Alternatives for Families: A Cognitive-Behavioral Therapy

1. Introduction

Version followed: AF-CBT Session Guide, 3rd edition revised (Kolko, Brown, Shaver, Baumann & Herschell, University of Pittsburgh School of Medicine): 3 phases and 17 topics, with caregiver and child handouts at the back of each topic (274 pages), plus seven "fundamental" clinical skills. The developers cite it as 2011; the NCTSN profile dates the integrated Ed. 3 to 2010 [uncertain on year]. Sources include the developers' own pages (Format and Content, Goals, Clinician Resources, Session Guide and Handouts, Treatment Monitoring) and the NCTSN 2026 profile, which confirm the 17 topic names and their order, the ALTERNATIVES acronym, the three phases, the seven fundamental skills and the CA$H wording. I cross-checked the caregiver, child and family content areas against the chapter structure of the predecessor book (Kolko & Swenson, 2002). The full Session Guide is released only to trainees. Its public preview, the Topics at a Glance sheet and the Topic and Task Checklist are posted on the developer site, but they are not drawn on here. Topic names, handout names, goals and the order of work are therefore sourced, but every step-by-step procedure below is still my reconstruction, tagged [synthesis]. Lineage: Ed. 1 (Kolko with Fishman/Hicks, 1985); Abuse-Focused CBT (Kolko & Swenson, 2002); Ed. 2, renamed Alternatives for Families (2007); Ed. 3, which merged in Brown's PARTNERS CBT for physical abuse. [source: AF-CBT Pittsburgh Format and Content and Session Guide pages; NCTSN 2026 profile; CEBC; Title IV-E Clearinghouse]

AF-CBT is a trauma-informed family treatment for children aged 5 to 17 and their caregivers. It targets family conflict, anger and verbal aggression (emotional abuse included), harsh or coercive physical discipline, child physical abuse, child behaviour problems and aggression, and the child's trauma symptoms that follow these. It combines learning and behavioural theory, cognitive therapy, family systems, developmental victimology and the psychology of aggression. [source: CEBC; AF-CBT Pittsburgh site, About page] The developers state these goals: better caregiver–child relationships; healthier parenting; stronger child coping and social skills; child safety and well-being and family safety; less anger, verbal aggression, threat of force and emotional abuse; less physical force; and lower risk of physical abuse or its recurrence. They list seven strategy components: coping skills and emotion regulation, behaviour management, problem solving, social skills training, positive thinking, communication, and clarification. [source: AF-CBT Pittsburgh Goals page]

How change happens: coercion is maintained by linked thoughts (misattributions about the child's intent, unrealistic expectations, beliefs that force is acceptable, the child's self-blame), feelings (anger, anxiety, hyperarousal) and behaviour (harsh discipline, child aggression, coercive exchanges). Working on all three domains, first within each person (emotion and thinking skills) and then between people (reinforcement, discipline without force, communication, problem-solving, a caregiver's clarification and apology), replaces force with skilled alternatives and makes the home safer. [source: CEBC; Allegheny County summary; NCTSN 2026 profile]

2. Framework

Format. Phases I and II are mainly separate individual sessions with the caregiver and with the child; Phase III is joint caregiver–child sessions. Caregivers can get a brief check-in after child sessions. Any adult caregiver (birth, foster, adoptive, kinship), whether or not they used force, can take part with at least one child, and co-parents are encouraged to join some sessions. Settings: outpatient clinic, home, school, community, and residential or inpatient care when caregiver–child contact is ongoing or likely. [source: CEBC; NCTSN 2026 profile; Allegheny County summary] The developers add that family interventions may take place before, during or after the individual services when needed. Skills are taught through role-play, performance feedback and home practice. [source: AF-CBT Pittsburgh Format and Content page]

Dose. Sources disagree [uncertain]. CEBC gives weekly 1–2 hour sessions, usually 20–24 hours of direct service or more over 6–9 months, with no fixed length. NCTSN (2026) gives 18–24 sessions of 30–120 minutes. Allegheny County gives 18–24 hours over 4–12 months. The 2012 NCTSN sheet gives about 20 sessions of 1–1.5 hours. Topics can be adapted, abbreviated or repeated depending on progress. [source: as named]

Session spine. From the second session on, open with CA$H, which the developers expand as "Check-in on Attendance, Safety, and Home Practice" (an agenda is set alongside), then the topic, rehearsal (role-play with performance feedback) and a tailored home-practice assignment. Track delivery after each contact on the Topic Tracker, which the developers call "a brief checklist of primary content" for sharing with the supervisor; a fuller Topic and Task Checklist and a Brief Case Progress Note also exist. Monitor safety with the Weekly Safety Check-in. Its research precursor, the Weekly Report of Abuse Indicators, collected child and caregiver ratings of parental anger and physical force at each session. [source: AF-CBT Pittsburgh Treatment Monitoring and Clinician Resources pages; NCA overview] [source: Title IV-E Clearinghouse; CEBC; NCTSN 2026; AF-CBT Pittsburgh telehealth page]

Assessment. Assess at intake and repeat, using four recommended measures: Alabama Parenting Questionnaire, Short Form (APQ-SF); Brief Child Abuse Potential Inventory (B-CAP); Child PTSD Symptom Scale (CPSS); and Strengths and Difficulties Questionnaire (SDQ). Combine these with interviews and a functional analysis of coercive episodes. The measures are released only to trainees under the authors' agreements, and no items are given here. [source: CEBC; AF-CBT Pittsburgh telehealth page]

