Alternatives For Families: A Cognitive Behavioral Therapy .
ISSUE BRIEFS JANUARY 2013Alternatives for Families:A Cognitive-BehavioralTherapy (AF-CBT)Families that experience conflict, coercion,and/or physical abuse create substantialrisk to children for the development ofsignificant psychiatric, behavioral, andadjustment difficulties, including aggression,poor interpersonal skills/functioning, andemotional reactivity. Caregivers in suchfamilies often report punitive or excessiveparenting practices, frequent anger andhyperarousal, and negative child attributions,among other stressful conditions. During thepast four decades, research has documentedthe effectiveness of several behavioral andcognitive-behavioral methods, many of whichhave been incorporated in alternatives forfamilies: a cognitive-behavioral therapy (AFCBT).WHAT'S INSIDEWhat makes AF-CBT uniqueTreatment phases and key componentsTarget populationEffectiveness of AF-CBTWhat to look for in a therapistConclusionResources for more informationChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov1
AF-CBT is an evidence-supportedintervention that targets (1) diverse individualchild and caregiver characteristics relatedto conflict and intimidation in the home and(2) the family context in which aggression orabuse may occur. This approach emphasizestraining in intra- and interpersonal skillsdesigned to enhance self-control and reduceviolent behavior. AF-CBT has been foundto improve functioning in school-agedchildren, their parents (caregivers), and theirfamilies following a referral for concernsabout parenting practices, including childphysical abuse (Kolko, 1996a; Kolko, 1996b;Kolko, Iselin, & Gully, 2011), as well as a child'sbehavior problems (Kolko, et al., 2009; Kolko,Hoagwood, & Springgate, 2010; Kolko, Campo,Kilbourne, & Kelleher, 2012).This issue brief is intended to build a betterunderstanding of the characteristics andbenefits of AF-CBT, formerly known as abusefocused cognitive behavioral therapy (Kolko,2004). It was written primarily to help childwelfare caseworkers and other professionalswho work with at-risk families make moreinformed decisions about when to referchildren and their parents and caregiversto AF-CBT programs. This information alsomay help parents, foster parents, and othercaregivers understand what they and theirchildren can gain from AF-CBT and what toexpect during treatment. In addition, thisissue brief may be useful to others with aninterest in implementing or participatingin effective strategies for the treatment offamily conflict, child physical abuse, coerciveparenting,1 and children with externalizingbehavior problems.WHAT MAKES AF-CBT UNIQUEAF-CBT is designed to intervene with familiesreferred for conflict or coercion, verbal orphysical aggression by caregivers (includingthe use of excessive physical force or threats),behavior problems in children/adolescents, orchild physical abuse. The treatment programhas been expanded to accommodate childrenand adolescents with physical abuse ordiscipline-related trauma symptoms, such asposttraumatic stress disorder (PTSD).AF-CBT addresses both the risk factors andthe consequences of physical, emotional,and verbal aggression in a comprehensivemanner. Thus, AF-CBT seeks to addressspecific clinical targets among caregiversthat include heightened anger or hostility,negative perceptions or attributions of theirchildren, and difficulties in the appropriateand effective use of parenting practices,such as ineffective or punitive parentingpractices. Likewise, AF-CBT targets children’sdifficulties with anger or anxiety, traumarelated emotional symptoms, poor socialand relationship skills, behavioral problemsthat include aggression, and dysfunctionalattributions. At the family level, AF-CBTaddresses coercive family interactions byteaching skills to improve positive familyrelations and reduce family conflict.¹ Coercive parenting refers to parenting by domination, intimidation, orhumiliation to force children to behave according to (often unrealistic) normsset by parents.Children’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov2
REFLECTS A COMPREHENSIVE TREATMENTSTRATEGYThe diversity of family circumstancesand individual problems associated withfamily conflict points to the need for acomprehensive treatment strategy thattargets both the contributors to caregivers'behavior and children’s subsequent behavioraland emotional adjustment (Chadwick Center,2004). Treatment approaches that focus onseveral aspects of the problem (for example,a caregiver's parenting skills, a child'sanger, family coercion) may have a greaterlikelihood of reducing re-abuse and more fullyremediating mental health problems (Kolko& Swenson, 2002). Therefore, AF-CBT adoptsa comprehensive treatment strategy thataddresses the complexity of the issues morecompletely.INTEGRATES SEVERAL THERAPEUTICAPPROACHESAF-CBT