Body-focused Repetitive Disorders: Hair Pulling, Skin Picking and Biting

Body-focused Repetitive Behaviors (BFRBs) have long been among the most poorly understood, misdiagnosed, and undertreated groups of disorders. The term BFRBs refers to a group of disorders that include hair pulling, compulsive skin picking, compulsive nail biting, biting the insides of the cheeks, lip picking, blemish squeezing, nose picking, etc. Although lightly regarded as “nervous habits” by many, they can have serious negative impact upon sufferers.

What Exactly Are BFRBs?

These are a group of behaviors in which an child damages his or her appearance or causes physical injury through:

• Biting the inside of the cheek
• Blemish picking or squeezing, causing scarring and infections
• Hair pulling to the point of having seriously thinned hair or bald spots, missing eyebrows, or eyelashes
• Nail and/or cuticle biting, causing bleeding or infected fingertips
• Skin picking, resulting in scabs, sores that never heal, holes in the skin, and scarring

These behaviors may be performed when the child is stressed or excited, or bored or inactive. Hours may be spent in these activities, taking children away from family or school activities. Depression, shame, and isolation can also result. BFRBs most often begin in late childhood or in the early teens, and may affect at least 1 out of 20 people. While once thought to be rare and impossible to treat, we now know that neither of these ideas is true. While it is not always easy to find practitioners who can treat these disorders, there are a growing number of resources, and the picture is gradually improving.

BFRBs and the Family—

BFRBs can seem extremely mysterious to family members and spouses, who at first, view them merely as bad habits, but then become more concerned when they begin to seriously damage the sufferer's appearance or cause emotional problems. The fact that many sufferers seem to be unaware they are doing these things, or report that the behaviors can be pleasurable or relaxing, can be even more puzzling and upsetting. Fighting sometimes occurs in families over the issue of these seemingly uncontrollable behaviors. Parents may scold or punish children who persist in doing these things, and spouses or significant others, at times, seem to take the sufferer's disorder personally, blaming them for an unsightly appearance. They can sometimes react as if the sufferer is having this problem just to make their lives difficult. These others may take it upon themselves to get the sufferer to stop, constantly calling the behavior to their attention, or simply telling them they must stop, leading to angry scenes and disputes.

As one patient told their angry and impatient spouse, "Do you actually imagine for one moment that I want to do these things? Don't you think I'd stop if I could?" Having a BFRB is a frustrating and upsetting experience, and negative attention from others can add to the stress.

Denial is another approach families take, and has prevented many sufferers, especially children, from being allowed to get the help they badly need. When it is impossible to ignore symptoms in a child or an adult, they may be minimized or explained away as being nervous habits, laziness, childish behavior, attempts to get attention, or get even. In the case of children, pediatricians or family physicians can unwittingly aid in this, telling families to "wait and see" or "they will grow out of it."

What Are Other Signs of BFRBs?

Many of the signs of BFRBs can be well hidden, and only revealed by accident. Many sufferers do such things as styling their hair to cover bald spots, wearing wigs or hair weaves, penciling in eyebrows, wearing clothing that hides skin damage, or keeping their hands behind their backs or in their pockets as much as possible, to name a few. Sufferers may go to great lengths to not undress or take their hair down in front of spouses. Children may suddenly refuse to go to school, to avoid being teased or reprimanded by their teachers. Adults may shy away from social situations, work, or job interviews. Feelings of depression are also very common.

When Should Someone Seek Help?

It is important for sufferers to find help when it becomes evident that the behavior is out of control and is starting to limit their lives or affect the sufferer's relationships. It may be clear at this point, that different attempts at stopping have not worked, and are not going to work. Along with these, there may also be emotional problems such as depression, substance abuse, or the avoidance of school, social events, or work that can also be warning signs. Frequent family fights or disputes over the behavior should also be indicators that some type of help is needed.

How Are BFRBs Treated?

There are three main types of help. These are behavioral therapy, medication, and family therapy. Ordinary talk therapy alone has not been shown to be of much help. Behavioral therapy usually consists of two approaches: Habit Reversal Therapy (HRT), which teaches the sufferer a set of alternative behaviors that can help them focus themselves, interrupt, and block the behavior, and Stimulus Control (SC), which teaches them how to identify, change, and control the different triggers present in their routines, environments, and moods that lead to the behaviors. Medication can be of help in some cases, although it does not seem to be equally effective for everyone. It should be regarded as a tool to help with behavior therapy. Medicinal use is advised when the urge to do the behaviors is so strong that the child feels it's irresistible and cannot follow behavioral therapy instructions.

