AF-CBT: Alternatives for Families A Cognitive Behavioral Therapy

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Treatment Description

Acronym (abbreviation) for intervention:AF-CBT

Average length/number of sessions:

The delivery of treatment is organized into three phases:

• Phase 1: Psychoeducation and Engagement

• Phase 2: Individual and Family Skills Training

• Phase 3: Family Applications

Treatment generally involves 12 to 24 hours of service over a period of 12 to 24 weeks and is applied in the clinic or home. Modalities of treatment have included parallel individual and family therapy sessions. Group treatment is also an option.

Aspects of culture or group experiences that are addressed (e.g., faith/spiritual component, transportation barriers):

Parental history of being disciplined as a child and of disciplining one’s own children; perspectives on the appropriate use of violence and the role of violence in media and family relationships; stressful life experiences from the perspective of each family member; community support and resources. Additional components related to cultural awareness and respect for cultural differences are in process. A research project completed in 2007 surveyed African-American stakeholders in the child welfare system and community at-large to determine their perspectives on clinical skills that contribute to professional competency with regard to culture and race. Their feedback will be incorporated into the engagement and behavioral management sections of the AF-CBT model.

Trauma type(primary): Physical abuse and exposure to harsh/excessive physical punishment (use of coercion/physical force)

Traumatype(secondary): Ongoing family conflict

Additional descriptors (not included above):

AF-CBT represents an approach to working with physically abused children and their offending caregivers that incorporates therapeutic principles/procedures from several areas, including learning/behavioral theory, family-systems, cognitive therapy, and developmental victimology. It was developed in an urban setting with primarily low-income families. AF-CBT integrates several behavior therapy and CBT procedures that target individual child and parent characteristics related to the abusive experience and the larger family context in which coercion or physical force/aggression occurs. Thus, this approach can be used to address parent and family risks for/correlates of physical abuse and/or common sequelae exhibited by children following the abuse. Treatment emphasizes instruction in specific intrapersonal (e.g., cognitive, affective) and interpersonal (e.g., behavioral) skills designed to promote the expression of prosocial behavior and discourage the use of coercive/abusive behavior at both the individual and family levels. For a detailed description, see Kolko & Swenson, 2002.

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Target Population Age range: School-age children

Gender: r Males rFemales rBoth

Ethnic/Racial Group (include acculturation level/immigration/refugee history--e.g., multinational sample of Latinos, recent immigrant Cambodians, multigeneration African Americans): Treatment is not specifically designed for any one ethnic/racial group, but has been used extensively with urban African-American families and reviewed with several African-American stakeholders in a systematic series of studies that evaluated the relevance and utility of its content/process.

Other cultural characteristics (e.g., SES, religion):

Primarily, but not exclusively, modest to low-income families

Language(s): Mostly English-speaking

Region (e.g., rural, urban): Rural and urban populations

Other characteristics (not included above): AF-CBT is appropriate for use with physically coercive/abusive parents and their school-age children. Although it has been primarily used in outpatient settings, the treatment can be delivered on an individual basis in alternative residential settings, especially if there is some ongoing contact between caregiver and child. This approach is designed for caregivers who exhibit, for example, negative child perceptions, heightened anger or hostility, and/ or harsh/punitive/ineffective parenting practices, or for families involved in verbally or physically coercive interactions. Related methods are designed for use with physically abused children who present with externalizing behavior problems, notably aggressive behavior, coping skills/adjustment problems, poor social competence, internalizing symptoms, and developmental deficits in relationship skills. Parents with serious psychiatric or personality impairments (e.g., substance use disorders, major depression) may benefit from adjunctive and/or alternative interventions. In addition, children or parents with limited intellectual functioning, or very young children may benefit from more simplified services or translations of key concepts. Children with psychiatric disorders (e.g., Attention Deficit Hyperactivity Disorder, Major Depressive Disorder) may benefit from additional interventions, and traumatized children, especially sexually abused children, may be more appropriate candidates for Trauma-Focused CBT.

