Behavior Management in Young Children Exposed to Trauma: A Case Study of Three Evidence-Based Treatments

Abstract

Young children are particularly vulnerable to traumatic events and the development of posttraumatic stress symptoms, including comorbid disruptive behaviors. Fortunately, several evidence-based interventions have been shown to be effective at decreasing both posttraumatic stress symptoms and disruptive behaviors in young children. This paper provides an overview of three such interventions—Child-Parent Psychotherapy (CPP), Parent-Child Interaction Therapy (PCIT), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). An illustrative case study is used to compare how each intervention addresses disruptive behaviors, with a focus on theoretical underpinnings, model similarities, and model differences. The models each have empirical evidence for the treatment of disruptive behavior in young children, and therefore, may be appropriate for treating children with a history of trauma exposure and comorbid disruptive behaviors. Child, caregiver, and environmental factors are essential to consider when identifying an evidence-based intervention for this population.

More than two thirds of children report experiencing at least one traumatic event by the age of 16 (Copeland et al., 2007), which may include child maltreatment (e.g., physical abuse, sexual abuse, neglect), natural disasters (e.g., tornadoes, floods, earthquakes), witnessing domestic violence, accidents (e.g., motor vehicle accidents, dog bites), and exposure to war and terrorism (De Bellis & Van Dillen, 2005). Young children may be particularly vulnerable to experiencing traumatic events (De Young et al., 2011; Lieberman & Van Horn, 2009), and one study found that nearly a quarter of children experience at least one adverse or traumatic event between ages 6 and 36 months (Mongillo et al., 2009). A nationally representative sample of youth in the United States found approximately one in eight children under the age of 5 had experienced maltreatment and one in five had witnessed violence (Finkelhor et al., 2009). Furthermore, more than half of all substantiated maltreatment reports in the United States are for children ages 6 and under (U.S. Department of Health & Human Services, 2022). Additional risk factors for young children can include the prevalence of intergenerational trauma, through which a child’s mental health can be impacted by family stressors in existence even prior to the child’s birth (Yehuda et al., 2001). These factors can be more pronounced among families of color, for whom societal stressors such as structural racism compound the impacts of individual- or family-level traumas (Hankerson et al., 2022). Finally, trauma that occurs in the early childhood years (particularly within the context of early caregiving relationships) can put individuals at greater risk for developing a complex trauma presentation, which is marked by difficulties with engaging in safe behaviors, forming trusting relationships with others, and regulating emotions and behaviors (van der Kolk, 2005).

Trauma may be particularly impairing for young children because early childhood marks a period of rapid social, emotional, and cognitive development (Carpenter & Stacks, 2009), and young children may be more susceptible to adverse outcomes of trauma compared to older children and adults (De Young et al., 2011; Dunn et al., 2017). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) includes distinct diagnostic criteria for posttraumatic stress disorder (PTSD) in children 6 years of age and younger. For example, intrusive symptoms in early childhood may include posttraumatic play (i.e., repetitive play related to themes of the trauma) or distressing nightmares that are not clearly linked to the trauma. Additionally, heightened arousal or reactivity may look like an increase in disruptive behaviors such as tantrums, hyperactivity, and inattention (De Young et al., 2011).

It is important to note that most children exposed to trauma do not develop PTSD—a recent meta-analysis found that among preschoolers exposed to trauma, about one-fifth met full criteria for PTSD (Woolgar et al., 2022). Beyond PTSD, there are a number of emotional and behavioral outcomes associated with early childhood trauma exposure. For instance, compared to those who have not experienced trauma, preschool children who have experienced trauma are more likely to experience separation anxiety, specific phobia, and conduct problems (Briggs-Gowan et al., 2010). The link between trauma and disruptive behavior is well-established in young children (Liming & Grube, 2018; Milot et al., 2010). In one study, those who had been exposed to trauma in early childhood were more likely to be diagnosed with other disorders (e.g., oppositional defiant disorder [ODD], attention-deficit/hyperactivity disorder [ADHD]) compared to peers without trauma exposure (De Young et al., 2011). In a sample of young children who had experienced trauma, 38% met criteria for ODD, half of which developed the disorder after the onset of the trauma exposure (Scheeringa & Zeanah, 2008). Additionally, there were borderline-clinical levels of behavior problems in a sample of highly traumatized young children referred for outpatient treatment (Mesman et al., 2021), and kindergarteners who had three adverse life experience were twice as likely to be considered aggressive by teachers compared to their classmates without adverse life experiences (Jimenez et al., 2016).

Evidence-Based Treatment for Disruptive Behavior and Trauma Symptoms

Several evidence-based interventions have been developed to treat children with a history of trauma exposure and comorbid disruptive behaviors, including Child-Parent Psychotherapy (CPP), Parent-Child Interaction Therapy (PCIT), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Each of these models have been shown to be effective in reducing posttraumatic stress symptoms and disruptive behaviors in young children, and therefore, are appropriate for this population. Similarly, these improvements have been noted for histories of acute/single instance traumatic experiences and children with histories of more chronic/complex trauma exposure (Cohen et al., 2012; Lawson & Quinn, 2013; Warren et al., 2022). As outlined in detail in Vanderzee, Sigel, Pemberton, and John (2018), clinicians need to consider several important factors when deciding which of these models to use, including child, caregiver, and environmental features of the case. For example, child factors could include the age and developmental level of the child, their physical size, how their symptoms manifest in relation to their life experiences, and how symptoms present over time. Caregiver factors might include the availability of a caregiver to participate in treatment services, their involvement in the trauma the child has experienced, and the caregiver’s primary concern. Environmental features might include stability of a child’s placement, case plan or goal if involved in child welfare, and whether there are other mental health treatments that are being provided to a family (Vanderzee et al., 2018).

