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
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
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)
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
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