the childtrauma academy introduction to the nmt

The ChildTrauma Academy Introduction to the NMT

Materials may not be replicated, repurposed or modified without permission

Bruce D Perry, MD, PhD © 2010

All rights reserved © 2010 Bruce D. Perry

Integra)ng Principles of Neurodevelopment into Clinical

Prac)ce Introduc)on to the Neurosequen)al Model of

Therapeu)cs (NMT)

2011


Theory of Change

Why do you do the things you do? How do you think they will cause

change for the client – for your child?


A. Brain Organiza)on and Func)on

NMT Core Principles


The Brain MaNers •  The human brain is the organ responsible for everything we do. It allows us to love, laugh, walk, talk, create or hate.

•  The brain -‐ one hundred billion nerve cells in a complex net of con)nuous ac)vity -‐ allows us our humanity.

•  For each of us, our brain’s func)oning is a reflec)on of our experiences.


Cortex

Limbic

Diencephalon Cerebellum

Brainstem

Abstract thought

Concrete Thought

Affiliation/reward

"Attachment"

Sexual Behavior

Emotional Reactivity

"Arousal"

Appetite/Satiety

Blood Pressure

Heart Rate

Body Temperature

Sleep

Motor Regulation

NE DA

ANS - body

SER


Complexity Plasticity

Neocortex

Limbic

Diencephalon

Brainstem





Cortical

Limbic

DE

BS

Cortex

Limbic

DE

BS

CORTICAL MODULATION

Cortex

Limbic

Developing/neglect Mature


“Out” “In”

Multi-level Processing


B. Neurodevelopment and Memory

NMT Core Principles


Cell Body

Dendrites

Myelin Sheath

Axon

The Neuron Synapses


The Brain Develops

The human brain, with all of its complex structure and func)on, does not just

“pop” into existence. In the 9 months following concep)on, 100 billion neurons and 10 trillion glial cells are

born. These cells organize, move, connect and specialize to create the amazing and func)oning brain of the newborn.


The more a neural system is “ac)vated,” the more that system changes to reflect that paNern of

ac)va)on This is the basis for development,

memory and learning

USE-DEPENDENT DEVELOPMENT





Age in Years

Mul)p

les o

f Weight a

t Birth

0 20 5 10

20

15

10

5

15

Body

Brain

Brain Growth vs. Body Growth


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Sequen9al Neurodevelopment •  The brain is undeveloped at birth •  The brain organizes from the “boNom” up -‐ brainstem to cortex and from the inside out

•  Organiza)on and func)onal capacity of neural systems is sequen)al

•  Experiences do not have equal “valence” throughout development


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What is Memory ? •  The capacity to bring elements of an experience from one moment in )me to another.

•  This is the unique property of life forms. •  There are many ways that life forms do this -‐ genes, immune system, nervous system

•  Nervous )ssue is designed to store elements of experience.


Associa)on

•  The brain makes associa)ons between sensory signals co-‐occurring in any given moment in )me

•  This capacity allows humans to learn, create images of the future and survive.

•  This capacity can also make humans vulnerable to false associa)ons -‐ crea)ng fears of non-‐threatening objects.


Crea)ng First Memories

The first set of unique sensory s)muli shape neural “networks” which will

“encode” and store – in neurons – the template for future sensory s)muli

similar to this original sensory experience.


Neuroarcheaology •  The age at which an adverse event takes place will influence the neurodevelopmental impact and the resul)ng func)onal consequences

•  Therefore, developmental history of adverse experiences is crucial to understanding current func)oning

•  NMT includes a developmental review of adverse experiences AND the buffering effects of rela)onal health





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“Out” “In”

New experience is “filtered”

through past

experience


C. Rela)onal Neurobiology and ANachment

NMT Core Principles


Human beings are social creatures.

The neural systems which mediate social interac)on, communica)on, empathy and the

capacity to bond with others are all shaped by the nature, quan)ty and )ming of early life

rela)onships.


