110 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD

patterns of unrepaired mismatch, with resulting difficul- 5

ties with emotional, attentional, and behavioral regulation.
When we take time to listen and discover the narrative
that makes sense of the current problem, we help parents to The Neurosequential
understand their child's behavior rather than simply naming
it as a disorder. When children feel understood, they feel Model of Therapeutics
calm. This caim contributes to an improvement in behav-
ior and, with that, a sense of caim and positive self-esteem
in the caregiver. Thus, a pattern of mutual dysregulation is
transformed into one of mutual regulation, parent and child
can rediscover joy in their relationship, and development
can get back on track.

The ideas of Bruce Perry, a leading child psychiatrist and

director of the ChildTrauma Academy (http://childtrauma
.org/), grew out of his frustration with the traditional
model of psychiatric care, where children who have expe-
rienced significant trauma are treated by medication and
are expected to sit and talk with a therapist about their
experience on a weekly basis. He recognized that this
approach was failing.
Perry's model has clinical relevance both in the setting
of major trauma, as in abuse and neglect, and in the setting
of everyday chronic mismatches as described in Chapter 4.
As Perry (2006) describes,

rather than focusing on any specific therapeutic tech-

nique, the Neurosequential Model of Therapeutics
(NMT) allows identification of the key systems and
areas in the brain which have been impacted by adverse
112 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequential Model of Therapeutics 1/3

developmental experiences and helps target the selec- knowledge of how the brain develops to guide treatment in
tion and sequence of therapeutic, enrichment, and edu- the clinical moment as well as in creating a treatment plan.
cational activities. (p. 28)
BRAIN DEVELOPMENT. A basic knowledge of brain struc-
Using the example of postpartum depression, Perry's ture and function is necessary for understanding the NMT.
NMT helps Us make sense of the long-term impact of this I have found that it can be very easily explained to parents
experience and guides us in treatment in the moment, what- and is extremely useful in helping them make sense of their
ever the age of the child. If in early infancy a child did not child's behavior and informing them of how to navigate dif-
have the scaffolding to develop capacities for emotional reg- ficult moments. With parents I use the terms "lower and
ulation, while development has progressed, when stressed higher centers of the brain" and the "centers of the brain
the child may regress to the level of functioning at which responsible for thinking and reasoning." Here I will use sci-
the original disruption occurred. Developmental disruption entific terminology to describe the hierarchical organiza-
in infancy will have a different impact from disruptions at tion of the brain:
eighteen months or five years. The "problem behavior" that
precipitates a mental health referral may represent func- Beginning at birth and throughout life, the basic
tioning at a more primitive level of development than we regulatory functions are performed by the brainstem,
expect from looking at the child. For example a 6 year-old- which mediates heart rate, respiration, blood pres-
child may behave like an infant when under stress if he sure, and body temperature. This area develops from
experienced significant neglect during that time. In every birth to nine months.
visit with a parent and child, I listen both for the level of The brainstem and diencephalon together are
brain development at which disruptions first occurred, as responsible for regulation of arousal, sleep, and
well as the level at which a child and parent are function- what I referred to in Chapter 3 as state regulation.
ing in a specific moment of disruption as part of the current The diencephalon develops as the next "layer" dur-
presenting problem. Drawing on Perry's model, we can aim ing infancy and is also responsible for integration
to tailor our intervention during that moment to develop- of sensory input and fine motor control. The stress-
mental age rather than chronological age, with the aim of response system (see Chapter 6) originates in the
returning the child to a level of functioning consistent with brainstem and diencephalon.
his chronological age. The limbic system, which mediates emotional states,
As I explore in Chapter 7 in the clinical setting, the stress social and language development, and interpretation
of the visit itself may lead both parent and child to regress of nonverbal information, develops most significantly
to lower levels of brain function, Perry's model helps us use between the ages of one and four years.
 114 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequentiai Model of Therapeutics 115

The cortex, which is responsible for abstract cogni- In a state of calm, a person is capable of abstract
tive functions, is present at birth but comes online in thinking.
a significant way at around age three and continues to As one moves into a higher' state of arousal, such as
develop into a person's twenties. when a parent is getting increasingly frustrated with
a child who won't put . on her shoes to go out of the
Each level of'development is dependent on the previous house, these higher cortical functions are impaired.
level of organization. Growing up in a sensitive, attuned Both parent and child may be thinking on a concrete
caregiving environment offers what Perry describes as level.
"regulated, synchronous patterns of input" (2009, p. 252). In a state of alarm, the limbic centers are running the
In this setting, the higher centers of the brain develop in show. Responses are emotional, and thinking is not
an organized fashion. But if early in development the input rational at all.
is extreme, dysregulated, and asynchronous, the higher With high arousal and fear, the primarily reac-
centers of the brain will be less organized, reflecting this tive responses are mediated by the midbrain and
abnormal pattern of input. Thus, a child with early devel- brainstem.
opmental disruption will be more vulnerable to disorga- Finally, in a state of terror, the brainstem mediates
nization of the higher centers, particularly in moments of purely reflexive reactions.
stress.
Children who have experienced early developmen- An individual's sense of time is increasingly distorted
tal trauma such as significant emotional and/or physical with increasingly aroused states. In a state of calm, it is pos-
neglect in infancy, may in times of stress, such as feel- sible to think about the extended future. As one becomes
ing overwhelmed in a busy classroom, have use of only stressed, thinking in terms of days or hours is still possible,
the lower centers of their brain that have basic regula- but in a state of fear or terror a person may experience time
tory functions. The higher centers that control emotion only in the moment or lose sense of time altogether.
and cognitive processing may in a sense go offline. A child This understanding of the level at which a child is func-
may have no sense of time other than that moment. Tra- tioning can guide parents and clinicians. Perry (2006)
ditional approaches of punishment-such as being sent organizes appropriate therapeutic activities according to
to the principal's office-will lead to worsening of the the level of brain functioning a child is experiencing at a
behavior. specific moment in time:
Perry (2006) identifies a continuum of arousal states,
from calm through arousal to alarm and then to fear. The When a child is functioning at the most primitive
capacity for cognitive function declines in parallel: level, rhythmic and patterned sensory input is

