Understanding the Neurosequential Model and Hierarchy of the Brain.

1. Introduction to the Neurosequential Model

The Neurosequential Model is a clinical framework developed by Dr. Bruce Perry, a prominent neuroscientist who has provided influential work in understanding the impact of developmental trauma. This model aims to offer potential solutions to help individuals affected by trauma and to enhance understanding and communication about people, particularly children, young people, and adults, who may have various diagnoses but share similar experiences and impacts on their mental health. By taking a neurodevelopmental perspective, the Neurosequential Model addresses the effects of trauma and factors that contribute to recovery. Its principles apply to a wide range of service providers and are integrated into training programs for CAMHS, care, and crime practitioners.

It is a developmentally-informed treatment approach that has been increasingly utilized in the last two years to inform decisions and documentation within the Queens University Child and Adult Care Master’s Program at the Jumpstart facility at the Brittany Glynn Children’s Shelter. Neurosequential therapists and developmentalists lead team meetings twice a year to review and provide guidance on treatment by utilizing the NMT or its appropriate components, like the NME, to progress outcomes for youth. Dr. Perry’s work makes it clear that the healing process in the brain/recovery is vastly different when trauma takes place during the brain’s development, as opposed to after development is complete.

The hierarchy of the brain

The human brain is a wonderful, amazing, complicated, remarkable organ that works with optimal design and efficiency when all parts are working as a team in a specific order. Creating a space that facilitates healthy brain development is an overwhelmingly necessary process. It will assist in identifying specific strategies that can most effectively harness the incredible neuroplasticity the brain demonstrates beautifully. In general, human brains will develop in a predictable sequence where lower brain nuclei (the most primitive part of the brain affecting bodily functions) develop first, followed by associated areas of the brain that make up the limbic system. These associated areas of the brain are critical to attach pleasure and the importance to behaviors necessary to protect the body, meet comfort and feeding needs and to help keep our species alive. Also developing, in a specific sequence, are the outside convexities of the brain’s hemispheres, our cortices. These areas are the processors of our sensory information and are responsible for analyzing decision-making and daily function of thought. This model of brain maturation is known as the Neurosequential Model.

Influential neuroscientists and psychiatrists such as Joseph Ledoux, Panksepp, Daniel Siegel, Stephen Porges, and others support the idea of brain hierarchy from the bottom up, including the brainstem, diencephalon, limbic system, and neocortex. When the development of the brain follows a different order than the normal, expected sequence, it can lead to distress. While genetics play a role, a child born into a healthy, supportive, and stress-free environment may still experience some difficulties. On the other hand, a wholesome, well-developed child may face significant challenges due to events occurring in utero or early in life, leading to increased vulnerability. Protecting the brain’s development process while allowing neurons to connect is challenging. These differences in maturation can result in extra work or challenges for a child, affecting brain architecture. Understanding neurosequential information can help predict the child’s capabilities and potential limitations due to underlying injuries.

1.1. Definition and Background

The Neurosequential Model: Developed and released by the Child Trauma Academy (CTA) and the CTA Education Division. The Neurosequential Model provides practical suggestions for interpreting complex profiles and applies the principles from several areas of research on child and brain development, traumatology, neurobiology, and systems theory into a working concept to help individuals better understand a particular child’s strengths and developmental challenges.

This model took shape through a process of cross-discipline, cross-sector dialogue among researchers (in a wide range of fields, including child development, child protection, psychology, social work, and neurodevelopmental disorders), program developers, directors, and front line staff (from schools and children’s programs, to juvenile justice, therapeutic community organizations, and child protection services), clinicians, educators, and policymakers from the U.S. and several other countries. The underlying concept of Neurodevelopment and Trauma was discussed, modified, written, and rewritten. Completed in 2004, the Model offers a coherent theoretical framework that pulls together a wide range of research, international Child Protection and System theories, neuroscientific and child development concepts, and over 25 years of global clinical and practice-based expertise. The Neurosequential Model is considered a recommended intervention for the treatment of complex developmental trauma, abuse, and neglect. It is not, however, intended to be the only intervention used. The Train the Trainer (TTT) initiative was begun in 2007.

