use of homework in cbt

How to Design Homework in CBT That Will Engage Your Clients

Take-home assignments provide the opportunity to transfer different skills and lessons learned in the therapeutic context to situations in which problems arise.

These opportunities to translate learned principles into everyday practice are fundamental for ensuring that therapeutic interventions have their intended effects.

In this article, we’ll explore why homework is so essential to CBT interventions and show you how to design CBT homework using modern technologies that will keep your clients engaged and on track to achieving their therapeutic goals.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with a detailed insight into positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

Why is homework important in cbt, how to deliver engaging cbt homework, using quenza for cbt: 3 homework examples, 3 assignment ideas & worksheets in quenza, a take-home message.

Many psychotherapists and researchers agree that homework is the chief process by which clients experience behavioral and cognitive improvements from CBT (Beutler et al., 2004; Kazantzis, Deane, & Ronan, 2000).

We can find explanations as to why CBT  homework is so crucial in both behaviorist and social learning/cognitive theories of psychology.

Behaviorist theory

Behaviorist models of psychology, such as classical and operant conditioning , would argue that CBT homework delivers therapeutic outcomes by helping clients to unlearn (or relearn) associations between stimuli and particular behavioral responses (Huppert, Roth Ledley, & Foa, 2006).

For instance, imagine a woman who reacts with severe fright upon hearing a car’s wheels skidding on the road because of her experience being in a car accident. This woman’s therapist might work with her to learn a new, more adaptive response to this stimulus, such as training her to apply new relaxation or breathing techniques in response to the sound of a skidding car.

Another example, drawn from the principles of operant conditioning theory (Staddon & Cerutti, 2003), would be a therapist’s invitation to a client to ‘test’ the utility of different behaviors as avenues for attaining reward or pleasure.

For instance, imagine a client who displays resistance to drawing on their support networks due to a false belief that they should handle everything independently. As homework, this client’s therapist might encourage them to ‘test’ what happens when they ask their partner to help them with a small task around the house.

In sum, CBT homework provides opportunities for clients to experiment with stimuli and responses and the utility of different behaviors in their everyday lives.

Social learning and cognitive theories

Scholars have also drawn on social learning and cognitive theories to understand how clients form expectations about the likely difficulty or discomfort involved in completing CBT homework assignments (Kazantzis & L’Abate, 2005).

A client’s expectations can be based on a range of factors, including past experience, modeling by others, present physiological and emotional states, and encouragement expressed by others (Bandura, 1989). This means it’s important for practitioners to design homework activities that clients perceive as having clear advantages by evidencing these benefits of CBT in advance.

For instance, imagine a client whose therapist tells them about another client’s myriad psychological improvements following their completion of a daily thought record . Identifying with this person, who is of similar age and presents similar psychological challenges, the focal client may subsequently exhibit an increased commitment to completing their own daily thought record as a consequence of vicarious modeling.

This is just one example of how social learning and cognitive theories may explain a client’s commitment to completing CBT homework.

Let’s now consider how we might apply these theoretical principles to design homework that is especially motivating for your clients.

In particular, we’ll be highlighting the advantages of using modern digital technologies to deliver engaging CBT homework.

Designing and delivering CBT homework in Quenza

Gone are the days of grainy printouts and crumpled paper tests.

Even before the global pandemic, new technologies have been making designing and assigning homework increasingly simple and intuitive.

In what follows, we will explore the applications of the blended care platform Quenza (pictured here) as a new and emerging way to engage your CBT clients.

Its users have noted the tool is a “game-changer” that allows practitioners to automate and scale their practice while encouraging full-fledged client engagement using the technologies already in their pocket.

To summarize its functions, Quenza serves as an all-in-one platform that allows psychology practitioners to design and administer a range of ‘activities’ relevant to their clients. Besides homework exercises, this can include self-paced psychoeducational work, assessments, and dynamic visual feedback in the form of charts.

Practitioners who sign onto the platform can enjoy the flexibility of either designing their own activities from scratch or drawing from an ever-growing library of preprogrammed activities commonly used by CBT practitioners worldwide.

Any activity drawn from the library is 100% customizable, allowing the practitioner to tailor it to clients’ specific needs and goals. Likewise, practitioners have complete flexibility to decide the sequencing and scheduling of activities by combining them into psychoeducational pathways that span several days, weeks, or even months.

Importantly, reviews of the platform show that users have seen a marked increase in client engagement since digitizing homework delivery using the platform. If we look to our aforementioned drivers of engagement with CBT homework, we might speculate several reasons why.

• Implicit awareness that others are completing the same or similar activities using the platform (and have benefitted from doing so) increases clients’ belief in the efficacy of homework.
• Practitioners and clients can track responses to sequences of activities and visually evidence progress and improvements using charts and reporting features.
• Using their own familiar devices to engage with homework increases clients’ self-belief that they can successfully complete assigned activities.
• Therapists can initiate message conversations with clients in the Quenza app to provide encouragement and positive reinforcement as needed.

The rest of this article will explore examples of engaging homework, assignments, and worksheets designed in Quenza that you might assign to your CBT clients.

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Let’s now look at three examples of predesigned homework activities available through Quenza’s Expansion Library.

Urge Surfing

Many of the problems CBT seeks to address involve changing associations between stimulus and response (Bouton, 1988). In this sense, stimuli in the environment can drive us to experience urges that we have learned to automatically act upon, even when doing so may be undesirable.

For example, a client may have developed the tendency to reach for a glass of wine or engage in risky behaviors, hoping to distract themselves from negative emotions following stressful events.

Using the Urge Surfing homework activity, you can help your clients unlearn this tendency to automatically act upon their urges. Instead, they will discover how to recognize their urges as mere physical sensations in their body that they can ‘ride out’ using a six-minute guided meditation, visual diagram, and reflection exercise.

Moving From Cognitive Fusion to Defusion

Central to CBT is the understanding that how we choose to think stands to improve or worsen our present emotional states. When we get entangled with our negative thoughts about a situation, they can seem like the absolute truth and make coping and problem solving more challenging.

The Moving From Cognitive Fusion to Defusion homework activity invites your client to recognize when they experience a negative thought and explore it in a sequence of steps that help them gain psychological distance from the thought.

Finding Silver Linings

Many clients commencing CBT admit feeling confused or regretful about past events or struggle with self-criticism and blame. In these situations, the focus of CBT may be to work with the client to reappraise an event and have them look at themselves through a kinder lens.

The Finding Silver Linings homework activity is designed to help your clients find the bright side of an otherwise grim situation. It does so by helping the user to step into a positive mindset and reflect on things they feel positively about in their life. Consequently, the activity can help your client build newfound optimism and resilience .

As noted, when you’re preparing homework activities in Quenza, you are not limited to those in the platform’s library.

Instead, you can design your own or adapt existing assignments or worksheets to meet your clients’ needs.

You can also be strategic in how you sequence and schedule activities when combining them into psychoeducational pathways.

Next, we’ll look at three examples of how a practitioner might design or adapt assignments and worksheets in Quenza to help keep them engaged and progressing toward their therapy goals.

In doing so, we’ll look at Quenza’s applications for treating three common foci of treatment: anxiety, depression, and obsessions/compulsions.

When clients present with symptoms of generalized anxiety, panic, or other anxiety-related disorders, a range of useful CBT homework assignments can help.

These activities can include the practice of anxiety management techniques , such as deep breathing, muscle relaxation, and mindfulness training. They can also involve regular monitoring of anxiety levels, challenging automatic thoughts about arousal and panic, and modifying beliefs about the control they have over their symptoms (Leahy, 2005).

Practitioners looking to support these clients using homework might start by sending their clients one or two audio meditations via Quenza, such as the Body Scan Meditation or S.O.B.E.R. Stress Interruption Mediation . That way, the client will have tools on hand to help manage their anxiety in stressful situations.

As a focal assignment, the practitioner might also design and assign the client daily reflection exercises to be completed each evening. These can invite the client to reflect on their anxiety levels during the day by responding to a series of rating scales and open-ended response questions. Patterns in these responses can then be graphed, reviewed, and used to facilitate discussion during the client’s next in-person session.

As with anxiety, there is a range of practical CBT homework activities that aid in treating depression.

It should be noted that it is common for clients experiencing symptoms of depression to report concentration and memory deficits as reasons for not completing homework assignments (Garland & Scott, 2005). It is, therefore, essential to keep this in mind when designing engaging assignments.

CBT assignments targeted at the treatment of depressive symptoms typically center around breaking cycles of negative events, thinking, emotions, and behaviors, such as through the practice of reappraisal (Garland & Scott, 2005).

Examples of assignments that facilitate this may include thought diaries , reflections that prompt cognitive reappraisal, and meditations to create distance between the individual and their negative thoughts and emotions.

To this end, a practitioner looking to support their client might design a sequence of activities that invite clients to explore their negative cognitions once per day. This exploration can center on responses to negative feedback, faced challenges, or general low mood.

A good template to base this on is the Personal Coping Mantra worksheet in Quenza’s Expansion Library, which guides clients through the process of replacing automatic negative thoughts with more adaptive coping thoughts.

The practitioner can also schedule automatic push notification reminders to pop up on the client’s device if an activity in the sequence is not completed by a particular time each day. This function of Quenza may be particularly useful for supporting clients with concentration and memory deficits, helping keep them engaged with CBT homework.

Obsessions/compulsions

Homework assignments pertaining to the treatment of obsessive-compulsive disorder typically differ depending on the stage of the therapy.

In the early stages of therapy, practitioners assigning homework will often invite clients to self-monitor their experience of compulsions, rituals, or responses (Franklin, Huppert, & Roth Ledley, 2005).

This serves two purposes. First, the information gathered through self-monitoring, such as by completing a journal entry each time compulsive thoughts arise, will help the practitioner get clearer about the nature of the client’s problem.

Second, self-monitoring allows clients to become more aware of the thoughts that drive their ritualized responses, which is important if rituals have become mostly automatic for the client (Franklin et al., 2005).

Therefore, as a focal assignment, the practitioner might assign a digital worksheet via Quenza that helps the client explore phenomena throughout their day that prompt ritualized responses. The client might then rate the intensity of their arousal in these different situations on a series of Likert scales and enter the specific thoughts that arise following exposure to their fear.

The therapist can then invite the client to complete this worksheet each day for one week by assigning it as part of a pathway of activities. A good starting point for users of Quenza may be to adapt the platform’s pre-designed Stress Diary for this purpose.

At the end of the week, the therapist and client can then reflect on the client’s responses together and begin constructing an exposure hierarchy.

This leads us to the second type of assignment, which involves exposure and response prevention. In this phase, the client will begin exploring strategies to reduce the frequency with which they practice ritualized responses (Franklin et al., 2005).

To this end, practitioners may collaboratively set a goal with their client to take a ‘first step’ toward unlearning the ritualized response. This can then be built into a customized activity in Quenza that invites the client to complete a reflection.

For instance, a client who compulsively hoards may be invited to clear one box of old belongings from their bedroom and resist the temptation to engage in ritualized responses while doing so.

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Developing and administering engaging CBT homework that caters to your client’s specific needs or concerns is becoming so much easier with online apps.

Further, best practice is becoming more accessible to more practitioners thanks to the emergence of new digital technologies.

We hope this article has inspired you to consider how you might leverage the digital tools at your disposal to create better homework that your clients want to engage with.

Likewise, let us know if you’ve found success using any of the activities we’ve explored with your own clients – we’d love to hear from you.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Bandura, A. (1989). Human agency in social cognitive theory. American Psychologist , 44 (9), 1175–1184.
• Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.) (pp. 227–306). Wiley.
• Bouton, M. E. (1988). Context and ambiguity in the extinction of emotional learning: Implications for exposure therapy. Behaviour Research and Therapy , 26 (2), 137–149.
• Franklin, M. E., Huppert, J. D., & Roth Ledley, D. (2005). Obsessions and compulsions. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 219–236). Routledge.
• Garland, A., & Scott, J. (2005). Depression. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 237–261). Routledge.
• Huppert, J. D., Roth Ledley, D., & Foa, E. B. (2006). The use of homework in behavior therapy for anxiety disorders. Journal of Psychotherapy Integration , 16 (2), 128–139.
• Kazantzis, N. (2005). Introduction and overview. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 1–6). Routledge.
• 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.
• Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 9–34). Routledge.
• Leahy, R. L. (2005). Panic, agoraphobia, and generalized anxiety. In N. Kazantzis, F. P. Deane, K. R., Ronan, & L. L’Abate (Eds.), Using homework assignments in cognitive behavior therapy (pp. 193–218). Routledge.
• Staddon, J. E., & Cerutti, D. T. (2003). Operant conditioning. Annual Review of Psychology , 54 (1), 115–144.

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Assigning Homework in Cognitive Behavioral Therapy

It’s certainly true that therapy outcomes depend in part on the work taking place in each session. But for this progress to reach its full impact, clients need to use what they learn in therapy during their daily lives. 

Assigning therapy “homework” can help your clients practice new skills during the week. While many types of therapy may involve some form of weekly assignment, homework is a key component of cognitive behavior therapy. 

Types of Homework

Some clients may respond well to any type of homework, while others may struggle to complete or find benefit in certain assignments. It’s important for clients to step outside of their comfort zone in some ways. For example, it’s essential to learn to challenge unwanted thoughts and increase understanding of feelings and emotions, especially for people who struggle with emotional expression. 

But there isn’t just one way to achieve these goals. Finding the right type of homework for each client can make success more likely. 

There are many different types of therapy homework. Asking your client to practice breathing exercises when they feel anxious or stressed? That’s homework. Journaling about distressing thoughts and ways to challenge them, or keeping track of cognitive distortions ? Also homework.

Some clients may do well with different assignments each week, while others may have harder times with certain types of homework. For example:

• An artistic client may not get much from written exercises. They might, however, prefer to sketch or otherwise illustrate their mood, feelings, or reactions during the week. 
• Clients who struggle with or dislike reading may feel challenged by even plain-language articles. If you plan to assign educational materials, ask in your first session whether your client prefers audio or written media. 

When you give the assignment, take a few minutes to go over it with your client. Give an example of how to complete it and make sure they understand the process. You’ll also want to explain the purpose of the assignment. Someone who doesn’t see the point of a task may be less likely to put real effort into it. If you give a self-assessment worksheet early in the therapy process, you might say, “It can help to have a clear picture of where you believe you’re at right now. Later in therapy I’ll ask you to complete another assessment and we can compare the two to review what’s changed.” 

Mental Health Apps

Some people may also find apps a useful way to develop and practice emotional wellness coping skills outside of therapy. Therapy apps can help people track their moods, emotions, or other mental health symptoms. They can provide a platform to practice CBT or other therapy skills. They can also offer structured mindfulness meditations or help clients practice other grounding techniques. 

If you’re working with a client who’s interested in therapy apps, you might try using them in treatment. Just keep in mind that not all apps offer the same benefits. Some may have limitations, such as clunky or confusing interfaces and potential privacy concerns. It’s usually a good idea to check whether there’s any research providing support for—or against—a specific app before recommending it to a client. 

Trusted mental health sources, such as the American Psychological Association or Anxiety and Depression Association of America websites, may list some popular mental health apps, though they may not specifically endorse them. These resources can be a good starting place. Other organizations, including Northwestern University’s Center for Behavioral Intervention Technologies and the Defense Department of the United States, have developed their own research-backed mental health apps. 

You can also review apps yourself. Try out scenarios or options within the app to get to know how the app works and whether it might meet your client’s needs. This will put you in a position to answer their questions and help give them tips on getting the most out of the app. 

Benefits of Homework

Some of your clients may wonder why you’re assigning homework. After all, they signed up for therapy, not school. 

