Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT)
About This Program
Target Population: Caregivers who are emotionally or physically aggressive or abusive with their children, children who experience behavioral dysfunction, especially aggression, or trauma-related symptoms secondary to their as exposure to physical discipline/abuse, and high conflict families who are at-risk for these problems.
For children/adolescents ages: 5 – 17
For parents/caregivers of children ages: 5 – 17
Alternatives for Families: A Cognitive-Behavioral Therapy (originally named Abuse-Focused Cognitive-Behavioral Therapy) is designed for families who are referred for problems related to the management of anger and/or aggression, which include several behaviors on a continuum reflecting the use of coercion and/or physical force. Specifically, AF-CBT seeks to improve the relationships between children and their parents/caregivers who experience any of the following clinical concerns:
- Anger and verbal aggression, including emotional abuse
- Ongoing family conflict
- Child behavior problems, including physical aggression
- Threats or use of harsh/punitive/ineffective physical discipline or punishment
- Child physical abuse
Any and all of these patterns may be demonstrated by an individual caregiver or a child/adolescent, but they also may characterize the interactions of the family. Accordingly, AF-CBT targets individual caregiver and child characteristics, as well as the larger family context.
AF-CBT is a treatment based on principles derived from learning and behavioral theory, family systems, cognitive therapy, developmental victimology, and the psychology of aggression.
The goals of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) are to:
- Improve caregiver-child relationships.
- Strengthen healthy parenting practices.
- Enhance children’s coping and social skills.
- Maintain family safety.
- Reduce coercive processes (anger, verbal aggression, threats of force, emotional abuse) by caregivers and other family members.
- Reduce use of physical force (aggressive behavior) by caregivers, child and, if relevant, other family members.
- Reduce child physical abuse risk or recidivism (prevention of child welfare system involvement or repeated reports/allegations).
- Improve child safety/welfare and family functioning.
The essential components of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) include:
- Eligibility Criteria - The following general criteria have been developed to facilitate the identification of individuals or families who may benefit from this intervention:
- Fully Required Characteristics (all of the following must be valid to benefit from AF-CBT):
- Child age 5-17
- A caregiver (biological, foster, or kinship) who will participate in services
- Child and caregiver appear appropriate for AF-CBT (i.e., can participate adequately, could benefit, may eventually be together/reunified)
- Partially Required Characteristics (one of the following must be valid to benefit from AF-CBT):
- A caregiver has an allegation or report of suspected physical abuse.
- A caregiver has done something that resulted or could have resulted in injury/harm to child.
- A caregiver has likely used excessive or harsh physical discipline with the child.
- A caregiver and the child/family have conflicts and/or heated arguments, which may include caregiver verbal aggression/abuse.
- The child has a pattern of oppositional, argumentative, and/or explosive/angry behaviors.
- The child has been verbally or physically aggressive, or exhibited other high-risk behaviors.
- The child has trauma symptoms related to a history of physical discipline or abuse.
- Recommended Assessments for Use in AF-CBT:
- The program begins with a multi-informant assessment to identify the nature of the child’s, caregiver’s, and family’s problems. Specifically of interest are those that may be contributing to family conflict or aggression, and the strengths of the individual child, caregiver, and the family that may influence change. 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. Tailoring the treatment to the family’s specific strengths and challenges is important in order to ensure that treatment is relevant, focused, and likely to key to achieve sustained outcomes.
- Four relevant and brief assessment instruments are currently suggested for use in AF-CBT, each of which examines a few of the key clinical problems targeted by this intervention. These tools include: 1) the Alabama Parenting Questionnaire (APQ), 2) the Brief Child Abuse Potential Inventory (B-CAP), which is based on the Child Abuse Potential Inventory, 3) the Child PTSD Symptom Scale (CPSS), and 4) the Strengths and Difficulties Questionnaire (SDQ). These measures can be completed independently or on via interview. Background information, scoring and interpretation guidelines for each instrument, a copy of the item content of each instrument in both English and Spanish, and information on how to obtain the tools is provided to practitioners who receive a formal training in AF-CBT.
- Many families referred for AF-CBT also may present with problems or concerns in other areas which are relevant to clinical case conceptualization and which, to varying degrees, have been addressed in this treatment (e.g., limited readiness/willingness to change, child maladaptive attributions, such as self-blame; child social skills problems, caregiver’s inappropriate developmental expectations and views of child’s intentions). Further, other measures may be needed to assess changes in competencies or skills learned in each phase of AF-CBT.