Since then, over 12,000 trained professionals have worked with 45,000 children and youths across Canada, the United States, Europe, and Asia. The Neurosequential Model helps us understand the “Integral Development” of the whole child. Integral Development means that every part of the child is developing in symphony with every other part of the child. This concept brings together the separation of the mind (cognitive development), spirit (emotional development), heart (social development), physical development, motor development, sequence of maturation, etc.. It identifies how each child’s parts develop concerning each other.

1.2. Key Concepts and Principles

The Neurosequential Model (NMT) is founded on several key concepts and principles—delineated succinctly here—that guide the theoretical and practical implementation of services, interventions, and other applications. Although many details, structures, and ideas may yet to be addressed in a specific field of interest, a solid understanding of these foundational elements will enhance the implementation processes.

The Triune Brain: The three evolutionary systems in the brain can be conceptualized as a structure that regulates hedonistic impulses (in the form of the “clam”, or brainstem), a control center that plays a prominent role in motor regulation and interoception (in the form of the “cat”, or cerebellum), and the various higher sectors of the brain that coordinate and regulate cognitive and higher-order functions, embodied in the form of the “primate” (forebrain). These systems can also be characterized as managing bodily functions and resources directly (brainstem), indirectly (thalamus), or by regulation of the internal and external environment (cerebellum, midbrain), or by reflection and planning for future events and adaptations (cortex).

Proximate Principle: It is assumed that experience and environment shape the brain in a fashion that might not be apparent from observation or physical measurement (i.e., neuroplastic changes may not lead to specific macroanatomic changes). A simple assumption is inherent in this principle — behavior and adaptation “travel” from the bottom up. Implication: A comprehensive assessment would need to consider the bottom-up aspects of the organismic response to stress and trauma in a manner that would also, directly and indirectly, identify the fractional function or those higher-order regions that are most affected by bottom-up adaptive constraints. By identifying ordered disruptions as early as possible, intervention would be more likely to correct existing disorders.

The body, particularly the brain and nervous system, are inherently impacted by such adaptive constraints (proximal questions). By identifying ordered disruptions as early as possible, intervention would be more likely to correct existing disorders. The Neurosequential Model does not negate the importance of top-down processing or externalizing a capacity for mastery and self-regulation in adaptive prediction regulation. Understanding the hemispheric role in emotional and stress regulation may be a general guideline for understanding this aspect of information management. Understanding the functional properties of the right hemisphere — particularly related to the maintenance of optimism and affective valence — would give professionals a clear guideline about what to hone in on when management dis-integrations related to environmental awareness and information management occur.

2. Neurodevelopmental Foundations

The model learns about some of the neurodevelopmental building blocks that are critical and important to understand if one is to fully understand the neurobiological foundation of the NMT. This knowledge will be important throughout the model process to facilitate the full implementation. Therefore, the following descriptions of the neurodevelopmental foundations are designed to be general summaries of complex processes.

The brain is organized in layers that reflect the life cycle of human development. The developing brain has three major components: the brainstem, the limbic system, and the cerebral cortex. The brain develops in a predictable sequence, with later-developing parts dependent on earlier-forming structures for stability of function. Trauma and toxic stresses directly impact the brain areas that can provide calming and soothing for hard-to-manage behaviors.

We begin with an explanation of brain development across childhood. These paragraphs help us to understand the plasticity of the brain – the brain’s ability to adapt to new information and to injury – as well as brain-based regulation development. From there we describe the impact of brain development on learning. This model is based on the concept that the brain has three major parts: the brainstem, limbic system, and cerebral cortex. When we watch the development of the brain, we see that the brain develops in a sequence, from bottom to top. The bottom part of the brain develops first and is the source of convergence and integration of information.

