Issue brief

U.S. Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

Children’s Bureau

Child Welfare Information Gateway

Children’s Bureau/ACYF

1250 Maryland Avenue, SW

Eighth Floor

Washington, DC 20024

703.385.7565 or 800.394.3366

Email: info@childwelfare.gov

www.childwelfare.gov

Abuse-Focused 

Cognitive 

Behavioral 

Therapy for Child 

Physical Abuse

March 2007

Promising Practices in 

Child Welfare

This issue brief was developed by 

Child Welfare Information Gateway, 

in partnership with the Chadwick 

Center for Children and Families. 

Contributing authors include David 

Kolko, Ph.D., Robyn Igelman, Ph.D., 

Nicole Taylor, Ph.D., Charles Wilson, 

M.S.S.W., and Maiken Thorvaldsen, 

M.A. Other contributors include 

Amy Herschell, Ph.D. and Barbara 

Baumann, Ph.D.

The conclusions discussed here 

are solely the responsibility of the 

authors and do not represent the 

official views or policies of the 

funding agency. The Children’s 

Bureau does not endorse any 

specific treatment or therapy.

What’s Inside:

What makes AF-CBT unique 

Key components

Target population

Effectiveness of AF-CBT

What to look for in a therapist

Resources for more information

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Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse www.childwelfare.gov

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Children who have experienced physical 

abuse are at risk for developing significant 

psychiatric, behavioral, and adjustment 

difficulties. During the past three decades, 

research has documented the efficacy of 

several behavioral and cognitive-behavioral 

methods, many of which have been 

incorporated in abuse-focused cognitive 

behavioral therapy (AF-CBT). AF-CBT 

has been found to improve functioning 

in school-aged children, their parents 

(caregivers), and their families (Kolko, 1996a; 

1996b). AF-CBT is an evidence-supported 

intervention that targets individual child and 

parent characteristics related to the abusive 

experience, and the family context in which 

coercion or aggression occurs. This approach 

emphasizes training in interpersonal skills 

designed to enhance self-control and reduce 

violent behavior.

This issue brief is intended to build a better 

understanding of the characteristics and 

benefits of AF-CBT. It was written primarily 

to help child welfare caseworkers and other 

professionals who work with at-risk families 

make more informed decisions about when to 

refer children and their parents and caregivers 

to AF-CBT programs. This information also 

may help parents, foster parents, and other 

caregivers understand what they and their 

children can gain from AF-CBT and what to 

expect during treatment. In addition, this 

issue brief may be useful to others with an 

interest in implementing or participating in 

effective strategies for the treatment of child 

physical abuse.

What Makes AF-CBT Unique

The families in which physical child abuse 

occurs have often experienced stressful life 

events that may lead parents to maintain 

negative perceptions or attributions of their 

children, heightened anger or hostility, 

coercive family interactions, and harsh or 

punitive parenting practices. As a result, 

abused children from these families may 

experience aggression, behavioral problems, 

trauma-related emotional symptoms, 

poor social and relationship skills, and 

cognitive impairment.

AF-CBT addresses both the risk factors and 

the consequences of physical abuse in a 

comprehensive manner. This approach draws 

from a variety of therapeutic approaches 

and implements procedures that have been 

successful in improving positive family 

relations and reducing family conflict in diverse 

populations of parents, children, and families.

Reflects a Comprehensive 

Treatment Strategy

The diversity of family circumstances 

and individual problems associated with 

physical abuse points to the need for a 

comprehensive treatment strategy that targets 

both the contributors to abusive behavior 

and children’s subsequent behavioral and 

emotional adjustment (Chadwick Center, 

2004). Treatment approaches that focus on 

several aspects of the problem (for example, 

a caretaker’s parenting skills, a child’s 

anger, family coercion) may have a greater 

likelihood of reducing re-abuse and more 

fully remediating any mental health problems 

(Kolko & Swenson, 2002). Therefore, AF-CBT 
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adopts a comprehensive treatment strategy 

that addresses the complexity of the issues 

more completely.