- AF-CBT Treatment Overview: AF-CBT 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.
- Consistent with cognitive-behavioral therapy (CBT) approaches, AF-CBT includes procedures that target three related ways in which people respond to different circumstances: cognition (thinking), affect (feelings and physiological reactivity), and behavior (doing). AF-CBT includes training in various psychological skills in each of these response channels that is designed to promote self-control and to enhance interpersonal effectiveness.
- AF-CBT adopts a comprehensive treatment strategy that incorporates psychoeducation about force and trauma, affect regulation, positive parenting and behavior management, cognitive restructuring, social skills and assertion training, problem solving, communication skills, and clarification. All of these techniques, relevant handouts, training examples, and outcome measures are integrated in a structured approach that practitioners and supervisors can easily access and use. In general, AF-CBT attempts to address both clinical (well-being) and safety concerns by integrating training in general psychological skills and relevant treatment procedures to address a specific aggressive, abusive, or traumatic experience.
- AF-CBT has primarily been used with children and adolescents (ages 5-17). The treatment has been delivered to families representing diverse racial and ethnic groups. The program has been used frequently with underserved, multi-problem, and low-resource families in a broad range of urban, suburban, and rural settings. Common sources of referral include child welfare, child protective services caseworkers, mental health agencies, child advocacy centers, family support centers, juvenile justice programs, and self-referral.
- AF-CBT Treatment Tasks
- Educate individuals/family about relevance of the CBT model and impact of exposure to verbal and physical coercion in family.
- Promote family commitment to using less verbal coercion and/or physical force, and to discuss any incidents involving conflict, hostility, and the use of force that increase a family’s risk of threats to personal safety or welfare.
- 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 (e.g., misattributions, high expectations) and/or their consequences in children (e.g., views supportive of aggression, self-blame) that could maintain any physically abusive or aggressive behavior.
- Teach affect (anger, anxiety) 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.
- With the child, process thoughts and feelings related to the abuse and other forms of trauma.
- As relevant, promote a clarification session to overcome the emotional and physical complications that often ensure following an incident of explosive anger, aggression, or abuse.
- AF-CBT Treatment Phases: 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. Caregivers may be seen occasionally for a brief “check-in” after a child session. The suggested sequence for conducting the treatment proceeds from teaching intrapersonal skills first (e.g., cognitive, affective), followed by interpersonal skills (e.g., behavioral, social). Of course, the topics/sessions can be flexibly delivered (adapted, abbreviated, or repeated) based on the family’s progress and treatment goals. The primary content in each topic noted below is organized into three phases.
- PHASE I: Engagement and Psychoeducation
- Topic 1: Orientation–Caregiver and Child
- Topic 2: Alliance Building and Engagement–Caregiver
- Topic 3: Learning about Feelings and Family Experiences–Child
- Topic 4: Talking about Family Experiences and Psychoeducation–Caregiver
- PHASE II: Individual Skill-Building (Skills Training)
- Topic 5: Emotion Regulation–Caregiver
- Topic 6: Emotion Regulation–Child
- Topic 7: Restructuring Thoughts–Caregiver
- Topic 8: Restructuring Thoughts–Child
- Topic 9: Noticing Positive Behavior–Caregiver
- Topic 10: Assertiveness and Social Skills–Child
- Topic 11: Techniques for Managing Behavior–Caregiver
- Optional Topic 12: Imaginal Exposure–Child
- Topic 13: Preparation for Clarification–Caregiver
- PHASE III: Family Applications
- Topic 14: Verbalizing Healthy Communication–Caregiver and Child
- Topic 15: Enhancing Safety through Clarification–Caregiver and Child
- Topic 16: Solving Family Problems–Caregiver and Child
- Topic 17: Graduation–Caregiver and Child
- Fundamental Skills included in AF-CBT: The program has incorporated strategies to address several common clinical or therapeutic issues that may arise during intervention and often require some type of planned professional response. The practitioner is offered some guidelines at the beginning of the AF-CBT Session Guide to address the following:
- Assessment and Functional Analysis
- “CA$H”: Check-in on Attendance, Safety, and Home Practice
- Alternatives for Families Plan (AFP)
- Safety Planning and Other Potential Crises
- Addressing Inconsistent Attendance
- Managing Escalation in Session
- Enhancing Motivation
Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) directly provides services to children/adolescents and addresses the following:
- Exposure to family conflict/aggression or a specific abusive experience, emotional and cognitive effects of such exposure (e.g., anger/anxiety, misattributions, trauma-related symptoms), aggression/behavioral dysfunction, poor social/interpersonal skills, poor communication and problem solving, and need for safety planning
Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) directly provides services to parents/caregivers and addresses the following:
- Limited motivation for or ambivalence about treatment, heightened personal stress and exposure to adverse family experiences, poor anger/anxiety management, attributional biases, limited effectiveness of child management and challenging child behavior, poor communication and problem solving, and need for clarification meeting to address a prior incident of abuse or conflict
One- or two-hour-long sessions per week; sessions can be longer as needed, especially when the required treatment duration is limited to a few months due to fiscal or programmatic regulations. Longer sessions can be conducted to address multiple family problems/crises.
