Body-focused repetitive behaviors (BFRBs) include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, lips, cheeks, or nails that can lead to physical damage to the body and have been met with multiple attempts to stop or decrease the behavior. Common BFRBs include hair pulling, skin picking, nail biting, and cheek biting. Other body-focused repetitive behaviors include hair eating, nail picking, skin biting, lip biting, tongue chewing, and hair cutting.

Research indicates that some people may have an inherited predisposition for skin picking or hair pulling. Several studies have shown a higher number of BFRBs in immediate family members of persons with skin picking or hair pulling disorders than would be expected in the general population. In addition, a recent study examined hair pulling in both identical and fraternal twins and produced results consistent with a significant inherited component in hair pulling disorder. So we can safely say that BFRBs are more than likely inherited, at least to some degree. However, even if a predisposition toward BFRBs is inherited, there are other factors involved as well, including temperament, age of onset, and environmental stress factors. More than likely BFRBs are caused by a variety of factors that interact with each other, resulting in the behavior. It is possible that a person has a predisposition to pull or pick, and the right stressor does not happen at the right time, so the behavior never manifests. Conversely, when a person starts experiencing a BFRB, it is not helpful to blame any one aspect of that person’s life that is happening at that time, but one might assume that the behavior most likely would have come to light at some point in the person’s life. One interesting point is that other species engage in similar behaviors. Primates such as the great apes or certain types of monkeys will pull hair, over-groom, and pick at nits and insects on their own fur and the fur of others. Birds will pull out their feathers; mice will pull fur or “barber” themselves and their cage mates; dogs and cats may lick their skin or bite at an area, removing fur until there are bald spots. Researchers interested in animal models of BFRBs are trying to understand these behaviors in animals in order to shed some light on the complex neurobiology that underlies the human experience of BFRBs. What these animal studies tell us is that BFRBs are likely, in part, hard-wired behaviors that are not solely the result of environmental factors.

Research into treatments for BFRBs, particularly hair pulling disorder and skin picking disorder, has grown steadily over the past decade. Although no one treatment has been found to be effective for everyone, a number of evidence-based treatment options have shown promise for many people. Psychotherapy A psychotherapy approach called Cognitive Behavior Therapy (CBT) is the treatment of choice for BFRBs. Existing studies suggest that CBT is superior to medication in treatment outcomes. However, some individuals may need medication first or in conjunction with CBT. CBT is a therapeutic approach that focuses on identifying thoughts, feelings, and behaviors that are problematic and teaches individuals how to change these elements to lead to reduced stress and more productive functioning. An emphasis is placed on matching the treatment to the unique symptoms of the individual. There are a number of different treatment approaches for BFRBs that fall under the umbrella of CBT: Habit Reversal Training (HRT) and Comprehensive Behavioral treatment (ComB). Acceptance and Commitment Therapy (ACT), and Dialectical Behavior Therapy (DBT) are two treatment approaches that may bolster the effectiveness of other cognitive behavior therapies.

Body-focused repetitive behaviors include any repetitive self-grooming behavior that involves biting, pulling, picking, or scraping one’s own hair, skin, or nails that results in damage to the body. Some of the BFRBs listed below are not specifically indexed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-5). They are classified as “other specified obsessive-compulsive and related disorders", with specification of “body-focused repetitive behavior.” Trichotemnomania (hair cutting) Is characterized by the compulsive cutting of one's own hair to achieve some visual goal (evenness, visual improvement). ‍ ‍Trichophagia (hair eating) Occurs in approximately 15% of patients with hair pulling disorder. Eating hair may cause serious medical complications in the form of trichobezoars – hairballs that may form in the stomach or bowel. Bezoars can be life-threatening. If you or your child experiences the following symptoms, it is recommended you seek advice from a medical doctor: feeling sick, vomiting, stomach pain, foul breath, or other symptoms of gastrointestinal problems. ‍ Lip Bite Keratosis (lip biting) Involves the repetitive biting of the skin of one’s own lips. ‍ Onychotillomania (nail picking) Involves damage to the fingernails or toenails by means of chronic picking of the nails. ‍ Dermatophagia (skin biting) Often occurs among patients with onychophagia. Dermatophagia behaviors include biting the cuticles or fingers, and digesting scabs or skin (usually as a result of skin picking disorder). Oftentimes, lip, cheek, and tongue biting are also considered dermatophagia. ‍ Tongue Chewing Chronic chewing on the tongue, most frequently the sides of the tongue, to the point of damage is a common oral problem and is considered to be a BFRB.

For some, the BFRB journey can last a lifetime. For others, their BFRBs wax and wane, with periods of no picking, pulling, or biting. For some, they are able to regulate and stop their behaviors completely. It's important to remember that this is a very personal, individual journey. No two BFRB journeys are alike. It's up to you to decide how to best manage your BFRBs. Finding space and grace to make good choices for yourself will help you gain clarity on what you want. Getting connected to community and meeting others on the BFRB journey gives you a variety of perspectives from which to grow. Strive for progress over perfection. You've got this and we've got you!

