AF-CBT Is an Evidence-Based Treatment Designed to Improve Relationships Between Children

Alternatives for Families (AF-CBT) Treatment Plan www.afcbt.org

Overview AF-CBT is an evidence-based treatment designed to improve relationships between children (patients) and parents (caregivers) in families involved in physical force and/or coercion and chronic hostility. AF-CBT emphasizes training in both inter and intrapersonal skills. The program is designed to enhance self-control, strengthen positive-parenting practices, improve family cohesion, improve communication, improve problem-solving, enhance child coping and social skills, and prevent further instances of hostility and possible abuse. AF-CBT is a family-centered intervention designed with broad clinical targets in which both children and caregivers are important participants in treatment. Appropriate candidates for AF-CBT include children (5-17) with externalizing behavioral problems who are at risk of physical abuse and their families. The AF-CBT program promotes pro-social behaviors and discourages the use of coercive and aggressive behaviors by focusing on the development of inter and intrapersonal skill building. In doing so, AF-CBT targets contributors/risk factors to physically aggressive or abusive incidents within the child, caregiver, family and community domains. Potential contributors include negative perceptions of children, heightened anger or hostility, harsh parenting practices, coercive family interactions, and heightened stressful events. In turn, AF-CBT targets common consequences of abusive and aggressive incidents exhibited by children and caregivers. Potential consequences in both children and parents, include aggression or behavioral dysfunction, poor social competence, trauma related emotional symptoms, developmental deficits in relationship skills, and cognitive impairments. Candidates deemed inappropriate for AF-CBT include a) children exhibiting symptoms of psychosis, acutely suicidal (i.e., serious cutting), currently abusing substances, and/or experiencing life-threatening violence (homicidality), and/or b) parents/caregivers whose, untreated mental health issues or low cognitive functioning would significantly limit participation or progress. ENROLLMENT CRITERIA RULE OUT CRITERIA  Ages 5 - 17  Psychosis  Demonstrating behavioral/emotional problems  Acutely suicidal (i.e., serious cutting)  Chaotic, highly conflictual/coercive families  Currently abusing substances  At risk for physical abuse  Life threatening violence (homicidality)  Exposed to family violence  Parents/Caregivers whose untreated MHS issues or low  Overly stressed parents cognitive functioning (would limit treatment)  Overly aggressive parenting  If child PTSD is primary problem, do TF-CBT first PROGRAM PARAMETERS 1 AF-CBT Treatment Plan  Treatment Length: 6-12 months  Outpatient (clinic, school, community, home, etc)  Weekly Sessions (60-90 minutes)  Psychotherapy & Cognitive Behavioral Therapy  Individual, family, or collateral sessions  Psycho-education & skill building  Core activities include:  Includes Medication Support (as clinically appropriate) o Assessment ( 90791)  Includes Case Management Services addressing related o Collateral (90887) psychosocial stressors o Individual Psychotherapy (90837, etc)  Includes Crisis Interventions Services (as needed) o Family Psychotherapy (90847)  Includes Psychological Testing (if necessary) o Rehabilitation (H2015) TREATABLE PROBLEMS PROBLEMS DEFINITIONS  Commonly diagnosed as:  Constant display of anger, explosiveness, and resentment o Disruptive Behavior Disorder  Pattern of negativistic, hostile and defiant behavior toward o Oppositional Defiant Disorder adults/authority figures; Constant arguing with adults o Conduct Disorder  Defying or refusing to comply with requests and rules even when o ADHD they are reasonable o Depression  Temper tantrums, blaming others for his/her mistakes; o PTSD deliberately annoying others  Aggression  Inconsistent parenting between mother and father  Aggressive Parenting  Parent's use of (or threat to use) physical force  Ineffective/Negative Parenting – excessive punitiveness  Poor communication between child and parents  Highly Conflictual/Dysfunctional Relationships w/ Parents/Adults  Misattributions, high expectations, or negative child  Highly Conflictual/Dysfunctional Relationships w/ Peers/Siblings perceptions/beliefs, cognitive distortions, self blame  Highly Conflictual/Dysfunctional Relationships  Disturbance in family functioning due to exposure to  Among Family Members violence/abuse  Unsafe/violent behaviors