There is no typical outpatient course of treatment, given the variability seen across referred families in problem severity, caregiver functioning, family resources, and treatment compliance/progress. Cases can be expected to receive between 20 and 30 hours of direct service (or longer), generally spanning 6-12 months.
This program is typically conducted in a(n):
- Adoptive Home
- Birth Family Home
- Foster / Kinship Care
- Outpatient Clinic
- Group or Residential Care
- School Setting (Including: Day Care, Day Treatment Programs, etc.)
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) has materials available in languages other than English:
Japanese, Korean, Spanish
For information on which materials are available in these languages, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).
Resources Needed to Run Program
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.
Education and Training
Prerequisite/Minimum Provider Qualifications
Mental health practitioners with:
- Master’s degree or higher in mental health field (e.g., clinical/counseling psychology, social work, or related field of counseling)
- Clinician has professional license to practice, is license eligible, or works under/with licensed supervisor.
Education and Training Resources
There is a manual that describes how to implement this program , and there is training available for this program.
- David J. Kolko, PhD
phone: (412) 246-5888
- Elissa J. Brown, PhD
phone: (718) 990-2355
Training is obtained:
AF-CBT training generally follows a Learning Community model that involves the delivery of a sequence of planned activities across interrelated phases to a specific cohort of practitioners. Lasting a year, the full training program can be conducted with the staff of a local or individual agency, or with practitioners from multiple agencies who join a regional or national training program or training institute. Whenever possible, preparation and training activities tailored to different roles or levels within a given agency or program (e.g., administrators, supervisors, clinicians) are conducted. A new online pre-training program has been developed to provide an initial overview of AF-CBT. A training request form can be submitted online through their website, www.afcbt.org.
Number of days/hours:
Trainings are tailored to the needs/backgrounds of the practitioner or program, but often include the following components:
- Agency readiness calls and launch activities to prepare organization & leadership team (administrators, supervisors, clinicians)
- Stakeholder engagement (public relations information/marketing)
- Staff completion of online pre-training evaluation
- Staff preview of AF-CBT materials (session guide, handouts, screening/assessment tools); with optional collection of agency metrics
- Development of training materials (slides) and exercises tailored to agency/population
- Basic Training workshop/experiential seminar (“learning session”) on use of AF-CBT (2.5 days)
- Advanced Training (“booster”) workshop - 6 months later (1/2 or full day; live or via videoconference)
- Case consultation calls with trainer (1-2 per month for 6-12 months; 2 presentations/call)
- Fidelity monitoring feedback based on trainer reviews of digital audio files uploaded by each trainee to our secure website (2 files/trainee).
- Supervisor consultation and support calls (4-12/year)
- Online access to the trainer for Q&A and to receive new/updated materials
- Clinician certification review feedback and technical assistance
- Staff completion of online post-training evaluation and agency metrics (follow-up)
- Program summary report to agency with feedback/recommendations and next steps
Practice Readiness and Preparation Phase (2-4 months prior to training)
Intensive Skills-Training Program (1 year)
Performance Review and Summary
There are pre-implementation materials to measure organizational or provider readiness for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:
The pre-implementation materials include:
- A pre-training launch agenda for calls with administrators and supervisors/clinicians
- A collaborative change framework document that outlines key AF-CBT competences in 3 domains: clinician, family engagement, and organizational capacity/support
- An overview of the Learning Community training model
- Relevant empirical papers and chapters on the application of AF-CBT to cases referred for child abuse/family conflict and child behavior problems
- Agency/staff training requirements
- A family screening and eligibility form
- Online family assessment measures and procedures
- PowerPoint files with readiness and orientation information
- Various flyers and brochures to orient stakeholders and families to AF-CBT
- Other program support, implementation, and monitoring materials
Please see www.afcbt.org for more information.