When clients ask about the benefits of therapy homework, you can point out how it provides an opportunity to put things learned in session into practice outside the therapy session. This helps people get used to using the new skills in their toolbox to work through issues that come up for them in their daily lives. More importantly, it teaches them they can use these skills on their own, when a therapist or other support person isn’t actively providing coaching or encouragement. This knowledge is an important aspect of therapy success. 

A 2010 review of 23 studies on homework in therapy found evidence to suggest that clients who completed therapy homework generally had better treatment outcomes. This review did have some limitations, such as not considering the therapeutic relationship or how clients felt about homework. But other research supports these findings, leading many mental health experts to support the use of therapy homework, particularly in CBT. Homework can be one of many effective tools in making therapy more successful. 

Improving Homework Compliance

You may eventually work with a client who shows little interest in homework and doesn’t complete the assignments. You know this could impede their progress in therapy, so you’ll probably want to bring this up in session and ask why they’re having difficulty with the homework. You can also try varying the types of homework you assign or asking if your client is interested in trying out a mental health app that can offer similar benefits outside your weekly sessions. 

When you ask a client about homework non-compliance, it’s important to do it in a way that doesn’t anger them, make them feel defensive, or otherwise damage the relationship you’re working to develop. Here are some tips for having this conversation:

• Let them know homework helps them practice their skills outside of therapy. In short, it’s helping them get more out of therapy (more value for their money) and may lead to more improvement, sometimes in a shorter period of time than one weekly session would alone. 
• Bring up the possibility of other types of homework. “If you don’t want to write anything down, would you want to try listening to a guided meditation or tips to help manage upsetting emotions?” 
• Ask about it, in a non-confrontational way. You might say something like, “Is something making it difficult for you to complete the homework assignments? How can I help make the process easier for you?” 

The prospect of homework in therapy may surprise some clients, but for many people, it’s an essential element of success. Those put off by the term “homework” may view “skills practice” or similar phrasing more favorably, so don’t feel afraid to call it something else. The important part is the work itself, not what you call it.    References:

• Ackerman, C. (2017, March 20). 25 CBT techniques and worksheets for cognitive behavioral therapy. Retrieved from https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets
• ADAA reviewed mental health apps. (n.d.). Anxiety and Depression Association of America. Retrieved from https://adaa.org/finding-help/mobile-apps
• 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. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939342
• Mental health apps. (n.d.). The American Institute of Stress. Retrieved from https://www.stress.org/mental-health-apps
• Novotney, A. (2016). Should you use an app to help that client? Monitor on Psychology, 47 (10), 64. Retrieved from https://www.apa.org/monitor/2016/11/client-app
• Tang, W, & Kreindler, D. (2017). Supporting homework compliance in cognitive behavioural therapy: Essential features of mobile apps. JMIR Mental Health, 4(2). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481663

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CBT Session Structure and Use of Homework

Importance of Time Management

The importance of promoting resilience and avoiding dependence makes it vital to manage time well, in terms of both individual sessions and the course of sessions as a whole. For example, many agencies that provide CBT may offer a limited number of sessions (perhaps from six to 12).

This means that careful planning is required to ensure that the client is clinically safe to leave at the end of each session and – in particular – at the end of the full course of sessions.

Having limited time can be used in a positive way to focus the client on working hard to collaborate with the therapist and to explore their own thoughts, feelings and behaviours. It is ethically appropriate to explain to the client that CBT is a gradual process that will help them take incremental steps towards changing their thoughts, emotions and behaviours.

Session Agenda

Structure is one of Bordin’s (1979) triad of elements of CBT. As well as the idiosyncratic formulation – often seen as the ‘backbone’ of CBT treatment, and displayed between therapist and client (e.g. on a table where each can see it clearly) during sessions – another key tool in structuring CBT is the session agenda.

The session agenda is agreed collaboratively at the start of each session, based on items that the therapist and client wish to include. It is helpful to relate the structure of each session to the formulation. This also has a role in supporting the client’s education in the CBT model. Key items would typically be:

• following up homework completed since the previous session
• briefly reviewing the client’s experience since then
• practising CBT tasks.

As the BABCP emphasises, it is vital in CBT that the therapist and client work together in changing the client’s behaviours, thinking patterns or both. Because the active involvement of the client is required, it is important to set and work to an agenda, so setting out clearly the expectations of the client at every stage, making use of limited time and giving the sessions a problem-solving atmosphere.

The therapist has a responsibility to ensure that the agenda is of a manageable size, reining in client expectation if need be so that it can be achieved within the 50-minute session. As with the formulation, it is useful for both parties to be able to see the agenda during the session.

Agenda-setting also serves to strengthen the working alliance. Simmons & Griffiths (2014: 39) observe: ‘Setting the agenda together with your client underlies the general philosophy of CBT, that of active collaboration between therapist and client.’ Indeed, the therapist may even include time to obtain client feedback on the working alliance at the end of each session (by adding ‘Feedback’ to the agenda).

Use of ‘Homework’

A common feature of CBT is that the therapist sets the client ‘homework’, which is then reviewed in the next session; this aims to help clients generalise and apply their learning.

Homework in CBT refers essentially to tasks set to be completed by the client between sessions. For some clients, ‘homework’ is a word that triggers difficult memories of school days, possibly for some linked to a failure or other schema. It is therefore important to be aware of any such sensitivity in clients.

For example, if a client’s failure schema is triggered by the term ‘homework’, we might choose either to refer to it instead as ‘between-session tasks’ or to look with the client at how our use of the word is different from the way teachers used it at school – e.g. that CBT homework is always agreed (i.e. set collaboratively rather than imposed), and is about exploration and learning rather than any externally imposed expectation of outcome.

Purpose of Homework

Homework tasks are an important part of CBT practice, based on the view that client change does not come about purely as a result of in-session work – i.e. that significant effort is required by the client between sessions. In other words, there are 168 hours in the client’s week and only one of them is spent with the therapist.

Introducing the concept of homework early in therapy is also useful in getting the message across to the client that the working alliance requires significant effort and commitment from them – i.e. in promoting the understanding that the responsibility for change lies very much with them, guided by the therapist as professional facilitator.

Homework can also help enhance client autonomy, showing them they can become their own therapist using the CBT model.

Tailoring Homework to Client Needs

Homework tasks should be tailored to the client’s idiosyncratic formulation. Key points to consider are how challenging it will be for the individual client – and also how specific, practical and measurable.

When negotiating homework, we must therefore always use the core conditions and put ourselves in the client’s frame of reference. For example, we might see a small change in activity levels as perfectly manageable but this may seem huge for a depressed client.

Homework tasks should be just enough to challenge a client to extend themselves but not so much that it feels overwhelming. In the latter case, the likelihood is that the client will then simply not attempt it at all, so negating the point of the homework entirely.

It is also important to bear in mind the client’s schemas when setting homework. For example, a client with a failure schema would need very manageable tasks in the early days (with less challenge built in), while a client with a subjugation schema might agree to homework they knew to be unsuitable just to please the therapist.

Checking Homework

It is important that the therapist remembers to check homework during the next session – otherwise, the client may feel frustrated that they have invested time and energy in doing this with no apparent interest or follow-up from their counsellor.

This could detrimentally affect the bond and also lead to non-compliance with homework tasks in future. Sufficient time should be allowed in the session agenda to discuss the client’s experience of their homework tasks and learning from these.

Again, the therapist should hold in mind when evaluating homework any client schemas that may affect this. For example, a client with an unrelenting standards schema might be harsh on themselves in evaluating their achievements.

In this case, the therapist would need to tease out the client’s successes, and could use the work to help challenge the related negative automatic thoughts (e.g. filtering, all-or-nothing thinking or discounting the positive).

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Non-compliance with homework.

There are many possible reasons for non-compliance with homework tasks, and exploring these is an important part of therapy. Homework non-compliance may link with schema avoidance.

For example, a client may use avoidance to protect themselves from the difficult feelings associated with a failure schema. In other words, they may think that if they don’t attempt the homework task, then at least they can’t fail at it.

Offering the client the core conditions is important in exploring the reasons for non-completion of homework tasks. Clients may initially say they have not had time, and the therapist needs to take the time to discuss their real reasons for not doing the homework. This provides a valuable opportunity for new learning about – and hence understanding of – the client’s patterns of thinking, feeling and behaving.

Bordin E (1979) ‘The generalizability of the psychoanalytic concept of the working alliance’, Psychotherapy: Theory, Research and Practice , 16, 252–260.

Simmons J & Griffiths R (2014) CBT for Beginners , Sage

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• Impact of CBT

What is the Status of “Homework” in Cognitive Behavior Therapy, 50 Years On?

By Nikolaos Kazantzis, PhD

The comedian Jerry Seinfeld once asked:

“ What’s the deal with ‘homework?’ It’s not like you’re doing work on your home… ”

The great thing about that quote is that it conveys that the “H” word has some of the most unpleasant associations for clients in CBT. In July 2016, Dr. Judith S. Beck and Dr. Francine Broder wrote an important contribution to the Beck Institute blog giving good reason for a move away from the “H” word in practice.

When developing Cognitive Therapy, Dr. Aaron T. Beck was inspired by existing therapies, including behavior therapy, wherein the educative model to generate clinically meaningful change had been adopted. The inclusion of homework as a crucial feature of Cognitive Therapy made perfect sense 1 . Homework is a collaborative endeavor. It is also ideally empirical and can help to promote the reappraisal of key cognitions 2 .

Asking clients to engage with therapeutic tasks between sessions, in a form of action plan has been subject to more empirical study than any other process in CBT 3 .  However, the evidence supporting homework is almost wholly derived from dismantling studies that contrast CBT with CBT without homework, or correlational studies of homework adherence and symptom reduction. Findings from our most recent meta-analysis suggest that homework quantity and quality have little difference in their relations with outcome 4 . As clinicians, we can take from this that we should use homework consistently and be especially encouraged when clients engage with tasks 5 .

However, if we try to seriously answer Jerry’s question above, we have to ask ourselves another important question – what are we actually really interested in with CBT homework?

Current definitions of homework adherence have been derived from the literature on pharmacotherapy, and that might be the source of the problem. Take our two client examples below, Bob and Rob. Both have been prescribed a daily medication script, and if we look at the quantity of what was “done,” Rob looks more “adherent” than Bob.

However, when we take into account the cognitive impairment that Bob has, as well as his capacity to swallow medication following a head injury, then his 6/7 days’ worth of adherence is particularly noteworthy. Of course, in CBT, the content of homework varies on a weekly basis, and is tailored for the client in its design and plan. Therefore, the scope for subjective views of difficulty, and array of unique practical barriers is considerable. Thus, if we are genuinely interested in “engagement,” we need to take into account the inherent difficulties of the homework and practical obstacles to it for each individual client, at each session 6 .

Dr. Judith Beck’s earliest teachings emphasize the importance of the client’s subjective evaluation of homework. Those who are depressed are less likely to recognize their achievements, those with anxiety presentations often have negative predictions about its utility or their ability to carry it out, and many clients abandon the task when encountering obstacles. Those with pervasive interpersonal difficulties often have their core beliefs triggered in carrying out the action plan.  When they do, they may experience intense negative emotion, viewing themselves and/or their therapist negatively. The working alliance may become strained. Dr. Beck has also advocated for use of the cognitive case conceptualization to understand clients’ patterns of engagement and anticipate problems of this nature 7-8 .

Fortunately, the research underpinning CBT homework is moving towards more clinically meaningful studies. Therapist skill in using homework has been shown to predict outcomes 9-10 , and recently a study found that greater consistency of homework with the therapy session resulted in more adherence. 11 Our Cognitive Behavior Therapy Research Lab (currently based at the Turner Institute for Brain and Mental Health at Monash University) is centrally focused on how clients’ adaptive beliefs about homework strengthen their sense of self-efficacy in engaging in homework tasks, despite the difficulties and obstacles they experience. Thus, for several reasons, we can be optimistic that the evidence for homework is an example of how a bridge between science and practice is being built on solid foundations.

A half century after the first practice guide for Cognitive Therapy was published (Beck et al, 1979), we can be curious in the personal meaning our clients attribute to the action plan. How do beliefs about coping and change affect engagement? Are there important maladaptive assumptions and compensatory strategies that might make it difficult for the client to engage? How does the task align with the client’s values? What might be the pros and cons to the client in choosing not to engage? It’s important to focus less on trying to achieve perfect – or even a close approximation of perfect – “adherence” and to focus more on facilitating engagement. An empathic  understanding of challenges clients face completing the homework tasks will better equip us to design and plan future homework. Rather than a focus on “compliance,” let us inspire our clients to tolerate the discomfort and uncertainty in their homework. Let us also celebrate in their discovery of new ideas and perspectives that homework brings.

Nikolaos Kazantzis, PhD is Editor of “Using Homework Assignments in Cognitive Behavior Therapy” (2 nd edition), currently in preparation with Routledge publishers of New York.

• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression . New York: Guilford Press.
• Kazantzis, N., Dattilio, F. M., & Dobson, K. A. (2017). The therapeutic relationship in cognitive behavioral therapy: A clinician’s guide. New York: Guilford.
• Kazantzis, N., Luong, H. K., Usatoff, A. S., Impala, T., Yew, R. Y., & Hofmann, S. G. (2018). The processes of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 42 (4), 349-357. doi: 10.1007/s10608-018-9920-y 
• Kazantzis, N., Whittington, C. J., Zelencich, L., Norton, P. J., Kyrios, M., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: A meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47 , 755-772. https://doi.org/10.1016/j.beth.2016.05.002
• Callan, J. A., Kazantzis, N., Park, S. Y., Moore, C., Thase, M. E., Emeremni, C. A., Minhajuddin, A., Kornblith, S., & Siegle, G. J. (2019). Effects of cognitive behavior therapy homework adherence on outcomes: Propensity score analysis. Behavior Therapy, 50 (2), 285-299. https://doi.org/10.1016/j.beth.2018.05.010
• Holdsworth, E., Bowen, E., Brown, S., & Howat, D. (2014). Client engagement in psychotherapeutic treatment and associations with client characteristics, therapist characteristics, and treatment factors. Clinical Psychology Review, 34 (5), 428–450. https://doi.org/10.1016/j.cpr.2014.06.004
• Beck, J. S. (2011). Cognitive therapy for challenging problems: What to do when the basics don’t work . New York: Guilford.
• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). New York: Guilford.
• Weck, F., Richtberg, S., Esch, S., Hofling, V., & Stangier, U. (2013). The relationship between therapist competence and homework compliance in maintenance cognitive therapy for recurrent depression: Secondary analysis of a randomized trial. Behavior Therapy, 44 (1), 162–172. doi:10.1016/j.beth.2012.09.004
• Conklin, L. R., Strunk, D. R., & Cooper, A. A. (2018). Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression. Cognitive Therapy and Research, 42 (1), 16–23. https://doi.org/10.1007/s10608-017-9873-6
• Jensen, A., Fee, C., Miles, A. L., Beckner, V. L., Owen, D., & Persons, J. B. (in press). Congruence of patient takeaways and homework assignment content predicts homework compliance in psychotherapy. Behavior Therapy. https://doi.org/10.1016/j.beth.2019.07.005

• Last edited on September 9, 2020

Homework in CBT

Table of contents, why do homework in cbt, how to deliver homework, strategies to increase confidence.

Homework assignments in Cognitive Behavioural Therapy (CBT) can help your patients educate themselves further, collect thoughts, and modify their thinking.

Homework is not something that you just assign randomly. You should make sure you:

• tailor the homework to the patient
• provide a rationale for why the patient needs to do the homework
• uncover any obstacles that might prevent homework from being done (i.e. - busy work schedule, significant neurovegetative symptoms)

Types of homework

Types of homework assignments.

