• Attention deficit hyperactivity disorder (ADHD)
• Eating disorders (bulimia nervosa and binge eating)
• Elimination disorders (enuresis and encopresis)
• Low self-esteem
• School refusal
• Motor tic disorders (including Tourette's Syndrome)
• Trichotillomania and chronic skin picking or nail biting

Attention deficit hyperactivity disorder (ADHD)

Inattentiveness, impulsivity, and hyperactivity are all symptoms of attention deficit hyperactivity disorder (ADHD). Inattentive and impulsive children have difficulty:

• Staying on task
• Following instructions
• Getting and staying organized
• Functioning effectively at home and in the classroom.

Medication has been shown to be an effective first-line treatment for moderate to severe ADHD-related symptoms. However, cognitive-behavior therapy can be helpful in addition to, and sometimes in lieu of, medication.

Cognitive-behavior therapy focuses on increasing the frequency of on-task and pro-social behaviors while decreasing the problematic impulsive or inappropriate behaviors of these children. Cognitive behavior therapy teaches parents how to adjust their parenting style to better meet the specific needs of their inattentive child. Parents can learn to give the child a light touch on the arm, to insist on eye contact before giving an instruction, and to avoid multi-step instructions; these behaviors on the part of the parent can help the child with ADHD complete tasks and stay on track. Homework time is often difficult for children with ADHD and their parents. Parents can learn skills to increase their child's pro-homework behavior, such as starting homework at the agreed-upon time and returning from breaks promptly, and can help their child to learn to accept corrective feedback without argument or complaint. These changes can decrease the amount of unnecessary time spent on homework and greatly improve the climate in the home. The therapist can also work closely with the child's teachers to set up behavioral management plans in the classroom to improve the child's functioning there.

back to top

Eating disorders (bulimia nervosa and binge eating)
Eating disorders typically develop in early adolescence and are characterized by:

• Episodes of restricting food (limiting the amount of food eaten or avoiding certain types of foods, such as carbohydrates or fat, or certain taboo foods)
• Binging (eating an excessive amount of food in a short period of time while feeling out of control)
• Purging (vomiting, laxative use, or excessive exercise)
• Distorted body image (believing they are overweight when they are not, and experiencing strong feelings of disgust or self-loathing about their bodies)

Restricting, bingeing, and purging appear to be linked and to follow a typical sequence. Often a youth who severely restricts her eating then experiences intense cravings that can trigger an episode of binge eating; the bingeing then leads to feelings of disgust or other intense distress that can trigger purging and/or renewed efforts to restrict, and the cycle begins again.

Cognitive-behavior therapy has been shown to be effective for two eating disorders: bulimia nervosa (recurrent episodes of binging and purging) and binge eating disorder (recurrent episodes of binging without purging). Cognitive-behavior therapy for these eating disorders includes teaching strategies to establish normal eating behavior in order to reduce the risk of binges, teaching activities and skills (such as relaxation and controlling situations that trigger urges to binge) to manage cravings and urges to binge or purge without engaging in harmful behaviors, teaching strategies to manage unpleasant emotions that contribute to disordered eating, and body image practice to help youth become more comfortable with their bodies.
back to top

Elimination disorders (enuresis and encopresis)
Although toilet training is a stressful process for many parents and youth, most children learn toilet training without serious delays or problems. However, when toilet training is unsuccessful, two types of elimination disorders may result:

• Enuresis (the involuntary discharge of urine), which can refer to wetting during the day, night, or both,
• Encopresis (the intentional or accidental discharge of feces).

Toileting problems in youth can be due to organic causes (problems in the shape or innervation of the bladder), stressful life events, or anxiety and mood disorders, such as the child who fears being separated from his parents or fears being kidnapped so that he is unable to go to the toilet in the evening, even in his own home. Any or all of these problems can contribute to incomplete or failed toilet training.

Cognitive-behavior therapy has been shown to provide effective treatment of many types of toileting difficulties in children. Treatment begins with a thorough assessment to identify the reasons for the toileting difficulties. If an anxiety disorder is the primary reason for the child's toileting difficulties (a child who avoids going to the bathroom because he his afraid of germs or fears being alone in another part of the house), cognitive-behavioral strategies can assist the child to manage his or her anxiety so that normal toileting behavior can occur. For other youth, behavioral interventions, such as dry-bed training, can correct functional enuresis (enuresis that does not have an organic cause) either alone or in conjunction with medications. Dry-bed training includes urine-detection systems, such as the Bell-and-Pad Alarm, which beep when a tiny amount of urine is detected in the child's underwear; positive reinforcement for appropriate toileting behaviors (limiting fluids in the evenings, toileting before bed, awakening when the alarm sounds and quickly and without complaint turning it off and going to the toilet), and self-correction of accidents (changing the bed sheets and into dry pajamas themselves). In combination, these behavioral techniques can be highly effective in correcting toileting difficulties.
back to top

Low self-esteem
Youth with low self-esteem view themselves as inadequate or lacking in some way due to some of the following factors:

• Setting unrealistic and excessive standards for themselves that they are unable to meet
• Experiencing repeated failures due to learning difficulties
• Exaggerating their weaknesses and minimizing their strengths
• Experiencing chronic failure in social situations because of interpersonal difficulties due to poor social skills or excessive fearfulness.
• Low self-esteem can contribute to unsatisfying relationships, limited opportunities and depression and anxiety.