combines elements drawn from thefollowing: Cognitive therapy, which aims to changebehavior by addressing a person's thoughtsor perceptions, particularly those thinkingpatterns that create distorted views Behavioral and learning theory, whichfocuses on modifying habitual responses(e.g., anger, fear) to identified situations orstimuli Family therapy, which examines patternsof interactions among family members toidentify and alleviate problems, and offersstrategies to help reframe how problemsare viewed Developmental victimology, whichdescribes how the specific effectsof exposure to traumatic or abusiveexperiences may vary for children atdifferent developmental stages and acrossthe life span Psychology of aggression, which describesthe processes by which aggression andcoercion develop and are maintained,which can help to understand one’s historyas both a contributor to and victim ofaggressive behaviorAF-CBT pulls together many techniquescurrently used by practitioners, such asbehavior and anger management, affectregulation, problem-solving, social skillstraining, cognitive restructuring, andcommunication. The advantage of thisprogram is that all of these techniques,relevant handouts, training examples, andoutcome measures are integrated in astructured approach that practitioners andsupervisors can easily access and use.TREATS CHILDREN AND PARENTSSIMULTANEOUSLYDuring AF-CBT, school-aged children (5-15years) and their caregivers participate inseparate but coordinated therapy sessions,often using somewhat parallel treatmentmaterials. In addition, children and parentsattend joint sessions together at various timesthroughout treatment. This approach seeks toaddress individual and parent-child issues inan integrated fashion.Children’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov3
DISCOURAGES AGGRESSIVE OR VIOLENTBEHAVIORTREATMENT PHASES AND KEYCOMPONENTSThe AF-CBT approach is designed to promoteappropriate and prosocial behavior, whilediscouraging coercive, aggressive, or violentbehavior from caregivers as well as children.Consistent with cognitive-behavioralapproaches, AF-CBT includes procedures thattarget three related ways in which peoplerespond to different circumstances:AF-CBT is a short-term treatment typicallyprovided once or twice a week, which mayrequire 18 to 24 hours of service (or longer,based on individual needs) over 4 to 12 months(although treatment may last as long asdetermined necessary). Treatment includesseparate individual sessions with the child andcaregiver/parent and joint sessions with atleast both of them. Where necessary, familyinterventions may be applied before, during,or after the individual services. The treatmentprogram for children, caregivers, and familiesincorporates the use of specific skills, roleplaying exercises, performance feedback, andhome practice exercises. Cognition (thinking) Affect (feeling) Behavior (doing)AF-CBT includes training in variouspsychological skills in each of these responsechannels that are designed to promoteself-control and to enhance interpersonaleffectiveness.Generally, the following are the goals of AFCBT treatmentTAILORS TREATMENT TO MEET SPECIFICNEEDS AND CIRCUMSTANCES Reduce conflict and increase cohesion infamilyAF-CBT begins with a multisource assessmentto identify the nature of the problems thechild is experiencing, specific parental andfamily difficulties that may be contributingto family conflict, and the child's and family'sstrengths that may help influence change.Tailoring the treatment to the family’s specificstrengths and challenges is key to efficientoutcomes (Kolko & Swenson, 2002). Reduce use of coercion (hostility, anger,verbal aggression, threats) by the caregiverand other family members Reduce use of physical force (aggressivebehavior) by the caregiver, child, and, asrelevant, other family members Promote nonaggressive (alternative)discipline and interactions Reduce child physical abuse risk orrecidivism (prevention of child welfaresystem involvement or repeated reports/allegations) Improve the level of child’s safety/welfareand family functioningChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov4
