The information in this program outline is provided by the program representative and edited by the CEBC staff. The Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) program has been rated by the CEBC in the area of: Trauma Treatment (Child & Adolescent).

• Types of Maltreatment: Physical Abuse, Emotional Abuse
• Target Population: Caregivers who are aggressive and physically, emotionally, or verbally abuse their children and their children who experience behavioral dysfunction, especially aggression, as a result of the abuse, as well as high conflict families who are at-risk for physical abuse/aggression.

AF-CBT (originally named Abuse-Focused Cognitive-Behavioral Therapy) is a treatment based on principles derived from learning and behavioral theory, family systems, cognitive therapy, developmental victimology, and the psychology of aggression. It integrates specific techniques to target school-aged abused children, their caregivers, and the larger family system. Through training in specific intrapersonal and interpersonal skills, AF-CBT seeks to promote the expression of appropriate/pro-social behavior and discourage the use of aggressive or hostile behavior.

AF-CBT addresses both the key risks for and clinical consequences of exposure to family aggression, conflict, and coercion. The key risks include coercive parenting practices, anger hyperarousal, negative child attributions, and family conflict. The clinical consequences include child aggression, poor interpersonal skills/functioning, and emotional reactivity. In general, it attempts to address both clinical (well-being) and safety concerns by integrating training in general psychological skills and, if relevant, treatment focusing upon a specific aggressive, abusive, or traumatic experience.

AF-CBT has primarily been used with children and adolescents (ages 5-16). Treatment is not specifically designed for any one ethnic/racial group. It has been used extensively with urban African-American families, but has more recently been applied with Latino, South Asian, and Caribbean-American families. Most of the cases come from urban, inner-city, and low-income families (e.g., Pittsburgh, New York City, Baltimore, Toronto, Seattle, San Francisco, Los Angeles), but there are more recent applications in rural areas across several states (e.g., Michigan, New Hampshire, Oregon). Common sources of referral include child welfare/child protective services caseworkers, mental health agencies, child advocacy centers, family support centers, and self-referral.

The goals of AF-CBT are to:

• Reduce conflict and increase cohesion in family.
• Reduce use of coercion (hostility, anger, verbal aggression, threats) by caregiver and, as relevant, other family members.
• Reduce use of physical force (aggressive behavior) by caregiver and, as relevant, other family members.
• Reduce child physical abuse risk or recidivism (prevention of child welfare system involvement or repeated reports/allegations).
• Improve level of child’s safety/welfare and, as relevant, family functioning.

• Educate individuals/family about relevance of the Cognitive Behavioral Therapy (CBT) model and physical abuse.
• Establish agreement with family to refrain from using physical force and to discuss any incidents involving the use of force within the family.
• Review the child's exposure to emotional abuse in the family and provide education about the parameters of abusive experiences (causes, characteristics, and consequences) in order to help child and caregiver better understand the context in which they occurred.
• Identify and address cognitive contributors to abusive behavior in caregivers (i.e., misattributions, high expectations, etc.) and/or their consequences in children (i.e., views supportive of aggression, self-blame, etc.) that could maintain any physically abusive or aggressive behavior.
• Teach affect management skills.
• Teach parents behavioral strategies to reinforce and punish behavior as alternatives to physical discipline.
• Teach pro-social communication and problem-solving skills to the family and help them to establish them as everyday routines.

AF-CBT is delivered across three treatment phases, as listed below. In general, the content of first and second phases is administered in individual sessions to caregivers and children/adolescents, whereas the content of the third phase is administered in joint caregiver-child sessions. However, caregivers may be seen occasionally for a brief “check-in” after a child session.

