Factors Associated with Assignment of Therapeutic Homework in a Large Public Children’s Mental Health System

  • Emily Velazquez Trask
  • Kya Barounis
  • Brandon L. Carlisle
  • Ann F. Garland
  • Gregory A. Aarons
Original Article


Therapeutic homework is a fundamental skill-building component of the majority of evidence-based therapies and is associated with better treatment outcomes. However, it is rarely utilized in public mental health settings. To determine barriers to homework use and identify predictors of clinicians’ assignment of homework, an online survey was administered to 267 clinicians in a large diverse public mental health system. Clinicians who were younger, licensed, whose supervisors asked about homework and whose clients completed their homework more frequently were predictors of greater homework utilization. The survey results are discussed and a novel idea to increase the use of homework is introduced.


Public mental health services Therapeutic homework Children 


Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

Ethics approval for this study was obtained from the UC San Diego Human Research Protection Program (HRPP). These data were collected as part of evaluation activities and analyses were conducted using an anonymized dataset.


  1. Aarons, G. A., Cafri, G., Lugo, L., & Sawitzky, A. (2012). Expanding the domains of attitudes towards evidence-based practice: The evidence based practice attitude scale-50. Administration and Policy in Mental Health and Mental Health Services Research, 39(5), 331–340.CrossRefPubMedGoogle Scholar
  2. Aarons, G. A., Ehrhart, M. G., Farahnak, L. R., & Sklar, M. (2014). Aligning leadership across systems and organizations to develop a strategic climate for evidence-based practice implementation. Annual Review of Public Health, 35, 255–274. Scholar
  3. Bertram, R. M., Charnin, L. A., Kerns, S. E. U., & Long, A. C. J. (2014). Evidence-based practices in North American MSW curricula. Research on Social Work Practice, 25(6), 737–748. Scholar
  4. Brookman-Frazee, L., Garland, A. F., Taylor, R., & Zoffness, R. (2009). Therapists’ attitudes towards psychotherapeutic strategies in community-based psychotherapy with children with disruptive behavior problems. Administration and Policy in Mental Health, 36(1), 1–12. Scholar
  5. Chacko, A., Anderson, L., Wymbs, B. T., & Wymbs, F. A. (2013). Parent-endorsed reasons for not completing homework in group-based behavioural parent training for high-risk families of youth with ADHD. Behavioural Change, 30(4), 262–272.CrossRefGoogle Scholar
  6. Chacko, A., Isham, A., Cleek, A. F., & McKay, M. M. (2016). Using mobile health technology to improve behavioral skill implementation through homework in evidence-based parenting intervention for disruptive behavior disorders in youth: Study protocol for intervention development and evaluation. Pilot and Feasibility Studies, 2(1), 57.CrossRefPubMedPubMedCentralGoogle Scholar
  7. Clarke, A. T., Marshall, S. A., Mautone, J. A., Soffer, S. L., Jones, H. A., Costigan, T. E., … Power, T. J. (2015). Parent attendance and homework adherence predict response to a family-school intervention for children with ADHD. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division, 53(1), 58–67. Scholar
  8. Clough, B. A., & Casey, L. M. (2011). Technological adjuncts to increase adherence to therapy. A review. Clinical Psychology Review, 31(5), 697–710. Scholar
  9. Clough, B. A., & Casey, L. M. (2015). Therapy on the move: The development of a therapeutic smartphone application. International Journal of Cyber Behavior, Psychology and Learning (IJCBPL), 5(1), 33–41.CrossRefGoogle Scholar
  10. Coughlin, S. S. (1990). Recall bias in epidemiologic studies. Journal of Clinical Epidemiology, 43(1), 87–91. Scholar
  11. County of San Diego, Health and Human Services Agency, Behavioral Health Services. (2016). Behavioral health services: Workforce assessment report. San Diego, CA: County of San Diego, Health and Human Services Agency, Behavioral Health Services.Google Scholar
  12. Cummings, C. M., Kazantzis, N., & Kendall, P. C. (2014). Facilitating homework and generalization of skills to the real world. Evidence-Based CBT for Anxiety and Depression in Children and Adolescents. Scholar
  13. Ehrhart, M. G., Aarons, G. A., & Farahnak, L. R. (2014). Assessing the organizational context for EBP implementation: The development and validity testing of the Implementation Climate Scale (ICS). Implementation Science, 9(1), 157.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Fehm, L., & Kazantzis, N. (2004). Attitudes and use of homework assignments in therapy: A survey of German psychotherapists. Clinical Psychology & Psychotherapy, 11(5), 332–343. Scholar
  15. Garland, A. F., Brookman-Frazee, L., & Chavira, D. A. (2010). Are we doing our homework? Clinical Psychology: Science and Practice, 17(2), 162–165. Scholar
  16. Garland, A. F., Brookman-Frazee, L., Hurlburt, M., Accurso, E. C., Zoffness, R., Haine, R. A., & Ganger, W. (2010). Mental health care for children with disruptive behavior problems: A view inside therapists’ offices. Psychiatric Services (Washington, D.C.), 61(8), 788–795. Scholar
  17. Garland, A. F., Hawley, K. M., Brookman-Frazee, L., & Hurlburt, M. S. (2008). Identifying common elements of evidence-based psychosocial treatments for children’s disruptive behavior problems. Journal of the American Academic of Child & Adolescent Psychiatry, 47(5), 505–514. Scholar
  18. Haine-Schlagel, R., & Walsh, N. E. (2015). A review of parent participation engagement in child and family mental health treatment. Clinical Child and Family Psychology Review, 18(2), 133–150. Scholar
