What can teachers, guidance counselors, or administrators do when they notice a child pulling out hair or picking at their skin? Here are some do's and don'ts for faculty and staff who become aware of these behaviors and wish to assist.
- Educate yourself with solid information from a reputable source
- Notify the family
- Determine if/how to include the child in problem solving
- Contact the teacher(s)
- Decide whether or not the members of the class need to be informed
- Immediately handle teasing and/or bullying
- Make assumptions about what motivates a child to engage in hair pulling
- Insist on the use of interventions that you think will work without consulting the child
- Eliminate challenging classes
- Instruct a family to medicate their child before exploring other options
- Let's talk about these do's and dont's in more detail.
Educate yourself with solid information from a reputable source
There is no shortage of websites that claim to have "The Answer" to these problems. Many websites charge money in order to obtain the elusive solution. Good, solid information is no secret. There have been quite a few smart, qualified professionals studying trichotillomania and skin picking (part of a larger family of behaviors called Body-Focused Repetitive Behaviors,or BFRBs) for years. There are still many questions yet to be answered, but research is out there that sheds some light on these misunderstood disorders. If a website claims "research shows" but does not specify what research and by whom, then the site likely contains information that is assumed (but not necessarily accurate), wishful thinking, or simply unfounded.
Notify the family
The next step is to have a conversation with the parents. Be clear, concise, and descriptive of the behavior when speaking with parents. Report only the behavior that has been observed, not assumptions or perceived motives for the behavior. Inquire about the child's pulling /picking behavior in the home. Is this the first time the family is aware of this behavior, or has the child experienced this in the past? Is the child receiving therapy for BFRBs currently? If so, how can the school assist the child? If a treatment provider is not easily available, or if the family chooses not to pursue therapy, there are books and web-based programs that might be useful in such circumstances.
Ask the family if they would be interested in having the child use some strategies in school to contend with this behavior. If so, do they have any suggestions of techniques that work for the child at home? Might some of those same tactics work in the school setting?
Determine if/how to include the child in problem solving
Some children are willing to use interventions in school, but hope to maintain some privacy and therefore are not interested in discussing the behavior or engaging in problem solving with the adults in the school. Other children are delighted to talk with the teacher, guidance counselor or other member of the school staff.
It is important to be sensitive to the child's wishes. If the child is not willing to speak with school personnel, would the child be comfortable with a parent speaking to the school on behalf of the child? Parents can sometimes arrange special accommodations for the child that can be used in the classroom to address these behaviors. (See "504 Plans and IEPs: How Can They Help My Child?" located in the Fall 2009 issue of In Touch and on your member CD, The Comprehensive Information Guide).
If the child is interested in working with his/her teacher, details of the process should be thought out ahead of time. How will the intervention be used? Will the teacher be involved in any way? What can the teacher do to support the student? (Ideas for alternative behaviors to be used in the classroom can be discussed with a therapist, found in books regarding hair pulling, or searched on the computer.)
Contact the teacher(s)
Once strategies have been discussed and decided upon, it is now time to ensure that there is appropriate communication between teachers, counselors or other school personnel. Explain the information you have gathered regarding BFRBs, inform the teacher or other school personnel who might be involved in the use of the interventions about the discussion with the parents, and introduce the idea of the child using some specific alternative behaviors designed to address BFRB behaviors in the classroom.
Teachers work tirelessly caring for, educating, encouraging, cajoling and pushing our children to reach their potential. If you are a counselor or the person with primary contact with the family, convey the information about the techniques to be used in the classroom clearly. Explicitly state what you are asking the teachers to do with each tactic that will be used by the child. Very often, the teachers are asked to be aware that these strategies will be used in the classroom and nothing further. Other times, the teachers could be asked to keep a supply of finger bandages in a desk drawer, devise a secret signal that alerts the student that his/her hand is drifting toward a pulling/picking site, or allow the child to take breaks when necessary.
The teachers should have ample opportunity to consider whether or not the suggestions being discussed will work in their particular classrooms. If not, consider alternatives. Teacher and student may need to negotiate in order to come to an agreement regarding specific intervention use that would be manageable for each of them in the classroom.
Do the other members of the class need to be informed?
Sometimes, other classmates might need to be informed that a fellow student will be using some unique items to help with a particular behavior. When informing the class, it will be important to present information in a way that engenders sensitivity to the plight of the child and includes information for the students about what they can do to support their classmate. It also should be made clear that there will be zero tolerance for teasing, bullying, or mean comments.
Is there any teasing or bullying?
