“A little learning is a dangerous thing;
Drink deep, or taste not the Pierian spring:
There shallow draughts intoxicate the brain,
And drinking largely sobers us again.”
—“AN ESSAY ON CRITICISM” (1711) ALEXANDER POPE
A FEW YEARS AFTER WE WROTE The Boy Who Was Raised as a Dog, a Child Protective Services (CPS) supervisor from out of state called our clinic. He wanted to review a treatment approach that was being used by a private contractor who worked with abused and neglected children “in the system.” Very few CPS agencies have internal clinical teams to provide therapeutic services, so these are often contracted out to private individuals or organizations in various ways.
Because the CPS system is essentially the legal guardian of the children involved, a caseworker is supposed to provide oversight of any treatment. In this particular instance, a supervisor had become aware that several young children with histories of sexual abuse were seeing a clinician who was using highly questionable therapeutic techniques. After providing a little context, he said, “Well, we want to know if what he is doing is in line with your theories.”
“OK,” I said, though I wasn’t exactly sure which theories she meant. “What is he doing?”
“He has the children re-enact their sexual abuse.”
“What do you mean?”
“Well he has them take sex toys and use them in reenacting anal and oral sex.”
“Really?”
“Yes. And he has the kids pull their pants down when they are doing this and insert the dildo just like it happened—and he films it.”
I was stunned. “That is not therapy. That is abuse.”
“When we questioned what he was doing, he justified it by saying it was based on your work on how trauma and other experience changes the brain.”
I took a deep breath. I said, “I have never, ever advocated that kind of behavior as part of a therapeutic approach. I would recommend you contact the police and report this. And certainly, do not allow these children to continue seeing this person. You can’t use the veil of therapy to do acts that in any other context would be abuse. If you heard that any other adult did this, you wouldn’t hesitate a second to call, well, CPS and the police”
The five-minute phone call was shocking to our clinical team: how could someone take what we had written and taught about our trauma and our therapeutic work and twist that into that kind of practice? What could they possibly have been thinking?
Not long after that incident we got another call, this time from a licensing board in another state. About six months earlier I had been in that state giving a “Grand Rounds” lecture at a medical school. I had an hour to provide an overview of our approach; as part of that presentation, I described our sequential treatment process with Connor, one of the boys whose stories was told in the chapter that gives this book its title. As you may recall, he had suffered from early life neglect and had a lifelong history of confusing and odd behaviors. In Connor’s case, we had started with a focus on sensory integration and used therapeutic massage at the start of the therapeutic process.
The licensing board was calling to ask about our “neurodevelopmental model.” A clinician who claimed to be using the “Perry neurodevelopmental model for trauma” had come to their attention. The distinguishing feature of this woman’s approach was that every client who came to see her was getting a massage—“because that is where you need to start” according to her interpretation of our work. Dr. Perry’s Massage Parlor, I thought. Not exactly the main message we had in mind for what we eventually came to call the Neurosequential Model of Therapeutics (NMT).
Again, our clinical team was surprised to hear this. It was such a misrepresentation of what we were doing or would ever intend to teach others to do. It became clear that we needed to create some way to ensure that individuals claiming to use the “Neurosequential Model” were adequately trained. The last thing I wanted to do was develop a “certification” process or unduly limit or censor the exportation of the core concepts that were the basis of the NMT, but I realized that the specific elements, the main ideas and our evolving “metrics” (a.k.a. measures), had to be exported properly so that they could be used with fidelity.
Basically, we had to develop a structured and well-controlled process to introduce clinicians to this model and ensure that they understood how to use our clinical practice tools and measurements in a responsible way. And so, for several years, we worked on the development of a formal NMT certification process and modifications to our NMT “Clinical Practice Tools”—the NMT metrics designed to help the clinician who is using the NMT approach. By 2008, about a year after The Boy Who Was Raised as a Dog was published, we started to offer “certification” in the NMT.
Even before Maia and I started writing this book, my colleagues and I at The ChildTrauma Academy had begun to systematize and then study the approach we described here. Our experiences with individuals like Connor gave us valuable insights that helped guide this process. By the time this book was published, 2007, our clinical team had already incorporated many of the core neurodevelopmental and clinical concepts presented in The Boy Who Was Raised as a Dog into our work.