Essential Components

Theoretical basis: Learning/behavioral theory, family-systems, cognitive therapy, and developmental victimology

Key components:

Child-directed components

• Disclosure of incidents involving hostility and physical force/abuse (causes, characteristics and consequences) to help child understand the context in which they occurred

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Essential Components continued

• Cognitive processing of key experiences to address potential consequences (i.e., views supportive of aggression, attributions of self-blame, etc.) that could maintain use of physical force/abuse

• Training in affect identification, expression, and management skills (e.g., relaxation training, anger control)

• Coping skills discussion and training (healthy vs. unhealthy coping) to address everyday problems (e.g., home, school)

• Social/interpersonal skills training to enhance social competence and development of social support plans

Caregiver/Parent-directed components

• Engagement/rapport-building that includes discussion of family of origin issues and current family circumstances

• Discussion of current referral reasons/child’s disclosure, and family contributors to coercive behaviors

• Cognitive processing of caregiver’s views on hostility/violence (attributions/ beliefs) and child-related developmental expectations that may promote coercive interactions

• Training in affect-regulation skills to manage reactions to abuse-specific triggers (e.g., escalating anger, anxiety, or depression)

• Training in behavior management principles and practices/strategies (e.g., reinforcement and punishment) that serve as alternatives to using physical discipline

Parent-Child or Family-System directed components

• Treatment orientation and socialization to the role of stress and CBT model (A-B-C’s)

• Psychoeducation about child abuse laws, child safety/welfare, and common abuse-related reactions/attributions to address potential consequences (i.e., views supportive of aggression, attributions of self-blame, etc.) that could maintain use of physical force/abuse

• Development of agreement for family to refrain from or limit use of physical force (“no-force” or “low/less” force) and to discuss any such incidents in the family

• Clarification sessions to establish responsibility for the abuse, focus treatment on the needs of the victims/family, and develop safety and relapse prevention plans, as needed

• Communication skills training to encourage constructive and supportive interactions

• Prosocial (nonaggressive) problem-solving skills training to minimize coercion, with home practice applications to help family incorporate them in everyday routines

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Clinical & Anecdotal Evidence

Are you aware of any suggestion/evidence that this treatment may be harmful?

r Yes r No r Uncertain

Extent to which cultural issues have been described in writings about this intervention (scale of 1-5 where 1=not at all to 5=all the time). 2

This intervention is being used on the basis of anecdotes and personal communications only (no writings) that suggest its value with this group. r Yes r No

Are there any anecdotes describing satisfaction with treatment, drop-out rates

(e.g., quarterly/annual reports)? r Yes r No If YES, please include citation: see articles below

Has this intervention been presented at scientific meetings? r Yes r No If YES, please include citation(s) from last five presentations:

APSAC, ABCT, San Diego Conference, others.

Are there any general writings which describe the components of the intervention or how to administer it? r Yes r No

If YES, please include citation: AF-CBT Implementation Guide, v.2.2; Kolko, 1996a; Kolko, 1996b; Kolko, 2002; Kolko & Swenson, 2002

Has the intervention been replicated anywhere? r Yes r No

AF-CBT has been applied in several other clinical and academic settings. Reports from trained practitioners generally indicate positive results in terms of clinical improvements (e.g., reductions in parental use of force/abusive behavior, improved parent-child relationships), and successful case closures within the CPS system.

Other countries? (please list) Canada, Germany, Holland, Israel

Other clinical and/or anecdotal evidence (not included above):

Descriptions of the materials included in the book provide examples of their general application on an outpatient basis in addition to specific suggestions for cases that may require adaptations or special circumstances. Overall, the outcomes of these and related interventions have been fairly robust across different child and caregiver demographic background variables (e.g., age, gender, ethnicity, intellectual functioning and family constellation.) However, specific applications to specific cultural groups or settings have not been formally reported.

x x x x x x

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Research Evidence Sample Size (N) and Breakdown

(by gender, ethnicity, other cultural factors)

Citation

Pilot Trials/Feasibility

Trials (w/o control groups) N=150 SAMHSA pilot study conducted with Safe and Healthy Families Program, Intermountain Care, Salt Lake City, UT

(manuscript in preparation) Randomized Controlled Trials N=55 children By gender: 72% male By ethnicity: 53% African-American or biracial

NCCAN Grant, 1990-1996; Kolko, 1996a; Kolko, 1996b

Studies Describing Modifications 1) Practictioners N=129 2) Children N=31 By gender: 1) 74% female 2) 77% male By ethnicity: 1) 70% Caucasian, 25% African-American, 2% Hispanic; 3% unknown 2) 57% Caucasian, 33% African-American, <1% Hispanic, 9% unknown

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Outcomes What assessments or measures are used as part of the intervention or for research purposes, if any?

