David J. Kolko, PhD, ABPP University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic

1. David J. Kolko , Ph.D., ABPP
University of Pittsburgh School of Medicine
Western Psychiatric Institute and Clinic
An Effectiveness Trial of
Alternatives for Families-A CBT (AF-CBT):
Initial Clinical Outcomes
BASPCAN, April 14, 2015 Edinburgh, Scotland
NIMH 074737, 074716

2. Treatment Effectiveness Gap
 Many EBPs being transported to community
 Few RCTs of training applications
 Need to evaluate clinical effectiveness
 Engagement, outcomes, safety/satisfaction
 Aims
 Promote AF-CBT implementation in community
 AF-CBT targets conflict/coercion (anger, aggression, & physical abuse)
 Document impact on family outcomes

3. Why EBP
Training
Is Important!
As understood
by practitioner.
As proposed by
the supervisor
As discussed
with client.
As written in
progress note.
As understood
by the client.
What was
actually needed.

4. Partnerships for Families Project
Design: Randomized Clinical Trial (AF-CBT vs. TAU)
 10 agencies
 6 outpatient settings
 4 in-home settings
 33 supervisors
 182 practitioners (randomization unit)
 195 families

5. Initial
Assessment (Pre)
AF-CBT (n=90)
Training Workshops (4 days/ month)
Practitioner Boosters (2 in 6 months)
Supervisor Boosters (2 in 6 months)
6-month Assessment (Post)
Consultation Visits (10 in 5 months)
Randomization
(practitioner)
Orientation
Enroll Families (n = 195)
TAU (n=92)
12- and 18-month Assessments (Follow-ups)
Recruitment:
Practitioners,
Supervisors
Design & Phases

6. Outcome Measures
Measure Source_______
Conflict Tactics Scales (CTS) P , C
Brief Child Abuse Potential Inventory (BCAP) P
Alabama Parenting Questionnaire (APQ) P
Weekly Report of Discipline Practices (WRDP) P
Vanderbilt ADHD Diagnostic Parent Rating Scale P
Child PTSD Symptom Scale (CPSS) C
Trauma Symptom Checklist for Children C
Individualized Goal Achievement Ratings (IGAR) P
Family Environment Scale (FES) C
Official Child Welfare Records O

7. Enrollment
AF-CBT TAU
Total In-Home OUPT Total In-Home OUPT
Practitioners
Enrolled (#) 90 33 57 92 44 48
In agency – 6MO 73% 79% 70% 74% 66% 81%
In agency – 18MO 44% 39% 47% 43% 32% 54%
Families
Enrolled (#) 122 29 93 73 35 38

8. AF-CBT Practitioner Status
(n=90)
nn %%
Any training daysAny training days 8080 8989
Any consult callsAny consult calls 8181 9090
Any boosters (optional)Any boosters (optional) 3838 4242
““CompleterCompleter”” (3/4 days & 7/10 calls)(3/4 days & 7/10 calls) 6161 6868

9. Treatment Process
In-home Outpatient
AF-CBT TAU AF-CBT TAU
Hours (# - Mdn) 60 57 89 95
Weeks (# - Mdn) 8 12 26 24
% with team 0% 0% 76% 95%
Case completion 68% 45% 61% 53%
Child improvement 52% 19% 21% 27%
Case disposition 72% 55% 22% 28%

10. Clinician’s Treatment Focus
In-home Outpatient
AF-CBT TAU AF-CBT TAU
Treated any cases with
physical force/abuse 92% 33% 83% 51%
Addressed physical
force/abuse 68% 42% 78% 66%

11. Group x Setting Analyses: HLM
TAU Outpat.
TAU InHome
AF-CBT Outpat.
AF-CBT InHome
Brief Child Abuse Potential Inventory – Abuse Risk

12. Group x Setting Analyses: HLM
Brief Child Abuse Potential Inventory – Family Conflict
TAU Outpat.
TAU InHome
AF-CBT Outpat.
AF-CBT InHome

13. Group x Setting Analyses: HLM
Conflict Tactics Scale – Psychological and Physical Aggression (Parent)
TAU Outpat.
TAU InHome
AF-CBT Outpat.
AF-CBT InHome

14. Group x Setting Analyses: HLM
Vanderbilt Disruptive Behavior Disorders Scale
TAU Outpat.
TAU InHome
AF-CBT Outpat.
AF-CBT InHome

15. Group x Setting Analyses: HLM
Family Assessment Device – General Dysfunction
TAU Outpat.
TAU InHome
AF-CBT Outpat.
AF-CBT InHome

16. Group x Setting Analyses: HLM

17. Group x Setting Analyses: ANOVA

18. Group x Setting Analyses: ANOVA

19. Within-Group Change:
Official Child Welfare Reports
Baseline Follow-up Change
AF-CBT TAU AF-CBT TAU AF-CBT
TAU
Physical 17% 13% 5% 3% .01 .07
Physical/Emotional 21% 13% 6% 3% .004 .13
Neglect 21% 13% 9% 3% .008 .01
Sample sizes: AF-CBT (n=94); TAU (n=60)Sample sizes: AF-CBT (n=94); TAU (n=60)

20. Within-Group Change:
Child PTSD Symptom Scale Cutoff
Timepoint Change (p)
Baseline 6MO 18MO BL-6MO BL-18MO
AF-CBT 33% 17% 17% .007 .065
TAU 14% 21% 19% 1.00 1.00

21. Summary
68% of AF-CBT clinicians met completer criteria
Some advantages for AF-CBT clinicians
 More likely to treat aggressive/abuse cases
 More likely to address aggression/abuse
Some benefits for AF-CBT families
 Lower caregiver use of physical force/abuse
risk
 Less family conflict
 Less child PTSD
 Fewer official reports (physical, emotional)

22. (cont’d)
Some benefits by setting
 AF-CBT in-home or outpatient sometimes better
 Agency and provider nesting merit evaluation
Effectiveness context is more challenging – modest
 56% of all clinicians left agency/withdrew
 Families get many services with high dose
 Most could/did NOT recruit a family
 12% of AF-CBT group got no training

23. Some Lessons Learned
 Train full program
 Include supervisor as “co-facilitators”
 Monitor internal quality; use incentives
 Give individual feedback on attendance & performance
 Fit methods to agency’s existing services/population
 Plan for sustainability during training
 Provide ongoing materials & support (online)

24. Thank you for your participation….
David J. Kolko, Ph.D.
kolkodj@upmc.edu 412-246-5888 (USA)
www.afcbt.org