The ChildTrauma Academy Introduction to the NMT
Transcript of 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
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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?
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A. Brain Organiza)on and Func)on
NMT Core Principles
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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.
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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
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Complexity Plasticity
Neocortex
Limbic
Diencephalon
Brainstem
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
Cortical
Limbic
DE
BS
Cortex
Limbic
DE
BS
CORTICAL MODULATION
Cortex
Limbic
Developing/neglect Mature
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“Out” “In”
Multi-level Processing
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B. Neurodevelopment and Memory
NMT Core Principles
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Cell Body
Dendrites
Myelin Sheath
Axon
The Neuron Synapses
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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.
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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
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
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.
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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.
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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.
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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
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
www.ChildTrauma.org
“Out” “In”
New experience is “filtered”
through past
experience
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C. Rela)onal Neurobiology and ANachment
NMT Core Principles
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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.
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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
The ChildTrauma Academy Introduction to the NMT
Materials may not be replicated, repurposed or modified without permission
Bruce D Perry, MD, PhD © 2010
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LC
NE Fear and confusion
Activation of key stress
related neural
systems Increase
physiological distress
Somatosensory cues
Primary caregiver
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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
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
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D. Stress, Distress and Trauma
NMT Core Principles
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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
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Dissocia)on
Trauma Stress
Terror
Fear
Alarm
Alert
Calm
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Females
Young Children
Torture/Pain
Inescapable Helplessness
Males
Older Children
Observer
Action Active Role
Arousal Dissociation
DISSOCIATIVE/AROUSAL BALANCE
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
Res)ng Heart Rates: Branch Davidian Children
80
90
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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
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Differen)al “State” Reac)vity
Extreme Stress Stress Baseline
Vulnerable
Normal
Resilient
Terror
Fear
Alarm
Alert
Calm
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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
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E. Neglect
NMT Core Principles
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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
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
Mul)ple Forms of Neglect
DOMAINS
Emo)onal Social
Cogni)ve Motor
PATTERN
Episodic Chao)c
Total global
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Extreme Neglect Normal
3 Year Old Children
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F. Neurosequen)al Model of Therapeu)cs
NMT Core Principles
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Neocortex
Limbic
Diencephalon
Brainstem
SEQUENTIAL DEVELOPMENT Sequen)al Vulnerability
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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
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Preliminary NMT Analysis (NMT Brain Func)on Score vs NMT Developmental Challenge Score)
Developmental Challenges (Adverse Events/Trauma/Neglect)
NMT FS Score
The ChildTrauma Academy Introduction to the NMT
Materials may not be replicated, repurposed or modified without permission
Bruce D Perry, MD, PhD © 2010
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30
40
50
60
70
80
90
100
110
20 30 40 50 60 70 80 90 100
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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
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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
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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
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Difficult to sooth: Birth
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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
All rights reserved © 2010 Bruce D. Perry
All rights reserved © 2010 Bruce D. Perry
All rights reserved © 2010 Bruce D. Perry
All rights reserved © 2010 Bruce D. Perry
All rights reserved © 2010 Bruce D. Perry
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
All rights reserved © 2010 Bruce D. Perry
All rights reserved © 2010 Bruce D. Perry
G. NMT Applica)on and Outcomes
NMT Core Principles
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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)
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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
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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
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
H. Current NMT Metric Reports
NMT Core Principles
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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
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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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