  19. Hoagwood, K., Peth-Pierce, R., Glaeser, E., Whitmyre, E., Shorter, P. & Vardanian. M. M. (2017). Implementing evidence-based psychotherapies for children and adolescents within complex mental health systems. In J. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents, (3rd ed.). New York: The Guilford PressGoogle Scholar
  20. Högström, J., Enebrink, P., Melin, B., & Ghaderi, A. (2015). Eighteen-month follow-up of internet-based parent management training for children with conduct problems and the relation of homework compliance to outcome. Child Psychiatry and Human Development, 46(4), 577–588. Scholar
  21. Hudson, J. L., & Kendall, P. C. (2002). Showing you can do it: homework in therapy for children and adolescents with anxiety disorders. Journal of Clinical Psychology, 58(5), 525–534. Scholar
  22. Kazantzis, N., & Dattilio, F. M. (2010). Definitions of homework, types of homework, and ratings of the importance of homework among psychologists with cognitive behavior therapy and psychoanalytic theoretical orientations. Journal of Clinical Psychology, 66, 758–773. Scholar
  23. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7(2), 189–202.Google Scholar
  24. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2004). Assessing compliance with homework assignments: Review and recommendations for clinical practice. Journal of Clinical Psychology, 60(6), 627–641.CrossRefPubMedGoogle Scholar
  25. Kazantzis, N., Lampropoulos, G. K., & Deane, F. P. (2005). A national survey of practicing psychologists’ use and attitudes toward homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73(4), 742–748. Scholar
  26. Kazantzis, N., Whittington, C., & Dattilio, F. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17(2), 144–156. Scholar
  27. Kelly, P. J., & Deane, F. P. (2011). Improving therapeutic use of homework: Suggestions from mental health clinicians. Journal of Mental Health, 20(5), 456–463. Scholar
  28. Kelly, P. J., Deane, F. P., Kazantzis, N., & Crowe, T. P. (2007). Case managers’ attitudes toward the use of homework for people diagnosed with a severe psychiatric disability. Rehabilitation Counseling Bulletin, 51(1), 34–43.CrossRefGoogle Scholar
  29. Kelly, P. J., Deane, F. P., Kazantzis, N., Crowe, T. P., & Oades, L. G. (2006). Use of homework by mental health case managers in the rehabilitation of persistent and recurring psychiatric disability. Journal of Mental Health, 15(1), 95–101.CrossRefGoogle Scholar
  30. Kelly, P. J., Deane, F. P., King, R., Kazantzis, N., & Crowe, T. P. (2007). A taxonomy for homework used by mental health case managers when working with individuals diagnosed with severe mental illness. Community Mental Health Journal, 43(6), 565–581.CrossRefPubMedGoogle Scholar
  31. Kling, Å, Forster, M., Sundell, K., & Melin, L. (2010). A randomized controlled effectiveness trial of parent management training with varying degrees of therapist support. Behavioral Therapy, 41(4), 530–542. Scholar
  32. Liang, K.-Y., & Zeger, S. L. (1986). Longitudinal data analysis using generalized linear models. Biometrika, 73(1), 13–22. Scholar
  33. Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated meta-analysis. Cognitive Therapy and Research, 34(5), 429–438. Scholar
  34. Nakamura, B. J., Higa-McMillan, C. K., Okamura, K. H., & Shimabukuro, S. (2011). Knowledge of and attitudes towards evidence-based practices in community child mental health practitioners. Administration and Policy in Mental Health and Mental Health Services Research, 38(4), 287–300. Scholar
  35. Novins, D. K., Green, A. E., Legha, R. K., & Aarons, G. A. (2013). Dissemination and implementation of evidence-based practices for child and adolescent mental health: A systematic review. Journal of the American Academy of Child & Adolescent Psychiatry, 52(10), 1009–1025.e18. Scholar
  36. Ogden, T., & Hagen, K. A. (2008). Treatment effectiveness of parent management training in Norway: A randomized controlled trial of children with conduct problems. Journal of Consulting and Clinical Psychology, 76(4), 607–621. Scholar
  37. Park, J. M., Small, B. J., Geller, D. A., Murphy, T. K., Lewin, A. B., & Storch, E. A. (2013). Does d-cycloserine augmentation of cbt improve therapeutic homework compliance for pediatric obsessive–compulsive disorder? Journal of Child and Family Studies, 23(5), 863–871. Scholar
  38. Podsakoff, P. M., MacKenzie, S. B., Lee, J. Y., & Podsakoff, N. P. (2003). Common method biases in behavioral research: A critical review of the literature and recommended remedies. Journal of Applied Psychology, 88(5), 879.CrossRefPubMedGoogle Scholar
  39. Ros, R., Hernandez, J., Graziano, P. A., & Bagner, D. M. (2016). Parent training for children with or at risk for developmental delay: The role of parental homework completion. Behavioral Therapy, 47(1), 1–13. Scholar
  40. Southam-Gerow, M. A., & Prinstein, M. J. (2014). Evidence base updates: The evolution of the evaluation of psychological treatments for children and adolescents. Journal of Clinical Child & Adolescent Psychology, 43(1), 1–6. Scholar
  41. Stokes, J. O., Jent, J. F., Weinstein, A., Davis, E. M., Brown, T. M., Cruz, L., & Wavering, H. (2016). Does practice make perfect? The relationship between self-reported treatment homework completion and parental skill acquisition and child behaviors. Behavioral Therapy, 47(4), 538–549. Scholar
  42. Williams, N. J., Glisson, C., Hemmelgarn, A., & Green, P. (2017). Mechanisms of change in the ARC organizational strategy: Increasing mental health clinicians’ EBP adoption through improved organizational culture and capacity. Administration and Policy in Mental Health and Mental Health Services Research, 44(2), 269–283.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of California, San DiegoSan DiegoUSA
  2. 2.Department of Counseling & Marital and Family TherapyUniversity of San DiegoSan DiegoUSA

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