You are hereWhat is the Status of Research on AF-CBT?
What is the Status of Research on AF-CBT?
History of the Model
Before reviewing this evidence base, it is important to provide a brief history of the AF-CBT Model. The content and name of AF-CBT has evolved over the past three decades. The initial approach described in the first edition (Ed.1) of the model was developed in 1985 by David J. Kolko, Ph.D., in collaboration with Sharon (Fishman) Hicks, MSW, with consultation from David Wolfe, Ph.D., James Alexander, Ph.D., and Art Robin, Ph.D. After an outcome study in 1996 (Kolko 1996a, 1996b), much of the original content of this approach was outlined in a sourcebook (Kolko & Swenson, 2002) and later described as Abuse-Focused Cognitive-Behavioral Therapy in an early compendium of interventions (Kolko 2003a, 2003b).
AF-CBT was then adapted (Ed.2) and the name changed to Alternatives for Families: A Cognitive-Behavior Therapy in 2007 by David J. Kolko, Ph.D., Amy D. Herschell, Ph.D., Barbara L. Baumann, Ph.D., and Meghan Shaver, MSW. The approach was renamed, in part, to more clearly reflect its focus on skills training designed to expand the family’s repertoire. Another reason for the change was related to the fact that the term “abuse” was later found to apply to only a minority of the families referred for AF-CBT and that, even when the term is applicable, the label may elicit stigma and obstruct rapport. A related model called the PARTNERS CBT for Physical Abuse was developed by Elissa J. Brown, Ph.D. in 2002, with consultation from Anne Marie Albano, Ph.D., Esther Deblinger, Ph.D., David J. Kolko, Ph.D., and Cynthia C. Swenson, Ph.D. Both of these interventions received federal support for their initial evaluation (NCCAN, NIMH, SAMHSA-NCTSN). Beginning in 2010, efforts were initiated to integrate these two related approaches into the current edition of AF-CBT (Ed.3) to enhance its scope, utility, and eventual dissemination.
Brief Summary of AF-CBT Outcomes
Turning to the evidence base on this model, AF-CBT has been found to improve clinical functioning in school-aged children, their parents (caregivers), and other family members following a referral for concerns about parenting practices including child physical abuse (Kolko, 1996a; 1996b, Kolko et al., 2011), as well as a child’s behavior problems (Kolko et al., 2009, 2010, 2012). With its effectiveness supported by outcome studies, AF-CBT has been recognized by other experts as a “model” or “promising” treatment program (see National Child Traumatic Stress Network, www.nctsn.org; Child). AF-CBT is rated a 3, Promising Practice, by the California Evidence Based Clearinghouse for Child Welfare (www.cebc4cw.org). The table below provides a brief summary of the key outcomes associated with AF-CBT based on research studies. The next section provides a more in-depth description of this research.
Summary of AF-CBT Outcomes
Demonstrated Effectiveness in Outcome
During the past three decades, many of the procedures incorporated into AF-CBT have been evaluated by outside investigators as effective in Improving child, parent, and/or family functioning, and promoting safety and/or reducing abuse risk or re-abuse among various populations of parents, children, and families. These procedures have included the use of stress management and anger-control training, cognitive restructuring, parenting skills training, psychoeducational information regarding the use and impact of physical force and hositlity, social skills training, imaginal exposure, and family interventions focusing on reducing conflict (see Kolko, 2002; Kolko & Kolko, 2010; Urquiza & Runyan, 2012). The details of specific research studies are outlined below.
Families Referred for At-Risk Parenting Practices or Child Physical Abuse
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: Journal of the American Professional Society on the Abuse of Children, 1, 322-342.
Kolko, D. J. (1996b). Cllinical monitoring of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse & Neglect, 20(1), 23-43.
The individual child and parent CBT, and family therapy (FT) components now integrated in AF-CBT were randomized and evaluated separately in a study published in 1996. The CBT and FT conditions were also compared to a third condition—participation in routine community services (RCS)—in a clinical trial that evaluated key outcomes through a 1-year follow-up assessment. Findings from this research reflected the following:
- In a comparison of individual CBT and FT (two separate randomized conditions), weekly ratings of parents’ use of physical discipline/force and anger problems during treatment decreased for both groups, although the decline was significantly faster for the group receiving individual CBT (Kolko, 1996a).