You should also decide the frequency of the homework should be assigned: should it be daily, weekly?

If your patient does not do homework, that’s OK! Explore as a team, in a non-judgmental way, to explore why the homework was not done. Here are some ways to increase adherence to homework:

• Tailor the assignments to the individual
• Provide a rationale for how and why the assignment might help
• Determine the homework collaboratively
• Try to start the homework during the session. This creates some momentum to continue doing the homework
• Set up systems to remember to do the assignments (phone reminders, sticky notes
• It is better to start with easier homework assignments and err on the side of caution
• They should be 90-100% confident they will be able to do this assignment
• Covert rehearsal - running through a thought experiment on a situation
• Change the assignment - It is far better to substitute an easier homework assignment that patients are likely to do than to have them establish a habit of not doing what they had agreed to in session
• Intellectual/emotional role play - “I’ll be the intellectual part of you; you be the emotional part. You argue as hard as you can against me so I can see all the arguments you’re using not to read your coping cards and start studying. You start.”

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Using Homework Assignments in Cognitive Behavior Therapy

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Homework is a central feature of Cognitive-Behavioral Therapy (CBT), given its educational emphasis. This new text is a comprehensive guide for administering assignments. The first part of the text offers essential introductory material, a comprehensive review of the theoretical and empirical support for the use of homework, models for practice, and systems for evaluating client compliance and therapist competence in administering assignments. Part two focuses on the role of homework in cognitive therapy, demonstrating successful methods of integration and discussing solutions to common barriers. Rather than offering one-size-fits-all, pre-designed tasks, this book illustrates application of a model with detailed case study and recommendations for adjusting administration methods for particular problems and specific client populations. Over the last nine chapters, homework administration is described within cognitive and behavioral therapy for anxiety and depression, chronic pain, delusions and hallucinations, obsessions and compulsions, marital and sexual problems, personality disorders, children and adolescents, group and family therapy, and older adults.

Readers are provided with a full range of knowledge to successfully incorporate individualized homework assignments into their practice to maximize the proven long-term benefits of CBT.

TABLE OF CONTENTS

Chapter 1 | 5  pages, introduction and overview, part | 2  pages, part i theoretical and empirical foundations, chapter 2 | 21  pages, theoretical foundations, chapter 3 | 21  pages, empirical foundations, chapter 4 | 11  pages, assessment of homework completion, part ii specific populations, chapter 5 | 16  pages, chapter 6 | 18  pages, adolescents, chapter 7 | 30  pages, older adults, chapter 8 | 15  pages, chapter 9 | 16  pages, part iii specific problems, chapter 10 | 22  pages, panic, agoraphobia, and generalized anxiety, chapter 11 | 14  pages, obsessions and compulsions, chapter 12 | 20  pages, chapter 13 | 16  pages, substance abuse, chapter 14 | 19  pages, delusions and hallucinations, chapter 15 | 17  pages, sexual problems, chapter 16 | 23  pages, borderline traits, part iv model for practice and conclusions, chapter 17 | 43  pages, a guiding model for practice, chapter 18 | 10  pages, summary and conclusion.

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A Comprehensive Model of Homework in Cognitive Behavior Therapy

• Original Article
• Published: 03 July 2021
• Volume 46 , pages 247–257, ( 2022 )

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• Nikolaos Kazantzis   ORCID: orcid.org/0000-0001-9559-4160 1 , 2 &
• Allen R. Miller 2  

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This article contributes a comprehensive model of homework in cognitive behavior therapy (CBT). To this end, several issues in the definition of homework and homework compliance are outlined, research on homework-outcome relations is critiqued, before an overview of classical and operant conditioning along with various cognitive theories are tied together in a c omprehensive model. We suggest engagement represents a more clinically meaningful construct than compliance (or adherence). We describe how established behavior and cognitive theories are relevant for understanding patient engagement and what between-session and in-session processes are useful in a comprehensive model. Our primary conclusion from the review of this literature is that current research has focused on limited aspects of homework and missed theoretically meaningful determinants of engagement. Further, little research has sought to examine the role of the therapist in facilitating these theoretically meaningful determinants. The literature on homework is the most advanced of the process research in CBT; the comprehensive model presented here offers clarity for the practicing clinician and represents a testable model for researchers interested in quantifying determinants of homework engagement and the process of integrating homework into CBT.

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The authors thank Aaron T. Beck and Judith S. Beck for helpful discussions and guidance on the topic of integrating homework into CBT.

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Kazantzis, N., Miller, A.R. A Comprehensive Model of Homework in Cognitive Behavior Therapy. Cogn Ther Res 46 , 247–257 (2022). https://doi.org/10.1007/s10608-021-10247-z

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What Is Therapy Homework?

Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

Dr. Sabrina Romanoff, PsyD, is a licensed clinical psychologist and a professor at Yeshiva University’s clinical psychology doctoral program.

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Types of Therapy That Involve Homework

If you’ve recently started going to therapy , you may find yourself being assigned therapy homework. You may wonder what exactly it entails and what purpose it serves. Therapy homework comprises tasks or assignments that your therapist asks you to complete between sessions, says Nicole Erkfitz , DSW, LCSW, a licensed clinical social worker and executive director at AMFM Healthcare, Virginia.

Homework can be given in any form of therapy, and it may come as a worksheet, a task to complete, or a thought/piece of knowledge you are requested to keep with you throughout the week, Dr. Erkfitz explains.

This article explores the role of homework in certain forms of therapy, the benefits therapy homework can offer, and some tips to help you comply with your homework assignments.

Therapy homework can be assigned as part of any type of therapy. However, some therapists and forms of therapy may utilize it more than others.

For instance, a 2019-study notes that therapy homework is an integral part of cognitive-behavioral therapy (CBT) . According to Dr. Erkfitz, therapy homework is built into the protocol and framework of CBT, as well as dialectical behavior therapy (DBT) , which is a sub-type of CBT.

Therefore, if you’re seeing a therapist who practices CBT or DBT, chances are you’ll regularly have homework to do.

On the other hand, an example of a type of therapy that doesn’t generally involve homework is eye movement desensitization and reprocessing (EMDR) therapy. EMDR is a type of therapy that generally relies on the relationship between the therapist and client during sessions and is a modality that specifically doesn’t rely on homework, says Dr. Erkfitz.

However, she explains that if the client is feeling rejuvenated and well after their processing session, for instance, their therapist may ask them to write down a list of times that their positive cognition came up for them over the next week.

"Regardless of the type of therapy, the best kind of homework is when you don’t even realize you were assigned homework," says Erkfitz.

Benefits of Therapy Homework

Below, Dr. Erkfitz explains the benefits of therapy homework.

It Helps Your Therapist Review Your Progress

The most important part of therapy homework is the follow-up discussion at the next session. The time you spend reviewing with your therapist how the past week went, if you completed your homework, or if you didn’t and why, gives your therapist valuable feedback on your progress and insight on how they can better support you.

It Gives Your Therapist More Insight

Therapy can be tricky because by the time you are committed to showing up and putting in the work, you are already bringing a better and stronger version of yourself than what you have been experiencing in your day-to-day life that led you to seek therapy.

Homework gives your therapist an inside look into your day-to-day life, which can sometimes be hard to recap in a session. Certain homework assignments keep you thinking throughout the week about what you want to share during your sessions, giving your therapist historical data to review and address.

It Helps Empower You

The sense of empowerment you can gain from utilizing your new skills, setting new boundaries , and redirecting your own cognitive distortions is something a therapist can’t give you in the therapy session. This is something you give yourself. Therapy homework is how you come to the realization that you got this and that you can do it.

"The main benefit of therapy homework is that it builds your skills as well as the understanding that you can do this on your own," says Erkfitz.

Tips for Your Therapy Homework

Below, Dr. Erkfitz shares some tips that can help with therapy homework:

• Set aside time for your homework: Create a designated time to complete your therapy homework. The aim of therapy homework is to keep you thinking and working on your goals between sessions. Use your designated time as a sacred space to invest in yourself and pour your thoughts and emotions into your homework, just as you would in a therapy session .
• Be honest: As therapists, we are not looking for you to write down what you think we want to read or what you think you should write down. It’s important to be honest with us, and yourself, about what you are truly feeling and thinking.
• Practice your skills: Completing the worksheet or log are important, but you also have to be willing to put your skills and learnings into practice. Allow yourself to be vulnerable and open to trying new things so that you can report back to your therapist about whether what you’re trying is working for you or not.
• Remember that it’s intended to help you: Therapy homework helps you maximize the benefits of therapy and get the most value out of the process. A 2013-study notes that better homework compliance is linked to better treatment outcomes.
• Talk to your therapist if you’re struggling: Therapy homework shouldn’t feel like work. If you find that you’re doing homework as a monotonous task, talk to your therapist and let them know that your heart isn’t in it and that you’re not finding it beneficial. They can explain the importance of the tasks to you, tailor your assignments to your preferences, or change their course of treatment if need be.

"When the therapy homework starts 'hitting home' for you, that’s when you know you’re on the right track and doing the work you need to be doing," says Erkfitz.

A Word From Verywell

Similar to how school involves classwork and homework, therapy can also involve in-person sessions and homework assignments.

If your therapist has assigned you homework, try to make time to do it. Completing it honestly can help you and your therapist gain insights into your emotional processes and overall progress. Most importantly, it can help you develop coping skills and practice them, which can boost your confidence, empower you, and make your therapeutic process more effective.

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Conklin LR, Strunk DR, Cooper AA. Therapist behaviors as predictors of immediate homework engagement in cognitive therapy for depression . Cognit Ther Res . 2018;42(1):16-23. doi:10.1007/s10608-017-9873-6

Lebeau RT, Davies CD, Culver NC, Craske MG. Homework compliance counts in cognitive-behavioral therapy . Cogn Behav Ther . 2013;42(3):171-179. doi:10.1080/16506073.2013.763286

By Sanjana Gupta Sanjana is a health writer and editor. Her work spans various health-related topics, including mental health, fitness, nutrition, and wellness.

How Much Does Homework Matter in Therapy?

What research reveals about the work you do outside of therapy sessions..

Posted April 16, 2017 | Reviewed by Ekua Hagan

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Homework is an important component of cognitive behavior therapy (CBT) and other evidence-based treatments for psychological symptoms. Developed collaboratively during therapy sessions, homework assignments may be used by clients to rehearse new skills, practice coping strategies, and restructure destructive beliefs.

Although some clients believe that the effectiveness of psychotherapy depends on the quality of in-session work, consistent homework during the rest of the week may be even more important. Without homework, the insights, plans, and good intentions that emerge during a therapy session are at risk of being buried by patterns of negative thinking and behavior that have been strengthened through years of inadvertent rehearsal. Is an hour (or less) of therapeutic work enough to create change during the other 167 hours in a week?

Research on homework in therapy

Research on homework in therapy has revealed some meaningful results that can be understood collectively through a procedure called meta-analysis. A meta-analysis is a statistical summary of a body of research. It can be used to identify the average impact of psychotherapy homework on treatment outcomes across numerous studies. The results of four meta-analyses listed below highlight the value of homework in therapy:

• Kazantzis and colleagues (2010) examined 14 controlled studies that directly compared treatment outcomes for clients assigned to psychotherapy with or without homework. The data favored the homework conditions, with the average client in the homework group reporting better outcomes than about 70% of those in the no-homework conditions.
• Results from 16 studies (Kazantzis et al., 2000) and an updated analysis of 23 studies (Mausbach et al., 2010) found that, among those who received homework assignments during therapy, greater compliance led to better treatment outcomes. The effect sizes were small to medium, depending on the method used to measure compliance.
• Kazantzis et al. (2016) examined the relations of both quantity (15 studies) and quality (3 studies) of homework to treatment outcome. The effect sizes were medium to large, and these effects remained relatively stable when follow-up data were collected 1-12 months later.

Taken together, the research suggests that the addition of homework to psychotherapy enhances its effectiveness and that clients who consistently complete homework assignments tend to have better mental health outcomes. Finally, although there is less research on this issue, the quality of homework may matter as much as the amount of homework completed.

To enhance the quality of homework, homework assignments should relate directly to a specific goal, the process should be explained with clarity by the therapist, its method should be rehearsed in session, and opportunities for thoughtful out-of-session practice should be scheduled with ideas about how to eliminate obstacles to completion.

To find a therapist, please visit the Psychology Today Therapy Directory .

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.

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.

Kazantzis, N., Whittington, C., Zelencich, L., Kyrios, M., Norton, P. J., & Hofmann, S. G. (2016). Quantity and quality of homework compliance: a meta-analysis of relations with outcome in cognitive behavior therapy. Behavior Therapy, 47(5), 755-772.

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.

Joel Minden, Ph.D., is a clinical psychologist, author of Show Your Anxiety Who’s Boss , director of the Chico Center for Cognitive Behavior Therapy, and lecturer in the Department of Psychology at California State University, Chico.

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What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

It is important to emphasize that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment.

CBT is based on several core principles, including:

• Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
• Psychological problems are based, in part, on learned patterns of unhelpful behavior.
• People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

• Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
• Gaining a better understanding of the behavior and motivation of others.
• Using problem-solving skills to cope with difficult situations.
• Learning to develop a greater sense of confidence in one’s own abilities.

CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:

• Facing one’s fears instead of avoiding them.
• Using role playing to prepare for potentially problematic interactions with others.
• Learning to calm one’s mind and relax one’s body.

Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work together, in a collaborative fashion, to develop an understanding of the problem and to develop a treatment strategy.

CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, patients/clients are helped to develop coping skills, whereby they can learn to change their own thinking, problematic emotions, and behavior.

CBT therapists emphasize what is going on in the person’s current life, rather than what has led up to their difficulties. A certain amount of information about one’s history is needed, but the focus is primarily on moving forward in time to develop more effective ways of coping with life.

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A Session-to-Session Examination of Homework Engagement in Cognitive Therapy for Depression: Do patients experience immediate benefits?

Laren r. conklin.

a Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus OH 43210

Daniel R. Strunk

Homework is a key component of Cognitive Therapy (CT) for depression. Although previous research has found evidence for a positive relationship between homework compliance and treatment outcome, the methods used in previous studies have often not been optimal. In this study, we examine the relation of specific aspects of homework engagement and symptom change over successive session-to-session intervals. In a sample of 53 depressed adults participating in CT, we examined the relation of observer-rated homework engagement and session-to-session symptom change across the first five sessions. Within patient (and not between patient) variability in homework engagement was significantly related to session-to-session symptom improvements. These findings were similar when homework engagement was assessed through a measure of general engagement with homework assignments and a measure assessing engagement in specific assignments often used in CT. Secondary analyses suggested that observer ratings of the effort patients made on homework and the completion of cognitive homework were the numerically strongest predictors of depressive symptom improvements. Patient engagement with homework assignments appears to be an important predictor of early session-to-session symptom improvements. Future research is needed to identify what therapist behaviors promote homework engagement.

Cognitive Therapy (CT) has been established as an efficacious treatment for depression ( DeRubeis, Webb, Tang, & Beck, 2010 ). The use of homework is an integral component of CT, with homework assignments serving as a critical way of encouraging patients to practice integrating the skills they learn in therapy into their everyday lives ( Beck, Rush, Shaw, & Emery, 1979 ; Kazantzis & Lampropoulos, 2002 ). Common homework assignments in CT for depression include monitoring the relationship between activities and moods, engaging in activities to promote a sense of pleasure or accomplishment, recording and developing alternative responses to one’s automatic thoughts, and engaging in behavioral experiments designed to test one’s depression-related beliefs ( Beck et al., 1979 ).

