Alternatives for Families: A Cognitive-Behavioral Therapy

Mental Health In-home Parent Skill-Based Does Not Currently Meet Criteria

Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) aims to improve relationships between children and their caregivers by reducing or preventing the effects of child physical abuse, exposure to child or family aggression, and hostile family environments. AF-CBT addresses contributors to conflict and abuse, such as harsh parenting practices, coercive family interactions, and heightened stressful life events. AF-CBT also addresses consequences of conflict and abuse, such as aggression or behavioral dysfunction and trauma-related emotional symptoms.

 

Before treatment begins, clinicians are encouraged to conduct an intake assessment to adapt the treatment plan to the family’s needs. Treatment includes both individual and joint sessions for children and caregivers over three consecutive phases covering 17 topics. During the Engagement and Psychoeducation phase, the clinician orients the family to treatment, engages the caregiver, learns about the child’s exposure to positive and negative experiences in the home, and gathers information from and provides psychoeducation to the child and caregiver separately. During the Individual Skill-Building phase, the clinician works on emotion regulation and restructuring thoughts with both the caregiver and child individually. The clinician also works on assertiveness and social skills with the child and behavior management with the caregiver. Optional sessions include imaginal exposure if the child is experiencing symptoms of posttraumatic stress disorder (PTSD) and helping the caregiver write a clarification letter that discusses the abuse or conflict with their child. During the Family Applications phase, the clinician teaches the caregiver and child together to verbalize healthy communication, enhance safety through clarification, and solve family problems. At the end of treatment, families graduate by reviewing progress and preparing for future problems.

 

In addition to session content, clinicians are encouraged to implement CA$H (Check-in on Attendance, Safety, and Home Practice) at the beginning of each session, starting with the second session. CA$H is a brief check-in routine that supports families by praising continued attendance, identifying safety plans, and identifying useful skills through home practice assignments.


AF-CBT does not currently meet criteria to receive a rating because no studies of the program that achieved a rating of moderate or high on design and execution demonstrated a favorable effect on a target outcome.


Date Research Evidence Last Reviewed: Aug 2021


Sources

The program or service description, target population, and program or service delivery and implementation information was informed by the following sources: the program or service manual and the program or service developer’s website.


This information does not necessarily represent the views of the program or service developers. For more information on how this program or service was reviewed, visit the Review Process page or download the Handbook.

Target Population

AF-CBT is designed for families with children ages 5 to 17 who are referred for issues related to verbal and/or physical aggression. AF-CBT is recommended for families experiencing frequent conflicts, caregivers with disciplinary concerns and/or a history of physical or emotional abuse, and children with challenging behaviors and/or trauma symptoms.

Dosage

AF-CBT is typically delivered weekly over the course of 6 to 9 months. The frequency of sessions and duration of treatment vary based on participants’ needs. Session topics determine whether sessions are conducted with the child, caregiver, or child and caregiver together. Clinicians are encouraged to follow the topics in order but should tailor the order and content of sessions and activities to each family’s needs.

Location/Delivery Setting
Recommended Locations/Delivery Settings

AF-CBT is typically delivered in outpatient and residential clinics, participants’ homes, community centers, and foster care programs. However, AF-CBT may also be delivered in other settings, such as residential treatment programs, hospitals, schools, and other community-based settings.

Education, Certifications and Training

Clinicians must have at least a master’s degree in mental health or a related field. Clinicians are encouraged to be licensed or supervised by a licensed clinician.

 

All trainings are offered in-person or via web conferencing by certified AF-CBT trainers. Before training, agencies participate in readiness calls to prepare program leadership, supervisors, staff, and stakeholders. As part of this process, training materials are modified to fit the needs of the agency and/or population being served. Trainees complete a pre-training survey and orientation videos. Training includes a Basic Training workshop on the use of AF-CBT (2 days in-person or four 4-hour remote sessions), a half-day remote Advanced Training workshop 6 months after the Basic Training, 12 monthly case consultation calls with the trainer that includes two case presentations, and fidelity monitoring feedback by the trainer on two audio files submitted by the trainee. At the end of training, trainees complete a post-training online assessment and discuss eligibility for the certification program. To become certified, trainees must score 80% or higher on the AF-CBT Knowledge Exam, achieve 80% fidelity or higher on at least two audio files, complete two AF-CBT cases, and submit one Case Completion Checklist for each of these two cases. Certified clinicians are also eligible to become AF-CBT in-house trainers after a nomination and additional training. This allows clinicians to lead authorized AF-CBT learning collaboratives within their agencies.

