From Treating Complex Traumatic Stress Disorders in Children and Adolescents. Edited by Julian D. Ford and Christine A. Courtois.
Copyright 2013 by The Guilford Press. All rights reserved.
Chapter 13
The Neurosequential Model
of Therapeutics
Bruce D. Perry
Christine L. Dobson
The Neurosequential Model of Therapeutics (NMT) is a developmen-
©
tally sensitive and neurobiologically informed approach to clinical problem
solving. Although it has been implemented in multiple clinical populations
across the full developmental spectrum (infants to adults), this approach
was developed, and has been most widely used, with traumatized and mal-
treated children and youth (e.g., Barfield, Gaskill, Dobson, & Perry, 2011).
Its utility is most apparent with the most complex cases of maltreatment
and psychological trauma, which are the focus of this chapter.
As has been well documented over the last 20 years, intrauterine sub-
stance use, neglect, chaos, attachment disruptions, and traumatic stress
all impact the development of the brain and result in complicated and
heterogeneous functional presentations in children, youth, and adults.
Furthermore, the timing, severity, pattern, and nature of these develop-
mental insults have variable and heterogeneous impact on the developing
brain (Perry, 2001, 2002). The result is a complex clinical picture with
increased risk of physical health, sensorimotor, self-regulation, relational,
cognitive, and a host of other problems (e.g., Felitti et al., 1998; Anda
et al., 2006). The current DSM neuropsychiatric labels do not capture
249
250 SYSTEMIC APPROACHES TO TREATMENT
this complexity. The development of evidence-based treatments for these
complex children and youth has been challenging. The very heterogene-
ity of their developmental histories and functional presentations impedes
the creation of the homogeneous “groups” required for quality outcome
or phenomenological research (e.g., Jovanovic & Norrholm, 2011). The
clinical challenges are even more daunting. A 15-year-old child may have
the self-regulation capacity of a 5-year-old, the social skills of a 3-year-
old, and the cognitive organization of a 10-year-old. And, due to the
unique genetic, epigenetic, and developmental history of each child, it
is very difficult to apply a “one-size-fits-all” treatment approach (Ungar
& Perry, 2012). The NMT was developed to help address some of these
complexities (Perry, 2006, 2009).
The NMT is not a specific therapeutic technique; it is multidimen-
sional assessment “lens” designed to guide clinical problem solving and
outcome monitoring by providing a useful “picture” of the client’s current
strengths and vulnerabilities in context of his or her developmental his-
tory. This neurodevelopmental viewpoint, in turn, allows the clinical team
to select and sequence a set of enrichment, educational, and therapeutic
interventions to best meet the needs of the client. The NMT draws on a
rich evidence base from research in multiple disciplines (e.g., the neurosci-
ences, social sciences, psychology, public health, epidemiology) to create a
semistructured and clinically practical way to ensure that the clinical team
considers and, to some degree, quantifies crucial elements of the client’s
developmental history and current functioning. This approach greatly aids
the clinician in his or her efforts to practice in an evidence-based, devel-
opmentally sensitive, and trauma-informed manner (Brandt, Diel, Feder,
& Lillas, 2012). The goal of this semistructured process is to “force” the
clinician/clinical team to systematically consider key developmental factors
that influence the client’s current functioning.
The NMT is meant to complement, not replace, other useful metrics or
assessment elements; each organization and clinical team have developed
an assessment process; the NMT was designed to complement and, to some
degree, provide a neurodevelopmental framework for the data obtained
from these various assessments. The functional data for a client gathered
in either quantitative (e.g., Weschler Intelligence Scale for Children, Wide
Range Achievement Test, Child and Adolescent Functional Assessment
Scale, Child and Adolescent Needs and Strengths, Child Behavior Check-
list, Trauma Symptom Checklist for Children, Parenting Stress Index) or
qualitative (e.g., direct observation, interview, parent/teacher report) ways
are organized into a neuroscience-focused “map.” This map provides the
clinical team with an approximation of the current functional organization
of the client’s brain.
