The Following Guidelines and Response Suggestionsin This Supplement May Be Relevant When

The following guidelines and response suggestionsin this supplement may be relevant when working with foster, resource, residential, and kinship caregivers and the children in their care.

Alternatives for Families – A Cognitive Behavioral Therapy (AF-CBT) is a treatment model that is an effective choice for many families who are involved in services due to high aggression or conflict on the part of the child or the caregiver. This aggression and conflict can take many forms, such as child physical abuse, high parent-child conflict, noncompliant behavior, coercive interactions and aggressive bullying.

AF-CBT should not be overlooked as a possible option for working with foster, kinship, or adoptive (resource) caregivers and the children in their care, even though these caregivers may not be aggressive or conflictual. Children who have been living in highly conflictual, abusive and/or chaotic homes do not forget their past experiences when placed with resource caregivers. These children often behave in ways that can be incredibly challenging for resource parents such as: repeating family patterns of interaction, utilizing ineffective communication styles and often exhibiting aggressive behaviors.

Additionally, resource caregivers often find their typical parenting strategies challenged, doubt their own abilities and/or may have their own traumatic or difficult experiences triggered. We have developed this supplemental guide to use in tandem with the AF-CBT Session Guide, 3rd Edition, for clinicians who are working with resource parents and the children they care for.

Even when the resource caregivers are not struggling with their own abilities or experiences, the concepts conveyed in the AF-CBT model can be important to assist them in providing a supportive environment for children to have a successful experience in the new home. It is intended to help clinicians identify specific areas of intervention using the AF-CBT modules that may be unique to these families and it emphasizes the important role that they can provide in supporting these children, as they live in and experience multiple homes and transitions.

Please feel free to contact the authors as you use these materials and adapt them for the ever changing situations in which many of our families exist.

Barbara Baumann chaired the workgroup that prepared this material. Participation by Drs. Baumann and Kolko in the development of this supplemental material was supported, in part, by SAMHSA grant 1U79SM061257-01 (Judith Cohen, MD; Principal Investigator).

Topic 1: Orientation

I. Introductions and Guidelines

(Caregiver and Child)

Explain Important Professional Rules and Regulations

Define your role as mandated reporter and relationship to key systemsinvolved with family (e.g.,. child protective services, court).

As a foster parent, you and I are both charged with keeping the child safe. Mandated reporting is a way of making sure we all do our jobs.

II. caregiver treatment experiences and referral

(Caregiver only)

Learn about the Caregiver and Family (Background)

Questions about living situation:

What was the transition like when the child came into your family?
What was it like for you?
What was it like for the child?
What was it like for other family members in your home?
How has the child adjusted to being in your home?
What information do you have on the child’s family or past upbringing that would be important for me to know?

Questions about systems issues:

What is the current service plan for the child?
What is the visitation plan for each of the child’s biological parents? Can you describe it?
My goal is to provide support to you and (child) in ways that will be helpful. Transitions can be especially challenging for families. It would help me to be supportive, if you could let me know when there are changes to (child’s) service, permanency, or visitation plan, if there is a change in legal status or even when hearings are planned. What would be the easiest way for me to find out about such changes?

Check in with the caregiver regularly regarding the child’s visitation and service plan. It may help to use the “S” in CASH for Safety/Service plan. Return to this section if the child’s placement changes.

Briefly Discuss Status of Family and Nature of Referral

Support the caregiver and promote engagement.

Have you cared for a child in the foster system before? What were the benefits to you and your family? What were the challenges?
It can be frustrating to continue to struggle with issues of aggression and oppositional behavior.Have you felt frustrated that the child is still not “better?”
One of the benefits of participating in treatment is that it will help you to better understand the child’s perspective and experiences.
Even though the child may only be in your home for a short time, you can both still benefit from treatment.
It can be difficult to put a lot of effort into helping a child who will only be with you for a short time. How do you handle that?
What are some issues you’re having in the home that would be helpful to discuss in therapy?
It sounds like you are doing a lot for (child). How does that feel?

If the caregiver does not express interest in participating in AF-CBT, try the following:

It sounds like you’re not sold on the idea of participating in treatment. Perhaps we could look at the pros and cons of participation (Use Decisional Balance worksheet).

III. Establishing Rapport/Goals with Child

(Child only)

Build a Therapeutic Alliance

Ask the child what else you should know about him/her

What was it like when you came to live with your foster parents?
How are things going in the home?
How are people getting along?

