Responding to Trauma through

Evidence-based interventions

San Mateo County

SMC Health System

Behavioral Health and Recovery Services

Toni De Marco, MFT

Clinical Services Manager, Youth Division

Where we started

History of struggling with the impact of complex

trauma in the lives of children

Change in “state of the art” treatment because of

brain science and understanding trauma differently

Adaptive Responses to Trauma

Amnesia Hopelessness

Insomnia Intrusive Memories

Nightmares

Shame & Self Hatred

Somatic Symptoms Chronic Pain

Dissociative Symptoms

Self Destructive Behavior

Eating Disorders Substance Abuse Generalized Anxiety

Panic Attacks

Depression

Irritability

Numbing

Decreased Interest

Hypervigilance

Physiological Hyperarousal

Agitation

Fisher, 2005

Traumatic

Event

The Neurosequential Model of

Therapeutics is a “trauma-informed,”

developmentally-sensitive, approach to the

clinical problem solving process.

It is not – and does not specifically imply,

endorse or require – any single therapeutic

technique or method.

All rights reserved © 2006-2011 Bruce D. Perry and The ChildTrauma Academy

Anthropology Neurobiology Developmental

Psychology

Developmental

Neuroscience

Neurosequential Model

in

Caregiving (NMC)

Neurosequential Model

Neurosequential Model

in

Education (NME)

Neurosequential Model of

Therapeutics (NMT)

Clinical Practices/Settings

Caregiving Practices

& Settings

Educational

Practices & Settings

Neurosociology

All rights reserved © 2006-2014 Bruce D. Perry and The ChildTrauma Academy

Neurosequential Model of Therapeutics

NMT is an approach that has:

Considered what science tells us about the brain in general and the

developing brain in particular.

Considered what science tells us about the developing brain when exposed

to chronic trauma or deprivation.

Considered which therapies work and when for children who experience

abuse and neglect.

Is an overarching developmental and relational approach directly informed

about the brain, trauma and deprivation to target areas of vulnerability

And has developed a set of ‘brain-region/neural network-

specific questions to target the functioning and

development of each of the four major regions of the

brain’

NMT Clinical Practice Tools (NMT Metrics)

1. Is not a stand-alone evaluation or assessment.

2. Should not be used out of context of broader

assessment and formulation.

3. Is a supplement not a replacement to clinical

problem solving and planning.

4. Can inform information gathering, analysis, action

and review but not appropriate for stand-alone

evidence in court.

5. Final decisions and recommendations must be

based on clinical expertise and judgment.

NMT responsive to the needs of youth and

their families…

Trauma-informed

Culturally flexible

Appropriate for co-occurrence and developed

for complicated presentation

Involves the community in helping children

and families heal

NMT Key Concepts

Sequential Interventions

Relational Poverty

Use-Dependent (function, arousal, learning)

States to Traits (state-dependent)

Cortical Modulation Ratio

Intimacy Barrier

Therapeutic Web

The Brain Matters

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 continuous activity - allows us our

humanity.

For each of us, our brain’s functioning is a

reflection of our experiences.

All rights reserved © 2006-2011 Bruce D. Perry and The ChildTrauma Academy

Typical Brain Development

Conception- 2 months

Brainstem – blood pressure, heart rate, body

temperature, primary sensory processing

2 months – 4 years

Diencephalon- sleep, appetite, motor skills, primary

sensory integration

5-12 years

Limbic system – memory, emotional regulation,

attachment, affect regulation

12 years and up

Neocortex – reasoning, problem-solving, and

abstraction

Complexity Plasticity

Neocortex

Limbic

Diencephalon

Brainstem

All rights reserved © 2006-2011 Bruce D. Perry and The ChildTrauma Academy

Neocortex

Limbic

Diencephalon

Brainstem

Abstract thought

Concrete Thought

Affiliation

"Attachment"

Sexual Behavior

Emotional Reactivity

"Arousal"

Appetite/Satiety

Blood Pressure

Heart Rate

Body Temperature

Sleep

Motor Regulation

All rights reserved © 2006-2011 Bruce D. Perry and The ChildTrauma Academy

Survival Brain

REGULATE

Learning Brain

REASON Cognitive

Relational

Self-

Regulation

Sensory

Integration

Arousal Continuum +

Intervention Sequencing

Feeling Brain

RELATE

~ from the ChildTrauma Academy Copyright © 2015 by The Art of Yoga Project

WE REMEMBER

“The therapeutic

process should

replicate the normal

sequential process of

brain development.”

