Introduction

Homework is one of the fundamental components of cognitive behavioral therapy (CBT) for youth anxiety and depressive disorders. Practicing CBT therapists report widespread use of therapeutic homework (Kazantzis, Lampropoulos, and Deane 2005), but they also acknowledge variations in how it is used (Houlding, Schmidt, and Walker 2010). Theoretically, homework tasks are important because they (i) encourage opportunities to practice skills learned in session; (ii) give the therapist a chance to determine the youth’s understanding of skills; (iii) allow the youth to generalize therapeutic skills to real-life situations; and (iv), in anxiety, help the youth gradually face feared situations in his/her own environment (Hudson and Kendall 2002). CBT homework is typically discussed and assigned during each session and reviewed at the beginning of the next session. Therapy homework for anxiety initially includes skills practice and eventually out-of-session exposure tasks: in both, the youth practices skills learned in therapy by engaging in real-life situations (Kendall and Hedtke 2006a). Therapy homework for youth suffering from depression entails keeping a mood diary or log, skills practice (e.g., challenging depressogenic thinking), and pleasant activity scheduling through behavioral activation (Clarke, Lewinsohn, and Hops 1990; Curry et al. 2005; Stark et al. 1996).

Among adults, homework assignments have shown small to moderate relationships with treatment outcome (see the meta-analysis by Kazantzis, Whittington, and Datilio 2010; also Mausbach, Moore, Roesch, Cardenas, and Patterson 2010). The same may be true for anxious youth: out-of-session exposure tasks are linked to improved treatment outcome. In one report (Puleo and Kendall 2011), out-of-session homework was found to be critical to positive gains for youth with anxiety and comorbid moderate autism spectrum disorders (ASD; Puleo and Kendall 2011; and see also Simons et al. 2012). When working with youth, therapists can use a variety of strategies to encourage therapeutic homework completion. Popular strategies include praising the client for completion, trouble-shooting any difficulties the child may have had, aligning homework completion with therapy goals, targeting client strengths, choosing homework collaboratively, and problem solving around barriers (Houlding et al. 2010). Homework is tailored on the basis of the therapist’s case conceptualization, and client beliefs about the homework can be explored. Determining homework tasks that facilitate real-world use of skills requires core therapeutic competencies (Weck, Richtberg, Esch, Höfling, and Stangier 2013). Non-compliance with homework, in particular, can require therapist creativity and flexibility (Kazantzis, Datilio, Cummins, and Clayton 2013). Among depressed youth, for instance, homework compliance has been reported to be moderate (approximately 50 percent of assignments completed) and declining over time (Clarke et al. 1992; Gaynor, Lawrence, and Nelson-Gray 2006). Features of the specific anxiety and depressive disorders can complicate the use of homework. Adolescents in particular may have difficulty adhering to recommendations for out-of-session practice. With youth, including caregivers (hereafter referred to as “parents”) in therapy homework tasks may be helpful. This chapter reviews these topics and considers some potential obstacles to therapy homework completion and real-world applications of skills.

Key Features of Competencies

Therapeutic homework is not an assignment that is always viewed favorably by children and adolescents. Unlike adults, youth are typically brought to therapy by their parents, as opposed to being self-referred. As a result, the youth may not be fully “on board” with the therapy, and the idea of therapy homework may be resisted. A key competency is the therapist’s ability to present homework as beneficial, personally relevant to the youth, and potentially enjoyable. In the Coping Cat for anxious children (Kendall and Hedtke 2006a) and in the Cat Project for anxious adolescents (Kendall, Choudhury, Hudson, and Webb 2002), therapeutic homework assignments are referred to as “Show-That-I-Can” (STIC) tasks and “Take-Home Projects,” respectively. Thus STIC tasks and take-home projects are conceptually distinct from school assignments, as the therapist will neither assign a grade on the basis of performance nor punish noncompletion. Rather, therapists provide a clear rationale for homework completion that is congruent with the youth’s goals – for example: “You can practice applying the skills you learned in session to other areas in your life, like making new friends.”

