Tara Peris Ph.D.

Touchy Subject

For Kids With BFRBs, Summer May Not Be as Much Fun

Skin picking and hair pulling disorders make kids reluctant to go bare.

Posted Jun 28, 2018

by Christopher Flessner, Ph.D.

As a kid, I could not wait for summer vacation. No more school. No more waking up early (spoiler alert: turns out that ends once you get a job). No more dress code. I loved running through sprinklers, riding my bike to my friend’s house, playing basketball, etc. Looking back, and now watching my kids experience summer break, I cannot imagine what my childhood would have been like without those experiences. Working hard for 9 ½ months in order to get 2 ½ months of fun! I am sure many of you reading this blog had a similar excitement towards summer. Who wouldn’t?

The TLC Foundation for Body-Focused Repetitive Behaviors
Source: The TLC Foundation for Body-Focused Repetitive Behaviors

Unfortunately, there is a significant percentage of kids who may not be quite so “geeked” about summer. Estimates suggest that 0.6-3.4 percent and 1.4-5.4 percent of people suffer from Hair Pulling Disorder (HPD) or Skin Picking Disorder (SPD), respectively. (Grant et al., 2012; Woods & Houghton, 2014) Although both children and adults are affected, both mental health conditions demonstrate a childhood onset. What does that mean? If you are a parent, chances are your child has at least one friend in class who picks their skin, pulls their hair, or engages in some other form of body-focused repetitive behavior (BFRB; i.e., nail biting, teeth grinding). Thus, BFRBs are more common than most people think; however, this makes the repercussions of BFRBs no less severe.

BFRBs can be particularly devastating during childhood. Evidence suggests that pediatric BFRBs result in substantial social, school, and interpersonal impairment  (Franklin et al., 2008)  For example, imagine what your childhood would have been like if you avoided sprinklers, super soakers, and swimming at all costs. Not because you don’t like swimming. Far from it. Instead, you are concerned about the water ruining the meticulous job you or your parent undertook to style your hair so as to avoid the perceived embarrassment from others noticing your hairless patch(es). Not a swimmer in your youth? Imagine riding your bike over to your friend’s house on a 90° summer afternoon…..in long sleeves and long pants. You wear that clothing, of course, because you are worried what others might think if they saw the scabs and scars over your arms and legs from picking your skin.

Kids experiencing BFRBs are hit with a double-whammy. They happen to be caught in a developmental period already fraught with much angst and frustration pertaining to peers (i.e., insults, rejection) as well as parents (i.e., increased desire/need for independence). Now, they must also deal with the fallout from behaviors (i.e., hair pulling, skin picking) which, unless concealed, result in a clear change in their outward appearance and are ripe for comments from peers, siblings, and parents. Thus, it may not be too surprising that nearly 56 percent of children with HPD report avoiding social events because of their hair pulling (Franklin et al., 2008).

Pediatric BFRBs impact the entire family. In this respect, BFRBs are no different from many other mental health conditions demonstrating a childhood onset (e.g., obsessive-compulsive disorder, anxiety, etc.). Unlike these other conditions, however, far less public and scientific knowledge is available on the topic; thus, a level of secrecy, shame, and/or fear seems to develop around BFRBs. Based upon my clinical experience, parents of kids with HPD or SPD are often fraught with fear and angst about what is happening to their child. Imagine, for example, that one day your child started to develop symptoms (i.e., missing hair) that seemed to appear out of the blue. You had never seen nor heard of this sort of behavior previously. You’d probably call your pediatrician, yet they’d have only slightly more information on the topic than you. You’d tell your child to stop pulling or picking probably because, as most parents would, you think it is a behavior that can be easily controlled. It can’t (at least not for most). It is no wonder that many parents exhibit worry and concern.

Increased research, awareness, and outreach are the cure to some of the issues and concerns raised above. Helpful treatments do exist, despite underfunding for research within this realm. For example, behavior therapy (BT; stimulus control, habit reversal training) has been shown to work better than a minimal attention control condition (i.e., check-ins with family to see how things are going (Franklin, Edson, Ledley, & Cahill, 2011).

Research, however, is really the caboose. Awareness and outreach are the co-engines. As more accurate information is disseminated to pediatricians, school counselors, teachers, etc. BFRBs can move out of the shadows and lead to enhanced awareness and understanding. In turn, this will initiate greater interest among researchers in related areas (i.e., pediatric OCD, anxiety) who can bring new insights and directions to the field. The success of advances in research, awareness, and outreach will, I sincerely believe, lead to a better understanding and treatment of BFRBs. With a lot of hard word (and a little luck), maybe someday kids with and without BFRBs can have equally amazing summers!

Source: Flessner

Christopher A. Flessner, Ph.D. is an Associate Professor in the Department of Psychological Sciences at Kent State University and director of the Pediatric Anxiety Research Clinic (PARC) at Kent State. He is also a licensed clinical psychologist specializing in working with children and actively sees patients through Kidslink Neurobehavioral Center in Northeast Ohio. His clinical interests  are in developmental psychopathology, with a particular interest in evidence-based treatments for pediatric anxiety and related disorders. His research interests focus upon developing a more comprehensive understanding of risk factors implicated in the development, maintenance, and treatment of pediatric anxiety, OCD, and BFRBs. Dr. Flessner is a member of the TLC Foundation for Body-Focused Repetitive Behaviors’ scientific advisory board.


Franklin, M. E., Edson, A. L., Ledley, D. A., & Cahill, S. P. (2011). Behavior therapy for pediatric trichotillomania: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry, 50(8), 763-771. doi:10.1016/j.jaac.2011.05.009

Franklin, M. E., Flessner, C. A., Woods, D. W., Keuthen, N. J., Piacentini, J. C., Moore, P., . . . Trichotillomania Learning Center-Scientific Advisory, B. (2008). The child and adolescent trichotillomania impact project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization. J Dev Behav Pediatr, 29(6), 493-500. doi:10.1097/DBP.0b013e31818d4328

Grant, J. E., Odlaug, B. L., Chamberlain, S. R., Keuthen, N. J., Lochner, C., & Stein, D. J. (2012). Skin picking disorder. Am J Psychiatry, 169(11), 1143-1149. doi:10.1176/appi.ajp.2012.12040508

Woods, D. W., & Houghton, D. C. (2014). Diagnosis, evaluation, and management of trichotillomania. Psychiatr Clin North Am, 37(3), 301-317. doi:10.1016/j.psc.2014.05.005

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