 

Supervisors and program managers can participate in an optional supervisor/leadership training. This training includes seminars and discussions about supervisory competence and program sustainability. Supervisor consultation calls are conducted routinely and on an as-needed basis.  

Program or Service Documentation
Book/Manual/Available documentation used for review

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

Available languages

The manual for AF-CBT is available in English, Spanish, and Japanese. Session handouts for AF-CBT are available in English, Spanish, Japanese, and Korean.  

Other supporting materials

Overview

Training Information

Certification Process

Contact Information for Developers

Website: http://www.afcbt.org/

Contact form: https://pitt.co1.qualtrics.com/jfe/form/SV_5zfOzirBUzZZAmF?Q_JFE=qdg

Results of Search and Review Number of Studies Identified and Reviewed for Alternatives for Families: A Cognitive-Behavioral Therapy
Identified in Search 8
Eligible for Review 1
Rated High 0
Rated Moderate 1
Rated Low 0
Reviewed Only for Risk of Harm 0
Outcome Effect Size Effect Size more info
and Implied Percentile Effect Implied Percentile Effect more info
N of Studies (Findings) N of Participants Summary of Findings
Child safety: Child welfare administrative reports -0.17
-6
1 (1) 155 Favorable: 0
No Effect: 1
Unfavorable: 0
Child safety: Self-reports of maltreatment 0.04
1
1 (4) 168 Favorable: 0
No Effect: 4
Unfavorable: 0
Adult well-being: Positive parenting practices 0.07
2
1 (3) 168 Favorable: 0
No Effect: 3
Unfavorable: 0
Adult well-being: Parent/caregiver mental or emotional health 0.06
2
1 (3) 168 Favorable: 0
No Effect: 3
Unfavorable: 0
Adult well-being: Family functioning 0.12
4
1 (6) 168 Favorable: 0
No Effect: 6
Unfavorable: 0

Note: For the effect sizes and implied percentile effects reported in the table, a positive number favors the intervention group and a negative number favors the comparison group.

Outcome Effect Size Effect Size more info
and Implied Percentile Effect Implied Percentile Effect more info
N of Studies (Findings) N of Participants Summary of Findings Months after treatment
when outcome measured
Months after treatment when outcome measured more info
Child safety: Child welfare administrative reports -0.17
-6
1 (1) 155 Favorable: 0
No Effect: 1
Unfavorable: 0
-
Kolko, 2018
Modified Maltreatment Classification System: Reports of Child Physical Abuse -0.17
-6
- 155 - 12
Child safety: Self-reports of maltreatment 0.04
1
1 (4) 168 Favorable: 0
No Effect: 4
Unfavorable: 0
-
Kolko, 2018
Parent-Child Conflict Tactics Scale: Child Report of Child-to-Parent Minor Assault 0.27
10
- 158 - 0
Parent-Child Conflict Tactics Scale: Child Report of Child-to-Parent Minor Assault 0.29
11
- 139 - 6
Parent-Child Conflict Tactics Scale: Child Report of Child-to-Parent Minor Assault -0.48
-18
- 99 - 12
Parent-Child Conflict Tactics Scale: Parent Report of Parent-to-Child Minor Assault 0.09
3
- 168 - 0
Adult well-being: Positive parenting practices 0.07
2
1 (3) 168 Favorable: 0
No Effect: 3
Unfavorable: 0
-
Kolko, 2018
Alabama Parenting Questionnaire: Positive Parenting 0.13
5
- 168 - 0
Alabama Parenting Questionnaire: Positive Parenting -0.01
0
- 146 - 6
Alabama Parenting Questionnaire: Positive Parenting 0.09
3
- 102 - 12
Adult well-being: Parent/caregiver mental or emotional health 0.06
2
1 (3) 168 Favorable: 0
No Effect: 3
Unfavorable: 0
-
Kolko, 2018
Brief Child Abuse Potential Inventory: Abuse Risk 0.07
2
- 168 - 0
Brief Child Abuse Potential Inventory: Abuse Risk 0.08
3
- 146 - 6
Brief Child Abuse Potential Inventory: Abuse Risk 0.03
1
- 101 - 12
Adult well-being: Family functioning 0.12
4
1 (6) 168 Favorable: 0
No Effect: 6
Unfavorable: 0
-
Kolko, 2018
Weekly Report of Abuse Indicators: Anger Rating 0.17
6
- 168 - 0
Weekly Report of Abuse Indicators: Anger Rating 0.08
3
- 146 - 6
Family Assessment Device: General Dysfunction 0.13
5
- 102 - 12
Brief Child Abuse Potential Inventory: Family Conflict 0.00
0
- 168 - 0
Brief Child Abuse Potential Inventory: Family Conflict 0.15
5
- 146 - 6
Brief Child Abuse Potential Inventory: Family Conflict 0.16
6
- 101 - 12

*p <.05

Note: For the effect sizes and implied percentile effects reported in the table, a positive number favors the intervention group and a negative number favors the comparison group. Effect sizes and implied percentile effects were calculated by the Prevention Services Clearinghouse as described in the Handbook of Standards and Procedures, Section 5.10.4 and may not align with effect sizes reported in individual publications.