The competent therapist demonstrates the ability to collaboratively select and plan appropriate homework tasks with the youth. In brief, collaboration is teamwork, where the therapist and youth work together, the therapist encouraging the youth’s involvement, providing helpful feedback, and offering contributions to the youth’s goals (Lambert and Cattani 2012). Collaboration has been linked to successful treatment outcomes of anxious youth (Chu and Kendall 2004; see also Chapter 10 of this volume). Many CBT manuals offer assignments for the youth; some provide sample handouts or worksheets. Keep in mind that these can be flexibly applied, to take into account each youth’s particular needs and goals (Kendall and Barmish 2007). When planning homework assignments, a collaborative therapist brainstorms with the youth possible ways to practice skills outside of session, while ultimately allowing the youth to decide. For example, when choosing an out-of-session exposure task for a socially anxious child, the therapist could say:

Depending on the child’s responses, the therapist and the child would decide together whom the child could talk to and what the child might say. In planning the homework task, the therapist considers the child’s ultimate goal: talking to other children at school.

Positive reinforcement, often in the form of rewards, facilitates homework completion. Environmental contingencies are essential in shaping behaviors (Skinner 1969), and positive reinforcement for homework is no different. Children in the Coping Cat program might earn stickers for each STIC task completed, and eventually stickers can be traded for a desirable reward of the child’s choice. Rewards are best when immediate and effective for each child. Rewards can be tangible, like stickers, small toys, gift cards, or a favorite food or treat. Non-tangible activity rewards are inexpensive and may be preferred, including time spent playing a game with the therapist, staying up past bedtime at home, or spending one-on-one time with a parent. The therapist can speak with the youth and the parent regarding preferred and appropriate rewards for homework completion. Of course, follow-through and consistency are very important: reward the youth for his/her efforts. In the Coping Cat it is emphasized: “Rewards are not just for perfect work.” Rather, rewards are given when the youth gives his/her best effort, for instance by facing a feared situation. Additionally, the therapist can emphasize the experimental nature of homework to the child; even if (s)he is unable to complete the homework task, the child may still learn something through his/her attempts. The therapist could illustrate this through the use of examples:

You know, even when we try our best, things don’t always work out the way we hoped they would. Even with our best efforts, we may make mistakes. I can think of a time when I had to take a test at school and I was really nervous. I missed some of the questions. But, hey, I tried my best, so I still rewarded myself by watching a movie later. Remember, we can try our hardest, but no one is perfect!

Youth are encouraged to reward themselves with positive self-talk (e.g., “I did it … I tried really hard!”). Tangible rewards may be phased out, as the youth experiences some of the nonmaterial benefits that come from completing homework tasks. These can include feeling proud, having fun, and feeling less anxious or sad.

The competent therapist strives to personalize homework tasks to the unique needs and goals for treatment of each child and adolescent (Houlding et al. 2010). Consider the child’s diagnoses and developmental level, as well as any environmental factors that may impede or facilitate homework completion. Therapists can also explore each client’s beliefs toward the homework: Does the client find the task relevant and doable? Appropriate levels of parental involvement will vary. For instance, Puleo and Kendall (2011) found that parental involvement in homework tasks was particularly valuable among anxious children with ASD. ASD has been associated with limited generalization across settings; this example illustrates the value of homework tasks for real-world applications of the skills learned. Some youth may have difficulty completing homework or grasping the skills, at which point homework assignments may need to be repeated or varied. Therapists strive for “flexibility within fidelity” (Kendall, Gosch, Furr, and Sood 2008) – maintaining fidelity to the important ingredients of CBT, but doing so with the flexibility needed to meet individual needs. Thus defined, therapist flexibility (that is, the therapist’s effort of adapting the treatment to the needs of a particular youth) may increase youth involvement and promote positive outcomes (Chu and Kendall 2009).