Phase	Topics (C = caregiver, Ch = child, J = joint)	Goals
I. Engagement and Psychoeducation	1 Orientation (C and Ch); 2 Alliance Building and Engagement (C); 3 Learning about Feelings and Family Experiences (Ch); 4 Talking about Family Experiences and Psychoeducation (C)	Engage both; set goals; learn about positive and upsetting home experiences and the referral incident; teach the CBT model and the effects of force and coercion; caregiver commits to limiting physical force; start challenging the child's self-blame
II. Individual Skill-Building	5 Emotion Regulation (C); 6 Emotion Regulation (Ch); 7 Restructuring Thoughts (C); 8 Restructuring Thoughts (Ch); 9 Noticing Positive Behavior (C); 10 Assertiveness and Social Skills (Ch); 11 Techniques for Managing Behavior (C); 12 Imaginal Exposure (Ch, optional); 13 Preparation for Clarification (C)	Build intrapersonal skills (affect, cognition) and then interpersonal ones (reinforcement, discipline without force, social skills); process trauma if PTSD symptoms are present; draft the clarification letter if the caregiver is ready
III. Family Applications	14 Verbalizing Healthy Communication; 15 Enhancing Safety through Clarification; 16 Solving Family Problems; 17 Graduation (all J)	Practise communication together; caregiver takes responsibility and apologises; safety plan and family rules; nonaggressive problem-solving; review skills and prepare for future problems

[source: CEBC; Allegheny County summary; NCA overview; Title IV-E Clearinghouse]

Moving between phases. Sourced rules: the order runs from intrapersonal to interpersonal skills; the order and content can be tailored after intake assessment; imaginal exposure only when the child has significant PTSD symptoms or anxiety about discussing the incident; the clarification letter only when the caregiver is ready. [source: CEBC; Allegheny County; NCA overview; Title IV-E Clearinghouse] Family interventions may also come before, during or after individual services when needed, so phase boundaries are not rigid. [source: AF-CBT Pittsburgh Format and Content page] No explicit readiness criteria from the developers are given in the public sources. Suggested markers [synthesis]:

I → II: the family attends regularly; the caregiver has made a stated commitment to limiting force; a safety plan exists; the child has described family experiences at least in outline.
II → III: the caregiver can name their anger triggers and use a calming skill; there are no recent incidents of force, or incidents are falling (Weekly Safety Check-in); the caregiver accepts responsibility and no longer blames the child; the child feels safe enough to be in the room; the letter has been rehearsed.
III → Graduation: goals are met or plateaued; repeat measures have improved; the family has used problem-solving at home without force.

3. Guiding principles

Sourced principles [source: Allegheny County summary (core principles); CEBC (treatment tasks); NCTSN 2012 and 2026; AF-CBT Pittsburgh site]:

Address thoughts, feelings and behaviour together. Every topic should touch all three. For each conflict, ask what the person thought, felt and did.
Tailor to each family's strengths and challenges. Choose which topics to emphasise and how long to stay on each according to assessment and progress, not page order.
Work comprehensively with caregiver, child and family. Keep the caregiver track, child track and joint work all going, rather than treating only the identified child.
Discourage aggression and coercion from every family member. The goal is no force or threats from anyone: caregiver, child or siblings.
Hold separate but coordinated child and caregiver sessions, then joint sessions. Have each person build skills privately before you bring them together.
Teach intrapersonal skills before interpersonal ones. Teach calming and thinking skills before discipline, communication and problem-solving.
Put safety first. The first treatment task is conflict and force that threaten safety. Review safety every session in CA$H.
Use a trauma-informed stance with the child. The child's reactions are understandable responses to conflict or abuse. Explicitly challenge the child's self-blame.
The caregiver is responsible for force. Through clarification the caregiver takes responsibility and apologises. The child never has to excuse it.
Include any caregiver, whatever their perpetrator status. Non-offending, foster and kinship caregivers are full participants.
Practise skills. Skills are taught with rehearsal, role-play, performance feedback and tailored home practice, not only discussion.
Offer a "one stop shop". One clinician covers what referrers might otherwise buy separately: parenting class, anger management, family therapy, individual therapy and trauma treatment.
Monitor and enhance motivation. Use measures, the Weekly Safety Check-in and the Topic Tracker, and treat engagement as a skill (decisional balance).
Use alternatives to force, not just prohibition. As the model's name implies, every "stop" is paired with a practised alternative. [synthesis: practical reading of the model name and treatment tasks]

4. Intervention inventory

How to read this section: the existence, purpose and placement of each item, and the names of its handouts, come from the sources cited. The Session Guide is restricted to trainees and is not drawn on here. Its public preview, Topics at a Glance and the Topic and Task Checklist are on the developer site but are not drawn on here. Every Steps list is therefore [synthesis]: a reconstruction from the topic descriptions and standard CBT and parent-training practice. Check the steps against the Session Guide if you are trained. All example language is illustrative. Handout names are cited, but their contents are not reproduced. [source: AF-CBT Pittsburgh telehealth page (handout lists); CEBC; Allegheny County summary]

A. Fundamental skills (used throughout)

Assessment and functional analysis

Purpose / when: At intake and at reassessment. Use it to set targets, tailor which topics get emphasis, and track change. The four measures are the APQ-SF (parenting practices), B-CAP (abuse risk), CPSS (child PTSD symptoms) and SDQ (child strengths and difficulties), plus interviews. [source: CEBC; NCTSN 2026]
Steps [synthesis]: (1) Give the measures to caregiver and child separately, by self-report or interview. (2) Interview each person separately about the referral incident and the two or three most recent conflicts. (3) For each episode, map the antecedent (setting, child behaviour, caregiver stressors), the thoughts and feelings, the behaviour (yelling, threats, hitting, objects used, injuries), and the consequences (child stops, escalates, caregiver relieved, guilty). (4) Look for the cycle: which child behaviours trigger force, and what the force achieves in the short term. (5) Turn the findings into two to four goals (handouts: My Goals for Treatment for caregivers, Goal Setting for children). (6) Repeat the measures at mid-treatment and at graduation.
Example language (illustrative): "Walk me through last Tuesday from the moment you got home. What did he do, what went through your mind, and what did you do next?"
Watch for: Caregiver minimisation, or a child's account that differs from the caregiver's. Anything that triggers a mandated report (see Section 5). Working: you can predict the next high-risk moment from the map.