The NMT clinical approach involves four key components:
1) Developmental History: Obtain a history of the timing, nature and severity of trauma, adversity and neglect, as well as relational experiences and “connectedness,” which are associated with resilience.
2) Current Functioning: Assess current functioning with a focus on: a) the individual’s strengths and vulnerabilities in multiple domains, such as sensory integration, regulation (the ability to manage stress, sensation, and emotion without becoming “overloaded” or shutting down), relational abilities (social skills and the general capacity to form relationships), and cognitive function. b) the individual’s actual “connectedness” to family, friends, community, and culture: what we call their “therapeutic web.”
3) Treatment Planning: Select and sequence educational, enrichment, and therapeutic experiences based upon the individual’s developmental needs.
4) Implementation: Track the implementation and effectiveness of the plan and make appropriate modifications.
This process had been developed and refined over many years. A major challenge was to ensure that we included the most important elements of assessment and treatment, while avoiding redundant or unnecessary elements that can derail the treatment process. (For example, things like having the first visit to the clinic start with someone asking “How are you going to pay?”—and then sitting the overwhelmed and struggling parent down with a pile of forms for billing.)
We started doing much more work in the client’s home and community. We worked to develop ways to get a better understanding of the child’s developmental history—even when there were not reliable historians or many records. We developed ways to track the progress—or lack of progress—a child was making when the treatment plan was implemented. The results within our clinic were very promising.
We started by gathering a detailed history of the client’s development, focusing on the nature, timing, and severity of trauma, neglect, and other adversities. This history also included the nature, timing, and quality of resilience-related factors, such as connection to family, community, and culture. Together, these findings gave us an estimate of the “developmental risk” that the individual had experienced at key times and developmental stages. This allowed us to “measure” the timing of developmental risk.
The evaluation of the current functioning of the client examines multiple capabilities that reflect different aspects of brain function—ranging from fine motor skills, to mood regulation, to speech and language. We assess a collection of these capabilities to give us some insight into how various areas of their brain are organized. For example, we measure heart rate regulation, respiration, the suck, swallow, and gag reflexes, and regulation of body temperature. All of these provide information about the organization and functioning of the brainstem. Similarly, measures of reading ability, the capacity to plan, delay gratification, and think in an abstract way give us insight into the workings of the cortex. By making some estimates of which brain areas have strengths and where deficits are found, we can develop a working model of the individual’s brain that allows us to get a “picture” of the individual’s current brain organization and functioning.
And I literally mean a picture: we use schematic diagrams of the brain, filled in with different colors to provide an easy way for clinicians and clients to visualize this data. These “brain maps” allow us to see which areas appear to be typical in development and organization and which areas seem underdeveloped or dysfunctional.
Once we have the client’s brain map, we can then select and sequence therapeutic, educational, and enrichment experiences based upon his or her specific developmental strengths and challenges. Early on, when all of the clients were in our own clinic, we were able to follow up and determine whether or not the family, school, and other professionals working with the client followed our recommendations and if so, whether they had carried out the recommendations with adequate “dosing.” The entire process required that the clinicians in our working group master core concepts from multiple disciplines that provide the theoretical underpinnings of the NMT approach.
Unfortunately, at this time, few social work, psychology, or even medical training programs had much teaching about the developmental neurosciences, trauma, attachment, neglect, and a range of related topics. Consequently, this meant that our clinical team was learning all the time—and that they needed to take an often unfamiliar, trans-disciplinary approach as a matter of course.
As we integrated these concepts and shifted our clinical model, we shared our experiences with colleagues in a variety of traditional academic ways. We presented on our findings at academic meetings. We did Grand Rounds at medical schools and consulted with other clinical teams. We published some of our work in academic books and journals. We had labeled our approach the “Neurosequential Model of Therapeutics” to capture some of the key concepts. Soon, other clinicians and clinical teams would adopt some of these ideas and use them in their work. A number of clinicians told us how helpful the shift in perspective had been for their work with any given challenging child; some organizations started to send us feedback about drops in “critical incidents” or the use of restraints when they started thinking in this developmentally-sensitive and trauma-informed way. This feedback was gratifying and mirrored our experiences with the utility of the approach.
Yet, we were soon to learn that “a little learning is a dangerous thing”—as I’d discovered to my horror from some of the phone calls I received.
