Neurosequential Model Of Therapeutics Research Articles

Reduction in Restraint and Critical Incidents in a Norwegian Residential Treatment Facility for Children Aged 7–13 Following the Implementation of the Neurosequential Model of Therapeutics

In child and adolescent inpatient, residential and day-treatment facilities, the use of physical restraints and the occurrence of critical incidents are a significant problem. Restraints may sometimes be necessary if a child exhibits dangerous aggressive behavior, but may also be misused or overused, and have been shown to be preventable in many cases. This study aims to investigate if the implementation of the Neurosequential Model of Therapeutics (NMT) has an effect on the annual number of physical restraint incidents in a residential treatment facility for children with complex mental health disorders. Data before and after NMT implementation were collected from the agency’s restraint records. The results showed that post-NMT implementation, there was a substantial and sustained reduction in restraint incidents, with a Cohen’s d value of 2.03, indicating a very large effect. Limiting restraint use in treating children with complex mental health disorders can foster a safer and more therapeutic environment, with potential improvements in treatment outcomes. This study demonstrated a substantial drop in restraint incidents following the implementation of the Neurosequential Model in a residential facility for children aged 7–13. This reduction is presumably pivotal for children with complex mental health disorders, making treatment less coercive and offering promise for settings in which restraint incidents are a concern.

Training in Trauma-Responsive and Anti-racist Telehealth: A Model for Behavioral Health Clinicians and Providers

AbstractTelehealth's uptake in behavioral health services has been accelerated by the COVID-19 pandemic. However, many clinicians continue to lack focused training in providing trauma-informed and culturally-responsive telehealth care. This article outlines a model curriculum that was created to instruct and coach behavioral health providers in California on how to integrate anti-racist and trauma-responsive techniques into telehealth. Topics like evidence-based trauma therapies, racial/ethnic trauma, marginalized communities, digital divide, and provider selfcare were all covered in the nine-part curriculum. Every three-hour session included evidence-informed didactic content, telehealth skills practice, and concrete planning for implementation. Trauma-responsive frameworks such as the tri-phasic model of trauma recovery (Herman in Trauma and recovery: The aftermath of violence—From domestic abuse to political terror, Basic Books, 2015) and the neurosequential model of therapeutics (Perry in The handbook of therapeutic care for children, Jessica Kingsley Publishers, London, 2020) served as the foundation for the sessions. The Tools to Improve Practice (TIPs) website was created as a supplementary digital resource portal to support clinicians with continuous implementation. This model illustrates a replicable approach to strengthening workforce capacity and competence in trauma-responsive, anti-racist telehealth practices.

Treatment Effects of Introducing the Neurosequential Model of Therapeutics in a Norwegian Residential Treatment Facility for Children Aged 7-13.

This study investigates the impact of the Neurosequential Model of Therapeutics (NMT) in child and adolescent psychiatric care, addressing a gap in current clinical methodologies that tend to focus on single problems rather than the interconnected nature of many real-life mental health issues. The study was conducted in a residential setting over an extended period, including children aged 7-13, to observe the effects of implementing NMT. The children presented with complex symptoms and multiple diagnoses. The methods incorporated the NMT approach, emphasizing individualized treatment plans based on each child's unique brain development, and aimed at addressing multiple, interconnected problems simultaneously. Results from multilevel model analyses of behavioral difficulties, measured using the Child Behavior Checklist (CBCL), revealed substantial improvements in treatment effectiveness post-NMT implementation. Despite the limitations, such as a non-randomized participant selection and limited sample size, the findings strongly suggest that NMT enhances care effectiveness in real-world clinical settings, particularly for children with complex mental health issues. The study concludes that relationally oriented milieu therapy, and specifically the NMT approach, holds great promise for advancing pediatric psychiatric care, advocating for its broader application and further research to refine and substantiate its efficacy.

Multi-systemic trauma and regulation: Re-centering how to BE with clients

ABSTRACT Systems of oppression, adult violence exposure, and adverse childhood experiences interact to contribute to traumatic-stress related disorders, which manifest in affective, cognitive, and interpersonal challenges. This paper focuses specifically on emotional/physiological dysregulation as a central driver of trauma-related difficulties. The ability to recognize, assess, and intervene with children and adults for whom the capacity to regulate is compromised is critical in social work practice. This paper seeks to a) describe the role of (dys)regulation in social work practice and to b) apply this understanding to interventions that aim to address trauma-related challenges. Consistent with social work’s mission, we focus on the application of these approaches to socially and economically marginalized populations from low-resourced communities. We discuss current trauma-informed concepts and models that focus on regulation as an important accompaniment to traditional cognitive-centered or insight-oriented approaches. Furthermore we argue that how to be with clients (e.g., our presence in relationship/alliance) is as important to client outcomes as what we do with clients. We present case examples to illustrate the use of interventions informed by leading theoretical models including Window of Tolerance, Polyvagal theory, and the Neurosequential Model of Therapeutics. Implications for teaching and practice are discussed.