Across a variety of cognitive-behavioral treatments for diverse psychological problems, the available evidence indicates that homework is both correlated with and experimentally linked to therapeutic outcomes. As meta-analytic evidence has shown, individual differences in completing homework are related to more positive treatment outcomes ( Kazantzis, Deane, & Ronan, 2000 ; Kazantzis, Whittington, & Dattilio, 2010 ). In addition, patients randomized to therapy including homework assignments have been found to experience superior outcomes relative to those randomized to therapy without such assignments ( Kazantzis et al., 2010 ). For example, Neimeyer and Feixas (1990) examined homework in the context of a group version of CT for depression and found that groups assigned homework outperformed those not assigned homework. However, this study did not include an assessment of the degree to which patients engaged in homework assignments. The meta-analytic evidence of a homework-outcome relation was based on a combination of studies examining different patient populations and treatments under investigation, with these treatments differing markedly in the homework utilized. In our search for studies of homework in individual CT for depression, we identified a relatively small group of seven studies ( Bryant, Simons, & Thase, 1999 ; Burns & Spangler, 2000 ; Coon & Thompson, 2003 ; Cowan et al., 2008; Detweiler-Bedell & Whisman, 2005 ; Persons et al., 1988 ; Startup & Edmonds, 1994 ). A review of these studies suggests that all but one (i.e., Detweiler-Bedell & Whisman, 2005 ) reported evidence of homework compliance in CT for depression being associated with positive outcomes at the end of treatment. However, it is important to consider the methodological and analytic features of these studies to understand what conclusions regarding the homework-outcome relation in CT for depression are currently warranted.

In our review of these seven studies, we identified five methodological or analytic features of the studies that we believe limit the conclusions one can draw regarding the nature of the relationship between homework engagement and therapeutic outcomes in CT for depression. First, earlier investigations of homework compliance utilized retrospective therapist ratings gathered at the end of treatment ( Burns & Spangler, 2000 ; Persons et al., 1988 ). When therapists make a retrospective assessment of patients’ homework engagement, it is impossible to ensure that these ratings are not contaminated by knowledge of patients’ ultimate outcomes. One might expect that therapists’ estimates of homework engagement would be inflated as patients achieved more positive outcomes. Second, six of seven studies examined the relation of homework engagement with symptom change as assessed over relatively long periods of time. In these studies, symptom change was only evaluated from pre- to post-treatment. As the exception to this, Detweiler-Bedell and Whisman (2005) included analyses of symptom change over the first half of treatment; these analyses failed to identify a significant relationship between early homework compliance and improvement in depressive symptoms across the first half of treatment. The problem with relying on studies examining the relation of homework and pre- to post-treatment symptom change is that the relation identified in these studies could at least partly reflect the impact of early symptom change on homework engagement much later in treatment. On average, patients tend to experience greater symptom improvements early in treatment, with one estimate suggesting that that 32% of symptom change occurs in the first 2 weeks (and four sessions) of a 16-week course of CT of depression ( Strunk, Brotman, & DeRubeis, 2010a ). Insofar as homework might be expected to have relatively immediate effects, analyses of the relation of homework engagement and session-to-session symptom change would be most sensitive to detecting the effects of interest. However, we are not aware of any studies examining the relation of homework engagement and session-to-session symptom change—in CT for depression or otherwise.

Third, a number of researchers have studied homework by examining patients’ compliance with the assignments given. This approach compares the homework completed with the amount of homework assigned, either using the percentage of homework completed (e.g., Coon & Thompson, 2003 ) or a Likert-type item reflecting the amount of homework completed relative to that assigned (e.g. 0 “patient did not attempt the assigned homework” to 6 “the patient did more of assigned homework than was requested”; Primakoff, Epstein, & Covi, 1986 ). This means that a high score could reflect either a great deal of work on the patient’s part or very little work if the therapist had only assigned little homework. Similarly, a low score could reflect either little work on the patient’s part or a large amount of work, if the therapist had assigned an even larger amount. An alternative way of examining homework is to assess the extent to which patients engage in homework activities between sessions—without a comparison to what was assigned in the preceding session (e.g., Rees, McEvoy, & Nathan, 2005 ). As we noted, these approaches can lead to important differences in the assessment of homework. In our view, establishing a relation of “homework engagement,” reflecting the patient’s absolute efforts rather than their efforts relative to the amount of homework assigned, provides the clearest test of the hypothesis that the more patients engage with the homework activities, the more symptom improvement patients will experience.

Fourth, patients’ homework efforts are often assessed broadly using a single variable ( Kazantzis, Deane, & Ronan, 2004 ). Most homework research has assessed the overall amount of homework completed. Single homework measures necessarily fail to reflect the degree to which patients engage in different types of homework assignments used in the treatment under investigation. Although Kazantzis et al. (2000) examined the role of homework type in their meta-analysis, the 11 studies included in that analysis were limited to those that exclusively used only one specific type of homework. Thus, homework type was confounded with other characteristics of the studies (e.g., the clinical problem being treated). The role of different kinds of homework within CT for depression is unknown.

To our knowledge, only two previous studies have examined patients’ homework engagement on multiple specific assignments within a given treatment ( Cammin-Nowak et al., 2013 ; Rees et al., 2005 ). Rees and colleagues examined several different homework types (relaxation, reading, thought diaries, and behavioral tasks) as predictors of post-treatment symptoms in a mixed anxious and depressed sample participating in group cognitive-behavioral therapy. They found a greater number of behavioral tasks (pleasant activities and exposure exercises) was significantly associated with greater change in depressive symptoms whereas a greater number of thought diaries was significantly associated with greater change in symptoms of anxiety. Cammin-Nowak and colleagues also found situational exposure predicted outcomes in CBT for panic disorder more strongly than other homework types. While treatment developers presumably would predict that all homework assignments included in their approach would be therapeutic, one can only evaluate potential differences in the relation of different homework assignments and outcome by including measures that reflect the use of the different types of assignments given. The results of the two studies of multiple specific homework assignments attest to the importance of examining individual types of homework within the same treatment.

Finally, while some researchers have used repeated homework measures, as noted earlier, researchers have yet to use such repeated measures to examine the relation of homework engagement and session-to-session symptom change. Session-to-session analyses are appropriate for examining the relation of homework engagement between two sessions and the associated changes in depressive symptoms during that between-session interval. We think such an approach coincides with the time period over which we suspect the benefits of homework would be most likely to be observed. Whether a patient is asked to engage in a pleasant activity or reappraising his or her negative automatic thoughts, these activities are hypothesized to have immediate therapeutic impact ( Beck et al., 1979 ). Previous research with other important therapeutic constructs supports the possibility that effects of psychological interventions can be detected over such short intervals. For example, both therapist competence and therapist adherence have been found to predict session-to-session symptom changes in CT ( Strunk et al., 2010a ; Strunk, Brotman, DeRubeis, & Hollon, 2010b ; Strunk, Cooper, Ryan, DeRubeis, & Hollon, 2012 ).

In addition, using repeated measures also allows one to parse within- and between-patient variability to rule out the potential impact of any stable patient characteristics serving as confounding factors ( Allison, 2005 ; Curran & Bauer, 2011 ). For example, certain types of patients (e.g., those who are motivated, agreeable, or relatively free of personality psychopathology) may be more likely to have higher homework engagement and respond positively to treatment. By focusing on within-patient variability in homework, any homework-outcome relation obtained could not be attributed to these (or any other) between-patient characteristics. By separating within- and between-patient variability in homework engagement, one also opens up the possibility of finding differing relations of within-patient and between-patient homework engagement and depressive symptom change (a point to which we will return later in this paper).

In consideration of the methodological decisions highlighted above, we explore session-to-session relationships between homework engagement and concurrent depressive symptom change. We utilize observer ratings, made by raters who were blind to subsequent outcomes. We focused our investigation on the early sessions of CT for two key reasons: (1) our assessments of homework engagement were labor intensive and therefore required a focused approach; and (2) symptom change occurs disproportionately early in treatment (Sasso, Strunk, Braun, DeRubeis, & Brotman, 2014). We examine assessments of homework that include both patients’ engagement with homework generally (e.g., the time and effort patients put into homework) and patients’ engagement with specific CT assignments. By using repeated measures and parsing within- and between-patient variability, we are also able to rule-out the potentially confounding influence of any stable patient characteristics. In using this approach, our primary hypothesis is that within-patient homework engagement will be related to session-to-session symptom change. We expected this to be the case across both general and CT-specific measures of homework engagement, but examined these measures to test these ideas empirically.

Participants

Drawing from a sample of 67 patients who participated a naturalistic study of CT (see Adler, Strunk, & Fazio, 2014 ), data for 53 patients were sufficient for inclusion in our primary analyses. Inclusion criteria into the original study were: (1) a primary diagnosis of current Major Depressive Disorder as assessed by the Structured Clinical Interview for the DSM-IV (SCID; First, Spitzer, Gibbon & Williams, 1994); (2) 18 years of age or older; and (3) willing and able to provide informed consent. Individuals were excluded from the study if any of the following were present: (1) a history of Bipolar I disorder or a psychotic disorder; (2) a primary diagnosis of a current Axis-I disorder other than Major Depressive Disorder only if it was judged to necessitate treatment other than that being offered; (3) meeting criteria for Substance Dependence in the 6 months prior to intake; (4) a below-normal intelligence (IQ < 80); (5) clear indications of secondary gain; or (6) an acute risk of suicide sufficient to preclude outpatient treatment. In addition, among patients on antidepressant medications, only those who agreed to stay on a stable dosage throughout the course of treatment were eligible. This study was approved by the Institutional Review Board at The Ohio State University.

As we describe more fully below (see Analytic Strategy), patients must have had session recordings available from at least four of their first five CT sessions given the requirements of our primary analyses. Fourteen patients failed to meet this criterion, thirteen of whom dropped out of the study prior to session five. One patient failed to meet the criterion due to missing session recordings. Of the 53 patients who had a sufficient number of recordings, 28 (53%) were female, with a mean age of 37.5 ( SD = 14.0, range: 18–69). The sample was 88% Caucasian ( n = 47), 8% African American ( n = 4), 2% Asian American ( n = 1), and 2% were Hispanic/Latino ( n = 1). Two-thirds of the sample (68%, n = 36) was diagnosed as having at least one depressive episode prior to the current one, and 58% ( n = 31) of the sample were diagnosed with one or more co-morbid anxiety disorders. Patients who had insufficient data for inclusion did not differ from those included in the analyses on age, sex, or intake BDI-II scores (all p s > .1). However, the representation of Caucasian vs. non-Caucasian patients differed significantly between those included and those not included in our analyses (two-tailed Fisher’s exact test, p = .04). Specifically, among patients not included, 9 of 14 (65%) were Caucasian; whereas 47 of 53 (88%) of those included in the analyses were Caucasian.

Four advanced graduate students provided CT and were supervised by the second author (DRS). At the beginning of the study, therapists had one to two years of experience providing CT. As reported previously ( Adler et al., 2014 ), therapists were rated on general competence using the Cognitive Therapy Scale ( Young & Beck, 1988 ), and the mean scores obtained were comparable to those obtained by Strunk and colleagues (2010b) when rating more experienced CT therapists in a clinical trial. For more information, see Adler et al.

Homework Engagement Scale—General (HES-General)

The HES-General is rated using a three-item observer-rated measure that includes items assessing the following forms of homework engagement over the past week: (1) the estimated amount of time the patients spent on homework (Time; possible scores from 0 “no time” to 4 “more than 3 hours”); (2) the frequency with which the patients reported using therapy skills when they were sad or upset (Frequency; possible scores from 0 “not at all” to 4 “every time”); and (3) the estimated effort the patients put into homework assignments (Effort; possible scores from 0 “no effort” to 4 “great effort”). Each of these variables has the benefit of not being tied to CT-specific homework assignments (thus can be used more broadly) and assesses components theoretically related to higher engagement in general. Beyond merely completing a homework assignment, it may be important for patients to spend the time, frequency, and effort that therapists would recommend in completing assignments (as opposed to, for example, quickly completing homework in the waiting area just prior to the session). Sum scores for the HES-General could range from 0 to 12, with higher scores indicating greater time, greater effort, and more frequent engagement in homework activities between sessions. The internal consistency of HES-General at each session was excellent, with Cronbach’s alphas ranging from .82 to .86 across sessions.

Homework Engagement Scale—CT-Specific (HES-CT)

The HES-CT is a three-item observer-rated scale that assesses the degree to which patients engage in several specific types of homework assigned in CT. The homework assessed includes: cognitive homework (e.g., use of thought records), self-monitoring homework (i.e., tracking activities and corresponding moods), and behavioral homework other than self-monitoring (i.e., activities intended to produce a sense of pleasure or mastery; practicing assertiveness). While the HES-CT items were rated on a zero (no engagement) to six (extensive engagement) scale during the study, screening of the items suggested non-normality due to a high percentage of zero values ranging from 39% (self-monitoring homework engagement) to 68% (behavioral homework engagement). This was the result of therapists often assigning one or two of the three homework types. To reduce the non-normality of the data, the non-zero ratings were recoded. Scores from one to three were coded as a one and scores from four to six were coded a two, thus resulting in a scale with values ranging from zero to two. Total HES-CT scores were calculated as the sum of these three recoded items and therefore could range from zero to six. Copies of the HES-General and HES-CT with the rating manual are available upon request.

Beck Depression Inventory - 2nd Edition (BDI-II)

The BDI-II ( Beck, Steer, & Brown, 1996 ) is the current version of the Beck Depression Inventory. The BDI-II is a reliable and well-validated 21-item self-report measure that assesses the severity of depressive symptoms according to the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV; American Psychiatric Association, 1994 ). Total scores can range from 0 (minimal depression) to 63 (high depression). To capture rapid changes in depressive symptoms, the BDI-II was modified to assess symptoms in the past week. Patients were asked to complete a BDI-II prior to each CT session.

CT Session Ratings

We utilized all existing recordings of the first five sessions for each of the 53 patients who were included in our analyses. Raters largely used video recordings, substituting audio recordings in cases when a video recording was missing or of poor quality. Among the 53 patients examined, a total of 263 sessions occurred between session one and five, and recordings of 260 sessions (99%) were available for coding.

Ratings of CT sessions were provided by 19 advanced undergraduate students trained to use the HES-General and HES-CT. Raters were trained for a total of 40 hours over a 10-week period and then began making study ratings (with three additional meetings occurring to minimize rater drift). Three raters were randomly assigned to code each of the sessions with the constraint that each rater coded no more than one session per patient and that each rater was paired with all other raters an approximately equal number of times. To reduce the likelihood that non-homework activities would be erroneously counted as homework engagement, raters identified the upcoming homework assignments and type of homework assignments for each session and entered a brief description of the assignments in a homework assignment log. Raters who were assigned to rate the following session consulted the homework assignment log to know which assignments had been given the previous week. They then rated homework engagement using the HES-General and HES-CT, with the instruction to use the previous homework assignments to determine which activities reviewed during the session had been part of a previous homework assignment. To allow for the fact that patients may continue with a prior homework assignment for more than one between-session interval, raters were instructed to count any tasks completed that clearly were tied to therapy-related homework (e.g., thought records or daily activity logs), even if not assigned explicitly in the previous session. The average of raters’ judgments for each session was used in the primary analyses. To assess inter-rater reliability, we utilized a reliability estimator, G ( q,k ), that yields more precise estimations than intraclass correlation coefficients when raters and those being rated are neither fully crossed or nested ( Putka, Le, McCloy, & Diaz., 2008 ). The inter-rater reliability for the HES-General was excellent, G (.28, 3) = .91, as was the inter-rater reliability for the HES-CT, G (.28, 3) = .94.