Integrates Several 

Therapeutic Approaches

AF-CBT combines elements drawn from:

Cognitive therapy, which aims to change 

behavior by addressing a person’s thoughts 

or perceptions, particularly those thinking 

patterns that create distorted views 

Behavioral and learning therapy, which 

focuses on modifying habitual responses 

(e.g., anger, fear) to identified situations 

or stimuli

Family therapy, which examines patterns 

of interactions among family members to 

identify and alleviate problems

Developmental victimology, which 

describes processes involved in the onset 

and maintenance of abusive behavior, 

and how the specific sequelae of the 

abusive experience may vary for children at 

different developmental stages and across 

the lifespan

AF-CBT pulls together many techniques 

currently used by practitioners, such as 

behavior and anger management, problem 

solving, social skills training, and cognitive 

restructuring. The advantage of this program is 

that all of these techniques, relevant handouts, 

training examples, and outcome measures 

are integrated in a structured approach that 

practitioners and supervisors can easily access 

and use.

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Treats Children and Parents 

Simultaneously

During AF-CBT, school-aged children and 

parents (or caretakers) participate in separate 

but coordinated therapy sessions, often using 

somewhat parallel treatment materials. In 

addition, children and parents attend joint 

sessions together at various times throughout 

treatment. This approach seeks to address 

individual and parent-child issues in an 

integrated fashion.

Discourages Aggressive 

or Violent Behavior

The AF-CBT approach is designed to promote 

appropriate and prosocial behavior, while 

discouraging coercive, aggressive, or violent 

behavior. Consistent with cognitive-behavioral 

approaches, AF-CBT includes procedures 

that target three related ways in which people 

respond to different circumstances:

Cognition (thinking) 

Affect (feeling) 

Behavior (doing)

AF-CBT includes training in various 

psychological skills in each of these channels 

that are designed to promote self-control and 

to enhance interpersonal effectiveness.

Tailors Treatment to Meet Specific 

Needs and Circumstances

Child maltreatment research has documented 

a variety of risk factors and consequences of 

physical abuse, and this variability requires 

treatment that can be adapted for different 

needs. So, for example, the treatment needs 

of a suicidal teen abused by an alcoholic 

father may differ from those of a child 

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reported to be aggressive at school and 

hostile toward a mother who is also a victim 

of violence.

AF-CBT begins with a multisource assessment 

to identify the nature of the problems the child 

is experiencing, specific parental and family 

difficulties that may be contributing to the risk 

of abuse, and the child’s and family’s strengths 

that may help influence change. Tailoring the 

treatment to the family’s specific strengths and 

challenges is key to efficient outcomes (Kolko 

& Swenson, 2002).

Key Components

AF-CBT is a short-term treatment typically 

provided over the course of 12 to 24 hours 

during 3 to 6 months (although treatment 

may last as long as determined necessary). 

Treatment generally is provided in an 

outpatient or in-home setting, but it may 

be used in residential settings (e.g., group 

home, residential treatment facility) or other 

placement settings (e.g., foster care) when 

the parent or caregiver is in regular contact 

with the child. Treatment includes separate 

individual sessions with the child and parent. 

Joint sessions with the child and parent also 

are held. Where relevant, family interventions 

may be applied before, during, or after the 

individual services. Following a brief outline of 

treatment goals, the key components in each 

treatment area are listed below.

Goals

Generally, the goals of AF-CBT treatment 

are to:

• Reduce parental anger and use of force

Promote alternative (nonaggressive) 

discipline approaches

Minimize risks for additional abusive 

incidents

Enhance the child’s coping skills and 

overall adjustment

Encourage prosocial problem-solving and 

communication in the family

Treatment for School-Aged Children

The school-aged child-directed therapy 

elements include the following:

Identifying the child’s exposure to 

and views of family hostility, coercion, 

and violence

Understanding the child’s perceptions of 

the circumstances and consequences of the 

physical abuse

Educating the child on topics related to 

child welfare and safety, child abuse laws, 

and common reactions to abuse

Discussing healthy vs. unhealthy coping

Training in techniques to identify, express, 

and manage emotions appropriately 

(for example, anxiety management, 

anger control)

Training in interpersonal skills to enhance 

social competence

Developing social support plans

The treatment program for children 

incorporates the use of specific skills, roleplaying exercises, performance feedback, and 

home practice exercises.