Meanwhile, as our clinical team began to use this new approach, our research group struggled with a parallel and related set of problems. Simply stated, people are complex; families are complex; communities are complex; culture is complex. Development is complex; genetics is complex; the impact of trauma on the individual is complex; the developmental consequences of trauma and neglect are complex; the power of relationships to help protect and heal is complex.
And, yet, with all of this complexity, the research on trauma and children was often simplistic. Take a small number of subjects, look at them after a traumatic event, and then see if they meet DSM criteria for PTSD; there are literally hundreds of published reports like this. Rarely are multiple time points of evaluation considered—or even pre-existing adversity or trauma. Rarely is the timing of the trauma carefully examined. Outcome measures tend to measure only some functions—or are completely focused on diagnostic criteria for PTSD and whether people recover and no longer have symptoms. The few studies about clinical intervention were similarly simplistic: small numbers of very poorly characterized subjects, inadequate “comparators” (“control groups”), and very short durations of treatment (e.g., 12 weeks). To be fair, these exploratory and simple studies are important when an area of investigation is “young” and emerging. And the area of developmental trauma was—and still is—young.
But we knew we had to move beyond that research model, just as we had moved beyond the typical 50-minutes/week-in the-office therapeutic model. We had to have some way to understand, integrate, and better measure meaningful aspects of the complexity. Without doing so, we weren’t going to make much progress in treating real, individual, complicated human beings. We now know much more about how trauma and neglect can change the course of brain development, and the importance of early childhood, bonding and attachment, community health factors, and culture. We also have more sophisticated ways to study therapies that can help manage these complexities.
Consequently, along with our new approach, we also needed to develop a better way of studying the people we treated. One immediate problem was how best to classify these children and the nature of their problems.
Sadly, most of the studies in traumatology still tend to classify people based on the kind of trauma they have experienced—but they don’t recognize that the timing of trauma is at least as important. For example, few studies acknowledge the difference between the effects of sexual abuse experienced at age five and sexual abuse at age fifteen: a typical study on the effects of sexual abuse would put those two individuals in the same study group and then proceed to compare them to “controls.”
Another problem of classification involves the nature of DSM diagnoses themselves. Take the case of “ADHD” and “Conduct Disorder.” Many studies of children with these diagnoses never even assess whether they have been abused, neglected, exposed to violence, or otherwise suffered potentially traumatic experiences—even though, as we’ve seen, early life trauma exposure can profoundly influence both attention and behavior.
Indeed, I have often speculated that many of the studies of ADHD and conduct disorder are complicated by the fact that more than 30 percent of study participants are actually manifesting trauma-related symptoms, not just some sort of genetically-based problem with the development of the brain’s attentional and executive control systems. Recent studies support this hypothesis.
For example, a retrospective study in a representative sample of 9,282 adults found that childhood adversities like trauma and neglect had strong correlations with thr onset of DSM-IV disorders. These connections were especially strong for children who experienced a host of different types of trauma linked to family dysfunction: for instance, having parents with both addiction and mental illness who are involved with the criminal justice system and experiencing family violence, neglect, and physical, emotional, and sexual abuse.
The study’s authors used statistical techniques to tease out the role of childhood adversity in mental illness, finding that it is linked to 44.6 percent of all childhood-onset disorders and 25.9 percent to 32.0 percent of later-onset disorders. Clearly the researchers in our field—including our group—were not adequately addressing the complexity of development and the way that the same symptoms can be caused by genetic differences, environmental exposures, or more typically, a complicated combination of both that will vary depending on the age at which adversities are experienced.
But probably the most difficult and substantial problem with the DSM is that it is merely descriptive: it categorizes individuals based upon symptoms and signs, not based upon underlying physiological mechanisms, as is seen in the rest of medicine. It does not categorize based upon the mechanism by which a symptom is created. As the former head of the National Institute of Mental Health, Tom Insel, once put it, it would be as if physical medicine saw “chest pain” as a disease—whether it was caused by heartburn or a heart attack. Obviously, this would result in serious problems with treatment.
Moreover, there is no existing DSM category that captures developmental trauma adequately. As we have tried to show throughout this book, the multiple manifestations of trauma and neglect don’t fit neatly into DSM diagnostic classes. As Insel wrote, “a diagnostic system limited to clinical presentation could confer reliability and consistency but not validity. The strength of each of the editions of DSM has been ‘reliability’—each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.” (Insel, 2013).