Inspiring Hope. Empowering Healing. Stronger Together. Founded in 1991, The TLC Foundation for Body-Focused Repetitive Behaviors is a health-related human services organization dedicated to supporting the 1-in-20 individuals experiencing body-focused repetitive behaviors (BFRBs) through advocacy, awareness, connection, health education, celebration, and equitable access to effective evidence-based treatments. Heart is at the center of everything we do – please join us to achieve our vision of a world where: Body-Focused Repetitive Behaviors (BFRBs) are diagnosed quickly. Body-Focused Repetitive Behaviors are widely known and understood in the general community. BFRBs are not a source of shame. Isolation is lessened. Equitable, effective treatment is available to all people experiencing BFRBs. Health education information and resources are readily available to people experiencing BFRBs and their families.

Get connected through health education and community programs. Participate in BFRB Awareness Week, annually October 1-7. Regularly visit the TLC website, Instagram and Facebook pages. Sign up to receive TLC's online newsletter for updates and programming details. There is a great big BFRB community waiting to support you. You are not alone!

We are stronger together, and when we work together, there's nothing we can't accomplish! As a donor-supported nonprofit, TLC relies on the kindness and generosity of our community to sustain operations and programming. You can help TLC by spreading awareness of our work and impact to the BFRB community to those you think may connect to our purpose. Encourage them to become allies to the 1-in-20 people experiencing hair pulling, skin picking, nail biting, cheek biting, and other associated behaviors. Attend health education and community programs. Participate in BFRB Awareness Week, annually October 1-7. Advocate to your local, state, and federal elected officials for additional funding to continue BFRB research.

Choosing a therapeutic provider to support your BFRB journey is critically important. Finding the right fit may take time, so knowing what you want to achieve from therapy is a good first start. Before you begin the search for therapeutic support, here are some questions to ask yourself: What do I want to achieve from therapy to support my BFRBs? Am I open to receive input and suggestions about my BFRBs? Am I committed to doing the work to help me improve my behaviors? I recognize that I may have setbacks in my road to recovery, how will I address them with my therapeutic provider? How do I need my therapeutic provider to “show up” for me? What type of experience in treating BFRBs do I want my therapeutic provider to have? Remember, therapeutic treatment is an individualized process. What might work for one person, may not work for most or all people. Patience and persistence are key to finding your own level of success.

Hair pulling disorder or trichotillomania (trick-o-till-o-may-nee-uh) (TTM or “trich”) is characterized by the repetitive pulling out of one's hair. Hair pulling disorder is one of a group of behaviors known as body-focused repetitive behaviors (BFRBs) and are technically classified as Obsessive-Compulsive and Related Disorders. BFRBs can be thought of as self-grooming behaviors in which individuals pull, pick, scrape, or bite their hair, skin, or nails, resulting in damage to the hair or body. Hair pulling can occur on any part of the body that grows hair. Research indicates that approximately 1 or 2 in 50 people experience hair pulling disorder in their lifetime. Hair pulling disorder usually begins in late childhood/early puberty, and occurs about equally in boys and girls. By adulthood, 80-90% of reported cases are women. Hair pulling varies greatly in its severity, location on the body, and response to treatment. Without treatment, hair pulling disorder tends to be a chronic condition; it may come and go throughout a lifetime. Signs and Symptoms Hair pulling disorder is currently classified under Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). ‍ The DSM-5 diagnostic criteria include: Recurrent hair pulling, resulting in hair loss Repeated attempts to decrease or stop the behavior Clinically significant distress or impairment in social, occupational, or other area of functioning Not due to substance abuse or a medical condition (e.g., dermatological condition) Not better accounted for by another psychiatric disorder Hair pulling may occur across a variety of settings and during both sedentary and active activities. There are times when pulling occurs in a goal-directed manner and it can also occur in an automatic manner in which the individual is less aware. Many individuals report noticeable sensations before, during, and after pulling. A wide range of emotions, spanning from boredom to anxiety, frustration, and depression can affect hair pulling, as can thoughts, beliefs, and values. Although the severity of hair pulling varies widely, many people with hair pulling disorder have noticeable hair loss, which they attempt to camouflage. Thinning or bald spots on the head may be covered with hairstyles, scarves, wigs, or makeup. Those with missing eyelashes, eyebrows, or body hair may attempt to camouflage with makeup, clothing, or other means of concealing affected areas. Due to shame and embarrassment, individuals not only try to cover up the effects of hair pulling, but may avoid activities and social situations which may lead them to feel vulnerable to being “discovered” (such as windy weather, going to the beach, swimming, doctor’s visits, hair salon appointments, childhood sleepovers, readying for bed in a lighted area, and intimacy).