Family therapy can be extremely valuable in a number of ways, and can make important contributions in healing the family, and aiding the sufferer's recovery. First, it can help family members to accept the problem, to not blame the sufferer, and to not become over-involved in the symptoms or treatment. It can also be of help in calming situations where fighting and conflict have resulted. Another contribution family therapy can make is to help those close to the sufferer to be patient about setbacks and lapses, which are not unusual.

How Do You Find Treatment?

When seeking help for BFRBs, it is extremely important to find practitioners who specialize in these disorders, and have the experience necessary to design a treatment program. Many kids begin with behavioral therapy, usually done by a behaviorally trained marriage and family therapist, psychologist, or social worker, and if medication is necessary, they will then seek out a psychiatrist who understands these problems. There are not great numbers of specialists out there, and a good place to begin seeking referrals is with the Trichotillomania Learning Center (www.trich.org) in Santa Cruz, CA.

Online Parent Support


Resources—

• "Bad Hair Life," Without question, the definitive video documentary on TTM. This is a must-see for all those with the disorder, and their significant others. It is available from Fanlight Productions (www.fanlight.com) 800-937-4113.
• Help for Hair Pullers: Understanding and Coping with Trichotillomania, Nancy J. Keuthen, Ph.D., Dan J. Stein, M.D., and Gary A. Christenson, M.D., New Harbinger Publications, Oakland, CA, 2001. An excellent guide written by three acknowledged experts and top researchers in the field of TTM.
• Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well, Fred Penzel, Ph.D., Oxford University Press, New York, 2000. A compendium of self-help information for those who suffer from OCD, BDD, Trichotillomania, Compulsive Skin Picking, and Compulsive Nail Biting.
• The Hair Pulling Problem: A Complete Guide to Trichotillomania, Fred Penzel, Ph.D., Oxford University Press, New York, 2003. This represents the latest, largest, and most comprehensive self-help book for hair pullers now available.
• The Hair-Pulling "Habit" and You (Revised Ed.), Ruth Golomb and Sherrie Vavrichek, Writers' Cooperative of Greater Washington, Silver Spring, Maryland, 2000. A very good self-help workbook for children with trichotillomania.
• The Trichotillomania Learning Center (TLC) (www.trich.org), Santa Cruz, CA. A nonprofit foundation, TLC is the premiere organization for BFRB sufferers, and provides support, information, and referrals.

Talking to Children & Teens about Drugs

Just as you inoculate your children against illnesses like measles, you can help "immunize" them against drug use by giving them the facts before they're in a risky situation.

When children don't feel comfortable talking to moms and dads, they're likely to seek answers elsewhere, even if their sources are unreliable. Children who aren't properly informed are at greater risk of engaging in unsafe behaviors and experimenting with drugs.

Preschool to Age 7—

Before you get nervous about talking to young children, take heart. You've probably already laid the groundwork for a discussion. For instance, whenever you give a fever medication or an antibiotic to your youngster, you have the opportunity to discuss the benefits and the appropriate and responsible use of those drugs. This is also a time when your youngster is likely to be very attentive to your behavior and guidance.

Start taking advantage of "teachable moments" now. If you see a character on a billboard or on TV with a cigarette, talk about smoking, nicotine addiction, and what smoking does to a person's body. This can lead into a discussion about other drugs and how they can potentially cause harm.

Keep the tone of these discussions calm and use terms that your youngster can understand. Be specific about the effects of the drugs: how they make a person feel, the risk of overdose, and the other long-term damage they can cause. To give your children these facts, you might have to do a little research.

Ages 8 to 12—

As your children grow older, you can begin conversations with them by asking them what they think about drugs. By asking the questions in a nonjudgmental, open-ended way, you're more likely to get an honest response.

Children this age usually are still willing to talk openly to their moms and dads about touchy subjects. Establishing a dialogue now helps keep the door open as children get older and are less inclined to share their thoughts and feelings.

Even if your question doesn't immediately result in a discussion, you'll get your children thinking about the issue. If you show your children that you're willing to discuss the topic and hear what they have to say, they might be more willing to come to you for help in the future.