Child-Parent Psychotherapy (CPP)

Child-Parent Psychotherapy (CPP; Lieberman et al., 2015) is a dyadic, relationship-based treatment for children birth through age 5 who have experienced trauma and are displaying attachment, traumatic stress, behavioral, or other mental health symptoms. The theoretical roots of CPP are based in psychoanalytic, attachment, developmental psychopathology, trauma, social learning, and cognitive behavioral perspectives. CPP unfolds over 20–26 weekly sessions in three distinct phases – Foundational Phase: Assessment and Engagement, Core Intervention, and Recapitulation and Termination. The process of CPP involves developing a detailed understanding of the family and presenting problem (e.g., caregiver and child mental health difficulties and child trauma history, family ecological context, qualities of the caregiver-child relationship, child development, and cultural values), collaboratively creating a treatment plan with caregivers, intervening to support the dyad based on knowledge of the relationship and promotion of healthy child development, planning the termination of treatment to sustain gains, and processing feelings associated with the termination of the therapeutic relationship. Details of the CPP model and process are available in the CPP manual (Lieberman et al., 2015).

CPP has been recognized as an evidence-based treatment by the National Child Traumatic Stress Network (National Child Traumatic Stress Network, 2012), and there have been five randomized controlled trials demonstrating CPP’s effectiveness with young children and their families. CPP has been shown to improve children’s behavior problems and PTSD symptoms at the end of treatment and at 6-month follow-up, improve attachment security, reduce placement disruptions for youth in child welfare, and demonstrate effectiveness among culturally-diverse families (Cicchetti et al., 2006; Lieberman et al., 2005; Weiner et al., 2009).

There are several tenets of CPP that may appropriately address disruptive behaviors often seen in children exposed to trauma. Gathering information about disruptive behaviors within a relational and cultural context during the first phase supports the clinician’s ability to collaborate with the caregiver in determining goals for symptom management in the second phase. CPP also includes six fidelity strands (procedural, reflective practice, content, dyadic relational, trauma framework, and emotional process) to facilitate clinician interventions that typically move from simplest to most complex. For example, a clinician may tie disruptive behavior to trauma history (trauma framework), help the caregiver to offer co-regulation to the child (emotional process), and/or illuminate moments of competing needs between caregivers and children and support the dyad in managing these conflicts lovingly (dyadic relational). All of these interventions are dependent on where the family is within treatment (procedural) and consider the clinician’s experience of the family (reflective practice) and the specific goals the family has co-determined with the clinician (content).

Parent-Child Interaction Therapy (PCIT)

Parent-Child Interaction Therapy (PCIT; Eyberg & Funderburk, 2011) is an evidence-based, manualized treatment for caregivers and children ages 2 to 7 with disruptive behavior problems, including those with trauma histories and/or trauma symptoms. PCIT is rooted in behavioral principles (e.g., learning theory) as well as attachment theory and Baumrind’s parenting styles (McNeil & Hembree-Kigin, 2010). PCIT clinicians provide in-vivo coaching to caregivers in play-based situations with their child. It includes two phases of treatment: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). CDI focuses on teaching the caregiver skills that promote positive behaviors and a warm relationship. In PDI, caregivers are taught to deliver consistent and appropriate discipline. Details of the process and model of PCIT are available in the PCIT manual (Eyberg & Funderburk, 2011).

Meta-analytic reviews have shown that PCIT is highly effective in reducing children’s disruptive behaviors with large effect sizes between pre- and post-treatment measures of disruptive behavior (Rae & Zimmer-Gembeck, 2007; Ward et al., 2016). The reductions in symptoms are stable, with multiple studies showing improvements in child internalizing and externalizing symptoms as well as caregiver skill use are maintained at follow-up assessments ranging from 1 to 6 years (Eyberg et al., 2001, 2014; Hood & Eyberg, 2003).

PCIT also is effective in decreasing internalizing and externalizing symptoms in youth who have experienced trauma (Timmer et al., 2010) and those living in foster care (Mersky et al., 2016). This includes reducing posttraumatic stress symptoms in addition to other disruptive behavior problems (Pearl et al., 2012). Furthermore, evidence suggests PCIT is effective at reducing parental risk of child abuse and/or maltreatment recidivism (Kennedy et al., 2016). Although Pearl et al. (2012) found PCIT reduces trauma-related symptoms without changes to the standard PCIT treatment model, other researchers have investigated ways in which PCIT can be adapted specifically to target trauma-related difficulties. For example, Gurwitch and Warner-Metzger (2022) have described a PCIT adaptation that includes a Trauma-Directed Interaction (TDI) module in addition to the standard CDI and PDI modules.

Trauma-Focused Cognitive Behavior Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al., 2017) is an evidence-based treatment for children ages 3 to 18 designed to treat posttraumatic stress symptoms related to a traumatic experience. TF-CBT utilizes theoretical underpinnings of cognitive behavioral therapy, exposure therapy, and widely recognized parenting strategies. TF-CBT is typically delivered in 12 to 16 weekly sessions across three phases of treatment – the stabilization phase, the trauma narration phase, and the integration or consolidation phase. The stabilization phase includes learning a variety of regulation strategies and coping skills. Within the trauma narration phase, children process thoughts, feelings, and behaviors related to the traumatic event. Finally, in the integration and consolidation phase, in-vivo mastery of trauma reminders and enhancing future safety are addressed.

Several systematic reviews and meta-analyses have found TF-CBT to be effective at decreasing posttraumatic stress symptoms (Cary & McMillen, 2012), and TF-CBT has been recognized as a well-established intervention (Silverman et al., 2008). There is somewhat less research on the efficacy of TF-CBT for preschool children specifically, although a recent systematic review found TF-CBT met criteria for a “level two” or “probably efficacious” designation for the preschool population (McGuire et al., 2021).

In addition to reducing PTSD symptoms in children, in one randomized control trial TF-CBT was effective in reducing behavior problems in preschool children compared to non-directive supportive therapy (Cohen & Mannarino, 1996). These improvements were maintained at 6- and 12-month follow-ups (Cohen & Mannarino, 1997). Other studies that include preschool children indicated those who received TF-CBT had reductions in behavior problems at the completion of treatment (Deblinger et al., 2011; Scheeringa et al., 2011), with improvements maintained up to 12 months later (Mannarino et al., 2012). TF-CBT utilizes various parenting strategies that are consistent with behavioral principles to help address behaviors that are common for children exposed to trauma, including functional analysis, praise, time-out and behavior charts (Cohen et al., 2017).