Formal Support for Implementation
There is formal support available for implementation of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:
A year-long Learning Community training model is used and includes ongoing consultation and technical assistance by an approved trainer, treatment material updates, e-mail support for Q&A, formal supervisor consultation calls, and access to a provider portal on the program’s website. The trainer also will review any audio session files and provide ongoing feedback both during consultation calls and through written summaries to the clinician. There is also a set of AF-CBT clinician certification requirements.
In addition, many resources and materials are made available to those agencies or individuals currently participating in a training or who have completed a training through a secure portal in the AF-CBT website. This “members only” portal on the home page provides access to all of their treatment and support materials, including AF-CBT practice checklists, an automated family assessment scoring program, and audio upload instructions.
There are fidelity measures for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:
There are several practice checklists, metrics checklists, agency supervision guidelines, and other procedures or guidelines for trainers who collect fidelity information. Most of these measures are available for members only (trainees or trainers) at www.afcbt.org.
Implementation Guides or Manuals
There are implementation guides or manuals for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:
The AF-CBT session guide includes implementation guidelines. There also is an implementation guide for working with foster caregivers, a summary of guidelines for the administration and scoring of the assessment measures, and a set of audio file uploads and sharing guidelines. Most of these are available through the “members only” portal at www.afcbt.org.
Research on How to Implement the Program
Research has been conducted on how to implement Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:
Kolko, D. J., Baumann, B. L.., Herschell, A. D., Hart, J., Holden, E. & Wisniewski, S. (2012).Implementation of AF-CBT by community practitioners serving child welfare and mental health: A randomized trial. Child Maltreatment, 17(1), 30-44. doi 10.1177/1077559511427346
Relevant Published, Peer-Reviewed Research
Kolko, D. J. (1996a). Individual cognitive behavioral treatment and family therapy for physically abused children and their offending parents: A comparison of clinical outcomes. Child Maltreatment, 1(4), 322-342.
Type of Study:
Randomized controlled trial
Number of Participants: 47
- Age — Child in family: Mean age = 8.6 years
- Race/Ethnicity — 47% African American, 47% Caucasian, and 6% biracial
- Gender — Not Specified
- Status — Participants were families referred by Child Protective Services or other agency for physical abuse.
Location/Institution: Pittsburgh, Pennsylvania
(To include comparison groups, outcomes, measures, notable limitations)
Families were randomly assigned to the Cognitive Behavioral Therapy (CBT; before intervention was named Alternatives for Families: A Cognitive Behavioral Therapy) or Family Therapy (FT) conditions. There was also a non-random group of families who requested and then received routine community services (RCS) through a local provider of their selection. Parents and children completed the Conflict Tactics Scale (CTS) and the Weekly Report of Abuse Indicators (WRAI) to evaluate high risk parental behaviors, and parents completed the Child Abuse Potential Inventory. Symptoms and problems relating to abuse were assessed using a subset of items from the Sexual Abuse Fear Evaluation (SAFE), the Children’s Attributions and Perceptions Scale (CAPS), the Youth Self-Report (YSR), the Children’s Depression Inventory (CDI), and Children’s Hostility Inventory. Research associates completed the Global Assessment Scale (GAS) for children. Parental dysfunction, adjustment, and attitudes were assessed with the Brief Symptom Inventory (BSI), the Beck Depression Inventory (BDI), a subset of the Child Rearing Interview (CRI), Parenting Scale (PS), and Parent Opinion Questionnaire (POQ). Finally, children and parents completed the Family Environment Scale (FES) and the Family Assessment Device (FAD) to assess family functioning. Assessments were taken pre and post treatment and at 3-month and 1-year follow-ups. The three treatment conditions were comparable on all child and parent demographic and outcome variables collected at baseline. Compared to RCS, the CBT and Family Therapy conditions showed significantly greater improvements in parent-to-child violence, parental distress and abuse risk, child externalizing problems, and family conflict and cohesion. The CBT and Family Therapy conditions had a lower rate of recurrence of abuse (5% and 6%) than RCS (30% one year after the completion of treatment, but the difference was not statistically significant. All three groups showed other improvements over time.
Length of postintervention follow-up: 1 year.
Kolko, D. J. (1996b). Clinical monitoring of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse and Neglect, 20(1), 23-43.