What if teasing or bullying does occur? It is crucial that these behaviors are dealt with immediately and effectively. Sometimes children who tease or bully are utterly and completely misinformed, if they have any knowledge at all about the problem, and would benefit from some very direct information regarding the disorder itself, the effect that teasing has on an individual and the specific consequences to an individual who continues exhibiting hurtful behavior. If teasing or bullying persists, the child should experience punishments that are consistent with the rules or laws of the county, community or township regarding bullying.
Now that we have considered some procedures that could be effective for school personnel to pursue when a child is struggling with hair pulling in the classroom, let's take a look at some actions that might not be as useful.
Assume motivations, feelings, or thoughts that the child "must" be having due to the fact that the student is pulling out hair or picking skin
There is a tremendous amount of misinformation and assumptions made about hair pulling and skin picking disorders. These are complex behaviors that are multi-faceted, and each child who struggles with it has his/her own unique experience. Some children find that feelings of sadness are a major contributing factor to their hair pulling, while others do not, for example. For a teacher or guidance counselor to automatically assume that the child is depressed, or having problems at home because he/she is engaged in pulling/picking behaviors is an example of being misguided and misinformed. Other common erroneous hypotheses about pulling and picking include stating that the behavior is a form of self-mutilation, a sign that the child has been a victim of abuse, or an indication that the child is losing touch with reality. Do not make assumptions. Educate yourself before sharing information with others.
Insist that a specific intervention be used
A teacher or guidance counselor could think that a certain suggestion is the "perfect" solution to the hair pulling problem. Ideas such as these generally do not work well when forced on a child. Most children find unsolicited advice to be unwelcome. Many adolescents experience a great deal of embarrassment as a result of their unwanted behavior. Having an alternative behavior thrust upon them can be mortifying. Even if younger children do not experience the same degree of discomfort, being forced to use a technique that does not feel right can lead to frustration and fail to provide effective aid for the behavior.
Children respond differently to each intervention. Two children might pull their hair out; one could respond extremely well to a silent signal from a teacher, while another finds that having a textured item in hand works well. Strategies work best when the child has been able to contribute thoughts, discuss how to use them, and understands the specific role of the teacher in the classroom during this process. Children also need the opportunity to "nix" ideas that they feel might not work for them at this time. The recommendation is always to discuss any and all considerations with the family and/or the child about how to better handle the BFRB behavior in the classroom.
Reduce the child's academically challenging classes
A guidance counselor or teacher may think that a child's BFRB behavior is due to stress as a result of academically advanced classes. In an attempt to try to solve this problem, the child is moved to a less challenging class. Unfortunately the usual result of a move such as this is that a bright child is now bored in a class that is less stimulating, continues to pull or pick and may develop feelings of low self-esteem.
If the child is placed correctly in a rigorous academic class, leave the schedule as is. Some very bright, academically gifted children engage in BFRBs. It is crucial to advocate for the child academically while at the same time providing encouragement and aid to manage the hair pulling or skin picking.
Suggest that the family pursue medication
There are certainly times when it is appropriate to suggest to a family that they consult with a professional to learn about medication options for a child who is exhibiting behaviors that interfere with learning. However, BFRBs are not those types of behaviors. Currently there is no medication recommended by the Food and Drug Administration to treat hair pulling or skin picking, or any BFRB for that matter.
Therefore, using medication is not the first recommendation to make when exploring treatment options outside of the school setting. Remember, cognitive behavior therapy is currently the recommended treatment for these behaviors.
(To learn more about this, see "Expert Consensus Treatment Guidelines for Trichotillomania, Skin Picking and Other Body-Focused Repetitive Behaviors").
School personnel now have an opportunity to offer assistance in an organized, effective manner designed to provide accurate information to the faculty and family. Families of children with BFRBs can have allies in the school who are knowledgeable about these behaviors and are willing to provide effective assistance to the student. The school, child and family members can work together in order to design a plan using specific strategies to effectively address these behaviors. Be aware of the "Do's and Don'ts" when working in a school setting in order to create a safe, supportive environment for children so that they may employ the tools necessary for them to successfully address the challenges inherent in struggling with BFRBs.
Ruth Goldfinger Golomb, MEd, LCPC, is a senior clinician, supervisor, and co-director of the doctoral training program at the Behavior Therapy Center of Greater Washington. She has conducted numerous seminars, and participated as an expert in panel discussions covering many topics, including Tourette Syndrome, Obsessive Compulsive Disorder, Trichotillomania, and managing anxiety disorders in the classroom. In addition to publishing articles for professional journals and newsletters, Ms. Golomb is an author of The Hair Pulling 'Habit' and You: How to Solve the Trichotillomania Puzzle, a book describing the comprehensive treatment of trichotillomania in children, and The Parent Guide to Hair Pulling, a book aimed at helping parents of children with trichotillomania. Ms. Golomb is a member of The TLC Foundation for Body-Focused Repetitive Behaviors Scientific Advisory Board.