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Case study #3
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(PADESKY’S 5 AREA FRAMEWORK)

• Antisocial and
aggressive behaviour. • I'm doing these things for fun.
• Physical fights (using • I enjoy see others pain.
weapons). • Nobody is going to stop me.
• Steal. • My parents are not there for me.
• Pyromania.
• Threatened others.
• Inappropriate sexual BEHAVIOR THOUGHTS
behavior.

SYBIL

• Revenge.
BODY/BRAIN
(SYMPTOMS) EMOTIONS • Anger.
• Frustration.
• Normal IQ • Loneliness.
• Antisocial and • Attacked.
aggressive behaviour.
• Injuries due to her
behavior?

ENVIRONMENT SITUATION: Sybil is 9 years old, since the age of 6 she has shown some violent behaviors. Her family is no longer to
control her violent outbursts (her family have been trying to cope with it?). Now Sybil is in a psychiatric inpatient facility (third
hospitalization). She has been in five different grade schools due to her disruptive behavior. Sybil’s mother is not in the picture. Dysfunctional
parenting style. She is living with a person with disabilities. Her father has been in jail for drug-related offenses (neglected care). Victim of
sexual abuse? Decreasing scholar performance and domestic battery charges pending against her in court.
 (2P) Predisposing Factors: (4P) Perpetuating Factors: 4

• Neglected care. • Lack of family support

(5P) Protective Factors:
• Lack of support (parental stress). • Wrong teachers approach to her
• Growing up in a conflict environment Timeline reactions? • Normal IQ
(drugs, abuse?, poverty?) • Not knowing how to cope with anger • Access to clinical
• Aggressive discipline? or resentment. attention.
• Poor social relations?
(3P) Precipitating Factors:
• Going through overwhelming situations.
• Seeing aggressive role models? Having her own
experience with successful aggressive tactics.
• Sexual abuse? (1P) The Problem:
•

(6P) Treatment Plan:

• Cohesive family model, focused
on child-parents (the ones that
play parents role not necessarily
her mon and dad) relationship.
• Psychoeducation to family and
teachers in order to make them
understand Sybil’s behavior.
• Work with emotional
validation, functional response
mechanisms and adaptative
social skills.
• Reinforce prosocial behaviors.
• Work on the self (self-concept,
self-image, self-esteem).
• Seek strategies to improve
school performance and social
relationships with teachers and
peers.
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Sybil's case formulation

1. The Problem

Sybil is a 9-year-old girl who lately has been acting aggressive threatening others, being involved in physical fights robbery and

using fire with animals (behavior/emotions); reasons why she had been remitted to a psychiatric inpatient facility since the age of 6

and being her third hospitalization this time. Her paternal grandmother said that Sybil has a normal IQ (body/brain) and at the age

of six she started having problems in school, behaving violent and showing inappropriate sexual conduct (behavior), also she reported

that Sybil’s mother hasn’t been very present in her daughter’s development and her father, a person with disabilities, was in jail for

drug charges. When people ask her why she acts like that, she answers she thought it was funny (thoughts), in fact she has some

domestic charges pending and her family reported feeling relieved with she hospitalized because they don’t understand her problem.

2. Predisposing factors

Based on Sybil’s family structure and environment, some important predisposing factors can be identified in relation to her family.

Neglected care and lack of support resulted of parental stress, both forms of childhood maltreatment, are closely related to

development of many psychiatric disorders like substance abuse disorders, anxiety disorders and antisocial or disruptive behavior

disorders. (Keyes, et al., 2012). Also, longitudinal studies have shown that growing up in a conflict environment characterized by

drug influence, poverty, low education opportunities or high risk of abuse, is a group of conditions that can being potentializing the

risk of develop a conduct disorder or at least being a resource of maladaptive or dysfunctional behaviors that a child could easily

learn and imitate. (Yalcin & Erdogan, 2013)

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3. Precipitating factors

When children do not have any regulation mechanism to deal with anger, frustration or face repression, they tend to develop sense

of revenge and dysfunctional behaviors such as aggressive and antisocial (Eisenberg, Fabes, Nyman, Bernzweig, & Pinuelas, 1994).

So, with this on mind, going through overwhelming situations like abuse and maltreatment might be an important trigger to

maladaptive behavioral reactions because it creates a scenario to expose the child onto situations where she would not know how to

properly deal. Also, the possibility of have aggressive role social models -from parents, teachers, peers- or not having good role

models, are precipitating factors when it is added to successful experiences with aggressive tactics, because that reinforces the violent

answers and make the child think those are the best or the only ways to behave (Walters & Willows, 1968). Finally, even if this is a

hypothesis, a possible sexual abuse should be investigated and if that is the case, being a victim of sexual abuse is closely related

with early onset on sexual behaviors and violent reactions to people (probably with the abuser or generalize the abuser´s sex as a

defense mechanism) seeing others like potential threat. (Spataro, Mullen, Burgess, Wells, & Moss, 2018)