CA$H check-in

Purpose / when: At the start of every session from session 2 on. The developers name it "CA$H: Check-in on Attendance, Safety, and Home Practice", and an agenda is set alongside it. Praise continued attendance, review the safety plan and any use of force, and identify which home-practice skills helped. Use the Weekly Safety Check-in handout and the Session Agenda handout. [source: Title IV-E Clearinghouse; CEBC; AF-CBT Pittsburgh telehealth page] [source for the wording: AF-CBT Pittsburgh Clinician Resources page]
Steps [synthesis]: (1) Thank the person for coming and name any attendance effort. (2) Set a shared agenda: their items plus the topic for today. (3) Go through the Weekly Safety Check-in: any yelling, threats, force or injury since last week, by anyone; ask caregiver and child separately when possible. (4) If force occurred, do a quick functional analysis and update the safety plan before anything else. (5) Review home practice: what was tried, what happened, and which skill helped. Praise any attempt. (6) Use the results to adjust today's topic.
Example language (illustrative): "Before we start, our weekly safety check. Since we met, were there any times someone yelled, threatened, or put hands on anyone?"
Watch for: Check-ins that become rote and take too long. Keep them brief, but never skip safety. Working: the family starts reporting near-misses on their own and names the skills they used.

Alternatives for Families Plan (AFP)

Purpose / when: CEBC and the developers' Clinician Resources page list the AFP as a fundamental clinical skill, and a child handout titled "Alternatives for Families Plan (AFP)" sits in Phase I. Its exact content was not found [uncertain]. Do not confuse it with "Alternatives for Professionals" (also abbreviated AFP), the developers' separate training for case managers and support staff. [source: CEBC; AF-CBT Pittsburgh telehealth, AFP and Clinician Resources pages]
Steps [synthesis, assumed to be an individual plan of alternatives and help-seeking]: (1) List the child's (or family member's) usual high-conflict moments. (2) For each, name one alternative action (leave the room, use a calming skill, ask for help) and one safe adult to contact. (3) Write the plan on the handout, keep a copy at home, and review it in CA$H.
Example language (illustrative): "When things start getting loud at home, what's one thing you can do and one person you can go to?"
Watch for: Plans that put responsibility for preventing adult violence on the child. Frame them as the child's own coping and help-seeking only.

Safety planning and crisis management

Purpose / when: From intake, and again whenever force, threats, a new disclosure or acute risk appears. The first treatment task is addressing conflict and force that threaten safety. [source: CEBC]
Steps [synthesis]: (1) Identify the high-risk situations from the functional analysis. (2) Agree with the caregiver on a no-force commitment and on concrete steps when anger rises (cool-down space, leaving the room, calling a support person, handing off to another adult). (3) Agree with the child on safe places and people (If I Need Help handout). (4) Make mandated reports when required and coordinate with child welfare. (5) Review the plan at every CA$H. (6) After any incident, debrief it in a separate session with each person, update the plan, and slow the move to joint work.
Example language (illustrative): "Your plan says when you notice your jaw tighten, you go to the porch for ten minutes. What got in the way on Saturday?"
Watch for: Safety plans that exist only on paper. Working: incidents fall on the Weekly Safety Check-in.

Managing inconsistent attendance

Purpose / when: Listed as a fundamental skill. Referred families, especially those referred by child welfare, often attend sporadically. [source: CEBC]
Steps [synthesis]: (1) Name and solve practical barriers (transport, schedules, home or school sessions, telehealth). (2) Use reminder calls. (3) Praise attendance at CA$H. (4) Link attendance to the family's own goals, not only to the mandate. (5) After a gap, run a short review and a safety check before going on.
Example language (illustrative): "It's been three weeks. What made it hard to get here, and what would make it easier?"

Managing in-session escalation

Purpose / when: When anger rises during individual or joint sessions. Listed as a fundamental skill. [source: CEBC]
Steps [synthesis]: (1) Set ground rules in the orientation session (no yelling, threats or put-downs, and anyone can call a break). (2) At early signs (raised voice, standing up), name it calmly and prompt the calming skill the person has learned. (3) If needed, separate the family members and meet with each briefly. (4) Process the episode once calm, using the ABC model. (5) Before the family leaves, check that it is safe for them to go home together, and update the plan.
Example language (illustrative): "I'm going to pause us. Let's each take three slow breaths. Mom, can you rate your feelings meter right now?"

Enhancing motivation (decisional balance)

Purpose / when: For mandated, ambivalent or blaming caregivers, and for reluctant youth. The caregiver and child handout lists both include Decisional Balance. [source: CEBC; AF-CBT Pittsburgh telehealth page]
Steps [synthesis]: (1) Explore what is good and not so good about the current way of disciplining or handling conflict. (2) Explore what is good and not so good about changing. (3) Reflect the costs the caregiver names (child's fear, CPS involvement, guilt), and tie them to the caregiver's own goals for the child. (4) Ask for a small commitment.
Example language (illustrative): "Spanking does stop him in the moment. What does it cost you and him over the longer run?"
Watch for: Arguing for change yourself, which tends to provoke the caregiver into defending current practice. Working: change talk increases.

Topic Tracker and session documentation

Purpose / when: After each session or contact. It records which AF-CBT topics were delivered and the family's participation and progress, and you review it with a supervisor. [source: AF-CBT Pittsburgh telehealth page; NCTSN 2026]
Steps [synthesis]: Log the topic, the skills practised, the home practice assigned and the safety status. Every two to three weeks, check for topics that have been skipped.