The ChildTrauma Academy (CTA) has developed a set of manualized
elements to facilitate the exporting and use of the NMT. These elements
include the NMT clinical practice tools (see below); an NMT certification
The Neurosequential Model of Therapeutics 251
process (90 hours of didactic and case-based training to ensure exposure
to core concepts of traumatology, developmental psychology, neurobiol-
ogy, and related areas relevant to a developmentally sensitive and trauma-
informed approach); an ongoing NMT fidelity process for certified users;
and NMT psychoeducational materials and related caregiving and educa-
tional components (the Neurosequential Model© in Education: NME; and
Neurosequential Model© in Caregiving [NMC]) to facilitate the creation
of a developmentally sensitive, trauma-informed clinical setting, home,
school, and community (see www.ChildTrauma.org for more information
on each of these elements of the NMT).
The theoretical background and rationale for the core elements of
the NMT are presented elsewhere (see Perry, 2006, 2009; Kleim & Jones,
2008; Ludy-Dobson & Perry, 2010). This chapter illustrates the use of the
NMT by presenting a clinical case in which a client had been treated previ-
ously in multiple systems. The clinical narrative and accompanying NMT
reports illustrate how the clinical team used these “metrics” to develop and
implement treatment.
Case Example: James
James is a 10-year-old boy living in a therapeutic foster home. He has no
biological siblings and there are two older biological children (of the foster
parents) in the home. The foster parents are middle-age, employed, and
experienced. They have four biological children (two adults and the two
older teens living at home) and have successfully fostered dozens of chil-
dren. James has been in out-of-home care since age 3. He has lived in this
foster home for approximately 2 years.
Developmental History and Initial Presentation
James’s mother was an 18-year-old runaway from a foster home. His bio-
logical father was a 24-year-old with a history of substance abuse and
assaultive behaviors. During the pregnancy James’s mother acknowledges
episodic binge alcohol and polysubstance use. She received minimal pre-
natal care, but apparently there were no complications with the birth. For
the first 18 months of his life, James lived with his mother in a chaotic and
abusive environment apparently permeated by domestic violence, drug use,
multiple moves, and profound neglect. At 18 months, he was removed by
child protective services after neighbors reported that he was left alone
for days on end. He was severely malnourished, had bruises, insect bites,
and possibly cigarette burns. He was lethargic, nonreactive, and exhibited
profound hypotonia. He was placed in foster care, where he rapidly gained
weight, began to show more appropriate social behavior (e.g., verbalization,
eye contact), and began to catch up in motor development. He resumed
252 SYSTEMIC APPROACHES TO TREATMENT
contact with his mother at 24 months. Episodic extreme “tantrums”
emerged around that time, appearing to be associated with the preunifica-
tion supervised visits with his mother. She complied with all elements of the
reunification plan, and he was returned to her care at 26 months.
He was once again removed at age 38 months (this time permanently)
after he was found wandering the streets at night. He was not toilet trained,
had minimal speech, indiscriminate affectionate behaviors and touch defen-
siveness, and profound primitive self-soothing behaviors such as rocking,
head banging, fecal smearing, and hoarding of food. He was placed in a
foster home, where he had severe difficulties with attention, sleep, impul-
sivity, aggression, oversexualized behaviors, speech and language delays,
fine motor and large motor coordination, among many other problems. All
of these issues resulted in referral for mental health services, where he was
diagnosed with attention-deficit/hyperactivity disorder (ADHD) and was
placed on psychostimulants. No other therapy or evaluation was provided
at that time.
This intervention and the efforts of the first foster family were ineffec-
tive. His behaviors ultimately led to a terminated placement. This pattern
repeated itself: Over the next several years James had five different place-
ments and two psychiatric hospitalizations prior to entering the home of
the current foster family. He was also enrolled, and expelled, from several
child care, early childhood, and educational settings. Over this time, he had
at least five different assessments and multiple changes in treatment. Two of
the clinical settings utilized trauma-focused cognitive-behavioral therapy
(TF-CBT); we were unable to determine from the records aspects of fidelity,
training, or progression through the TF-CBT protocol at these sites. What
was clear, however, is that the impact of the interventions at this time was
minimal. His behaviors remained extreme. He exhibited frequent explosive
behaviors, particularly when he was told “no” or when he did not get his
way. The undersocialized and odd behaviors described above persisted.