Peculiarities of the formation of early attachment models in children with traumatic experiences

This article presents the results of a meta-analysis of relevant studies published in English literature between 2010 and 2022, focusing on the definition of traumatic experience, types of psychological trauma, early attachment models, and the concept of mentalization. The search services PsycInfo, PubMed, APA Web-of-Science, and Research Gate were used to accomplish the set objectives. The influence of childhood traumatic events on the development of primary attachment models was explored. It was established that early attachment models are internal representations or perceptions formed during childhood, that determine a child’s perception of close individuals and their relationships. The effectiveness and scientifically substantiated aspects of the Neurosequential Model in Education and the Neurosequential Model of Therapeutics (NMT) in working with children who have experienced traumatic events are described. It was found that childhood traumatic experience affects seven main aspects of psychology: sensory development, dissociation (changes in consciousness), attachment, affect regulation, behavioral regulation, cognitive domain, self-awareness, and identity development. Each type of traumatic experience has its conditions, characteristics, mechanisms, and consequences for the formation of early attachment models in children and overall psychosocial functioning. Thus, understanding the entire spectrum of changes, including neurobiological aspects, is crucial when working with children who have experienced traumatic events and require specialized support. This analysis revealed that the quality of parent-child interaction depends on parents' ability to mentalize and their capacity to understand the child‘s inner world, which, in turn, influences the formation of early childhood attachment models. Depending on the presence or absence of traumatic experiences in a child's life, different attachment styles can be developed. The identified generalizations shed light on the pathogenesis of relationship trauma-related disorders and can be practically applied in the development and implementation of professional recommendations or programs for psychosocial support for children who have experienced traumatic events. Emphasizing the necessity for further empirical research to gain a more detailed understanding of this issue.

Longitudinal Evaluation of the Neurosequential Model of Therapeutics with Adoptive Families in Tennessee

ABSTRACT Purpose This study evaluated effectiveness of the Neurosequential Model of Therapeutics (NMT) with adoptive families who received post adoption services in Tennessee. Methods Researchers obtained a sample of 552 families who received post adoption services in the U.S. state of Tennessee. Most families (77%) had adopted children through public child welfare services. A quasi-experimental design examined wellbeing outcomes for an NMT group (n = 319) versus a services-as-usual (SAU) group (n = 233) in intent-to-treat analyses. Then, the SAU group was contrasted to an NMT subgroup that had high adherence to the NMT model (n = 109) in an analysis of treatment-on-the-treated. Results Intent-to-treat models indicated no differences on outcomes between the NMT and SAU groups. However, the results of treatment-on-the-treated analyses showed slightly greater reduction on the Behavior Problems Index over time for the NMT with high adherence group as compared to SAU. Discussion and Conclusion Adoptive families may face challenges that could be addressed through developmentally sensitive, trauma-informed services, such as NMT. The results of this study suggest that the NMT might benefit adoptive families if greater attention is paid to implementation adherence, or fidelity.

De-Implementing a Point and Level System in Youth Residential Care without Increased Safety Risk: A Case Study

ABSTRACT Point and level (P&L) systems are commonly used for behavior management and modification in youth residential treatment centers. In 2019, the Association of Children’s Residential Centers (ACRC) released a position paper urging youth residential programs to abolish prescriptive, universally applied point and level systems because they are inconsistent with the principles of trauma-sensitive care and can be counterproductive to treatment. Despite this, few residential agencies have executed this change, possibly due to the complexities of dismantling long-held practices, concerns about youth safety, and lack of knowledge about other trauma-sensitive approaches. In this case study, we describe how one agency de-implemented its universal P&L system across three residential campuses, replacing it with the Neurosequential Model of Therapeutics (NMT) and Collaborative Problem Solving (CPS). An analysis of administrative data before and after the removal of P&L suggests no evidence of increased safety risk for youth or staff. We discuss the agency’s strategies for de-implementation and the determinants that helped and hindered the process and provide recommendations for other residential agencies seeking to make this change.