We knew that we would never be able to get beyond simplistic study of these complex issues without a complete change in our frame of reference. Advancing research in developmental trauma will be impossible without addressing the complex interplay between genes, environment, and developmental timing. Much larger sample sizes are also required because there are so many different interacting factors—ranging from the complex biology and genetics of the brain to chemicals in the environment to social experiences, economic factors like employment, to culture, and, potentially, even to things like someone’s grandparents’ experiences of trauma, particularly in the context of multi-generational trauma like the colonization of indigenous peoples.
And so, in 2006, we decided we had no choice but to break away from the DSM framework. This was a daunting prospect for an academic psychiatrist: the DSM is referred to as the “Bible” for the mental health world—and, perhaps even more importantly, the entire medical economic reimbursement process in the United States is yoked to it. Fortunately, we did most of our clinical work pro bono—and got the majority of our clinical resources from other sources like private foundations, state-funded program development grants, and consultation work.
To begin, we intentionally stopped giving “labels” to individuals and started creating “pictures” of their developmental journey and their current brain organization and functioning. This immediately had a quite positive “side effect”: it helped reduce stigma for our clients and made them feel less broken and alien. Further, the description of their journey to the present and the visual image of their current functioning helped them become more engaged participants in their own treatment planning process. They understood the rationale for certain recommendations; many of the older children could predict more about how the process might go and what kind of healing to realistically expect in a particular time frame. This gave them more control, more ownership, and more hope—all of which have been shown to help healing, in and of themselves.
With one foot in the clinical world and one foot in the research world, I realized that the need to create a “certification” process had been a blessing in disguise. If clinicians in multiple large systems began to use the same developmental and current functioning assessments, we might actually be able to collect useful information in a systematic way from thousands of clients. This way, we could actually get the large sample size we’d need to test our ideas properly. The clinical benefits of the model and the potential research benefits could seamlessly serve each other if we had an adequate export and fidelity model. The key was to make sure we could create a clinically-useful, affordable, and practical way to teach clinicians to use a modified, updated version of our Clinical Practice Tools (NMT metrics). And if we made the assessment components web-based, all of them could go into a common database.
Initially, I had been simply entering the data by hand and using Excel to create our “brain maps” within our clinic. As we started to teach other clinicians and organizations about the NMT, we started to use this beta-version of our metrics with their clients; the amount of data that I had to enter by hand to create these “brain maps” and NMT reports made it incredibly time consuming. We needed a way for each clinician to enter data on their own clients—we needed a web-based version of our NMT metrics.
The formal NMT certification process started in 2008. However, going back as far as 2002, I had hand-entered about 1,000 NMT assessments into this simple Excel version. It was a pain in the butt. But doing so had allowed me to really get a feel for which items were important, which were redundant, and how we could actually create something useful that we could standardize. In 2010, we launched our web-based version of the NMT Clinical Practice Tools, and the NMT Certification process took off.
Over the last ten years, The ChildTrauma Academy has been focusing on further refinement of the NMT, along with efforts to export it in responsible ways, mainly through our certification process. The results have been heartening. As I sit and write this chapter, over 1,500 clinicians from more than fifteen countries across the world have been fully certified—and each week more organizations and individual clinicians enroll in the certification process.
Over 90 large clinical organizations have incorporated NMT into their clinical practice model, including Casey Family Programs, University of California Davis Extension’s Infant-Parent Mental Health Fellowship Program (California), Cal Farley’s Ranch for Boys and Girls (Texas), NFI (Vermont), Alexander Youth Network (North Carolina), Mount St. Vincent Home (Colorado), Hull Services (a leader in child welfare and mental health in Alberta, CA), Take Two of Berry Street (a leader in child welfare in Australia), Kibble (a child welfare leader in Scotland), Palier (a specialized mental health facility in the Netherlands), the RVTS centers (specialized trauma treatment teams in Norway) among many others (see ChildTrauma.org for more).
In 2015 the Federally funded National Quality Improvement Center for Adoption/Guardianship Support and Preservation (QIC-AG: http://qic-ag.org) rated the NMT as Level 3 Promising Practice, and in 2016, NMT was selected as the emerging best-practice framework to include in a randomized controlled trial in one of the primary phases of this five-year program project dedicated to the development of best practices in child welfare.