Several instruments may be used to evaluate factors in each of the following domains that may contribute to the risks for and/or consequences of child physical abuse (see Kolko & Swenson, 2002). An individualized assessment of this nature is encouraged to help the clinician better identify clinical targets for intervention:

Caregiver parenting practices, including the use of coercive, aggressive, or violent behaviors (e.g., harsh physical discipline) and positive management practice:

• Weekly Report of Abuse Indicators (WRAI; Kolko, 1996a)

• Conflict Tactics Scales—Parent to Child version (CTSPC; Straus et al., 1998)

• Alabama Parenting Questionnaire (APQ; Shelton et al., 1996) Child social skills, interpersonal effectiveness, social withdrawal:

• Child Behavior Checklist (CBCL; Achenbach, 1991)

• Social Skills Rating Scale (SSRS; Gresham and Elliot, 1990) Parental psychological distress and clinical targets

• Brief Symptom Inventory (BSI; Derogatis et al., 1983)

• Parent Opinion Questionnaire (POQ; Azar, 1986) Children’s behavioral and emotional problems

• Child Behavior Checklist (CBCL; Achenbach, 1991)

• Strengths and Difficulties Questionnaire (Bourdon, Goodman, Rae, Simpson & Koretz, 2005)

• Trauma Symptom Checklist for Children (TSCC; Briere, 1996) Family functioning, especially levels of conflict and cohesion

• Family Environment Scale (FES; Moos et al., 1974)

• Family Adaptability Scales-II (FACES-II; Olson et al., 1982)

If research studies have been conducted, what were the outcomes?

Outcome evaluation can include the use of any of the above listed measures for follow-up assessment across a variety of domains (caregiver practices, child emotional and behavioral problems, family cohesion/conflict, etc.). Other measures may be found in Kolko, 2002.

Some of the methods incorporated in AF-CBT have been found efficacious in outcome studies conducted with various populations of parents, children, and families over the past three decades (see Chalk & King, 1998; Kolko, 2002). The individual and family approaches in AF-CBT were evaluated relative to routine community services (RCS) in a clinical trial that evaluated key outcomes through a one-year follow-up assessment. In an initial analysis comparing the treatment course of the two randomized

conditions (individual CBT vs. family therapy; see Kolko, 1996a), weekly ratings of parents’ use of physical discipline/force and anger problems were found to decrease significantly faster among the individual child and parent CBT cases than those receiving family treatment, but both showed significant improvements over time.

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Outcomes continued

In terms of overall clinical outcomes through follow-up (Kolko, 1996b), both the individual CBT and family therapy conditions reported significantly greater improvements than RCS on certain child (i.e., less child-to-parent aggression, child externalizing behavior), parent (i.e., child abuse potential, individual treatment targets reflecting abusive behavior, psychological distress, drug use), and family outcomes (i.e., less conflict, more cohesion.) The official recidivism rates for CBT and family were lower (5-6%) than the rate for RCS (30%). Both CBT and family therapy had high consumer satisfaction ratings.

Implementation Requirements & Readiness

Space, materials or equipment requirements?

Clinicians are encouraged to review the book and maintain copies of relevant materials for efficient use during sessions. It is also helpful to develop tapes for later review during supervision. Clinicians who reach integrity ratings of 75 percent with at least two cases should be adequately competent to administer the treatment. Having a confidential space for conducting sessions, access to clinical supervision, and a system for monitoring and responding to clinical emergencies are important aspects of a clinician’s general readiness for this work.

Supervision requirements (e.g., review of taped sessions)?

We encourage bi-weekly supervision for the first six-12 months to review case progress, issues, and obstacles

To ensure successful implementation, support should be obtained from:

Dr. Kolko, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine

Training Materials & Requirements

List citations for manuals or protocol descriptions and/or where manuals or protocol descriptions can be obtained.

AF-CBT Implementation Guide, AF-CBT Session at a Glance, AF-CBT Session Guide and Handouts; all available from Dr. Kolko.

How/where is training obtained?