Skin picking (excoriation), is characterized by the repetitive picking of one’s own skin. Individuals who struggle with this disorder touch, rub, scratch, pick at, or dig into their skin in an attempt to improve perceived imperfections, remove rough patches/scabs, smooth areas, or accomplish some goal. Skin picking often results in tissue damage, discoloration, or scarring. Occasional picking at cuticles, acne, scabs, calluses, or other skin irregularities is a very common human behavior; however, research indicates that approximately 2%- 5% of the population picks their skin to the extent that it causes noticeable tissue damage and marked distress or impairment in daily functioning. An estimated 75% of people experiencing skin picking disorder are female. The behavior typically begins in early adolescence, although skin picking disorder can begin at any age. Without treatment, skin picking disorder tends to be a chronic condition that may wax and wane over time. ‍ Signs and Symptoms Skin picking disorder is currently classified as Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). ‍ The DSM-5 diagnostic criteria include: Recurrent skin picking that results in skin lesions Repeated attempts to stop the behavior The symptoms cause clinically significant distress or impairment The symptoms are not caused by a substance or medical or dermatological condition The symptoms are not better explained by another psychiatric disorder Those who engage in skin picking tend to pick from multiple body sites, for extended periods of time, targeting both healthy and previously damaged skin. Targeted areas of the body may change over time. Commonly reported experiences that lead to picking include: an urge or physical tension prior to picking, unpleasant emotions, cognitions (permission-giving thoughts, beliefs about how the skin should look or feel), sensations (a bump, sore spot), and/or a displeasing aspect of one’s own appearance (visible blemish). Commonly reported experiences following picking behavior include: urge reduction, sense of relief or pleasure, psychosocial difficulties or embarrassment, avoidance, reduced productivity, emotional sequelae such as anxiety or depression, skin infections, scars, lesions, and/or disfigurement. Although the severity of skin picking disorder varies greatly, many people who struggle with skin picking exhibit noticeable skin damage, which they attempt to camouflage with makeup, clothing, or other means of concealing affected areas. Due to shame and embarrassment, individuals may also engage in avoidance behaviors, including the avoidance of certain situations that may lead them to feel vulnerable to being “discovered” (e.g., wearing shorts, being seen by others without makeup, or intimacy). Due to the nature of skin picking, it is important to consider whether the behavior is characteristic of excoriation disorder or whether it is better accounted for by another psychiatric disorder which warrants treatment. For example, skin picking may be a symptom of a dermatological disorder, an autoimmune disorder, body dysmorphic disorder, obsessive-compulsive disorder, substance abuse disorder (e.g., opiate withdrawal), developmental disorder (e.g., autism spectrum disorder), or psychosis. Comprehensive evaluation and accurate diagnosis is important in determining an appropriate treatment plan.

Chronic cheek biting (morsicatio buccarum) is a compulsive behavior whereby an individual repeatedly bites the inside of their cheek, causing damage to the tissue. This behavior may result in ulcerations, sores, and infections within the oral tissue. Furthermore, repetitive biting in a target area typically leads to the development of white patches of keratosis– a callus-like formation. Cheek and lip biting are estimated to occur in approximately 3% of U.S. adults, with more than half of individuals reporting childhood onset. Similar to skin picking (excoriation) and hair pulling (trichotillomania), chronic cheek biting is classified as Other Obsessive-Compulsive and Related Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Signs and Symptoms As with other BFRBs, the roots of chronic cheek biting seem to be multifactorial. The behavior is more common for people who experience higher levels of stress and anxiety. Some people are compelled by the need for a smooth feeling of the inner cheek lining. Any perceived impurity such as a bump or scratch may produce the uncontrollable urge to remove the imperfection by biting the area. Because chronic cheek biting has both behavioral and emotional components, treatment should focus on both aspects. Similar to the case with other BFRBs, managing the behavior is very difficult if you are unaware you are doing it or in a trance-like state.

Nail biting or onychophagia involves damage to fingernails by means of habitual biting. Although not specifically indexed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), nail biting is currently classified under Obsessive-Compulsive and Related Disorders in the DSM-5 and is considered to be a body-focused repetitive behavior. Signs and Symptoms Nail biting is often associated with visible nail damage, tension prior to or when attempting to resist nail biting, feelings of pleasure after biting, nail eating, and psychological distress. Many describe the behavior as “automatic.” While few scientific studies have examined nail biting, it is believed to be a common behavior that typically begins in childhood. It is estimated that 20%-30% of the general population engages in chronic nail biting although prevalence estimates greatly vary, with estimates ranging from 12% to 44%. In addition to hair pulling disorder and skin picking disorder, frequently co-occurring behaviors include bruxism (teeth clenching or grinding), and cheek biting.

Many parents find that explaining their child's appearance to close friends and family is essential, since these are people that your child will see often. Start with the facts - define body-focused repetitive behaviors and how they affect your child. Remind your friends and family members that your child's BFRB is a medical diagnosis that doesn't define them, it's only one part of them. People with BFRBs lead full and productive lives. They attend college, hold down employment, get married, and have children. BFRBs are not self-harm and are not a result of trauma. Parents don't cause BFRBs. People with BFRBs are worthy of love and support, just like anyone else. Share health education resources, like TLC's website, www.bfrb.org. Encourage ongoing conversations with family members and answer questions to help them better understand. Your journey is not unique, and you are not alone.

Once a BFRB has developed, it is important to be aware that it is possible to reoccur, even after a significant period without acting on urges. In the event of the return of the BFRB itself, or of strong urges, techniques and strategies that worked best during active treatment can be re-employed during vulnerable phases. Some individuals find it especially useful to check in with their therapist for added support. In some situations, the formerly useful techniques may no longer be as effective as they once were. This would present a good opportunity to see a therapist and explore some additional interventions or approaches. It is critically important that you keep the lines of communication open with your child in order to support their overall physical health and emotional well-being. The more informed you become about BFRBs, the better advocate you can be for your child.

Although BFRBs may, in some forms, be relatively benign, when they are done in excess they can cause serious medical problems. For the subset of individuals who swallow pulled hairs (a BFRB called trichophagia), gastrointestinal distress or even digestive blockage called a trichobezoar (or hairball) can occur, sometimes requiring surgical removal. This is a very serious medical condition that may require immediate action. It is important to see a doctor if your child eats their hair. Regarding skin picking, it is important to keep wounds clean and treat them with antibiotic cream to prevent infection. In some cases, frequently practiced BFRBs may result in repetitive motion injuries. It is critically important that you keep the lines of communication open with your child in order to support their overall physical health and emotional well-being. The more informed you become about BFRBs, the better advocate you can be for your child.