Exploring Adherence to Client Treatment Recommendations in the Neurosequential Model of Therapeutics

Purpose: Treatment adherence is a central component of implementation fidelity and key to our understanding of client outcomes. This study examines treatment adherence in the Neurosequential Model of Therapeutics (NMT) and four functional outcomes among a sample of adopted youth: sensory integration, self-regulation, and relational and cognitive functioning. Methods: The sample includes 178 youth receiving supportive services from a U.S. adoption service provider. Regression analysis was used to examine clinician adherence to NMT recommendations and child outcomes. Results: Most (61.24%) of the essential or therapeutic treatment recommendations were carried out with majority adherence. A key finding is the predictive relationship between adherence to treatment recommendations and improvement in child outcomes at T2, controlling for all other variables in the model. Conclusions: Findings illustrate the importance of treatment adherence in promoting positive outcomes for children engaged in NMT. Implications are discussed regarding clinician training and reducing barriers to treatment adherence.

Child Traumatic Stress and the Sacred: Neurobiologically Informed Interventions for Therapists and Parents

Children experience trauma and adverse experiences at an alarming rate. The negative impact of traumatic experiences on a child’s developing brain is pervasive, adversely affecting one’s thoughts, feelings, behaviors, physiological reactions, and social relationships. Conversely, the nature, pattern, timing and duration of therapeutic experiences can change the brain in ways that support and cultivate therapeutic growth and healing. The purpose of this paper will be to review and expand on two prominent neurobiological therapeutic frameworks within the field of child trauma therapy: the Neurosequential Model of Therapeutics and Interpersonal Neurobiology. We will discuss the ways in which trauma experiences are organized in the brain and how therapeutic and parenting interventions can address the key areas of the brain that are impacted. Further, this paper will expand on these frameworks to explore how the sacred (within primarily a Judeo-Christian monotheistic religious tradition) can be integrated within the therapeutic process—specifically through the themes of safety, relational connection, and meaning-making.

Including Neuroscience in Social Work Education: Introducing Graduate Students to the Neurosequential Model of Therapeutics

ABSTRACT To fill a gap in research on the incorporation of neuroscience in social work education, this article describes Master of Social Work (MSW) student and alumni experiences learning a neuroscience-informed model for practice with clients who have endured developmental trauma. The Neurosequential Model of Therapeutics (NMT) is a clinical decision-making tool that provides an estimate of how a client’s current neurobiological functioning may have been impacted by trauma during the developmental period in order to inform the selection and sequencing of interventions. MSW students and alumni participated in focus groups exploring their perspectives on learning the NMT, the utility of the model in their work, and the fit between the model and social work theory and practice. Participants found the model helpful in conceptualizing client cases and applicable to their work, but challenging to implement due to others’ lack of familiarity with the model, and insufficient infrastructure. These findings suggest the NMT may be a valuable tool for teaching neuroscience within schools of social work.

Timing of Early-Life Stress and the Development of Brain-Related Capacities.

Early-life stress (ELS) poses risks for developmental and mental health problems throughout the lifespan. More research is needed regarding how specific ELS experiences influence specific aspects of neurodevelopment. We examined the association between ELS, defined as severe adversity (e.g., domestic violence, caregiver drug use) and severe relational poverty (e.g., caregiver neglect, lack of caregiver attunement), occurring during the first 2 months of life and a variety of brain-related, clinician-rated functions, including self-regulation and relational capacities. Interdisciplinary clinicians using the Neurosequential Model of Therapeutics (NMT), an approach to clinical problem solving, reported on the timing and type of treatment-seeking children’s (N = 2,155; 8–10 years) stressful experiences during four developmental periods: Perinatal (0–2 months), Infancy (2–12 months), Early Childhood (13 months to 4 years), and Childhood (4–11 years). They also reported on children’s current functioning in 32 brain-related domains (e.g., sleep, arousal, impulsivity, empathy, concrete cognition). Non-negative matrix factorization (NMF) was conducted on the 32 brain-related domains to identify latent factors, yielding four factors comprising Sensory Integration, Self-Regulation, Relational, and Cognitive functioning. Regularized hierarchical models were then used to identify associations between ELS and each latent factor while controlling for stress occurring during subsequent developmental periods, and children’s current degree of relational health. ELS (stress occurring during the first 2 months of life), specifically a severe lack of positive relational experiences (e.g., caregiver neglect, lack of caregiver attunement), was associated with the Sensory Integration and Self-Regulation factors. The Relational factor was better explained by stress occurring during childhood, and the Cognitive factor by stress occurring during infancy and childhood. Implications for how the timing and type of stress experiences may influence brain-related outcomes that are observed in clinical settings are discussed. Future directions include longitudinal follow-ups and greater specification of environmental variables, such as types of interventions received and when they were received, that may interact with ELS experiences to influence brain-related outcomes.