2.1. Brain Development in Children and Adolescents

Skilled practitioners often say that young children are “developing brain cell”. Here they are referring to neurobiological states in which the quality of brain architecture has been shaped by and mirrors, in many ways, the quality of caregiving being provided. In early stages of development, the most prominent growth in the brain is in areas that support emotional and homeostatic regulation and motor development. Over time, areas responsible for information processing—rather than regulation—mature and are increasingly recruited.

Computers rely on both hardware and software. In young children and adolescents, hardware is developed first (basic emotional and regulation areas), and cognitive and emotional skill areas are added over time, such as adding software to hardware on a computer. In the developing brain, the earlier-forming areas (familiarity and face processing areas, lower emotional and motor control areas) increasingly regulate the newer-forming areas of “skill” (cognitive areas). One implication is that interventions with children should focus on areas of the brain that have already developed to prime the development of newer areas of functioning. Anything that is hierarchical functionality has a critical or sensitive period of growth. Neurobiological development is dominated by bottom-up functions, where internally driven state patterns recruit neuroception. Loss/alteration of brainstem development has global implications for neurodevelopment.

2.2. Impact of Trauma and Adversity on Brain Development

Understanding of toxic stress has clarified the profound impact of such trauma and adversity on the developing brain. The core brain capacities (e.g., attention, memory, and perception) impacted by these events depend on the severity of trauma and exposure and the developmental level at the time of occurrence (e.g., prenatal, early childhood, puberty). Trauma at certain developmental stages can also trigger the emergence of prematurely developed brain capacities in response to that experience, for example, allowing for extreme focus on all of the bad things going on in an environment. There can be increased integration between different brain parts (e.g., emotional and cognitive), influencing availability and mutual influence among capacities. The plasticity of developing brains results in complex, layered patterns of strengths and challenges, requiring multi-disciplinary assessment and intervention strategies for remediation. The Neurosequential Model is a developmentally informed, strength-based model of care for organizing evaluation, progress monitoring, prediction, and selecting appropriate activities for children, adults, and the elderly with psychological, social, cognitive, and physical difficulties.

Understanding advancement in neuro-regulatory infrastructures allows for complex restriction and enrichment activities tailored to each patient’s needs. Optimal application of such activities allows for rapid reorganization of the neural information processing infrastructure. The recognition of the many patterns and levels of function and dysfunction in conditions ranging from prenatal alcohol syndrome to neglect complements expertise regarding specific psychological diagnoses and co-morbid conditions. The hallmark of clinical Neurosequential Model services is the creation of individualized treatment plans based on an integrated understanding of the presenting problem, developmental history, family situation, specific strengths and liabilities, and the functional outcome of these patterns. Neurosequential Model care closes the gap between what we know and what we do. This historically machine-based assessment model uses national guidelines for physical outcomes, usually FEMA standards, to stage development across multiple brain systems and behavioral factors.

3. Assessment and Intervention Approaches

As a comprehensively informed and categorized assessment and intervention, the Neurosequential Model starts by offering this picture of a child and helps us decide where to go—what interventions might benefit most. Assessment tools include the Neurosequential Record Review, which provides a dynamic history of a child and points to peer-reviewed research that guides assessments. Using this information, the Neurosequential Assessment can then offer a head-to-toe look at the sequelae of developmental trauma on the brain development of the child. Subscale tools can also provide a child’s physical, cognitive, and sensory profile as needed for specialized treatment settings. Applying the neurosequential concept to interventions can inform the model and setting. Starkenburg Children’s Colony in Iowa, USA was also informed by the neurosequential model and is utilizing it in practice.

Strategized intervention decisions are developed based on the information collected during and after a neurosequential assessment process. Worksheets and templates for collecting this information for the Neurosequential Record Review are available. The NME was developed to provide advanced consultation services to agencies and states, and the neurosequential model of therapeutics has been developed utilizing the Neurosequential Assessment tool. This intervention assists the child in learning to “control” their body. For some, this may present as a consequence or behavioral modification model; however, underlying techniques are often more reflective in a sensory-rich setting that teaches a child mind-body awareness skills. The overarching goal of the Neurosequential Model is to gather assessment data in one comprehensive model and then use that information to assist an individual in reaching their fullest potential by providing developmentally appropriate interventions to meet that child’s unique needs.