Competence in Treating Anxiety and Depressive Disorders in Youth

Therapists can consider how homework tasks in CBT may vary across different anxiety and depressive disorders. Notably, homework tasks will also vary at an individual level, so we offer guidelines, not rules, for planning and conducting homework tasks for each disorder.

We have found homework tasks to be particularly salient among youth with social phobia (SoP). Although youth with SoP respond poorly to treatment by comparison with youth with other anxiety diagnoses, there are some data to suggest that SoP may be a predictor of non-remission on some outcome measures for CBT (Ginsburg et al. 2011). Additionally, youth with SoP may have more difficulties with the long-term maintenance of gains (Puleo et al. 2011). One possible reason for poor response rates is that exposure tasks conducted in the clinic may not generalize to the youth’s real-world experiences with others, in particular his/her peers. Using the client’s real peers when conducting exposure tasks in the clinic may not be possible (confidentiality concerns), in which case out-of-session exposure tasks with peers may be especially helpful. Youth with SoP may show initial reluctance to plan and engage in out-of-session exposure tasks with peers, and such fears can be targeted in treatment. The therapist may increase the youth’s self-efficacy by role-playing such encounters with the youth during session. Imaginal exposures to real-life situations can also be a useful start. Social skills and assertiveness training is included in the Stand Up, Speak Out manual for SoP in adolescents (Albano and DiBartolo 2007) and may target skill deficits that would impede real-world applications. Examples of out-of-session exposure tasks for youth with SoP can include talking to a new peer, calling a friend, raising one’s hand in class, or performing in front of others. Additionally, therapists can prepare the youth for the out-of-session challenge by practicing the “worst case scenario” during session. For example, the youth can make a speech in front of a group of confederates in the clinic and purposely make some errors. In doing so, the youth may discover that what is thought to be “errors” may go unnoticed, or that the worst outcome (e.g., “everyone will think I’m stupid”) does not actually occur. Additionally, sharing feelings and thoughts when reviewing completed homework assignments can be in itself an exposure task for a youth with SoP. The therapist can provide a supportive environment by rewarding the youth for the effort and by normalizing anxiety through modeling of the homework tasks. For instance, the therapist can say:

Let’s see, as I recall, your take-home project was to write about a time you felt anxious this past week. Is that right? OK. You know, I remember feeling worried when I forgot my friend’s birthday this past Tuesday. I worried that she would be disappointed in me, think that I forgot her, and never forgive me. But, you know, I realized that everyone forgets once in a while. When I called her the next day to say “Happy belated birthday” she actually understood and didn’t seem angry. What about you? When were you nervous this week?

A diagnosis of generalized anxiety disorder (GAD) also calls for specific therapist competencies in planning homework tasks. Youth with GAD can be perfectionists around homework. The therapist may wish to place a time limit on homework completion (e.g., 10 minutes) and recruit the parents to help enforce this. The therapist takes particular care not to reinforce perfectionism during homework review; for instance, spelling and grammatical errors are not corrected. In fact the therapist may suggest that the youth purposefully makes mistakes on his/her homework and may reward the youth for his/her efforts. For instance, the youth can do the assignment with the non-dominant hand, or with the eyes closed. GAD is often associated with rigid thinking and an intolerance of uncertainty. The therapist can target this by varying the homework tasks or by providing incomplete or vague instructions. Youth with GAD may also experience more abstract worries, which require particular creativity in the planning of out-of-session exposure tasks. For instance, a youth who fears thunderstorms could engage in out-of-session exposure tasks, where (s)he views videos and/or recordings of thunderstorms. Sometimes, out-of-session exposure tasks focusing on school-related concerns may require the help of teachers. A teacher can be notified that the youth has been given the task of answering one question per class. If the child does not complete this task, the teacher may be asked to call on the child.