Training is intended for mental health professionals with at least some advanced training in psychotherapy skills/methods and experience working with physically abusive caregivers and their children. Participants are encouraged to review a brief summary of the treatment approach beforehand; whenever possible, it is desirable to become familiar with the materials in the author’s book, which provides more detail on assessment and treatment methods. In addition, a pretraining assessment survey is administered to gain an understanding of therapist’s practices and

knowledge. Training generally involves at least six hours of didactic instruction. We strongly advise additional training experiences, including follow-up consultation and supervision on the implementation of AF-CBT with a small caseload; the duration of this experience may vary by level of experience and case difficulty (typical range: six to 18 hours over three to six months). Contact Dr. Kolko to discuss training opportunities.

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Training Materials & Requirements continued

Are intervention materials (handouts) available in other languages?

r Yes r No Not yet; we are working on a Spanish version.

Pros & Cons/ Qualitative Impressions

What are the pros of this intervention over others for this specific group

(e.g., addresses stigma re. treatment, addresses transportation barriers)?

Comprehensive content for children, parents, and families; focus on general use of physical force including child physical abuse; structured session guide with handouts to facilitate implementation.

What are the cons of this intervention over others for this specific group

(e.g., length of treatment, difficult to get reimbursement)?

Requires clinician decision-making about what content should be emphasized.

Other qualitative impressions:

Based on independent supervisor ratings from the author’s original clinical trial (Kolko, 1996a), high levels of therapeutic integrity have been found among trained master’s-level clinicians who have conducted individual CBT (81 percent) and family treatment (85 percent). A simplified version of this integrity checklist for community application is being developed by the author.

Contact Information

Name: David J. Kolko, PhD

Address: University of Pittsburgh, School of Medicine

Phone number: (412) 246-5888

Email: kolkodj@upmc.edu

Website: www.pitt.edu/~kolko

References Achenbach, T. M. (1991). Integrative guide to the 1991 CBCL/4-18, YSR, and TRF profiles. Burlington, VT: University of Vermont, Department of Psychology.

Azar, S. T. & Rohrbeck, C. A. (1986). Child abuse and unrealistic expectations: Further validation of the Parent Opinion Questionnaire. Journal of Consulting and Clinical Psychology, 54, 867-868.

Bourdon, K. H., Goodman R., Rae, D. S., Simpson, G. & Koretz, D. S. (2005). The Strengths and Difficulties Questionnaire: U.S. normative data and psychometric properties. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 557-564.

Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC) professional manual. Odessa, FL: Psychological Assessment Resources.

Chalk, R. & King, P. A. (Eds.). (1998). Violence in families: Assessing prevention and treatment programs. Washington D.C.: National Academy Press.

Derogatis, L. R. & Melisaratos, N. (1983). The Brief Symptom Inventory: An introductory report. Psychological Medicine, 13, 595-605.

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References continued

Kolko, D. J. (1996b). Individual cognitive-behavioral treatment and family therapy for physically abused children and their offending parents: A comparison of clinical outcomes. Child Maltreatment, 1, 322-342. Kolko, D. J. (2002). Child physical abuse. In J.E.B. Myers, L. Berliner, J. Briere, C.T. Hendrix, C. Jenny & T. Reid (Eds.), APSAC handbook of child maltreatment (2nd Ed., pp. 21-54). Thousand Oaks, CA: Sage Publications.

Kolko, D. J. & Swenson, C. C. (2002). Assessing and treating physically abused children and their families: A cognitive behavioral approach. Thousand Oaks, CA: Sage Publications.

Moos, R. H., Insel, P. M. & Humphrey, B. (1974). Combined preliminary manual: Family, work and group environment scales. Palo Alto, CA: Consulting Psychologists Press.

Olson, D. H., Portner, J. & Bell, R. Q. (1982). FACES II: Family Adaptability and Cohesion Evaluation Scales. Minneapolis, MN: Family Social Science, University of Minnesota.

Straus, M. A., Hamby, S. L., Finkelhor, D., Moore, D. W. & Runyan, D. (1998). Identification of child maltreatment with the Parent-Child Conflict Tactics Scales: Development and psychometric data for a national sample of American parents. Child Abuse and Neglect, 22, 249-270.

Shelton, K. K., Frick, P. J. & Wootton, J. (1996). Assessment of parenting practices in families of elementary school-age children. Journal of Clinical Child Psychology, 25, 317–329.

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