Program Goals

The goals of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) are to:

• Strengthen parent-child and family relationships
• Increase use of positive parenting and appropriate discipline practices
• Enhance adaptive behaviors/competencies and well-being
• Increase ability to manage or cope with distressing emotions and be flexible in thinking
• Support ways to help maintain safety in home
• Reduce hostile behaviors that result in conflictual or coercive interactions (e.g., anger, verbal aggression, threats of force, emotional abuse)
• Reduce the use of physical force (i.e., aggressive behavior)
• Lower physical abuse risk or recidivism (i.e., prevent child welfare system involvement or repeated reports/allegations).
• Reduce severity of child posttraumatic stress symptoms

Logic Model

View the Logic Model for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT).

Essential Components

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):
• At least one child aged 5-17 years
• A caregiver (biological, foster, adoptive, or kinship) who will participate in services
• Caregiver and child have adequate capacity/repertoire to learn/benefit from AF-CBT
• One of the following must be valid to benefit from AF-CBT:
• A family who has conflicts and/or heated arguments
• A caregiver who has a history of anger/hostility, uses physical force/discipline/coercion, or an allegation/history of child physical abuse
• A child (age 5-17 years) has a history of anger, behavior problems (e.g., defiance, aggression, explosiveness), trauma symptoms/posttraumatic stress disorder (PTSD) after physical discipline/abuse, or prior exposure to harsh discipline/physical abuse
• Recommended Assessments for Use in AF-CBT:
• Four brief assessment instruments are currently suggested for use in AF-CBT, each of which examines a few key clinical targets. These tools include:
• The Alabama Parenting Questionnaire – Short Form (APQ-SF)
• The Brief Child Abuse Potential Inventory (B-CAP)
• The Child PTSD Symptom Scale (CPSS)
• The Strengths and Difficulties Questionnaire (SDQ)
• These measures can be completed independently (hard copy, electronically/online) or 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.
• Information on how to obtain the tools is provided to practitioners who receive a formal training in AF-CBT and can be accessed via the website.
• AF-CBT Treatment Overview:
• AF-CBT integrates specific techniques to target school-aged abused children, their caregivers, and the family system. Through training in specific intrapersonal and interpersonal skills, AF-CBT seeks to promote self-control/interpersonal effectiveness and discourage the use of coercive or aggressive behavior.
• Consistent with cognitive-behavioral therapy (CBT) approaches, AF-CBT includes techniques that target three related domains 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.
• The descriptions of these techniques, relevant handouts, training examples, and outcome measures are integrated in a structured approach (comprehensive session guide) that practitioners and supervisors can easily access and use.
• AF-CBT is designed to be primarily used with children and adolescents (ages 5-17) and their caregivers. The treatment can be delivered to families representing diverse racial and ethnic groups. The program also can be used frequently with underserved, multiproblem, and low-resource families in a broad range of urban, suburban, and rural settings in the U.S. and other countries.
• 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.
• 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/Agenda-setting, Safety, and Home Practice
• Alternatives for Families Plan (AFP)
• Safety planning and other potential crises
• Addressing inconsistent attendance
• Managing escalation in session
• Enhancing motivation
• AF-CBT Treatment Tasks:
• Discuss any incidents involving conflict, hostility, and the use of force that increase a family's risk of threats to personal safety or welfare.
• Educate individuals/family about relevance of the CBT model and impact of exposure to verbal and physical coercion 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 to enhance self-control and reduce escalation/outbursts.
• Train parents to use behavioral strategies to reinforce and punish behavior as alternatives to physical discipline.
• With the child, process thoughts and feelings related to the abuse experience.
• As relevant, help the caregiver and child to overcome the emotional and cognitive complications that often ensue following an incident of explosive anger, aggression, or abuse.
• Identify and practice healthy communication and effective problem-solving skills to help the family establish them as everyday routines.
• 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., affective, cognitive), 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 needs. The primary content in each topic is organized into three phases and is reflected in the acronym, A-L-T-E-R-N-A-T-I-V-E-S.
• 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

Program Delivery

Child/Adolescent Services

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

Parent/Caregiver Services

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

Recommended Intensity:

One- or two-hour-long sessions per week; sessions can be longer or additional sessions can be scheduled per week, 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.

