ISSUE BRIEFS | JANUARY 2013

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT)

Families that experience conflict, coercion, WHAT'S INSIDE and/or physical abuse create substantial risk to children for the development of What makes AF-CBT unique significant psychiatric, behavioral, and adjustment difficulties, including aggression, poor interpersonal skills/functioning, and Treatment phases and key components emotional reactivity. Caregivers in such families often report punitive or excessive parenting practices, frequent anger and Target population hyperarousal, and negative child attributions, among other stressful conditions. During the past four decades, research has documented Effectiveness of AF-CBT the effectiveness of several behavioral and cognitive-behavioral methods, many of which What to look for in a therapist have been incorporated in alternatives for families: a cognitive-behavioral therapy (AF- CBT). Conclusion

Resources for more information

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 1 AF-CBT is an evidence-supported WHAT MAKES AF-CBT UNIQUE intervention that targets (1) diverse individual child and caregiver characteristics related AF-CBT is designed to intervene with families to conflict and intimidation in the home and referred for conflict or coercion, verbal or (2) the family context in which aggression or physical aggression by caregivers (including abuse may occur. This approach emphasizes the use of excessive physical force or threats), training in intra- and interpersonal skills behavior problems in children/adolescents, or designed to enhance self-control and reduce child physical abuse. The treatment program violent behavior. AF-CBT has been found has been expanded to accommodate children to improve functioning in school-aged and adolescents with physical abuse or children, their parents (caregivers), and their discipline-related trauma symptoms, such as families following a referral for concerns posttraumatic stress disorder (PTSD). about parenting practices, including child AF-CBT addresses both the risk factors and physical abuse (Kolko, 1996a; Kolko, 1996b; the consequences of physical, emotional, Kolko, Iselin, & Gully, 2011), as well as a child's and verbal aggression in a comprehensive behavior problems (Kolko, et al., 2009; Kolko, manner. Thus, AF-CBT seeks to address Hoagwood, & Springgate, 2010; Kolko, Campo, specific clinical targets among caregivers Kilbourne, & Kelleher, 2012). that include heightened anger or hostility, This issue brief is intended to build a better negative perceptions or attributions of their understanding of the characteristics and children, and difficulties in the appropriate benefits of AF-CBT, formerly known as abuse- and effective use of parenting practices, focused cognitive behavioral therapy (Kolko, such as ineffective or punitive parenting 2004). It was written primarily to help child practices. Likewise, AF-CBT targets children’s welfare caseworkers and other professionals difficulties with anger or anxiety, trauma- who work with at-risk families make more related emotional symptoms, poor social informed decisions about when to refer and relationship skills, behavioral problems children and their parents and caregivers that include aggression, and dysfunctional to AF-CBT programs. This information also attributions. At the family level, AF-CBT may help parents, foster parents, and other addresses coercive family interactions by caregivers understand what they and their teaching skills to improve positive family children can gain from AF-CBT and what to relations and reduce family conflict. expect during treatment. In addition, this issue brief may be useful to others with an interest in implementing or participating in effective strategies for the treatment of family conflict, child physical abuse, coercive parenting,1 and children with externalizing behavior problems.

¹ Coercive parenting refers to parenting by domination, intimidation, or humiliation to force children to behave according to (often unrealistic) norms set by parents.

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 2 REFLECTS A COMPREHENSIVE TREATMENT ƒ Developmental victimology, which STRATEGY describes how the specific effects The diversity of family circumstances of exposure to traumatic or abusive and individual problems associated with experiences may vary for children at family conflict points to the need for a different developmental stages and across comprehensive treatment strategy that the life span targets both the contributors to caregivers' ƒ Psychology of aggression, which describes behavior and children’s subsequent behavioral the processes by which aggression and and emotional adjustment (Chadwick Center, coercion develop and are maintained, 2004). Treatment approaches that focus on which can help to understand one’s history several aspects of the problem (for example, as both a contributor to and victim of a caregiver's parenting skills, a child's aggressive behavior anger, family coercion) may have a greater AF-CBT pulls together many techniques likelihood of reducing re-abuse and more fully currently used by practitioners, such as remediating mental health problems (Kolko behavior and anger management, affect & Swenson, 2002). Therefore, AF-CBT adopts regulation, problem-solving, social skills a comprehensive treatment strategy that training, cognitive restructuring, and addresses the complexity of the issues more communication. The advantage of this completely. program is that all of these techniques, relevant handouts, training examples, and INTEGRATES SEVERAL THERAPEUTIC APPROACHES outcome measures are integrated in a structured approach that practitioners and AF-CBT combines elements drawn from the supervisors can easily access and use. following:

