With the prevalence of skin picking in PWS, it's easy to start to worry every time your child itches, scratches, or gets a bug bite. This week we will cover strategies to help prevent, reduce, and eliminate skin picking.
When to Worry?
Anything that is itchy or irritated is fair game for picking, regardless of whether or not a child has PWS. So how do you draw the line and know what's typical kid behavior, and what's PWS? In general, if your child either opens up a new wound where no skin irritation was present before, or (without intervention) your child will aggravates current abrasions frequently enough that they take over a month to heal, it's safe to say that picking is related to PWS. If you are noticing your child begin to pick more, or if you child is already having significant skin picking, you can use the strategies below to help them manage his or her picking.
Prevention
If you know your child is prone to pick, use as much prevention as you can. This includes both preventing the development of new irritated areas, and preventing picking of already irritated areas.
Preventing Skin Irritation
Use bug spray or cover skin whenever possible. If bug bites do occur, keep them covered by clothing or bandaids as much as possible, and use anti-itch cream.
If your child tends to pick at a particular area, keep that skin exfoliated and moisturized. Any irregularities in skin such as dry or dead skin can prompt skin picking. This is particularly true for children who pick their lips. Using a nightly lip exfoliant and moisturizer can prevent the presence of dead, hanging skin and reduce urges to pick. Similarly, exfoliating and moisturizing can prevent acne which often prompts face picking.
Preventing Picking of Irritated Areas
If your child already has an area that is irritated, there are a couple of strategies you can use to help prevent further picking. As mentioned, keeping areas covered as much as possible is ideal. Try to keep bandaids over any irritated areas. You will likely have to try a couple of different types of bandaids to see what stays on best. Cloth bandaids tend to work better on hands and other areas that often get wet. For small wounds, the small circular or square bandaids area ideal because they don't have room for picking beneath the bandaid, and they tend to be very sticky. If your child tends to take bandaids off, or does not tolerate bandaids, keep clothing over the area as much as possible.
For wounds that can't be easily covered, keeping a moisturizing wound ointment on the area can often help reduce the itchiness associated with healing. This can also help prevent re-opening of newly healing or scarred skin. This ointment seems to work well, but always defer to a physician if there is any concern about the speed of wound healing.
Offering Alternatives to Skin Picking
Often times you can anticipate when your child is going to pick. This might be during long car rides, stressful events such as doctor appointments, or during down time, such as when they are watching TV. It may help to offer your child something to do with their hands. Some children prefer items such as fidget spinners, balloons filled with sand, or rubbery toys they can squeeze and stretch, however some kids really need to sensation of picking at something. In this case, you can offer your child something appropriate to pick at. If they carry a water bottle, this may be as simple as sticking some paper stickers onto their bottle for them to peel off during car rides. You may have to try a few different options before you find what works best for your child.
Applying Token Economies to Skin Picking
Last week we learned about how to create token economies. When creating a token economy for skin picking, there are a couple of things you need to consider before deciding how to set up your system. I always recommend using your system to reinforce keeping bandaids on, rather than reinforcing them for not picking. The reason for this is twofold. First, your child may sometimes pick without even noticing it. If there is a bandaid on, touching the wound won't cause any damage. Second, the more attention we pay to a behavior, the more we risk increasing it. If you are reinforcing your child for not picking, you have to constantly watch them and remind them not to pick, which can inadvertently increase picking. The less attention you can pay to skin picking while still making progress towards fewer wounds, the better.
If your child tolerates bandaids, you could make your child's goal to keep bandaids on, and avoid opening any new wounds. It can be helpful to initial or otherwise mark bandaids to ensure that your child does not change his or her bandaids without asking you.
If your child does not tolerate bandaids, you could make your child's goal to have no "wet" wounds from one interval to the next. Wet wounds are any wounds that when touched with a paper towel, leave any type of liquid on the paper towel. If you child picks a wound, he or she could have the option to put a bandaid on the wound in order to still be eligible to earn the reinforcer. This helps both to keep wounds covered, and to increase the tolerance of bandaids.
The second thing you need to consider is the length of time that you will require your child to meet their goal before receiving a token. Behaviors that are automatically reinforced such as skin picking often require a dense schedule of reinforcement. Try to choose time periods that will be easy to remember. For example, you might decide to check wounds/bandaids at breakfast, lunch, snack time, dinner and bedtime, or at breakfast, after school, after bed time. Make sure these times are as consistent as possible. You will use these opportunities to check wounds, change bandaids as needed, and deliver tokens if your child earned them. If you notice that your child is earning fewer than 75% of token opportunities for a week, you need to either shorten your intervals to allow your child to earn more tokens, or take a look at your list of reinforcers to see if there is anything more exciting you can add.
Implementing these strategies always requires a bit of trial and error to get things right. Feel free to reach out if you feel you need a little bit of extra help.