- Groups receiving both individual CBT and FT reported greater improvements than routine community services (RCS) on certain outcomes, including:
- Child outcomes, such as less child-to-parent aggression and fewer child externalizing behaviors
- Parent outcomes, such as decreased child abuse potential, improvement in individual treatment targets reflecting abusive behavior, less psychological distress, and less drug use
- Family outcomes, such as less conflict and more cohesion (Kolko, 1996b)
- Official records for the entire study period revealed lower, yet nonsignificant, rates of recidivism among the adults who participated in individual CBT (5 percent) and family therapy (6 percent), compared to those receiving routine services (30 percent).
- Both CBT and FT had high rates of session attendance and high consumer satisfaction ratings.
Kolko, D. J., Iselin, A. M., & Gully, K. (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.
This report describes the long-term sustainability and outcome of Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) as delivered by practitioners in a community-based child protection program who had received training in the model several years earlier. Seven practitioners received a day-long training workshop, 12 monthly case consultation calls, and a follow-up booster workshop. The program’s routine evaluation system was used to document the clinical and treatment outcomes of 52 families presenting with a physically abused child who received AF-CBT content between two and five years after training had ended. Measures of the use of AF-CBT and four other EBTs documented their frequency, internal consistency, intercorrelations, and relationship to several therapist- and parent-rated outcomes. The amount of AF-CBT General and Abuse-specific content delivered was found to predict several clinical and functional improvements in both children and caregivers, above and beyond the influence of the unique content of the other four EBTs. The two AF-CBT content scores were differentially related to several of these outcomes. These novel naturalistic data document the sustainability and clinical benefits of AF-CBT in an existing community clinic serving physically abused children and their families, and are discussed in the context of key developments in the treatment model and dissemination literature.
A recent randomized clinical trial was designed to evaluate the dissemination of AF-CBT with practitioners from the child welfare and mental health systems (Kolko et al., 2012). In sample of 182 practitioners randomized to AF-CBT training or training as usual (TAU), training and consultation in AF-CBT were provided over a 6 month period. HLM analyses based on four time-points (months 0, 6, 12, and 18) revealed significant initial improvements for those in the AF-CBT training condition in their knowledge about AF-CBT and its targeted population, and their use of AF-CBT teaching processes, abuse-specific skills, and general psychological skills. The training program was associated with high rates of practitioner satisfaction. These supportive findings are discussed in the context of treatment training, research, and work force issues that are now being considered more fully as we develop our training program outline/structure, such as the need to understand the diverse professional experiences, client populations, and service settings of interested community practitioners. This is one of the first large-scale randomized trials of the impact of training practitioners in an evidence-based treatment for use with families referred for child abuse or neglect.
Children Referred for Child Behavior Disorders/Problems
Kolko, D. J., Dorn, L. D., Bukstein, O. G., Pardini, D., 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.
This study examines the treatment outcomes of 144, 6-11 year-old, clinically referred boys and girls diagnosed with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) who were randomly assigned to a modular-based treatment protocol that was applied by research study clinicians either in the community (COMM) or a clinic office (CLINIC). The protocol was adapted from the key content modules in AF-CBT. To examine normative comparisons, a matched sample of 69 healthy control children was included. Multiple informants completed diagnostic interviews and self-reports at six assessment time points (pretreatment to 3-year follow-up) to evaluate changes in the child’s behavioral and emotional problems, psychopathic features, functional impairment, diagnostic status, and service involvement. Using HLM and logistic regression models, COMM and CLINIC showed significant and comparable improvements on all outcomes. By 3-year follow-up, 36% of COMM and 47% of CLINIC patients no longer met criteria for either ODD or CD, and 48% and 57% of the children in these two respective conditions had levels of parent-rated externalizing behavior problems in the normal range. The authors discuss the nature and implications of these novel findings regarding the role of treatment context or setting for the treatment and long-term outcome of behavior disorders.
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 Behavioral and Developmental Pediatrics, 31(5), 393-404.