Research shows that some people may have an inherited predisposition to skin picking or hair pulling. Several studies have shown a higher number of BFRBs in immediate family members of persons with skin picking or hair pulling than would be expected in the general population. However, this does not mean your child will develop a BFRB; there are a number of other factors that are involved, such as temperament, environment, age of onset, and family stress factors.

Unfortunately, there is nothing you can do to ensure this won't happen. It is not uncommon for people with BFRBs to pick/pull from other areas of their body, so don't be alarmed if your child starts to do so. It's very hard to stop pulling/picking from an area once you start, so don't expect your child to automatically stop. The best thing you can do is offer your support and unconditional love. Do not scold your child or punish them for their BFRBs. Your child's BFRB is not something they can control, and it is not their fault. It's not your fault either. BFRBs are not self-harm. BFRBs are not caused by trauma. It is critically important that you keep the lines of communication open with your child in order to support their overall physical health and emotional well-being. The more informed you become about BFRBs, the better advocate you can be for your child.

Unfortunately, there is nothing you can do to ensure this won't happen. It is not uncommon for people with BFRBs to pick/pull from other areas of their body, so don't be alarmed if your child starts to do so. It's very hard to stop pulling/picking from an area once you start, so don't expect your child to automatically stop. The best thing you can do is offer your support and unconditional love. Do not scold your child or punish them for their BFRBs. Your child's BFRB is not something they can control, and it is not their fault. It's not your fault either. BFRBs are not self-harm. BFRBs are not caused by trauma. It is critically important that you keep the lines of communication open with your child in order to support their overall physical health and emotional well-being. The more informed you become about BFRBs, the better advocate you can be for your child.

It's a big myth that parents are responsible. No, your child's BFRB is not your fault. You are not to blame for your child's BFRB. Your child's BFRB is not a reflection of you as a parent. BFRBs are caused by a multitude of things, such as temperament, environment, age of onset, etc. Even if you personally struggle with a BFRB yourself, it is still not your fault.

No, not at all. Chances are, your child would have developed their BFRB even if you were around all of the time. Try not to blame yourself (or your child) for this problem! It is truly out of their control and you have not caused their BFRB in any way whatsoever.

Body-focused repetitive behaviors are complex mental health disorders. Most people who experience BFRBs can't just simply stop, and some simply don't want to stop pulling, picking, or biting, as it helps their bodies self-regulate. However, even if a predisposition toward BFRBs is inherited, there are other factors involved as well, including temperament, age of onset, and environmental stress factors. More than likely, BFRBs are caused by a variety of factors that interact with each other, resulting in the behavior. It is possible that a person has a predisposition to pull or pick, and the right stressor does not happen at the right time, so the behavior never manifests. Conversely, when a person begins a BFRB, it is not helpful to blame any one aspect of that person’s life that is happening at that time, but one might assume that the behavior most likely would have come to light at some point in the person’s life. One interesting point is that other species engage in similar behaviors. Primates, such as the great apes or certain types of monkeys, will pull hair, over-groom, and pick at nits and other insects on their own fur and the fur of others. Birds will pull out their feathers; mice will pull fur or “barber” themselves and their cage mates; dogs and cats may lick their skin or bite at an area, removing fur until there are bald spots. Researchers interested in animal models of BFRBs are trying to understand these behaviors in animals in order to shed some light on the complex neurobiology that underlies the human experience of BFRBs. What these animal studies tell us is that BFRBs are likely, in part, hard-wired behaviors that are not solely the result of environmental factors. Research indicates that some people may have an inherited predisposition for skin picking or hair pulling. Several studies have shown a higher number of BFRBs in immediate family members of persons with skin picking or hair pulling disorders than would be expected in the general population. In addition, a recent study examined hair pulling in both identical and fraternal twins and produced results consistent with a significant inherited component in hair pulling disorder. So, we can safely say that BFRBs are more than likely inherited, at least to some degree.

The TLC Foundation for BFRBs is an excellent resource to find well trained professionals who have experience treating BFRBs. Many of these therapists have participated in an intensive training program called the Virtual Professional Training Institute (VPTI) created by The TLC Foundation to provide training in state-of-the-art treatment for BFRBs. However, if you cannot find someone who has this specific training, a therapist with a cognitive behavior therapy (CBT) background may be helpful.

While taking your child to a therapist is optional, without therapeutic treatment such as cognitive behavioral therapy (CBT), habit reversal training (HRT), or other form of psychotherapy, managing behaviors can be challenging. Your child may at first be resistant to try therapy or access therapeutic support for their BFRBs. Being honest and encouraging about how therapy can help them manage their behaviors is a great start. It is extremely important to find a therapist who you and your child both trust, and is knowledgeable about BFRBs. Most therapists specializing in BFRBs have waiting lists. Be prepared to wait from between two to six months. Be patient and persistent. While you're waiting to access therapeutic support, register for TLC's health education and community programs, to get connected and learn more.