B. Phase I: Engagement and Psychoeducation

Topic 1: Orientation (caregiver and child)

Purpose / when: First contact. Explain the model and what to expect, build rapport, and set goals. Handouts: Session Agenda, Learning About Each Other, Goal Setting (child), My Goals for Treatment (caregiver). [source: CEBC; AF-CBT Pittsburgh telehealth page]
Steps [synthesis]: (1) Explain the three phases and the individual-then-joint format. (2) Explain the limits of confidentiality and mandated reporting, to caregiver and child separately. (3) Do a get-to-know-you exercise. (4) Elicit each person's goals in their own words. (5) Set ground rules (no force in or outside session; breaks allowed). (6) Agree a schedule.
Example language (illustrative): "This program is about finding alternatives to yelling and hitting that work better for everyone. Each of you will learn some skills on your own first, and later we'll practise them together."

Topic 2: Alliance Building and Engagement (caregiver)

Purpose / when: Early, especially with mandated or defensive caregivers. Build the working relationship and gather family-of-origin history, stressors and current circumstances. Handouts: Stressful Life Experiences, Decisional Balance. [source: NCTSN 2012; NCA overview; AF-CBT Pittsburgh telehealth page]
Steps [synthesis]: (1) Ask how the caregiver was disciplined growing up and how that felt. (2) Review the stressors piling up now (finances, housing, partner conflict, health). (3) Validate the stress without endorsing force. (4) Run a decisional balance on change. (5) Link the caregiver's goals (a child who listens, keeping custody) to the program.
Example language (illustrative): "It sounds like you were raised the way a lot of us were. Some of that you want to keep, and some of it maybe you don't. Let's sort that out."
Watch for: A caregiver who feels judged. Working: they move from talking about the referral to talking about what they want for their child.

Topic 3: Learning about Feelings and Family Experiences (child)

Purpose / when: Early child sessions. Engage the child, identify feelings, explore both positive and upsetting family experiences, teach about safety and common reactions to conflict, and process incidents of force to challenge self-blame. Handouts: Look, Listen, Ask; Identifying Feelings; My Positive Experiences at Home; My Upsetting Experiences at Home; AFP. [source: Allegheny County summary; NCA overview; AF-CBT Pittsburgh telehealth page. The predecessor book's child chapters cover the same ground: the child's experiences of family hostility and violence, clarifying and changing the child's view of violence, normalising abuse-related reactions, and psychoeducation about abuse (Kolko & Swenson, 2002, chs. 7–8, contents page)]
Steps [synthesis]: (1) Start with feelings vocabulary, using faces or lists matched to the child's age. (2) Ask about good times at home first. (3) Then ask about upsetting times, including the referral incident: what happened, why the child thinks it happened, and what happened afterwards. (4) Teach that conflict and force are never a child's fault, and that fear, anger and jumpiness are common reactions. (5) Gently correct self-blame. (6) Make an initial safety and help-seeking plan.
Example language (illustrative): "Lots of kids think they got hit because they were bad. Grown-ups are in charge of keeping their hands safe, even when kids misbehave."
Watch for: Fear of getting the caregiver in trouble, loyalty conflicts, new disclosures (report as required) and signs of PTSD (which indicate Topic 12).

Topic 4: Talking about Family Experiences and Psychoeducation (caregiver)

Purpose / when: After rapport is built. Get the caregiver's account of the incident and their views on physical discipline, and judge whether those views can change. Teach the CBT (ABC) model and the effects of physical abuse and coercion, review the child's exposure to emotional abuse, and obtain a commitment to limit physical force. Handout: ABC Model. [source: Allegheny County summary; NCA overview; CEBC]
Steps [synthesis]: (1) Ask for the caregiver's account without challenging it yet. (2) Draw the ABC chain of that incident with them: Activating event, Beliefs/thoughts, Consequences (feelings and actions). (3) Ask what the caregiver believes about physical discipline and where those beliefs came from. (4) Explain how force and harsh words affect children: fear, aggression, damage to the relationship, and that obedience lasts only in the short term. (5) Ask for a written or spoken commitment to limit physical force, linked to the safety plan.
Example language (illustrative): "So the A was him talking back in front of your sister, the B was 'he's disrespecting me on purpose', and the C was you grabbing his arm. That B is something we can work with."
Watch for: Defensiveness. Go back to decisional balance if needed. Working: the caregiver can name their own B.

C. Phase II: Individual Skill-Building

Topics 5 and 6: Emotion Regulation (caregiver, then child)

Purpose / when: Teach caregivers to manage anger and anxiety, especially around abuse-specific triggers, and address depression. Teach children self-control when frustrated or stressed: identifying, expressing and managing feelings, with relaxation and anger control. Handouts (both tracks): The Body's Response to Anger and Anxiety, Feelings Meter, How to Relax, Relaxation Plan; for the child, also Feelings Meter Graph. [source: Allegheny County; NCA overview; NCTSN 2012; AF-CBT Pittsburgh telehealth page; Kolko & Swenson (2002), contents page: ch. 12, the adult's self-management of abuse-specific triggers, anger, anxiety/PTSD and depression; ch. 9, the child's affect identification and expression and stress, anxiety and anger management]
Steps [synthesis]: (1) Explain the body's alarm response: heart rate, muscle tension, heat, tunnel vision. (2) Have the person map their own early warning signs. (3) Introduce the feelings meter (a 0–10 intensity rating) and identify the point at which they lose control. (4) Teach and rehearse in session at least one calming skill: slow breathing, progressive muscle relaxation, or calming imagery for children. (5) Add cognitive coping statements and a cool-down or time-away plan. (6) Write a Relaxation Plan (when, where, which skill). (7) Assign daily practice when calm, plus use at a meter rating of about 4–5, before the danger zone. (8) Children can chart their ratings on the graph through the week.
Example language (illustrative): Caregiver: "Where's the first place you feel it, and what number is that on your meter? That's your cue to step out, not the 9." Child: "Let's make your belly rise like a balloon. Breathe in for four and out slowly."
Watch for: Relaxation practised only in session, or skills tried at 9/10 and then declared useless. Caregiver depression or substance use may need extra care (a substance-use supplement exists [source: CEBC]). Working: the person reports catching themselves earlier and lower ratings at incidents.

