Understanding BFRBs: Why Kids and Teens Pull Hair or Pick Skin

If you’ve noticed your child or teen pulling out their hair, picking at their skin, or repeatedly touching certain areas of their body to the point of irritation or injury, you are not alone. And just as importantly, this behavior is not a sign of bad parenting, defiance, or a lack of willpower.

Body-Focused Repetitive Behaviors (BFRBs) are common, deeply misunderstood, and often emotionally exhausting for families. Parents frequently arrive feeling worried, confused, and unsure how to help. Many have already tried reminding, correcting, pleading, bribing, or even punishing the behavior, only to feel heartbroken when nothing seems to work.

This blog will highlight what is really going on when kids and teens pull hair or pick skin, and what actually helps.  

What Are BFRBs?

Body-Focused Repetitive Behaviors (BFRBs) are a group of conditions in which individuals repeatedly engage in behaviors that damage their hair, skin, or body tissues. The most commonly recognized BFRBs include:

• Hair pulling (trichotillomania)
• Skin picking (excoriation disorder)

Other BFRBs can include nail biting, cheek biting, lip biting, or repetitive rubbing and touching behaviors.

These behaviors are not habits in the casual sense. They are not done “for attention,” and they are not easily stopped through willpower alone. For many kids and teens, BFRBs happen automatically, outside of conscious awareness, or during moments of stress, boredom, fatigue, or emotional overload.

Trichotillomania: When Hair Pulling Takes Over

Trichotillomania is a condition in which a person experiences repeated urges to pull out hair from the scalp, eyebrows, eyelashes, or other parts of the body. Some kids describe the urge as a sensation that doesn’t feel “right” until the hair is pulled. Others don’t realize they’re doing it until they see hair on their hands or on the floor or someone else has pointed out the behavior to them.

In children and teens, hair pulling often begins subtly:

• Twirling or tugging at hair while reading or watching TV
• Pulling during homework or at bedtime
• Targeting a specific spot that “feels different”

Over time, this can lead to noticeable hair loss, bald patches, broken hair, and significant embarrassment or distress.

If you’re searching for information about trichotillomania or where to find treatment in Houston, you’re likely already aware that this condition can feel isolating and overwhelming. The good news is that with the right treatment, kids and teens can absolutely learn to manage hair pulling more effectively.

Skin Picking Disorder: Sores and Painful Scabs Can Lead to Scars or Infections

Skin picking disorder (also called excoriation disorder) involves repetitive picking at the skin that leads to sores, scabs, scars, or infections. Kids may pick at acne, bug bites, scabs, cuticles, or perceived “imperfections.”

Parents often tell us:

• “They don’t even notice they’re doing it.”
• “They pick until they bleed.”
• “When we tell them to stop, it gets worse.”

This is a common experience. Asking a child to “just stop picking” misunderstands the nature of the behavior.

If you’re looking for help with skin picking disorder in Houston, it’s important to know that skin picking is often driven by sensory urges, emotional regulation needs, or both. It is not about vanity, stubbornness, or lack of discipline.

But… Why Do Kids and Teens Develop BFRBs?

This is one of the most important questions parents ask, and the answer is rarely simple.

Sensory Regulation

For many kids, BFRBs serve a sensory function. The sensation of pulling or picking may feel soothing, relieving, or satisfying. Over time, the brain learns that this sensation temporarily reduces internal discomfort.

Emotional Regulation

BFRBs often show up alongside anxiety, stress, perfectionism, boredom, or emotional overwhelm. Pulling or picking can briefly reduce tension, even if shame or frustration follows afterward.

Automatic vs. Focused Behaviors

Some kids engage in BFRBs automatically, without awareness (often during screens, reading, or bedtime). Others experience focused urges, where they feel a strong pull to act and struggle to resist it. Many kids experience both.

Brain Wiring, Not Parenting

BFRBs are rooted in how the brain processes urges, reward, and inhibition. They are neurobehavioral conditions, not the result of poor parenting or lack of structure.

What BFRBs Are Not

• They are not attention-seeking
• They are not self-harm
• They are not defiance
• They are not caused by laziness or weakness

Shame almost always makes BFRBs worse.

The Emotional Toll on Kids and Teens

Kids with BFRBs often experience embarrassment, anxiety, and fear of being noticed. Teens may wear hats, hoodies, makeup, or avoid social situations entirely. Many believe they are the only ones struggling with this kind of behavior.

One of the most powerful moments in therapy is when a child realizes:
“This has a name. Other kids struggle with this. It’s not just me!”

How Parents Often (Understandably) Respond

Most parents are doing the best they can with the information they have. Common responses include:

• Pointing out the behavior repeatedly
• Asking them to stop
• Taking away mirrors or tools
• Threatening consequences

While well-intentioned, these approaches often increase anxiety, shame, and secrecy.

The goal is not to control the behavior through force, but to help your child build awareness, and skills -  and for parents to express compassion and unconditional positive regard in a way that comes across for your child.