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Rela)onal Neurobiology Founda)onal Neural Systems

The neural systems media)ng the stress-‐

response, reward, procrea)on, reproduc)on, social-‐affilia)on and communica)on are all are inter-‐related -‐ indeed, they oden share the very same fundamental neurotransmiNer

networks and brain regions.



VTA

DA Sensation of pleasure and

safety

Release of hormones

and “calmer” regulation of

key stress related neural

systems

Decrease physiological

distress

Somatosensory cues

Primary caregiver







LC

NE Fear and confusion

Activation of key stress

related neural

systems Increase

physiological distress

Somatosensory cues

Primary caregiver








Intimacy Barrier

History of Relational

Interactions

Casual - Routine - Personal - Intimate All rights reserved © 2010 Bruce D. Perry

NA

DA

Positive Human Interaction

Stimulation of “Reward” Neural Systems in the Human Brain: Multiple

Sensation of pleasure and

safety

Release of hormones

and “calmer” regulation of

stress response

neural systems Decrease

physiological distress

Drugs of Abuse cocaine, opiates, stimulants

EtOH

Sweet, salty, fatty

foods

Behavior consistent

with value or belief system

Cut, pick, pull Sex

Music and rhythmic sensory input


D. Stress, Distress and Trauma

NMT Core Principles


www.ChildTrauma.org 34

Responses to Stress, Distress, Trauma

•  Heterogeneity of response paAerns •  Adap)ve changes in cogni9on •  Adap)ve changes in affects •  Adap)ve changes in behavior •  Adap)ve changes in neurophysiology •  Adap)ve changes in physiology



Dissocia)on

Trauma Stress

Terror

Fear

Alarm

Alert

Calm



Females

Young Children

Torture/Pain

Inescapable Helplessness

Males

Older Children

Observer

Action Active Role

Arousal Dissociation

DISSOCIATIVE/AROUSAL BALANCE





Res)ng Heart Rates: Branch Davidian Children

80

90

100

110

120

130

140

3/8/

93

3/13

/93

3/18

/93

3/23

/93

3/28

/93

4/2/

93

4/7/

93

4/11

/93

4/16

/93

4/21

/93

Fire Parent Visits

Assault



Differen)al “State” Reac)vity

Extreme Stress Stress Baseline

Vulnerable

Normal

Resilient

Terror

Fear

Alarm

Alert

Calm


Bruce D Perry, MD, PhD © 2010 www.ChildTrauma.org

Cognition Abstract Concrete “Emotional”

Reactive Reflexive Mental State CALM ALARM FEAR ALERT TERROR

Primary secondary

Brain Areas

NEOCORTEX Subcortex

SUBCORTEX Limbic

LIMBIC Midbrain

MIDBRAIN Brainstem

BRAINSTEM Autonomic

Sense of Time

Days Hours

Hours Minutes

Extended Future

Minutes Seconds

Loss of Sense of

Time


E. Neglect

NMT Core Principles


To neglect a child is to murder them.

Daniel Dafoe All rights reserved © 2010 Bruce D. Perry

•  Lack of a specific paNern of experience during development results in abnormal development of a core brain func)on

•  The abnormal development is in those brain systems which sense, perceive, process, “interpret”, and “act on” informa)on related to that specific experience or input.

A Neurodevelopmental Definition of Neglect





Mul)ple Forms of Neglect

DOMAINS

Emo)onal Social

Cogni)ve Motor

PATTERN

Episodic Chao)c

Total global


Extreme Neglect Normal

3 Year Old Children


F. Neurosequen)al Model of Therapeu)cs

NMT Core Principles


Neocortex

Limbic

Diencephalon

Brainstem

SEQUENTIAL DEVELOPMENT Sequen)al Vulnerability


Neurodevelopmental Risk

•  The NMT process involves assessing the )ming, nature and intensity of adverse events

•  The )ming, nature and quality of “buffering” rela)onal health is assessed as well

•  An es)mate of “developmental risk” is obtained at various )mes during development by combining the AE and RH scores


