Therapy homework (or home practice) has long been a part of mental health treatment for children and families. It has been understood a variety of ways but can be defined as ‘tasks assigned to clients to promote skill acquisition between treatment sessions’ (Dozois, 2010).

Homework completion/adherence has also been often studied - either as a standalone behaviour, or part of a group of ‘adherence’ or ‘engagement’ behaviours. Most of these studies find that higher levels of homework completed – both by parents (parent management training/parent therapeutic interventions) and by children results in better outcomes, as well as lower drop out and higher treatment satisfaction.

There have been a small number of exceptions however (ie studies which did not find the above relationships). It has been suggested these have occurred due to a) some families/clients doing less homework because they have already improved and feel less need for it, or b) variation in the quality of the homework set – and the quality of homework is more important than the quantity and c) the variation in the way homework completion is measured (self report versus behavioural methods).

It is also worth noting that there is a body of research which suggests that higher levels of ‘activation’ generally (i.e., anything which gets the child/family doing something differently – compared to understanding information – whether that be at home or in session) is one of the most important factors in whether therapy is useful. If this is true, then given that homework setting and adherence is likely be a type of ‘activation’ – then this research also supports the importance of homework setting/adherence.

Therefore, for us as child mental health therapists, helping children and families to complete at home and in between (and in) session tasks is arguably an important goal for most of the families we work with.

This is not easy. Therapists typically cite homework completion as being challenging. In parent management programs or treatment, therapists say about half of their parents have problems completing homework. Other studies have found up to 60% of parents/caregivers did not complete PCIT homework (a commonly implemented approach). Other studies show that parents often complete only half of their homework assignments (eg Chacko et al., 2009 for one example of these studies).

Difficulties completing homework seem to occur for families and children/adolescents from many kinds of backgrounds and with all kinds of challenges. We do not seem to have any accurate predictors of who will complete homework or not. Some studies have found relationships family income/education related to homework compliance, others have not. Contradictory to some therapists intuition - some studies have found families with more child behaviour problems are more likely to complete therapy homework. Interestingly, male gender is associated with lower homework completion in many studies.

What might encourage homework completion according to the literature?

Although there are not many studies directly addressing this issue specifically there are a handful which exist. These studies (which are preliminary) suggest that a) therapists being more collaborative, b) parents/caregivers having higher expectations of the benefits of therapy, and c) parents/children who have better understand the treatment concepts in session – are all factors which may be associated with greater completion.

Despite the paucity of research in this specific area, we can arguably draw upon other areas of research which address factors which increase engagement more generally. Below I have listed strategies and options for increasing homework completion which are supported both by research and my clinical experience.

Options to consider to increase homework/therapy home practice adherence

Setting up expectations for homework:

Consider:

· Telling the client/client family about homework from the beginning of treatment (or in pre-therapy information).

· Providing a rationale which outlines the specific expectations (i.e., approximate number of minutes, approximate number of times per week) and which is appropriate for the caregivers, age of child, problem, and situation. This rationale might include reasons, evidence, or analogies. For example:

The reason we set homework or out of session practice is that research tells us that families who do this kind of work each day or nearly every day - are much more likely to see changes in themselves/their young people compared to those who don’t.

I’m sure this makes sense to you – it’s a bit like having instrument lessons and just going to the lesson but never picking up your instrument outside of the lesson – or like going to a physio who gives you exercises but not doing them.

· Choosing a homework schedule which relies more on increased regularity rather than longer intensity – i.e., suggesting 5-10 minutes per day, rather than a 20-minute task once a week.

· Telling the client the agenda for sessions (or writing on the white board) which includes when/how you will address homework.

Just so you know the structure of sessions: at the beginning I will ask for a very brief recap of anything significant which has happened for the week, then we will review together how you went with the therapy homework/practice tasks, and then we will look at the skills or topics we are going to discuss next.

· Inviting feedback and briefly addressing barriers and difficulties before they occur

I wanted to check in on how you feel about being able to complete the 5-10 minutes of homework each day (and/or spending time with your child to help them complete their homework) – and whether there is anything we should talk about to help you be able to remember to do it/manage to solve problems and find a way to do it on the busy and tricky weeks. Sometimes families set up alarms, or do things like reduce expectations for themselves in other areas while they are in therapy so they can find time to do the therapy homework. Sometimes we have an agreement that if you can’t do the homework, we delay sessions for a bit until you have time.

· Setting up a schedule of sessions which facilitates homework completion. Specifically, seeing clients weekly or fortnightly rather than 3-4 weekly is likely to increase homework completion as families are more likely to remember and feel motivated to complete homework they know will be discussed at a session less further away. Where 1-2 weekly sessions are not possible/appropriate over the longer term, consider having 1-2 weekly sessions for a number of sessions and then a break, and then another 1-2 weekly sessions before another break.

· Possibly using a different word (therapy task, activity of the week) if “homework” arouses resistance.

Throughout therapy – strategies for setting homework/home practice which is most likely to be achieved:

· Consider recapping the agenda at beginning of sessions to remind them of homework expectations.

As you know, today I will get a very brief recap of anything significant which has happened for the week, then we will review together how you went with the therapy homework/practice tasks, and then we will look at the skills or topics we are going to discuss next.

· Ensuring all homework set is specific:

We have discussed a few different concepts today, let’s see if we can think of some action/therapy homework which will summarise what we have been talking about today.

· Ensuring all homework set is achievable according to a family’s resources:

I suggest/recommend you do X, rather than Y – as Y will probably take/involve more than the number of minutes we agreed upon and may also require…

· Ensuring the homework fits with the client/family’s values – including consider asking the client to choose a homework task

What task/activity/idea do you most want to remember and use over this next fortnight?

