Understanding Body-Focused Repetitive Behaviors: Symptoms and Support

Body-focused repetitive behaviors (BFRBs) — from hair pulling and skin picking to cheek and nail biting — are treatable conditions, given a trained therapist and a willing child. Yes, BFRBs can be very difficult for families to manage; sometimes, though, it’s parents who have a harder time coping with their child’s BFRB than does the actual child.

It’s normal and understandable to worry about your child as you walk this road together. You might have lots of unanswered questions about pulling or picking behaviors, and why your child continues to engage in them. No matter where your family is along the journey, the best way to support your child is by meeting them with compassion, understanding, and positivity every step of the way.

All BFRBs are functional behaviors — they are self-soothing, self-regulating processes that help your child meet a need, even when they are not completely aware of this process. Treatment, therefore, focuses on exploring these needs and finding alternate ways for your child to meet them. Understanding BFRBs in this way will hopefully allow you to develop compassion for your child and to focus on solutions, not on the pulling or picking itself.

A complex set of internal and external factors can trigger and reinforce the BFRB cycle.

Ambivalence is common in people with BFRBs, as it is for individuals who engage in all kinds of self-regulating behaviors, from smoking cigarettes to emotional eating. The truth is that most people with a BFRB enjoy engaging in their BFRB, even though they absolutely hate the outcome of their pulling or picking. The ambivalence is seen when a child openly states that they want to stop their BFRB, and then secretly still engages in it.

As with any kind of behavior change (and regardless of age) stopping a repetitive behavior — especially one that has been ingrained over a long time to the point of feeling automatic — is not so simple. Be patient with your child and know that this is a process that will likely take time and will involve some ups and downs.

Your child is a garden. As parents, you want to fertilize the flowers — everything about your child that makes them amazing — not the weeds (i.e., the BFRB).

An example of fertilizing the weeds: Your child comes up to you, excited to share that they got an A on a test. But when you look at your child, you notice that they’ve pulled out all of their lashes. You immediately say, “What happened to your eyelashes?!”— completely missing the opportunity to praise your child for their test score.

Remember to focus on your child as a whole person who has many wonderful capabilities, qualities, and talents. Focusing too much on the BFRB can create a negative pattern that inadvertently fuels the BFRB.

If your child isn’t already working with a behavioral therapist trained in treating BFRBs, you can find one through The TLC Foundation for BFRBs. BFRB therapists work to understand all the factors that trigger and reinforce BFRBs to help patients meet their individual needs in alternative ways. Alongside treatment, you can support your child through the following steps.

1. Ask your child what they need from you. You must be on the same team as your child. Have ongoing conversations with them about what would feel most supportive and respect their wishes.

2. Resist the urge to police. Children don’t typically want their parents to say or do anything related to the BFRB — that includes side-eye glances and “ahems” — while the BFRB is happening. You might think you’re helping, but calling out the BFRB might frustrate your child and make them uncomfortable. (Does anyone like to be micromanaged?) Unless your child asks you to do so, avoid bringing any attention to the BFRB. Stay calm when you see the BFRB in action. Leave the room if you must.

3. If your child does want you to stop the BFRB in action, agree on strategies beforehand. Your child might want you to distract them with a fidget or a task. A subtle code word alerting your child to the behavior could also work.

4. Reduce your focus on your child’s body and outcomes. You might be tempted to comment on your child’s growing hair, nails, or healing skin, but please don’t. Your child will likely feel uncomfortable and under intense pressure to keep it up, when the BFRB treatment journey isn’t always so linear. Setbacks are to be expected. What can take eight weeks to grow can take eight minutes to remove. In any case, focus on the eight weeks of amazing work, not the latter.

5. Focus on problem-solving, not on solving the BFRB. When you notice that your child has pulled or picked, don’t rush for an explanation. Instead, at a later time, gently approach your child with respectful curiosity. Say, “Tell me about today.” If you learned that a stressful day at school triggered the BFRB, go into problem-solving mode with questions like: What could you have done differently in that moment of stress? How might you handle the situation next time? How will you remember to use your coping strategies? What else can you do/we do to reduce stress in your life? The point is to talk to your child about what’s going on with them (if they’re up for it), not to make them feel like they did something wrong.

6. Be sensitive when talking to others about the BFRB. Talk to your child first to see if they want you to tell others about the BFRB. I encourage families to normalize BFRBs by being open about it: “Oh, yeah, it’s no big deal. We’re working on it.” Set boundaries with family and friends. Depending on what your child wants, you can say to others, “If you see my child doing it, please don’t respond at all.” Or, “If you see my child doing it, you can respond in this way.” Educate your child’s teachers about BFRBs, too, and what they can do to help. Remember: If you view the BFRB as just another thing that your child and family are working through, others will, too.

7. Talk to your child about how to handle unsolicited comments and questions about the BFRB. There are a million right ways to approach this, but it’s important to go with what’s comfortable for your child, whether the response is, “I have trichotillomania. What else do you want to know?” or, “I’m afraid that’s none of your business.”

8. Pick your battles. Timing is everything. If ongoing stressful circumstances are triggering your child’s BFRB, it may not be the best time to try to curb the behavior. Wait until you and your child have the bandwidth to address it.

9. Stay positive and supportive, which may be easier said than done. Seek help to cope with your own thoughts and feelings so you can fully show up for your child on their journey. Be kind to yourself and know that you’re not alone. Make sure your child knows that they’re not alone either.

10. Love your child unconditionally. At the end of the day, your child only wants your love and approval. Making your approval or love seem conditional on the resolution of their BFRB feels terrible for your child and creates undue stress. Your child needs to hear, “I love you no matter what.” Celebrate your child’s strengths and abilities and remind yourself each and every day of how cool and amazing they are, irrespective of their BFRB.

The content for this article was derived from the ADDitude ADHD Experts webinar titled, “BFRB + ADHD: Helping Your Child with Hair Pulling and Skin Picking” [Video Replay & Podcast #453] with Suzanne Mouton-Odum, Ph.D., which was broadcast on May 4, 2023.