Beyond the Habit: Understanding and Supporting Your Child with Body-Focused Compulsive Behaviors (BFCBs)

As a parent, you’ve likely seen your child twirl their hair, pick at a scab, or bite their nails. For most children, these are fleeting, harmless behaviors. But for some, these actions can escalate into something more, becoming what we call Body-Focused Compulsive Behaviors (BFCBs).

As a pediatric psychologist, I see the worry and confusion in parents’ eyes when they realize their child's "bad habit" is impacting their health, social life, or emotional well-being. This blog post is a guide to help you understand BFCBs and how to support your child.  I have treated each of the BFCBs described below in my 26-year career.

What Exactly Are Body-Focused Compulsive Behaviors (BFCBs)?

BFCBs are a group of repetitive self-grooming behaviors that involve a person's body and can result in physical damage. They are not just "habits"; they are complex, often driven by an urge or a feeling of "not-rightness" that can be difficult to resist. The main types of BFCBs include:

• Trichotillomania (Hair Pulling Disorder): The repetitive pulling out of one's hair, leading to noticeable hair loss. This can involve hair from the scalp, eyelashes, eyebrows, or other body parts.
• Excoriation (Skin Picking) Disorder: The repetitive picking at one's skin, resulting in skin lesions, scabs, or scarring. This can involve picking at acne, scabs, or perceived skin imperfections.
• Onychophagia (Nail Biting): Chronic, severe nail biting that can lead to damage of the nails and surrounding skin.
• Dermatillomania/Dermatophagia (Skin Picking/Biting): This includes picking or biting the skin around the nails, cuticles, or lips.  In rare cases it may appear as picking at the gums around the teeth, which can lead to gum recession, bleeding, and infections.

Unfortunately, each of these subtypes of BFCBs can eventually lead to open sores, infections, and scarring.

Etiologies and Contributing Variables: Why Does This Happen?

The exact cause of BFCBs is not fully understood, but it's believed to be a complex interplay of genetic, biological, and environmental factors.

• Genetics: BFCBs often run in families, suggesting a genetic predisposition.
• Neurobiology: Brain imaging studies have shown differences in brain circuits related to habit formation, emotional regulation, and impulse control in individuals with BFCBs.
• Emotional Regulation: BFCBs can sometimes be a way for children to cope with difficult emotions like anxiety, stress, boredom, or frustration. The act of pulling, picking, or biting can provide a temporary sense of relief or distraction.
• Sensory Soothing: The physical sensation of the behavior can be calming. Some children engage in these behaviors to "fix" a perceived sensory mismatch, like a loose hair or a rough patch of skin.

Comorbid Conditions: A Broader Picture

It's important to know that BFCBs often co-occur with other conditions. This is not because one causes the other, but rather because they may share common underlying vulnerabilities. Common comorbid conditions include:

• Anxiety Disorders: Generalized Anxiety Disorder, Separation Anxiety, and Social Anxiety are frequently seen alongside BFCBs.
• Attention-Deficit/Hyperactivity Disorder (ADHD): The restlessness and difficulty with impulse control associated with ADHD can sometimes contribute to BFCBs.
• Comorbid ADHD and Anxiety: These two conditions which occur in approximately 28% of children with a primary diagnosis of ADHD are one of the most common combined correlations with BFCBs.
• Obsessive-Compulsive Disorder (OCD): While BFCBs are no longer classified as a subtype of OCD, they share some similarities, such as the compulsive nature and difficulty stopping the behavior.
• Major Depressive Disorder: The presence of depression can make it harder for a child to resist the urges associated with BFCBs.
• Certain Seizure Disorders: In some cases, BFCBs can manifest as a subtle, repetitive movement during a seizure, especially with focal seizures that affect the parts of the brain responsible for motor movements. It is important to rule out a seizure disorder with a pediatric neurologist if the behaviors are sudden, involuntary, brief but reoccurring or a new development.  They may also pick at their clothes, not respond to their name and their facial/eye expression may appear “glazed”.

Course of Illness: What to Expect

BFCBs typically emerge in children ages 4-10 but can continue into adolescence, often during periods of stress or in young teens, even hormonal changes. The course of the condition is highly variable. For some, the behaviors may wax and wane over time, while for others, they can become a chronic issue if not addressed. Early intervention is key to preventing these behaviors from becoming deeply ingrained and to minimize the potential for physical and emotional harm.

What Parents Should and Shouldn't Do

Your role as a parent is crucial in creating a supportive environment.