While taking your child to a therapist is optional, without therapeutic treatment such as cognitive behavioral therapy (CBT), habit reversal training (HRT), or other form of psychotherapy, managing behaviors can be challenging. Your child may at first be resistant to try therapy or access therapeutic support for their BFRBs. Being honest and encouraging about how therapy can help them manage their behaviors is a great start. It is extremely important to find a therapist who you and your child both trust, and is knowledgeable about BFRBs. Most therapists specializing in BFRBs have waiting lists. Be prepared to wait from between two to six months. Be patient and persistent. While you're waiting to access therapeutic support, register for TLC's health education and community programs, to get connected and learn more.

Parents play an important role in the treatment process for BFRBs. Your most important role is to educate yourself about BFRBs in order to be your child's best advocate and find a therapeutic match. It's also important that you listen to your child's feedback on a therapist to gauge treatment efficacy. What's working and what's not? What therapeutic intervention needs your support? Where can you be most helpful? Are there opportunities for you to meet with the therapist to gain insight on how best to support your child? Children do best in treatment when their parents are supportive and loving, without adding pressure, judgment, or expectations. Refrain from telling your child to stop pulling, picking, biting, or scolding them when they act on their behaviors. This only leads to increased behaviors and emotional shut down. Keeping the lines of communication open with your child is important to their overall physical health and emotional well-being.

Yes! The TLC Foundation has compiled a list of BFRB support groups, which you can access below. In addition, TLC offers health education and community programs to connect, grow, and learn together. This is a great way for both you and your child to find support, along with attending BFRB Awareness Week, annually on October 1-7, along with TLC's Conference. Find support groups here

There is no one way to cope with your child's BFRB medical diagnosis. You have two options on this journey: let the tide pull you down, or let a friend throw you a buoy to help you, by getting connected to resources through TLC. It is also important to remember that a BFRB is a medical diagnosis. It does not define your child's ability to live a full, productive life. You are not alone. Your family is not alone. Your child is not alone. There is a community full of people who are on the same journey. Reach out, get connected. You've got this, and we've got you!

A BFRB medical diagnosis is a label that provides individuals with access to medical and educational supports to reach their full potential. That medical diagnosis does not define one's life. People with BFRBs live full and productive lives. They participate in arts and sports activities, are engaged in their community, attend college, pursue meaningful employment, get married, and have children. Encouraging your child to live fully into themselves from a young age despite their medical diagnosis gives them courage to explore who they are, as a person, first.

First and foremost, make sure your child feels safe. Then smile and make it a no-big-deal. Our world is filled with insensitive individuals who don't quite know how to interact when encountering a situation that makes them uncomfortable. Remember, disclosing your child's BFRB is their decision, not yours. It's up to them if they want to tell anyone, let alone a stranger, about their BFRB. Making sure your child's emotional and physical well-being is protected during uncomfortable encounters in public helps them know they can engage in community settings without fear, which in turn helps them participate more fully in community as their authentic selves.

Many parents find that explaining their child's appearance to close friends and family is essential, since these are people that your child will see often. Start with the facts - define body-focused repetitive behaviors and how they affect your child. Remind your friends and family members that your child's BFRB is a medical diagnosis that doesn't define them, it's only one part of them. People with BFRBs lead full and productive lives. They attend college, hold down employment, get married, and have children. BFRBs are not self-harm and are not a result of trauma. Parents don't cause BFRBs. People with BFRBs are worthy of love and support, just like anyone else. Share health education resources, like TLC's website, www.bfrb.org. Encourage ongoing conversations with family members and answer questions to help them better understand. Your journey is not unique, and you are not alone.

When teachers and school staff know about your child's BFRB, it may make for an easier school year for the child, family, and school. However, disclosing your child's BFRB is a very personal decision. Start by talking with your child about their comfort level of sharing their BFRB at school. If they're new to the school, it may take time to build rapport and trust with teachers and school staff. If they're a returning student, ask them if there's a teacher or school staff member who they trust to be their safe person/advocate in case uncomfortable interactions with peers occur during the school day. If your child's BFRB is noticeable, such as bald patches, heavy scarring, etc., consider asking the teacher if additional education can be provided to classmates and their parents about body-focused repetitive behaviors to help break down myths and misperceptions and build inclusion. Forming a strong school and home partnership sets everyone, most importantly your child, up for a successful school year.

If your child is struggling at school with BFRBs consider the types of interventions that work well in other environments. Engage your child in a dialogue about what they think might be helpful, then approach your child's teacher about coming up with a plan together. If your child qualifies for special education services, additional accommodations may be possible through their Individual Education Plan (IEP) or 504 Plan.

Going to a salon can be a big emotional step for people with hair pulling. TLC offers a referral directory listing of BFRB-friendly salons. We're working every day to grow the number of salons listed with TLC, so come back regularly to check for updates near you. Remember that it may take some time to find the right stylist for your child. It's okay to try several before you decide on the one that works best. Find a Salon

Your child's journey with BFRBs is very personal. Remember that a BFRB is a medical diagnosis that doesn't define your child. They have so many special gifts beyond their hair pulling, skin picking, nail biting, or cheek biting. Disclosing to anyone should be their decision. If they're at a place where they feel comfortable sharing their medical diagnosis with their friends - trust them, even though you may be afraid their choice to disclose may hurt them. Perhaps they've discovered that their friends have interests in common like music, movies, fashion, art, sports, or more. Trust your child to make a good decision for themselves; and be there to celebrate if things go well or with encouragement if things become challenging. Offer to role-play with your child how they plan to tell their friends. Make gentle suggestions where needed, coming from a place of love. Keeping the lines of communication open with your child is important for their overall physical health and emotional well-being. Learning more about BFRBs gives you the opportunity to become your child's best advocate. The TLC website is a good start, along with participating in TLC's health education and community programs.