ƒ Cognitive therapy, which aims to change TREATS CHILDREN AND PARENTS SIMULTANEOUSLY behavior by addressing a person's thoughts or perceptions, particularly those thinking During AF-CBT, school-aged children (5-15 patterns that create distorted views years) and their caregivers participate in separate but coordinated therapy sessions, ƒ Behavioral and learning theory, which often using somewhat parallel treatment focuses on modifying habitual responses materials. In addition, children and parents (e.g., anger, fear) to identified situations or attend joint sessions together at various times stimuli throughout treatment. This approach seeks to ƒ Family therapy, which examines patterns address individual and parent-child issues in of interactions among family members to an integrated fashion. identify and alleviate problems, and offers strategies to help reframe how problems are viewed

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 3 DISCOURAGES AGGRESSIVE OR VIOLENT TREATMENT PHASES AND KEY BEHAVIOR COMPONENTS The AF-CBT approach is designed to promote AF-CBT is a short-term treatment typically appropriate and prosocial behavior, while provided once or twice a week, which may discouraging coercive, aggressive, or violent require 18 to 24 hours of service (or longer, behavior from caregivers as well as children. based on individual needs) over 4 to 12 months Consistent with cognitive-behavioral (although treatment may last as long as approaches, AF-CBT includes procedures that determined necessary). Treatment includes target three related ways in which people separate individual sessions with the child and respond to different circumstances: caregiver/parent and joint sessions with at ƒ Cognition (thinking) least both of them. Where necessary, family interventions may be applied before, during, ƒ Affect (feeling) or after the individual services. The treatment ƒ Behavior (doing) program for children, caregivers, and families AF-CBT includes training in various incorporates the use of specific skills, role- psychological skills in each of these response playing exercises, performance feedback, and channels that are designed to promote home practice exercises. self-control and to enhance interpersonal Generally, the following are the goals of AF- effectiveness. CBT treatment

TAILORS TREATMENT TO MEET SPECIFIC ƒ Reduce conflict and increase cohesion in NEEDS AND CIRCUMSTANCES family AF-CBT begins with a multisource assessment ƒ Reduce use of coercion (hostility, anger, to identify the nature of the problems the verbal aggression, threats) by the caregiver child is experiencing, specific parental and and other family members family difficulties that may be contributing ƒ Reduce use of physical force (aggressive to family conflict, and the child's and family's behavior) by the caregiver, child, and, as strengths that may help influence change. relevant, other family members Tailoring the treatment to the family’s specific ƒ Promote nonaggressive (alternative) strengths and challenges is key to efficient discipline and interactions outcomes (Kolko & Swenson, 2002). ƒ Reduce child physical abuse risk or recidivism (prevention of child welfare system involvement or repeated reports/ allegations) ƒ Improve the level of child’s safety/welfare and family functioning

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 4 TREATMENT PHASES ƒ Topic 9: Noticing Positive Behavior– Caregiver AF-CBT includes three treatment phases, each with key content that is designed ƒ Topic 10: Assertiveness and Social Skills– to be relevant for both the caregiver and Child child. The sequence for conducting the ƒ Topic 11: Techniques for Managing treatment generally proceeds from teaching Behavior–Caregiver intrapersonal (e.g., cognitive, affective) ƒ Optional Topic 12: Imaginal Exposure–Child skills first, followed by interpersonal skills ƒ Topic 13: Preparation for Clarification– (e.g., behavioral). Topics/sessions can be Caregiver flexibly delivered (adapted, abbreviated, or repeated) based on the family's progress and/ PHASE III: FAMILY APPLICATIONS or treatment needs/goals in each phase. ƒ Topic 14: Verbalizing Healthy Although AF-CBT has primarily been used in Communication–Caregiver and Child outpatient and home settings, the treatment has been more recently delivered in inpatient ƒ Topic 15: Enhancing Safety Through and residential settings when there is some Clarification–Caregiver and Child ongoing or potential contact between the ƒ Topic 16: Solving Family Problems– caregiver and the child. The primary content Caregiver and Child in each topic noted below is organized into ƒ Topic 17: Graduation–Caregiver and Child three phases reflected in the acronym A-L-T-E-R-N-A-T-I-V-E-S. KEY COMPONENTS

PHASE I: ENGAGEMENT and AB-CBT includes specific therapy elements PSYCHOEDUCATION for children, parents, and families.