Method

The present study used a novel hypothetical case study approach to outline comparisons of the use of three treatment models (i.e., CPP, PCIT, and TF-CBT) in the context of addressing behavior management issues in children exposed to trauma. This approach allowed for detailed comparison of the use of different treatment models, as clinical application of treatment models is typically influenced by the details of a specific case. The use of a shared hypothetical case study, to the authors’ knowledge, is a novel approach that may serve as an ideal methodology for treatment model analysis and application.

The authors consulted with certified CPP, PCIT, and TF-CBT trainers when developing the case study and intervention case treatment examples. The trainers provided a de-identified overview of child, caregiver, and environmental factors of several young child patients who they have treated recently. Similarly, each trainer provided de-identified information about the patients’ progress through the course of the treatment model. Therefore, the following case study and corresponding three intervention case treatment examples are amalgamations of multiple patients and are not reflective of an individual one. Patient confidentiality was maintained throughout this process as no identifiable information was obtained by the authors. Finally, the authors in conjunction with the certified trainers discussed together the similarities and differences between the interventions, including theoretical underpinnings, techniques, and strengths and weaknesses.

The authors then developed a table of specification that outlines the specific model goals and techniques used in the case study (see Table 1 for details). The contents of this table focus entirely on behavior management techniques in the context of the case study outlined below. This table is intended to highlight goals and techniques to improve behavior management and subsequently does not detail every strategy that might be employed when utilizing each treatment model in its entirety with the hypothetical case study.

Table 1.

Treatment model characteristics, goals, and techniques used to support behavior management in case study

Model Characteristics	Treatment Model
	CPP	PCIT	TF-CBT
Model theory and structure
Primary therapeutic stance	Reflective	Directive	Directive
Dyadic sessions	Yes	Yes	No
Family-oriented treatment	Yes	Yes	Yes
Assessment driven	Yes	Yes	Yes
Trauma processing	Yes	No	Yes
Theoretical orientation	Integrative	Behavioral	CBT
Play-based	Yes	Yes	Noa
Goals and techniques used to support behavior management
Relationship building	Yes	Yes	Yes
Co-regulation	Yes	No	No
Self-regulation	Nob	No	Yes
Functional behavior analysis	Yes c	No	Yes
Praise	Yes	Yes	Yes
Active ignoring	No	Yes	Yes
Limit setting	Yes	Yes	Yes
Time-out	No	Yes	Yes
Behavior chart	No	No	Yes

^a TF-CBT is not a play-based treatment, but play may be used to teach skills and to support trauma narration, particularly in young children

^b CPP would not typically include a primary focus on self-regulation, as treatment would typically target co-regulation first. However, self-regulation might be included as a secondary goal, if indicated, or as a primary goal if co-regulation within a dyad is already established

^c CPP would likely not include functional behavior analysis in traditional behavioral/cognitive-behavioral terms, but treatment often includes a focus on examining the causes and consequences of behavior in order to address behavioral issues

Case Study

Camila is a 4.5-year-old Puerto Rican female who was referred for psychotherapy due to concerns of aggressive behaviors at preschool. Her mother, Ms. Durham, explained that Camila was recently suspended for throwing a wooden block at her teacher and kicking a peer in the stomach who was napping. Ms. Durham reported she is worried about Camila starting kindergarten in the fall and is fearful she will have to leave her job to stay home with her if she is expelled from preschool.

Ms. Durham reported she and her husband adopted Camila within the past year shortly after she turned 4 years old. She said Camila was raised in the Southern United States by her biological parents until she was 2.5 years old and was removed from their care after a neighbor called the police because she was repeatedly seen playing unsupervised in the front yard for long periods of time. Upon police investigation, her biological mother and father were arrested for possession of methamphetamine. Camila was subsequently placed into foster care due to allegations of drug endangerment and neglect. Camila’s biological parents also are Puerto Rican and had an income below the federal poverty threshold when she was removed from their care. Their parental rights were eventually terminated.

Ms. Durham said Camila resided in several foster homes, one of which disrupted due to allegations of physical abuse by a foster parent. Ms. Durham noted Camila was placed into her home when she was 3.5 years old and stated she and her husband adopted Camila within the subsequent year. Camila currently lives with Ms. Durham, her husband, and their 2-year-old biological son. Ms. Durham and her husband are Black and have a self-reported income in one of the highest income brackets. Ms. Durham reported at the intake she had a history of experiencing neglect due to her parents’ use of alcohol as well as exposure to domestic violence in a previous romantic relationship.

Aside from the specific reason Camila was referred for treatment, Ms. Durham expressed significant concerns regarding Camila’s emotional, behavioral, and relational functioning. She reported Camila exhibited several challenging behaviors shortly after she began living with the family, many of which have increased in frequency and intensity over time. In regard to emotional functioning, Ms. Durham described Camila as moody and said she is difficult to console when upset. She also stated Camila has significant separation anxiety and struggles with transitions to school. Additionally, Camila frequently awakens at night crying and screaming and is difficult to soothe and return to sleep.

Behaviorally, Ms. Durham described Camila as physically aggressive towards adults and domineering in her play with her younger brother. More specifically, she often kicks, bites, punches, or pushes others in response to limit setting or when denied her own way. Ms. Durham said Camila is noncompliant and has daily temper tantrums in home and school settings, lasting up to 30 min per tantrum. She additionally reported Camila and her adoptive father have trouble connecting to one another, with her father reporting limited ability to engage Camila and Camila responding to these efforts by asking him to go away. Ms. Durham noted Camila engages in aggressive play with themes of families hitting each other and yelling. Camila additionally has reportedly told unfamiliar adults, “My mommy hit my daddy, and my daddy left.” She also sometimes plays with dolls and says, “The baby is crying. Help the baby.” Ms. Durham believes these statements are in reference to experiences she had in previous homes. Notably, during Camila’s initial appointment at an outpatient clinic, Ms. Durham explained that although she and Mr. Durham both prefer to be involved in Camila’s therapy appointments, Mr. Durham’s work schedule does not allow him the flexibility to participate consistently. Therefore, Ms. Durham is the identified caregiver attending sessions across treatment modalities described in subsequent sections.

