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 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' 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: 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, 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 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 Cognition (thinking) least both of them. Where necessary, family interventions may be applied before, during, Affect (feeling) or after the individual services. The treatment 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 Reduce conflict and increase cohesion in NEEDS AND CIRCUMSTANCES family AF-CBT begins with a multisource assessment 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 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 Promote nonaggressive (alternative) strengths and challenges is key to efficient discipline and interactions outcomes (Kolko & Swenson, 2002). Reduce child physical abuse risk or recidivism (prevention of child welfare system involvement or repeated reports/ allegations) 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 Topic 9: Noticing Positive Behavior– Caregiver AF-CBT includes three treatment phases, each with key content that is designed Topic 10: Assertiveness and Social