Analytic Strategy

To examine the relation of homework engagement between successive sessions and corresponding session-to-session changes in depressive symptoms, we used repeated measures regression analyses implemented in SAS Proc Mixed (without specification of random effects). The dependent variable in these models consisted of current BDI scores for each participant, with BDI scores from the previous session entered as a covariate. We disaggregated within-patient and between-patient variability in each homework engagement variable into two separate variables and examined these within-patient and between-patient variables as separate predictors. In each model where we examined a given homework variable (i.e., HES-General or HES-CT) as a predictor, we included two variables: the within-patient and the between-patient scores for that homework variable. Following the approach described by Curran and Bauer (2011) , we used procedures inspired by those described in detail by Sasso et al. (2014). See Sasso et al. for additional discussion of theses models. Specifically, for each patient, we utilized a separate regression model in which session number (centered) was entered as a predictor of each homework engagement variable (i.e., HES-General or HES-CT). This step required ratings of the first session where homework was initially assigned plus a minimum of three homework ratings per patient (for a total of four sessions). To obtain between-patient scores for a given homework engagement measure, we used the intercepts of the patient-specific models. To obtain within-patient scores, we used the residuals of the patient-specific models. By definition, within-person values varied across sessions for each patient, while each patient had only one between-patient score for each homework engagement variable. We used an unstructured covariance structure because it was the best-fitting structure of the four we examined (unstructured, compound symmetry, autoregressive, and Toepliz), decided by Akaike’s Information Criterion (AIC).

Descriptive Statistics

Across sessions one through five, BDI-II scores improved an average of 7.5 points ( d = .82, t (49) = 6.11, p < .0001). The average session-to-session change (i.e., difference score) for the four intervals we studied ranged from 1.6 to 2.8, with the SDs ranging from 6.4 to 8.1. Our primary analyses involve identifying predictors of this session-to-session variability in BDI symptom improvement across these early sessions.

Homework assignments were rated in sessions one through four. Across these sessions, homework was assigned in 207 of 208 sessions (nearly 100%). The average number of homework assignments was 2.1 ( SD = 1.1), with a range of zero to seven assignments. There was variability in the percentage of clients who received a particular homework assignment type at each session, with no homework type having fewer than 30% of patients assigned that type at any of the rated sessions. The most commonly assigned type of homework during these sessions was cognitive homework, which was assigned in 75% of the sessions. Self-monitoring was assigned in 59% of sessions, and behavioral homework was assigned in 47% of sessions. Combining the self-monitoring and behavioral homework categories, one of these forms of homework was assigned in 68% of the sessions rated.

Across sessions two through five, patients reported that they completed some homework in 89% of sessions. Using the item anchors to interpret the mean homework scores reported in Table 1 , on average, patients completed the equivalent of a partially completed self-monitoring form, two partially completed thought records, and one behavioral task between each session. Additionally, as reflected in the item anchors, raters estimated that on average patients had spent “less than 30 minutes” on homework, “occasionally” used therapy skills when they felt sad or upset, and put “some effort” into completing homework assignments between sessions. The HES-General and HES-CT were significantly correlated with each other across sessions, with a mean correlation of .75.

Means and Standard Deviations for Homework Measures

Note . The means reported are the means of the patient average scores. HES-CT = Homework Engagement Scale—CT-Specific; HES-General = Homework Engagement Scale—General.

As discussed in the Analytic Strategy section, we disaggregated the within-patient and between-patient effects for each homework variable of interest. Each patient had one between-patient score and four within-patient scores (one for each session) for each homework variable. Using intraclass correlations coefficients of patient’s scores on each homework measure, we examined the percentage of the overall variability in homework engagement scores reflected between-patient variability (with the remaining portion being within-patient variability). Overall, only a relatively small portion of variability in homework engagement scores was due to between-patient variability (17% for both HES-General and HES-CT), with the remaining portion reflecting within-patient variability (83%).

Homework Engagement Variables and Session-to-Session Depressive Symptom Change

As noted above and shown in Table 2 , within-patient and between-patient variables were included in each model as predictors of depressive symptom change. For HES-General, within-patient variability was significantly related to greater session-to-session depression symptom improvement, whereas between-patient variability did not significantly predict session-to-session depressive symptom changes. For the HES-CT, within-patient variability was significantly related to greater session-to-session depression symptom improvement. Surprisingly, there was a non-significant trend for between-patient variability in HES-CT scores to predict less marked session-to-session symptom change.

Within-Patient and Between-Patient Homework Engagement as Predictors of Session-to-Session Symptom Change

Note . Each line shows results from a separate model, in which within-patient and between-patient scores on the line were entered as predictors into the same model. As described in the Analytic Strategy section, current session BDI served as the dependent variable with previous session BDI included as a covariate. Est is the estimate (i.e., regression coefficient) for each within-patient or between patient predictor. β is the estimate obtained in the same model when predictors were standardized to a mean of 0 and a SD of 1. These standardized estimates show the change in BDI points associated with a one SD increase in the predictor (at each session). HES-CT = Homework Engagement Scale—CT-Specific; HES-General = Homework Engagement Scale—General. For each model, df = 51.

To better understand the relationships we observed, we conducted a set of secondary analyses to examine within-patient and between-patient variation in individual homework items as predictors of concurrent depressive symptom change (see Table 2 ). Within-patient variability in effort and cognitive homework engagement were the only significant predictors of symptom improvement. There was a nonsignificant trend for the relation of within-patient variability in frequency of using skills and depressive symptom improvement. With regard to between-patient variation in our predictors, only self-monitoring exhibited a relation. Self-monitoring was related to less marked symptom improvement across sessions. Taken together, these analyses suggested that the significant relation of within-patient variability in HES-CT and greater depressive symptom improvement was driven by cognitive homework engagement. The significant relation of within-patient variability in HES-General and depressive symptom improvement was driven by effort that patients put into homework (and perhaps the frequency of using therapy skills). Similarly, the trend level relation of between-patient HES-CT and less marked symptom improvements was driven primarily by self-monitoring homework engagement. 1

Consistent with our expectations, across early sessions of CT, between-session intervals in which patients showed greater homework engagement were marked by greater session-to-session symptom improvement. These findings were similar when homework engagement was assessed generally and when it was assessed by examining CT-specific homework. The similarity of findings is understandable given the relatively high correlation between these two homework scores. Our evidence of a relation of within-patient variability in homework engagement and symptom improvement is consistent with previous research documenting a relationship between homework and treatment outcome across mood and anxiety disorders ( Kazantzis et al., 2000 ; 2010 ). Due to the methodological approach used in this study, we can rule out the possibility that the relationship between homework engagement and depressive symptoms were accounted for by stable patient characteristics. In addition, whereas previous studies have often measured patients’ homework activities in relation to the assignments given (e.g., percentage completed), we examined homework variables that characterize the absolute amount of homework completed. Consequently, our results provide a direct test of the relation of patients’ use of homework and symptom improvement.

Interestingly, secondary analyses of the within-patient variability in the individual types of CT-specific homework engagement indicated patients’ engagement in more cognitive homework and putting more effort into homework were each associated with greater depressive symptom improvements. While these analyses should be interpreted with some caution given the naturalistic variability in therapists’ use of homework assignments, these findings suggest that patients’ engagement in cognitive homework may be important to patient improvement in early CT sessions. This finding is consistent with the idea that patients’ homework efforts pay off in the short term (i.e., in a single between-session interval).

While we were primarily interested in the relation of within-patient homework scores and symptom change, it is worth considering how to interpret the results for the between-patient scores. There was a nonsignificant trend for patients who tended to engage in more CT-specific homework to exhibit less marked improvement in depressive symptoms. A closer examination of these results indicated that these findings were particularly driven by self-monitoring homework. Given that within-patient variability in CT-specific homework was significantly associated with greater improvements in depressive symptoms, we consider two possible explanations. First, a subset of patients may have been simply more likely to complete higher levels of CT-specific homework, especially self-monitoring, and were also less likely to improve as quickly as other patients. Alternatively, a second possibility is that therapists’ assignment of self-monitoring homework may have been due to the extent to which patients had trouble completing earlier assignments and were not improving as rapidly as hoped. To be clear, the relationship of between-patient variability in homework engagement and depressive symptom does not fundamentally alter the interpretation of our findings involving within-patient scores. Within-patient variability in homework engagement and concurrent session-to-session improvements in depressive symptoms were significantly related. This pattern does remind us that had we not parsed within- and between-patient variability, we would have failed to distinguish patient effects (which could be explained by stable patient characteristics) from the effects due to variability in homework engagement.

While our study focused on the role of homework engagement, it is important to recognize that a number of other potentially important psychotherapy processes may be important to consider. These include variables characterizing therapist behaviors such as therapist competence and therapist adherence. Some aspects of both variables are likely relevant to promoting homework engagement. Therapist competence has been found to predict subsequent symptom improvement, with at least one study showing that a single item assessing therapist behaviors related to homework also predicted symptom improvements ( Strunk et al., 2010b ). Future research is needed to provide more fine-grained characterizations of the specific therapist behaviors that might be useful in promoting patients’ homework engagement.

Much as competence can be distinguished from adherence by its assessment of quality as compared to quantity, one could similarly assess not only the quantity of homework engagement, but also its quality. Looking beyond studies of treatments for depression specifically, some research has addressed this issue. While Rees and colleagues (2005) failed to find that quality of thought record completion predicted outcomes for depression or anxiety symptoms above and beyond homework quantity, Schmidt and Woolaway-Bickel (2000) found quality of homework was a stronger predictor of outcomes than percentage of homework completed in their study of CBT for panic disorder. Additional research is needed to clarify whether it is the quality or quantity of homework that better predicts therapeutic outcomes.

There are several limitations of this study that warrant discussion. First, similar to previous studies, examination of concurrent changes in homework engagement and depressive symptom change do not rule out the possibility of a reverse causal relation; thus, it is possible that a relation between homework engagement and depressive symptom change could reflect improvements in depressive symptoms helping patients engage in more homework. However, to rule out this possibility of reverse causality in an observational study of CT, one would need repeated assessments of homework engagement and depressive symptoms within each between-session interval. Future studies using ecological momentary assessments could be used to achieve this goal. Second, because we examined only early sessions in CT, it is unclear whether the findings would generalize to later in treatment. While Startup and Edmonds (1994) used a different definition of early treatment (only the first two sessions instead of the first five), they did find early CT homework compliance was related to treatment outcome whereas homework compliance in the remainder of treatment was not related to outcome. Third, our analyses of specific homework types should be interpreted with caution. If homework assignments were made systematically across therapist-patient dyads as a function of third variables, the relation of CT specific homework and symptom change could partly reflect the impact of therapists’ selection of homework assignments. For our analysis of between-patient variables, any stable patient characteristic that informed therapists’ use of homework assignments could have contributed to the relations identified (as we discussed for self-monitoring above). For our analysis of within-patient variables, only time-varying covariates could bias the relations of interest. While we cannot rule out such a possibility, we have no reason to suspect such time-varying effects would have been present. Finally, because we utilized homework information obtained from session recordings, it is possible that patients may not have always discussed a completed homework assignment or therapists did not always conduct a thorough review of completed homework. While we lack data to address this possibility empirically, it is our impression that therapists were fairly comprehensive and little homework was likely to have been missed.

In closing, this study examined the relationship of within and between-patient variability in homework engagement and depressive symptom change over session-to-session intervals – a plausible interval to explore immediate effects of homework engagement. Our findings that within-patient variability in general and CT-specific homework engagement were related to concurrent depressive symptom improvements, particularly greater cognitive homework engagement and greater homework-related effort, are consistent with what one would expect if homework engagement contributed to the early symptom improvements patients experience in CT.

While the relations of general engagement and CT-specific homework with symptom change were quite similar in our study, the examination of individual items from these scales provided distinct information about the aspects of homework engagement that were most strongly related to depressive symptom improvement. Clinically, our results are consistent with the recommendation that patients should be encouraged to engage fully with homework assignments ( Beck et al., 1979 ), perhaps particularly cognitive homework. Patients who manage to put considerable effort into their homework assignments are among those who benefit most from their early CT sessions. We encourage future investigations to examine specific therapist strategies for increasing the likelihood that clients maximally engage in completing homework assignments. Research in this area has been very limited to date ( Bryant, Simons, & Thase, 1999 ). With a number of studies showing the benefits of homework engagement, this is a vital next step.

• Examines the relationship of homework and session-to-session symptom improvements
• CT-specific homework was related to improvement in depression symptoms
• General homework (time, frequency, effort) also related to depression improvements

Acknowledgements

This project was supported by Award Number TL1RR025753 from the National Center for Research Resources. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.

We thank our colleagues for making this research possible. Abby D. Adler, Andrew A. Cooper, Lizabeth A. Goldstein, and Elizabeth T. Ryan served with Laren R. Conklin as cognitive therapists and clinical interviewers. Abby D. Adler served as study coordinator. Daniel R. Strunk provided training in and supervision of clinical assessments and cognitive therapy.

Special thanks to those who served as raters of homework engagement; without their hard work and dedication, this research would not have been possible.

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1 Our analytic strategy necessitated the removal of participants who dropped out of treatment early in the study. As dropout is also an outcome of interest, we examined whether early homework engagement variables predicted dropout using average scores on homework variables within the full sample of 67 participants. None of the homework variables significantly predicted dropout, though lower engagement in cognitive homework, Wald’s χ 2 = 3.8, p = .05, b = −1.48, SE (.76), CI (.05; 1.01), and lower frequency of using skills to cope, Wald’s χ 2 = 3.4, p = .07, b = −.89, SE (.49), CI (.16; 1.06), were related to a higher change of dropout at the level of nonsignificant trends.

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• Open access
• Published: 02 June 2022

Cognitive behavioural group therapy as addition to psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: a randomised controlled trial

• Anne-Lise Juul Haugan 1 ,
• Anne Mari Sund 1 , 2 ,
• Susan Young 3 , 4 ,
• Per Hove Thomsen 1 , 5 ,
• Stian Lydersen 1 &
• Torunn Stene Nøvik 1 , 2  

BMC Psychiatry volume  22 , Article number:  375 ( 2022 ) Cite this article

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Cognitive behavioural therapy (CBT) is recommended for attention-deficit/hyperactivity-disorder (ADHD) in adolescents. However, all CBTs are not created equal, and the guidelines do not specify which CBT interventions are the most effective for this patient group. This study examines the efficacy of a group CBT without parent involvement as follow-up treatment compared to no additional CBT in adolescents with persistent and impairing ADHD symptoms after a short psychoeducational intervention and medical treatment.

The authors conducted a two-arm parallel randomized controlled trial in two child and adolescent mental health outpatient clinics in Norway. One hundred patients aged 14–18 years with a diagnosis of ADHD (66%) or subthreshold ADHD (34%) were randomized to either a 12-week group CBT program ( N  = 50) or a non-CBT control condition ( N  = 50). Assessments were made at admission to the clinic, two weeks before and two weeks after treatment. The primary outcomes were parent-, teacher- and self-ratings of ADHD symptoms (ADHD Rating Scale-IV), and the secondary outcomes were ratings of ADHD symptom severity, executive function, functional impairment, and emotional problems. Evaluators blinded to group allocation rated ADHD symptom severity with the Clinical Global Impression Scale for Severity (CGI-S) at baseline and post-treatment.

Analyses using mixed-effects models showed no difference between the treatment arms from baseline to post treatment in primary and secondary outcomes.