This study sought to determine the effectiveness of an on-site modular intervention based on AF-CBT content in improving access to mental health services and outcomes for children with behavioral problems in primary care, relative to enhanced usual care (outside referral to a local provider). Boys and girls from six primary care offices in metropolitan Pittsburgh, PA were the participants: one-hundred and sixty three clinically referred children who met a modest clinical cutoff (75th percentile) on the externalizing behavior scale of the Pediatric Symptom Checklist-17 were randomized to a protocol for on-site, nurse-administered intervention (PONI) or to enhanced usual care (EUC). PONI applied treatment modules from an evidence based treatment for children with disruptive behavior disorders (AF-CBT) that were adapted for delivery in the primary care setting; EUC offered diagnostic assessment, recommendations, and facilitated referral to a specialty mental health provider in the community. The main outcome was measured using standardized rating scales, including the PSC-17, individualized target behavior ratings, treatment termination reports, and diagnostic interviews were collected. PONI cases were significantly more likely to receive and complete mental health services, reported fewer service barriers and more consumer satisfaction, and showed greater, albeit modest, improvements on just a few clinical outcomes that included remission for categorical behavioral disorders at one-year follow-up. Both conditions also reported several significant improvements on several clinical outcomes over time. These findings suggest that psychosocial intervention for behavior problems that was delivered by nurses in the primary care setting is feasible, improves access to mental health services, and has some clinical efficacy. Options for enhancing clinical outcome include the use of multifaceted collaborative care interventions in the pediatric practice.
Kolko, D. J., Campo, J. V., Kilbourne, A. & Kelleher, K. (2012). Doctor-Office Collaborative Care for Pediatric Behavior Problems: A Preliminary Clinical Trial. Archives of Pediatrics & Adolescent Medicine, 166, 224-231.
This study evaluates the feasibility and clinical utility of an integrated mental health intervention (Doctor-Office Collaborative Care, DOCC) vs. enhanced usual care (EUC) for children with behavior problems. The first two of every three eligible cases were assigned to DOCC (n = 55) and every third case to EUC (n = 23). Initial assessment was conducted in one of six pediatric primary-care practices. Posttreatment assessment was conducted in the pediatric or research office. DOCC was delivered in the practice; EUC was initiated in the office but involved a facilitated referral to a local mental health specialist. Of 125 referrals (ages 5-12), 78 children participated. Children and their parents were assigned to receive DOCC or EUC. In terms of measures, pretreatment diagnostic status was evaluated on the Schedule for Affective Disorders and Schizophrenia for School-Aged Children. Pretreatment and 6-month posttreatment ratings of behavioral and emotional problems were collected from parents on the Vanderbilt ADHD Diagnostic Parent Rating Scale and Individualized Goal Achievement Ratings form. At discharge, care managers and an evaluator completed the Clinical Global Impression Scale, and both pediatricians and parents completed satisfaction and study feedback measures. Group comparisons found significant improvements for DOCC over EUC in service use and completion, behavioral and emotional problems, individualized behavioral goals, and overall clinical response. Parent and pediatrician reports were highly satisfied with DOCC. The feasibility and clinical benefits of DOCC for behavior problems supports the integration of collaborative mental health services for common mental disorders in primary-care.
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Frick, P. J. (1991). Alabama parenting questionnaire. University of Alabama: Unpublished instrument.
Goodman, R., Meltzer, H., Bailey, V. (1998). The strengths and difficulties questionnaire: A pilot study on the validity of the self-report version. European Child & Adolescent Psychiatry, 7(3), 125-130.
Herschell, A. D., Kolko, D.J., Baumann, B.L., & Brown, E.J. (in press). Alternatives for Families: A Cognitive-Behavioral Therapy: Applications in the Schools. Psychology in the Schools.
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, 322-342.
Kolko, D. J. (1996b). Clinical monitoring of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse and Neglect, 20(1), 23-43.
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 (Second ed., pp. 21-54). Thousand Oaks, CA: Sage.
Kolko, D. J., & Kolko, R. P. (2010). Psychological impact and treatment of child physical abuse. In Carol Jenny (ed.), Child abuse and neglect: Diagnosis, treatment and evidence (pp. 476-489). New York: Elsevier, Inc.
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.
Kolko, D. J., Baumann, B. L.., Herschell, A. D., Hart, J., Holden, E. & Wisniewski, S. (2012). Implementation of AF-CBT by Community Practitioners Serving Child Welfare and Mental Health: A Randomized Trial. Child Maltreatment, 17 (1), 30-44. DOI: 10.1177/1077559511427346.
Kolko, D. J., Iselin, A. M., & Gully, K. (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, 105-116.
Kolko, D. J., Brown, E. J., Zelnik, L.. (February, 2013). Assessment and Outcome Measures for Use in AF-CBT (Version #5, 2-1-2013). Unpublished report.
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