NMT functional brain ‘‘map’’: 6-year-old traumatized and neglected child vs. comparison child (normal development). This map is generated from an interdisciplinary staffing process examining the functional status of various brain-mediated functions. Each rectangle in the diagram indicates a brain function. Each rectangle is shaded to indicate functional status (see key above). Brain functions (e.g., regulation of heart rate: Brainstem; speech and language: CTX; attunement: Limbic) are ‘‘localized’’ to a brain region mediating the specific function (this oversimplification attempts to assign function to the brain region that is the final common mediator of the function with the knowledge that almost all brain functions are influenced and mediated by complex, trans-regional neural networks). This approximation allows a useful estimate of the developmental = functional status of the child’s key functions, estab- lishes the ‘‘strengths and vulnerabilities’’ of the child, and determines the starting point and nature of enrichment or therapeutic activities most likely to meet the child’s specific needs. 

Context in source publication

Context 1

... while the ongoing process of ‘‘tri- balism’’ — creating an ‘‘us’’ and ‘‘them’’ — is a powerful but destructive aspect of the human condition, exacerbating trauma in individuals, families, and communities attempting to heal. The clinical implications of this understanding of the power of relational health are, again, profound. As one would predict, research suggests that social connectedness is a protective factor against many forms of child maltreatment, including physical abuse, neglect, and nonorganic failure to thrive, as well as a means of promoting prosocial behavior (Belsky et al., 2005; Caliso & Milner, 1992; Egeland, Jacobvitz, & Sroufe, 1988; Rak & Patterson, 1996; Travis & Combs-Orme, 2007; Chan, 1994; Coohey, 1996; Guadin et al., 1993; Hashima & Amato, 1994; Pascoe & Earp, 1984; Altemeier, O’Connor, Sherrod, & Vietze, 1985; Benoit, Zeanah, & Barton, 1989; Crnic, Greenberg, Robinson, & Ragozin, 1984; Gorman, Leifer, & Grossman, 1993). The number, quality, and stability of relational interactions matter to the child. Removing children from abusive homes also may remove them from their familiar and safe social network in school, church, and community. And worse, the presence of new and unfamiliar individuals can actually activate the already sensitized stress-response systems in these children, making them more symptomatic and less capable of benefiting from our efforts to comfort and heal. Our well-intended interventions often result in relational impermanence for the child: foster home to foster home, new schools, new case workers, new therapists as if these are interchangeable parts. They are not. Even ‘‘best-practice’’ therapeutic work is ineffective in an environment of relational instability and chronic transition. Over the last 20 years, we have been adapting our clinical practice to incorporate emerging findings from neuroscience. This has resulted in a shift from a traditional medical model approach to a more developmentally sensitive, neurobiology-guided practice. The results are promising (see Perry, 2006; Barfield et al., 2009). A brief overview follows. The neurosequential model of therapeutics (NMT) is not a specific therapeutic technique or intervention; it is an approach to clinical work that is informed by neuroscience (Perry, 2006). It is, in short, an effort in translational neuroscience that has been evolving over the last 15 years. The NMT process structures assessment and identification of primary problems and strengths, and it sequences the application of interventions (educational, enrichment, and therapeutic) in a way that reflects the child’s specific developmental needs in a variety of key domains and is sensitive the to core principles of neurodevelopment — some of which have been articulated above. There are three central elements of the model: a developmental history, a current assessment of functioning, and a set of recommendations for intervention and enrichment that arise from the process. The brain organizes as a reflection of experiences both good and bad. To understand an individual, therefore, one needs to know his or her history. The NMT assessment is focused on the developmental history of the child. The NMT core assessment reviews the timing, nature, and severity of developmental challenges; these are scored, resulting in an estimate of developmental ‘‘load.’’ This also allows an estimate of which neural networks and functions would plausibly be impacted by the child’s developmental insults or history of trauma (Perry, 2001, 2006). For example, intrauterine insults such as alcohol use or perinatal caregiving disruptions (such as an impaired, inattentive primary caregiver) will predictably alter the norepinephrine, serotonin, and dopamine systems of the brainstem and diencephalon that are rapidly organizing during these times in life. These early life disruptions, in turn, will result in a cascade of regulatory functions impacting a wide distri- bution of other brain areas and functions that these important neural systems innervate (for more, see Perry, 2008). A second important element of the NMT core assessment is a review of the relational history of the child during development. As discussed above, relational milieu can be protective and confer some capacity to buffer the impact of trauma, while relational instability and multiple transitions can exacerbate developmental insults. This