Body-Focused Repetitive Behaviors in Children Under 5

Trichotillomania, or hair-pulling disorder, is a body-focused repetitive behavior (BFRB) that often begins in childhood. While it is frequently associated with older children, adolescents, and adults, "baby trich" refers to hair-pulling in children under the age of 5. This behavior can be puzzling and distressing for parents, especially since children in this age group may lack the verbal skills to express their feelings or reasons for engaging in hair-pulling.

Parents and other caregivers may notice their child playing with their hair, twirling, repeatedly tugging, or even pulling out strands. Over time, this can result in noticeable hair loss, commonly in patches on the scalp, but it may also affect eyelashes and eyebrows. It is important for caregivers to note any biting or eating of the hair as well as any symptoms of belly pain or changes in eating, digestion, or weight. Although uncommon, ingestion of hair can result in a trichobezoar (hairball), which is a serious condition requiring medical attention.

Excoriation (skin picking) disorder may also be observed in young children, appearing as picking at the nail cuticles; scratching the skin of the face, arms, or legs; or picking at scabs or other skin irregularities. Nail biting of the hands and/or the feet may also be observed. While mild nail-biting might be dismissed as common, more significant nail-biting can lead to damage to the nail bed or increase the risk of infection. As with hair-pulling, parents may begin to notice damage as a result of these behaviors. While these behaviors may arise as part of sensory exploration during early development, they may escalate into a more serious condition if the child creates open wounds or scars.

Why Do Young Children Engage in These Behaviors?

While the triggers driving these behaviors may vary and are often more complex in older children, teens, and adults, these behaviors in young children are often associated with:

• Self-regulation. Similar to thumb-sucking, hair-pulling, skin-picking, nail-biting, and other BFRBs in young children can be a self-soothing or calming behavior. The textures or feeling of engaging in these behaviors can be stimulating or comforting. The textures and/or sensations associated with the behavior may feel good. For some children, it serves as a way to manage feelings of stress, boredom, or fatigue.
• Attention-seeking. In rare cases, young children may engage in these behaviors as a way to garner attention from caregivers, especially if the behavior has previously resulted in a response.

While there is little research to date examining these behaviors in early youth, some have suggested that stress, environmental changes, and even developmental milestones can trigger or exacerbate these behaviors (Flessner et al., 2009). Research also suggests that genetics may play a role; children with a family history of anxiety disorders or BFRBs might be more prone to developing these behaviors (Reid et al., 2024).

It is not uncommon for parents and other caregivers to experience guilt and other feelings of distress when their young children are exhibiting these behaviors. It is important for parents and other caregivers to know that these behaviors are not their “fault.” They are not the cause, but they can be part of the work toward minimizing or eliminating these behaviors.

Is It Really a BFRB?

As with other psychiatric disorders, such behaviors are only clinically significant (and diagnosable) if they cause notable distress or impairment for the individual and/or their functioning. BFRBs are no exception. To meet diagnostic criteria at any age, the behavior must result in hair loss/skin damage, cause significant distress or impairment, and may not be better explained by another medical condition.

This being said, body-focused repetitive behaviors (BFRBs) in children under 5 may be transient in nature (unlike what is often a chronic course in older individuals), sometimes manifesting for a period of time and then resolving on their own without intervention. There is presently no means of determining for whom the behavior will be temporary and for whom the behavior may be more persistent.

What Can Parents/Caregivers Do to Help?

Parents and other caregivers may play a crucial role in addressing BFRBs in young children. Here are a few strategies:

• Provide alternative soothing strategies. Introduce other self-soothing methods, such as soft toys, blankets, or even textured fidgets, to help divert the child’s attention away from the BFRB.
• Positive reinforcement. Encourage and praise children for engaging in alternative behaviors. This can reinforce more adaptive behaviors. Be careful to avoid punitive reactions, which may increase stress and escalate the behavior.
• Reduce environmental stressors and other BFRB cues. Identify and address situations that more often precede the behavior. Consistent routines, a calming bedtime environment, and sensory-friendly activities may benefit young children prone to BFRBs.
• Consult professionals. If hair-pulling, skin-picking, nail-biting, or another BFRB becomes a significant concern, consult a therapist with specialized expertise in BFRBs for guidance and support.

Body-Focused Repetitive Behaviors Essential Reads

The Overlooked Impact of Pulling Pet Hair

BFRB Treatment: Does a Child Have to Want to Stop?

While BFRBs in early youth may resolve with age, persistent, distressing, or disruptive symptoms can benefit from behavioral interventions that focus on stimulus control (minimizing the contextual triggers) and redirection of the behaviors. In a therapeutic setting, this behavioral therapy work is done with the caregivers, who learn to observe the behavior patterns and implement strategies for their child.

Conclusion

Hair-pulling, skin-picking, nail-biting, and other body-focused repetitive behaviors (BFRBs) in children under 5 can be alarming for caregivers, but understanding the behavioral cues and patterns may prove helpful. Most importantly, early recognition and gentle, nonpunitive interventions can go a long way in addressing these behaviors effectively. Although BFRBs in early youth may resolve after a period of time, persistent or distressing symptoms can be addressed through behavioral interventions involving stimulus control and redirection, with caregivers learning to observe and implement these strategies in a therapeutic setting. For parents facing this challenge, awareness of the behavior, patience, and support can make all the difference in helping a young child manage and overcome BFRBs.

To find a therapist, please visit the Psychology Today Therapy Directory.