10 Things Every Pediatrician Should Know About BFRBs

How pediatricians can address hair pulling, skin picking, and related disorders.

Posted Nov 13, 2018

The following guest post was authored by Fred Penzel, Ph.D, a licensed psychologist who specializes in the treatment of BFRBs and OCD.

 F. Penzel
Dr. Fred Penzel, psychologist.
Source: F. Penzel

Body-focused Repetitive Behaviors (BFRBs), a group of disorders that includes hair pulling disorder, excoriation disorder (compulsive skin picking), and nail-biting, represent a group of problems not well recognized or understood by health professionals. Even psychologists, psychiatrists, and dermatologists may not always get it right, and so it should come as no surprise that pediatricians are not as well educated about them as they could be. As a psychologist, over the years I have seen countless examples of how these child specialists, when faced with a BFRB, would brush it off with such statements as, “It’s just a phase,” “Give it time—they’ll grow out of it,” “They must be really stressed out,” or “It’s just a bad habit.” Their suggestions can include punishing the child for the behavior, rewarding the child for not doing the behavior, putting bandages on their fingers, or having them wear hats.

I recently saw a case of a young adolescent girl taken to a dermatologist who examined the patient and simply sent her home with a prescription for a topical steroid cream. In another case, a pediatrician called a child’s hair-pulling "a bad habit" and recommended that the mother punish her child whenever she was spotted pulling her hair. No attempt was made to understand what was going on or to make a real diagnosis.This is, unfortunately, all too typical.

 My suggestions for medical professionals would be as follows:

1.     When you see a child with hair loss, do not neglect to ask if they pulled it out themselves. If there are scabs or skin wounds, ask if they did this to their own skin. Do not be surprised if you are met with excuses or denial, as many children and adults with BFRBs feel extremely stigmatized and may be reluctant to admit to doing it.

2.     These disorders have a great deal of emotional fallout and can be great sources of shame and isolation. Watch your own reactions when encountering people with BFRBs. Things like tone of voice, body language, facial expressions, and the way you examine them can have a very powerful impact. Try to be more reassuring that many other children and young people do these types of things also, and that this doesn’t make them abnormal or "bad" people.

3.     As far as we know, females with BFRBs may outnumber males at a ratio of 9 to 1.

4.     If necessary, also try to reassure parents that the pulling or picking is not a sign of some serious underlying disturbance, and can be effectively treated with the right type of therapy. Also, try to discourage parents from blaming themselves.

5.     Don’t simply assume that hair pulling and skin picking are due to stress, are a sign of some other deep underlying problem, or are some kind of developmental phase. These behaviors are much more complex than that and need to be understood. Aside from a minority of very early onset cases seen in toddlers that eventually resolve themselves, they are not simply developmental and can be lifelong. 

6.     Don’t assume the pulling or picking behaviors are a reaction to some kind of hardship or trauma, like abuse. These behaviors are largely due to sensory issues, and are most often done when a child is either understimulated (bored or sedentary) or overstimulated (stressed or even happily excited).

7.     In the case of hair pulling, be sure to inquire about whether or not the child is swallowing the hairs. Such behavior can lead to the formation of Trichobezoars. which then have to be removed surgically and can be life-threatening.

8.     Try to educate yourself about BFRBs. As a group, they involve around 5 percent of the population, so you will undoubtedly encounter them in your practice. The information is out there.  The TLC Foundation for Body-Focused Repetitive Behaviors provides an excellent source at bfrb.org.

9.     BFRBs can be effectively treated via a type of comprehensive behavioral therapy, but only as practiced by those who have specialized training and experience with these disorders. Ordinary talk or play therapy, or such approaches as relaxation training or hypnosis have never been shown to be effective interventions.

10.  Develop a list of referral sources in your region of specialized behavioral therapists who treat BFRBs, and don’t hesitate to send people to them for treatment. Effective treatment is out there if you take the time to look. You can get names from the TLC Foundation and also the Association for Behavioral and Cognitive Therapy.

Here are some simple screening questions you can ask if you spot hair loss or skin damage:

1.     Do you pull out your hair or pick your skin?

2.     How often do you do this?

3.     Do your parents know that this is happening?  (If the answer is ‘Yes,’ then ask, “Are they doing anything to help you with this?”

4.     Is it causing you any problems in school or with other kids?

5.     Would you like to get some help for it?

By helping patients and their parents realize that BFRBs are both relatively common and particularly difficult to resolve without intervention, you can save people years of shame and isolation and start them on the path to recovery.

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