First and foremost, help your child determine if the person giving the negative comment is a friend, acquaintance, or a stranger in public. When friends make negative comments, they may be lacking information. Education is the most powerful way to react. Most negative comments are born from ignorance. Providing useful pieces of information can be very helpful. Suggest they visit TLC's website, www.bfrb.org.

Knowing that this is your child's journey, clearly listening to their needs, hopes, and dreams can help you navigate best practices in empowering them to live fully into themselves. Asking gentle clarification questions like, "How can I support you?", "What would you like me to know about your BFRB?", "How can I be your best advocate?" can be a great place to start a conversation. Keep in mind that this is a journey; that means there will be good days and there will be difficult days - but through it all, focus on the person your child is first, not their behaviors. What do they need to feel safe? What do they need to feel supported? What do they need to honor themselves? As parents, it's not always easy to take a step back and let our children guide us. Asking for help from others on this journey connects you to resources and support. Signing up for TLC's health education and community programs to learn more helps you become the best parent you can be.

The hair loss experienced from hair pulling can impact self-esteem and self-confidence. Many BFRB community members, especially girls and teens, share that not having hair impacts their feeling of femininity and/or belonging with peers. A wig can restore their self-confidence while also helping manage their behaviors. Although a wig may not stop their hair pulling, having a wig allows them to feel more comfortable at school and in community.

The physical effects of BFRBs on one's appearance can lead to unpleasant interactions with classmates and other peers. Meeting with your child's teacher (if your child agrees to this; ultimately it is their decision whether to disclose their BFRB or not) before the school year starts to talk about their BFRB and discuss opportunities to educate classmates and other peers about the reasons behind their physical appearance may lessen negative interactions. Encourage your child to be proud of who they are, that they are worthy and important. Try to create peer bonds through sports, clubs, and other activities that help your child see that they have many special gifts beyond their BFRBs. Getting connected to community also helps. It's as easy as registering for an upcoming TLC health education and community event.

Love, love, love your child, on the good days and on the challenging days. Love your child as your child first - not their BFRB. This is your child's journey. Standing alongside them with encouragement and not judgment keeps the lines of communication open - a critical component of ensuring their emotional and physical well-being. You may not understand what drives their behaviors to pull, pick, or bite. Asking gentle clarification questions, instead of judging, may give you better awareness of what they may be experiencing before, during, and after acting on their urges. Please do not tell your child to stop pulling, picking, or biting. BFRB community members will tell you that telling them to stop their behavior only makes it worse - further inducing shame and isolation. Some say it makes them pull, pick, or bite even more. Becoming as informed as you can about body-focused repetitive behaviors helps you become your child's best advocate. The TLC website is a great resource, as are TLC's health education and community programs. You are not alone.

Say I love you You are beautiful You are important You are worthy Your BFRB does not define you ‍ Do not say Stop pulling, picking, biting You look like you've been pulling, picking, biting a lot Cover that spot Do not tell other people about your child's BFRB without their permission Do not scold, shame, or punish your child for their BFRBs. Your child's BFRB is not something they can control and it is not their fault. It's not your fault either. BFRBs are not self-harm. BFRBs are not caused by trauma. ‍ It is critically important that you keep the lines of communication open with your child in order to support their overall physical health and emotional well-being. The more informed you become about BFRBs, the better advocate you can be for your child. To help parents and family members learn how to provide the best support for their child, the TLC Young Adult Action Council provided answers to some common questions parents have about BFRBs and created a video, "A Parent Perspective: Talking to a Loved One with a BFRB", to demonstrate how, sometimes, good intentions can go wrong and to share how you can show your support in a way that they'll hear it.

Every person with a BFRB has felt this way at some point. Feeling alone is completely natural, because the truth is that most have not experienced hair pulling, skin picking, or other BFRBs. What's more, many people do not know about BFRBs, and even more do not understand them. It can be tempting to look at other people, people who can walk out of their houses in the morning without makeup or go swimming without thinking twice and think that we are completely on our own. But this isn't true. At least 2 in 50 people have BFRBs, which means that you probably know and come across people just like you every day. Likely, those people are also experiencing a silent struggle, feeling isolated, believing that someone like you doesn't exist. Even people who don't struggle with BFRBs have their own secret battles—our feelings of aloneness, ironically, are what make us all the same.

Sharing about your BFRB can be liberating. It can lighten some of the shame, isolation, and desperation that we feel. This allows us to create a network of support for ourselves, a group of individuals who will serve as our companions, our fellow warriors, our cheering squad, as we start on our journeys toward healing. You always have the right to choose the time, place, and person that you share this important information with. Make sure you give them the TLC website, www.bfrb.org, as a resource they can look to for accurate information—so that they can support you better, and also provide support for themselves. ‍ Some of the unhelpful people in our lives will continue being unhelpful. There is always a chance that the people we share our secret with will not react the way that we want. Remember that this usually has more to do with them than you—usually their fear, which can make people narrow-minded. Don’t waste time on people who bring you down—fill your days with those who lift you up. ‍ Most of all, know that you should make the choices that are best for you when deciding whether or not to tell people about your BFRB. Sharing can be rewarding but, if you're not there yet, then there is absolutely no pressure to do so. Do what's best for you!