3.1. Neurosequential Assessment Tools

Intriguingly, the assessment tools that Dr. Perry and his team have developed continue to use core precepts of the terror unconscious models described by Perry in 1980, which underpins the Neurosequential Model discussed in this paper. Surreptitious sudomotor testing, like the Skin Conductance measures used in NP, has been previously used by the Child Trauma Academy and others interested in developing an understanding of neurobiological regulation within the individual. The various assessment tools offer professionals the ability to help clients with different and most comprehensive profiles. The Sensory-Motor Psychotherapy training teaches professionals to use the surreptitious sudomotor testing of the Neurosequential Profile as well as Polyvagal theory to select the transdiagnostic targets Motivation, Fear, and Illness according to whether the body is stuck in sympathetic energization, dissociation or parasympathetic freeze response – and there are techniques for each that regulate that particular level of the autonomic nervous system. Dr. Ruby Oates might be interested in attending this training or would possibly consider training others to apply this approach. You can contact me if you think this would be useful.

The Neurosequential Profile (NP) is part of the Neurosequential Model developed by Dr. Bruce Perry and his colleagues at the Child Trauma Academy since 1990 and is used as part of the NMT Clinical Practice programs to translate the findings of the NP into practical recommendations designed to guide the focus and intensity of treatments to the developing brain, most especially trauma or decay. The NPT is therefore the person who is most in taking the data, e.g. psychologist, psychiatrist, doctor, speech pathologist, occupational therapist. In the words of Dr. Perry, the NP provides a “so what” value. Your report provides a comprehensive exploration of 12 development domains and their client’s presentation. Can you please describe the individual assessment results in depth for processing speed.

3.2. Integrating Neurosequential Strategies into Interventions

It is integrating neurosequential strategies into interventions. The use of the neurosequential model has provided practitioners in a variety of fields with a set of guiding principles that are consistent with neurobiological findings, ultimately helping adults working with children and youth to better understand and implement interventions related to developmental trauma through a biological lens. Unique to the neurosequential model is the integration of a variety of traditional intervention strategies combined with the prioritization of specific crucial principles for all who seek to promote healing and overall health. At the heart of the neurosequential model is the relationship-based, developmental approach that utilizes an individual’s strengths and interests in novel, sensory-rich environments.

In addition to a variety of other services such as occupational, recreational, and presidential therapy, a school developed an inpatient therapeutic environment [the NeuroNet]. Developmental capabilities of the child, determined by a relationship-based model, were combined with the principles of trauma-informed care and processed by guidebooks offered by Acadie Academics and the Child Traumatic Stress Network. The NeuroNet is structured with the same principles that inform the entire milieu. In doing this, the NeuroNet can heal disruptive behaviors of the RTT student body. All who work with students at RTT are trained in equipping with skills and strategies for working with developmentally affected students. NeuroNet staff are additionally trained in the use of NBML psycho-educational training materials and neurological positioning developed at the Summer Brain Institute. Sports are coached with an understanding of how working on gross motor abilities helps in the organization of the brain. Processes began with thorough physicals to prevent problems and coaching of coaches. The method worked as discipline problems fell. Soccer won championship games and started playing other teams. In some cases, NeuroNet admission occurred when a student was misdiagnosed and, therefore, received care that did not meet their pedagogical needs.

4. Applications in Various Settings

Finally, advances in neuroscience are leading educators, early childhood workers, parents, and the general public to understand the importance of addressing a spectrum of learning and developmental challenges within an individual child’s developmental strengths and weaknesses. Information on brain development has been utilized to help parents and service providers understand age-appropriate behaviors and to recalibrate expectations of children under extreme stress and in whom trauma has impacted cognitive development. Through this ongoing process, the NMT has been further developed and expanded into the Neurosequential Model of Therapeutics (NMT, Perry and Hambrick, in press). The NMT is currently used in settings as diverse as residential treatment programs for maltreated children, a community-wide prevention and early intervention program, child welfare, pediatric care, and an adoption program.