Clarify Treatment Expectations

Confirm that child understands confidentiality/mandated reporting

I may think it is important to talk with your (foster parent, aunt, mother, etc.) about the progress you’re making in our sessions or concern about your safety, but I will discuss that with you first.
I’ll mainly be working with you and your (mother, father, foster parent, etc), but I’ll also be talking with ______sometimes/when I can so that everyone who is in your life knows what’s going on.
Your caseworker may contact me with questions. Because the caseworker’s job is to keep you safe, I will need to keep her/him updated on what we are doing in our sessions. What questions do you have about that?

Explain how therapy works.

We’ll talk about things that are happening in the home you’re living in now and in the home you lived in previously.

Topic 2: Alliance Building and Engagement

I. Personal coping skills and stressors

Identify Positive Life Experiences

Explore the caregiver’s positive life and parenting experiences.
What are some of the benefits of fostering (child)?
What does it mean to you to take care of another child(ren)?

Identify Stressful Life Experiences

Review and discuss life stress and challenges as a caregiver on theStressful Life Experiences handout. (Also, refer to issues brought up in Topic 1)
In addition to the stressors on listed on this handout, tell me about the added stress of being a foster parent. What is that like?
For example, some issues that often come up as being stressful are:
Visitation
Communication
Transportation
Caring for another child

Topic 3: Learning About Feelings and Family Experiences

II. Understanding Positive/Negative Family Interactions

Cover the positive/negative family interactions for all of the homes in which the child has or had regular contact. The focus is on the interactions with the caregivers in those homes. For example, a foster home, mother’s home, father’s home, or grandmother’s home. Do your best to keep the child oriented to the home which you are talking about. It may be helpful to use different colors of paper or ink to differentiate homes.

III. Psychoeducation on Use and Impact of Family

Abuse/conflict

You may need to change or omit the last bulleted item in this section (see below) if there are no issues of force or physical discipline in the current placement.

Give rationale for why treatment will focus on helping the caregiver find alternatives to using force and trying new discipline techniques.

As I mentioned before, we are going to encourage your (caregiver) to rely more on solving problems in ways that are more likely to be helpful and to keep you and your family safe. Why do you think we are going to do that?

IV. Alternatives for Families Plan

If appropriate, the child can complete an AFP for each home in which the child is a member. Similarly, when adding items to the AFP, it may be beneficial to track mastery of behaviors by setting.

Topic 4: Talking about Family Experiences and Psychoeducation

I. caregiver’s family of origin discipline

The goals for this session are to help the caregiver(s) increase their ability to empathize with the child and to reflect on their own parenting. This may apply to non-biological or custodial caregivers. It may be appropriate to tailor the conversation to fit the current situation of a resource or foster parent. For example, you may steer the discussions toward how they have parented other children in the past, their experiences in professional settings with other children, or modify the task so that the discussion generates a list rather than a letter.

Use questions such as these to generate discussion among non-biological caregivers.

What brought you to the role of foster parent or to this child in particular?
Describe some times when you disciplined your own children? How did it go? How did you feel?
How do you wish you had parented them differently?
What are your strengths as a caregiver?

Do not simply dismiss this topic because you are not working with the child’s biological parent or the offending caregiver.

II. Child’s Exposure to Positive and Negative Family interactions

Explore Exposure to Positive and Negative Talk

Provide a rationale for discussion.Talk with parent about why you normally explore this topic.
I want to better understand the home environment where the child is now.

Provide the caregiver with information about this approach.
You and I are partnering to keep this child and your family safe.
By talking with you about the positive and negative interactions s/he has at your home and in other homes, I can work with you and yourchild on behavior and patterns that will help your family to function more pleasantly.
By working together we can figure out what words or behaviors may trigger the child to become angry or anxious and work to help him/her handle these situations.

Explore their child’s exposure to positive talk.
What positive things do you think the child hears in the other home s/he is in?
Explore their child’s exposure to negative/upsetting talk.
What upsetting things do you think the child hears in the other home s/he is in?
Do you notice a change in the child’s behavior when s/he returns from visits?
What are your beliefs about the other caregivers in the child’s life and how they talk in front of him/her?
How do you view the other caregivers?
What experience do you think the child has had with negative talk in the past?