Children with obsessive–compulsive disorder (OCD), like those with GAD, often display rigidity and perfectionism concerns. Homework will include skills practice and planned out-of-session exposure and response prevention (Lewin, Peris, Bergman, McCracken, and Piacentini 2011). In their manual, March and Mulle (1998) emphasize that homework tasks are chosen by both the youth and the therapist. As with GAD, homework is time-limited. As OCD is characterized by recurrent obsessions and compulsions that cause impairment in a youth’s daily life, homework assignments may need to be completed every day. Additionally, as family members often participate in a youth’s rituals and routines, these family members may need to change their own behavior in the home. The therapist can gently explain to the youth, ahead of time, that (s)he will be asking the parent to avoid participating in the daily rituals, which will prepare the youth and may prevent arguments when the parents refrain. At the same time, children are not expected to immediately cease their daily rituals, as homework takes a gradual approach. March and Mulle (1998) suggest choosing a “too easy” task for the initial out-of-session practice, in order to promote positive views of homework and of the child’s own self-efficacy. The therapist may wish to call the family between sessions to problem-solve the difficulties the youth may have in completing the exposure task.

Conducting homework assignment for youth with separation anxiety disorder (SAD) requires particular planning on the behalf of the therapist, child, and parent. Parental involvement is usually a necessity, not an option. The therapist can include the parents in the discussions surrounding out-of-session exposure, planning to ensure their feasibility and follow-through. The out-of-session challenges may require the parents to change their behavior: for example, a parent may agree to leave his/her child home with a baby-sitter and not answer calls or texts from the child who seeks reassurance.

Homework assignments for youth with post-traumatic stress disorder (PTSD) require sensitivity from the therapist. The youth may be distrustful of adults or may struggle with feelings of shame, guilt, or self-blame. The therapist can carefully take into account the youth’s circumstances. In trauma-focused CBT, an evidence-based treatment for PTSD (TF-CBT Web 2012: Medical University of South Carolina 2005), some tasks are not assigned as homework; such as creating a trauma narrative, which can lead to distress for the caregiver and youth and therefore is best completed during session. Otherwise homework can include practicing appropriate feelings expression, relaxation techniques, cognitive coping, and challenging trauma-related dysfunctional cognitions. After the youth has created the trauma narrative, (s)he may be asked to listen to an audio recording of the narrative each night. Gradually the therapist, the parent, and the youth work together to decrease avoidance of trauma-related cues in the youth’s environment. For example, a youth who has avoided going into a room in the house where a traumatic event occurred may be asked to spend increasing amounts of time per day in that room. At the same time, the therapist always takes into account the youth’s safety when planning out-of-session exposure tasks.

Although not an official diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR; American Psychological Association 2000), school refusal occurs when a youth is chronically tardy to school, has difficulty staying for a full day, is frequently absent from school, or engages in misbehaviors to avoid school. Such school refusal behaviors can result from anxiety and avoidance of fearful school-related stimuli or from difficulty with separating from the parents (Kearney and Albano 2007). For school refusal cases, homework assignments for parents may involve monitoring the youth’s behaviors and resistance to school throughout the day. Children may be assigned the task of recording throughout the day their levels of anxiety associated with school. Behavioral homework assignments include gradually increasing the youth’s school attendance and following an established contingency plan. As chronic absenteeism from school can have serious consequences for both the child and his/her family (see review by Kearney 2008), families and school staff often communicate a sense of urgency to the therapist. Nonetheless, homework assignments are carefully planned in the best interest of the youth. For instance, a child who is more fearful of attending school in the morning can arrive in the afternoon. Once this is achieved, the child can go earlier each day until (s)he is attending for the full day.

Pleasant activity scheduling or behavioral activation is an important competency for treating youth depressive disorders. When depressed, youth tend to decrease the time spent in enjoyable activities, which serves to maintain depression over time. The therapist works with the youth in session to identify and list naturally reinforcing and easily accessible activities. The youth can be encouraged to identify a range of activities that are fun, social, active, and/or helpful to others. It is recommended that the therapist and youth first engage in some of these activities during session, to demonstrate their impact on mood (Bearman and Weisz 2009). Continuing to practice and monitoring these activities at home can increase real-world practice and application of these skills.