Recommended Duration:

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 24 hours of direct service (or longer), generally spanning 6-9 months.

Delivery Settings

This program is typically conducted in a(n):

• Adoptive Home
• Birth Family Home
• Foster / Kinship Care
• Hospital
• Outpatient Clinic
• Group or Residential Care
• School Setting (Including: Day Care, Day Treatment Programs, etc.)

Homework

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.

Languages

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) has materials available in languages other than English:

Hebrew, 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, assessment, treatment, and documentation materials, and optional digital audio or video-taping equipment to facilitate case supervision

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Mental health practitioners with:

• Master's degree or higher
• Clinician has professional license to practice, is license eligible, or works under/with licensed supervisor.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual Information:

• Kolko, D. J., Brown, E. J., Shaver, M. E., Baumann, B. L., & Herschell, A. D. (2011). Alternatives for Families: A Cognitive-Behavioral Therapy: Session guide. (3rd ed.). University of Pittsburgh School of Medicine.

This session guide is only available to those enrolled in a training group.

Training Information

There is training available for this program.

Training Contacts:

• David J. Kolko, PhD
  kolkodj@upmc.edu
  phone: (412) 246-5888
• Elissa J. Brown, PhD
  browne@stjohns.edu
  phone: (718) 990-2355

Training Type/Location:

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. An online pretraining overview of AF-CBT (4, 1-hour videos with option for CEUs) provides 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:

• Practice Readiness and Preparation Phase (2 months prior to training):
• Agency readiness calls and launch activities to prepare organization & leadership team (administrators, supervisors, clinicians)
• Stakeholder engagement (public relations information/marketing)
• Staff completion of online pretraining evaluation
• Staff review of online AF-CBT Orientation video
• 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
• Intensive Skills-Training Program (1 year):
• Basic Training workshop ("learning session") on use of AF-CBT (2 days in person or four, 4-hour remote/virtual sessions)
• Advanced Training workshop ("booster") - 6 months later (1/2 day; in person or via videoconference)
• Case consultation calls with trainer (usually, 1/month for 12 months with 2 presentations/call; could be more frequent in less time)
• 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 (4-6/year)
• Online access to the trainer for Q&A and to receive new/updated materials (screening, assessment, treatment, and monitoring materials/forms)
• Performance Review and Summary (follow-up):
• Review of clinician performance/status 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

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:

Applicants complete a comprehensive training request form (http://www.afcbt.org/training/sign-up-for-training). Trainers conduct a brief follow-up interview with each agency or trainee to review their readiness for AF-CBT and fit of the intervention for their setting.

Formal Support for Implementation

There is formal support available for implementation of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:

Ongoing support is provided throughout the implementation phase. This includes consult calls, supervisor calls, fidelity monitoring with clinician feedback, booster training, and performance evaluations.

Fidelity Measures

There are fidelity measures for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:

During training, all digital audio samples are rated for fidelity on a topic specific fidelity form and feedback is provided to the clinician. Feedback on treatment delivery is also provided during monthly consultation calls. Clinicians are not required to use the fidelity forms once training is complete, but they can if desired.

Implementation Guides or Manuals

There are implementation guides or manuals for Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as listed below:

There is an implementation guide in English, Spanish, Japanese, and Korean. In addition, there is a supplement for substance abuse and foster care applications. All are available on the program’s website for enrolled or prior trainees. An assessment/evaluation manual for administering all of our assessments is also available.

Implementation Cost

There are no studies of the costs of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT).

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. https://doi.org/10.1177/1077559511427346

Kolko, D. J., Herschell, A. D., Baumann, B. L., Hart, J. A., & Wisniewski, S. R. (2018). AF-CBT for families experiencing physical aggression or abuse served by the mental health or child welfare system: An effectiveness trial. Child Maltreatment, 23(4), 319–333. https://doi.org/10.1177/1077559518781068

Relevant Published, Peer-Reviewed Research

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

Additional References