News, such as steroid use in professional sports, can be springboards for casual conversations about current events. Use these discussions to give your children information about the risks of drugs.

Ages 13 to 17—

Children this age are likely to know other children who use alcohol or drugs, and to have friends who drive. Many are still willing to express their thoughts or concerns with moms and dads about it.

Use these conversations not only to understand your youngster's thoughts and feelings, but also to talk about the dangers of driving under the influence of drugs or alcohol. Talk about the legal issues — jail time and fines — and the possibility that they or someone else might be killed or seriously injured.

Consider establishing a written or verbal contract on the rules about going out or using the car. You can promise to pick your children up at any time (even 2:00 AM!) no questions asked if they call you when the person responsible for driving has been drinking or using drugs.

The contract also can detail other situations: For example, if you find out that someone drank or used drugs in your car while your son or daughter was behind the wheel, you may want to suspend driving privileges for 6 months. By discussing all of this with your children from the start, you eliminate surprises and make your expectations clear.

Laying Good Groundwork—

No parent, youngster, or family is immune to the effects of drugs. Some of the best children can end up in trouble, even when they have made an effort to avoid it and even when they have been given the proper guidance from their moms and dads.

However, certain groups of children may be more likely to use drugs than others. Children who have friends who use drugs are likely to try drugs themselves. Those feeling socially isolated for whatever reason may turn to drugs.

So it's important to know your youngster's friends — and their moms and dads. Be involved in your children's lives. If your youngster's school runs an anti-drug program, get involved. You might learn something! Pay attention to how your children are feeling and let them know that you're available and willing to listen in a nonjudgmental way. Recognize when your children are going through difficult times so that you can provide the support they need or seek additional care if it's needed.

A warm, open family environment — where children are encouraged to talk about their feelings, where their achievements are praised, and where their self-esteem is bolstered — encourages children to come forward with their questions and concerns. When censored in their own homes, children go elsewhere to find support and answers to their most important questions.

Online Parent Support

Children's Attachment Relationships

A number of childhood problems are particularly worrisome to moms and dads. Lying, stealing, anger or aggression, refusal to follow family rules, withdrawal, and depression are just a few of them. In addition, parents may be troubled because they do not feel a sense of connection with their youngster even at a very early age, or they secretly find their youngster unusually frustrating or even unlikable.

A common feature of parent-child relationships that underlies or runs parallel to many of these troublesome problems is an insecure attachment. Because kid’s early attachment relationships govern other relationships throughout life, early intervention is a key to reducing the long-term effects of attachment difficulties.

What Should I Know About Attachment Relationships?

Attachment is a biologically based strategy that provides emotional and physical protection for kids. Even before birth, a foundation is laid for the bond between a mother and her infant. Attachment relationships begin developing at birth and are generally fully established by eighteen months of age. Infant behaviors such as crying when separated from the parent, seeking proximity to the parent, using the parent as a secure base, and joyfully greeting the parent after separation are attachment-based. Secure attachment results when moms and dads respond sensitively to their kid’s cues and responses.

Research has indicated that school-age kids who are securely attached are more cooperative with their parents, more inclined to competently explore the environment, and more likely to get along with their peers.

Unfortunately, as many as 30% of kids develop insecure attachment relationships with their moms and dads. Insecure attachment may take the form of avoidant, distant behavior or anxious clinging behavior. When kids have insecure attachments with their parents, any number of negative consequences can follow, such as depression, anxiety, a lowered ability to cope with stress, and poor relationships with others.

A disruption in the development of secure attachment could occur due to parental illness, parental unavailability because of other life commitments, or the serious illness of the youngster. Kids who move from foster home to foster home or spend the early years of their lives in orphanages can experience long-term attachment difficulties. In addition, kids sometimes have inborn temperaments or disabilities that can impede the attachment process. Finally, kids who are abused or neglected or otherwise traumatized will often show signs of impaired attachment.

When Should I Seek Help?

Therapy for attachment difficulties may be the primary treatment or may be used along with other therapy. The following are signs of distress that should not be ignored:

When your youngster-

• Defiantly opposes your efforts to set limits more often than not.
• Displays anger that does not seem normal.
• Has difficulty regulating strong emotions.
• Is constantly manipulative, beyond the normal range for kids.
• Is exceptionally clingy to you most of the time, to the point of distress, and there are no other circumstances to explain the clinginess.
• Is frequently distant and doesn’t accept help from you.
• Is hurtful to animals or threatening to other kids or adults.
• Lies or steals despite your interventions and beyond the normal testing of kids.
• Seems more affectionate with strangers than with family members.
• When you feel disconnected from your youngster for long periods of time.