ƒ Topic 1: Orientation–Caregiver and Child Treatment for School-Aged Children. The school-aged child-directed therapy elements ƒ Topic 2: Alliance Building and Engagement– include the following: Caregiver ƒ Topic 3: Learning About Feelings and Family ƒ Promoting engagement and treatment Experiences–Child motivation by identifying individualized goals ƒ Topic 4: Talking About Family Experiences ƒ Identifying the child's exposure to and and Psychoeducation–Caregiver views of positive experiences and upsetting ones (family hostility, coercion, and PHASE II: INDIVIDUAL SKILL-BUILDING violence), including the child’s perceptions (Skills Training) of the circumstances and consequences of ƒ Topic 5: Emotion Regulation–Caregiver the physical abuse or other conflict ƒ Topic 6: Emotion Regulation–Child ƒ Educating the child on topics related to child welfare, safety/protection, service ƒ Topic 7: Restructuring Thoughts–Caregiver participation, and common reactions to ƒ Topic 8: Restructuring Thoughts–Child abuse and family conflict

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 5 ƒ Training in techniques to identify, express, expectations) and/or their consequences and manage emotions appropriately (e.g., in children (i.e., views supportive of anxiety management, anger control) aggression, self-blame) that could maintain ƒ Processing the child's exposure to incidents any physically abusive or aggressive involving force or family conflict to behavior understand and challenge any dysfunctional ƒ Teaching parents strategies to support thoughts/views that encourage the use of the child and encourage positive behavior aggression or support self-blame for these using active/listening attention, praise, and situations rewards ƒ Training in interpersonal skills to enhance ƒ Training in effective discipline guidelines social competence and developing social and strategies (e.g., planned ignoring, support plans withdrawal of privileges, time out,) as ƒ For those with significant PTSD symptoms, alternatives to the use of physical force conducting imaginal exposure and helping ƒ If the caregiver is ready, working on a to articulate the meaning of what happened clarification letter to be read to the child to the child Treatment for Families (or the Parent Treatment for Parents (or Caregivers). and Child). Parent-child or family therapy Parent-directed therapy elements include: elements include the following:

ƒ Education about relevance of the CBT ƒ Conducting a family assessment using model and physical abuse multiple methods and identifying family ƒ Establishing a commitment to limit physical treatment goals force ƒ Encouraging a commitment to increasing ƒ Encouraging discussion of any incidents the use of positive behavior as an involving the use of force within the family alternative to the use of force ƒ Reviewing the child's exposure to ƒ Conducting a clarification session in which emotional abuse in the family and providing the caregiver can support the child by education about the parameters of abusive providing an apology, taking responsibility experiences (causes, characteristics, and for the abuse/conflict, and showing a consequences) in order to understand the commitment to safety plans and other rules context in which they occurred in order to keep the family safe and intact ƒ Teaching affect management skills to help ƒ Training in communication skills to identify and manage reactions to abuse- encourage constructive interactions specific triggers, heightened anger, anxiety, ƒ Training in nonaggressive problem-solving and depression to promote self-control skills with home practice applications ƒ Identifying and addressing cognitive ƒ Involving community and social systems, as contributors to abusive behavior in needed caregivers (i.e., misattributions, high