The Neurosequential Model can also be conceptualized as a universal taxonomy, socializing a common language for educational caregivers who interact with children without the individual’s parents or a diagnostic assessment. Lastly, the Neurosequential Model is used by several community-based programs for case staffing and the development of clinical recommendations across professional systems (Perry, Azad, Hambrick, Zageris, 2003). With the development of this universal taxonomy and universal application of the Neurosequential Model, it is hoped that the number of children not receiving services in the absence of a clinical diagnosis will decrease. The clinical application of the Neurosequential Model will begin to occur in preschool and school-age settings in support of the education and prevention mandate (Perry et al., 2003).

4.1. Educational Environments

There are as many educational settings now involved in the application of the Neurosequential Model across the spectrum of care, including inpatient psychiatric hospital settings, residential care settings/juvenile justice facilities, therapeutic boarding schools, day treatment programs, therapeutic foster care, and adoption. As with all settings, the NMEI continues to work to enhance its wide applicability across the various environments that many children and adolescents are connected with at some point.

Children who attend public schools likely make up the largest population of the individuals who come to us for care in our offices as part of our clinical teams. For this reason, there is a special effort made by TBRI® in schools to share, educate, encourage, and support neurodevelopmentally-informed practices in education for students, families, and schools. As part of that effort, the following fact sheet was developed by TBRI® at Texas Christian University to summarize the Neurosequential Model’s contributions to the field of education.

Education is about drawing out the truth that a child’s soul already knows, with a goal of drawing that truth—authentic self—into the world. Dr. Bruce Perry and The ChildTrauma Academy’s Neurosequential Model [NM] provides a revolutionary understanding of the human brain and how adversity and trauma shape behavior. Today, when a student displays behavior indicating he exists on a sensory/neurodevelopmental level far below his chronological age, a diagnosis is often made, and a corresponding educational “cure” is employed. Educational interventions may be only designed to meet the child where “he is.” The NM postulates that adverse experiences—many of which occur developmentally—are to blame for these behaviors. Educational environments are encouraged to look at the root causes, not just the symptoms, of behavior.

4.2. Clinical Practice

The final setting in which the NMT is used is in clinical practice. There are already over one thousand professionals registered globally completing NMT training, and many of these professionals are using the three levels of certification to help structure their tailor the appropriate applications of the NMT to the setting and population with which they work. A number of further research studies are in preparation and in progress that we believe will further evidence the value of a neurodevelopmentally-informed approach to practice.

Considerable feedback has been sought as part of the NMT certification process in the past NMT cohorts, and in years before formal certification processes, there have been thousands of conversations about the usefulness of the NMT in clinical settings. Here, We have tried to provide an overview of that field of data—articulated by professionals working across three streams—to give an idea of some of the reported outcomes of using the NMT in various settings. This is not a comprehensive picture; rather, it represents a summary, a mere snapshot of clinical reports of change. It speaks of change for whole settings such as educational institutions, hospitals, and care homes; for whole systems such as those providing targeted treatment to young people who have been sexually harmed; or for children and families in which there has been child-to-parent violence, as well as for individuals, groups, and families. It also speaks of change in systems and how introducing NMT principles can have an effect across organizations as well as within them.

4.3. Community Programs

So many involved in trauma recovery work are part of a larger group or organization. Perhaps you are working on trauma-informed systems of care in your county, overseeing a HIPPY program or discussing how to improve your Head Start program. The more you understand the NMT and how it has been implemented, the more you can participate in shaping the framework and applying it in community or group settings. As our voice grows as a community, we want you to understand the fullness of the Neurosequential Model, the NMT, and how it works in many settings.

Other independent programs often take a developmental and neurosequentially-informed perspective regarding children. These practitioners and programs often do not employ a neuropsychological approach to assessment, intervention, and treatment recommendations. They tend to focus only on one level of functioning, often not being very focused on the physical aspects of a child. When independent programs interlink with the Neurosequential Model, we see an increase in 1) assessment of physical function and 2) a holistic look at a child. In those organizations that approach children from a developmental perspective, as a result of these changes in focus, we have seen an increase in conversations with classroom teachers regarding physical interventions and a decrease in multi-disciplinary professionals seeing children in their offices because more are connected to sites.