Topic 7: Restructuring Thoughts (caregiver)

Purpose / when: After emotion regulation. Identify and change thoughts that drive coercion, such as hostile misattributions ("he does it to get at me"), unrealistically high expectations for the child's age, and beliefs that endorse force. Handouts: ABC Model, ABC Model Pathway. [source: CEBC; Allegheny County; NCTSN 2012; AF-CBT Pittsburgh telehealth page; Kolko & Swenson (2002), contents page, ch. 11: parental views on hostility and violence, expectations of children, negative or distorted thinking, stress management]
Steps [synthesis]: (1) Review a recent incident on the ABC model. (2) Catch the automatic thought at the B. (3) Test it: what else could explain the behaviour? What can a typical child of this age do? What evidence is there? (4) Generate a balanced alternative thought. (5) Trace the pathway: how the new B changes the feeling and action at C. (6) Rehearse the new thought for the family's typical triggers. (7) Home practice: log one or two episodes a week on the ABC sheet.
Example language (illustrative): "When she spilled the juice, the thought was 'she never listens.' What would a five-year-old's brain actually be doing in that moment?"
Watch for: Arguing with the caregiver instead of using guided discovery. Working: the caregiver spontaneously offers a less hostile explanation.

Topic 8: Restructuring Thoughts (child)

Purpose / when: Address the child's self-blame, beliefs that support aggression ("hitting is how you get respect"), and hostile attributions toward peers. Teach cognitive coping tools. Handouts: ABC Model, ABC Model Pathway. [source: CEBC; NCA overview; NCTSN 2012; Kolko & Swenson (2002), contents page, ch. 8: clarifying and changing the child's view of violence]
Steps [synthesis]: (1) Teach thoughts, feelings and actions using a cartoon or story ABC suited to the child's age. (2) Identify the child's own unhelpful thoughts. (3) Practise helpful self-talk ("I can walk away"; "It's not my fault"). (4) Role-play peer and home situations. (5) Practise at home.
Example language (illustrative): "When Jaylen bumped you, you thought he did it on purpose. What else might have happened?"
Watch for: Teaching a child to reframe genuinely unsafe treatment as acceptable. Restructuring targets self-blame and aggression, not the child's accurate perception of danger [synthesis].

Topic 9: Noticing Positive Behavior (caregiver)

Purpose: increase positive caregiver attention and reinforcement so the caregiver relies less on punishment. It covers active listening, praise, rewards and differential reinforcement. Handouts: Matching Parenting Technique with Behavior, Attending to Your Child, Praise Statements, Types of Rewards, When-Then Statements, Positive Opposites. [source: Allegheny County; NCA overview; AF-CBT Pittsburgh telehealth page; Kolko & Swenson (2002), contents page, ch. 13: techniques and guidelines for rewarding behaviour] The component steps below are [synthesis] based on standard behavioural parent training.

Matching parenting technique to behaviour

Purpose / when: Before teaching any discipline tool, sort the child's behaviours into those to encourage, minor annoyances to ignore, and dangerous or destructive behaviours that need a consequence.
Steps: (1) List the child's behaviours. (2) Assign each to a category and the technique that fits it. (3) Use the list to choose this week's targets.
Example language (illustrative): "Whining goes in the 'ignore' box, hitting his sister goes in the 'consequence' box, and sharing goes in the 'praise like crazy' box."

Attending (active listening and child-led time)

Steps: (1) Hold a short daily period (several minutes) of child-led play or chat. (2) The caregiver describes and reflects what the child is doing and saying. (3) No commands, questions or criticism during this time. (4) Coach it live in session, then assign it daily.
Example language (illustrative): "Just narrate. 'You're building the tower really high.' Like a sportscaster, no instructions."
Watch for: Commands creeping back in. Working: the child seeks out the caregiver.

Praise statements

Steps: (1) Make praise specific (labelled praise names the exact behaviour). (2) Give it immediately. (3) Keep it warm and free of sarcasm or "but". (4) Set a target number of praises per day, tracked at CA$H.
Example language (illustrative): "Thank you for putting your shoes away the first time I asked."

Rewards

Steps: (1) Choose social, activity and small tangible rewards with the child. (2) Link each to a clearly defined target behaviour. (3) Deliver consistently, then fade to praise.
Watch for: Rewards that get withheld for unrelated misbehaviour.

When-then statements

Steps: State the expected behaviour first and the privilege second, calmly, then follow through. Handout: When-Then Statements.
Example language (illustrative): "When your homework is done, then you can have the tablet."

Positive opposites (differential reinforcement)

Steps: (1) For each problem behaviour, name its positive opposite (hitting → gentle hands; yelling → inside voice). (2) Praise and reward the opposite whenever it happens. (3) Pair with ignoring minor versions of the problem behaviour.
Example language (illustrative): "He's not hitting his brother right now. That's the moment to catch: 'Nice job keeping your hands to yourself.'"
Working (all Topic 9 tools): The praise-to-criticism ratio rises at CA$H, and the caregiver reports fewer power struggles.