Moms and dads should also consider treatment for a youngster who is affected by autism and other pervasive developmental disorders such Aspergers; for a youngster who experiences Attention-Deficit/Hyperactivity Disorder (ADHD); as well as for a foster or adoptive youngster who is having difficulty forming relationships. In all of these childhood problems, kids have difficulties interacting with other people, and attachment therapies can effectively address and treat these problems.

What Is Therapy Like?

There are various models of therapy that are used for treating attachment problems. Moms and dads should explore the treatment options available by consulting with a licensed marriage and family therapist. Because attachment has to do with family relationships, therapists with degrees and licenses in family therapy are an excellent choice.

Typical therapy for attachment problems will include both the parent(s) and youngster. Initially, moms and dads meet with the therapist or, in some models, a team of two therapists, who will ask the parents to describe their experiences with the youngster during pregnancy, and from birth to the present. Parents will also discuss their current concerns regarding the youngster. Therapists may meet with the individual youngster for a period of time while the parents observe, meet with the moms and dads alone, or with parents and the youngster together, but parents fully participate in attachment therapy from beginning to end.

Attachment therapies often involve fun and rewarding activities that enhance the attachment bond while dealing with serious issues. In some cases, attachment therapies can reach their therapeutic goals within approximately twenty sessions.

Secure and insecure attachment relationships are present in every racial and ethnic group. However, how attachment relationships are expressed within these groups can vary greatly. A sensitive therapist will recognize that your youngster’s attachment relationship may well be influenced by cultural differences and adapt their therapy accordingly.

Online Parent Support

Teen Substance Abuse

Being an adolescent and raising a adolescent are individually, and collectively, enormous challenges. For many adolescents, illicit substance use and abuse become part of the landscape of their teenage years. Although most adolescents who use drugs do not progress to become drug abusers, or drug addicts in adulthood, drug use in adolescence is a very risky proposition. Even small degrees of substance abuse (for example, alcohol, marijuana, and inhalants) can have negative consequences. Typically, school and relationships, notably family relationships, are among the life areas that are most influenced by drug/alcohol use and abuse.

One of the most telling signs of an adolescent's increasing involvement with drugs is when drug use becomes part of the adolescent's daily life. Preoccupation with drugs can crowd out previously important activities, and the manner in which the adolescent views him or herself may change in unrealistic and inaccurate directions. Friendship groups may change, sometimes dramatically, and relationships with family members can become more distant or conflictual. Further bad signs include more frequent use or use of greater amounts of a certain drug, or use of more dangerous drugs, such as cocaine, amphetamines, or heroin. Persistent patterns of drug/alcohol use in adolescence are a sign that problems in that adolescent's environment exist and need to be addressed immediately.

What causes adolescent substance abuse?

There is no single cause of adolescent drug/alcohol problems. Drug/alcohol abuse develops over time; it does not start as full-blown abuse or addiction. There are different pathways or routes to the development of an adolescent's drug/alcohol problems. Some of the factors that may place adolescents at risk for developing drug/alcohol problems include:

• family conflict
• favorable parental attitudes toward adolescent alcohol and drug/alcohol use, and parental alcoholism or drug use
• inconsistent and excessively severe discipline
• insufficient parental supervision and monitoring
• lack of communication and interaction between moms and dads and kids
• poorly defined and poorly communicated rules and expectations
against drug/alcohol use

It is important to also pay attention to individual risk factors. These include:

• difficulty maintaining emotional stability
• high sensation seeking
• impulsiveness
• perceived low harmfulness to use
• perceptions of extensive use by peers
• psychological distress

How do you know when to seek help?

