Treatment for Hair-pulling, Skin-picking

Hair-pulling, skin-picking, and nail-biting can start out as harmless habits. But when kids can’t stop doing them, even when they’re hurting or embarrassing themselves, these habits can become a serious problem. Experts call them body-focused repetitive behaviors (BFRBs). And there is evidence that the best way to treat these behaviors is an approach called comprehensive behavioral treatment, or ComB.

ComB is an approach that draws from several different kinds of therapies and is tailored to each individual.

Think of body-focused repetitive behaviors as self-grooming behaviors that have gotten out of control. And attempts to stop or cut back have been unsuccessful. BFRBs include:

• Trichotillomania (hair-pulling)
• Excoriation (skin picking)
• Onychotillomania (nail biting)
• Trichotemnomania (compulsive hair cutting)
• Trichophagia (hair eating),
• Dermatophagia (skin biting)

Kids who engage in these behaviors often describe them as uncontrollable. They find that doing them brings a sense of relief or helps them calm down, which is part of why they can be hard to stop. BFRBs can emerge at any age but tend to pop up in early adolescence or the teen years.

There are plenty of people who bite their nails or pick at their skin once in a while, but typically these behaviors are bad habits — not disorders. If a child has tried to stop a behavior multiple times and can’t, and if they are harming their bodies, causing distress, or impairing daily functions, then it’s time to pursue treatment.

“It’s only a disorder if it has bad effects,” explains William Benson, PsyD, director of the Tourette’s and Trichotillomania Service at the Child Mind Institute. “If it’s causing patches of baldness, scars on your skin, you’re getting infections in your nails, or your nails are really down to the bone.”

Often kids who engage in BFRBs end up feeling ashamed by their behavior and resulting appearance. They may get bullied because of bald spots, scabs, or scars.

The go-to treatment for BFRBs has traditionally been a form of cognitive behavioral therapy called habit reversal training (HRT), which was developed in the 1970s.

HRT starts with awareness training. Patients are encouraged to focus on the targeted behaviors — when and where they happen, what tends to precede them, and what makes them worse. The second phase is developing a competing response, or an alternative action that prevents you from doing the thing you’re trying to stop doing. “The idea is that you do something that is physically incompatible with that behavior while you’re also resisting doing the behavior,” says Dr. Benson. For example, you can’t bite your nails if you are sitting on your hands. And you can’t pull your hair if you’re squeezing a stress ball.

But while HRT helps some people with BFRBs, it doesn’t always produce consistent results on its own. ComB was developed beginning in the 1990s to incorporate other strategies to address things that are triggering these behavior. Research on the long-term efficacy of ComB for treating BFRBs is promising.

ComB is a personalized treatment that uses a combination of different approaches, depending on what the patient needs and what works best for them. The patient and therapist collaborate to identify the target behaviors, when and why they happen, and what strategies to try.

This treatment relies on a partnership between the patient and the therapist. And it needs to start with a child who is motivated to make a change. “Just because the parents want the child to change doesn’t mean the kid is ready,” says Jerry Bubrick, PhD, director of the Intensive Pediatric OCD Program and a senior psychologist at the Child Mind Institute. “Motivation and compliance are our two biggest predictors of success.”

Assessment and functional analysis

Drawing from HRT, ComB begins with an analysis of the problem behaviors to better understand when they are happening and what is driving them. Are there particular feelings, times of day, or environments that seem to trigger the urge to pull or pick? Does the action soothe stress or anxiety?

“It’s kind of looking at a current overview of everything that’s happening, and then trying to figure out where we can make changes so that you’re more effective in your coping skills,” explains Dr. Bubrick. “Perhaps you need different coping skills. Perhaps we need to sharpen the ones you have.” The therapist will work with the child and their family to monitor the behaviors and raise awareness about these details.

Expecting anyone — but kids in particular — to self-monitor and gather data regarding their BFRBs is challenging, but the emergence of wearable technology is promising. A device similar to a smart watch detects specific arm movements, vibrates when the arm raises, and tracks information regarding where, when, and how long BFRBs are happening. This can inform the treatment plan.  

Create and implement a treatment plan

The therapist and patient will then work together to explore which specific strategies may be helpful. They may decide to focus on one treatment or borrow strategies from multiple approaches to develop an individualized plan that they will continue to revisit and modify as needed.

“In the beginning, it’s what I consider to be damage control,” says Dr. Bubrick. “We may not be able to stop it all together, but is there a way to slow it down?” Once the behavior is less intense, work can begin to extinguish it.

For example, if a child is mindlessly skin-picking or hair-pulling, they may draw from HRT practices to come up with a competing response like wrapping their fingertips in bandages or wearing gloves. This would make it much harder to pick or pull without noticing. If the action is in response to a sensory craving, then they can find an alternative but similarly satisfying action like playing with clay or snacking on crunchy foods. And if stress exacerbates the BFRB, then relaxation and mindfulness strategies might be a productive place to start.

Strategies from dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) are commonly part of ComB. DBT helps kids manage difficult feelings without self-destructive behaviors. ACT focuses on accepting uncomfortable emotions and committing to goals rather than allowing upsets to trigger unwanted behaviors.

Modify the plan as necessary

Once a treatment plan is mapped out, the therapist and child continue to revisit and tweak it as needed. If the treatment is successful and the urges are reduced, then they can slowly decrease the intensity of the interventions.

Sometimes kids have a hard time going through with treatment because the BFRB is helping them deal with an underlying problem, Dr. Benson notes. In these cases, it’s necessary to back up and address the underlying or coexisting conditions that might be driving the BFRB. For example, according to one study ,79% of people with trichotillomania have at least one other mental health diagnosis such as anxiety, depression, OCD, PTSD, or ADHD. Once other conditions are better under control, then ComB may prove to be more effective.

Medication hasn’t proven to be the helpful in reducing BFRBs, he adds, though it may helpful for reducing symptoms of other disorders that are contributing to the behavior.

Families play an important role when children are engaged in ComB. They can offer valuable insights and observations to the clinician to inform treatment. But it’s also important for parents to examine their interactions with their child and determine whether they are helping or exacerbating the BFRBs.

For example, drawing a lot of attention to a child’s hair pulling or nail biting may be well meaning, but can increase anxiety. “I ask parents to come in first to learn how to change the way they’re talking to and relating to kids, and how they’re addressing things, and to learn some skills before we ask the kid to come in for treatment,” says Dr. Bubrick. He finds that in cases where parents initiate treatment it’s helpful for them to be able to show their child that they’ve put in work too.

Once the child starts treatment, parents can also be coached to focus on positive reinforcement rather than nagging about the behaviors they are trying to extinguish. “So, when a parent sees a child using the skills or using the toolkit,” says Dr. Bubricik, they’re able to praise that really powerfully.”