Over time, his diagnoses accumulated to include bipolar disorder,
oppositional defiant disorder, ADHD, reactive attachment disorder, rule
out childhood schizophrenia, rule out autism spectrum disorder, pervasive
developmental disorder, intermittent explosive disorder, and, in several of
the assessments, posttraumatic stress disorder (PTSD) was added to the
other diagnoses. He received multiple medication “trials” and ultimately
ended up on Risperdal, Adderall, lithium, and clonidine. No significant
enduring improvement in behavior or academic functioning was seen by fos-
ter parents, school personnel, or child protective services workers—indeed
most of reports described escalation in his aggressiveness and inability to
manage his impulsivity. Ultimately, all who worked with James became
fatigued, resulting in a series of failed placements.
At age 8½ James was referred to his current foster home. He was
placed in a special education classroom in the local public school and was
performing at the level of PreK academically. He was referred to a clinical
The Neurosequential Model of Therapeutics 253
group that this foster family had worked with previously. Clinicians in
this group were trained in dialectical behavior therapy (DBT), TF-CBT,
parent–child interactive therapy (PCIT), eye movement desensitization and
reprocessing (EMDR), and were becoming certified in the NMT. For the
first 6 months of treatment, James worked with a clinician who utilized a
TF-CBT approach in combination with some behavior modification, psy-
choeducation for the foster family, and consultation to the school. Sev-
eral attempts were made to progress to the trauma narrative phase with
minimal success. The medication combination (see above) that he was on
when he came to the foster home was maintained. He received tutoring
and speech and language therapy. After an initial 6-week “honeymoon”
following placement, James began to struggle both in school and at home
with an escalation of the behaviors described earlier.
NMT Case Consultation
James’s case was selected and presented as part of the NMT certification
process by a training clinician. The initial NMT Metric Report for James is
shown in online Appendix 1 (Figure 13.1 is an excerpt from the appendices;
the complete appendices are online at www.childtrauma.org/images/sto-
ries/Articles/PerryDobson_Appendices_2012.pdf). The first page of the
initial NMT Metric Report summarizes the findings of the semistructured
developmental history. As outlined in Table 13.1, this process involves
quantifying the nature, timing, and severity of adverse experiences as well
as relational health factors. As can be seen in the graphs on page 1 of online
Appendix 1, estimates of James’s developmental adversity and relational
health during this time put him in a very high-risk category throughout his
development. When there is incomplete historical information, the scoring
strategy is for the assessor to use clinical judgment to reconstruct the history
but to be conservative so that the reconstruction is, if anything, an underes-
timate of developmental risk. The brain develops in a use-dependent fash-
ion, essentially as a reflection of the developmental environment; the level
of developmental adversity (along with minimal relational or social buf-
fers) that James experienced would predictably alter the developing brain
and lead to a complex and clinically confusing presentation. Broad-based
functional compromise, of course, was well documented in James’s history.
The second page of this initial assessment (see online Appendix 1)
shows how James’s brain-mediated functioning was organized on the
NMT brain map, summarizing his pervasive neurobiological compromise.