How We Treat BFRBs: ComB, HRT, and Evidence-Based Care

Effective treatment for BFRBs goes beyond simply trying to stop the behavior. At Houston Anxiety and Wellness Center, we use Comprehensive Behavioral Treatment (ComB) as the foundation for care, alongside Habit Reversal Training (HRT), teaching competing responses, and cognitive restructuring.

This integrated, evidence-based approach allows treatment to be tailored to the individual child or teen rather than relying on a one-size-fits-all strategy.

The ComB Model: Understanding the “Why”

The ComB model helps us understand the specific factors that drive a child’s hair pulling or skin picking. We assess five key areas:

• Sensory: What sensations trigger or relieve the urge?
• Cognitive: What thoughts show up before, during, or after the behavior?
• Emotional: What emotions increase vulnerability (stress, anxiety, boredom, frustration)?
• Motor: What hand movements, postures, or routines are involved?
• Environmental: Where and when does the behavior happen most often?

Understanding these patterns allows us to design interventions that actually work for your specific child.

Habit Reversal Training and Competing Responses

Habit Reversal Training (HRT) is a core component of BFRB treatment. It focuses on increasing awareness of urges and teaching competing responses, or alternative behaviors that are physically incompatible with pulling or picking.

These are not random distractions. Competing responses are chosen intentionally to meet the same sensory or emotional need as the BFRB, helping the brain learn new ways to regulate discomfort.

Cognitive Restructuring: Reducing Shame and All-or-Nothing Thinking

Many kids and teens with BFRBs carry a harsh inner dialogue:

• “I should be able to stop.”
• “Something is wrong with me.”
• “I already messed up, so it doesn’t matter.”

Through cognitive restructuring, kids learn to notice these thoughts, challenge them, and replace them with more compassionate and realistic ones. Urges are treated as information, not failures.

How Parents Can Help at Home

Helpful shifts include:

• Commenting less and supporting more
• Using neutral, non-shaming language
• Offering tools instead of reminders
• Praising effort, not just outcomes

Instead of “Stop picking,” try:

“I notice your hands are busy. Would you like help, or do you want to handle it on your own?”

Small changes can make a big difference.

Additional Supports That Can Help: Books, Research, and NAC

Therapy is the cornerstone of effective BFRB treatment and many families also benefit from additional resources.

Helpful Books for Parents, Kids, and Teens*

For Parents:

• A Parent Guide to Hair Pulling Disorder: Effective Parenting Strategies for Children with Trichotillomania by Suzanne Mouton-Odum and Ruth Golomb
• Overcoming Body-Focused Repetitive Behaviors by Charles S. Mansueto, Sherrie Mansfield Vavrichek, and Ruth Golomb
• The BFRB Recovery Workbook: Effective Recovery from Hair Pulling, Skin Picking, Nail Biting, and Other Body-Focused Repetitive Behaviors by Marla Deibler and Renae Reinardy

For Kids and Teens:

• The Hair Pulling “Habit” and You by Ruth Golomb and Sherrie Mansfield Vavrichek
• Skin Picking: The Freedom to Finally Stop by Annette Pasternak, PhD
• BFRBs for Kids: A Gentle Introduction to Body-Focused Repetitive Behaviors by Kate Blake

These resources reinforce a crucial message: this is something you’re learning to manage, not something you’re failing at.

*A quick note: some links are Amazon affiliate links, and using them helps support our work with families, at no additional cost to you.

What the Research Shows

Research consistently supports behavioral treatment as the first-line intervention for BFRBs. Studies show that:

• Habit Reversal Training significantly reduces hair pulling and skin picking
• The ComB model improves outcomes by tailoring treatment to individual triggers
• Reducing shame and addressing emotional regulation improves long-term success

Punitive or shaming approaches have been shown to be ineffective and often worsen symptoms.

What About N-Acetylcysteine (NAC)?

Many parents ask about N-acetylcysteine (NAC), an over-the-counter supplement that has been studied as a possible adjunct treatment for BFRBs.

NAC affects glutamate regulation in the brain, which plays a role in impulse control and repetitive behaviors. Some research suggests NAC may reduce urges for hair pulling or skin picking for some individuals, particularly when combined with behavioral therapy.

Important considerations:

• NAC is not a standalone treatment
• It does not work for everyone
• It should always be discussed with a pediatrician or prescribing provider
• Therapy remains the gold standard

When helpful, NAC is best viewed as a supportive tool, not a replacement for skill-building.

When to Seek Professional Help

It may be time to work with a trained BFRB therapist if:

• The behavior causes physical damage
• Your child feels distressed or ashamed
• School, sleep, or social life are affected
• Attempts to help your child or teen stop actually increase secrecy or meltdowns

If you’re searching for a specialist to help with trichotillomania or skin picking disorder, make sure the provider has specific training in BFRBs. Expertise matters.

A Final Word to Parents

Your child is not choosing this.
Your child is not broken.
And BFRBs are treatable.

With the right support, kids and teens can learn to understand their urges, build new skills, and reduce the impact BFRBs have on their lives. Progress may not be linear, but it is absolutely possible.

And you do not have to navigate this alone.

If your child, teen, or family is struggling with a BFRB right now, you don’t have to navigate it alone. Our team is here to help. Schedule a consultation or intake today!