Body-Focused Repetitive Behaviors

Body-Focused Repetitive Behaviors: Understanding BFRBs in Children

“Teenagers pluck their eyebrows, pop zits, or change hairstyles all the time. These behaviors are normal; taken to the extreme, however, hair pulling and skin picking are problematic.” Learn how to identify body-focused repetitive behaviors (BFRBs) in children and the best avenues for treatment.

BFRBs in children

Trichotillomania and excoriation sound like beings from a dystopian sci-fi novel. In fact, they are the scientific names for hair pulling and skin picking disorders, respectively — two of the most common body-focused repetitive behaviors (BFRBs).

Trichotillomania and excoriation disorder occur in 1 to 3 percent of children and adults, more commonly in females than in males. Chances are that several students at your child’s school have either (or both) of these disorders, or perhaps another BFRB like teeth grinding, nail biting, or lip biting. Though the scientific link between BFRBs and ADHD remains undetermined, anecdotal evidence suggests a connection.

BFRB Overview: Understanding Signs in Children

BFRBs are clinical disorders, but only trichotillomania and excoriation have their own standalone diagnostic classifications. Diagnoses for other BFRBs are often subsumed under the unspecific catchall classification “other specific obsessive-compulsive and related disorder.”

Consider the following behaviors and collateral effects if you suspect your child is engaging in skin picking, hair pulling, or any other BFRB:

Noticeable Hair Loss or Physical Damage to the Skin

Teenagers pluck their eyebrows, pop zits, or change hairstyles all the time. These behaviors are normal; taken to the extreme, however, hair pulling and skin picking are problematic.

[Take This Test: Obsessive-Compulsive Disorder in Children]

A child with BFRBs may pull out  eyelashes or eyebrow hairs, or create bald patches on her head. By picking her skin, she may create or worsen bleeding, scarring, or infections.

Children with chronic hair pulling or skin picking disorders do not engage in these behaviors to maintain personal hygiene or appearance, or to express their individuality. These behaviors happen again and again — and with enough intensity and frequency to produce clear physical consequences.

Secrecy & Concealment

Though not a formal symptom of hair pulling or skin picking disorder, secrecy is common to BFRBs. Pulling and picking are often done in private, and effort is taken to hide them.

The physical consequences of hair pulling and skin picking often suggest that something is amiss. Yet the physical damage can be concealed. Hair can be styled creatively to cover bald patches. Face makeup can conceal picking, and clothing can hide picking or pulling from the limbs or torso.

[Read: When OCD and ADHD Coexist]

Embarrassment, Shame, & Guilt

A child who is missing large patches of hair can face confusion, sadness, frustration, and even anger — from her parents and herself.

Before even receiving a formal diagnosis, a child with a hair pulling or skin picking disorder has often tried to stop many times and couldn’t do so. This leads to increased feelings of shame, guilt, and embarrassment.


Recent studies suggest that 20 to 38 percent of children with trichotillomania also meet the criteria for ADHD. Available prevalence rates are few, but they suggest that about 10 percent of kids who pick their skin have ADHD.

BFRB Treatment

No medications have been approved by the FDA for the treatment of BFRBs in children. In fact, studies have failed to demonstrate that any medication is better than a placebo for the treatment of BFRBs in youths. However, the volume of research is small. Medications may work; we just don’t know.

As for psychosocial interventions, research suggests youths with BFRBs may benefit from cognitive behavioral therapy (CBT) — specifically the techniques of self-monitoring, habit reversal training, and stimulus control.

1. Self-Monitoring. Patients are asked to track the number of times they have pulled hair, picked skin, or bitten their nails over a certain period. This can establish patterns and contexts, allowing for better targeted treatment.

2. Habit Reversal Training (HRT). HRT typically includes three primary components:

  • Awareness training is designed to increase a child’s awareness of when, where, and how he picks.
  • Competing response training teaches the child to use an incompatible behavior when he feels the need to pull or pick.
  • Social support is activated when parents praise the child’s implementation of a competing response and offer gentle reminders to do so when the child has forgotten.

3. Stimulus Control studies the situations or contexts where pulling or picking may occur, then modifies environments to make those behaviors less likely. For example, wearing gloves at bedtime may help a child who pulls or picks in bed.

Science has much to learn about BFRBs and how to help families manage these behaviors. As one might imagine, the CBT-based techniques described above require considerable effort and commitment on the part of the child and her family. Willingness and ability to change can make a big difference in the success of any treatment process.

BFRB Overview: Next Steps

Christopher A. Flessner, Ph.D., is an associate professor in the Department of Psychological Sciences at Kent State University. He is also director of the Pediatric Anxiety and Allergy Research Clinic (PAARC) at Kent State.

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