On the left-hand side of the page are the specific functional areas that are
scored and on the right are a series of “maps” that organize these func-
tions at James’s age in order to provide a normative benchmark (see also
Table 13.1). The resulting “map” is a heuristic construct that is reflective
of the actual organization of the brain. The functional scores are color-
coded (see key on page 2 of online Appendix 1): pink/red indicating either
254 SYSTEMIC APPROACHES TO TREATMENT
Current CNS Functionality
Time 1-Year Typical
Brainstem
1 Cardiovascular/ANS 8 10 12
2 Autonomic Regulation 6 9 12
3 Temperature regulation/Metabolism 9 10 12
4 Extraocular Eye Movements 9 10 12
5 Suck/Swallow/Gag 5 8 12
6 Attention/Tracking 3 6 12
DE/Cerebellum
7 Feeding/Appetite 7 9 11
8 Sleep 4 8 11
9 Fine Motor Skills 6 8 10
10 Coordination/Large Motor Functioning 6 8 9
11 Dissociative Continuum 4 6 10
12 Arousal Continuum 2 7 10
13 Neuroendocrine/Hypothalamic 8 8 10
14 Primary Sensory Integration 6 8 11
Limbic
15 Reward 4 6 11
16 Affect Regulation/Mood 4 6 10
17 Attunement/Empathy 4 6 10
18 Psychosexual 4 6 9
19 Relational/Attachment 4 7 9
20 Short-term memory/Learning 7 9 11
Cortex
21 Somato/Motorsensory Integration 5 7 10
22 Sense Time/Delay Gratification 3 6 8
23 Communication Expressive/Receptive 8 9 11
24 Self-Awareness/Self-Image 4 6 8
25 Speech/Articulation 8 9 10
26 Concrete Cognition 7 8 9
Frontal Cortex
27 Nonverbal Cognition 6 7 8
28 Modulate Reactivity/Impulsivity 2 4 8
29 Math/Symbolic Cognition 4 5 8
30 Reading/Verbal 4 5 8
31 Abstract/Reflective Cognition 3 5 8
32 Values/Beliefs/Morality 4 5 8
Total 168 231 317
FIGURE 13.1. Change in James’s brain-mediated functioning over
time.
The Neurosequential Model of Therapeutics 255
TABLE 13.1. Elements of the Web-Based NMT Metrics
1. Demographics
2. History—Developmental
a. Genetic
b. Epigenetic
c. Part A. Adverse events measure
i. Developmental timing
1. Nature, severity, pattern
d. Part B. Relational health measure
i. Developmental timing
1. Bonding and attachment
2. Family supports
3. Community supports
3. Current status
a. Part C. Central nervous system (CNS) functional status measure
i. Brainstem
ii. Diencephalon/cerebellum
iii. Limbic
iv. Cortex/frontal cortex
b. Part D. Relational health measure
i. Family
ii. Peers
iii. School
iv. Community
4. Recommendations
a. Therapeutic web
b. Family
c. Client
i. Sensory integration
ii. Self-regulation
iii. Relational
iv. Cognitive
underdeveloped or severely impaired functioning, yellow shades indicating
moderate compromise or precursor developmental functioning, and green
shades indicating typical and appropriately emerging functional capacity of
a young adult. Each client, therefore, is compared against a fully organized
young adult and age-typical peers.
James’s initial brain map scores demonstrated significant and pervasive
functional problems; corresponding to these scores there are pink or red
boxes in every area of his brain. This is a typical pattern seen in individuals
whose extreme and prolonged histories of developmental chaos, neglect,
and trauma are similar to what James experienced. What this map suggests
is that, despite being 9 years old at the time of his assessment, James had
the developmental capabilities—in multiple domains—of a much younger
child. On the third page of the initial assessment in online Appendix 1, the
degree to which James is behind his same-age peers in four main functional
domains (sensory integration, self-regulation, relational, and cognitive) is
readily apparent.
256 SYSTEMIC APPROACHES TO TREATMENT
One of the most important items on this assessment is the cortical mod-
ulation ratio (CMR). This ratio gives a crude indicator of the “strength” of
cognitive regulatory capacity relative to the “dysregulation” (i.e., disorga-
nization, underdevelopment, impairment) of lower networks in the brain;
in essence, it is an estimate of how hard it is for a client to use cortical
(top-down, executive functioning) mechanisms to self-regulate. This factor
is related to the executive function and “self-control” indicators (Moffitt et
al., 2010; Piquero, Jennings, & Farrington, 2010) known to be predictive
of positive outcomes in high-risk children. The higher the CMR value, the
“stronger” the cortical mechanisms of self-control. A typical 9-year-old
child would have a CMR of 4.7; James’s CMR was 0.72 (more typical of
an infant; there is only a millisecond between impulse and action, provid-
ing an explanation for many of his aggressive, impulsive, and inattentive
behaviors). This finding alone can tell a great deal about his previous fail-
ure with “evidence-based treatment” provided by good clinicians follow-
ing appropriate training. He was not, at that point, neurodevelopmentally
capable of benefiting from that work. For any cognitive-predominant activ-
ity (e.g., routinely following verbal commands from a caregiver, sitting and
attending in a classroom, engaging in TF-CBT) to be successful, the CMR
needs to be greater than 1.0. And even then, the level of sustained attention
will be very brief. The older the child, the greater the expectation that he
or she will be capable of sitting and “learning” (“He is, after all, 10 years
old”); yet this is a significant challenge for many severely maltreated chil-
dren such as James. He literally is not biologically able to do the things that
are expected of him. The result can be a toxic negative feedback cycle of
adults getting frustrated, angry, confused, and demoralized, while James
feels stupid, inadequate, misunderstood, rejected, and unloved. All of this
just creates more threat, loss, rage, and chaos—reinforcing and adding to
his history of developmental adversity.