NMT relational health history provides important insights into attachment and related resiliency or vulnerability factors that may have impacted the functional development of the child (see Figure 1). The second component of the NMT process is a review of current functioning that allows us to make estimates of which neural systems and brain areas are involved in the various neuropsychiatric symptoms. An interdisciplinary staffing is typically the method for this functional review. This process helps in the development of a working functional brain map for the individual (see Figure 2). This visual representation gives a quick impression of developmental status in various domains of functioning: A 10-year-old child, for example, may have the speech and language capability of an 8-year-old, the social skills of a 5-year-old, and the self-regulation skills of a 2-year old. This visual ‘‘map’’ is very helpful when talking about trauma, brain development, and the rationale of various recommendations with educators, mental health staff, caregivers, and clients. It is also very useful to help track progress; improvement, as shown in changes in the shadings of various brain areas, is quick to see in the comparison of today’s brain map with one from 6 months ago and is a powerful reinforcement for tired parents and hard- working frontline staff who feel their efforts are for naught. This review requires a working knowledge of neural organization and functioning. In order to ‘‘localize’’ a set of functions to any set of brain networks or regions, the senior clinician leading the interdisciplinary NMT staffing must know child development, clinical traumatology, and developmental neurosciences. At present, this is the major impediment in exporting the NMT approach: It requires a senior clinician to lead the process with a unique combination of clinical and preclinical skills. The third major element of the NMT process is providing specific recommendations. The NMT ‘‘mapping’’ process helps determine a unique sequence of developmentally appropriate interventions and enrichments that can help the child reapproximate a more normal developmental trajectory. As outlined in brief below, these recommendations are made with various principles of neurobiology in mind; while many deficits may be present, the sequence in which these are addressed is important . The more the therapeutic process can repli- cate the normal sequential process of development, the more effective the interventions are (see Perry, 2006). Simply stated, the idea is to start with the lowest (in the brain) undeveloped = abnormally functioning set of problems and move sequentially up the brain as improvements are seen. This may involve initially focusing on a poorly organized brainstem = diencephalon and the related self-regulation, attention, arousal, and impulsivity by using any variety of patterned, repetitive somatosensory activities (which provide these brain areas with the patterned neural activation necessary for reorganization) such as music, movement, yoga (breathing), and drumming or therapeutic massage. Once there is improvement in self-regulation, the therapeutic work can move to more relational-related problems (limbic) using more traditional play or arts therapies; ultimately, once fundamental dyadic relational skills have improved, the therapeutic techniques can be more verbal and insight oriented (cortical) using any variety of cognitive-behavioral or psychodynamic approach. Further, the recommendations and enrichments are not limited to the conventional limits of ‘‘mental health’’ symptoms; issues in speech, learning, motor functioning, and social functioning are all addressed as part of a compre- hensive, more holistic approach to the child and her or his family. Patterned, repetitive activities shape the brain in patterned ways, while chaotic experiences create chaotic dysfunctional organization. Therapeutic activities, then, are most effective when implemented with focused repetition targeting the neural systems one wishes to modify. One cannot change a neural system without activating it; one cannot learn how to write by watching a DVD on how to write — one has to hold the pencil, make the movements, and practice and master the skill. The NMT assessment and functional mapping allow targeted therapeutic efforts in the neural systems that mediate the child’s specific symptom array. When symptoms related to the persisting ‘‘fear’’ response (common in maltreated children) are addressed, therefore, remembering that these first arise in the brainstem and then move through the brain up to the cortex, the first step in therapeutic work is brainstem regulation. The child may also have a host of cortically mediated symptoms such as self-esteem problems, guilt, and shame. The most effective intervention process would be to first address and improve self-regulation, anxiety, and impulsivity before these cognitive problems become the focus of therapy. A key component of the NMT recommendations relates to the child’s current relational milieu. A primary finding of our clinical work (and many other researchers; see above) is that the relational environment of the child is the major mediator of therapeutic experiences. Children with relational stability and multiple positive, healthy adults invested in their lives improve; children with multiple transitions, chaotic and unpredictable family relationships, and relational poverty do not improve even when provided with the best ‘‘evidence-based’’ therapies. A simple ...