How Each Treatment Model Would Address the Case Study

Child-Parent Psychotherapy Case Study

As mentioned, CPP is conducted in three separate phases, beginning with the Foundational Phase: Assessment and Engagement. This phase is primarily conducted in caregiver-only sessions in which information is gathered related to child and caregiver trauma history, child and caregiver symptoms, child development, and qualities of the caregiver-child relationship through dyadic relationship observation session. CPP is dyad-specific and frequently includes work with more than one caregiver.

Within the first phase of treatment, the clinician noted several important contextual and cultural factors to consider when working with this dyad: (1) the child and caregiver have different racial backgrounds, both of which have unique and important histories of oppression to consider within the context of historical and current trauma; (2) The child has a prolonged history of exposure to neglect, financial insecurity, parental drug abuse, and separation from caregivers within her biological family and physical abuse within a previous foster family, all during the first 4 years of life; (3) the caregiver reported experiencing neglect when she was a child due to her parents’ use of alcohol, in addition to domestic violence as an adult within a prior romantic relationship; (4) the caregiver is worried about the child’s ability to remain in the classroom, elaborating that she worries Camila’s race will lead school staff to take a more punitive approach with her, and (5) the caregiver-child relationship is notably impaired, with several instances of emotional and behavioral dysregulation from the child and caregiver that occurred within the relationship observation (e.g., separation anxiety, aggression). The clinician shared her impressions with Ms. Durham in a caregiver-only session, and they jointly agreed that improving the dyad’s ability to regulate emotions/aggression and helping both the caregiver and child to understand responses to trauma was most important.

Within intervention, the clinician initially utilized a “watch, wait, wonder” stance to notice when dysregulation was emerging. The clinician noted a pattern in which the child and caregiver frequently missed each other’s needs during play, especially when trauma themes were present (e.g., Camila needed Ms. Durham to bear witness while she played out scenes in which parent dolls were hitting a child doll, and Ms. Durham responded by asking Camila several questions to gather more information about the difficult events she saw). This resulted in each party becoming frustrated, Camila raising her voice and starting to throw toys or hit Ms. Durham, and Ms. Durham looking away from Camila, asking her to stop using a quiet voice, and asking the clinician for help on how to calm her down. Once the clinician noted these patterns, she began by sharing her observations out loud (e.g., “Camila has a story to tell, and mommy has questions about those stories.”) which helped the dyad to notice the similarities and differences in their experiences and needs. The clinician further prompted Ms. Durham to reflect on what Camila needed in these moments and how her behavior changed in response to Ms. Durham’s behavior. Ms. Durham quickly noted Camila became angrier and more aggressive when she asked about her biological family but was unsure of what to do to help her. The clinician provided developmental guidance on traumatic stress responses in relation to trauma reminders, and she asked Ms. Durham to reflect on her own needs during times in which she is exposed to reminders of her difficult experiences as a child. Ms. Durham noted that, in those moments, she needed others to “back off” and “just listen” to her and wanted to utilize this strategy with Camila. Over the course of several sessions, Ms. Durham was increasingly able to bear witness without interfering in Camila’s story, and Camila began allowing Ms. Durham to play in the story with her and ask more questions about how she felt and what she needed. Aggression during play largely subsided.

Within the course of treatment, the clinician also noted several instances of emotion dysregulation associated with transitions in session activities or in ending the session in which Camila began screaming, refusing caregiver directives, and falling to the floor. Ms. Durham explained these behaviors were especially worrisome for her as Camila was entering kindergarten next school year. The clinician, utilizing Ms. Durham’s growing capacity to reflect on Camila’s needs, prompted Ms. Durham to think about what Camila might be feeling and needing in those moments. She also validated Ms. Durham’s fears about the possibility Camila’s behavior may be judged more harshly by the school due to her race. This led Ms. Durham to explore her own experiences of racism in school and how lonely she felt as a child, prompting her desire to “listen and be there” for Camila. The clinician also utilized the 12 developmental themes to further explore the meaning behind separation anxiety as a normative fear in childhood that is likely exacerbated by Camila’s history of frequent caregiver separations. Ms. Durham realized moments in which Camila was aggressive often triggered a “freeze” response in her, and they were associated with her own history of domestic violence. This freeze response was hindering her ability to be attuned to Camila. The clinician worked with the dyad to identify body cues associated with emotion dysregulation and engage in body-based regulation (e.g., holding hands, deep breathing together) before proceeding to limit setting (e.g., using gentle hands). Within limit setting, Ms. Durham was able to prioritize attunement and emotional safety by first labeling Camila’s emotion (e.g., “You’re stomping your feet. I think you might be mad.”), emphasizing her desire to support Camila (e.g., “I’m here to help you with your big feelings and keep you safe.”) and proceeding to praise and limit setting once Camila was more regulated (e.g., “Great job calming down Camila. It’s time to go today, and I’m sad our time is done. I’m glad we are coming back next week to play more. Would you like to hold my hand to leave, or would you like me to pick you up?”). Camila improved in her ability to verbalize her feelings and keep her body calm as Ms. Durham consistently engaged in body-based regulation. Ms. Durham also noted these strategies helped her to regulate during Camila’s other temper tantrums, sharing that Camila was more easily soothed when she was calm.

After 4 months of intervention, Ms. Durham reported improvements in Camila’s ability to manage emotions without aggression and felt more competent in managing her behavior. Ms. Durham, with coordinated care support from the clinician, scheduled a meeting with school personnel in which she shared how Camila’s history of trauma and current symptoms could manifest in the classroom and strategies she had learned in therapy that could be helpful for them to use (e.g., connecting with co-regulation before correcting with limit-setting). Camila more readily played about prior instances of trauma, and Ms. Durham’s initial stance of listening helped Camila to allow Ms. Durham to make statements and play about her life now compared to her life during trauma. The dyad agreed to proceed into the last phase of treatment that focused on maintaining gains in treatment, processing goodbye, and empowering the family to continue advocating on behalf of Camila’s needs.