IV. the referral incident/other conflict situationS

Summarize the Incident Based on Caregiver(s) Reports

Ask caregiver to briefly describe the referral incident or other conflict situation, as much as they know.
We’ve already talked a little bit about (describe incident), but I would like to learn more about what happened?
What do you know about the incident?
What would you still like to know?
What are your thoughts about the caregiver’s actions?
What are your impressions of the parents?

Help caregivers to find hope and validation of the child’s parents. Normalize stressful moments this caregiver has experienced with the child and help him/her to understand the child’s triggers from this or similar incidents.

PHASE II: IndividualSkillBuilding

(Skills Training)

Topics 5-8

For Caregivers

For Emotion Regulation and Thought Restructuring, explain to the caregiver that this is the next skill you will be teaching the child, so it’s important for them to know it so that they can reinforce the skills.
You are important role models for the child and possibly, for the child’s parent.
I’m going to work with you on the same skills I’ll be teaching to the child. This way you will be able to help the child to practice the skills at home.
In addition, the skillsmay be useful with other children in your home.
Consistency between the two of us will help the child succeed.These skills can contribute to the child achieving permanency and maintaining a stable placement.
Present examples that have come up during the course of treatment.
If relevant, discuss unhelpful thoughts caregiver has related to the placement and his/her role as a resource caregiver.

For Children/Adolescents

Explore Emotion Regulation and Thought Restructuring in the context of the client’s settings and caregivers.
Discuss how to use skills in each setting and what the obstacles would be.
Remind the child who they can go to for support with these skills, reminders, and help.

Topics 9 & 11

ii. the importance of your Parenting style and Role

Introduce Topic of Parent Training

Discuss the importance of the unique caregiver’s role.
You are important role models for the child and possibly, for the child’s parent.
To create consistency between all of the child’s homes it will be important for both of us to know what the other person is doing or recommending.
Consistency between the two of us will help the child succeed and can contribute to the child achieving permanency and maintaining a stable placement.
Give rationale for reviewing and revising parenting practices.
Because children need structure and a clear understanding of both expectations and consequences, we will spend time talking about different ways you might provide these to the children in your home.
Children bring different experiences and expectations with them.
Some of these experiences may be known to us, while others may not.
For example, the child may have experienced trauma that is now affecting his/her behavior. (Share results from PTSD assessment if appropriate)
Other parents I’ve worked with have sometimes found parenting their foster children to be different than parenting their own children, or even other children they have cared for.
We can learn from each other about the child and what parenting is most successful as we go along.

Ideas for working with biological parents when they are not living with their children. How do they practice the parenting skills. Use more role playing, focus on strengths, how can they apply positive parenting to short visits. Talk with caregivers about the rules of supervised visits and their interaction with the people supervising them. What are the opportunities and limitations? Is it possible to be outside with the children, walk around, or meet in an area that is more conducive to play. Determine if it’s possible to attend a visitation with the caregiver to facilitate positive parenting skills.

Some foster or resource caregivers may appear offended when asked to review parenting skills or uninterested in working on their own skills since they are here for the child. For these caregivers, it may be helpful to use the ABC model to discuss different challenging situations and alternatives to current feelings, thoughts, and behaviors. It may also prove more beneficial to begin with the desired consequences and work backwards through the model. If appropriate, acknowledge the stress that being in the system can create for all caregivers and incorporate into an ABC model pathway worksheet.

X. developing materials for clarification letter

Document Material for Clarification

Take notes as you would with a biological caregiver. It may be appropriate for a foster or resource caregiver to state to the child how s/he will maintain a safe home given that the child has not come to expect that in the past.

Topic 10: Assertiveness and Social Skills

Assertiveness skills are important for children who have experienced transitions in their home environment. Here are some questions to keep in mind:

What assertiveness skills would work in this home?

Assertiveness looks different in different cultures, what should the child be aware of?

Is it appropriate to practice different skills for the different homes in which the child resides?

Find out from the caseworker, foster parent, and biological parent as much as you can about the rules in each home, their similarities and differences, peer relationships, and the structure of visits.

i. Social skills with friends and family

Review Ways to Show Good Social Skills with Friends/Family

Discuss how manners and respect are the same and how they are different between the child’s current home and their previous home, or between different adults with whom they interact.

Topic 12: Imaginal Exposure and Preparation for Clarification