Hair Pulling and Skin Picking in Autism

Repetitive behaviors such as hair pulling and skin picking are quite often seen in individuals on the Autistic Spectrum and can be difficult for parents and educators to manage. These behaviors are a form of stimming that provide needed sensory input for people on the spectrum to help calm or regulate themselves. But it can also be problematic, leading to scars or hair loss and emotional distress. So what do you do if your child is constantly pulling their hair or picking their skin, and how do you convince them to stop?

According to the study, Characteristics of trichotillomania and excoriation disorder across the lifespan, Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are body-focused repetitive behaviors, which often first present in adolescence and cause distress and impairment into adulthood. Symptom severity appears to peak at the transition from adolescence to adulthood and two common general types of engagement with body-focused repetitive behaviors have been identified: ‘focused’, where the behavior is performed with full awareness, and ‘automatic’, where the behavior is performed outside of the person’s awareness.

 

The Sensory Link

The Trichstop website notes that ,aside from its repetitive nature there is a sensory element to body-focused repetitive behaviors (BFRBs) as well. Under-responsive and over-responsive sensory processing behaviors are often seen in children on the spectrum and studies suggest than more than three-quarters of children with autistic spectrum disorders also have significant symptoms of SPD. In under-responsive SPD the individual requires stimulation to remain alert and active, while in the over-responsive subtype, calming or soothing is often required to cope with day to day functioning. BFRBs are self-stimulating or self-soothing activities used by individuals affected by SPD and autism to self-regulate. In seeking sensory stimulation or sensory soothing, there is a tendency to target sites where there are many nerve endings such as the hands, feet, mouth and scalp. Therefore behaviors such as hair pulling, skin picking, and nail biting are commonly seen in people with autism and SPD. These same behaviors, when engaged in repetitively, causes damage to the targeted site, and results in psychological or social impairment.

 

Other body-focused repetitive behaviors

Think of body-focused repetitive behaviors as self-grooming behaviors that have gotten out of control. And attempts to stop or cut back have been unsuccessful. Other BFRBs include:

• Onychotillomania (nail biting)
• Trichotemnomania (compulsive hair cutting)
• Trichophagia (hair eating),
• Dermatophagia (skin biting)

 

Trichotillomania

The paper, Trichotillomania and Skin-Picking Disorder: Different Kinds of OCD in Psychiatry Online, describes Trichotillomania, also known as hair-pulling disorder, as characterized by the repetitive pulling out of one’s own hair leading to hair loss and functional impairment. The most common sites pulled include the scalp, eyebrows, and eyelashes, although any bodily site with hair can be affected. Pulling from multiple sites is common, and pulling episodes can last from a few minutes to several hours.

Criteria for Trichotillomania:

• Pulling of hair that results in hair loss
• The person endorses trying to decrease or stop pulling
• Significant distress or impairment in some aspect of social, work, or other area of functioning results from pulling
• The pulling cannot be attributed to another medical condition
• The pulling cannot be better explained by another mental health condition (e.g., pulling to improve one’s appearance or a perceived defect, as seen in body dysmorphic disorder)

 

Skin-Picking Disorder

Skin-picking disorder, which is also referred to as pathological skin picking, neurotic excoriation, or psychogenic excoriation, is characterized by repetitive and compulsive picking of skin leading to tissue damage. Although most individuals at some time pick at their skin, either to smooth out irregularities or to improve blemishes or acne, clinicians must differentiate between normal picking and more pathological forms. The diagnostic criteria for skin-picking disorder require that picking be recurrent and result in skin lesions, thereby reflecting the frequency and intensity of the picking. In addition, the clinical diagnosis requires that the picking result in the person feeling distressed or impaired.

Criteria for Skin-Picking Disorder: 

• Picking of skin that results in lesions
• The person endorses trying to decrease or stop picking
• Significant distress or impairment in some aspect of social, work, or other area of functioning results from picking
• The picking cannot be attributed to the physical effects of drug use (e.g., cocaine) or a medical condition
• The picking cannot be better explained by another mental health condition (e.g., picking to improve one’s appearance or a perceived defect, as seen in body dysmorphic disorder.

 

How to help your child with hair-pulling and skin picking

There are several things you can do to help your child. First, it is important to cultivate a safe, supportive environment in your home so that your child feels secure and receptive to your feedback. You also will likely want to find ways to keep your child safe while you continue working with them to reduce body-focused repetitive behaviors. This might look like encouraging your child to wear a bandana or hat to reduce access to their hair and cover sensitive bald spots. 

Here are a few strategies that can help:

• Redirect your little one to another sensory activity that keeps their hands busy, like a basket of fidget toys.
• Prepare a visual schedule for your child to offer security, reduce stress, and let them know what to expect throughout the day.
• Reinforce moments when your child is not engaging in hair-pulling or skin picking. Offer words of encouragement (e.g., “Nice gentle hands!”), hugs, or even a small reward that will be meaningful to your child.
• Avoid reacting in a harsh, animated manner when your child engages in the behavior. Remain calm and gently redirect, limiting the attention given to the hair-pulling or skin picking behavior.
• Encourage healthy coping strategies, including meditation, deep breathing, or walking away to do something they love, like build with Legos. These healthy habits will reduce stress, and when you practice them with your child, you will strengthen your bond and help yourself to be a more relaxed, present parent. 

As you begin to identify your child’s triggers, you’ll be better able to mitigate them. If your child is driven by anxiety, finding ways to reduce stressful situations and preparing them for unavoidable anxiety-inducing circumstances can target your child’s motivation at the source.

Additionally, offering extra support during those times can be beneficial. Early intervention is important, as is individualized support based on your unique child’s needs. 

 

Patience and understanding

Body-focused repetitive behaviors can be tough as it creates the potential for injuries that can turn serious. It’s important to find the triggers and help your child overcome them before it causes significant distress to them and their caregivers.

While it can be used as a coping mechanism or emotional regulation, the potential long-term issues make it necessary to help the person find other behaviors that don’t have the potential to lead to negative feelings or struggles with mental or physical health.

It’s important for caregivers to be empathetic and understanding as the person may feel compelled to pick their skin or pull their hair without knowing why. They need to know someone supports them as they go on their journey to change this behavior for the better.

There is no one-size-fits-all approach to helping stop skin-picking. Therapies may work, environmental changes may work, and some combination of the two may work. Still, medication may be necessary. What’s important is your loved one knows you are there to help them as they address their skin-picking behaviors.

 

Self-management

According to the NHS, there are things you can try that may help:

Skin Picking Disorder:

• keep your hands busy – try a fidget toy or putting on gloves
• identify when and where you most commonly pick your skin and try to avoid these triggers
• try to resist for longer and longer each time you feel the urge to pick
• care for your skin when you get the urge to pick it – for example, by applying moisturiser
• tell other people – they can help you recognize when you're picking
• keep your skin clean to avoid infection
• do not let your nails grow long – keep them trimmed
• do not keep things like tweezers and pins where you can easily get at them

Trichotillomania:

• squeeze a stress ball or something similar
• form a ball with your fist and tighten the muscles in that arm
• use a fidget toy
• wear a bandana or a tight-fitting hat, such as a beanie
• take a soothing bath to ease any stress or anxiety
• practise deep breathing until the urge to pull goes away
• exercise
• put plasters on your fingertips
• cut your hair short

Resources:

Trichotillomania: All you need to know about hair pulling disorder

Skin Picking in Autism: Causes and Management

Baby Hair-Pulling and Autism: Causes and Management