you as a parent can support your children with compassion and evidence-based strategies. We’ll also explore tools and interventions that can help your child manage these behaviors and provide links to resources for additional support.
What Are Body-Focused Repetitive Behaviors (BFRBs)?
BFRBs are a group of compulsive behaviors where individuals repetitively damage their hair, skin, or nails. These actions are not self-harm but rather a form of coping mechanism, often performed unconsciously or in response to stress, boredom, or anxiety.
Common BFRBs in Children:
1. Trichotillomania: The repeated pulling out of one’s hair, often from the scalp, eyebrows, or eyelashes.
2. Dermatillomania (Skin Picking Disorder): Recurrent picking at the skin, leading to sores, scabs, or scars.
3. Nail Biting (Onychophagia): Chronic biting of nails or cuticles, which can lead to damage or infection.
4. Cheek or Lip Biting: Persistent biting of the inside of the cheeks or lips.
Although we use the common names of trichotillomania and dermatillomania in this article, many professionals in the fields of dermatology, the behavioral sciences, and psychiatry are suggesting that these names be changed to trichotillosis and dermatillosis instead. These name changes would create less stigma since "mania" can be misunderstood as someone being manic. They would also better align with our true understanding of trichotillomania and dermatillomania as part of the spectrum of body-focused repetitive behaviors.
Why Do These Behaviors Happen?
The exact causes of BFRBs are not fully understood, but they are often linked to a combination of genetic, neurological, and environmental factors.
Contributing Factors:
• Neurological Differences: Studies suggest that BFRBs are associated with differences in brain regions responsible for impulse control.
• Anxiety or Stress: Children may engage in these behaviors as a way to self-soothe during overwhelming situations.
• Boredom or Focus: Some children develop these habits during moments of boredom or when deeply focused on a task, like watching TV or reading.
• Perfectionism: A desire for smooth skin or symmetrical hair can trigger picking or pulling.
Body-focused repetitive behaviors (BFRBs) are also more commonly seen in children with the following:
1. Anxiety Disorders
Generalized Anxiety Disorder (GAD): BFRBs can act as a coping mechanism for managing anxiety or stress.
Social Anxiety Disorder: The behaviors may be a response to feelings of self-consciousness or distress in social situations.
Panic Disorder: BFRBs might emerge during or after panic episodes as a form of self-soothing.
2. Obsessive-Compulsive Disorder (OCD)
While BFRBs are not the same as OCD, they share overlapping features, such as repetitive behaviors and urges. Children with OCD might engage in BFRBs due to intrusive thoughts or to reduce anxiety associated with obsessions.
3. Autism Spectrum Disorder (ASD)
Individuals with ASD may engage in repetitive behaviors, including BFRBs, as part of sensory regulation or as a self-soothing mechanism. These behaviors may be triggered by sensory overload, stress, or boredom.
4. Tourette Syndrome and Tic Disorders
BFRBs can overlap with tics, though they are distinct. For example, a person with Tourette Syndrome might exhibit hair pulling or skin picking as part of their repertoire of repetitive behaviors.
5. Depression
BFRBs are sometimes used as a form of emotional regulation or distraction from depressive thoughts and feelings.
6. Body Dysmorphic Disorder (BDD)
Individuals with BDD might engage in skin picking, excessive grooming, or other BFRBs as a way of attempting to “fix” perceived imperfections in their appearance.
7. Stress-Related Conditions
High stress or trauma can increase the prevalence of BFRBs, even in children without a formal diagnosis. These behaviors serve as a coping mechanism to manage overwhelming feelings.
8. Substances
Certain substances, such as stimulants (e.g., methamphetamine) which are used to treat ADHD can increase repetitive behaviors, including BFRBs, as a side effect of heightened nervous system activity.
9. Insomnia or Sleep Disorders
Children with disrupted sleep patterns or insomnia may exhibit more BFRBs, possibly as a result of increased fatigue, stress, or nervous system dysregulation.
10. ADHD
Children with ADHD may also have more BFRBs as a result of impulsivity, boredom, restlessness, or sensory under or over stimulation. Some children with ADHD who are on stimulant medications may actually have more challenges with picking because of the stimulant meds. These children may benefit from non-stimulant medications like Strattera.
Why These Conditions Are Associated
Many of these conditions involve:
-Dopamine Dysregulation: Impulsivity and reward-seeking behavior linked to dopamine pathways can play a role in BFRBs.
-Stress Regulation Issues: Difficulty managing stress, whether due to anxiety, ADHD, or trauma, often leads to repetitive behaviors.
-Sensory Processing Sensitivities: In conditions like ASD or ADHD, BFRBs can serve as a sensory outlet.
Dr. Carol Novak, a psychologist specializing in BFRBs, explains:
“These behaviors are not a child’s choice or flaw but rather an automatic response to underlying emotional or neurological triggers.”
