Bruce Perry Slides

The ChildTrauma Academy Introduction to the NMT
Integra)ng Principles of

Neurodevelopment into Clinical
Prac)ce
Introduc)on to the Neurosequen)al Model of Theory of Change
Therapeu)cs (NMT)

Why do you do the things you do?
How do you think they will cause
change for the client – for your child?
2013
All rights reserved © 2005-2013 Bruce D. Perry All rights reserved © 2005-2013 Bruce D. Perry

The Brain MaOers

•  The human brain is the organ responsible for
everything we do. It allows us to love, laugh, walk,
talk, create or hate.
NMT Core Principles •  The brain -‐ one hundred billion nerve cells in a
complex net of con)nuous ac)vity -‐ allows us our
A. Brain Organiza)on and Func)on humanity.
•  For each of us, our brain’s func)oning is a reflec)on

of our experiences.

Efferent Distribution of Primary Regulatory Networks
Abstract & Reflective Cognition

Cortex Concrete Cognition
Affiliation
Attachment/Reward
Limbic Sexual Behavior
Emotional Reactivity
Motor Regulation
Diencephalon Arousal
Cerebellum
Appetite/Satiety
DA
NE Sleep
SER
Blood Pressure
Brainstem
Heart Rate
Body Temperature
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All rights reserved © 2005-2013 Bruce D. Perry All rights reserved © 2005-2013 Bruce D. Perry ANS - body

Bruce D Perry, MD, PhD © 2013 Materials may not be replicated, repurposed or
modified without permission
Afferent Components: Modulation of Primary Regulatory Networks
Cerebro-modulatory Somatosensory
Neocortex Top-down modulation Bottom-up modulation
Internal
World:
Limbic Brain
External
Plasticity World:
Complexity
Primary
Senses
Diencephalon
Internal
Brainstem World:
Body

CORTICAL MODULATION “Out” “In”

Mature Developing/neglect
Cortex Cortical
Cortex
Limbic Limbic
Limbic
DE
Multi-level
DE
Processing
BS BS
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The Neuron
Synapses
Dendrites
NMT Core Principles Axon
B. Neurodevelopment and Memory Cell Myelin

Body Sheath


The Brain Develops USE-DEPENDENT DEVELOPMENT

The human brain, with all of its complex
structure and func)on, does not just The more a neural system is
“pop” into existence.
“ac)vated,” the more that system
In the 9 months following concep)on, 100 changes to reflect that paOern of
billion neurons and 10 trillion glial cells are ac)va)on
born. These cells organize, move, connect and
specialize to create the amazing and This is the basis for development,
func)oning brain of the newborn. memory and learning

Brain Growth vs. Body Growth

Sequen9al Neurodevelopment
20
•  The brain is undeveloped at birth

Mul)ples of Weight at Birth
15
•  The brain organizes from the “boOom” up -‐
Body brainstem to cortex and from the inside out

10 •  Organiza)on and func)onal capacity of
neural systems is sequen)al
Brain
5 •  Experiences do not have equal “valence”
throughout development

0 5 10 15 20
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What is Memory ? Associa)on

•  The capacity to bring elements of an experience
from one moment in )me to another. •  The brain makes associa)ons between sensory
signals co-‐occurring in any given moment in
•  This is the unique property of life forms. )me

•  There are many ways that life forms do this -‐
genes, immune system, nervous system •  This capacity allows humans to learn, create
images of the future and survive.
•  Nervous )ssue is designed to store
elements of experience. •  This capacity can also make humans vulnerable
to false associa)ons -‐ crea)ng fears of non-‐
threatening objects.
All rights reserved © 2005-2013 Bruce D. Perry www.ChildTraumaAcademy.org All rights reserved © 2005-2013 Bruce D. Perry

Neuroarcheaology
Crea)ng First Memories •  The age at which an adverse event takes place
will influence the neurodevelopmental impact
and the resul)ng func)onal consequences
The first set of unique sensory s)muli
shape neural “networks” which will •  Therefore, developmental history of adverse
“encode” and store – in neurons – the experiences is crucial to understanding
template for future sensory s)muli current func)oning
similar to this original sensory •  NMT includes a developmental review of
experience. adverse experiences AND the buffering effects
of rela)onal health

“Out” “In”
New
experience
is “filtered” NMT Core Principles
through
C. Rela)onal Neurobiology and AOachment
past

experience
All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org All rights reserved © 2005-2013 Bruce D. Perry

Rela)onal Neurobiology
Human beings are social Founda)onal Neural Systems
creatures.
The neural systems media)ng the stress-‐
response, reward, procrea)on, reproduc)on,
The neural systems which mediate social social-‐affilia)on and communica)on are all
interac)on, communica)on, empathy and the are inter-‐related -‐ indeed, they oeen share
capacity to bond with others are all shaped by the the very same fundamental neurotransmiOer
nature, quan)ty and )ming of early life networks and brain regions.
rela)onships.
All rights reserved © 2005-2013 Bruce D. Perry All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org