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 6 TARGET POPULATION LIMITATIONS FOR USE OF AF-CBT AF-CBT is most appropriate for use with Parents with psychiatric disorders that physically, emotionally, and/or verbally may significantly impair their general abusive or coercive parents and their functioning or their ability to learn new school-aged children (Kolko, 1996a; Kolko, skills (e.g., substance use disorders, major 1996b). AF-CBT has also been adapted for depression) may benefit from alternative children diagnosed with behavior problems or adjunctive interventions designed to or disorders, including conduct disorder and address these problems (Chadwick Center, oppositional defiant disorder (Kolko, Dorn, 2004). In addition, children or parents with et al., 2009). Often, the children experience very limited intellectual functioning, or very behavioral dysfunction, especially aggression, young children, may require more simplified as a result of abuse. AF-CBT may also help services or translations of some of the more high-conflict families who are at risk for complicated treatment concepts. Children physical abuse/aggression. with psychiatric disorders such as significant attention-deficit disorder or major depression Thus, AF-CBT is recommended for use with may benefit from additional interventions. families that exhibit any or all of the following: Sexually abused children may respond ƒ Caregivers whose disciplinary or better to trauma-focused therapy. For more management strategies range from mild information, see Child Welfare Information physical discipline to physically aggressive Gateway's Trauma-Focused Cognitive or abusive behaviors, or who exhibit Behavioral Therapy for Children Affected by heightened levels of anger, hostility, or Sexual Abuse or Trauma. explosiveness EFFECTIVENESS OF AF-CBT ƒ Children who exhibit significant The effectiveness of AF-CBT is supported by a externalizing or aggressive behavior (e.g., number of outcome studies, and AF-CBT has oppositionality, antisocial behavior), with been recognized by other experts as a "model" or without significant physical abuse/ or "promising" treatment program. discipline related trauma symptoms (e.g., anger, anxiety, PTSD) ƒ Families who exhibit heightened conflict or coercion or who pose threats to personal safety

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 7 DEMONSTRATED EFFECTIVENESS IN OUTCOME STUDIES Summary of AF-CBT Outcomes During the past four decades, many of the procedures incorporated into AF-CBT have Parent Outcomes been evaluated by outside investigators as ƒ Achievement of individual treatment effective in the following: goals related to the use of more ƒ Improving child, parent, and/or family effective discipline methods functioning ƒ Decreased parental reports of overall ƒ Promoting safety and/or reducing abuse psychological distress risk or re-abuse among various populations ƒ Lowered parent-reported child abuse of parents, children, and families potential (risk) These procedures have included the use ƒ Reduction in parent-reported drug use of stress management and anger-control Child Outcomes training, cognitive restructuring, parenting skills training, psychoeducational information ƒ Reduction in parent-reported severity regarding the use and impact of physical force of children's behavior problems and hostility, social skills training, imaginal (externalizing behavior), including child- exposure, and family interventions focusing to-parent aggression and likelihood of on reducing conflict (see Kolko, 2002; Kolko & violating other children’s privacy Kolko, 2009; Urquiza & Runyon, 2010). ƒ Reduction in child anxiety Foundational studies by Kolko (1996a, 1996b) ƒ Greater child safety from harm showed the effectiveness of the individual components of AF-CBT when compared to Family Outcomes routine community services with abusive ƒ Greater child-reported family cohesion families in terms of improved child, parent, and family outcomes. A more recent study ƒ Reduced child-reported and parent- by Kolko, Iselin, and Gully (2011) documents reported family conflict the sustainability and clinical benefits of AF- Child Welfare Outcome CBT in an existing community clinic serving physically abused children and their families. ƒ Low rate of abuse recidivism or Key AF-CBT outcomes from the literature are concerns about the child being harmed summarized in the exhibit below.