How to Help Children with Compulsive Behaviors
Supporting children with BFRBs requires understanding, patience, and a combination of strategies. Here are steps you can take as a parent:
1. Understand the Behavior
Help your child recognize their triggers. Do they pick or pull when anxious, tired, or bored? Identifying patterns is the first step toward intervention.
2. Practice Compassionate Communication
Avoid punishment or shaming, as this can worsen the behavior. Instead, talk openly and compassionately.
• Example: “I’ve noticed you’ve been pulling at your hair. Are you feeling stressed or bored? Let’s figure out how we can help.”
3. Offer Substitutions
Providing a safer alternative can reduce the urge to pick or pull. For example:
-Fidget Toys: Stress balls, silicone poppers, or tactile rings can keep hands busy.
- Textured Stickers: •These stickers provide a satisfying surface for scratching or rubbing.
-Try options like these Sensory Stickers from Amazon
• Scratch Pads or Stim Tools: Offer items like pumice stones or scratch pads to redirect scratching behaviors. The picking stone called FidgetGone also comes highly recommended as do the picky pads found on Etsy .
4. Behavioral Tools
Devices and tools can help interrupt unconscious behaviors:
-Habit Awareness Devices: Watches or bracelets that vibrate when a hand moves toward the face, such as the Keen2 Habit-Aware Bracelet.
-Finger Covers: Silicone finger caps or gloves can act as physical barriers.
-Fake or acrylic nails may be helpful for some. These make it harder to pick or pull and may not make the sensation as satisfying for some children and teens. Even just having nails manicured may be helpful for some to avoid nail biting.
-Regular lotion or vaseline especially at night or in the evenings can be helpful to avoid picking and pulling for some. Some children/teens may also be okay with putting mittens on their hands to sleep or comfortable socks over their hands when they sleep. You could make this more of a "spa" experience for them by applying lotion or vaseline first.
-At school offering fidgets and opportunities for brain breaks can be helpful too.
5. Create a Calming Environment
Since stress and anxiety can exacerbate BFRBs, focus on creating a calm and supportive home environment. This could include relaxation techniques like deep breathing, mindfulness, or yoga.
6. Professional Support
Sometimes, BFRBs require additional interventions:
• Cognitive Behavioral Therapy (CBT): Helps children understand and manage triggers.
• Habit Reversal Training (HRT): A specialized form of CBT designed for BFRBs.
• Occupational Therapy: Can teach sensory-based strategies to reduce behaviors.
7. Medications
While there aren't any specific medications that officially treat body-focused repetitive behaviors, N-acetylcysteine is an over the counter supplement that may help. The research on this supplement is promising because it has shown some potential in treating body-focused behaviors like skin picking, hair pulling, and nail biting. More studies still need to be done to confirm how effective this supplement is as well as an optimal dose. Before considering this supplement, even though it is over the counter, you should always talk with your child's doctor to ensure that this is a safe option for your child.
SSRIs are commonly used to treat anxiety, depression, and OCD. IF BFRBs are linked to underlying anxiety, depression, or OCD then this type of medication may be helpful for some children. Starting a medication like this is something that should always be discussed with your child's physician.
What Parents Can Do at Home
1. Set Realistic Goals
Change takes time. Focus on small wins rather than expecting immediate cessation of the behavior.
2. Develop Replacement Routines
Replace BFRBs with engaging, hands-on activities:
• Drawing or coloring or pulling out the fur on a Stuffiez stuffed animal like these!
• Playing with slime or kinetic sand.
• Building with blocks or LEGOs.
3. Model Stress-Reduction Techniques
Show your child healthy ways to cope with stress, such as taking a walk, journaling, or talking about feelings.
4. Celebrate Progress
Praise effort, not just results. Celebrate when your child identifies triggers or uses a replacement strategy.
Dr. Laura Markham, author of Peaceful Parent, Happy Kids, advises:
“Children need our empathy and guidance, not criticism, to overcome habits that even adults struggle with.”
5. Encouraging Stories and Family Traditions
Consider introducing stories or books that promote self-acceptance and perseverance. You can also use creative family traditions to support stress management, like having a weekly “calm night” with soothing activities.
When to Seek Professional Help
If BFRBs interfere with your child’s daily life or cause significant physical harm, it’s important to consult a professional. Therapists, pediatricians, and child psychologists can provide tailored support.
Signs Your Child Might Need Additional Help:
• Open sores or infections from skin picking.
• Significant hair loss or bald patches.
• Emotional distress related to their behavior.
Final Thoughts: Supporting Your Child with Compassion
Compulsive behaviors like picking or hair-pulling can feel overwhelming, but they are manageable with understanding and the right tools. By providing a safe space, offering substitutions, and seeking professional support when needed, parents can help their children navigate these challenges with confidence and resilience.
As a gentle reminder from Dr. Carol Novak:
“Compassion and patience are the most powerful tools parents have. Your child isn’t defined by their behavior—they’re growing and learning with your guidance.”
What strategies have worked for your family? Share your tips and experiences in the comments below!
Parenting Alongside You!
Dr. Emma Hostetter and the Aparently Parenting Team
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