Conclusions

Contrary to our hypothesis, we found no incremental treatment effect on the part of a group CBT as follow-up to psychoeducation and pharmacological treatment on ADHD symptoms and accompanying impairments. Limitations with the CBT was the large number and low dosage of treatment components, causing restricted time for practice. Unlike evidence-based, individualized targeted CBTs with parent involvement, a group CBT directed solely at the adolescents with no parent involvement does not appear effective for treating ADHD.

Trial registration

NCT02937142 , 18/10/2016.

Peer Review reports

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by levels of inattention, hyperactivity and impulsivity that lead to impairment [ 1 ]. In adolescence, ADHD is often associated with a range of social and emotional sequelae, including anxiety, depression, interpersonal difficulties, low self-esteem, low academic achievement, and substance abuse [ 2 , 3 , 4 , 5 ]. Although medication may be effective in reducing ADHD’s core symptoms [ 6 ], this treatment alone may not be sufficient to remediate ADHD and its associated conditions. Some patients experience adverse side effects or do not respond well to medical treatment [ 7 ], the long-term effect of pharmacotherapy is inconclusive [ 8 ] and many adolescents discontinue treatment in the transition to adulthood [ 9 , 10 ]. Because ADHD often persists across the lifespan [ 11 ], there is a need for additional treatments to learn strategies and skills for coping with impaired executive functioning and functional impairments. This seems especially imperative for adolescents, who are at a crossroads, with expectations of parental detachment and increased independence on the one hand and a need for external structure and emotional support on the other hand. The National Institute for Health and Care Excellence (NICE) guidelines recommend multimodal treatment for children and young adults with ADHD [ 12 ]. This includes ADHD-focused support, including education and information about the causes and effects of ADHD, advice on parenting strategies and supportive measures in school. Pharmacotherapy is recommended if ADHD symptoms persist after environmental modifications. In addition, cognitive behavioural therapy (CBT) is recommended as a treatment option for young people if symptoms remain impairing after pharmacological treatment [ 12 ]. A limitation with this recommendation however, is that all CBTs are not created equal, and the guidelines do not specify which CBT programs to use for young people with ADHD [ 12 , 13 ]. Systematic reviews of psychosocial interventions directed at children and adolescents show that most interventions combine components from behaviour therapy/behaviour contingency management, cognitive restructuring techniques and skills training, to reduce symptoms of ADHD and its` associated impairments [ 6 , 14 ]. Compared to the childhood treatments that involve parents to a large extent, treatments directed at adolescents have a more moderate parent involvement, and they include more individualized engagement components, as well as skills training compared to the childhood treatments. According to Evans et al. [ 14 , 15 ], behaviour management treatments including behavioural parent training, behaviour classroom management and behavioural peer interventions are considered well-established treatments for children with ADHD. For adolescents, only organization training has been considered well established. CBT programs directed at adolescents and their parents have so far been considered as probably efficacious [ 14 ], but preliminary results have been promising [ 16 , 17 ].

The CBTs targeting adolescents with ADHD may be divided into school-based and clinic-based treatments. Evans and colleagues developed the Challenging Horizons Program (CHP), a school-based training intervention to help young adolescents with ADHD improve their inattention, social and scholastic skills [ 18 ]. In the CHP, the adolescents meet twice a week for about 2h after school, across one academic year. The program also includes three parent meetings. In a randomised trial, the participants demonstrated significant improvements in parent-rated organization and time management skills, homework completion, and ADHD inattention symptoms, but not social skills, compared to participants in two control conditions [ 19 ]. Another school-based intervention developed by Langberg and colleagues is the Homework, Organization, and Planning Skills (HOPS) program [ 20 ]. This intervention which is delivered during the school day by school mental health providers, aims to improve organizational skills and homework problems in middle school students with ADHD. It includes 16 short sessions (20 minutes) over an 11-week period. Parents are included in two of the sessions. A randomized study comparing participants receiving HOPS to a waitlist control group demonstrated significant improvements on parent-, but not on teacher- ratings of materials management, planning skills, and homework completion in favour of HOPS [ 21 ].

Sibley and colleagues developed a clinic-based skills intervention for adolescents with ADHD between the ages of 11 to 15 [ 22 ]. The Supporting Teens` Autonomy Daily (STAND) program is a modular treatment with 10 1-hour parent-teen sessions with a menu of skills that can be targeted (e.g, organization, time management, test taking and note taking) from which the family selects four to address. Parent- teen contracts are used, in which parents provide behavioural contingencies based on the adolescents’ use of the targeted skills at home and school to facilitate the skills. Motivational interviewing (MI) is integrated to enhance treatment engagement. Results from both a pilot study and a randomized trial revealed significant improvements in parent-, but not teacher- rated, ADHD symptom severity, planning and organizational skills, as well as parenting stress compared to a treatment as usual control group [ 17 , 22 ]. Another promising CBT program for adolescents with ADHD was conducted by Sprich and colleagues [ 16 ]. This CBT, originally developed for adults with ADHD [ 23 ] was conducted with medicated adolescents between 14 to 18 years. The 12-session program which also involves the parents in two of the sessions, includes three modules focusing on psychoeducation, cognitive restructuring techniques and training in organisation and planning skills. A randomized trial revealed significantly reduced parent- and adolescent-rated symptom severity and reduced ADHD symptoms in the control group compared to a waitlist control group, demonstrating initial efficacy of CBT for adolescents [ 16 ]. Furthermore, two short-term CBT interventions targeting adolescents with ADHD was developed by Boyer and colleagues. Both interventions include elements from MI in combination with either planning skills (Plan My Life) or a Solution-Focused Treatment. The programs consist of eight adolescent-sessions and two parental-sessions [ 24 ]. A comparison of the programs in an ADHD population aged 12 to 17 years revealed reduced parent-rated ADHD symptoms, planning problems and improved executive functions in both treatment arms. A limitation of this study was the lack of waitlists or treatment as usual control group.

The first RCT to examine the efficacy of group CBT on a sample of late adolescents and young adults medicated for ADHD was conducted by Vidal et al. [ 25 ]. Different from the previous clinic-based CBTs that involve parents to various extent, this was a patient focused 12-session multicomponent CBT program based on psychoeducation and cognitive behavioural principles to facilitate skills related to impulsivity, emotion regulation, interpersonal skills, planning strategies and techniques to improve inattention using MI techniques. The study showed beneficial effects on both parent- and self-rated ADHD symptoms and parent rated functional impairment as compared to a waitlist control condition. One limitation of the study was the exclusion of patients with comorbid emotional disorders, which are common in this patient group [ 4 , 26 , 27 ]. Similar to the CBT programs of both Vidal and Sprich, the Young-Bramham program (YBP) incorporates elements from psychoeducation, structured skills training and cognitive behavioural therapy to target ADHD core symptoms as well as comorbid problems. The program is modular based, and the choice of modules and number of sessions may be adjusted to fit the needs of the individual patient or group participants [ 28 ]. In addition to cognitive restructuring techniques, the YBP includes strategies to improve attention and memory functions, it includes skills training in planning and organization and incorporates behavioural techniques such as graded task assignments, modelling and roleplay to improve social regulation and communication [ 28 ]. The YBP program has not previously been studied in an adolescent population, but Bramham and colleagues studied the effect of a short and intensive YBP group program with ADHD adults, which revealed promising preliminary results with significantly greater improvement on measures of knowledge about ADHD, self-efficacy, and self-esteem in the CBT group compared to the waitlist control group [ 29 ].

When planning a treatment study for adolescents with ADHD, we found no manual suited for the purpose in a Scandinavian language. Inspired by the positive results from the group treatment by Vidal et al. [ 25 ], we decided to develop a Norwegian research manual based on selected modules from the YBP in collaboration with one of its authors, SY. After selecting modules from the YBP thought appropriate for our adolescent population, we translated it to Norwegian and tested the manual, the feasibility and acceptability of the program in a pilot study. We refer to Novik and colleagues for the study protocol [ 30 ]. We preferred group treatment to individual treatment as the group format provides the opportunity to meet other patients with similar problems which offers normalisation, mutual understanding, and also opportunities to share strategies for coping with problems and acquire news skills in a non-judgemental environment which we consider important for adolescents with ADHD.

The NICE guideline recommends CBT as an additional treatment in ADHD patients who still present impairing symptoms after psychoeducation and pharmacological treatment [ 12 ]. To our knowledge, no published studies have examined the efficacy of CBT as follow-up treatment in a sample of ADHD adolescents with and without comorbid emotional disorders who previously received this recommended treatment. The aim of our study was thus to assess the efficacy of an age-adapted group CBT program as additional treatment to a short psychoeducational intervention and medical treatment in adolescents still presenting impairing ADHD symptoms. Based on previous CBT studies on medicated adolescent populations [ 16 , 25 ] we predicted that the CBT group would be superior in terms of showing incremental improvement in ADHD symptoms, executive functions, and functional impairment compared to a control group having received the same previous interventions as the CBT group, but no additional CBT.

Study design and procedure

This was a 12-week, RCT efficacy trial with two study arms comparing CBT group therapy as a follow-up treatment with a passive no additional CBT control condition in a clinical context. A detailed research protocol has been published elsewhere [ 30 ]. The recruitment, intervention and data collection were conducted in two outpatient child and adolescent psychiatry (CAP) university clinics in Mid-Norway. Recruitment began in February 2017, and the last follow up data were collected in January 2020. The measures included self-, parent, and teacher reports and were collected while the participants were on medication, two weeks before and two weeks after the intervention. Clinical evaluations of ADHD symptom severity using the Children’s Global Assessment Scale (CGAS) [ 31 ] and Clinical Global Impression Scale for Severity (CGI-S) [ 32 ] were collected two to four weeks before the intervention and two weeks after the intervention, by clinicians (a clinical psychologist or a child and adolescents psychiatrist) blinded to the participants’ group allocation. Participants were screened for eligibility and recruited from the two CAP outpatient units by the last author in cooperation with the clinicians responsible for this patient group. Participants ( N  = 9) who previously received pharmacotherapy but were unable to continue treatment because of intolerable side-effects or little effect were included in the study for ethical reasons and to achieve enough participants for the study. During recruitment, we included patients with mild to moderate behavioural problems to achieve enough participants. The inclusion of patients with behaviour problems was a deviation from the trial registration but was described in the study protocol [ 30 ]. Six participants were recruited through primary care physicians after postings in a local newspaper and advertising via social media. The last author screened these participants before inclusion, and they previously underwent the same diagnostic procedures as well as received psychoeducation and pharmacological treatment in a CAP clinic similar to the other participants before being discharged. Furthermore, they followed the same inclusion criteria as the other participants. All participants and their parents were provided oral and written information about the content of the study and its treatment arms by CAP clinicians. A flowchart for the timeline for the recruitment, follow-up assessments and post-treatment analyses is presented in Fig.  1 .

Flow diagram of participants in cognitive behavioural group therapy for adolescents with ADHD – a randomised controlled trial

Participants

The sample characteristics are presented in Table  1 . The participants were recruited from a group of adolescents between the ages of 14 to 18, the mean age was 15.3 (SD = 1.3), with a previous clinical diagnosis of ADHD according to the International Statistical Classification of Disease and Related Health Problems (ICD-10) [ 33 ]. A clinical psychologist or a child and adolescent psychiatrist made psychiatric diagnoses at the first intake to the CAP clinic (0–13 years). The CAP clinic’s standardised procedure for the assessment and diagnosis of hyperkinetic disorder is based on the national guidelines for the assessment and treatment of ADHD [ 13 ], which are similar to the NICE ADHD guidelines [ 12 ]. This procedure requires a thorough developmental history, an examination of comorbid psychiatric disorders, a somatic assessment and the use of questionnaires filled out by the adolescents, parents, and teacher informants to obtain ADHD symptom scores (ADHD rating scale). The diagnostic criteria for hyperkinetic disorder in ICD-10 are nearly identical to those of the Diagnostic and Statistical Manual of Mental Disorder 5th edition’s (DSM-5) [ 1 ] diagnosis of ADHD combined presentation. The Norwegian ADHD guidelines [ 13 ] allow for hyperkinetic disorder to be diagnosed in patients with severe inattentive symptoms only, corresponding to the DSM-5 Inattentive type. Patients receiving an ADHD diagnosis at the CAP clinic are usually offered interventions as described under the subheading “CAP standard clinical intervention” before being transferred to community care. When patients are being referred to the clinic for a follow-up medical treatment and/or associated conditions because of increased symptoms or impairments, and the patient received an ADHD diagnosis at an early time-point, the parents need to confirm ADHD symptoms and clinical impairment in a clinical interview together with the patient at readmission. All the participants received an initial ADHD diagnosis or ADHD symptoms were confirmed by a parent informant within 0 to 5 years before inclusion (Mean = 1.5 years, SD = 1.2). For 94% of the population, the ADHD symptoms were confirmed by a parent rater within the last three years of inclusion. In addition, we interviewed each participant with the Schedule for Affective Disorders and Schizophrenia for school age children-Present and Lifetime Version (Kiddie-SADS-PL) [ 34 ] at the CAP units before intake to the study to assess for the presence of ADHD symptoms and psychiatric comorbidities. In cases of diagnostic uncertainty, current comorbidities were checked with the adolescents’ medical record. Ultimately, 66% of the adolescents reported symptoms above threshold for a DSM-5 ADHD diagnosis. Adolescents who reported symptoms below the threshold for ADHD according to the DSM-5 but had impairing ADHD symptoms while on medication (34%) were allowed into the study [ 30 ] and were designated as subthreshold ADHD. The participant population’s mean ADHD RS-IV parent total score at the first intake to the CAP clinic was 33.7 (SD = 8.8, n  = 75), while the mean baseline score before the trial was 25.0 (SD = 8.8, n  = 97). Ninety-one percent of the participants were on pharmacological treatment for ADHD. Fifty-three percent of the participants had at least one current comorbid condition according to the DSM-5 (see Table 1 ). Additionally, IQ scores were obtained by using the Wechsler Intelligence Scales for Children (WISC-IV) [ 35 ] or Adults (WAIS-IV) [ 36 ].

The inclusion criteria were thus a previous full diagnosis of ICD-10 ADHD, a DSM-5 diagnosis of ADHD or subthreshold ADHD, confirmed by the Kiddie-SADS-PL interview, and evidence of clinically impairing symptoms (a Clinical Global Impression Scale for Severity (CGI-S) clinician score of 3 (mildly ill) or greater at baseline). Participants with comorbid diagnosis including mild to moderate depressive disorders, anxiety disorders, bipolar disorders, tic disorders, oppositional defiant disorder and mild degree of autism spectrum disorders were included in the study. All participants needed to have been on a stable pharmacological treatment for ADHD for at least two months prior to randomisation into the study. However, participants who had previously been medicated but terminated treatment because of minimal treatment effect or having experienced intolerable side effects after at least two medication trials were included. The participants could not be seeking or engaged in parallel psychosocial interventions during the study period. A crisis involving the considerable worsening of psychiatric problems (family crisis, worsening of depressive symptoms or aggression/acting out in the home environment) could, however, necessitate a limited supplemental examination or supportive intervention with the parents or the patient. One participant received two extra hours with parental support after acting out at home, and four participants received four supplemental therapy sessions related to depressive symptoms/emotional dysregulation. All of them were part of the control group.

The exclusion criteria were severe depression, suicidal behaviour, conduct disorder, psychoses, intellectual disability (IQ < 70) and current substance abuse. Patients in on-going psychotherapy or previously having received CBT for ADHD (CBT with treatment modules directed at core ADHD symptoms or executive functions as shown in Table  2 ), and patients not interested in psychopharmacological treatment, were also excluded.

In all, 102 patients were randomised, and 100 participants completed the baseline assessments. The two participants who withdrew consent were not included in the analyses. Those who completed measures at baseline but not post-treatment were included in the analyses according to intention-to-treat principles.