Perhaps one of the greatest challenges is that youth with depression often experience low levels of motivation, accompanied by poor energy and diminished goal-directed behavior. As a result, youth may have difficulty completing their school assignments and may feel daunted by the concept of additional therapy homework. In the Adolescent Coping with Depression Course, Clarke and colleagues (1990) recommend four principles to emphasize with depressed adolescents: (i) homework can help you gain control over depression and is for you, not for the therapist; (ii) unlike school assignments, therapy homework has real-life significance by allowing reflection on things that are bothering you; (iii) homework is kept brief and easily fits into your schedule; (iv) homework is ultimately voluntary, and it is up to you to complete it. If homework is not finished, youth are encouraged to complete it at the beginning of each session. Pleasant activity scheduling can be linked to rewards to motivate the youth for change. Additionally, explaining the rationale of the homework can help the youth understand its importance. Curry and colleagues (2005) recommend reinforcing even partial completion. Maladaptive self-talk (e.g., “This isn’t going to help me, so what’s the point?”) and behavioral skill deficits that may be associated with noncompletion can be targeted directly in therapy. Likewise, youth are encouraged to make internal attributions when they succeed in completing their homework.

Developmental Considerations: Competence in Treating Children and Adolescents

When working with youth, therapists consider the developmental level of the youth when they collaboratively plan and assign homework tasks. The following illustrates some competencies to consider when utilizing CBT homework for children versus adolescents. At the same time, children and adolescents may vary greatly at the individual level, and comorbidities such as pervasive developmental, attention-deficit hyperactivity and conduct problems can require various degrees of the strategies described below.

In therapy with children, in most cases, parents are involved at least minimally in homework tasks. As described above, some anxious children may need time limits placed on their homework assignments to target perfectionism concerns, which can be monitored by the parents. Particularly young children may lack insight into their difficulties, and parents can help with goal setting and the selection of out-of-session tasks that may increase generalization to the real world. Often, meeting with the parents and the children at the beginning of the session to discuss progress made on homework tasks can be very rewarding, as the youth may have the opportunity to hear a parent “brag about” the child’s accomplishments that week.

In many instances, parents are integral to the planning of more behaviorally oriented homework tasks. For example, in order for a child with SoP to practice talking to new people, the parent must provide the child with these opportunities between sessions. Parents may need to plan to bring their child to a new friend’s house, or to attend a restaurant where the child can order for her-/himself a favorite food. The parent is encouraged to review coping strategies and role-play with the child prior to the task, and to provide immediate praise and rewards after the child has completed the task. Such behavior exemplifies transfer of control, where knowledge, skills, and techniques are gradually transferred from the therapist in the clinic to the parent and child in the real world (Kendall and Hedtke 2006a).

In many instances, parents may have homework tasks of their own. For young children, parents can collect data throughout the week: the particular situation, the child’s behaviors, and the parent’s response. As described earlier, for specific problems such as SAD, the parent may play the central role in an out-of-session exposure task, perhaps by leaving the child with a baby-sitter for increasing amounts of time, to run errands. Finally, the therapist may ask parents to monitor and reduce behaviors that unknowingly reinforce the child’s anxious or depressive behaviors. Parents of children with GAD, for instance, are encouraged to decrease reassurance-giving behaviors, and parents of children with OCD may need to evaluate their own role in their child’s compulsive routines. Therapists normalize this process and empathize with the parents around these maladaptive behaviors, as many parents may feel blamed and defensive. The therapist might say:

You know, it’s natural for parents to want to protect their child from harm and to provide comfort when he or she is distressed. In general, these seem like the right things to do. However, with overly anxious kids, parents who protect their children may be allowing them to avoid things, and the child may not get the chance to see that they can cope on their own. This week, I’d like you to be your own detective: pay attention to what you do that might allow your child to “avoid” … watch and write down any instances where you may be allowing your child to avoid distressful situations. We’ll discuss them together.