One of the hardest parts of having a BFRB, especially at the beginning, is helping our parents understand what we are going through. Our parents only want what’s best for us, and they’re trying to learn about BFRBs too. Sometimes they may not say the right thing out of worry, like “just stop.” This can be extremely upsetting and can create feelings of guilt and anger; sometimes our parents can actually be a source of stress that fuels our pulling. But it's important to realize that, in all likelihood, your parents' intentions are good. Sometimes we don't realize that our parents are going through their own battles—they are scared and feel helpless because, as parents, they are engineered to want to take care of us and to fix what ails us. They can see that we are struggling and it is so, so difficult for them to accept that there is little that they can do to stop the pulling or picking. Your parents need support too. Encourage them to become more educated on BFRBs by attending a TLC health education and community event. Try to establish an open line of communication between your parents and yourself; if you need them to back off, tell them so. If you've had a terrible day and need their support, let them know that too. Your parents love you more than you can imagine, and they will do anything they can to make things better—but they need some support from others who understand, and some guidance from you on how they can best be supportive. Consider developing a system with your parents so that you establish guidelines for how all of you deal with your BFRB. For example, you can ask that your parents make a gesture or use a code word when they see you pulling or picking. Or set up one time during the day where you check in with them about your BFRB—that way, you don't have to worry about BFRB talk infiltrating all of your conversations with your parents. The key is to give your parents what they need, while remaining true to what you need.

Anxiety is extremely common among people with BFRBs. The difficult part is that anxiety worsens BFRBs, and BFRBs worsen anxiety; this creates a vicious cycle that can seem nearly impossible to break. But the good news is that anxiety is treatable, both through therapy and medications, and by implementing day-to-day strategies. There are so many potential stressors in our lives, from school to social situations to daily tasks. The key is recognizing what aspects of your life activate your anxiety, and then to use techniques to lessen the stress and pressure associated with those tasks. Remember that exercise, healthy eating, and sleep are absolutely critical for emotional well-being and minimizing anxiety. If you know that writing essays makes you stressed, incorporate a run or a walk into your schedule. If reading or painting puts you at ease, then do those things. ‍ Oftentimes there are resources available that will support you in developing healthy ways of coping with anxiety. For example, most schools have academic resource centers that help students with study skills, and many schools provide accommodations for individuals who have mental, physical, or psychological challenges. Also consider seeking out a counselor, either at school or elsewhere, to come up with solutions. If you find that your anxiety is severe, you may have an accompanying anxiety disorder in addition to your BFRB. You should see a therapist and get the proper treatment. Be sure to utilize all of the supports around you to help you manage your stress and anxiety—you don't have to do this alone!

Yes, it will. The truth is that, currently, most people with BFRBs will deal with their behaviors throughout their lives. Many people with BFRBs develop treatment plans for themselves (often with the help of a therapist), incorporating strategies for managing urges into their day-to-day lives. The more time you invest in finding good coping strategies, the more you will be able to get your BFRB under control. For some, this means bringing fidget toys to school or to work. For others, it means going to sleep with conditioner in their hair to create a barrier to pulling. Most people with BFRBs experience relief from connecting with others with BFRBs, whether it's during BFRB Awareness Week, on social media groups, or in a support group. Shame and isolation are often the most challenging parts of BFRBs, the biggest obstacles in the way of feeling happy. Getting involved with TLC health education and community programs is a great way to build support on your journey.

Most people with BFRBs experience some sort of discomfort related to how they look. We may have a bald patch or a new scab, and oftentimes we feel certain that everyone notices and thinks we are weird or gross or ugly. This is normal. But here's the truth: every single person has insecurities about how he or she looks. In fact, most people are so busy worrying about how they themselves look that they don't even notice you! People with BFRBs may have a unique set of concerns, and yes, we do have challenges that make us distinctive from our non-BFRB family members and friends. However, we are in a society that values appearance to an unreasonable degree and the result is that almost everyone has doubts about whether he or she fits in or looks "normal." There are products available that help to fill in bald spots and conceal scars. However, it's important to realize that confidence in your appearance has to come from within, no matter how you look. You can be beautiful without hair and with damaged skin. You are so much more than your hair or your skin, but reaching this point of acceptance takes internal work—get involved in TLC health education and community programs to support you on your journey!

Sharing about your BFRB can be liberating. It can lighten some of the shame, isolation, and desperation that we feel. This allows us to create a network of support for ourselves, a group of individuals who will serve as our companions, our fellow warriors, our cheering squad, as we start on our journeys toward healing. You always have the right to choose the time, place, and person that you share this important information with. Make sure you give them the TLC website, www.bfrb.org, as a resource they can look to for accurate information—so that they can support you better, and also provide support for themselves. ‍ Some of the unhelpful people in our lives will continue being unhelpful. There is always a chance that the people we share our secret with will not react the way that we want. Remember that this usually has more to do with them than you—usually their fear, which can make people narrow-minded. Don’t waste time on people who bring you down—fill your days with those who lift you up. ‍ Most of all, know that you should make the choices that are best for you when deciding whether or not to tell people about your BFRB. Sharing can be rewarding but, if you're not there yet, then there is absolutely no pressure to do so. Do what's best for you!