Only publications with eligible contrasts that met design and execution standards are included in the individual study findings table.

Full citations for the studies shown in the table are available in the "Studies Reviewed" section.

Sometimes study results are reported in more than one document, or a single document reports results from multiple studies. Studies are identified below by their Prevention Services Clearinghouse study identification numbers.

Studies Rated Moderate

Study 11692

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

Kolko, D. J., Baumann, B. L., Herschell, A. D., Hart, J. A., Holden, E. A., & Wisniewski, S. R. (2012). Implementation of AF-CBT by community practitioners serving child welfare and mental health: A randomized trial. Child Maltreatment, 17(1), 32-46. https://doi.org/10.1177/1077559511427346




Studies Not Eligible for Review

Study 11688 

Herschell, A. D., Kolko, D. J., Baumann, B. L., & Brown, E. J. (2012). Application of Alternatives for Families: A Cognitive-Behavioral Therapy to school settings. Journal of Applied School Psychology, 28(3), 270-293. https://doi.org/10.1080/15377903.2012.695768

This study is ineligible for review because it does not use an eligible design (Study Eligibility Criterion 4.1.4). 

Study 11689 

Herschell, A. D., Quetsch, L. B., & Kolko, D. J. (2020). Measuring adherence to key teaching techniques in an evidence-based treatment: A comparison of caregiver, therapist, and behavior observation ratings. Journal of Emotional & Behavioral Disorders, 28(2), 92-103. https://doi.org/10.1177/1063426618821901

This study is ineligible for review because it does not use an eligible design (Study Eligibility Criterion 4.1.4). 

Study 11690 

Herschell, A. D., Taber-Thomas, S. M., Kolko, D. J., McLeod, B. D., & Jackson, C. B. (2020). Treatment-as-usual for child physical abuse in community mental health centers: Therapist characteristics, client profiles, and therapy processes. Journal of Emotional & Behavioral Disorders, 28(4), 223-234. https://doi.org/10.1177/1063426619866188

This study is ineligible for review because it does not use an eligible design (Study Eligibility Criterion 4.1.4). 

Study 11691 

Kolko, D. J. (1996a). Individual cognitive behavioral treatment and family therapy for physically abused children and their offending parents: A comparison of clinical outcomes. Child Maltreatment, 1(4), 322–342. https://doi.org/10.1177/1077559596001004004 

Kolko, D. J. (1996b). Clinical monitoring of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse & Neglect, 20(1), 23-43. https://doi.org/10.1016/0145-2134(95)00113-1

This study is ineligible for review because it is not a study of the program or service under review (Study Eligibility Criterion 4.1.6). 

Study 11693 

Kolko, D. J., Iselin, A.-M. R., & Gully, K. J. (2011). Evaluation of the sustainability and clinical outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) in a child protection center. Child Abuse & Neglect, 35(2), 105-116. https://doi.org/10.1016/j.chiabu.2010.09.004

This study is ineligible for review because it does not use an eligible design (Study Eligibility Criterion 4.1.4). 

Study 11834 

Kolko, D. J., Dorn, L. D., Bukstein, O. G., Pardini, D. A., Holden, E. A., & Hart, J. D. (2009). Community vs. clinic-based modular treatment of children with early-onset ODD or CD: A clinical trial with three-year follow-up. Journal of Abnormal Child Psychology, 37, 591–609. https://doi.org/10.1007/s10802-009-9303-7

This study is ineligible for review because it is not a study of the program or service under review (Study Eligibility Criterion 4.1.6). 

Study 11835 

Kolko, D. J., Campo, J. V., Kelleher, K., & Cheng, Y. (2010). Improving access to care and clinical outcome for pediatric behavioral problems: A randomized trial of a nurse-administered intervention in primary care. Journal of Developmental & Behavioral Pediatrics, 31(5), 393–404. https://doi.org/10.1097/DBP.0b013e3181dff307 

This study is ineligible for review because it is not a study of the program or service under review (Study Eligibility Criterion 4.1.6).