Parent-Child Interaction Therapy Case Study

During the first PCIT session, the clinician conducted a standardized observational assessment in which she observed Ms. Durham interact with Camila in three different situations: child-led play, parent-led play, and clean-up. Across the three situations, similar parental behaviors occurred. Ms. Durham almost exclusively asked questions, gave commands, or issued negative talk, and these parental statements were highest during parent-led play and clean-up. Camila was reluctant to clean up the toys, and she protested, whined, and threw a few toys in response to this directive from Ms. Durham. At the completion of the observational assessment, the clinician asked Ms. Durham how typical Camila’s behavior was in each situation. She replied that Camila’s behaviors during the session were similar to her home behavior. Ms. Durham was also administered the Eyberg Child Behavior Inventory (ECBI) during the session which suggested Camila’s behaviors were in the clinical range on both the Intensity and Problem scales.

The following week, Ms. Durham attended the didactic CDI Teach session with the clinician without Camila. Ms. Durham expressed considerable concern she feels like she has not bonded with Camila despite her best efforts and is worried she will never feel as close to her as she does to her son. Therefore, the clinician spent considerable time explaining how the goal of CDI is to strengthen their relationship and highlighted how the 5 min of special time in particular is conducive to developing attachment. The clinician also emphasized how each of the PRIDE skills can be utilized to show affirmation, acceptance, and approval for Camila, all of which are important characteristics to strengthening relationships. The clinician explained how these same skills may be used to reduce problem behaviors as well by providing positive attention and reinforcing the behaviors Ms. Durham wishes to see Camila exhibit (E.g., “Great job listening,” or “Thank you for playing gently even when you got mad.”). During this session, the clinician encouraged Ms. Durham to conduct special time every day at the same time and location in the house in order to establish a routine. The clinician explained how building structure into Camila’s life is helpful with establishing predictability, which is beneficial for children who have experienced trauma.

Ms. Durham attended eight sessions before she achieved the CDI goal criteria. The clinician coached her to increase her labeled praise, descriptions, and reflections, as well as decrease her questions, commands, and negative talk. Ms. Durham’s biggest area of growth was learning how to effectively ignore Camila when she engaged in a mildly disruptive behavior (e.g., playing with the toys aggressively) and praise her when she exhibited a prosocial behavior (e.g., playing with the toys gently). Ms. Durham noted that ignoring was a particularly challenging practice to implement, as it reminded her of her own history of neglect. She also felt compelled to correct any mildly disruptive behaviors as she feared how she would be perceived in public, particularly given her concerns of being viewed as a neglectful or inattentive Black mother. The clinician provided psychoeducation about ignoring versus neglect and highlighted how briefly the ignoring typically lasted before Camila resumed appropriate behavior and Ms. Durham could re-establish attention and positive interaction. Ms. Durham and the clinician scheduled a separate phone call to discuss the benefits of individual therapy for Ms. Durham, given her trauma history and stress, and the clinician facilitated a referral to a well-respected Black clinician at Ms. Durham’s request. The clinician validated Ms. Durham’s concerns of inaccurate or unfair perceptions of her parenting because of her and Camila’s race and reinforced the use of CDI skills only during special time at this point in treatment. Much of Ms. Durham’s time in CDI coaching, however, was related to strengthening her attachment to Camila since this was a primary concern. The clinician focused on helping her better follow Camila’s lead during play; becoming more attuned to her needs, feelings, and behavior; establishing herself as a safe base for exploration; and building Camila’s self-esteem. Along with Ms. Durham’s verbal reports, her scores on the ECBI suggested Camila’s disruptive behaviors were improving during the first phase of treatment on both the Intensity and Problem scales.

Following the completion of CDI, Ms. Durham met with the clinician without Camila for a didactic PDI Teach session in which the clinician provided an overview of PDI components. The clinician taught her how to give effective commands, to determine compliance, and to effectively use a time-out procedure to manage defiance and rule-breaking behavior. Ms. Durham initially stated she was uncomfortable with using time-out because she thought the strategy may “re-traumatize” Camila and time-out may be a trauma trigger if she was put in time-out by her biological parents. Ms. Durham noted the idea of time-out was also initially upsetting given her own history of neglect, but she understood the rationale for time-out and was able to identify differences in time-out (e.g., in the same physical space, close enough to hear Camila if she was in danger) to her own experiences of neglect. The clinician also explained time-out is done calmly, quickly, and safely, and it likely is conducted in a manner that is different from Camila’s previous experience (e.g., caregivers speaking in a neutral tone of voice, less physical aggression). In addition, the clinician noted time-out is brief, usually lasting only a few minutes, and after time-out children engage in a period of special time with their caregivers in which they reconnect and re-establish their relationship.

Ms. Durham required nine PDI coaching sessions before she completed this phase of treatment. Ms. Durham initially struggled with consistency in the steps of the time-out procedure, but with coaching from the clinician and encouragement to practice memorizing the words and sequence between sessions, she quickly improved. The first time Camila went to time-out for noncompliance, the time-out sequence took most of the session, lasting approximately 35 min. However, the subsequent time-outs were less lengthy, and Camila did not appear to be as emotionally or behaviorally dysregulated. Ms. Durham also noted the frequency of time-outs between sessions were decreasing as she became more familiar with the time-out sequence. The clinician explained how the tenets of predictability, consistency, and follow-through were helping to decrease Camila’s behavioral difficulties. By the end of the PDI phase, Camila’s scores on the ECBI were within normal limits, and Ms. Durham expressed confidence in her improved relationship with Camila and her ability to manage problem behaviors moving forward.

To address daycare concerns, the clinician obtained a release of information from Ms. Durham and then met with Camila’s preschool teacher by phone and shared strategies consistent with PCIT that could also be incorporated into the classroom to address Camila’s aggression. For example, the clinician discussed how to increase labeled praise for prosocial classroom behaviors, create and utilize games to practice listening and minding, and use a discipline ladder in which the teacher gradually issues more severe consequences for misbehavior. The clinician also shared handouts in the PCIT manual specifically intended for classroom teachers that summarized these behavioral strategies. The clinician consulted with Camila’s preschool teacher at the beginning of the CDI phase and a few months later once Ms. Durham had advanced to the PDI phase in which she learned that Camila’s behavior in the classroom had greatly improved.