Although BFRBs can cause damage to the body, the goal is quite different than that of people who engage in self-harming behaviors. Self-harm (cutting, scratching, burning, etc.) is done with the goal of intentional harm to one’s body in an attempt to reduce the sensation of emotional pain or to manifest physical pain to drown out emotional pain. Alternately, BFRB behaviors are, for many people, self-regulating and serve some internal need. Many people who engage in BFRBs report that they are pleasurable, that they help them in some way, or that they help them to achieve some goal (symmetry or smoothness). When a person engages in their BFRB, physical damage is created as a result of their behavior but is an unintentional result of their repetitive behavior. BFRBs are not self-harm. BFRBs are not caused by trauma.

Some people assume that hair pulling, skin picking, nail biting, cheek biting, and associated behaviors are signs of some unresolved issue or problem that needs to be addressed, including past trauma. There is no evidence supporting the belief that BFRBs are associated with past trauma or are caused by past trauma. BFRBs are also not a form of self-harm. Only 50% of people report any negative event around the time they started pulling. However, these negative events were not traumatic events, but more like “my family moved” or “my teacher left the school.” The truth is that many, if not most people with BFRBs, grew up in households filled with love and support. Unfortunately, too many misinformed clinicians tell people that if they have a BFRB, there must have been a trauma in their past. This is not only confusing, but wrong.

BFRBs are often described as a cousin to OCD, but there are enough differences between the two that they are treated differently. Currently, hair pulling and skin picking are classified as Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Body-focused repetitive behaviors are distant cousins to OCD. Although individuals with BFRBs engage in repetitive, seemingly compulsive behaviors, there are enough differences between BFRBs and OCD to suggest that these are different disorders. First, BFRBs are treated with cognitive behavior therapy that is function-based, while OCD is treated with exposure and response prevention. Second, BFRB behaviors do not respond to the same medications that work well for OCD. Third, OCD involves obsessions that increase anxiety and compulsions that then reduce that anxiety, at least temporarily. People with BFRBs do not report having obsessions such as “If I don’t pull out this hair, something bad will happen/someone will die,” instead, they report that pulling/picking serves to reduce a number of negative sensations, cognitions, emotions, and serves a self-regulating function. Finally, people with BFRBs often like their pulling/picking and often do not want to let go of it, while people with OCD cannot stand their rituals, yet they feel compelled to perform them.

Similar to other mental health disorders, BFRBs are a combination of neurobiological, environmental, and genetic factors, not the result of “bad parenting.” In fact, most parents of children with BFRBs are quite supportive and would do just about anything to help their child with a BFRB. Conversely, there are many families fraught with trauma and abuse where BFRBs are completely absent. Unfortunately, when parents try to help and the BFRB persists, parents can become frustrated and even frightened for their child. To support parents, TLC offers ongoing health education webinars and connection to support your child in ways that feel empowering and that lead to healing.

BFRBs are equal opportunity behaviors that affect both men and women. They are highly underreported and undiagnosed disorders, which oftentimes provides the illusion that women are more susceptible to experience hair pulling, skin picking, nail biting, cheek biting, and other associated behaviors. It is possible that men are less likely to report having a BFRB than women; therefore, present less frequently for treatment. Although research shows that more women likely suffer with hair pulling, it may be that men are just as implicated, but do not report their symptoms.

Almost everyone with a BFRB reports pulling/picking at least some of the time when they are feeling anxious or stressed, however a host of other emotions, beliefs, sensations, and habitual triggers are also reported. The goal of therapy is to understand the internal and external triggers that lead a person to engage in their BFRB, as well as the internal and external events that reinforce them (make them more likely to happen again in the future). For some people with a BFRB, anxiety management skills are a key focus of treatment, while for others it is not a part of treatment at all. The key to good treatment is understanding what is driving the behavior for that person, and then offering interventions to address those unique drivers. Treatment for BFRBs is tailor-made to the individual and should be customized to the needs of the presenting person.

There are many ways to make your gift to The TLC Foundation for Body-Focused Repetitive Behaviors. Many donors prefer the ease and convenience of using debit/credit cards on our secure online giving site. You may also choose to give by mail, phone, or by donating securities. ‍ Online donations can be made through: add link ‍ Mailed donations can be sent to: The TLC Foundation for BFRBs 716 Soquel Avenue, Suite A Santa Cruz, CA 95062-2352 ‍ If you'd like to make a donation of securities, please call our office at 831-457-1004.

You can make a donation to TLC through the mail by a check or money order written to The TLC Foundation for BFRBs. Please include a note or memo that this is a donation. ‍ Our address is: The TLC Foundation for BFRBs 716 Soquel Avenue, Suite A Santa Cruz, CA 95062-2352

TLC staff are available by phone weekdays, 9 am to 5 pm, Pacific Standard Time, at 831-457-1004. Please call or email info@bfrb.org.

For information about wills, trusts, gift annuities, IRA charitable rollovers, and insurance, contact TLC at info@bfrb.org or call 831-457-1004.

Many people choose to make a gift to TLC in honor—or in memory—of a family member, friend, or someone who has inspired them. When making such a gift, be sure to indicate the name of the person being honored or remembered.

TLC staff are available by phone weekdays, 9 am to 5 pm, Pacific Standard Time, at 831-457-1004. Please call or email info@bfrb.org.

The TLC Foundation for Body-Focused Repetitive Behaviors is a 501(c)(3) nonprofit organization. Your gift is tax-deductible to the extent permitted by law. Our tax identification number is 77-0266587.

For more information on how to donate stocks, go to the stock donation page. For additional assistance, please contact TLC at info@bfrb.org or call 831-457-1004.

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