5. Research and Evidence Base

A growing body of evidence supports the effectiveness of NMT and the neurodevelopmental principles. In 2013, Muir and Fisher published the results of a six-year research project in Australia. They reported that 68% of children in residential care scored in the clinical range prior to the treatment phase of the NMT, well above the rates reported in other studies. After the NMT, only 25% of the children scored in the clinical range. Their reports are correlational rather than experimental studies; client scores were not compared to those of a control group. However, their findings support the applicability of the NMT in Australia. This research is now part of a PhD research project in Brisbane under the leadership of Muir and Fisher.

Dr. Isa Wolmer, a clinical associate professor at Barull College in Israel, formally studied the NMT with 100 orphaned children in Russia. She reported significant changes in communication, behavior, and affect in these children as they transitioned through the NMT treatment model and that, on average, the NMT significantly reduced problematic behaviors for scores at each phase of treatment. Researchers Dr. Charles Zeanah and Dr. Smyke visited our research department and offered pointers and their support for our research on NMT. In addition, Drs. Zeanah and Smyke conducted a study of institutionalized children in Bucharest who had suffered from maltreatment in early life. They found that the majority of children suffered problems with attention, emotional lability, and attachment disorders. In Bucharest, the biological parent or parents of these children were unknown or unwilling. Those children provided to us as part of our Phase II research will be offered the NMT intervention, and we will follow their progress.

5.1. Studies on the Effectiveness of the Neurosequential Model

Several studies have been conducted in this area, identifying empirical support for the proposed principles and practices. In evaluating the Neurosequential Model’s efficacy in treating complex trauma symptoms among 137 children (mean age 10.84; 41% male), individuals serving as a comparison group were non-equivalent and excluded from inferential statistical analyses. The chart review study found that participants demonstrated a 19.3-point reduction in symptoms on average as measured by the Child Behavior Checklist’s Total Problems score, as well as significant reductions in specific problems such as anxious/depressed, withdrawn/depressed, somatic symptoms, rule-breaking behaviors, and aggressive behaviors. Parents, caseworkers, and therapists also reported positive changes in functioning for 96% of participants in the study, as well as a reduction in stress for families. Overall, the severity of pathology and functional problems decreased for 86% of participants discharged from services. These results provide mixed evidence for the theory that developmental trauma is best treated using interventions based on the principles of NMT.

An examination of the efficacy of NMT and Brain Network Reorganization therapy (BNR) in the more significant population of cases seen at the ChildTrauma Academy, using best-practice intervention regimens with the application of NMT principles and activities, was conducted for 170 children between the ages of two and seventeen (mean age = 11.4 years; 68% African American, 60% male). A study on the efficacy of therapeutic activities targeting the developmental neurobiology of children was carried out in which participants and their families were exposed to therapeutic activities and interventions designed to remediate the effects of complex trauma on underlying neurodevelopment, using sixty-five foster children who, on average, had 18.16 types of trauma exposure (at the baseline). Baseline results showed that contrary to expectations, higher NME-L scores (i.e., more significant abnormality in tactile perception and sensory filtering) were associated with higher CANS scores-dismissive/disorganized behaviors in the home, and excessive punishment by caregivers. Participants in the three states of involvement with the Child Welfare System (e.g., supervised visits with reunification goal, where parental rights have been terminated and adoption is the goal and final adoption) were then evaluated in terms of length of time up to the October 2016 status (e.g., adoption finalized or children reunified with birth families). Results also indicated that there was neither a pattern concerning the length of time in foster care and the disposition of the case nor physiological status (as determined by NME-L scores at baseline). Instead, results from the current study suggest a potential path of using specific data from the Neurosequential Model of Therapeutics to predict future maltreatment issues in a population to develop targeted preventative interventions.