Take Two – Implementing a Therapeutic Service for Children who have Experienced Abuse and Neglect: Beyond Evidence‐Informed Practice

Helping children recover from the impact of child abuse and neglect is complicated by the limited evidence available on programme effectiveness and efficacy. This paper describes the implementation of a therapeutic service, in Victoria, Australia, known as Take Two, and provides a profile of client characteristics. The paper describes some of the barriers to children in the child protection system accessing therapeutic or mental health services and the approach attempted to overcome these barriers. The Take Two Practice Framework and the subsequent contribution of the Child Trauma Academy's Neurosequential Model of Therapeutics are discussed. There is exploration of evidence‐based practice and how this and related concepts are considered in the evolving theory of change and the Practice Framework. This includes consideration of what else is needed to supplement the evidence. The paper provides a useful model for other agencies that are planning or implementing a therapeutic programme for children traumatised by abuse and neglect.‘Describes the implementation of a therapeutic service, in Victoria, Australia, known as Take Two, and provides a profile of client characteristics’Key Practitioner Messages Systematic reviews conclude that there is insufficient evidence to allow reliance on any single intervention with this client group. This poses a genuine dilemma for services that aim to utilise evidence‐informed interventions but find their offerings limited. Taking a research‐based and evidence‐informed approach with a strong theory of change has assisted one such programme to respond to this dilemma.

Beyond the ACE score: Examining relationships between timing of developmental adversity, relational health and developmental outcomes in children

BackgroundThe association between developmental adversity and children's functioning is complex, particularly given the multifaceted nature of adverse experiences. The association between the timing of experience and outcomes is underresearched and clinically under-appreciated. We examine how the timing of both adverse (including potentially traumatic) events and relational poverty are associated with developmental outcomes. MethodClinicians using the Neurosequential Model of Therapeutics (NMT), an approach to clinical problem solving, reported on the timing of children's developmental experiences, their degree of current relational health, and current functioning in key brain-mediated domains (N = 3523 6- to 13-year-old children). A regularized hierarchical model produced stable and generalizable estimates regarding associations between the timing of experiences across four developmental periods: Perinatal (0–2 mos), Infancy (2–12 mos), Early Childhood (13 mos to 4 years), and Childhood (4 to 11 years) and current functioning. ResultsPerinatal developmental experiences were more strongly associated with compromised current functioning than such experiences occurring during other periods. Perinatal relational poverty was a stronger predictor than perinatal adversity. During subsequent developmental periods, the influence of relational poverty diminished, while the influence of adversity remained strong throughout early childhood. Current relational health, however, was the strongest predictor of functioning. ConclusionFindings expand the understanding of the association between the timing of adversity and relationally impoverished experiences and children's functioning. Although early life experiences are significantly impactful, relationally enriched environments may buffer these effects.

Examining Developmental Adversity and Connectedness in Child Welfare-Involved Children

Identifying optimal out-of-home placements for child welfare-involved youth is challenging. Examples of youth recovering within each “out-of-home” placement type (foster, relative, residential) are evident, as are examples of youth who are deteriorating. The heterogeneity in developmental history and current functioning of youth makes blanket policies regarding placement unwise. Examination of developmental heterogeneity and functioning of youth in the welfare system can provide insights about factors influencing outcomes, thereby informing practice, program and policy. We explore whether current relational health (connectedness) promotes positive outcomes for child welfare-involved youth while controlling for developmental risk (history of adverse, and lack of relationally positive, experiences). Clinicians at 19 organisations serving child welfare-involved youth used a neurodevelopmentally informed approach to intervention, the Neurosequential Model of Therapeutics (NMT), which includes metrics to assess the developmental timing of children's risk, “connectedness” and neurodevelopmental functioning (e.g., sleep, arousal, cortical control). Data-driven statistical techniques were used to produce stable, generalisable estimates. Risk during the perinatal (0–2 months) period significantly predicted children's functioning; current relational health predicted outcomes more strongly. Although early life developmental risk has a persistent effect on functioning, relationally supportive contexts may mitigate this risk. Improving relational contexts of child welfare-involved youth, regardless of placement type, is key.