Topic 10: Assertiveness and Social Skills (child)

Purpose / when: Build the child's social competence and interpersonal skills, plus a social support plan. Handouts: Ways to Be Nice to Friends and Family, If I Need Help. [source: Allegheny County; NCA overview; NCTSN 2012; AF-CBT Pittsburgh telehealth page; Kolko & Swenson (2002), contents page, ch. 10: children's coping skills, social support, social competence and relationships]
Steps [synthesis]: (1) Teach the difference between passive, aggressive and assertive responses. (2) Model assertive requests and refusals: calm voice, eye contact, "I" statements. (3) Role-play peer and sibling scenarios, with feedback. (4) Practise kind behaviours (Ways to Be Nice). (5) Make a help plan naming trusted adults at home, at school and in the community, and when to go to them.
Example language (illustrative): "Let's try it strong but not mean: 'Stop, I don't like that. Give it back, please.'"
Watch for: Assertiveness used against a caregiver who still uses force, which could raise risk. Coordinate with the caregiver track and the safety plan [synthesis].

Topic 11: Techniques for Managing Behavior (caregiver)

Purpose: discipline alternatives to physical force for dangerous, destructive or noncompliant behaviour, including planned (active) ignoring, removing privileges and time out. Handouts: Giving Effective Instructions, Natural and Logical Consequences, When-Then Statements, Active Ignoring, Removing Privileges Plan, Time Out from Positive Reinforcement Plan, Contracts. Teach these only after Topic 9 is in place. [source: Allegheny County; NCA overview; CEBC; AF-CBT Pittsburgh telehealth page; Kolko & Swenson (2002), contents page, ch. 13: techniques and guidelines for punishing behaviour] The component steps below are [synthesis] based on standard behavioural parent training.

Giving effective instructions

Steps: (1) Get close and get the child's attention. (2) Give one direct, specific, positively stated instruction ("put the cup in the sink", not "stop being messy"). (3) Wait a few seconds in silence. (4) Praise compliance. (5) If the child does not comply, give one calm warning that names the consequence, then follow through.
Example language (illustrative): "Marcus, look at me. Please put your backpack on the hook."
Watch for: Question-commands, strings of several commands, and shouting from another room.

Natural and logical consequences

Steps: (1) Let natural consequences happen when they are safe (a forgotten jacket means feeling cold). (2) Choose logical consequences that are related to the behaviour, brief, and announced in advance (crayons on the wall means cleaning the wall). (3) Deliver them calmly, without lecturing.

Active ignoring

Steps: (1) Use only for minor attention-seeking behaviour such as whining or tantrums, never for dangerous behaviour. (2) Withdraw eye contact, comments and touch. (3) Expect the behaviour to get worse briefly before it improves, and warn the caregiver about this in advance. (4) Re-engage and praise as soon as the child behaves well (pair with positive opposites).
Example language (illustrative): "It'll probably get louder before it stops. If you give in at the loudest point, he learns that loud works."

Removing privileges

Steps: (1) Agree on a menu of privileges in advance (screen time, a later bedtime). (2) Make each removal short and proportionate, and set a clear time for the privilege to come back. (3) No stacking of removals into days or weeks. (4) Write it on the Removing Privileges Plan.

Time out from positive reinforcement

Steps: (1) Use for target behaviours such as hitting or defiance after a warning. (2) Choose a boring, safe spot with no toys or screens. (3) Use a brief time, matched to age, and a calm, short instruction to go. (4) Have a backup if the child refuses, such as losing a privilege. Do not physically force or hold the child in time out [synthesis]. (5) Afterwards, return to the original instruction and praise compliance. (6) Rehearse with the caregiver through role-play before using at home.
Example language (illustrative): "You hit. Time out, four minutes." (Then silence.)
Watch for: Time out used angrily or for very long periods, locked rooms, or physical struggles to enforce it. These recreate coercion and must be stopped [synthesis].

Contracts

Steps: (1) Mainly for older children and teens: negotiate a written agreement listing specific behaviours, the privileges earned, the consequences, and a review date. (2) Both sign it. (3) Review it at CA$H.
Working (all Topic 11 tools): Fewer incidents on the Weekly Safety Check-in, and the caregiver reports using a planned tool instead of yelling or force.

Topic 12: Imaginal Exposure (child, optional)

Purpose / when: Only for children with significant PTSD symptoms (for example on the CPSS) or with anxiety about discussing the incident or other home conflict. It helps the child say what happened and make meaning of it. Use it after the child has emotion-regulation and cognitive skills. [source: CEBC; Allegheny County; NCA overview; NCTSN 2012 ("Imaginal exposure and making meaning")]
Contraindications, safety and consent [synthesis]: Do not start, or pause, if the child is still in an unsafe home with ongoing force, if there is acute suicidality or self-harm, if the child is psychotic or acutely dissociative, or if the child cannot yet use a calming skill. Get informed consent from the legal guardian (and check whether child welfare must also consent) and assent from the child. Explain the rationale (facing memories in small steps makes them less upsetting) and the child's right to pause. Agree a stop signal. Consider whether the caregiver who used force should be told the details, and protect the child from any retaliation.
Steps [synthesis]: (1) Give the rationale in words suited to the child's age. (2) Build a hierarchy of memories or reminders, from least to most upsetting, using the feelings meter. (3) Start at a moderate item. The child tells what happened, in present tense if able, using drawing, play or writing if that is easier. (4) Take meter ratings during and after. (5) Repeat the account across sessions until distress falls, then move up the hierarchy. (6) After each exposure, process the meaning: correct self-blame and identify what the child now knows about safety. (7) End every session with a calming skill and a pleasant activity. (8) Check with the caregiver after the session about sleep and behaviour (without sharing details if that is unsafe).
Example language (illustrative): "Tell me what happened that night, starting when you heard the door. I'll ask for your number now and then. Hold up your hand any time you need a break."
Watch for: Avoidance, distress that does not come down within the session, dissociation, nightmares or behaviour getting worse at home. Slow the pace and add coping. Working: meter peaks fall across repetitions, avoidance drops, and CPSS scores fall.