What to Do:

• Educate Yourself and Your Child: Learning about BFCBs helps to destigmatize the condition. Explain to your child that this is not a "bad habit" they can simply "stop," but a real challenge that can be managed.
• Communicate Openly and Without Judgment: Create a safe space for your child to talk about their feelings and the urges they experience. Use "I" statements, such as "I've noticed your skin is irritated. I'm concerned and want to help."
• Focus on Problem-Solving, Not Blame: Frame the behavior as an external problem that you and your child can work on together.
• Provide Specific “Replacement Behaviors”: If you notice the behavior when your child is not engaged in an activity, ask them to do a “favor” for you that involves the use of their hands such as helping you put the silverware away.
• Teach Emotion Regulation Skills: Help your child identify and label their emotions. Teach them healthy coping strategies like deep breathing, mindfulness, or taking a break.

What to Avoid:

• Punishing or Scolding: Yelling, shaming, or punishing your child for the behavior will only increase their stress and anxiety, which can worsen the BFCB.
• Saying "Just Stop It": This is unhelpful and invalidates your child's experience. If they could "just stop," they would.
• Drawing Excessive Attention to the Behavior: Constant reminders to "stop pulling" or "stop picking" can be counterproductive and increase the child's self-consciousness.
• Attempting to Control It as the Parent: Sometimes even the most nurturing of parents will attempt to assist the child by holding their hand.  While this is what any kind and nurturing parent might attempt, the treatment goal is to assist the child or teen to “take control” of the behavior.

Evidence-Based Treatment

The good news is that BFCBs are highly treatable. The most effective approach typically involves a combination of psychological and, in some cases, medical interventions.

Psychological Treatment:

• Habit Reversal Training (HRT): This is the gold standard for BFCBs. It involves four key components:

1. Awareness Training: Helping the child recognize the triggers, urges, and situations that lead to the behavior.

2. Competing Response Training: Teaching the child to substitute the BFCB with a new, less harmful behavior. For example, instead of picking their nails, the child might squeeze their hands into a fist and count to five or sit on them for five seconds.

3. Social Support: Involving parents and other family members to provide positive reinforcement and support when the substitute behavior is observed.

4. Motivation and Compliance: Encouraging the child's commitment to the treatment plan.

• Acceptance and Commitment Therapy (ACT): ACT helps children learn to accept their urges and thoughts without acting on them. It focuses on clarifying values and committing to actions that align with those values, rather than being controlled by the BFCB.
• Dialectical Behavior Therapy (DBT): In teens, DBT can be helpful for those who struggle with significant emotional regulation. It teaches skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
• Special Replacement Tools: If recommended to you by your child’s psychologist, “replacement tools” such as small squeeze balls or “worry stones” may be a temporary “fix” in significant cases to limit risk of infection. These can be found easily online. Be sure and purchase “pediatric” sized that fit your child’s hands. Additionally, you may need to let the school know of their recommended use with a signed note from a fully licensed psychologist or physician. Some schools may require a “Section 504” plan allowing their use during the school day. Special Note: Fidgets are contraindicated and should not be used.

Medical Treatment:

While there are no medications specifically approved by the FDA for BFCBs, certain medications are sometimes used to help manage co-occurring conditions like anxiety or depression, which can in turn reduce the frequency of BFCBs. These may include:

• Selective Serotonin Reuptake Inhibitors (SSRIs): These are commonly used to treat anxiety and depression. While there are three SSRIs approved for use in pediatric psychopharmacology, sertraline and fluoxetine tend to have the best results with this condition.
• Stimulant Medication for ADHD: If there is a comorbid diagnosis of ADHD, certain stimulant medications are known to lesson BFCBs along with the core symptoms of ADHD.  But if the BFCBs began with the initiation of a new or higher dose of stimulant medication, consulting with the prescriber is a MUST. A small percentage of children may develop BFCBs or tics with their pharmacological treatment for ADHD.  Sometimes it can be as simple as switching to another stimulant medication or adding a very low dose of an alpha agonist, such as guanfacine or clonidine, which have a long history of both safety and efficacy.
• N-acetylcysteine (NAC): Some research suggests that this amino acid supplement may be helpful for reducing BFCBs, although significantly more research is needed and this pediatric psychologist in no way endorses its use.

A behavioral healthcare professional with prescribing privileges, such as a psychiatry practitioner or a pediatric neurologist, in consultation with the pediatric psychologist, should always be involved in the decision to use medication and to rule out other medical causes.

Doctoral trained pediatric psychologists are typically well versed in possible “medical” causes of BCFBs and should “leave no stone unturned” working collaboratively with your child’s pediatrician or referring to a physician specialty provider if there is any question in making a definitive diagnosis.

Final Thoughts

Learning that your child has a BFCB can be overwhelming, but you are not alone. By understanding the nature of these behaviors, approaching your child with empathy, and seeking evidence-based behavioral psychological treatment and occasionally medical treatment, you can provide the support your child or teen needs to manage their BFCB and thrive. Remember, the goal is not perfection, but progress and a healthier, happier life for your child.

As always, if I can be of assistance, please reach out.

Dr M