Skin picking is one of a group of body focussed repetitive self-grooming behaviours which result in damage to the body. Other similar body focussed repetitive behaviours (BFRBs) include finger sucking, nail-biting, lip- or cheek-biting, nose-picking, and hair pulling (trichotillomania). Young people who experience problematic skin picking repetitively touch, rub, scratch, pick at or dig into their skin resulting in sores or scabs developing that may eventually become infected or cause scarring.
BFRBs usually first present around 11-13 years of age, however certain types of BFRBs may present in younger age groups (e.g., finger sucking). Some children first experience a feeling of tension, itchiness, pain or tingling, leading to a strong urge to engage in the behaviour. They then experience pleasure and relief from the sensation when engaging in the behaviour (this is called focussed behaviour). At other times children may engage in automatic BFRBs without awareness of what they are doing. This type of behaviour is more likely to occur during sedentary activities such as watching television. Young people suffering from BFRBs may also search for perceived irregularities in their appearance which they attempt to fix by engaging in the behaviour.
Treatment for Skin-Picking in Children
A comprehensive behavioural intervention has been shown to reduce the problem behaviour, improve ability to cope with unpleasant thoughts, feelings and sensations, and improve overall quality of life.
The main components of treatment are:
Awareness Training: This involves teaching the young person to describe in detail their body focussed repetitive behaviour and become more aware of the urges and triggers associated with the behaviour. The young person then practices noticing the triggers, and real or simulated BFRBs.
Competing Response Training: The young person is helped to choose a behaviour that is physically incompatible with the skin picking or other behaviour. For example, if skin-picking occurs while reading, a competing response would be to always hold the book with both hands. In order to break the link between the urge and the actual behaviour the young person practices this behaviour when the urge or warning signals are noticed or when the young person notices they have started the behaviour.
Stimulus Control: Factors in the environment that trigger the repetitive behaviour are identified and a problem-solving approach is taken to identify strategies to manage or avoid these environmental factors. For example, if the behaviour occurs while looking in the mirror, mirrors may be removed or covered up for a period of time.
Social Support and Rewards: A support person (usually a parent) is chosen to praise the young person when they use a ‘competing response’ instead of the repetitive behaviour and to prompt these responses if the young person hasn’t noticed that they are engaging in the behaviour. A motivating reward system can also be implemented by the support person to increase the child’s motivation to use a competing response when they have an urge to engage in the behaviour.
Managing Difficult Thoughts and Feelings: Young people with BFRBs often experience a number of co-morbid conditions including anxiety, low self-esteem, shame, self-consciousness, social isolation/rejection and depression. Cognitive Behavioural Therapy (CBT) can be used to teach strategies to cope with and manage the symptoms of these co-occurring conditions and to manage unpleasant thoughts, feelings and urges that are likely to result in the repetitive behaviour. This is particularly important as internal states such as stress and anxiety are likely to influence the frequency and intensity of focussed BFRBs.
Improving Quality of Life: Many young people have withdrawn from social relationships, study and other life activities as a result of their skin-picking or other repetitive behaviours and the feelings of shame associated with these behaviours. One goal of therapy is to assist with re-engaging in these activities and addressing difficult thoughts and feelings that may get in the way of this, to assist the young person to return to the tasks of normal childhood/adolescent development.
If you would like to find out more about our treatment for skin-picking or other repetitive body-based behaviours, or to book an appointment with one of our child clinical psychologists who provides treatment for these conditions, please email or call the clinic on 02 9438 2511.