AF-CBT Treatment Plan 3 PHASE CLINICIAN GOALS PATIENT GOALS OBJECTIVES (not included on treatment (included on treatment (included on treatment plan) plan) plan) I: Engagement and i. Orient patient and parents to 1. Patient/Parents will a) Actively participate in weekly Psycho-education the AF-CBT Model and demonstrate an understanding safety check-ins.(1,2) educate them on the of the importance of, purpose b) Demonstrated ability and Alternatives for Families Plan of, and benefits of participating willingness to share information (AFP) in the AF-CBT program about self and family experiences 2. ii. Understand parents' family of Parents will identify goals of (4,5) change based upon an origin and their childhood c) Demonstrated ability (parent) understanding of their own and willingness to share information experiences of being experiences with being about childhood experience of being parented, as well as parented, their current coping parented and identify the values, understand their current skills, as well as positive and beliefs, and traditions they would like values and traditions stressful life experiences that are to implement in their family (2) iii.Learn about patient's feelings related to how they parent d) Patient/Parents will identify and his/her family experiences 3. Patient will demonstrate an (written or verbal) three or four iv. Provide psycho-education on understanding of his/her own changes they would like to see impact of family feelings, as well as the feelings happen in the family/home (2) abuse/conflict on a child of others e) Parents will identify (written or 4. Patient/Parents will verbal) positive coping skills they demonstrate an understanding currently use and continue to use of Positive/Negative Interactions them to appropriately deal with in their family stressful situations on a daily basis (2) 5. Patient/Parents will f) Patient/Parents will actively demonstrate an understanding participate in the development of the of the use of and impact of (AFP) on a weekly basis. (1) Family Abuse/Conflict g) Demonstrated ability to identify & define his/her feelings and the feelings of others in a respectful/affirming manner (3) h) Demonstrated ability to identify how positive and negative family interactions affect their life/family (4) PHASE CLINICIAN GOALS PATIENT GOALS OBJECTIVES (not included on (included on treatment (included on treatment plan) treatment plan) plan) II: i. Educate patient/parents 1. Patient/Parent will a. Demonstrated ability to regulate Individual Skill on emotional regulation demonstrate an emotions through application of the Building ii. Educate patient/parents understanding of the ABC Reaction Triangle to positive and on restructuring Model and Reaction Triangle negative situations (1) thoughts 2. Patient/Parent will b. Patient/Parents will identify (written or verbal) anger and/or iii. Educate parents on demonstrate the role and anxiety triggers or cues (2) positive parenting impact of anger and anxiety c. Demonstrated ability to calm and strategies and improve anger and relax self via use of relaxation skills iv. Educate patient on anxiety control (i.e. controlled breathing, progressive assertiveness and socials 3. Patient/Parent will muscle relaxation, etc) and will skills demonstrate an develop and implement a Relaxation v. Educate parents on understanding of cognitive Plan (2) behavior management coping d. Demonstrated ability to challenge techniques and effective 4. Parents will demonstrate an maladaptive thinking automatic discipline understanding of their thoughts, reactions to those thoughts, vi. Guide the patient parenting style and use as well as alternative thoughts via use of the ABC model (3) through the imaginal positive parenting strategies e. Demonstrated ability to challenge exposure process (if 5. Patient will learn and use negative "hostile" intent attributed to effective assertiveness and applicable) the patient's behavior via use of the vii. Educate and prepare the social skills ABC model (3) patient/parents on the 6. Parents will support the clarification process (if patient with their social applicable) support plan

PHASE CLINICIAN GOALS PATIENT GOALS OBJECTIVES

AF-CBT Treatment Plan 5 (not added to treatment (included on treatment (included on treatment plan) plan) plan) 7. Parents will demonstrate f) Demonstrated ability to an understanding of implement and effectively use positive different types of parenting strategies [describe] (4) behaviors and learn to use g) Demonstrated ability to identify appropriate behavior and utilize positive social skills, stand management and up for self, and to make requests in an discipline techniques effective manner (5,6) h) Patient will develop a social 8. Patient will demonstrate support plan that will be implemented his/her ability to discuss when necessary (5,6) trauma(s) with a decrease i) Demonstrated ability to effectively in negative emotional and use behavior management and cognitive responses (if discipline techniques [parent, applicable) describe] (7) 9. Patient/Parents will j) Demonstrated ability to openly demonstrate an verbalize thoughts/feelings about understanding of the abuse/conflict and explore "meaning Clarification Process and making" (5,8) demonstrate their k) Parent will begin clarification letter preparedness for the in preparation for the clarification completion of the process process (if applicable) (1,9) (if applicable) PHASE CLINICIAN GOALS PATIENT GOALS OBJECTIVES (not added to treatment (included on treatment (included on treatment plan) plan) plan) III: Educate patient/parents on 1. Patient/Parent will a. Demonstrated ability to identify Family Applications healthy communication demonstrate consistency current positive communication skills Help parents enhance safety for in improved used in the family, common *includes all discharge the patient communication communication obstacles, and activities preferred communication Educate patient/parents on 2. Parents will participate in preferences (1) problem solving strategies the Clarification Process b. Demonstrated ability to utilize which results in enhancing Review treatment and progress positive communication strategies Help patient/parents develop the patient's safety (1) relapse prevention plans 3. Patient/Parents will solve c. Patient/Parents will complete Facilitate closure of treatment problems effectively final preparation for the clarification through a graduation ritual 4. Patient/Parents will process (2) acknowledge positive d. Demonstrated ability changes and the progress (patient/parents) to utilize effective made in treatment problem-solving strategies (3) 5. Patient/Parents will e. Patient/Parents will review skills demonstrate an learned and make a commitment to understanding of relapse use skills after end of treatment (4) prevention plans that will f. Patient/Parents will actively address potential family participate in developing relapse prevention plans to manage future problems family problems (5)

AF-CBT Treatment Plan 7 AF-CBT Interventions Provide psycho-education about AFCBT, common responses to exposure to conflict/violence/abuse, diagnostic symptoms/problems Teach skills to identify feelings, specific behavioral symptoms, specific problem areas, making connection between problem area and behavioral symptoms, understanding family experiences Teach skills to self-monitor feelings related to stressful life events that contribute to problem areas, utilize new behaviors to minimize aggressive/conflictual episodes Learning about each other worksheet, goal setting worksheet, weekly safety check in worksheets Stressful life experiences worksheet, decisional balance worksheets, my goals for treatment worksheets, feelings identification worksheets, my positive and upsetting experiences worksheets Teach, role-play and implement problem-solving skills, social skills, assertiveness skills, confident body language/demeanor, and encourage practice/use of skills outside of session Teach ABC Model pathway Teach patterns of personal thinking Use decisional balance worksheets to teach helpful thinking, problem solving Identify triggers and symptoms of anger and/or anxiety feelings related to the identified problem area(s) Teach relaxation techniques: Progressive Muscle Relaxation and Controlled Breathing Explore parenting style and techniques; teach positive parenting and techniques that promote pro-social behavior Communication obstacles worksheets, psycho-education on positive communication strategies Education on effective problem solving strategies Use ABC model pathway to help educate on effective problem solving Help parents learn to identify potential family problems and create a plan for them

www.afcbt.org