Trauma-Focused Cognitive Behavior Therapy Case Study

Within the parenting skills component of TF-CBT, Camila’s behaviors of physical aggression, noncompliance, daily tantrums, difficulty with separations and transitions, difficulty being consoled, and sleep disturbance were addressed in a variety of ways through collaboration between Mr. and Ms. Durham and the clinician. Of note, Mr. Durham participated in biweekly phone calls with the clinician to review progress.

Parenting strategies were routinely discussed during the caregiver-only portion of TF-CBT sessions with Ms. Durham throughout the course of Camila’s treatment. The clinician began the parenting work with Ms. Durham by inquiring about parental views on discipline. Ms. Durham reported she implements most of the discipline in their home and her husband tends to be more permissive. Both parents hold a strong value of respecting authority and are concerned how Camila’s aggressive behavior may put her in danger later in life as a woman of color. Although Ms. Durham does not favor corporal punishment, she has considered spanking Camila in response to her aggression because she does not know what else to do. Ms. Durham reported she was reluctant to use ignoring and time-out, as she was reminded of her own experience of neglect. Consistent with the TF-CBT model, to help address Camila’s behaviors, the clinician conducted a functional behavioral analysis to determine the antecedents, consequences, severity, and Camila’s response related to her physical aggression, noncompliance, tantrums, and sleep disturbance across both home and school settings. The clinician obtained a release of information to discuss Camila’s behaviors with her preschool teacher. Following this discussion, it became clear Camila’s aggression was primarily in response to rules about mealtime, boundaries, and snacks – which indeed may be related to Camila’s biological home environment where food was scarce or unavailable at times and there were few boundaries. Although it can be difficult to determine the exact association between a child’s behavior and a child’s traumatic experiences, the clinician recognized the importance of helping Ms. Durham to consider potential relationships between Camila’s experiences and behaviors in order to maximize the effectiveness of her behavior management strategies. Given Camila’s history of physical abuse within her previous foster home, her physically aggressive behaviors towards peers and adults were tentatively considered to be the result of modeling of violent behaviors. The clinician discussed over a few sessions with Ms. Durham the specific instances in which Camila became physically aggressive in response to limit setting within the home environment. Ms. Durham was able to identify a pattern where Camila’s behaviors seemed to escalate after Ms. Durham or her husband spoke at loud volumes. The clinician spoke to Ms. Durham about how she and her husband’s volume level may be a trauma reminder for Camila that is associated with precursors to acts of physical abuse she experienced. The clinician also provided psychoeducation about how children’s misbehavior may be reinforced by a caregiver’s response, resulting in a negative coercion cycle (Patterson et al., 1991).

After the clinician provided Ms. Durham with psychoeducation, the clinician then discussed with Ms. Durham the use of praise in response to Camila’s desirable behaviors. For example, Ms. Durham was encouraged to give labeled praise when Camila used gentle hands during play (“Great job using gentle hands!”) or times when she was sharing with her brother (“Thank you for sharing so nicely with your brother.”) over a period of a week in efforts to increase the likelihood of these behaviors continuing. The clinician proceeded to review the strategy of active ignoring with Ms. Durham to help address Camila’s disruptive but minor misbehavior. The clinician explored Ms. Durham’s concerns regarding active ignoring given her own history of neglect, and Ms. Durham was relieved upon realizing she could stay close to Camila and monitor her safety while engaging in active ignoring. She also felt comfortable using active ignoring when considering other discipline approaches (e.g., using a loud voice, spanking) may be trauma triggers for Camila. Some of the behaviors Ms. Durham identified within sessions included Camila’s whining, tantrums, and her tendency to say hurtful things to Ms. Durham in response to limit setting. Ms. Durham was instructed to ignore these behaviors and actively praise the opposite behaviors (e.g., asking nicely for things, compliance after first request).

To manage Camila’s aggressive behaviors, the clinician taught Ms. Durham how to safely implement a time-out procedure. The clinician began by discussing Ms. Durham’s feelings about time-out and her perceptions of how using time-out might impact her consistency. Ms. Durham reported she had begun her own trauma-focused therapy and she felt more comfortable implementing a time-out procedure. The clinician worked with Ms. Durham to identify a quiet place in their house to ensure the time-out chair that was separate from toys and other stimuli but close enough where Ms. Durham could monitor safety through sight and sound. Ms. Durham mentioned she previously had Camila go to time-out for 10–15 min, which was deeply distressing for Ms. Durham and Camila. The clinician explained a time-out of only a few minutes (~ 3) has been shown to be effective. Ms. Durham and the clinician decided time-out would be used every time Camila was aggressive towards her parents or her younger brother. After Ms. Durham learned about praise, ignoring, and time-out, the clinician and Ms. Durham practiced several role-plays so Ms. Durham could become comfortable using these skills with the clinician prior to practicing with Camila. When opportunities arose in session for Ms. Durham to use various parenting strategies, she was then encouraged to use them. For instance, she was encouraged to praise Camila for practicing various stabilization skills and for sharing her trauma processing during a conjoint session. Ms. Durham was assigned homework to use the various parenting skills she learned with Camila at home during the week, and the clinician asked in each subsequent session about whether she was using the skills and answered any questions she had related to implementing them.

In addition to praise, ignoring, and time-out, the clinician talked with Ms. Durham about other behavior management techniques consistent with TF-CBT and asked her to identify one behavior she wanted to increase with a behavior chart. Ms. Durham explained Camila often does not want to go to school in the mornings, so she delays and whines when asked to get dressed. On several occasions, Camila has had intense tantrums related to getting dressed, and Ms. Durham has had to dress her even though Camila is capable of putting her clothes on independently. The clinician and Ms. Durham created a behavior chart where Camila could earn a sticker for each morning she dresses herself for school. The clinician included Camila in deciding weekly rewards she could earn for getting five stickers in a week. Camila, Ms. Durham, and the clinician agreed on several non-monetary rewards, such as extra screen time, trips to the playground, and baking special recipes. Behavior charts are generally flexible, but some guidelines that are commonly effective include discouraging caregivers from using negative consequences for children failing to engage in the desired behavior, frequently reminding children of the behavior chart, gradually increasing the number of stars or points needed to earn rewards as behaviors improve, and substituting in new behaviors once targeted ones have reached a desirable level. After introducing the skill, the clinician asked Ms. Durham about her implementation of the behavior chart in subsequent sessions to ensure appropriate implementation.