Similarly, the therapist works with the child to select relevant homework tasks. Younger children may have difficulties completing homework with abstract concepts and may benefit from increased numbers of examples and exercises. For instance, helping a young child understand the difference between a thought and a feeling could be illustrated through the use of “thought bubbles” that the child practices at home. Children could be sent home with specific tools to practice the skills learned in therapy, such as an audio recording of a relaxation script. Finally, material rewards are particularly useful for encouraging homework completion among young children, as more abstract rewards such as “feeling better” may be too vague.

Utilizing homework techniques in CBT with adolescents can require a very different approach on the part of the therapist (Jungbluth and Shirk 2012). Adolescents are the age group least adherent to a variety of treatment regimens (see, e.g., Hack and Chow 2001). Although the specific mechanisms underlying this finding are unknown, adolescents’ aspiration of independence from parents and professionals, peer pressure and social demands, and negative attitudes toward treatment may play a role. In consequence, the therapist can approach CBT homework as the adolescent’s own responsibility as a mature young adult (Clarke et al. 1990; Kendall and Barmish 2007). Actively collaborating with the adolescent to select effective homework assignments can help the adolescent feel empowered and claim ownership over his/her successes. The adolescent and the therapist can work together to identify goals that are personally relevant to the adolescent, and these goals can be directly targeted through homework tasks. For instance, an adolescent may wish to make more friends, learn to play the guitar, or simply “feel better” each day, and homework tasks can be framed to achieve these goals. The adolescent’s fear of embarrassment in front of peers can be directly targeted in treatment by helping the adolescent identify maladaptive thinking patterns, such as the belief in an imaginary audience (Elkind and Bowen 1979). Parental involvement in homework tasks for adolescents can be varied, as some adolescents may wish to exercise independence. Finally, adolescents may feel self-conscious about identifying rewards for their homework completion. Activity rewards may be particularly reinforcing for adolescents, and parents can agree to allow the adolescent to earn extra time on the phone or computer, or to drive the adolescent to a favorite restaurant or sporting event.

Common Obstacles to Competent Practice and Methods to Overcome Them

Obstacles in the collaborative planning and completion of CBT homework can and do occur, and competent implementation needs to be prepared. Two common obstacles are: (i) non-compliance; and (ii) difficulty in generalizing skills.

Non-compliance is a common hurdle to homework assignments (Gaynor et al. 2006). To address it, the therapist begins with simple, nonthreatening homework tasks (shape homework compliance by starting with easy assignments). For example, in the Coping Cat (Kendall and Hedke 2006b, p. 4), the first STIC task is:

Describe a time this week when you felt really great – when you weren’t upset or worried. Remember to describe the situation you were in, what you were thinking, and what you were feeling. You can write it in your workbook.

This initial task allows the child to elaborate on a positive experience, with minimal direction or requirements. This STIC task introduces the idea of homework in a nonthreatening way, while allowing the child to practice the skills learned in the first session: mainly the connection between thoughts, feelings, and situations.

Despite this, the youth may still be non-adherent to the homework, either by not doing the assignment or by doing a poor or incomplete job. First, the therapist adopts a non-punitive approach, and can offer the youth the opportunity to complete the homework in session. If the youth tries very hard in session, a partial reward could be offered, such as one sticker instead of two. Next, if non-compliance with the homework appears to be a pattern, the therapist may wish to explore with the youth specific reasons for non-compliance. This can vary from child to child, but common reasons can include forgetting, avoidance, faking good, or homework that is too challenging for the youth (Hudson and Kendall 2002). Additionally, a youth may refuse to complete homework as a way of acting out or rebelling against the therapy. Once these specific reasons have been identified, the therapist and the youth can identify either personal or environmental barriers to homework completion.