· Ensuring the homework set is visual/written down (verbal homework set is significantly less likely to be done).

· Consider asking for homework to be “ticked” and dated or have some component which requires the client to be able to show completion beyond just verbal description:

I’ll just draw 5 boxes, and you can just date each one and we can look at them next time – would you rather bring this sheet in or take a photo of it and email me?

· Asking about barriers briefly when setting the homework:

Is there anything we should chat about to make sure you/child are able to complete this homework? It might be that *child* needs support to do this, as this sounds good in theory but sometimes therapy homework is tricky to remember or feel motivated to do, so often parents have to support them to do it.

· Remind clients/family when you will follow up on homework

I’m looking forward to seeing you activity sheet/record of homework/that task at the beginning of next session.

Addressing initial homework non-compliance:

1. Ask questions and discuss – either with client alone or with parent in session where appropriate. While always prioritising warmth and care, avoid falsely reassuring the client about homework completion but instead provide empathy:

I’m sorry to hear you had some difficulties this week with the homework. Let’s just take a minute to see if we can problem solve this for next time. What was hardest aspect? Was it forgotten? Was it avoided? How much did you believe it was important?

2. After above information gathered, take actions, give further rationale, and modify homework to make easier/more specific/more useful/understandable/increase motivation etc. This might include the following:

· Take steps to increase motivation/belief

It sounds like you are not 100% sure if the homework will be helpful. Can you tell me about what is it that you think might not help? May I share with you my thoughts about this?

· Consider whether appropriate to tell child/teen what the parent homework is to increase accountability.

Jane, your homework is X, but Mum’s homework is X – are you both able to check with each other about how you are going with the homework.

· Consider whether appropriate to tell parent/caregiver what the child homework is to increase accountability.

Mum/Dad, I have asked Jane/John to do X this week. He/she may understandably need some support or accountability to make sure this happens. Is there a time which would work for you to check with him/do it with him/her.

· Consider whether appropriate to give same homework again to reinforce importance

I know you didn’t do it this week, but because we have both agreed this is importance, I will just photocopy this homework again.

· Consider whether possible to decrease time between sessions to increase accountability for homework completed

Just to make sure we don’t lose momentum and can make sure you are able to do the homework this time, can you please make an appointment in 1 weeks’ time rather than us waiting X weeks before the next session? We can have a larger space in X sessions time, but it will be better for us to have sessions X weeks apart for now.

Chronic homework non-compliance options:

When all other best practice guidelines as above have been consistently followed:

· Discuss feelings aroused in having to do homework/underlying difficulties with homework (issues with authority/therapy processes? Usefulness of therapy? Motivation generally? Other fears?)

I’d like to have a tough conversation with you. As you know, my understanding of the research and having worked with families is that the best chance of (goal identified) occurring is that you/child do (homework). I know this has been, understandably, difficult for you. However my best guess is that (outcome – i.e., no or minimal progress) will continue to occur so I just want to be transparent about that and see what you think.

· Discuss options for having client/client family email “homework is done” before further session

One option is for us to wait until you have been able to (complete homework) before we have the next session, so that we can spend the next session on….

· Discuss readiness for therapy with client and client family.

· Consider whether appropriate to cease sessions, balancing whether it is still useful to have sessions with client even though they will be less effective, or whether it is more damaging for client to be in therapy without progress. Take into account therapist well-being in working with a client not completing homework.

One option is for us to have a break from therapy for now, given that you have so much happening and may just not be able to do the kinds of things we are talking about. Or you could work with a different service who does not have the same emphasis on in between therapy tasks. This is just an option – and certainly not one you have to take up – I just wanted to see what you think.

· With chronic homework non-compliance, consider may be appropriate to mention in GP letters, i.e., client “found it difficult to complete homework”.

Finally:

It is worth noting that homework compliance is really behaviour change. In other words, when we ask clients to complete homework we are really asking them to make significant life changes. It is not surprising that this is hard, and requires much of our patience, compassion, and attention.

All of the above strategies are options, and should be implemented according to your own clinical judgement about what the family most needs. *Sometimes* ignoring homework non-completion is the wisest clinical decision to make – but this is often best done while being transparent with the family about likely consequences of it.

References which may be of interest:

Danko, CM, Brown, T, Van Schoick, L & Budd, KS 2016, ‘Predictors and Correlates of Homework Completion and Treatment Outcomes in Parent–Child Interaction Therapy’, Child & Youth Care Forum, vol. 45, no. 3, pp. 467–485.

Arendt, K, Thastum, M & Hougaard, E 2016, ‘Homework Adherence and Cognitive Behaviour Treatment Outcome for Children and Adolescents with Anxiety Disorders’, Behavioural and Cognitive Psychotherapy, vol. 44, no. 2, pp. 225–235.

Ros, R, Graziano, PA & Hart, KC 2017, ‘Parental Homework Completion and Treatment Knowledge During Group Parent–Child Interaction Therapy’, Journal of Early Intervention, vol. 39, no. 4, pp. 299–320.

If you work with 4 to 11 year old children, and would like a resource to assist in your work with them, go to www.calmkidpro.com or click on the image to the left.

In this program, we have a new video for professionals about how to increase therapy homework adherence. There is also a variety of other videos, games, and posters for kids, along with articles and modules for parents/caregivers and professionals, to support children with emotional, mental health or life challenges.

Click here to download/print the parent version of this article to give to parents you work with