The clinician also provided psychoeducation to Ms. Durham related to difficulty with regulation that some children evidence following trauma in the form of trauma triggers, and the connection to problem behaviors such as tantrums and non-compliance. Over the course of several sessions, the clinician taught Camila and Ms. Durham various skills to help Camila increase her ability to regulate. The clinician worked with Ms. Durham to consider how to help support Camila in using various relaxation (e.g., deep breathing), affect modulation (e.g., feelings identification, creation of a calm down kit), and cognitive coping skills (e.g., identifying her thoughts and telling herself, “I can calm down”). Ms. Durham was also responsive to developing a soothing bedtime routine and allowing Camila to sleep with a nightlight and stuffed toy to act as a security object when sleeping alone. Using skills with support from Ms. Durham allowed Camila to increase her ability to identify and express her feelings, calm when upset, separate from caregivers, transition from activities, and fall back to sleep after awakening from nightmares.

Finally, during the trauma narration and processing phase of Camila’s treatment, the clinician provided Camila with a variety of toys, including some that matched her experiences (e.g., police car; male and female adult and child dolls; blocks to represent houses). The clinician labeled the toys for Camila and responded to her play by asking questions and taking notes on Camila’s comments during the play (e.g., “mommy was asleep when the baby was crying”). Over the course of a few sessions, the clinician reviewed Camila’s trajectory of play and helped Camila identify feelings related to different experiences enacted in her play. During the parent-only portion of Camila’s therapy sessions, the clinician reviewed Camila’s play with Ms. Durham and elicited her thoughts, feelings, and reactions. In preparation for the conjoint session, the clinician discussed how Ms. Durham could respond to Camila’s sharing of her play (i.e., trauma narration) and provided feedback to Ms. Durham about her ideas related to supporting Camila during this session (e.g., praising her for sharing, avoiding questions, and reflecting statements that Camila makes during explanation of her play). As Camila and Ms. Durham approached the end of TF-CBT, Ms. Durham reported significantly less disruptive behavior for Camila. She also described feeling more prepared to respond to Camila in situations that might elicit emotional or behavioral dysregulation after gaining awareness of Camila’s representation of her traumatic experiences through play.

Discussion

The paper reviews how three evidence-based treatment models could address managing behavioral difficulties in the context of a clinical case presentation involving trauma exposure and traumatic stress. In CPP, behavioral difficulties are primarily managed through co-regulation and other developmentally-sensitive parenting strategies, all with the goal of supporting an emotionally-safe caregiver-child relationship. Through processing of trauma, navigating competing needs, and increasing attunement, Camila became more responsive to limit setting by Ms. Durham. The use of co-regulation prior to limit setting allowed Camila to regulate her emotions in tandem with Ms. Durham more appropriately, subsequently limiting disruptive behaviors and increasing compliance. In PCIT, the use of CDI skills helped improve Camila’s relationship with Ms. Durham while simultaneously reducing her problem behaviors. This was especially encouraging to Ms. Durham, given her concerns about her relationship with Camila at the beginning of treatment. The use of selective attention reduced mildly disruptive behaviors, and PDI skills allowed Ms. Durham to manage more problematic behaviors. In addition, the consistency and predictability of limit setting and responses to behaviors appeared to be calming to Camila, reducing her tantrums and emotion dysregulation over time. In TF-CBT, the use of a functional behavior analysis revealed unique patterns of behaviors in school and home settings. Some behaviors appeared related to trauma triggers, which were subsequently improved through the use of relaxation, affect modulation, and cognitive coping skills. In addition, Ms. Durham implemented praise, active ignoring, time-out, and a behavior chart to help manage disruptive behaviors.

Our case study, though not reflective of an individual clinical case, represents aspects of real patients encountered by the authors. We feel, given our collective experiences treating children with comorbid trauma histories and disruptive behaviors, that each of the example courses of treatment are representative of potential courses of clinical treatment in a typical clinical setting.

Each of the models has unique theoretical underpinnings, yet some principles of behavior management in the context of clients with a history of traumatic stress, overlap. For example, both PCIT and TF-CBT rely on the use of rewards (i.e., attention or reward charts), negative reinforcement (i.e., selective attention and active ignoring), and punishment (i.e., time-out). Both CPP and TF-CBT emphasize the importance of emotion regulation skills to manage disruptive behaviors. Furthermore, both CPP and TF-CBT carefully consider the antecedents and origins of behaviors (i.e., functional analysis in TF-CBT, fidelity strands in CPP). All three models prioritize the caregiver-child relationship to varying degrees, with particular importance placed on the caregiver as a key agent of change.

