Alternatives for Families: A Cognitive-Behavioral Therapy
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 download the Handbook of Standards and Procedures, Version 1.0
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
For More Information
Website: http://www.afcbt.org/
Contact form: https://pitt.co1.qualtrics.com/jfe/form/SV_5zfOzirBUzZZAmF?Q_JFE=qdg
Note: The details on Dosage; Location; Education, Certifications, and Training; Other Supporting Materials; and For More Information sections above are provided to website users for informational purposes only. This information is not exhaustive and may be subject to change.
| 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
 and Implied Percentile Effect
|
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
and Implied Percentile Effect
|
N of Studies (Findings) | N of Participants | Summary of Findings |
Months after treatment when outcome measured
|
|---|---|---|---|---|---|
| Child safety: Child welfare administrative reports |
-0.17
-6 |
1 (1) | 155 |
Favorable:
0 No Effect: 1 Unfavorable: 0 |
- |
| Study 11692 - Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) vs. Treatment as Usual (TAU) (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 |
- |
| Study 11692 - Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) vs. Treatment as Usual (TAU) (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 |
- |
| Study 11692 - Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) vs. Treatment as Usual (TAU) (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 |
- |
| Study 11692 - Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) vs. Treatment as Usual (TAU) (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 |
- |
| Study 11692 - Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) vs. Treatment as Usual (TAU) (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.
The participant characteristics display is an initial version. We encourage those interested in providing feedback to send suggestions to preventionservices@abtglobal.com.
The table below displays locations, the year, and participant demographics for studies that received moderate or high ratings on design and execution and that reported the information. Participant characteristics for studies with more than one intervention versus comparison group pair that received moderate or high ratings are shown separately in the table. Please note, the information presented here uses terminology directly from the study documents, when available. Studies that received moderate or high ratings on design and execution that did not include relevant participant demographic information would not be represented in this table.
For more information on how Clearinghouse reviewers record the information in the table, please see our Resource Guide on Study Participant Characteristics and Settings.
| Characteristics of the Participants in the Studies with Moderate or High Ratings | ||||||
|---|---|---|---|---|---|---|
|
Study Location
|
Study Year
|
Age or Grade-level
|
Race, Ethnicity, Nationality
|
Gender
|
Populations of Interest*
|
Household Socioeconomic Status
|
| Study 11692 - Alternatives for Families: A Cognitive Behavioral Therapy (AF-CBT) vs. Treatment as Usual (TAU) | ||||||
| Characteristics of the Children and Youth | ||||||
| Pennsylvania, USA | -- | Average age: 12 years | 55% Minority | 46% Female | -- | -- |
| Characteristics of the Adults, Parents, or Caregivers | ||||||
| Pennsylvania, USA | -- | -- | -- | -- | 37% Report/allegation of physical abuse; 15% Physical abuse report; 17% Physical or emotional abuse | 80% Family income less than US $30,000 |
“--” indicates information not reported in the study.
* The information about disabilities is based on initial coding. For more information on how the Clearinghouse recorded disability information for the initial release, please see our Resource Guide on Study Participant Characteristics and Settings. The Clearinghouse is currently seeking consultation from experts, including those with lived experience, and input from the public to enhance and improve the display.
Note: Citations for the documents associated with each 5-digit study number shown in the table can be found in the “Studies Reviewed” section below. Study settings and participant demographics are recorded for all studies that received moderate or high ratings on design and execution and that reported the information. Studies that did not report any information about setting or participant demographics are not displayed. For more information on how participant characteristics are recorded, please see our Resource Guide on Study Participant Characteristics and Settings.
Studies Rated Moderate
Study 11692Kolko, 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
This study was conducted in a usual care or practice setting (Handbook Section 6.2.2)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).