History of
Relational
Intimacy Barrier
Interactions
All rights reserved © 2005-2013 Bruce D. Perry Casual

All rights reserved © 2005-2013 Bruce D. Perry - Routine - Personal - Intimate

Stimulation of “Reward” Neural Systems in

the Human Brain: Multiple
Music and Behavior
rhythmic Drugs of Abuse
cocaine, opiates, stimulants
consistent
sensory input
with value or
Sweet, belief system
salty, fatty
foods Sensation of
pleasure and NMT Core Principles
Positive NA safety
Human
DA Release of
Interaction
hormones
and “calmer”
D. Stress, Distress and Trauma
regulation of
stress
Sex response
Cut, pick, pull
neural
Decrease systems
EtOH physiological
distress

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
AllAll rights
rights
reserved
reserved
©©2010-2012
2005-2013
Bruce
Bruce
D. D.
Perry
Perry All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org 34

Dissocia)on DISSOCIATIVE/AROUSAL BALANCE
Terror Dissociation
Arousal
Fear
Females Males
Alarm
Young Children Older Children
Alert
Torture/Pain Observer
Calm
Inescapable Action
Helplessness Active Role
Stress Trauma
All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org 35 All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org 36

Branch Davidian Res)ng Heart Rates: Branch Davidian Children

Child 140
Assault Parent Fire
(1995) 130 Visits
120
A five year old girl
who survived the 110
ATF raid on Ranch
Apocalypse - asked 100
to draw her home.
The dots in the roof 90
are from bullets.
80
3/13/93
3/18/93
3/23/93
3/28/93
4/16/93
4/21/93
4/11/93
3/8/93
4/2/93
4/7/93

Differen)al “State” Reac)vity “Out” “In”
Terror Evocative
Fear cues
Vulnerable
associated
Alarm
Normal
with
Alert Resilient previous
Calm trauma
Baseline Stress Extreme Stress
All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org 39 All rights reserved © 2005-2013 Bruce D. Perry www.ChildTrauma.org

NMT Core Principles
E. Neglect


A Neurodevelopmental Definition of Neglect
To •  Lack of a specific paOern of experience

neglect a during development results in abnormal
child is to development of a core brain func)on
•  The abnormal development is in those
murder brain systems which sense, perceive,
them. process, “interpret”, and “act on”
informa)on related to that specific
experience or input.
Daniel Dafoe

3 Year Old Children

Mul)ple Forms of Neglect
DOMAINS PATTERN

Emo)onal Episodic
Social Chao)c
Cogni)ve Total global
Motor
Normal Extreme Neglect

All rights reserved © 2010 Bruce D. Perry All rights reserved © 2005-2013 Bruce D. Perry

SEQUENTIAL DEVELOPMENT
Sequen)al Vulnerability
Neocortex
NMT Core Principles
Limbic
F. Neurosequen)al Model of Therapeu)cs

Diencephalon

Brainstem

Preliminary NMT Analysis

Neurodevelopmental Risk (NMT Brain Func)on Score vs NMT Developmental Challenge Score)
•  The NMT process involves assessing the

)ming, nature and intensity of adverse events
•  The )ming, nature and quality of “buffering” NMT FS
Score
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
Developmental Challenges (Adverse Events/Trauma/Neglect)

110
Current Rela)onal Health
•  A major factor in healing appears to be the
100
90
nature, quality, intensity and stability of a
80 person’s rela)onships
70 •  The NMT assessment process includes a simple
60
metric that looks at current rela)onal health
50
•  The score on this metric is a key indicator of
outcome – good rela)onal stability predicts
posi)ve outcome – and poor rela)onal health
40
30
20 30 40 50 60 70 80 90 100
predicts poor outcomes

NMT Brain Mapping Process CNS Func)onal Map

•  The key indicator of brain organiza)on and •  Several “brain map” models have been used in
neurophysiological status is func)on the process of crea)ng and refining the NMT
•  By crea)ng a simplified construct – the brain •  Current mapping process involves a web-‐
map – assessment of key brain-‐mediated based menu-‐driven review of various brain-‐
func)ons can help “localize” mediated func)ons
neurodevelopmental vulnerabili)es and
•  The resul)ng “map” creates a visual
strengths
representa)on that is useful for teaching,
•  This “localiza)on” helps direct treatment planning and tracking outcomes
developmentally-‐sensi)ve interven)ons

Core elements of posi)ve developmental,

educa)onal and therapeu)c experiences

•  Rela)onal (safe)
NMT Core Principles •  Relevant (developmentally-‐matched)
•  Repe))ve (paOerned)
G. NMT Applica)on and Outcomes •  Rewarding (pleasurable)
•  Rhythmic (resonant with neural paOerns)
•  Respecoul (child, family, culture)

Primary Neural Impact of Various

Therapeutic, Educational or Enrichment Activities
Primary Somatosensory Traditional Psychotherapy
or Primary Cognitive Activity
Relational/Somatosensory
All rights reserved © 2005-2013 Bruce D. Perry All rights reserved © 2005-2013 Bruce D. Perry Bruce D Perry, MD, PhD © 2010