Type of Study:
Randomized controlled trial
Number of Participants: 38 children and their families
- Age — Child in family: Mean Age = 8.6 years
- Race/Ethnicity — 50% Caucasian, 42% African American, and 8% biracial
- Gender — 72% males and 28% females
- Status — Participants were referred by Child Protective Services, caseworker, other agency or self-referred.
(To include comparison groups, outcomes, measures, notable limitations)
Note: The participants in this study are a subsample from the group used in Kolko, 1996a. Families were randomly assigned to receive either Cognitive Behavioral treatment (CBT; before it was named Alternatives for Families: A Cognitive Behavioral Therapy) or Family Therapy (FT). At pre-treatment assessment children and parents completed the Conflict Tactics Scale (CTS) and the Family Environment Scale (FES). Parents completed the Child Abuse Potential Inventory (CAP), the Parenting Scale (PS), and the Beck Depression Inventory (BDI). In this report, the main outcome variables were based on child and parent reports of potential physical abuse indicators, including ratings of anger, physical discipline, and injuries, at the beginning of each treatment session. Researchers found a moderate to high degree of correspondence between child and parent reports. Levels of parental anger and physical discipline improved from early to late treatment, with CBT parents showing significantly greater improvement. Limitations include small sample size and the use of self-report measures.
Length of postintervention follow-up: None.
Kolko, D. J., Iselin, A. M., & Gully, K. (2011). Evaluation of the Sustainability and Clinical Outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a Child Protection Center. Child Abuse & Neglect, 35(2), 105-116.
Type of Study:
One group pre-post test
Number of Participants: 52 families
- Age — Families with children 3 to 17 years. Mean age of child in family = 9.1 years
- Race/Ethnicity — 88.6% Caucasian, 3.8% Asian, 3.8% multiracial, 1.9% African-American, and 1.9% Native American
- Gender — 51.9% male and 48.1% female
- Status — Families receiving therapeutic services from seven therapists in a child protection program located in the Western United States.
Location/Institution: Salt Lake City, Utah
(To include comparison groups, outcomes, measures, notable limitations)
Seven practitioners participated in a year-long Learning Collaborative in AF-CBT in 2002 and in similar training programs for four other EBTs (TF-CBT, PCIT, CCP, CBITS) at around the same time. The agency’s routine data collection system that included all treated families was used to document the clinical and adjustment outcomes of 52 families presenting with a physically abused child who received their services between two and five years after the AF-CBT training had ended. Measures included the Child Behavior Checklist for Ages 6-18, Trauma Symptom Checklist for Children, and Child Sexual Behavior Inventory, as well as measures of the use of all five EBTs which documented their frequency, internal consistency, and intercorrelations. Controlling for the unique content of the other four EBTs, the amount of AF-CBT Abuse-specific content delivered was significantly related to improvements on standardized parent rating scales (i.e., child externalizing behavior, anger, anxiety, social competence) and both parent and clinician ratings of the child’s adjustment at discharge (i.e., child more safe, less scared/sad, more appropriate and respectful of privacy with peers). The amount of AF-CBT General content was related to a few discharge ratings (e.g., better child prognosis, helpfulness to parents).
Length of postintervention follow-up: None.
Kolko, D. J., Baumann, B. L.., Herschell, A. D., Hart, J., Holden, E. & Wisniewski, S. (2012). Implementation of AF-CBT by community practitioners serving child welfare and mental health: A randomized trial. Child Maltreatment, 17(1), 30-44. doi 10.1177/1077559511427346
Kolko, D. J., Iselin, A. M., & Gully, K. (2011). Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center. Child Abuse & Neglect, 35(2), 105-116.
Kolko, D. J., Simonich, H., & Loiterstein, A. (2014). Alternatives for Families: A Cognitive Behavioral Therapy. An overview and a case example. In A. Urquiza & S. Timmer (Eds.), Evidence-based approaches for the treatment of maltreated children (pp. 187-212). New York:Springer.
- David J. Kolko, PhD, ABPP
- Agency/Affiliation: University of Pittsburgh, School of Medicine
- Department: Department of Psychiatry
- Website: www.afcbt.org
- Email: firstname.lastname@example.org
- Phone: (412) 246-5888
- Fax: (412) 246-5341
Date Research Evidence Last Reviewed by CEBC: November 2017
Date Program Content Last Reviewed by Program Staff: October 2017
Date Program Originally Loaded onto CEBC: May 2006