CAP standard clinical intervention

The CAP clinical interventions are conducted shortly after receiving an initial ADHD diagnosis. Sixty-five percent of the participants received a short psychoeducational intervention (1–2 hours) together with his or her parents after receiving an ADHD diagnosis at the CAP clinic, as recommended in the ADHD guidelines [ 12 , 13 ]. This psychoeducation typically consisted of information about ADHD diagnoses, symptoms, causes and treatment options. It was delivered by the patient’s clinician (a psychologist, medical doctor/child and adolescent psychiatrist or clinical education specialist). Fifty-three percent of the participants received 1–2 individual psychoeducational sessions with their clinician either in addition to the meeting with parents, or as the only psychoeducational intervention received at the CAP clinic. The content of these sessions was not standardized, so the information varied across clinicians and participants. Ninety-two percent of the participants received at least one of these psychoeducational interventions. The patient’s parents and schoolteachers had a collaborative meeting with the CAP clinician and/or a clinical education specialist to inform about the ADHD diagnosis and discuss individualised supportive measures in school (1 hour). Parents and a schoolteacher were also offered a standardized full-day lecture, with information about ADHD, pharmacotherapy, psychosocial interventions (help with planning and organising, supportive communication and the use of helping aids), and school interventions (regular daily routines, the use of a daily plan and week plans in school, clear communication/ short messages, and the use of rewards). These lectures are delivered by various ADHD specialists. All the families of the participants received at least one of these psychoeducational interventions. See Additional file  1 for more comprehensive information about the content.

Patients with persistent ADHD symptoms after receiving psychoeducation and a limited supportive school intervention were offered pharmacological treatment according to National clinical guidelines for ADHD [ 13 ]. Documents included in the hospital quality system (EQS) give detailed procedures for beginning and evaluating treatment. Methylphenidate is first drug of choice, while amphetamine or atomoxetine are second choices. The ADHD rating scale [ 37 ] was used as systematic effect measure during the titration trial using both parent and teacher ratings. In addition, the patient or his or her parents completed an adverse reaction form. Clinicians mapped specific problematic ADHD symptoms before beginning medication and considered improvement in symptoms and function in everyday life and any significant side effects during the evaluation. A second or third trial was indicated if the first drug was ineffective or caused significant side-effects. See Additional file  2 for information on participant medication type and dosage.

CBT intervention

The first and last author developed the CBT treatment manual in collaboration with Dr. Susan Young. It is based on the “Young Bramham programme” which is a CBT program developed for adolescents and adults with ADHD and comorbid symptoms by Susan Young and Jessica Bramham [ 28 ]. The YBP includes information on ADHD, the principles of CBT and strategies for managing core ADHD symptoms, such as inattention and memory problems, impulsivity, and organization and time management issues. Modules with strategies for problem-solving, interpersonal problems, anxiety, depression, frustration, and anger management were also included, as these are common problem areas in our patient group. Our CBT program was adapted to fit a 12-week group format with 90-minute sessions (see Table 2 for the main contents of the program and Additional file  3 for a more detailed description of the program). Basic CBT elements including the ABC model with the triangulation of thoughts, feelings, and behaviour, identifying dysfunctional thoughts/cognitive restructuring techniques, Socratic questioning and positive reinforcement were used throughout the program. All the sessions were structured using the same format, with psychoeducation, group discussions, skills training, role-play, and individualised weekly home assignments. The language, in terms of the material and choice of modules, was adapted to fit an adolescent ADHD population with comorbid disorders. A PowerPoint presentation was developed for a visual presentation of the material, and the participants received accompanying handouts containing the main content of the modules. The groups consisted of 4–6 participants and were conducted by two clinicians recruited from the clinic (a clinical psychologist, a child and adolescent psychiatrist/and or a clinical education specialist). All the group leaders had experience with CBT, but only one was a CBT therapist. All the group leaders were trained before delivering the intervention. The training included a full day course on CBT and delivering of the research treatment manual before the intervention. They were also given a copy of the Young-Bramham textbook describing treatment strategies in CBT for ADHD. We refer to Andersen et al. for supplemental background information on the group leaders [ 38 ].

The group leaders registered the attendance of each participant. Parents were not involved in the program. A research assistant telephoned the participants every week, reminding them of their home assignment; evaluated medical adherence and verified that they did not receive any other type of psychological treatment. One routine medical follow-up was usually performed during the intervention period. This consultation involved a child and adolescent psychiatrist evaluating general health status, the side effects of medication and blood pressure, heart rate and weight. The patient was encouraged to report any difficulties related to the medication since the last consultation.

Control group

The participants in the control group continued medical treatment and received one routine medical follow-up (as in the CBT group). This was a passive control condition with no additional intervention received after the CAP standard intervention. A research assistant contacted them once a week to monitor medication adherence and verify that no other psychological treatment was received. The participants were not offered entry into a CBT group after the post-intervention assessments. They could, however, engage in other treatments according to their clinical needs after completing the post-treatment assessments.

Continuous CBT supervision was given to the group leaders on a nearly weekly basis by an experienced CBT supervisor (AMS), whereby the therapists could receive guidance and support for upcoming sessions to stay adherent to the method. AMS also attended some sessions as an observer.

All sessions were videotaped, and adherence to the manual and CBT core principles relevant to the study was rated based on a random selection of 20 sessions (22%) and stratified by early [ 2 , 3 , 4 , 5 , 6 , 7 ] and late [ 7 , 8 , 9 , 10 , 11 ] sessions by an external clinician experienced with group CBT. The Competence and Adherence Scale for Cognitive Behavioural Therapy (CAS-CBT) [ 39 ] covers basic CBT components, as well as specific session goals that can be adapted to fit a specific treatment. A minimum score of 3 is considered adequate for both manual adherence and therapist competence. Treatment fidelity was acceptable across all measures, including adherence related to the CBT content (M = 3.38, SD = 0.75), program adherence (M = 3.47, SD = 0.69) and the CBT competence score (M = 3.25, SD = 0.87).

Medication adherence was assessed by telephone, specifically interviewing the participants on a weekly basis during the intervention period. The participants were asked about what medication they were on, the dosage and whether they had used the medication as prescribed during the last week.

Inter-rater reliability was calculated for the CGAS scores using the intraclass correlation coefficient (ICC) at baseline. The last author (TSN) scored a random sample of 20 participants (20%) originally scored by the first author (AJH) based on the written records of the participant interviews. The ICC was 0.78 (95% CI 0.53 to 0.91). Three other child and adolescent psychiatrists experienced in the assessment of ADHD scored the CGAS post-treatment. A random sample of 18 (19%) of the participants was simultaneously scored by TSN at this time. The ICC for the CGAS ratings was 0.92 (95% CI 0.80 to 0.97).

The CGI-S scores were based on short interviews with the adolescent and a parent and set by TSN at baseline and three other child and adolescent psychiatrists post treatment. The child and adolescent psychiatrists scoring CGI-S with the adolescent and parent post-treatment scored the CGAS at the same time. A random sample of 16 (17%) of the participants was scored simultaneously by TSN. Cohen’s weighted quadratic kappa for the CGI-S ratings was 0.78 (95% CI 0.54 to 1.00).

See Table  3 for an overview of the various outcome measures with different informants at different time points. All the questionnaires (except for the teacher reports) were filled out at the CAP clinic under the surveillance of a research assistant. Psychiatric diagnoses were assessed using the Schedule for Affective Disorders and Schizophrenia for school-age children-Present and Lifetime Version (Kiddie-SADS-PL) [ 34 ]. The instrument covers DSM-IV psychiatric diagnosis for school-age children (age 7–17), and the findings suggest that it generates reliable and valid child psychiatric diagnoses [ 34 ].

Primary outcomes

ADHD symptoms were assessed using parent, teacher, and self-ratings on the ADHD Rating Scale (ADHD RS-IV) [ 37 , 40 ]. The questionnaire contains an 18-item scale corresponding to the diagnostic criteria for ADHD and rates the frequency of each item from 0 = not at all to 3 = very often, with higher scores indicating more symptoms. The scale consists of nine symptoms of inattention and nine symptoms of hyperactivity, which represents two subscales, in addition to a total score. The scale has been validated for children and adolescents (age 5–18) with ADHD, with adequate reliability and validity [ 40 ]. A pan-European study found strong evidence for cross-cultural factorial validity, internal consistency as well as convergent and divergent validity supporting use of the ADHD-RS-IV across European countries [ 41 ]. In the current study, the Cronbach alpha coefficients were 0.78 to 0.81 on the ADHD-RS IV parent report, 0.80 to 0.82 for teacher ratings, and 0.80 to 0.84 for self-ratings.

Secondary outcomes

The Clinical Global Impression Scale for Severity (CGI-S) [ 32 ] was used to rate the severity of a patient’s illness related to ADHD symptoms. This rating is based on observed and reported symptoms, behaviour, and function in the past seven days. It is a 7-point scale ranging from 1 = normal, meaning not at all ill, 3 = mildly ill, to 7 = among the most extremely ill patients, with 0 = not assessed. Higher scores indicate more severe ADHD symptoms. This scale is often used in psychopharmacological research and has shown to have adequate sensitivity in drug trials [ 32 ].

The Children’s Global Assessment Scale (CGAS) [ 31 ] is a numeric scale used to measure the general psychosocial functioning of children under the age of 18 during the last month. The range is from 1 (lowest function) to 100 (excellent function). The Norwegian version has shown acceptable convergent, discriminant and predictive validity as well as acceptable interrater reliability [ 42 ].

The Weiss Functional Impairment Rating Scale parent and self-report (WFIRS-P, WFIRS-S) [ 43 ] consist of 50 and 69 items, respectively, divided into six and seven domains of impairment that are typically affected in ADHD (family, school and learning, life skills, self-concept, social activities and risky activities). Items range from 0 = not at all to 3 = very often, with 4 = not applicable, with higher scores indicating more impairment. We used the mean total score in this study, which represented the mean of all the subscales. The Norwegian version has shown acceptable psychometric properties in an adolescent ADHD population [ 44 ]. In this study, the Cronbach alpha coefficients for the WFIRS-P were 0.62 to 0.88 and 0.70 to 0.92 for the WFIRS-S.

The Behaviour Rating Inventory of Executive Function (BRIEF) [ 45 ] is an assessment of executive function behaviours at home and school for children and adolescents aged 5 to 18. It includes an 86-item parent and teacher report (BRIEF-P, BRIEF-T) and an 80-item self-report (BRIEF-SR). The scales range from 0 = not true to 2 = very true and converted T-scores above 65 indicate executive dysfunction. The inventories contain both a metacognitive (MI) and a behaviour regulation index score (BRI), in addition to a global executive composite score (GEC). We used the GEC index T-score in this study. The inventories have shown good psychometric properties in American and Norwegian children and adolescent populations [ 46 , 47 , 48 ].

The Screen for Child Anxiety-Related Emotional Disorders (SCARED) [ 49 ] is a 41-item self-report screening questionnaire measuring anxiety symptoms in youth. The item scale ranges from 0 = not at all to 2 = often, and a total score ≥ 25 may indicate the presence of an anxiety disorder. The instrument is sensitive to detecting specific and/or comorbid anxiety diagnoses in youth [ 50 ]. The Norwegian version has shown excellent internal consistency and convergent validity with other measures of anxiety in a non-clinical population [ 51 ]. The Cronbach’s alpha was 0.95 in the current study.

The Mood and Feelings Questionnaire-short version (SMFQ) [ 52 ] is a 13-item inventory tool that measures depressive symptoms in children and adolescents from 8 to 18 years. The scale ranges from 0 = not true to 2 = true. We used the total score, with higher scores representing more depressive symptoms. In a Swedish clinical population, the SMFQ’s ability to discriminate depression was fair for boys and good for girls. A Norwegian study found the measure to be a fast, practical, and feasible measure to detect depression in school adolescents [ 53 , 54 ]. The Cronbach’s alpha was 0.93 in the current study.

The General Perceived Self-Efficacy Scale [ 55 ] is a ten-item one-dimensional scale that is designed to assess belief in one’s ability to cope with a broad range of stressful and challenging demands in life. The items range from 1 = all wrong to 4 = completely right, and a high score represented positive self-efficacy. Studies have found self-efficacy to be a universal construct with high internal consistency across 25 nations, and convergent validity with other similar constructs has been moderate to low [ 56 , 57 ]. In this study, the Cronbach’s alpha was 0.88.

The Rosenberg Self-Esteem Scale (RSES) [ 58 ] is a ten-item self-report instrument for evaluating one’s overall sense of worthiness as a person in adolescents and adults. Responses were coded on a 4-point scale ranging from 1 = strongly disagree to 4 = strongly agree. Items 2, 5, 6, 8 and 9 were reversed to yield opposite values, and a high total score indicates positive self-esteem. The scale has exhibited high internal consistency, acceptable criterion validity and discriminant validity, as well as sensitivity to change [ 59 ]. In this study, the Cronbach’s alpha was 0.93.

The Adolescent Sleep-Wake Scale (ASWS) [ 60 ] is a 28-item scale widely used to measure sleep quality in 12 to 18-year-old adolescents. The scale ranges from 1 = always to 6 = never. Eight of the items were reversed for opposite scores. A higher score equals a better quality of sleep. We calculated the mean score in this study. The scale is considered a reliable and valid measure of overall sleep behaviour in a young adult population, with good psychometric properties [ 60 , 61 ]. The Cronbach’s alpha was 0.70 in the current study.

Randomisation

A research assistant randomised the participants in a 1:1 ratio (simple randomisation) into one of the treatment arms after the baseline assessments. This was done by a randomization program supplied by the Unit for Applied Clinical Research, a centre of expertise in the Central Norway Health Region. Codes were used to ensure participant confidentiality and anonymity. The participants were not blinded to the treatment condition.

Statistical analyses and sample size

Previous CBT programs have shown a 5- to 10-point reduction in ADHD-RS IV scale scores post-treatment [ 16 , 25 ]. Sample size was calculated for a six-point difference, assuming a standard deviation of nine on the ADHD-RS IV, as recommended by Coghill and Seth [ 62 ]. With a significance level of 5%, we needed 37 participants in each group to obtain 80% power. To allow for dropouts, we aimed to include 48 participants in each group, for a total of 96. We used mixed models, with the outcome variable as the dependent variable, time point and the interaction between treatment group and time point as fixed effects, and the patient as a random effect. In this way, by not including any systematic main effect on the part of treatment group at baseline, we handled the baseline values of the outcome variable as recommended by Twisk et al. [ 63 ]. We did not adjust for any background variables in the main analyses, because we did not have a priori evidence that there are strong prognostic factors that we ought to adjust for. Analyses were based on intention-to-treat (ITT). Separate analyses were conducted for each outcome. Missing data were handled using single imputation on scales using the mean item score if 70% or more of the questions were answered. Otherwise, the outcome of that specific questionnaire for that participant was treated as missing. The normality of residuals was checked via a visual inspection of QQ plots. There were a few residuals for which we were in doubt regarding whether they should be considered outliers. We repeated the three analyses without the four, one and two observations related to these residuals. The results of the analyses were substantially the same (data not shown). Finally, post-hoc subgroup analyses were conducted to explore whether age, IQ, socioeconomic status (SES), the severity of anxiety symptoms or the severity of ADHD symptoms (ADHD-RS IV) would act as a moderator, using the parent-rated ADHD-RS IV total score. This was done by adding the potential moderator and the relevant interactions into the linear mixed models. Statistical analyses were conducted using IBM SPSS Version 25. We report 95% confidence intervals (CIs) where relevant and regard two-sided p -values ≤0.05 as significant.

