This paper attempts to integrate psychoanalytic thinking with understandings about executive functions as well as with recent neurobiological research. A clinical case is described in detail to illustrate the need, as Anne Alvarez has proposed, to work at the appropriate level for the child’s development. Links are made to Freud’s thinking about the ego as well as to contemporary neuroscience. It is suggested that maltreatment, both abuse and neglect, gives rise to serious developmental deficits, such as in processing emotions, planning, using working memory and indeed in basic thinking capacities. It is argued that therapeutic technique must be adjusted to take this into account and that there are opportunities for further research into these issues.