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Treatment for Parents (or Caregivers)

Parent-directed therapy elements include:

Identifying views on violence, physical 

punishment, and sources of stress

Understanding the role of parental and 

family stressors that may contribute 

to conflict

Examining the role of expectations 

related to child development and 

general attributions that may promote 

coercive interactions

Identifying and managing reactions to 

abuse-specific triggers, heightened anger, 

anxiety, and depression to promote 

self-control

Training in effective discipline strategies 

(e.g., time out, attention reinforcement) as 

alternates to the use of physical force

The treatment program for parents 

incorporates the use of specific skills, roleplaying exercises, performance feedback, and 

home practice exercises.

Treatment for Families (or 

the Parent and Child)

Parent-child or family therapy elements 

include:

Conducting a family assessment using 

multiple methods and identifying family 

treatment goals

Discussing a no-violence agreement

Clarifying attributions of responsibility for 

the abuse and developing safety plans, 

as needed

Training in communication skills to 

encourage constructive interactions

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Training in nonaggressive problem-solving 

skills with home practice applications

Involving community and social systems, 

as needed

Target Population

AF-CBT is most appropriate for use with 

physically abusive or coercive parents 

and their school-aged children (Kolko, 

1996a; 1996b). 

Appropriate Populations 

for Use of AF-CBT

Appropriate candidates for this program 

include:

Parents of physically abused children who:

Need to improve their child behavior 

management skills

Lack knowledge of alternatives to 

punitive forms of child discipline

Need guidance in creating more positive 

interaction with their child

Physically abused children who exhibit 

externalizing behavior problems, including 

aggressive behavior and poor social 

competence. Often these characteristics are 

found in families with heightened levels of 

conflict and coercion.

Limitations for Use of AF-CBT

Parents with psychiatric disorders that may 

significantly impair their general functioning or 

their ability to learn new skills (e.g., substance 

use disorders, major depression) may benefit 

from alternative or adjunctive interventions 

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designed to address these problems 

(Chadwick Center, 2004). In addition, children 

or parents with very limited intellectual 

functioning, or very young children, may 

require more simplified services or translations 

of some of the more complicated treatment 

concepts. Children with psychiatric disorders 

such as attention-deficit disorder (ADD) or 

major depression may benefit from additional 

interventions. Traumatized children, especially 

sexually abused children, may respond 

better to trauma-focused therapy. For more 

information, see the Child Welfare Information 

Gateway issue brief, Trauma-Focused 

Cognitive Behavioral Therapy: Addressing the 

Mental Health of Sexually Abused Children.

Effectiveness of AF-CBT

The effectiveness of AF-CBT is supported 

by outcome studies, and AF-CBT has been 

recognized by other experts as a “model” or 

“promising” treatment program.

Demonstrated Effectiveness 

in Outcome Studies

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

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, child behavior management 

training, information regarding appropriate 

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developmental expectations, social skills 

training, and family interventions focusing on 

reducing conflict (see Chalk & King, 1998; 

Kolko, 2002).

The individual child CBT, parent CBT, and 

family therapy components now integrated in 

AF-CBT were evaluated separately in a study 

published in 1996. The CBT components 

were also compared to a third condition—

participation in routine community services—

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 

family therapy (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 family therapy reported greater 

improvements than routine community 

services on certain outcomes, including:

Child outcomes, such as less childto-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 

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participated in individual CBT (5 percent) 

and family therapy (6 percent), compared 

to those receiving routine services 

(30 percent).

Both CBT and family therapy had high rates 

of session attendance and high consumer 

satisfaction ratings.

Key AF-CBT outcomes are summarized in the 

exhibit below.