There are notable differences in the ways each of the models addresses disruptive behaviors as well. CPP emphasizes co-regulation within the dyad and uses a “watch, wait, and wonder” stance, interpreting the causes of behaviors through a developmentally-sensitive and trauma-informed lens. The goals for treatment, and techniques needed to support those goals, are individualized for each dyad. Therefore, caregiver expertise regarding their child and cultural values surrounding parenting help the clinician and caregiver to jointly determine which specific techniques are utilized within behavior management (Lieberman et al., 2015). PCIT relies on learning theory principles and does not formally differentiate between trauma-related behaviors and disruptive behaviors as part of the standard protocol, though many clinicians incorporate trauma-related concepts into their PCIT implementation (Gurwitch & Warner-Metzger, 2022). For instance, clinicians may integrate psychoeducation about the impacts of trauma in children and enhance parents’ identification and understanding of trauma-related dysregulation versus behavior in response to limit-setting and rules. Additionally, clinicians may emphasize the importance of consistency and predictability in the PCIT protocol that helps both increase the effectiveness of managing child behavior and promote a sense of safety within the parent-child dyad. In PCIT, desired behaviors are increased through positive reinforcement and less desired behaviors are reduced through punishment, both delivered via caregiver-child interactions (Eyberg & Funderburk, 2011). TF-CBT prioritizes parenting skills that are taught and implemented by the caregiver, with special attention focused on increasing child regulation capacities to reduce trauma-related misbehavior. Antecedents to behaviors are considered in functional behavioral analyses, which may influence the approach used to manage the behavior (e.g., skills use for trauma-related dysregulation, punishment and reinforcement for other behaviors; Cohen et al., 2017). For example, in CPP, the caregiver, as opposed to the therapist, is viewed as the child’s rightful guide in life and in therapy. The therapist strives to support the caregiver to enhance attunement, co-regulation, physical and emotional safety, and enable the child to talk and play about the trauma(s) they have experienced. In PCIT, the caregiver also is viewed as central to the child’s healing. The therapist coaches the caregiver to use the PRIDE skills to increase warmth in the relationship and enhance acceptance and affirmation of the child. The caregiver, with the therapist’s support, also provides effective limit setting in the second phase of treatment. In TF-CBT, the caregiver is also thought to be central to the child’s healing. They learn to provide structure by implementing various parenting strategies. They also support the child’s use of relaxation, affect identification and modulation, and cognitive coping skills at home, thereby increasing the child’s ability to regulate and cope with trauma reminders. The caregiver also typically participates in the conjoint session during which the child shares their trauma experiences and thoughts and feelings related to those experiences. Such sharing, despite its difficult content, may be a relationship enhancing experience for the family particularly when caregivers share their positive feelings about the hard work the child has engaged in to tell their story. By focusing on enhancing the caregiver child-relationship, each of these interventions uses sometimes similar, and other times different, strategies to help the child return to a typical developmental trajectory and feel safe and supported.

Each of the models has strengths in its approach to managing disruptive behaviors in children with a history of traumatic stress. CPP includes a focus on “angels in the nursery,” in which caregivers consider positive aspects of caregiving relationships in their own lives from the past (Lieberman et al., 2015). This approach may facilitate values-driven behavior changes in caregivers, which may be more meaningful and sustainable over time. Furthermore, CPP has a strong evidence based for reducing trauma-related symptoms in children, which may manifest as disruptive behaviors related to alterations in arousal and reactivity and negative alterations in cognition and mood. Therefore, resolving trauma symptoms through CPP treatment may avoid the need for subsequent behaviorally-focused therapy services. There is ample evidence for the benefits of PCIT in reducing disruptive behaviors and often in a relatively brief timeframe (Rae & Zimmer-Gembeck, 2007; Ward et al., 2016). For children presenting with trauma exposure but few trauma symptoms, PCIT may be an ideal intervention. Furthermore, for families where the primary concern is disruptive behaviors rather than traumatic stress, PCIT may address the primary focus of treatment while still reducing trauma-related symptoms (Pearl et al., 2012; Timmer et al., 2010). TF-CBT focuses on improving positive parenting principles and behavior management strategies while increasing the child’s capacity to regulate their emotional responses and tolerate trauma reminders (Cohen et al., 2017). Children who complete TF-CBT may develop coping skills that will benefit them in the future. Although behavior management is the focus of this manuscript, it is also important to note that these interventions also demonstrate positive impacts on general child and caregiver wellbeing, through building warmer, more secure parent-child relationships, increasing caregiver and child self-esteem, and reducing parenting stress (Cohen et al., 2017, Lieberman et al., 2015, Rae & Zimmer-Gembeck, 2007).

Similarly, there are drawbacks of each treatment model in addressing disruptive behaviors in children with a history of trauma. In CPP, the primary focus of treatment is building capacity within the dyad to process trauma, regulate emotions within the dyad, and return the child to a more typical developmental trajectory. The reflective and non-directive stance of CPP moves away from specific skills-building, cognitive behavioral approaches. This style may not be compatible for all caregivers, including those with limited cognitive/reflective abilities or those who prefer a more structured, directive therapeutic style. Conversely, the focus of PCIT is reducing disruptive behaviors and strengthening the caregiver child relationship through a directive and skills-based approach. Although PCIT has evidence for reducing trauma symptoms in children (Pearl et al., 2012), there is no focus on trauma processing or building emotion regulation capacities in the child or caregiver to manage trauma-related stress as part of the standard PCIT protocol. Finally, though TF-CBT incorporates both trauma processing and behavior management principles to address disruptive behaviors, behavior management is less intensively addressed than in models such as PCIT. Furthermore, behavior management strategies are implemented through the caregiver’s efforts at home and clinicians have less opportunity to observe disruptive behaviors in the context of the caregiver child relationship.

It is essential to note all three treatment models, though unique in their approaches, have empirical evidence in reducing symptoms of trauma and disruptive behaviors (Cohen & Mannarino, 1996; Lieberman et al., 2005; Pearl et al., 2012). Each of the models has benefits and drawbacks in addressing disruptive behaviors in children with a history of traumatic stress. We do not assert that one model is superior in working with this population. Rather, we suggest equifinality, where each model, under the right circumstance, could benefit each family appropriate for its use. The “best” treatment does not only mean identifying an evidence-based model, but also considering various factors that may impact treatment outcomes. Child, caregiver, and environmental factors are important predictors of treatment success and dropout (Sprang et al., 2013; Wamser-Nanney & Steinzor, 2016; Werba et al., 2006), and the present study highlights considerations related to these factors through a novel case study method. Effective treatment incorporates a model with empirical support that is a good fit with families’ values, goals, and needs and considers child, caregiver, and environmental factors needed when deciding between CPP, PCIT, and TF-CBT (Vanderzee et al., 2019).

In sum, this paper highlights the importance of assessing for trauma exposure and trauma-related symptoms when working with children with behavioral difficulties, as there is much overlap in symptoms that occurs in children with trauma. Understanding the etiology of such behavioral difficulties may be used to guide intervention selection and treatment. CPP, PCIT, and TF-CBT each take unique approaches to addressing trauma symptoms and disruptive behaviors, though all are evidence-based treatments for young children exposed to trauma and exhibiting disruptive behaviors. Child, caregiver, and environmental factors may be the most important considerations when selecting an intervention model to address disruptive behaviors in the context of young children exposed to trauma.

Declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Competing interests

The authors have no relevant financial or non-financial interests to disclose.