NMT Recommendations
Central to NMT recommendations is the recognition of the importance
of the therapeutic, educational, and enrichment opportunities provided in
the broader community, especially school. The power of relationships and
the mediation of therapeutic experiences in culturally respectful relational
interactions are core elements of the NMT recommendations (Ludy-
Dobson & Perry, 2010). Although not a formal wraparound process, the
NMT recommendation process starts with a focus on the therapeutic
web: the collective of healthy, invested adults and peers who provide the
relational milieu of the child: The quality and permanence of this relational
milieu are two of the most essential elements of successful outcomes (see
Mears, Yaffe, & Harris, 2010; Bruns et al., 2010). As seen in online Appen-
dices 2 and 4, various elements of the community, culture, and school are
taken into consideration as the clinical team attempts to increase and sup-
port healthy relational connections. In the case of James, his school needed
The Neurosequential Model of Therapeutics 257
support and psychoeducation to create realistic expectations and services
to “meet” James where he was at, developmentally.
The next set of recommendations focuses on the family, often the key
to the therapeutic approach. In many cases, the parents’ histories will mir-
ror the child’s developmental history of chaos, threat, trauma, or neglect.
When this is the case, the NMT will include the parents and provide recom-
mendations to help address their multiple needs in addition to those of their
child. Transgenerational aspects of vulnerability and strength in a family
play important roles in the child’s educational, enrichment, and therapeu-
tic experiences. When the caregivers and parents are healthy and strong,
their capacity to be present, patient, positive, and nurturing is enhanced.
When the parents’ needs are unmet and their own mental health is com-
promised as a result, it is unrealistic to ask them to play a central role
in the child’s healing process. In the case of James, although the foster
parents were experienced and nurturing and had previously worked with
children who were maltreated, they were not very “trauma-informed” in
terms of their responses and interventions. Psychoeducation to help them
understand James’s specific neurocognitive deficits leading to his difficulty
in inhibiting impulses, his need for control, his relational sensitivity (i.e.,
sensitized to both intimacy and abandonment, making it difficult at times
for the foster parents to find the “right” emotional distance), his resultant
impaired developmental capabilities, and the need for their own self-care.
Further, James had alienated the siblings in the household; they needed to
be included in psychoeducational efforts to help them understand James
and repair their relationship with him.
The final stage of treatment planning involves the client. Individual
recommendations are based upon the client’s neurodevelopmental organi-
zation. As described in online Appendix 2, the general direction for the
selection and sequencing is based upon selecting the lowest “level” of sig-
nificant impairment and then moving up the neurodevelopmental ladder.
The selection and timing of enrichment, educational, and therapeutic expe-
riences are guided by the developmental capabilities and vulnerabilities of
the child. The NMT consultation process suggests some, but not all, activi-
ties that can provide patterned, repetitive, and rewarding experiences. The
goal is to help create therapeutic experiences that are sensitive to develop-
mental status in various domains and to state regulation capacity.
As seen in the recommendations for James, the team felt that his cur-
rent educational and therapeutic approach was too “top-heavy.” At this
point in his treatment, James was not capable of benefiting from cognitive-
predominant or even typical relational interactions; recall his CMR was
less than 1.0. He was too dysregulated. The recommendations (see online
Appendix 2, p. 3) suggested suspending tutoring, speech and language
therapy, and TF-CBT, and creating an enriched somatosensory diet with a
variety of experiences that would plausibly help provide the necessary den-
sity of patterned rhythmic experiences required to help create “bottom-up”
regulation and reorganization (see Kleim & Jones, 2008; Perry, 2008). The
258 SYSTEMIC APPROACHES TO TREATMENT
goal is to provide the bottom-up regulation that can allow other relational
and cognitive experiences to succeed; the challenge in this case is to make
sure that when he is regulated, that the relational and cognitive expecta-
tions and opportunities are developmentally appropriate for him (and not
selected based on his chronological age).
