Homework Adherence in Exposure-Based CBT for Youth with Obsessive-Compulsive Disorder: Clinical Outcomes and Predictors Across Treatment

Exposure-based cognitive behavioral therapy (CBT) is the frontline treatment for pediatric obsessive-compulsive disorder (OCD), but not all youth fully respond to this treatment. While multiple factors may influence CBT response, homework adherence in CBT is a modifiable target that can improve treatment outcomes. This report examines the relationship between homework adherence and clinical outcomes in a large sample of youth with OCD who received exposure-based CBT. Here, 137 youth with OCD between 7 and 17 years old ( M = 12.42, SD = 2.88) participated in a randomized controlled trial of exposure-based CBT. Homework adherence was monitored weekly, and OCD severity was assessed by independent evaluators masked to treatment condition using gold-standard rating scales. Mixed-effects linear and logistic regression models examined the relationship between homework adherence, reductions in OCD severity, treatment response, and clinical remission at post-treatment. Follow-up investigations explored differences in patterns between early- and late- homework adherence. Finally, baseline clinical predictors of homework adherence were explored. There was a significant predictive relationship between greater homework adherence and reduced OCD severity, greater incidence of treatment response, and greater incidence of clinical remission at post-treatment. Greater homework adherence later in treatment—as opposed to earlier in treatment—was most impactful in predicting positive clinical outcomes in exposure-based CBT. Presence of co-occurring ADHD was a significant predictor of decreased homework adherence. Taken together, findings provide insight into a modifiable therapeutic target that can improve treatment outcomes in exposure-based CBT. • This study examines homework adherence in exposure-based CBT for youth with OCD. • Greater homework adherence predicted increases in clinically meaningful outcomes. • Youth with ADHD evidenced significantly less homework adherence. • Results highlight targets to optimize treatment outcomes in exposure-based CBT.