All rights reserved © 2006-2014 Bruce D. Perry and The ChildTrauma Academy

Sequence of Engagement

Reason

Relate

Regulate All rights reserved © 2007-2014 Bruce D. Perry

Impact on Development

• “Use-dependent”- memorizing a poem,

practicing the piano, staying in a state of fear

• Persisting activation of the neurophysiology of

threat “re-sets” homeostasis-leading to

potentially life long traits (personality sets)

–Persisting hyperarousal

–Persisting dissociation

These STATES become TRAITS!

All rights reserved © 2006-2014 Bruce D. Perry and The ChildTrauma Academy

Cognition Abstract Concrete Emotional Reactive Reflex

Hyperarousal

Continuum Rest Vigilance Resistance Defiance Aggression

Dissociative

Continuum Rest Avoidance Compliance Dissociation Fainting

Mental

State CALM ALARM FEAR AROUSAL TERROR

Primary

secondary

Brain Areas

F-CORTEX

Cortex

CORTEX

Limbic

LIMBIC

Midbrain

MIDBRAIN

Brainstem

BRAINSTEM

Autonomic

Rest Vigilance Freeze Flight Adaptive

Response Fight

Bruce D Perry © 2010

www.ChildTrauma.org

States to traits

Cortica

l

Limbic

DC

BS

Neocortex

Limbic

DC

BS

Neocortex

Limbic

Cortical Modulation of Reactivity

All rights reserved © 2006-2012 Bruce D. Perry and The ChildTrauma Academy

Poverty of Relationships

The compartmentalization of our

culture has resulted in material

wealth yet poverty of social and

emotional opportunities.

NA

DA

Positive

Human

Interaction

Stimulation of “Reward” Neural Systems in

the Human Brain: Multiple Mediators

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, rhythm

All rights reserved © 2006-2011 Bruce D. Perry and The ChildTrauma Academy

Intimacy Barrier

History of Relational

Interactions

Casual - Routine - Personal - Intimate

All rights reserved © 2006-2011 Bruce D. Perry and The ChildTrauma Academy

NMT Clinical Metrics

• Enter developmental and current data

Online Metrics tool

• Graph comparing developmental relational health and adverse experiences

• Graph re developmental risks

Developmental history and

risk • Use

functional item key

• Client’s CNS functionality based on presentation

• Compared to typical child of same age

Current CNS functionality

• Sensory integration (brainstem)

• Self regulation (Diencephalon)

• Relational (Limbic)

• Cognitive (Cortex)

Functional Domains

Functional Brain Map Report

On-line Metrics Tool (NMT)

Demographics

History - Developmental

◦ Part A. Adverse Events measure

◦ Part B. Relational Health measure

Current

◦ Part C. Central Nervous System (CNS) Functional

Status Measure

◦ Part D. Relational Health measure

Recommendations

◦ Essential, therapeutic & enrichment

6 year old– NMT metric – (Part A & B)

Perinatal = Birth-2 months Infancy = 1 yr Early childhood = 2-5 yrs Childhood = 6-12 yrs Youth = 13 +

Abstract Cognition

Math/ Symbolic Cognition

Performance Modulate Reactivity/ Impulsivity

Verbal Values/ Beliefs/ Morality

Speech/ Articulation

Language/Communication

Somato/ Motorsensory Integration

Sense Time/Delay Gratification

Self Awareness/ Self Image

Concrete Cognition

Share/ Relational

Attunement Reward Affect Regulation/

Mood

Psycho-sexual Short-term memory/ Learning

Neuroendocrine/ Hypothalamic

Dissociative Continuum

Arousal Continuum

Primary Sensory Integration

Fine Motor Skills Feeding/ Appetite

Sleep Coordination/ Large Motor Functioning

Suck/Swallow/ Gag

Attention/ Tracking

Temperature regulation/ Metabolism

Extraocular Eye Movements

Cardiovascular Autonomic Regulation

Functional Brain Map Key (Part C)