TREATMENT PHASESAF-CBT includes three treatment phases,each with key content that is designedto be relevant for both the caregiver andchild. The sequence for conducting thetreatment generally proceeds from teachingintrapersonal (e.g., cognitive, affective)skills first, followed by interpersonal skills(e.g., behavioral). Topics/sessions can beflexibly delivered (adapted, abbreviated, orrepeated) based on the family's progress and/or treatment needs/goals in each phase.Although AF-CBT has primarily been used inoutpatient and home settings, the treatmenthas been more recently delivered in inpatientand residential settings when there is someongoing or potential contact between thecaregiver and the child. The primary contentin each topic noted below is organized intothree phases reflected in the acronymA-L-T-E-R-N-A-T-I-V-E-S. Topic 9: Noticing Positive Behavior–Caregiver Topic 10: Assertiveness and Social Skills–Child Topic 11: Techniques for ManagingBehavior–Caregiver Optional Topic 12: Imaginal Exposure–Child Topic 13: Preparation for Clarification–CaregiverPHASE III: FAMILY APPLICATIONS Topic 14: Verbalizing HealthyCommunication–Caregiver and Child Topic 15: Enhancing Safety ThroughClarification–Caregiver and Child Topic 16: Solving Family Problems–Caregiver and Child Topic 17: Graduation–Caregiver and ChildKEY COMPONENTSPHASE I: ENGAGEMENT andPSYCHOEDUCATIONAB-CBT includes specific therapy elementsfor children, parents, and families. Topic 1: Orientation–Caregiver and ChildTreatment for School-Aged Children. Theschool-aged child-directed therapy elementsinclude the following: Topic 2: Alliance Building and Engagement–Caregiver Topic 3: Learning About Feelings and FamilyExperiences–Child Promoting engagement and treatmentmotivation by identifying individualized goals Topic 4: Talking About Family Experiencesand Psychoeducation–Caregiver Identifying the child's exposure to andviews of positive experiences and upsettingones (family hostility, coercion, andviolence), including the child’s perceptionsof the circumstances and consequences ofthe physical abuse or other conflictPHASE 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 Educating the child on topics related tochild welfare, safety/protection, serviceparticipation, and common reactions toabuse and family conflictChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov5
Training in techniques to identify, express,and manage emotions appropriately (e.g.,anxiety management, anger control) Processing the child's exposure to incidentsinvolving force or family conflict tounderstand and challenge any dysfunctionalthoughts/views that encourage the use ofaggression or support self-blame for thesesituations Training in interpersonal skills to enhancesocial competence and developing socialsupport plans For those with significant PTSD symptoms,conducting imaginal exposure and helpingto articulate the meaning of what happenedto the childTreatment for Parents (or Caregivers).Parent-directed therapy elements include: Education about relevance of the CBTmodel and physical abuse Establishing a commitment to limit physicalforceexpectations) and/or their consequencesin children (i.e., views supportive ofaggression, self-blame) that could maintainany physically abusive or aggressivebehavior Teaching parents strategies to supportthe child and encourage positive behaviorusing active/listening attention, praise, andrewards Training in effective discipline guidelinesand strategies (e.g., planned ignoring,withdrawal of privileges, time out,) asalternatives to the use of physical force If the caregiver is ready, working on aclarification letter to be read to the childTreatment for Families (or the Parentand Child). Parent-child or family therapyelements include the following: Conducting a family assessment usingmultiple methods and identifying familytreatment goals Encouraging discussion of any incidentsinvolving the use of force within the family Encouraging a commitment to increasingthe use of positive behavior as analternative to the use of force Reviewing the child's exposure toemotional abuse in the family and providingeducation about the parameters of abusiveexperiences (causes, characteristics, andconsequences) in order to understand thecontext in which they occurred Conducting a clarification session in whichthe caregiver can support the child byproviding an apology, taking responsibilityfor the abuse/conflict, and showing acommitment to safety plans and other rulesin order to keep the family safe and intact Teaching affect management skills to helpidentify and manage reactions to abusespecific triggers, heightened anger, anxiety,and depression to promote self-control Training in communication skills toencourage constructive interactions Identifying and addressing cognitivecontributors to abusive behavior incaregivers (i.e., misattributions, high Involving community and social systems, asneeded Training in nonaggressive problem-solvingskills with home practice applicationsChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov6