Preliminary NMT Analysis (NMT Brain Func)on Score vs NMT Developmental Challenge Score)

Developmental Challenges (Adverse Events/Trauma/Neglect)

NMT FS Score





30

40

50

60

70

80

90

100

110

20 30 40 50 60 70 80 90 100


Current Rela)onal Health •  A major factor in healing appears to be the nature, quality, intensity and stability of a person’s rela)onships

•  The NMT assessment process includes a simple metric that looks at current rela)onal health

•  The score on this metric is a key indicator of outcome – good rela)onal stability predicts posi)ve outcome – and poor rela)onal health predicts poor outcomes


NMT Brain Mapping Process •  The key indicator of brain organiza)on and neurophysiological status is func)on

•  By crea)ng a simplified construct – the brain map – assessment of key brain-‐mediated func)ons can help “localize” neurodevelopmental vulnerabili)es and strengths

•  This “localiza)on” helps direct developmentally-‐sensi)ve interven)ons


CNS Func)onal Map

•  Several “brain map” models have been used in the process of crea)ng and refining the NMT

•  Current mapping process involves a web-‐based menu-‐driven review of various brain-‐mediated func)ons

•  The resul)ng “map” creates a visual representa)on that is useful for teaching, treatment planning and tracking outcomes


Difficult to sooth: Birth








G. NMT Applica)on and Outcomes

NMT Core Principles


Core elements of posi)ve developmental, educa)onal and therapeu)c experiences

•  Rela)onal (safe) •  Relevant (developmentally-‐matched) •  Repe))ve (paNerned) •  Rewarding (pleasurable) •  Rhythmic (resonant with neural paNerns) •  Respecoul (child, family, culture)


TIME 3 14 to 16 9 6 8 8 7 9 10 10 10 10 10 10 8 7 8 8 8 6 12 12 12 10 10 11 8 10 9 9 10 7 11 11 12 11 10 12

9 7 7 9 11 11 11 12 11 11 11 11 12 12 12 11

12 11 12 11 11 12 12 12 11 11 12 12

Developmental

TIME 1 11 to 13 Functional 5 4 4 3 5 6 9 9 9 9 9 9 12 DEVELOPED 8 6 6 4 4 5 11 11 11 9 9 10 11 NORMAL RANGE 4 4 6 6 8 5 10 10 11 11 10 11 10

6 4 2 4 11 11 11 11 9 EPISODIC/EMERGING 8 9 9 9 11 12 12 10 8 MILD Comprimise

11 4 12 11 7

8 10 12 12 6 PRECURSOR CAPACITY 8 9 12 12 5 MODERATE Dysfunc)on

4

TIME 2 14 to 16 3 UNDEVELOPED 7 5 5 6 6 7 10 10 10 10 10 10 2 SEVERE Dysfunc)on 8 6 7 6 5 6 12 12 12 10 10 11 1

6 6 8 7 9 6 11 11 12 11 10 12 8 6 4 6 11 11 11 12

10 10 10 10 12 12 12 11

11 6 12 11

10 11 12 12

9 10 12 12

Christopher 14 yo M Sandhill Child Development Center

7/08

12/08

10/09


The ChildTrauma Academy NMT Project All rights reserved © 2010 Bruce D. Perry

0

10

20

30

40

50

60

1 2 3 4

Drop in Restraints at AYN Residential and Day-hospital programs with NMT

12 mos prior 3rd 6 mos NMT 1s t 6 mos NMT 2nd 6 mos NMT

Res

train

ts/m

onth





H. Current NMT Metric Reports

NMT Core Principles



M.; 6 yo M Hx intrauterine SA/EtOH; severe neglect and abuse; removed at 12 mos; multiple placements; adopted at age 2 Dx at time of eval: ODD, ADHD


J. : 19 yo F No sig Hx of dev AE; stable family; Fam Hx bipolar Hx depressive episodes Eval s/p MVA; multiple evaluators assign Dx PTSD


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the childtrauma academy introduction to the nmt

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