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 8 RECOGNITION AS AN EVIDENCE-BASED ƒ It is included in EBT dissemination activities PRACTICE by the Defending Childhood Initiative Based on systematic reviews of available sponsored by the Attorney General’s Office, research and evaluation studies, several U.S. Department of Justice. groups of experts and agencies have ƒ It is currently being disseminated by highlighted AF-CBT as a model program or the National Child Traumatic Stress promising treatment practice: Network (NCTSN) in a National Learning Collaborative on AF-CBT ƒ AF-CBT is rated a 3, which is a Promising Practice, by the California Evidence-Based WHAT TO LOOK FOR IN A Clearinghouse for Child Welfare. THERAPIST ƒ AF-CBT is featured in the Chadwick Caseworkers who are considering a Center’s (2004) Closing the Quality Chasm family’s referral for AF-CBT should become in Child Abuse Treatment: Identifying and knowledgeable about commonly used Disseminating Best Practices. treatments before recommending a treatment ƒ AB-CBT is featured in Trauma-Informed provider to families. Parents or caregivers Interventions: Clinical and Research should receive as much information as Evidence and Culture-Specific Information possible on the treatment options available to Project, published by the National Child them. If AF-CBT appears to be an appropriate Traumatic Stress Network and the Medical treatment model for a family, the caseworker University of South Carolina (de Arellano, should look for a provider who has received Ko, Danielson, & Sprague, 2008). adequate training, supervision, and ƒ It is approved as an evidence-based consultation in the AF-CBT model. If feasible, treatment (EBT) by the Los Angeles County both the caseworker and the family should Office of Mental Health. have an opportunity to interview potential AF- CBT therapists prior to beginning treatment. ƒ AF-CBT is included as a promising EBT in AF-CBT can be provided in multiple settings— the website maintained by the U. S. Office in the home, in clinics, or other community of Justice Programs. settings—and the average length of services varies depending on the client’s needs, goals, and progress. Relevant information may also be available on the AF-CBT website.

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 9 AF-CBT TRAINING Some specific questions to ask regarding AF- CBT include the following: Mental health professionals with at least some advanced training in psychotherapy ƒ Will the child and parent each receive skills and methods and experience working individualized therapy using corresponding with physically abusive caregivers and their (coordinated) treatment protocols? children are eligible for training in AF-CBT. ƒ Will social learning principles be used Training generally involves the following: to address the thoughts, emotions, and ƒ An initial didactic workshop training behaviors of the child and parent? (3 days) ƒ Is there a focus on enhancing the parent- ƒ Follow-up case consultation calls during child relationship and improving parental “action plan” periods (6 to 12 months) discipline practices? ƒ Review of session performance samples for ƒ Is the practitioner sensitive to the cultural integrity/competency background of the child and family? ƒ Booster retraining and advanced case ƒ Is there a standard assessment process review (1 day) used to gather baseline information on the functioning of the child and family and to ƒ Review of community metrics and progress monitor their progress in treatment over report time? See Training and Consultation Resources, ƒ Is this the most appropriate treatment for below, for contact information. this child and family?

QUESTIONS TO ASK TREATMENT CONCLUSION PROVIDERS AF-CBT is an evidence-supported treatment In addition to appropriate training and intervention for parents and school-aged thorough knowledge of the AF-CBT model, children in families in which physical, emotional, it is important to select a treatment provider or verbal abuse or family conflict has occurred. who is sensitive to the particular needs of AF-CBT uses an integrated approach to address the child, caregiver, and family. Caseworkers beliefs about abuse and violence and improve recommending an AF-CBT therapist should skills to enhance emotional control and reduce ask the treatment provider to explain the violent behavior. Improvements resulting from course of treatment, the role of each family the use of AF-CBT include reductions in the risk member in treatment, and how the family’s of child abuse, fewer abuse-related behavior specific cultural considerations will be problems in children, and improvements in addressed. The child, caregiver, and family family cohesion. Increased awareness of this should feel comfortable with and have treatment option among those making referrals, confidence in the therapist. coupled with increased availability, may create

opportunities for helping to strengthen families

and reduce the risks for and consequences of

child physical abuse.

