Body-Focused Repetitive Behaviors

Younger and older humans, like animals, engage in habits, also known as repetitive behaviors. Some human habits include tapping your fingers on a flat surface when thinking, thumb sucking, tapping a pencil on a desk during a test, shaking your foot when your ankles are crossed or twirling your hair.


There isn’t anything wrong with regularly demonstrating these actions. In most cases, minimal attention is given to these habits or “quirks.” Yet, some of the same behaviors, when repetitive and excessive, can cause interference with everyday functioning and cross over from being just a behavior to being a diagnosable mental health disorder – a pattern of behavioral or psychological symptoms that impact multiple life areas and/or create distress for the person experiencing the symptoms. Because children are less aware of others’ perceptions and societal norms, parents are likely to be the ones experiencing distress or negative impact as a result of a child’s behavior.


Children and adolescents who are seen regularly engaging in skin picking, nail biting, hair pulling, lip biting or cheek biting, whereby there are physical and visual ramifications, are technically demonstrating a body-focused repetitive behavior (BFRB). BFRB is a catch-all category for impulse-control behaviors causing damage. Research and public awareness of mental health disorders in children tends to be focused on attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD) and anxiety disorders; therefore it’s helpful to compare and contrast with these disorders when discussing BFRBs.


BFRBs may cause difficulties with focus and concentration because the behavior can be distracting. While this mirrors one symptom of ADHD, a BFRB is not ADHD. A BFRB is expressed through compulsive behavior. Yet it is not the same as OCD because OCD is diagnosed as a result of engaging in behaviors to get away from anxiety; one struggling with a BFRB may not report feelings of anxiety. This is what also differentiates a BFRB from an anxiety disorder. So, while some disorders can have overlapping symptoms, being diagnosed with the right disorder has important implications for treatment for your child.


Here are some things parents can look for to know if a child is expressing a BFRB:


* Look for constant hair stroking, touching or twirling because this may (but not always) be a warning that hair pulling is on the horizon. Scan your child’s body and scalp (bath time is a great opportunity) for scabs, pick marks or bald patches.


* Red, peeling or bleeding lips can be an indication of lip biting.


* Does your child seem to be holding things in, seem burdened or appear to have mood swings? If yes, encourage your child to express her emotions. In discussing emotions, pay attention to how well your child is able to name and share his or her emotions based on what is developmentally appropriate. Make sure your child knows what different emotions are and what they may feel like. Pictures, stories and movies can serve as a clear example of how to demonstrate those emotions. Encourage expression, which can be done verbally, through art or through play. BFRBs can develop to regulate emotion or self-soothe.


* Does your child seem to be overly annoyed, reactive or distracted by lots of visual stimulation or sound in the environment? In many cases, there is a sensory component to skin picking, nail biting or hair pulling, for example.


When seeking a diagnosis, while pediatricians are familiar with these behaviors, it may be best to find a BFRB specialist. Do not seek medication as the first line of defense. In most cases, an antidepressant/antianxiety medication seems to strengthen or magnify the behavior instead of help.


Some children and teens grow out of the behavior, while others do not. Typically, the younger the child at the time the behavior started, the more he is likely to grow out of the behavior. It is important to take the issue seriously and find someone who can offer effective treatment. Proper treatment approaches include behavioral therapy, cognitive behavioral therapy and acceptance and commitment therapy. For younger children, behavioral therapy, art therapy and play therapy are great places to start.


Most children and teens do not understand why this behavior is happening, when it started or how to stop. By remaining patient, loving and supportive, your child will be able to work on addressing the BFRB in an encouraging and hopefully stress-free environment.


Lindsey M. Muller, M.S., LPCCI, is a mental health therapist and BFRB coach. A former skin picker, nail biter, and hair puller, Lindsey works with parents of children, adult clients and adolescent clients who struggle with a BFRB, OCD and other anxiety disorders, and disordered eating. She is the author of a psychology memoir about BFRBs titled Life is Trichy.



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