Parent Outcomes

Achievement of individual treatment 

goals related to the use of more 

effective discipline methods

Decreased parental reports of overall 

psychological distress 

Lowered parent-reported child abuse 

potential (risk) 

Reduction in parent-reported drug use

Child Outcomes

Reduction in parent-reported severity 

of children’s behavior problems 

(externalizing behavior)

Reduction in parent-reported severity of 

child-to-parent aggression

Family Outcomes

Greater child-reported family cohesion 

Reduced child-reported and parentreported family conflict

Child Welfare Outcome

Low rate of abuse recidivism

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SUMMARY OF AF-CBT OUTCOMES

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Recognition as an EvidenceBased Practice

Based on systematic reviews of available 

research and evaluation studies, several 

groups of experts and Federal agencies have 

highlighted AF-CBT as a model program or 

promising treatment practice. This program is 

featured in the following sources:

Closing the Quality Chasm in Child Abuse 

Treatment: Identifying and Disseminating 

Best Practices (Chadwick Center, 2004)

www.chadwickcenter.org/Documents/

Kaufman%20Report/ChildHospNCTAbrochure.pdf

The National Child Traumatic Stress 

Network (Empirically Supported Treatments 

and Promising Practices, supported by 

the Substance Abuse and Mental Health 

Services Administration, 2005) 

www.nctsn.org/nccts/nav.do?pid=ctr_top_

trmnt_prom

Child Physical and Sexual Abuse: 

Guidelines for Treatment (Saunders, 

Berliner, & Hanson, Eds., National Crime 

Victims Research and Treatment Center 

and The Center for Sexual Assault and 

Traumatic Stress; Office for Victims of 

Crime, U.S. Department of Justice, 2004) 

www.musc.edu/ncvc/resources_prof/OVC_

guidelines04-26-04.pdf

The California Evidence-Based 

Clearinghouse for Child Welfare (2006) 

www.cachildwelfareclearinghouse.org

What to Look for in a Therapist

Caseworkers should become knowledgeable 

about commonly used treatments before 

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recommending a treatment provider to 

families. Parents or caregivers should receive 

as much information as possible on the 

treatment options available to them. If AF-CBT 

appears to be an appropriate treatment model 

for a family, the caseworker should look for a 

provider who has received adequate training, 

supervision, and consultation in the AF-CBT 

model. If feasible, both the caseworker and 

the family should have an opportunity to 

interview potential AF-CBT therapists prior to 

beginning treatment.

AF-CBT Training

Mental health professionals with at least some 

advanced training in psychotherapy skills 

and methods and experience working with 

physically abusive caregivers and their children 

are eligible for training in AF-CBT. Training 

generally involves at least 2 days of initial 

instruction involving a review of background 

materials, discussion of key procedures 

(e.g., session guide), and presentation of 

case examples/tapes. Additional learning 

experiences are recommended, including 

ongoing follow-up consultation and 

supervision (by phone) on the implementation 

of AF-CBT with a small caseload (for 3 to 6 

months) and booster training and advanced 

case review. The duration of this experience 

may vary by level of experience and case 

difficulty. See Training and Consultation 

Resources, below, for contact information.

Questions to Ask 

Treatment Providers

In addition to appropriate training and 

thorough knowledge of the AF-CBT model, 

it is important to select a treatment provider 

who is sensitive to the particular needs of 

the child, caregiver, and family. Caseworkers 

recommending an AF-CBT therapist should 

ask the treatment provider to explain the 

course of treatment, the role of each family 

member in treatment, and how the family’s 

specific cultural considerations will be 

addressed. The child, caregiver, and family 

should feel comfortable with and have 

confidence in the therapist.

Some specific questions to ask regarding AFCBT include:

Will the child and parent each receive 

individualized therapy using corresponding 

(coordinated) treatment protocols?

Will social learning principles be used 

to address the thoughts, emotions, and 

behaviors of the child and parent?

Is there a focus on enhancing the parentchild relationship and improving parental 

discipline practices?

Is the practitioner sensitive to the cultural 

background of the child and family?

Is there a standard assessment process 

used to gather baseline information on 

the functioning of the child and family 

and to monitor their progress in treatment 

over time?

Is this the most appropriate treatment for 

this child and family?

Conclusion

AF-CBT is an evidence-supported treatment 

intervention for parents and school-aged 

children in families where physical abuse 

has occurred. AF-CBT uses an integrated 

approach to address beliefs about abuse 

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Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse

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and violence and improve skills to enhance 

emotional control and reduce violent behavior. 