TARGET POPULATIONLIMITATIONS FOR USE OF AF-CBTAF-CBT is most appropriate for use withphysically, emotionally, and/or verballyabusive or coercive parents and theirschool-aged children (Kolko, 1996a; Kolko,1996b). AF-CBT has also been adapted forchildren diagnosed with behavior problemsor disorders, including conduct disorder andoppositional defiant disorder (Kolko, Dorn,et al., 2009). Often, the children experiencebehavioral dysfunction, especially aggression,as a result of abuse. AF-CBT may also helphigh-conflict families who are at risk forphysical abuse/aggression.Parents with psychiatric disorders thatmay significantly impair their generalfunctioning or their ability to learn newskills (e.g., substance use disorders, majordepression) may benefit from alternativeor adjunctive interventions designed toaddress these problems (Chadwick Center,2004). In addition, children or parents withvery limited intellectual functioning, or veryyoung children, may require more simplifiedservices or translations of some of the morecomplicated treatment concepts. Childrenwith psychiatric disorders such as significantattention-deficit disorder or major depressionmay benefit from additional interventions.Sexually abused children may respondbetter to trauma-focused therapy. For moreinformation, see Child Welfare InformationGateway's Trauma-Focused CognitiveBehavioral Therapy for Children Affected bySexual Abuse or Trauma.Thus, AF-CBT is recommended for use withfamilies that exhibit any or all of the following: Caregivers whose disciplinary ormanagement strategies range from mildphysical discipline to physically aggressiveor abusive behaviors, or who exhibitheightened levels of anger, hostility, orexplosiveness Children who exhibit significantexternalizing or aggressive behavior (e.g.,oppositionality, antisocial behavior), withor without significant physical abuse/discipline related trauma symptoms (e.g.,anger, anxiety, PTSD)EFFECTIVENESS OF AF-CBTThe effectiveness of AF-CBT is supported by anumber of outcome studies, and AF-CBT hasbeen recognized by other experts as a "model"or "promising" treatment program. Families who exhibit heightened conflict orcoercion or who pose threats to personalsafetyChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov7
DEMONSTRATED EFFECTIVENESS INOUTCOME STUDIESDuring the past four decades, many of theprocedures incorporated into AF-CBT havebeen evaluated by outside investigators aseffective in the following: Improving child, parent, and/or familyfunctioning Promoting safety and/or reducing abuserisk or re-abuse among various populationsof parents, children, and familiesThese procedures have included the useof stress management and anger-controltraining, cognitive restructuring, parentingskills training, psychoeducational informationregarding the use and impact of physical forceand hostility, social skills training, imaginalexposure, and family interventions focusingon reducing conflict (see Kolko, 2002; Kolko &Kolko, 2009; Urquiza & Runyon, 2010).Foundational studies by Kolko (1996a, 1996b)showed the effectiveness of the individualcomponents of AF-CBT when compared toroutine community services with abusivefamilies in terms of improved child, parent,and family outcomes. A more recent studyby Kolko, Iselin, and Gully (2011) documentsthe sustainability and clinical benefits of AFCBT in an existing community clinic servingphysically abused children and their families.Key AF-CBT outcomes from the literature aresummarized in the exhibit below.Summary of AF-CBT OutcomesParent Outcomes Achievement of individual treatmentgoals related to the use of moreeffective discipline methods Decreased parental reports of overallpsychological distress Lowered parent-reported child abusepotential (risk) Reduction in parent-reported drug useChild Outcomes Reduction in parent-reported severityof children's behavior problems(externalizing behavior), including childto-parent aggression and likelihood ofviolating other children’s privacy Reduction in child anxiety Greater child safety from harmFamily Outcomes Greater child-reported family cohesion Reduced child-reported and parentreported family conflictChild Welfare Outcome Low rate of abuse recidivism orconcerns about the child being harmedChildren’s Bureau/ACYF/ACF/HHS 800.394.3366 Email: info@childwelfare.gov https://www.childwelfare.gov8
RECOGNITION AS AN EVIDENCE-BASEDPRACTICEBased on systematic reviews of availableresearch and evaluation studies, severalgroups of experts and agencies havehighlighted AF-CBT as a model program orpromising treatment practice: AF-CBT is rated a 3, which is a PromisingPractice, by the California Evidence-BasedClearinghouse for Child Welfare. AF-CBT is featured in the ChadwickCenter’s (2004) Closing the Quality Chasmin Child Abuse Treatment: Identifying andDisseminating Best Practices. AB-CBT is featured in Trauma-InformedInterventions: Clinical and ResearchEvidence and Culture-Specific InformationProject, published by the National ChildTraumatic Stress Network and the MedicalUniversity of South Carolina (de Arellano,Ko, Danielson, & Sprague, 2008). It is approved as an evidence-basedtreatment (EBT) by the Los Angeles CountyOffice of Mental Health. AF-CBT is included as a promising EBT inthe website maintained by the U. S. Officeof Justice Programs. It is include
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