Phase 1: Engagement and Psychoeducation

• Orientation to Treatment
• Parental Engagement and Safety Planning
• Psychoeducation about and Monitoring of Force/Discipline
• Child Discussion/Disclosure of Positive/Negative Experiences
• Consideration of Clarification/Preparation

Phase 2: Individual Skill-Building (Skills Training)

• Cognitive Processing and Coping
• Emotion Regulation: Controlling Your Anger and Anxiety
• Assertion/Social Skills/ Support Plans
• Behavior Management -- Promoting Positive Behavior and Managing Misbehavior (Discipline)

Phase 3: Family Applications and Routines

• Clarification Process
• Communication Skills
• Problem-Solving Skills
• Developing Family Routines

This is a suggested sequence for conducting the treatment, which generally proceeds from teaching intrapersonal (e.g., cognitive, affective) skills first, followed by interpersonal skills (e.g., behavioral). Of course, topics/sessions can be flexibly delivered (adapted, abbreviated, or repeated) based on the family’s progress and/or treatment needs/goals in each phase. Although AF-CBT has primarily been used in outpatient and home settings, the treatment has been more recently delivered in inpatient and residential settings when there is some ongoing or potential contact between the caregiver and the child.

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) was designed with a child component that addresses the following presenting problems and symptoms:

• Emotional and cognitive effects of abuse or exposure to aggression/conflict (e.g., anger/anxiety, misattributions), aggression/behavioral dysfunction, and poor social/interpersonal skills.

Age range: 6 – 15

Developmental Delays:

This program was not developed for children with developmental delays, and has not been tested for children with developmental delays.

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) was designed with a parent/caregiver component that addresses the following presenting problems and symptoms:

• Limited motivation for or ambivalence about treatment, heightened family stress, anger/anxiety management, attributional biases, limited effectiveness of child management and challenging child behaviors, and inadequate parent-child communication and problem-solving skills.

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) was not designed to be conducted in a group setting, and has not been tested for use in a group setting.

Recommended Intensity:

One or two 60-minute long sessions per week. Sessions can be longer as needed.

Recommended Duration:

The typical outpatient course of treatment lasts for 12 to 18 hours of direct service (or longer), generally spanning 3-6 months.

This program is typically conducted in a(n):

• Adoptive Home
• Birth Family Home
• Hospital
• Outpatient Clinic
• Residential Care Facility

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) includes a homework component:

Children and caregivers are requested to complete tailored home practice assignments designed to facilitate skills acquisition and to provide feedback regarding the utility of specific treatment methods.

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) does not have materials available in a language other than English.

The typical resources for implementing the program are:

A confidential space, trained practitioner, documents for assessment, treatment, and progress records, and optional audio or video-taping equipment to facilitate case supervision.

Mental health practitioners with:

• General training in behavioral or cognitive-behavioral techniques.
• An understanding of the clinical characteristics and treatment course of child physical abuse.
• Formal didactic training in the program model/methods.
• 1-2 completed pilot treatment cases for which ongoing consultation/feedback was obtained.

It is strongly recommended that practitioners interested in this approach have at least a Master's degree in a field relevant to psychology/counseling, however it is recognized that some practitioners with a BA degree and considerable clinical experience have successfully applied this model in various settings.

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:

• David J. Kolko, PhD
  kolkodj@upmc.edu
  phone: (412) 246-5888

Training is obtained:

AF-CBT’s Learning Collaborative approach to training can be provided on a flexible basis (i.e., in a local or individual agency or in context of a regional program or training institute.)

Number of days/hours:

Trainings are tailored to the needs/backgrounds of the practitioner or program, but often include the following components:

• Initial didactic workshop training (3 days).
• Follow-up case consultation calls during “action plan” periods (6-12 months).
• Review of session performance samples for integrity/competency.
• Booster re-training and advanced case review (1 day).
• Review of community metrics and progress report.

This program is rated a "3 - Promising Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one study utilizing some form of control (e.g., untreated group, placebo group, matched wait list study) establishing the practice's benefit over the placebo, or found it to be comparable to or better than an appropriate comparison practice. Please see the Scientific Rating Scale for more information.

Child Welfare Outcomes: Safety and Child/Family Well-Being