Improvements resulting from the use of 

AF-CBT include reductions in the risk of 

child abuse, fewer abuse-related behavior 

problems in children, and improvements 

in family cohesion. Increased awareness of 

this treatment option among those making 

referrals, coupled with increased availability, 

may create opportunities for helping to 

strengthen families and reduce the risks for 

and consequences of child physical abuse.

Resources for More Information

References for AF-CBT

Azar, S. T. (1997). A cognitive behavioral approach to understanding and treating parents who 

physically abuse their children. In D. A. Wolfe, R. J. McMahon, & R. D. Peters (Eds.), Child abuse: 

New directions in prevention and treatment across the lifespan (pp. 79-101). Thousand Oaks, 

CA: Sage Publications.

Brown, E. J., & Kolko, D. J. (1999). Child victim’s attributions about being physically abused: An 

examination of factors associated with symptom severity. Journal of Abnormal Child Psychology, 

27, 311-322.

Chadwick Center. (2004). Closing the quality chasm in child abuse treatment: Identifying and 

disseminating best practices. San Diego, CA: Author.

Chaffin, M., & Hanson, R. F. (2000). Treatment of multiply traumatized abused children. In R. M. 

Reece (Ed.), Treatment of child abuse: Common ground for mental health, medical, and legal 

practitioners (pp. 271-288). Baltimore, MD: The Johns Hopkins University Press.

Chalk, R., & King, P. (1998). Assessing family violence interventions. American Journal of Preventive 

Medicine, 14(4), 289-292.

Kolko, D.J. (2004). Individual child and parent physical abuse-focused cognitive-behavioral 

treatment. In B. E. Saunders, L. Berliner, & R. F. Hanson (Eds.), Child physical and sexual abuse: 

Guidelines for treatment (pp. 43-44). Charleston, SC: National Crime Victims Research and 

Treatment Center.

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.
Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse www.childwelfare.gov

10 This material may be freely reproduced and distributed. However, when doing so, please credit 

Child Welfare Information Gateway. Available online at www.childwelfare.gov/pubs/cognitive/.

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). Clinical monitoring of treatment course in child physical abuse: Psychometric 

characteristics and treatment comparisons. Child Abuse & Neglect, 20(1), 23-43.

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.

Mammen, O. K., Kolko, D. J., & Pilkonis, P. A. (2002). Negative affect and parental aggression in 

child physical abuse. Child Abuse & Neglect, 26, 407-424. 

Mammen, O. K., Kolko, D. J., and Pilkonis, P. A. (2003). Parental cognitions and satisfaction: 

relationship to aggressive parental behavior in child physical abuse. Child Maltreatment, 8, 

288-301.

National Child Traumatic Stress Network. (n.d.). Abuse-focused cognitive behavioral therapy for 

child physical abuse. Los Angeles, CA: Author. Retrieved August 2007 from www.nctsnet.org/

nctsn_assets/pdfs/promising_practices/AF-CBT_fact_sheet_3-20-07.pdf

Swenson, C. C., & Kolko, D. J. (2000). Long-term management of the developmental 

consequences of child physical abuse. In R. M. Reece (Ed.), Treatment of child abuse: Common 

ground for mental health, medical, and legal practitioners (pp. 135-154). Baltimore, MD: The 

Johns Hopkins University Press.

Training and Consultation Resources

David J. Kolko, Ph.D.

Western Psychiatric Institute and Clinic

University of Pittsburgh School of Medicine

541 Bellefield Towers

Pittsburgh, PA 15213

412.246.5888 

kolkodj@upmc.edu

Website: www.pitt.edu/~kolko

Clinicians are encouraged to read the following book:

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. (Available from 

www.sagepub.com)
Abuse-Focused Cognitive Behavioral Therapy for Child Physical Abuse

11 This material may be freely reproduced and distributed. However, when doing so, please credit 

Child Welfare Information Gateway. Available online at www.childwelfare.gov/pubs/cognitive/.

www.childwelfare.gov

This document is made possible by the Children’s Bureau, Administration on Children, Youth and Families, 

Administration for Children and Families, U.S. Department of Health and Human Services.

Suggested Citation: Child Welfare Information Gateway. (2007). Abuse-focused cognitive behavioral therapy 

for child physical abuse. Washington, DC: U.S. Department of Health and Human Services.