Topic 13: Preparation for Clarification (caregiver)

Purpose / when: Begin a clarification letter to read to the child, if the caregiver is ready. In the letter the caregiver takes responsibility, apologises and explains how the home will be made safer. Handout: Clarification Letter Sections. [source: Allegheny County; Title IV-E Clearinghouse; NCA overview; AF-CBT Pittsburgh telehealth page. In the predecessor book, clarification is the bridge from individual to family treatment and has its own chapter on its general structure and the clarification family meeting (Kolko & Swenson, 2002, ch. 14, contents page)]
Readiness [synthesis]: The caregiver takes responsibility without blaming the child, can manage their own emotion when talking about the incident, and has had no recent force. Child welfare or court constraints have been checked.
Steps [synthesis]: (1) Explain what clarification is for: the child hears from the adult that the force was the adult's responsibility and what will be different. (2) Draft the letter across one or more sessions. Likely contents are an honest description of what happened, acceptance of responsibility, an apology, recognition of the child's feelings, and the safety changes and family rules going forward (the published section names were not found [uncertain]). (3) Edit out any blame of the child, any minimising, any excuses, and any demand for forgiveness. (4) Rehearse reading it aloud, and role-play the child's possible reactions (anger, silence, questions). (5) Separately, prepare the child: what will happen, their right to respond or to say nothing, and a stop signal.
Example language (illustrative): "Read me the line about why it happened again. Hear the 'because you wouldn't listen' in there? Let's rework it so it's about your choice."
Watch for: Letters that are really about the caregiver's guilt or that ask the child to reassure them. Working: the letter is short, specific and centred on the child.

D. Phase III: Family Applications (joint sessions)

Topic 14: Verbalizing Healthy Communication

Purpose / when: Change the verbal and nonverbal habits that derail family communication, and practise constructive, supportive talk together. Handouts: Common Communication Obstacles, Communication Alternatives. [source: NCA overview; NCTSN 2012; AF-CBT Pittsburgh telehealth page]
Steps [synthesis]: (1) Each person names obstacles they notice in themselves (yelling, sarcasm, name-calling, bringing up the past, eye-rolling, interrupting). (2) Teach alternatives: "I" statements, staying on one topic, listening and reflecting before responding, a calm tone and body posture. (3) Practise on a low-conflict topic with turn-taking. Coach in the moment and give feedback. (4) Move to moderate topics. (5) Home practice: a short family talk time each week.
Example language (illustrative): "Mom, before you answer, tell her back what you heard her say."

Topic 15: Enhancing Safety through Clarification

Purpose / when: The joint clarification session. The caregiver reads the letter, takes responsibility, apologises and explains how the home will be made safer. The child listens, responds or asks questions. The family commits to safety plans and family rules. [source: NCA overview; Allegheny County; NCTSN 2012 (clarification establishes responsibility, centres victims' needs and creates safety and relapse-prevention plans); Kolko & Swenson (2002), ch. 14, "The Clarification Family Meeting" (contents page)]
Steps [synthesis]: (1) Hold a brief separate check-in with each person first. (2) Restate the ground rules and the stop signal. (3) The caregiver reads the letter. (4) The child responds or asks questions, and the therapist supports the child's voice. (5) Review the family safety plan and family rules together. (6) Close with a calming activity. (7) Hold separate debriefs afterwards, the same day or at the next session.
Example language (illustrative): To the child: "You can say anything you want, ask anything, or just listen. You don't have to say it's okay."
Watch for: A caregiver going off-script into excuses (pause and redirect), a child who feels pressured to forgive, or a child who shuts down. Working: the child reports feeling safer, and the safety plan is followed at home.

Topic 16: Solving Family Problems

Purpose / when: Teach steps for solving problems without aggression, applied to real family issues, with home practice so the skills become part of daily routines. Handout: Problem Solving Skills (both tracks). [source: NCA overview; NCTSN 2012; Allegheny County; AF-CBT Pittsburgh telehealth page]
Steps [synthesis; standard problem-solving sequence]: (1) Define the problem specifically and without blame. (2) Brainstorm options without judging them. (3) Weigh the pros and cons of each for every family member. (4) Choose an option and plan who does what and when. (5) Try it at home. (6) Review at the next CA$H and revise. Start with small problems such as chores or screen time before moving to hot topics.
Example language (illustrative): "Let's write the problem as 'mornings are rushed and everyone ends up yelling', not 'Tyler is lazy'."

Topic 17: Graduation

Purpose / when: When goals are met. Review progress and the skills learned, revisit safety plans, and prepare for future problems. [source: Title IV-E Clearinghouse; NCTSN 2012]
Steps [synthesis]: (1) Repeat the four measures and share the change. (2) Each member names the skills they will keep using. (3) Identify future high-risk times (adolescence, new partners, stress) and plan for them. (4) Update the safety plan and the list of supports. (5) Celebrate, for example with a certificate. (6) Offer booster contacts.
Example language (illustrative): "What will be the first sign that things are slipping, and what's the first thing you'll do?"

E. Cross-cutting methods

Rehearsal, role-play and performance feedback

Purpose: The model teaches skills through role-play, performance feedback and home practice. [source: Allegheny County]
Steps [synthesis]: Model the skill, have the client practise, give specific praise and one correction, then practise again. Use reverse role-play (therapist plays the child) for caregivers.

Tailored home practice

Purpose: Tailored home practice is assigned for each skill, with feedback, and reviewed at CA$H. [source: CEBC]
Steps [synthesis]: Assign one small, specific task each session, written on the relevant handout. Troubleshoot barriers before the family leaves.

Brief caregiver check-in after child sessions

Purpose: Keep the caregiver informed, coordinate the two tracks and check safety after child sessions. [source: CEBC]
Steps [synthesis]: Share the skill the child learned and how the caregiver can prompt or praise it. Protect the child's confidential disclosures unless safety requires sharing them.

