Skin Picking: What Causes It, How Can We Prevent It?

Natalie, my daughter who has attention deficit hyperactivity disorder (ADD/ADHD), anxiety, and sensory processing issues has developed a habit that grosses me out something terrible: picking off her toenails. Yes, you read that right. She doesn’t just pick the skin around them or rip them a little too short. She’s actually completely pulled off two nails.

Natalie has always been a picker and a squeezer. She picks scabs and bug bites. She scratches her lips until they bleed. She squeezes all of these owies to keep the blood flowing. I’m no expert, but my mom instincts tell me that Natalie’s propensity to pick could stem from any of her three diagnoses.

Skin Picking and ADD/ADHD

I blame her ADD/ADHD because I see picking as a form of fidgeting, which is rooted in the ADD/ADHD brain’s need for stimulation. I also blame ADD/ADHD for giving Nat a lack of impulse control, making it harder for her to fight off her picking urges.

Skin Picking and Anxiety

Bits and pieces of her anxiety must come into play, too. Her anxiety level goes up, and she turns to obsessive-compulsive behaviors to relieve the pressure. The first time that Nat’s picking behavior went from just a bad habit to actually inflicting self-harm was when she was going through a particularly anxiety-provoking social situation. The relief this maladaptive behavior provided led her to repeat it in times of increased stress so that it has become an ingrained habit.

Skin Picking and Sensory Processing Disorder

I think sensory processing issues play a part, too. When we were in the midst of addressing Natalie's self-injury problem, our psychologist had us try to replace the picking with another behavior that provides strong sensory input -- he recommended having Natalie hold ice in her hands. During an acute incident, when Nat was very upset and intent on hurting herself, my husband, Don, worked to help her calm down and stay safe for most of one afternoon, and having her focus on how the ice felt was very helpful. Just keeping existing spots covered with Band-Aids helps, too.

How to Prevent Skin Picking?

You know, a few months ago I really thought we had this picking thing under control. We implemented a reward system, where Natalie could earn one dollar each day that she didn’t make herself bleed. We encouraged her to mess with a fidget toy when she felt like picking. That incentive was enough to make her kick the habit for a long, long time. I was so pleased, and impressed with her ability to make a positive change.

But then, a few weeks ago, one of Nat’s favorite picking spots, her little toe, became infected. It was swollen, red, and hot to the touch. Still, she kept messing with it, and eventually made it drain. It hurt so much that it kept her awake during the night. She ended up taking antibiotics for 10 days, and it was during the healing phase that she picked what remained of the nail completely off. It freaked me out. I could hardly even stand to bandage it.

In addition to bringing these symptoms up with Natalie's psychologist and psychiatrist, it looks like we need to start that incentive program up again (but right now, we’re working on hygiene!) and find some more alternatives to picking to teach her. In the meantime, I stocked up on bandages, antibiotic cream, and OxiClean to wash the blood from her clothes, and I’ll listen to any advice you other ADD/ADHD parents have to give me!

More on Skin Picking

According to the International OCD Foundation "Skin Picking Disorder Fact Sheet", skin picking disorder involves repeated skin picking, skin picking that interferes with daily activities, and skin picking that can cause tissue damage. "People may pick out of habit or boredom, and, at times, may not even be aware that they are picking," explains the International OCD Foundation "Skin Picking Disorder Fact Sheet." "People may also pick in an attempt to cope with negative emotions (e.g., anxiety, sadness, anger) and/or in response to feelings of mounting stress and tension." Skin picking disorder may affect as many as 1 in 20 people. Skin picking disorder is classified as an impulse control disorder but can also be referred to as a “body focused repetitive behavior" or an "obsessive compulsive spectrum disorder," the fact sheet notes.

Learn more about skin picking from the International OCD Foundation "Skin Picking Disorder Fact Sheet" and the Trichotillomania Learning Center.

Does your child have a picking problem? Do you think it’s related to ADD/ADHD?