Reevaluation and Progress
The clinical team shifted their approach with James based upon the NMT
assessment. A little over 1 year later, the team repeated the NMT metrics
(see Figure 13.1 and online Appendix 3).
The clinical team and foster family acted on most of the key initial
recommendations (see online Appendix 4). The results of the multidimen-
sional enrichment, educational, and therapeutic experiences are visible in
the change in James’s functioning scores from beginning NMT (Figure
13.1, left-hand column) to 1 year later (Figure 13.1, middle column). More
importantly, James did not act in ways that disrupted the placement or
got him kicked out of school, as had occurred repeatedly in the past. His
medications were slowly decreased and ultimately stopped completely.
His CMR doubled from 0.7 to 1.4—still not at age level but certainly at a
level that would allow him to begin to tolerate and benefit from cognitive-
predominant experiences. He was now ready to benefit from tutoring,
speech and language interventions, and TF-CBT. The success experienced
by the developmentally sensitive teachers, foster parents, and James con-
tributed to a positive and rewarding environment, leading to a shift from
the negative, toxic cycle described earlier to a positive healing cycle.
Program Review, Clinical Outcomes, and Research
This is, of course, one client, but he is representative of hundreds of simi-
lar “stories” from our NMT-certified clinical partners. A central question
from this approach arises: which aspect of this multidimensional approach
resulted in the positive outcome? Was it the “in-room” aide? The creation
of regulatory time in school? The psychoeducation for the foster family?
Stopping the medications? The challenge of tracking outcomes and devel-
oping an “evidence base” and outcome studies for the clinical settings using
the NMT will have to be differentiated, to some degree, from the applica-
tion of specific treatments (many of them evidence-based treatments) that
end up being recommended by the NMT process. For this reason we have
built elements to do this into the NMT Follow-up Recommendations sec-
tion (see Fidelity and Follow Up columns, online Appendix 4). Multiple
projects are underway to examine various aspects of the application of the
NMT, and, although NMT is still a “young” approach, the central collec-
tion of data using the web-based metric will allow a very rapid accumu-
lation of data from which to learn. We anticipate ongoing modifications
The Neurosequential Model of Therapeutics 259
and improvements in this approach; the initial clinical outcomes are very
promising, as illustrated by James’s case.
Of primary interest to our group is whether the brain map (a heuristic
construct) is actually reflective of actual brain organization. A comparison
of actual neuroimaging using single photon emission computed tomogra-
phy (SPECT) scanning and independent creation of the NMT brain map is
underway. The preliminary analysis is promising; areas of the brain that
have abnormal perfusion on the SPECT scan match remarkably well with
the areas determined to be abnormal on the NMT Brain Map (preliminary
results available from first author).
Conclusion
The NMT offers a cost-effective way to introduce a developmentally sen-
sitive and neurobiology-informed perspective into clinical settings. The
capacity to utilize this approach in public systems means that large numbers
of children with complex issues can be evaluated with relatively high fidelity.
This will allow the creation of more homogeneous groups to study the clini-
cal phenomenology and neurobiology associated with maltreatment. Cur-
rently there are more than 4,000 children, youth, and adults in the NMT
clinical dataset. Over 50 organizations are using this approach as part of
their standard clinical practice. More than 100 individuals and sites are cur-
rently being trained. The projected number of NMT-assessed individuals
will approach 15,000 in the next 2 years. As with any approach, there are
shortcomings—most notably, the need for training in the core concepts, the
challenge of fidelity, and the lack of available resources to follow through
with the NMT-derived key recommendations. We believe that these are
outweighed by the capacity to track outcomes, ensure acceptable fidelity,
and help create a developmentally sensitive, trauma-informed lens through
which to understand children with complex issues and their families.
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Ontario, Canada: WLU Press.
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