Christopher 14 yo M Sandhill Child Development Center

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 7/08 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 12/08 12 12
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 10/09 12 12
The ChildTrauma Academy

Bruce D Perry, MD, PhD © 2009
NMT Project
All rights reserved © 2005-2013 Bruce D. Perry All
Bruce D Perry, MD, PhD © 2010 rights reserved © 2005-2013 Bruce D. Perry

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

60
50
Restraints/month
40
NMT Core Principles

30
20 H. Current NMT Metric Reports

10
0
1 2 3 4
12 mos prior 1s t 6 mos NMT 2nd 6 mos NMT 3rd 6 mos NMT


M., 15 yo F
AYN
15 yo F, Hx of abuse,
DV, neglect; removed at
age 6; 20 + placements:

Time 1
M., 15 yo F J. : 19 yo F
AYN: Six months of primarily
SS = Rel > Cog Tx No sig Hx of dev AE;
stable family; Fam Hx
bipolar
Hx depressive episodes
Eval s/p MVA; multiple

evaluators assign Dx
PTSD
Time 2

J. : 19 yo F T. D.: 13 yo M
No sig Hx of dev Hx severe abuse/neglect;

AE; stable family; adopted at age 5
Fam Hx bipolar
At time of eval Dx: ADHD, CD,
Hx depressive Bipolar
episodes
Eval s/p MVA;

multiple
evaluators assign
Dx PTSD

T. D.: Hx severe Mx.; 6 yo M

abuse/neglect;
adopted at age 5 Hx intrauterine SA/EtOH;
severe neglect and abuse;
At time of eval Dx removed at 12 mos; multiple
ADHD, CD, Bipolar placements; adopted at age
2
Dx at time of eval: ODD,

ADHD

Mx.; 6 yo M D. D.; 13 yo M
Hx intrauterine SA/ Hx early dev
EtOH; severe neglect abuse/neg; adopted at
and abuse; removed at 10 mos of age
12 mos; multiple
placements; adopted At time of eval Dx:
at age 2 ADHD, Hx ODD, CD
Dx at time of eval:
ODD, ADHD

D. D.; Hx early dev

abuse/neg; adopted at
10 mos of age
At time of eval Dx:

ADHD, Hx ODD, CD
Crea)ng Policy and Prac)ce that

Capitalize on Biological Reali)es
Democracy, public educa)on, suffrage,
civil rights – and, ul)mately, early
childhood investment

The Mismatch Between Opportunity and Investment

CTA Websites
www.ChildTrauma.org
Spending on Programs to “Change the Brain”
www.ChildTraumaAcademy.com

Brain’s Capacity for Change CTA on Facebook
The ChildTrauma Academy
CTA on TwiOer

@ChildTraumaAcad
0 3 6 Mental Health Juvenile Justice 20
Headstart Public Education Substance Abuse Tx
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Age www.ChildTrauma.org
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The ChildTrauma Academy Introduction to the NMT

Integra)ng Principles of

The Brain MaOers

Efferent Distribution of Primary Regulatory Networks

Abstract & Reflective Cognition

Afferent Components: Modulation of Primary Regulatory Networks

CORTICAL MODULATION “Out” “In”

NMT Core Principles Axon

B. Neurodevelopment and Memory Cell Myelin

The Brain Develops USE-DEPENDENT DEVELOPMENT

Brain Growth vs. Body Growth

What is Memory ? Associa)on

All rights reserved © 2005-2013 Bruce D. Perry Casual

Stimulation of “Reward” Neural Systems in

Responses to Stress, Distress,

Dissocia)on DISSOCIATIVE/AROUSAL BALANCE

Branch Davidian Res)ng Heart Rates: Branch Davidian Children

Diﬀeren)al “State” Reac)vity “Out” “In”

NMT Core Principles

A Neurodevelopmental Definition of Neglect

To • Lack of a speciﬁc paOern of experience

3 Year Old Children

Normal Extreme Neglect

F. Neurosequen)al Model of Therapeu)cs

Preliminary NMT Analysis

• The NMT process involves assessing the

Developmental Challenges (Adverse Events/Trauma/Neglect)

NMT Brain Mapping Process CNS Func)onal Map

Core elements of posi)ve developmental,

Primary Neural Impact of Various

Christopher 14 yo M Sandhill Child Development Center

TIME 1 11 to 13 Functional

TIME 2 14 to 16 3 UNDEVELOPED

TIME 3 14 to 16

The ChildTrauma Academy

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

NMT Core Principles

20 H. Current NMT Metric Reports

Eval s/p MVA; multiple

No sig Hx of dev Hx severe abuse/neglect;

Eval s/p MVA;

T. D.: Hx severe Mx.; 6 yo M

Dx at time of eval: ODD,

D. D.; Hx early dev

At time of eval Dx:

Crea)ng Policy and Prac)ce that

The Mismatch Between Opportunity and Investment

CTA on TwiOer

All rights reserved © 2005-2013 Bruce D. Perry

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To •  Lack of a speciﬁc paOern of experience

•  The NMT process involves assessing the