4. Perpetuating Factors

Based on the huge positive impact of cohesive family model as treatment in these cases, it can be said that having lack of family

support not only is a predisposing factor and it also keeps running the problems because it reduces the possibility to develop prosocial

skills and means nobody is really teaching healthy bounds to her (Breslau & Lucia, 2006). Other perpetuating factor could be her

teachers’ approach at school and having trouble at social relationships, because negative judgements, authoritative orders and

rejection will reinforce an aggressive or disruptive answer (Huesmann, 1988) as same as treat her like a criminal instead of

understanding what caused her behavioral answer and give to her an appropriate treatment.
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5. Protective Factors

Sybil´s having a normal IQ is protective factor for her case because she has a normal use of her mental faculties, is not suffering a

cognitive disorder and is not directly related to CD or ODD as low IQ is (Koenen, Caspi, Moffitt, Rijsdijk, & Taylor, 2006). Also,

having access to clinical attention means she can reach professional help now, which must be effective in order to stop the

development of the problem and precisely to establish any kind of treatment and follow up.

6. Formulation and Clinical Reflection

Based on the available information of Sybil's case, since she has shown a behavior against social norms and people´s rights during

the last 3 years evidenced by threatening others, starting physical fights, being cruelty with others and animals, starting fire setting

and showing inappropriate sexual behavior; it can be said she apparently meets criteria for Conduct Disorder (American Psychiatric

Association, 2013). However, there is some information that must be indagated and clarify before any hypothesis conclusion or

future diagnosis. For example, as an attempt to understand what triggered Sybil´s behavior, the possibility of sexual abuse must be

investigated; mostly because she has shown inappropriate sexual behavior and longitudinal studies say there is a correlation between

children being victims of sexual abuse and tendency to show sexual behavior on childhood (Mcclellanm, et al., 1996). As well as

indagate if aggressive discipline is used on her and has been taught to her, just to make sense of where she has learned violent

conducts because whereas it is, she must learn it from some source. But, like I said, this is just a hypothesis, and more information

is required to understand her behavior and for looking the best treatment approaches.
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7. Treatment Plan

Once a diagnosis can be confirmed, the most appropriate treatment plan according to Sybil´s needs should be the Cohesive Family

Model, which is focused on child- caretakers relationship. Not only working on improving their relationship bones in an accurate

way but also giving psychoeducation to them (parent or caregiver, family members and teachers) in order to inform and make sense

of the child´s pathology creating empathy around it. Also, since this is a behavioral issue, the use of behaviorism techniques like

positive reinforcers of prosocial behavior (Parent Management Training) are very common and highly effective (Ramaswamy &

Bergin, 2009). As well as, working emotional validation with the child by teaching her functional response mechanisms to anger,

adaptative social skills, effective communication and work on the self (self-concept, self-image, self-esteem).

Bibliography

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (Fifth ed.). Retrieved September 9,

2021, from https://doi.org/10.1176/appi.books.9780890425596

Breslau, N., & Lucia, V. (2006). Family cohesion and children's behavior problems: A longitudinal investigation. Psychiatry Research,

141(2), 141-149.

Eisenberg, N., Fabes, R., Nyman, M., Bernzweig, J., & Pinuelas, A. (1994). The Relations of Emotionality and Regulation to Children's

Anger-related Reactions. Child development, 65(1), 109-128.

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Keyes, K., Eaton, N., Krueger, R., McLaughlin, K., Wall, M., Grant, B., & Deborah, H. (2012). Childhood maltreatment and the structure

of common psychiatric disorders. British Journal of Psychiatry, 200(2), 107–115.

Koenen, K., Caspi, A., Moffitt, T., Rijsdijk, F., & Taylor, A. (2006). Genetic influences on the overlap between low IQ and antisocial

behavior in young children. Journal of Abnormal Psychology, 115(4), 787–797.

Mcclellanm, J., Mccurryph, C., Ronneiph, M., Adams, J., Eisnerm, A., & Storckm, M. (1996). Age of Onset of Sexual Abuse:

Relationship to Sexually Inappropriate Behaviors. Journal of the American Academy of Child & Adolescent Psychiatry, 35(10),

1375-1383.

Ramaswamy, V., & Bergin, C. (2009). Do Reinforcement and Induction Increase Prosocial Behavior? Journal of Research in Childhood

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Spataro, J., Mullen, P., Burgess, P., Wells, D., & Moss, S. (2018). Impact of child sexual abuse on mental health. The British Journal

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Nonaggressive Models. Child Development, 39(1), 79-89.

Yalcin, O., & Erdogan, A. (2013). Neurobiological, Psychosocial and Enviromental Causes of Violence and Agression. Current

Approaches to Psychiatry, 5(4), 388-420.

Huesmann, R. (1988). An information processing model for the development of aggression. Aggressive Behaviour, 14(1), 13-24.