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 10 RESOURCES FOR MORE Kolko, D. J., Campo, J. V., Kelleher, K., & INFORMATION Cheng, Y. (2010). Improving access to care and clinical outcomes for pediatric REFERENCES behavioral problems: A randomized trial of a nurse-administered intervention in Chadwick Center. (2004). Closing the quality primary care. The Journal of Behavioral and chasm in child abuse treatment: Identifying Developmental Pediatrics, 31(5), 393–404. and disseminating best practices. San Diego, CA: Author. https://lastradainternational. Kolko, D. J., Campo, J. V., Kilbourne, A., org/lsidocs/kauffmanfinal_child_ & Kelleher, K. (2012). Doctor-office treatment_0108.pdf collaborative care for pediatric behavior problems: A preliminary clinical trial. de Arellano, M. A., Ko, S. J., Danielson, C. K., Archives of Pediatrics & Adolescent & Sprague, C. M. (2008). Trauma-informed Medicine, 166, 224–231. interventions: Clinical and research evidence and culture-specific information Kolko, D. J., Dorn, L. D., Bukstein, O. G., project. Los Angeles, CA, & Durham, NC: Pardini, D., Holden, E. A., & Hart, J. D. National Center for Child Traumatic Stress. (2009). Community vs. clinic-based modular treatment of children with early- Kolko, D. J. (1996a). Individual cognitive- onset ODD or CD: A clinical trial with behavioral treatment and family therapy three-year follow-up. Journal of Abnormal for physically abused children and their Child Psychology, 37, 591–609. offending parents: A comparison of clinical outcomes. Child Maltreatment: Journal of Kolko, D. J., Hoagwood, K., & Springgate, B. the American Professional Society on the (2010). Treatment research for trauma/ Abuse of Children, 1, 322–342. PTSD in children and youth: Moving from efficacy to effectiveness.General Hospital Kolko, D. J. (1996b). Clinical monitoring Psychiatry, 32(5), 465–76. of treatment course in child physical abuse: Psychometric characteristics and Kolko, D. J., Iselin, A. M., & Gully, K. (2011). treatment comparisons. Child Abuse & Evaluation of the sustainability and clinical Neglect, 20(1), 23–43. outcome of alternatives for families: A cognitive-behavioral therapy (AF-CBT) in Kolko, D. J. (2004). Individual child and a child protection center. Child Abuse & parent physical abuse-focused cognitive- Neglect, 35(2), 105–116. behavioral treatment. In B. E. Saunders, L. Berliner, & R. F. Hanson (Eds.), Child Kolko, D. J., & Kolko, R. P. (2009). Psychological physical and sexual abuse: Guidelines for impact and treatment of child physical treatment (pp. 43–44). Charleston, SC: abuse of children. In C. Jenny (Ed.), Child National Crime Victims Research and abuse and neglect: Diagnosis, treatment Treatment Center. and evidence (pp. 476–489). Philadelphia: Saunder/Elsevier, Inc.

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 11 Kolko, D. J., & Swenson, C. C. (2002). Assessing The latest AF-CBT session guide and handouts and treating physically abused children (version 3; 11-1-2011) are described on the and their families: A cognitive behavioral AF-CBT website, which also includes training approach. Thousand Oaks, CA: Sage opportunities and research updates. Publications. ACKNOWLEDGMENT: Urquiza, A., & Runyon, M. (2010). Interventions This issue brief was developed by Child for physically abusive parents and abused Welfare Information Gateway, in partnership children. In J. E. B. Myers (Ed.), The with the Chadwick Center for Children and APSAC Handbook on Child Maltreatment Families at Rady Children’s Hospital-San (3rd edition). Thousand Oaks, CA: SAGE Diego. Contributing authors include David Publications Kolko, Ph.D, ABPP; Daniel Kleiner, Psy.D.; TRAINING AND CONSULTATION Barbara Baumann, Ph.D.; and Charles Wilson, RESOURCES M.S.S.W. This document is made possible by the Children’s Bureau, Administration on David J. Kolko, Ph.D., ABPP Children, Youth and Families, Administration Director, Special Services Unit for Children and Families, U.S. Department of Western Psychiatric Institute and Clinic, Health and Human Services. The conclusions University of Pittsburgh School of Medicine discussed here are solely the responsibility of 541 Bellefield Towers the authors and do not represent the official Pittsburgh, PA 15213 views or policies of the funding agency. The 412.246.5888 Children's Bureau does not endorse any [email protected] specific treatment or therapy. Website: http://www.afcbt.org

Clinicians are encouraged to read the SUGGESTED CITATION: following book: Child Welfare Information Gateway. (2012). Kolko, D. J., & Swenson, C. C. (2002). Assessing Alternatives for families: A cognitive- and treating physically abused children and behavioral therapy (AF-CBT). U.S. Department their families: A cognitive behavioral approach. of Health and Human Services Administration Thousand Oaks, CA: Sage Publications. for Children and Families, Children's Bureau. (http:www.sagepub.com)

U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau

This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway. This publication is available online at https://www.childwelfare.gov/pubs/cognitive/.

Children’s Bureau/ACYF/ACF/HHS | 800.394.3366 | Email: [email protected] | https://www.childwelfare.gov 12