Participant attrition and adherence

See Fig. 1 . for a flow diagram of the participants in the RCT. Of the 100 participants randomised into the study, 94 (94.0%) completed the post-treatment assessment. The reasons for dropping out of the control group were dissatisfaction with the control condition ( N  = 2) and low motivation ( N  = 1). The reasons for dropping out of the CBT group were lack of motivation to continue with the therapy ( N  = 2). One participant completed the CBT treatment but contracted an illness during the study period, making a post-treatment assessment of ADHD symptom severity impossible ( N  = 1).

Regarding CBT group attendance, 20 participants (43%) attended all twelve sessions, and 39 participants (83%) attended ten or more sessions. Mean attendance was 10.7 sessions (SD 1.4).

Medication adherence

A majority of the study participants reported good medical adherence (medication ≥ five days a week), at 80.0% in the CBT group and 86.0% in the control group, respectively. Two participants in the CBT group and three in the control group stopped taking their ADHD medication during the trial. Four participants in the CBT group and three in the control group changed their type of ADHD medication during the same period.

Between- and within-group differences are presented in Table  4 . No differences were observed between the groups regarding post treatment changes in parent-rated (estimated difference − 0.08, 95% CI, − 2.5 to 2.32, p  = 0.95), self-rated (estimated difference 1.44, 95% CI, − 1.65 to 4.52, p  = 0.36) or teacher-rated (estimated difference − 1.51, 95% CI, − 5.1 to 2.0, p  = 0.40) ADHD symptoms. All three informants reported reduced ADHD symptoms post treatment, with parents and teachers reporting larger symptom reductions than the adolescents. Additional interpretations of the CIs were made to distinguish between negative or inconclusive treatment effects, as recommended by Gewandter et al. [ 64 ]. None of the CIs for the ADHD RS-IV parent-, teacher and self-report total scores crossed the 6-point symptom reduction limit, considered a clinically meaningful difference, defined as a 30% symptom reduction from the baseline scores [ 65 ]. This strengthens the conclusion of no treatment effect.

Supplementary analyses excluding posttreatment data on five participants in the control group receiving extra intervention, gave substantially the same results for all the outcomes (data not shown). Post-hoc subgroup analyses exploring the potential moderating effects of age, IQ, SES, the severity of anxiety symptoms and ADHD symptoms revealed no significant effect on treatment outcome using parent-rated ADHD symptom scores.

No differences were observed between the CBT group and the control group regarding symptom impairment, functional impairment, executive functions, emotional symptoms, self-efficacy, or self-esteem (see Table 4 ). Within-group differences revealed reduced symptom severity in both groups on the IE-rated CGI-S symptom severity scale, the parent- and self-rated WFIRS-scales and the BRIEF parent, self- and teacher reports. The IE-rated C-GAS score did not improve post treatment in either group.

Treatment guidelines for ADHD recommend multimodal interventions, including psychoeducation and pharmacological treatment in young people with moderate to severe symptoms [ 12 , 13 ]. Many patients find this combined treatment insufficient in alleviating their symptoms however, indicating a need for complementary treatments. The NICE guidelines consider CBT as a treatment option for young people with continued impairment after medication [ 12 ]. Although, behavioural interventions are considered well established for children with ADHD, this categorization has been limited to organization training for young adolescents (15 years and younger) with ADHD. CBT based interventions directed at adolescents with parent involvement were classified as probably efficacious in a review by Evans et al. [ 14 ]. Trials of CBT interventions targeting older adolescents (15 years and older) are limited, however preliminary results from a study of individualised CBT by Sprich et al. [ 16 ] and a group CBT by Vidal et al. [ 25 ] showed preliminary positive results. Our study thus aimed to assess the efficacy of a group CBT as a follow-up treatment for adolescents who still presented ADHD symptoms and functional impairments, after previously having received a psychoeducational intervention and medication.

In contrast to our hypothesis, the additional group CBT program could not demonstrate an incremental treatment effect as compared to the control condition. Indeed, previous studies of CBT with adolescents found larger post-treatment reductions in ADHD symptoms and improved functional impairment as compared with medicated waitlist controls [ 16 , 25 ]. In our study, the participants received psychoeducation and pharmacological treatment, interventions recommended by ADHD treatment guidelines, prior to additional CBT. The ADHD symptoms at baseline were thus somewhat lower than in comparable studies [ 16 , 25 ]. Another reason for the lower baseline scores could be an actual difference in populations (more females, less hyperactivity symptoms and few participants with comorbid ODD). Although our CAP standard intervention may in part explain a lack of treatment effect regarding ADHD symptoms compared to studies including participants with more severe symptoms, it cannot explain the nonsignificant effect of group CBT as compared to the control condition. However, the result is consistent with findings from other studies of youth directed psychosocial treatments without parent involvement [ 66 , 67 ]. These findings suggest that a more focused and/or individually targeted intervention with the inclusion of parents, similar to the evidence-based treatment programs by Sprich et al. [ 16 ], and Sibley et al. [ 17 ], could be more effective for this patient group.

However, several questions remain. First, the mean age of our study population was 15.8 years (SD = 1.3), and somewhat younger than the mean age of 17.2 (SD = 1.8) years in a comparable CBT group study by Vidal et al. [ 25 ]. Perhaps, the group format is more appropriate for older adolescents or young adults, who are more mature and thus more able to incorporate CBT principles and strategic tools into their daily lives. Second, our treatment program contains eleven modules, with new concepts and skills being introduced over a brief period. Although we consider all the modules relevant when treating adolescents with ADHD and comorbid conditions, such a comprehensive program leaves little time to practice new skills. Based on the adolescents` own report, only one third of the homework assignments was completed. This lower-than-expected completion rate may be explained by too little time to practice new strategies in and between sessions. Because practising new skills is considered a prerequisite for change, this may have contributed to lack of treatment effect. Another hypothesis explaining the low homework adherence may be a more general “lack of motivation” to work between sessions. This pattern was observed across themes and participants and was reported by both group-leaders in checklists and by descriptions from the research assistants talking to the participants between session. These observations suggests a particular challenge working with adolescents with ADHD who often struggle with poor decision making and poor insight into own functioning [ 68 ]. The inclusion of more engagement-focused components such as a more systematic exploration of goals and values, a stronger emphasis on motivational interviewing techniques [ 69 ] to target out-of-session skills application, and an even stronger emphasis on rewards to improve homework adherence using contingencies based treatment (with the help of parents), could have enhanced treatment engagement [ 70 , 71 ]. Following this, parent involvement is considered an important treatment component in other programs focusing on helping adolescents with ADHD who struggle with organization, time management and planning for homework assignments [ 16 , 24 , 72 ]. As such, the inclusion of parents in the CBT program could have improved treatment outcome. Third, the parents`- and teachers` BRIEF scores indicated executive dysfunction (T > 65) across groups at baseline. The adolescents reported symptoms just below this cut-off. Although these scores were reduced post-treatment, they still indicated ongoing impairment in both groups. This result pinpoints a need for more extensive training in planning, organisation, and time management over several sessions, as suggested in both school-based behaviour studies [ 19 , 21 ] and clinic-based CBT studies [ 17 , 24 ]. Fourth, a structured group format makes it harder to follow up on each participant and individual treatment goals. This could be addressed with the inclusion of an early parallel individual session, working on a case formulation in agreement with the adolescent and thereafter gradually openly sharing each one’s problems in the group. Fifth, our CBT program did not alleviate symptoms of anxiety. This was similar in the study by Vidal and colleagues [ 25 ] and suggests a need for more extensive treatment to reduce these symptoms. An RCT by Emilsson et al. [ 73 ] found an integrated group and individual CBT program to alleviate both ADHD symptoms and comorbid conditions in adults with ADHD. Such a combined model should be studied in future studies of adolescents with comorbid emotional and behavioural conditions.

This study is to the best of our knowledge, the first RCT to explore the efficacy of a group CBT as follow-up treatment for adolescents with impairing ADHD symptoms who previously received medication and psychoeducational interventions. Strengths of this study include the use of a control condition, the use of blinded evaluators and treatment fidelity ratings. In addition, the use of multiple informants, with self-, parent- and teacher ratings, is considered a strength in terms of the evaluation of the treatment effect. Furthermore, the inclusion of diverse outcome measures covering functional impairment, executive functions, and psychiatric symptoms paints a broader picture of areas in which CBT may have potential treatment effects. Finally, the study was delivered in a real-world setting using clinical staff and covering a total catchment area.

This study has several limitations. First, the large number and low dosage of treatment components caused restricted time to practice each module, which may have affected the treatment outcome. Second, 91% of the population was on pharmacological treatment for ADHD, limiting the study’s generalisability to non-medicated patients. Third, although most study participants fulfilled the diagnostic criteria for an ADHD diagnosis at inclusion, 34% of the participants presented subthreshold ADHD symptoms prior to study inclusion, thus limiting the room for further improvement. Fourth, although the treatment fidelity and deliverance of the CBT program was acceptable, the CBT experience and background of the group leaders varied, which may have affected treatment outcome. Fifth, the socioeconomic status (SES) of the participants was higher than in a typical ADHD population [ 74 , 75 ], which limits the generalisability of the results to populations with lower SES. Sixth, even though more boys than girls receive an ADHD diagnosis at the CAP clinics [ 76 , 77 ], girls were easier to recruit for this study, and represented 57% of the population. Boys with comorbid behaviour disorders were particularly hard to recruit, which may suggest that individual- or family-based interventions are more appropriate for this patient group [ 14 ]. Seventh, data on homework completion was incomplete, leaving little room for analyses on its impact on treatment effect. Also, there were substantially fewer teacher ratings than self- and parent ratings. This is considered a limitation since their ratings may represent unbiased observations that add to the more proximate and potentially biased parent observations.

Even though our CBT program revealed no overall incremental treatment effect as compared to the control condition, the participants receiving group CBT were positive about joining the program, and dropout rates were low [ 38 ]. Future research should examine whether CBT-based treatment programs with parent involvement, focusing on core ADHD symptoms and executive functions that include individualised skills training, contingency management and MI components would be even more effective for this patient group, similar to the clinic-based programs by Sprich [ 16 ], Sibley [ 17 ] and Boyer [ 24 ]. These components are included in an evidence-based psychosocial treatment model for younger adolescent with ADHD [ 14 , 17 ], but were not included in the current treatment model.

Although treatment guidelines recommend CBT as additional treatment for ADHD in adolescents who still experience functionally impairing symptoms after receiving psychoeducation and medical treatment [ 12 ], more research is needed to support the effect of CBT as an adjunct to medication and a historic previous psychoeducation (mean years = 1.8). The guidelines might be clarified to highlight that not all CBT is created equal and that behavioral and cognitive behavioral interventions that include individualized skills training coupled with parent involvement rather than a group program without parent involvement, is the primary evidence-based model for this adolescent age group [ 16 , 17 , 21 ].

To our knowledge, this RCT is the first study to assess the efficacy of a group CBT as addition to pharmacological treatment and psychoeducational intervention in adolescents with ADHD symptoms and related impairments. In this study the group CBT did not show an incremental effect as a follow-up treatment after a CAP standard clinical intervention. Further studies are warranted to explore the efficacy or effectiveness of a more focused group CBT intervention as addition to medication and psychosocial interventions, and preferably with parents involved. It is also relevant to explore whether more individualised CBT treatment, in a group or individual setting, may be more effective than a standardised program intended to fit all.

Availability of data and materials

The datasets used in the current study are not publicly available due to privacy policy, but they will be made available from the corresponding author on reasonable request.

Change history

27 august 2022.

The OA funding note has been added. The article has been updated to rectify the error.

Abbreviations

Attention-Deficit/Hyperactivity-Disorder

ADHD Rating Scale IV

The Behaviour Rating Inventory of Executive Function parent report and self-report

Cognitive Behavioural Therapy

Child and Adolescent Psychiatry

The Competence and Adherence Scale for Cognitive Behavioural Therapy

Children’s Global Assessment Scale

Clinical Global Impression Scale for Severity

Confidence Intervals

Consolidated Standards of Reporting Trials

the Diagnostic and Statistical Manual of Mental Disorder 5th edition

Intraclass Correlation Coefficient

The International Statistical Classification of Disease and Related Health Problems 10th version

Independent evaluator

Intention-to-treat

the Schedule for Affective Disorders and Schizophrenia for school age children-Present and Lifetime Version

Motivational interviewing

National Institute for Health and Care Excellence

Randomised Controlled Trial

the Wechsler Adult Intelligence Scale IV

the Wechsler Intelligence Scales for Children IV

Young Bramham programme

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Acknowledgments

The authors are grateful for the contribution of Eirin-Katrine Støkkan, Jorun Schei, Marit Skrove and Hanne Greger for their support in gathering patient data. We also want to thank the patients, parents and the teachers participating in the study.

The study was funded by a PhD grant to the first author by the Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), Faculty of Medicine and Health Sciences, The Norwegian University of Science and Technology (NTNU). The study received additional funding from the Child and Adolescent Psychiatric Clinic, St. Olav’s University Hospital; the Regional Network for Autism, ADHD, and Tourette syndrome, Mid-Norway Health Trust; The National Research Network for ADHD, Ullevål University Hospital, Oslo, and the Regional Competence Network for ADHD, RKBU, NTNU. Open access funding provided by Norwegian University of Science and Technology.

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Department of Mental Health, Faculty of Medicine and Health Sciences, Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU), NTNU- Norwegian University of Science and Technology, Trondheim, Norway

Anne-Lise Juul Haugan, Anne Mari Sund, Per Hove Thomsen, Stian Lydersen & Torunn Stene Nøvik

Department of Child and Adolescent Psychiatry, St. Olav University Hospital, Trondheim, Norway

Anne Mari Sund & Torunn Stene Nøvik

Psychology Services Limited, London, UK

Susan Young

Department of Psychology, University of Reykjavik, Reykjavik, Iceland

Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark

Per Hove Thomsen

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Contributions

The main research team undertook the research design: TSN, AMS, PHT and SL. AJH, TSN and SY contributed to the CBT treatment manual, and AJH and TSN participated in the gathering of the data. AMS supervised the therapists in the study, while TSN, PHT and SL supervised the first author. SL was the statistical expert in this study; AJH performed the statistical analyses with the supervision of SL. All authors read and provided substantial contributions to the paper and approved of the final version of the manuscript.

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Correspondence to Anne-Lise Juul Haugan .

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Ethics approval and consent to participate.

Written informed consent was obtained from adolescents and parents before enrolment into the study (parents signed the forms for participants under 16 years). In the case of dropouts, the participants were asked to consent to the use of the baseline data. The study was approved by the Regional Committee for Medical and Health Research Ethics in Southeast Norway (2015/2115). The study was conducted according to the principles set forth in the Declaration of Helsinki from 1964 and later amendments. The study was also performed and reported according to CONSORT guidelines [ 78 ] (see checklist in supplemental material).

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Not applicable.

Competing interests

PHT has received speaker’s fees from Medice and Shire in the last three years. TSN has received a speaker’s fee from Medice during the last three years. SY has received honoraria for consultation and/or educational talks in the last 5 years from Janssen, HB Pharma, Shire and Medice. AMS has received travel support and a congress fee from Medice in the last three years. AJH has received travel support and a speaker’s fee from Medice in the last year, SL declares no conflicts of interest.

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Haugan, AL.J., Sund, A.M., Young, S. et al. Cognitive behavioural group therapy as addition to psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: a randomised controlled trial. BMC Psychiatry 22 , 375 (2022). https://doi.org/10.1186/s12888-022-04019-6

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Received : 15 November 2021

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DOI : https://doi.org/10.1186/s12888-022-04019-6

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