Child Trauma & Behavioral Problems
Marcus, 8, referred by school
Fictional teaching case
Compare the formulations ↓Presentation
Aggressive outbursts at school: hitting peers, throwing objects, defying teachers. Nightmares 3-4x/week. Wets the bed. Clings to mother at drop-off, then erupts within an hour. Teacher says: 'He goes from zero to sixty with no warning.' Mother says: 'He wasn't like this before.'
Read the full case history and clinical context
Witnessed domestic violence between parents ages 3-6. Father incarcerated when Marcus was 6. Mother working two jobs. Currently living with maternal grandmother. Grandmother is warm but overwhelmed. No prior therapy.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
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Showing 2 of 6 formulations.
Child-Parent Psychotherapy
Marcus's aggression is a trauma response embedded in the caregiving relationship. He witnessed his primary attachment figures in violence: the very people meant to protect him were the source of danger. His internal working model says: love is dangerous, closeness leads to violence, I must protect myself. Grandmother is safe but she carries her own ghosts: her daughter's victimization, her son-in-law's violence.
Dyadic work with Marcus and grandmother together. Address the ghosts in the nursery, meaning her own grief, guilt and trauma responses, which arrive in the room before Marcus does. Then look for the angels, which is Lieberman's other half and the one that gets forgotten: the memories of having been cared for that she can be helped to draw on, and the moments she is already getting it right. Help her read Marcus's behaviour as communication about his internal world. Co-construct a trauma narrative that holds both of their experiences.
"[To grandmother, with Marcus playing nearby] When he throws things, what happens inside you? ... That fear makes sense. You saw your daughter live with violence. Part of you worries Marcus is becoming like his father. But what if the throwing is his way of saying 'I'm scared too'?"
PCIT
Marcus's behavior problems are maintained by a coercive caregiver-child cycle. Grandmother may be inadvertently reinforcing the aggression through inconsistent responding, giving in one time and punishing harshly the next, which is close to the worst schedule for the behaviour you want less of. The relationship has to be rebuilt before the discipline half can hold, which is why the two phases run in that order and not the other. Worth naming the fit problem: PCIT is standardised for ages 2 to 7, so at 8 Marcus is at or past the ceiling and this is an adaptation rather than the protocol.
CDI phase: Grandmother learns PRIDE skills (Praise, Reflect, Imitate, Describe, Enthusiasm) in live-coached sessions to rebuild the relationship. PDI phase: Consistent discipline through specific commands and structured follow-through. Coached live through bug-in-ear.
"[Through earpiece to grandmother] Nice description, you told him exactly what he was doing. Now give me a labelled praise, tell him what you liked about it: 'I really like how gently you're stacking those.' ... Perfect. He looked up at you. That is the whole mechanism, right there."
TF-CBT
Marcus has trauma-related cognitions ('It's my fault Dad left,' 'The world is dangerous') driving hyperarousal and behavioral dysregulation. Aggression is a fight response triggered by perceived threats. Avoidance of trauma material maintains symptoms.
PRACTICE components: Psychoeducation and parenting skills, Relaxation, Affective modulation, Cognitive coping, Trauma narrative and processing, In vivo mastery, Conjoint child-caregiver sessions, Enhancing safety and future development. Parallel caregiver sessions throughout. The parenting-skills half of the first P is not optional in this case, because grandmother is the one who has to hold anything gained between sessions.
"[To Marcus] We're going to make a book about what happened: your story. You get to be the boss of your story. And your grandma is going to learn how to be your best helper."
IFS
Firefighter parts (aggression, defiance) are protecting exiles carrying terror from the domestic violence. A manager part tries to control everything (hypervigilance at school). The bedwetting suggests an exile frozen at the age of the trauma. Marcus's Self is intact but buried under protective parts doing emergency duty.
Adapted for a child: drawings, puppets or sand to help Marcus unblend, which in IFS means getting enough distance to look at the part rather than be it. Help him name and befriend the angry one ('What is the fighter trying to protect you from?'). Then, only with the protectors' permission and only when there is enough safety in the room, go toward what is underneath, which is the boy who could not stop the violence.
"So there's a part of you that gets really mad and wants to fight. That part is pretty strong, huh? Can you draw what it looks like? ... Does the fighter have a job? What's it trying to protect?"
Structural Family Therapy
The family structure is disrupted: father absent, mother overworked, grandmother in a parental role she didn't sign up for. Marcus may be parentified (protecting grandmother) or triangulated (caught between mother and grandmother's different parenting). The behavioral problems signal structural dysfunction, not individual pathology.
Map the structure: who actually holds authority, are the boundaries clear, is grandmother being undermined by mother's intermittent presence? Then restructure toward one executive subsystem rather than two competing ones, which means getting mother and grandmother aligned and visibly backing each other in front of Marcus. Strengthening a grandmother-and-Marcus alliance instead would build exactly the cross-generational coalition Minuchin warns about, with the mother left outside it.
"[To grandmother and mother together] Marcus needs to know who's in charge. Right now he's getting different rules from each of you, and when he's confused, he acts out. This isn't about blame: you're both doing everything you can. But he needs one consistent structure."
Play Therapy
Marcus is 8 and can talk, but talking is not where an 8-year-old does this work. Axline's premise is developmental rather than a claim that the memories are out of reach: he witnessed the violence between 3 and 6 and can describe some of it. What he cannot do is narrate what it did to him, or say it to an adult who might then be hurt by hearing it. Play is his natural medium for that, and the aggression is already communication, showing what he cannot say.
Non-directive child-centered play therapy. Provide a consistent, safe relationship. Follow Marcus's lead in play: he'll show you what he needs to process through his metaphors, his drawings, his sandbox scenes. Track the themes without interpreting prematurely.
"[In playroom] In here, you can play with the toys in most of the ways you'd like. You can decide what we do. [Tracking] You're putting the soldiers all around the house. They're guarding every door."
Where Approaches Genuinely Disagree
The child needs direct trauma processing. Parents are involved but the child does the work.
The relationship IS the treatment. Repair the dyad and the child heals.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Marcus's aggression is not the problem. It is the hope. Winnicott's concept of the antisocial tendency holds that when a child acts out (stealing, hitting, destroying), they are making a claim on the environment. They are saying: something was taken from me, and I am going to make you notice. The child who gives up, who becomes compliant and withdrawn, is in worse shape. Marcus hits peers, throws objects, defies teachers, and clings to his mother at drop-off. The clinging and the aggression are the same gesture: a demand for the environment to hold what he cannot hold alone. His mother says 'he wasn't like this before.' Winnicott would agree: the behavior emerged when the facilitating environment failed, when the father's violence and incarceration and the mother's overwhelm made the world unreliable. Marcus is not disordered. He is protesting.
The school refers Marcus as a problem. The teacher describes his behavior. The system diagnoses. At no point does anyone ask Marcus what he is experiencing: he is eight, and the institutional apparatus treats him as an object to be managed, not a subject with knowledge about his own situation. Freire would recognize this as the banking model applied to children's emotional lives: the experts deposit their interpretations, the child receives them. But Marcus already knows something the adults do not: he knows what it is like to live in a body that witnessed violence, that lost a father to incarceration, that moves between a working mother and an overwhelmed grandmother. His 'zero to sixty' is not a deficit of regulation. It is a form of knowledge about danger that the school environment has no framework to receive. A Freirean approach would begin by treating Marcus as someone who has something to teach the adults around him about what is actually happening.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.