Once the potential barriers have been identified, the therapist, the youth, and the parent can find solutions to overcome these barriers. A youth may forget to complete the homework due to a busy schedule or to comorbid symptoms of attention deficit hyperactivity disorder. If so, the parent can gently remind the youth during the week, or the youth and the therapist can create a reminder note to be displayed in a noticeable place. Avoidance is a trademark symptom of anxiety in youth and can affect homework completion. A youth may be able to complete exposure tasks during session with the support and encouragement of the therapist, but completing them on his/her own may seem daunting. The therapist can target this avoidance through therapeutic techniques such as cognitive restructuring and setting realistic expectations for the youth. At-home practice of therapeutic skills and exposure tasks is typically gradual.

Additionally, the youth may complete homework inaccurately due to a desire to make a favorable impression on the therapist. For instance, the youth may be hesitant to report times (s)he felt anxious or depressed, for fear of disappointing the therapist. The therapist can normalize these feelings, while targeting anxiety about disappointing others. Hudson and Kendall (2002) suggest that it may be helpful to assign a task where the youth has to complete the homework incorrectly for one week. Thus the youth learns to cope with making mistakes and potentially disappointing the therapist. When tasks are overly difficult, the therapist, the youth, and the parent determine what level the youth is capable of achieving. While homework aims to challenge the youth, a seemingly impossible task will leave the youth feeling discouraged and hopeless. A collaborative, teamwork approach toward homework where the therapist, youth and parent work together to identify challenging yet achievable homework tasks for the youth to undertake will also reduce the possibility of this occurrence.

Finally, the therapist watches for any comorbid behavioral problems that may interfere with homework completion. An unwilling youth may go to therapy each week when taken by a parent, but homework completion may become a battle. If so, the therapist may wish to integrate parent training into the sessions. Further, homework assignments can be tailored to meet the youth halfway. For instance, a youth who does not wish to write a homework task can describe it to a parent, who can record it for the therapist. An artistically inclined youth can draw a picture or make a collage that achieves similar goals as the original homework task. Practicing a skill every day can be reduced to practicing it every other day. If the youth still does not complete the homework despite these efforts, extra time can be carved into the therapy session to allow the youth to complete the homework from the previous week. Finally, non-compliance may occur naturally over the course of therapy, particularly as a youth experiences symptom relief (Gaynor et al. 2006). The therapist can emphasize the importance of continued practice for reducing the probability of a relapse of the symptoms. Anxious children are often encouraged to adopt an “exposure lifestyle,” where confronting instead of avoiding the feared stimuli becomes a way of life.

Effective CBT homework planning and completion are designed to facilitate the generalization of skills learned in therapy to the youth’s environment. Despite the therapist’s efforts, youth may not view homework as being relevant to everyday life. The youth may not plan to continue exposure tasks or pleasant activity scheduling once the therapy is terminated. To target this, the therapist encourages the youth to engage in homework tasks over a variety of settings and with a variety of people during treatment. For instance, an adolescent may find speaking to a new peer much more anxiety provoking than speaking to an unfamiliar store clerk, so both skills would be practiced outside of therapy. In doing so, these tasks are repeated until they become routine for the youth. Once routine, the youth will be more likely to continue these tasks after therapy termination.

Utilizing flexibility (as described above) when prescribing homework tasks is also important for promoting generalization. For instance, an adolescent may feel that relaxation is “embarrassing” but might enjoy engaging in activities that promote it, such as mindful meditation or yoga classes. Pleasant activity scheduling can include joining an afterschool sports team or club. The youth can create reminders of the skills learned in therapy that can be posted around the home environment, such as coping cards, where coping techniques can be easily accessed. Also, a final project that summarizes the youth’s success in therapy can be helpful to reiterate the skills learned. In the Coping Cat, the child’s last STIC task is to plan a commercial that describes accomplishments in therapy. During the last session, the therapist helps the child create this commercial, which allows the child the opportunity to “show off” with what (s)he has learned. Importantly, the child is provided with a copy of the commercial to take home for the future. Adolescents may also enjoy making a commercial; if not, they can write a story or a poem, draw a picture, perform a song, or keep a journal to record the progress made for future reference.