5. Handling problems

The sources name four of these problems as "fundamental skills" (safety planning and crises, inconsistent attendance, in-session escalation, enhancing motivation) and describe adaptations for foster care, substance use and telehealth, but they do not give the procedures [source: CEBC; NCTSN 2026; AF-CBT Pittsburgh telehealth page]. The developers' Clinician Resources page confirms the titles (Safety Planning and Other Potential Crises; Addressing Inconsistent Attendance; Managing Escalation in Session; Enhancing Motivation) and says the guidance is at the start of the Session Guide. Everything below is [synthesis] unless tagged otherwise.

New incident of force, or a new disclosure, during treatment. Make a mandated report as required by local law and tell child welfare if the family has an open case. Explain to the caregiver that you are reporting, unless that would endanger the child. Pause joint work. Hold separate safety sessions, do a functional analysis of the incident, and revise the safety plan. Return to Topics 5, 7 or 11 as the analysis indicates. Do not move on to clarification until there has been a stretch of time with no force.
Denial, minimising or blaming the child. Do not argue. Go back to decisional balance (Topic 2) and to the caregiver's own goals for the child. Use the ABC model on low-stakes episodes first. Accept partial responsibility as a starting point. Postpone clarification (Topic 13 is explicitly conditional on readiness [source: Allegheny County]). If denial persists, the child track and safety planning can still go ahead.
Mandated, hostile or "I don't need this" caregivers. Separate yourself from the court or agency. Frame the program as a way to get child welfare out of the family's life and to get a child who listens. Use the "one stop shop" framing: one service meets several mandated requirements [source: NCTSN 2026].
Strong cultural or religious endorsement of physical discipline. Explore the values behind it (respect, safety, raising a good adult). Use decisional balance about outcomes, not morality. Present Topics 9 and 11 as more effective routes to the same values. Note that cultural adaptations are in development for Black/African-American and Spanish-speaking families, and that advisory groups have reviewed the materials [source: NCTSN 2026].
Inconsistent attendance. Problem-solve practical barriers. Offer home, school or telehealth sessions (all are permitted settings [source: CEBC; AF-CBT Pittsburgh telehealth page]). After a gap, run a short re-entry session (CA$H, safety, recap) before introducing new topics. Shorten or combine topics rather than dropping the safety work.
Non-adherence to home practice. Make tasks smaller and more specific, and practise them in session until they are easy. Link each task to a problem the caregiver raised that week. Praise partial attempts at CA$H. Ask "what got in the way?" rather than "why didn't you?"
Escalation in session (caregiver, child or both). Use the in-session escalation skill (see Section 4): pause, prompt calming, separate the family if needed, and process once calm. Before the family leaves, check that it is safe for them to go home together, and update the plan if needed.
Overwhelmed caregiver (depression, trauma history, poverty, substance use). Spend extra time on Topic 5, cut the session content to one skill, and link the family to concrete supports. Refer for adult treatment when needed. A supplement covers substance use [source: CEBC]. The effectiveness trial excluded adults with severe mental illness, substance abuse or intellectual limitations, so evidence for these groups is limited [source: APSAC brief on Kolko et al., 2018].
Child overwhelmed, avoidant or dissociating. Strengthen Topic 6 skills first. Use the feelings meter and pace exposure gradually. Switch to drawing or play. If PTSD symptoms are severe or there is ongoing risk, defer Topic 12 or consider a dedicated trauma treatment. Screen for suicidality and self-harm with standard risk assessment, and if risk is present, do safety planning and lethal-means counselling (secure or remove medications and weapons).
Child refuses joint sessions or is afraid of the caregiver. Do not force contact. Keep doing individual work. Use graded steps: a letter read by you, then a brief joint session with an exit plan. Respect the child's veto on clarification. Coordinate with child welfare where the caregiver who used force does not live with the child.
Clarification goes badly. If the caregiver makes excuses, blames the child or asks for forgiveness, stop the session and meet with each person separately. Repair with the child first ("that wasn't okay, and it's not your job to fix it"), then rework the letter with the caregiver. Repeat clarification only once readiness is re-established.
Ruptures with the caregiver (feeling judged, sided against) or with the youth (seeing you as the caregiver's agent). Name the rupture and ask for the person's view. Take responsibility for your part. Restate confidentiality limits openly. Rebalance time between the two tracks. Brief caregiver check-ins after child sessions [source: CEBC] can reduce suspicion if you keep them transparent.
Escalation when extinction is used. Warn the caregiver in advance that ignoring and time out can make behaviour worse at first. Rehearse a plan for the worst case. Forbid physical enforcement. If the risk of force rises, drop back to praise and positive opposites and add safety planning.
Caregiver changes (placement moves, reunification, kinship). AF-CBT can involve any caregiver and has a foster-care supplement [source: CEBC; NCTSN 2026]. Re-run orientation with the new caregiver, adapt the clarification work (a non-offending caregiver can affirm that the child is not to blame and commit to safety) [synthesis], and plan joint sessions around visitation.
Slow progress or a plateau. Re-administer the measures. Check the Topic Tracker for skipped topics. Re-tailor the goals. The trial authors recommend more emphasis on tailoring goals and strategies to each family [source: APSAC brief]. Consult your AF-CBT consultant or supervisor (consultation is part of the training model [source: CEBC]).
Telehealth delivery. Use fillable handouts on a shared screen, and administer measures by shared screen, email or phone. Record per agency policy (a therapist-only recording is acceptable for fidelity review). [source: AF-CBT Pittsburgh telehealth page] Confirm the child has privacy and safety during child sessions, and pause any exposure or clarification work that cannot be done safely remotely [synthesis].

Sources

Sources:

Further reading (not drawn on): Kolko, Iselin & Gully (2011) full text; the developers' PDFs (Session Guide 3rd ed. preview, Topics at a Glance, Topic and Task Checklist); the Kolko (1996a) full text (abstract only); Kolko & Swenson (2002).