Cognitive-behavior therapy for low self-esteem focuses on helping youths modify the excessive standards they have for themselves so that they can experience successes rather than failures. Other strategies include assisting the youth to test beliefs that underpin poor self-esteem, such as "I'm a loser" or "I can't really play sports" or "I don't have anything interesting to say." Cognitive-behavior therapy can also teach skills to overcome obstacles such as making more friends or staying on a task until it is done; these skills can help youths develop a sense of mastery and self-worth.
back to top

School refusal
There are a number of reasons why children refuse to attend school, including:

• Being bullied or teased by peers
• Feeling demoralized and depressed about academics due to a learning disability
• Experiencing anxiety or fear about something in school, such as fearing that they might throw up or have a panic attack, or when separating from primary caretakers.

Whatever the reason the child refuses to attend school, school refusal is always a serious problem, and is often the key event that propels parents to seek help for their child.

Cognitive-behavior therapy has been shown to provide effective treatment for school refusal in children. Treatment begins with a thorough assessment to determine why the child is avoiding school. Once the reasons for the child's school refusal are understood, the child and parents can be taught strategies to assist the child in returning to school. If anxiety is a central reason, cognitive-behavior therapy includes teaching the child a variety of anxiety management strategies, including helping the child return to the classroom in a gradual way, perhaps starting with spending 15 minutes in the library on a Saturday and working up to longer periods of time. The cognitive-behavior therapist can also work with the child, parents, and school to develop a plan to address other problems, such as learning difficulties or bullying.
back to top

Motor tic disorders (including Tourette's syndrome)
Motor tics are sudden, rapid, repetitive movements (motor tic) or vocalizations (vocal tic). Motor tics usually involve muscles in a single location of the face or upper body and can involve one muscle group (simple tics), such as a child who shakes his head or blinks his eyes, or more than one muscle group (complex tics), such as the child who jumps and hops or twirls while walking. Tourette's syndrome includes both motor and vocal tics. Often motor tics are mild and require nothing more than to explain to the child what they are and how he might delay the tic until he is home or alter the expression of the tic to something less noticeable (exhaling a breath rather than humming). Motor tics tend to become less severe as the child matures.

Severe motor tics can cause the child to be the target of relentless teasing and loss of self-esteem. For these reasons, severe motor tics require active intervention. Recent research suggests that cognitive-behavior therapy, either alone or in combination with medications, can decrease the frequency of motor or vocal tics in youth. Cognitive-behavioral strategies include habit reversal, which involves helping the child learn strategies to reduce the urge to tic, such as relaxation and breathing techniques, as well as strategies to break the link between the tic and the physiological relief the child often experiences after the tic. These strategies include engaging in certain actions that are incompatible with the tic. For example, a child with a motor tic such as blinking or eye rolls can learn to look straight ahead at an object while he or she waits for the urge to decrease. In addition, the child can learn to shape a particularly noticeable motor tic into one that is less obvious and less disruptive. Because the frequency of motor or vocal tics can increase when the child is anxious or stressed, the child can also benefit from learning cognitive-behavior strategies to decrease anxiety and to cope effectively with teasing and other social difficulties that arise because of the tics.
back to top

Chronic hairpulling (trichotillomania), skin picking, or nail biting
Children often pull or twist their hair or bite or pick at their nails. Typically, these self-soothing behaviors diminish as the child matures. For some children, however, these behaviors are chronic and debilitating. A child might pull her hair until she has a bald spot on her head or has no eyebrows or eyelashes. Another child might bite his nails and cuticles until they are bloody and raw. These behaviors and their results can be distressing to the child or become a focus of teasing or social rejection.

Although chronic hairpulling, skin picking, or nail biting are difficult to treat, cognitive-behavior therapy can help some children decrease the frequency of these behaviors and or even stop them altogether. Cognitive-behavioral interventions include habit reversal, which involves helping the child learn to use strategies to reduce urges to pull or pick and to manage them effectively when the urges occur. Strategies include using relaxation and deep breathing to reduce urges to pick, and controlling the stimuli that trigger urges to pull or pick by wearing Band Aids on their fingers or gloves and caps. The child can also learn strategies to break the link between the habit and the physiological relief the child experiences as a result of pulling or picking, including engaging in certain actions that are incompatible with pulling or picking (such as wearing mittens) while waiting for the urge to decrease, as it inevitably does. Because children who chronically pull or pick are often easily stressed, they can also benefit from learning cognitive-behavior strategies to decrease anxiety and cope with social rejection and other difficulties that sometimes arise because of the chronic picking and pulling.
back to top