In 2016, the Ministry of Human Services in Alberta, Canada (Alberta Human Services) formally announced that they would be using NMT as the practice framework to support therapeutic work with at-risk, maltreated, and traumatized children and youth. And in New Mexico, the NMT is a key part of their state-wide approach in the child welfare system.
Our adaptation of the model for schools, which is called the Neurosequential Model in Education (NME), has been an effective resource for teachers and others who work in schools. When educators implement NME in a systematic fashion, many positive outcomes have been reported. One example comes from an inner-city school in the Midwest. This school serves a high poverty population, and most of the children who attend have significant academic and behavioral struggles. Before instituting NME, 498 students per year had been sent to a “punishment” classroom—one year later, after NME was implemented, this number was cut by more than half, to 161.
Moreover, the “punishment” room has now become more of a regulation area, where a teacher helps guide children to regulating activities—basically, whatever that particular child has previously found helpful—to help them calm down enough to return to class. Out of school suspensions decreased from 36 to 9 post-NME. There are now over 300 NME trainers across the world, who affect thousands of students in hundreds of classrooms.
Another variant of the Neurosequential Model has been created for caregivers like foster and adoptive parents. It is called NMC and so far it has been implemented with very positive results. This is a relatively new initiative and we are hopeful that this capacity-building project can help these carers—and, thereby, the children they nurture.
An international community of practice has also been created and is continuing to grow. Articles about the use of NMT have been published in several different languages and several books. Critically, NMT—a relatively young approach—has been established as an “evidence-based practice” and we continue to learn of positive outcomes. There have been two international Neurosequential Model Symposia; held in 2014 and 2016 with another planned for 2018. The exchange of ideas and experiences continues to teach us at The ChildTrauma Academy how to improve our work and our models.
Of course, not everything is positive. The NMT certification process is challenging. It includes over 130 hours of instruction, clinical case conferences, multimedia content, and practice with NMT metrics. Web-based and web archived learning modules make this process more convenient for the learners, but it is always a challenge to change your frame of reference and learn a new way of thinking.
Indeed, this neurodevelopmental perspective and the NMT are major conceptual shifts for some clinicians and clinical settings—and introducing any novelty to systems in which people are already feeling overloaded and distressed is likely to elicit pushback. So now we are learning about what’s known as “implementation science.” That is, how do you get large systems to change, not just individuals? Many of the core principles introduced in this book, and our second collaboration, Born for Love: Why Empathy Is Essential—and Endangered have helped us begin to understand this, but we have much more to learn.
In general, and not too surprisingly, we find that if people and organizations seek us out and want to become certified, things go well; if, however, there is some administrative mandate to become certified and the clinical site or clinician has had no prior introduction to these concepts and they are simply told to comply, the process is less efficient.
We are trying to use what we know about the brain and stress to ease the introduction of novel techniques and ideas like NMT into large systems. The NMT certification process includes a Train-the-Trainer component because we want the organization to be able to continue growing and training itself without dependence on us.
To date, this has worked well. We now have more individuals who have been certified in using NMT by our trainers than those who trained in a direct certification process with The ChildTrauma Academy. In fact, I personally want to get out of the training business and back to more research and writing. Now that the original vision of thousands of similarly evaluated individuals is coming to fruition, my research team has a unique opportunity.
So far, approximately 30,000 NMT assessments have been conducted and the data have been collected into a single data set. Each month, thousands more entries are added. Of these, at least 10,000 are high-quality assessments from users with good fidelity, making them suitable for research and outcomes evaluation. We have a team of researchers—including a big data statistical genius—and they are now able to learn from these thousands of children, youth, and adults.
The preliminary findings are exciting and powerful. We now have the infrastructure for a completely new way to understand and study motor, emotional, social, and cognitive functioning—and rather than give an imprecise and potentially stigmatizing diagnosis, we are able to describe each person in a dynamic and visual manner.
Without expensive equipment, we can literally create a picture of how their brains seem to be organized and use it for treatment planning. The core assumption of the NMT model is that each person has an individual developmental path and a unique combination of strengths and vulnerabilities. We are always best able to help someone if we first know them. We can help them better know themselves, too, if we give them a picture, not a label.
We continue to explore. The children and families we work with continue to teach us; our colleagues from multiple cultures and disciplines continue to teach us. And we hope to continue to “Drink deep” and share more than “a little learning”—and that you will join us on this path towards a better understanding of how our experiences shape us as we each weave our unique life story.