The earlier one seeks help for their adolescent's behavioral or drug/alcohol problems, the better. How is a parent to know if their adolescent is experimenting with or moving more deeply into the drug culture? Above all a parent must be a good and careful observer, particularly of the little details that make up an adolescent's life. Overall signs of dramatic change in appearance, friends, or physical health may be signs of trouble. If a parent believes his or her child may be drinking or using drugs, here are some things to watch for:

 Physical evidence of drugs and drug paraphernalia
 Physical changes such as bloodshot eyes, runny nose, frequent sore throats, rapid weight loss
 Lying or increased evasiveness about after school or weekend whereabouts
 Hostility, irritability, or change in level of cooperation around the house
 Emotional distancing, isolation, depression, or fatigue
 Dizziness and memory problems
 Decrease in interest in personal appearance
 Changes in mood, eating, or sleeping patterns
 Change in friendships or extreme influence by peers
 Behavior problems and poor grades in school

What kinds of treatment will work?

Evidence shows that certain forms of family therapy are the most effective treatments for drug/alcohol problems. A qualified Marriage and Family Therapist can evaluate and assess an adolescent's substance abuse problem, and will then provide appropriate treatment for the adolescent, which may include outpatient therapy or therapy in a residential treatment facility. Therapy will focus on a number of important life areas of the adolescent, in addition to his or her relationships with moms and dads. It is essential for parents to be involved in the adolescent's treatment. Relationships are a critical ingredient to combat an adolescent's drug/alcohol problems.

How can I help my adolescent avoid substance abuse?

Parents and guardians need to be aware of the power they have to influence the development of their kids throughout the teenage years. Adolescence brings a new and dramatic stage to family life. The changes that are required are not just the adolescent's to make; moms and dads need to change their relationship with their adolescent. It is best if moms and dads are proactive about the challenges of this life cycle stage, particularly those that pertain to the possibility of experimenting with and using alcohol and drugs.

Parents cannot be afraid to talk directly to their kids about drug/alcohol use, even if they have had problems with drugs or alcohol themselves. An excellent resource on how to talk to kids about drugs is Parents - The Anti-Drug (www.theantidrug.com). Moms and dads are encouraged to give clear, no-use messages about smoking, drugs, and alcohol. It is important for kids and adolescents to understand that the rules and expectations set by parents are based on parental love and concern for their well being. Parents should also be actively involved and demonstrate interest in their adolescent's friends and social activities. Spending quality time with adolescents and setting good examples are essential. Even if problems such as substance abuse already exist in the adolescent's life, parents and families can still have a positive influence on their adolescent's behavior.


Online Parent Support

Books:

· Boys into Men: Raising our African American Teenage Sons. By Nancy Boyd Franklin and AJ Franklin. EP Dutton (2000).

· Field Guide to the American Teenager: A Parent's Companion. By Joseph DiPrisco and Michael Riera. NY: Perseus Book Group (2000).

· Raising Emotionally Intelligent Teenagers: Parenting with Love, Laughter, and Limits. By Maurice Elias, Steven Tobias, Brian Friedlander, and Gotham Chopra. NY: Harmony Books (2000).

· Reviving Ophelia: Saving the Selves of Adolescent Girls. By Mary Pipher. NY: Ballantine Books (1995).

· When Nothing Matters Anymore: A Survival Guide for Depressed Teens. By Bev Cobain and Elizabeth Verdick. NY Free Spirit Publishing (1998).

· You and Your Adolescent. By Laurence Steinberg and Ann Levine. NY: Harper/Collins (1997).

Organizations and Internet Sites:

Marijuana: Facts for Teens
http://165.112.78.61/MarijBroch/Marijteens.html
Provides information about marijuana on a level that teens can relate to, such as its effects on school activities and how to quit using the drug.

Marijuana: Facts Parents Need to Know:
http://165.112.78.61/MarijBroch/MarijParentsN.html
Gives information for parents about marijuana, its uses and effects, as well as tips on talking to your child about marijuana.

Parents - The Anti-Drug
www.theantidrug.com
Provides advice, information, and resources for parents who are battling adolescent drug abuse.

Partnership for a Drug-Free America
www.drugfreeamerica.org
Latest news on drugs, stories of recovery and treatment, as well as help for teens and parents.

Talking with Kids about Tough Issues
www.talkingwithkids.org
Provides instructions and information for parents when talking to their children about issues such as drug and alcohol use, HIV and AIDS, violence, and sex.

Teen Drug Use and Abuse Prevention
www.parentingteens.com
Gives parents information on drugs, as well as how to talk to their teens about certain substances.

Tips 4 Youth
www.cdc.gov/tobacco/tips4youth.htm
Details reasons why smoking is such a health risk, as well as how youth can find help to quit smoking.