Restraint and Critical Incident Reduction Following Introduction of the Neurosequential Model of Therapeutics (NMT)

ABSTRACTChildren with developmental trauma are at risk for severe and complex behavioral problems, often requiring long-term residential and day treatment. The Neurosequential Model of Therapeutics (NMT) is a developmentally sensitive approach to clinical work with a capacity-building component focusing on attachment, the impact of maltreatment and trauma, and emerging concepts in developmental psychology, neuroscience and traumatology. Research has demonstrated its effectiveness with trauma-exposed populations. NMT training may help providers working with trauma-exposed youth prevent critical incidents and reduce restraints. Restraint and critical incident data were obtained from 10 organizations providing residential and/or day-treatment services following exposure to, or certification in, the NMT. Data from the Pre-NMT Introduction period through to the Maintenance phase of NMT Certification were used to examine changes in restraints and critical incidents across phases of NMT exposure/certification. Multilevel logistic regression models suggested that NMT exposure and/or certification was associated with significant reductions in restraints and critical incidents. Reductions were sustained throughout the Maintenance phase. Estimates of potential staff hour and financial savings associated with these reductions are discussed. Implementation of the NMT in residential and day-treatment settings may result in staff, behavioral health provider, and organization-level changes that reduce critical incidents and restraint use.

A neuro-developmentally sensitive and trauma informed service delivery approach for child and youth mental health and psychiatry

This presentation will introduce the innovative approach to child and youth mental health and psychiatry using the neurosequential model of therapeutics (NMT). This is a neuro-developmentally sensitive and trauma informed approach and acknowledges the importance of early experiences shaping the organization of the brain. An outline of the stress response and its relevance to hyper-arousal and dissociative responses will be discussed as this impacts attachment and the reward neuro-biology. The hierarchy of brain development will be emphasized in the clinical approaches to child psychiatry especially in reference to child maltreatment and neglect. The critical role of sensory integration, self regulation, relational health and cognitive development in treatment planning will be discussed versus the categorical diagnosis of ADHD, autism, bipolar disorder and depression. This has profound economic and psychopharm practice implications in child and youth mental health treatments. Consequently the importance of these concepts in informing public policy for early child development and school mental health literacy will be emphasized. Additionally the outcome of these approaches on the reduction of staff turnover, critical incidents in schools and residential placements will be shared.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Applying principles of the Neurosequential Model of Therapeutics across an adolescent day program and inpatient unit

The process of applying the principles of the Neurosequential Model of Therapeutics (NMT) as a practice framework in an Adolescent Day Program and Adolescent Inpatient Unit is described. NMT as a practice framework guided construction of a neurobiologically sensitive group therapy program whereby specific group therapies can be selected to target a young person's specific clinical needs within the context of a broader mental health treatment plan. The practice framework has been practical, logical and feasible to implement and may encourage other child and adolescent mental health services to consider the application of neuroscience-informed models such as NMT.

Infant and Early Childhood Mental Health

Infant and Early Childhood Mental Health

The Neurosequential Model of Therapeutics: An Interview with Bruce Perry

In this interview with Bruce Perry, MD, PhD, Senior Fellow of The Child Trauma Academy, Laurie MacKinnon discusses with Dr Perry developmental trauma and the Neurosequential Model of Therapeutics, an approach to clinical problem solving that utilises a developmental lens and incorporates advances in neurobiological development. Dr Perry gives his perspective on the causal connection between childhood abuse and later psychiatric diagnosis, the child's contact with a violent parent post‐separation, the importance of interventions that address the organisation and functioning of lower parts of the brain and his perspective on the use and limitations of psychotropic medications, cognitive behaviour therapy and family therapy.

Examining Child Maltreatment Through a Neurodevelopmental Lens: Clinical Applications of the Neurosequential Model of Therapeutics

This article provides the theoretical rationale and overview of a neurodevelopmentally-informed approach to therapeutic work with maltreated and traumatized children and youth. Rather than focusing on any specific therapeutic technique, the Neurosequential Model of Therapeutics (NMT) allows identification of the key systems and areas in the brain which have been impacted by adverse developmental experiences and helps target the selection and sequence of therapeutic, enrichment, and educational activities. In the preliminary applications of this approach in a variety of clinical settings, the outcomes have been positive. More in depth evaluation of this approach is warranted, and is underway.