6 year old– NMT metric (Part D)

4 1 3 1 1 1

7 8 4 2 3 2

3 2 5 3 3 3

7 3 3 5

4 4 5 10

10 4

4 9

6 6

Functional Brain Maps and Key (NMT metrics – Part C)

Client (6 years, 0 months)

7 7 7 7 7 7

9 10 9 7 7 8

8 9 10 10 8 10

10 9 9 10

9 11 10 8

12 10

12 12

11 12

Age Typical – 6 to 7

DEVELOPMENTAL

Functional

12 DEVELOPED

11 TYPICAL RANGE EPISODIC/EMERGING

10

9

8 MILD Compromise PRECURSOR CAPACITY

7

6

5 MODERATE Dysfunction UNDEVELOPED

4

3

2 SEVERE Dysfunction

1

12.5 year old – Functional Domains

Neurosequential Model of Therapeutics (NMT) –

Recommendations

Essential = activities crucial to child’s future growth in

particular area. (below 65% of typical age score) Unless

functioning in essential area is increased child will lack

foundations for future growth and development in this and

other areas.

Therapeutic = activities aimed at building in strength and

growth in particular area. (within 65 to 85% of typical age are

appropriate for more focused treatment) These activities are

important for child’s continued growth and improvement in

area.

Enrichment = activities providing positive, valuable

experiences that continue to build capacity in given area. (at or

above 85% of age typical functioning) Activities are designed

to enhance and reinforce strengths previously built into area.

We are the Therapeutic Web*

Central to NMT’s Recommendations is an

emphasis on the importance of therapeutic,

educational and enrichment opportunities in the

broader community

◦ School/childcare

◦ Extracurricular

◦ Culture/Community of Faith

◦ Other

The best predictor of outcomes is

the health of the milieu…

Sequential interventions

Improved functioning after 8 months Impact of somatosensory-enriched play activities

Client, 6 years, 7 months Report Date: 2011

Client, 7 years, 3 months Report Date: 2012

Bruce D. Perry, M.D., Ph.D.

Age of child

0 3 6 20

Spending on Programs to “Change the Brain”

Brain’s Capacity for Change

Headstart Public Education

Juvenile Justice Mental Health

Substance Abuse Tx

Measure A – Building Full NMT Capacity

Creation of Sensory-specific/sensitive spaces at

multiple sites

Developing Somatosensory services* through

Measure A funding including the following:

◦ Animal assisted therapy

◦ Therapeutic Infant massage

◦ Dance and Movement

◦ Yoga*

◦ YMCA-based activities*

◦ Expressive arts*

◦ Drumming*

◦ Art and/or crafts therapy

◦ Horticultural therapy

◦ Speech and language/Occupational Therapy services*

◦ Therapeutic Preschool Consultation partnership*

Highlights of the last three years

Greater results for youth:

Canyon Oaks Youth Center-

expanding Trauma-informed model change

7/09-7/10 (n=16 youth) AWOLs:15, Hands on Interventions:53

7/14-7/15 (n=25 youth) AWOLs:8, Hands on Interventions:5

30+ staff NMT Phase I Certified

Invited to Present at NMT

International Symposium 2014

120+ staff completed in 16-hour NMT

concepts training (BHRS,CBOs, PHNs, CFS, CASA)

STC certification for Probation staff training

Highlights of the last three years

Over 350 assessments completed

Minimum 90 additional

individuals to complete

16-hour training program

this coming year

SMC first site to implement

NMT in a large public health

system –frequently referred to by CTA

Next Steps

Happening in 2016 ~

◦ Year 4 Metric training group

◦ Expansion program for Adult System

Future Activities ~

◦ Participation in NMT International

Symposiums – presentation June 2016

◦ T4T plan to maintain sustainability and expand capacity

◦ Future SMC hosted NMT conference

Firefly Center: Therapy Services for Children

The ChildTrauma Academy

AUM Art, Unity, Movement

Measure A Youth Trauma

Interventions Funds