------------------------------_._._-------
116 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequential Model of Therapeutics 117

needed, such as the range of auditory, tactile, and fore, remembering that these first arise in the brainstem
motor input an infant receives in the context of and then move through the brain up to the cortex, the
being cared for. Re-creating this kind of experience, first step in therapeutic work is brainstem regulation. The
within the reality of a larger and often physically child may also have a host of cortically mediated symp-
combative child, is called for when a child is at the toms such as self-esteem problems, guilt, and shame.
highest level ofdysregulation and in a state of fear. The most effective intervention process would be to first
As child begins to calm down and the diencephalon address and improve self-regulation, anxiety, and impul-
comes online, the child can integrate sensory input sivitybefore these cognitiveproblems become the focus of
and regain fine motor control. The child is respon- therapy. (p.252)
sive to simple language in the context of emotional
warmth and is capable of more complex rhythmic Often referred to as "bottom-up" approach to therapy,
movements, such as going for a walk. Horseback rid- the idea is that regulation must come first. Next, when both
ing, music, yoga, and drumming are examples of parent and child are regulated, relationships can begin to
excellent therapeutic activities for a child functioning heal. The scaffolding offered by relationships gives both
at this level. parent and child access to the higher cortical functions
When the limbic system is engaged, a child is able to that allow for reasoning and insight. The sequence "regu-
interpret more complex nonverbal information and late, relate, reason" offers a simple frame that helps us to
make sense of others' emotional states. The child may apply these ideas in multiple situations.
be able to make use of play therapy and performing Most people have had the experience of being agi-
and creative arts, such as theater and dance, for emo- tated and upset and taking a walk to cool down. This
tional regulation. is an example of rapid alternating movements that help
Finally, when the highest cortical centers are function- the lower centers of the brain function more evenly, in
ing, the child may be capable of abstract reasoning and a better-regulated fashion. As a result, the higher cen-
can make sense of consequences and cause and effect. ters come back online and a person regains the capacity
The child may respond to the more complex conversa- for rational thought. If the lower centers continue to be
tion as occurs in insight-oriented therapy. disrupted, they in turn will disrupt the higher centers.
Parents who try to reason with a child in the middle of a
Summarizing this approach, Perry (2009) wrote, tantrum have intimate knowledge of this fact.
Perry developed the NMT in work with children who
When symptoms related to the persisting "fear" response were in the child protective system and thus have expe-
(common in maltreated children) are addressed, there- rienced significant trauma. However, as we integrate his
1[8 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequential Model of Therapeutics 1[9

'.','

model with Tronick's and understand the full range of It is not simply that activities such as drumming, swim-
clinical problems related to the stress of unrepaired mis- ming, or martial arts help with self-regulation. Equally
match, we can see how it can also be applied in developing important is that these activities' occur within the context
appropriate interventions across levels of clinical sever- of supportive relationships. I often recommend that young
ity. Equally important, we can use Perry's model in the children and parents take a.martial arts class together. On
clinical moment. as we help both child and parent move a swim team, not only the activity of swimming itself but
from lower to higher levels of brain function. When par- also the relationships with the coach and with teammates
ents don't know what to do about their child's "difficult" can play important roles in growth and healing. Perry
behavior, a detailed history often reveals that the only wrote that a key element of NMT "relates to the child's
tools they are using are words, and when words do not current relational milieu. A primary finding of our clinical
work, parents resort to the equally futile endeavor of yell- work is that the relational environment of the child is the
ing, in a sense analogous to speaking loudly to a person major mediator of therapeutic experiences" (2009, p. 252).
who does not understand the language. By helping par-
ents recognize that the thinking or processing parts of the USING THE BODY TO HELP THE BRAIN. Often when kids
child's brain are in a sense offline in these moments, they are struggling in school, teachers express concern that
can begin to reframe the child's behavior not as defiant but they are "overscheduled." But if extracurricular activities
as helpless. We can help parents begin to be creative about are carefully planned and well thought out, they can be an
ways to get the thinking parts of the brain working again. essential part of treatment. It is best to have some kind of
We can put this model together with what we know about a calming activity interspersed with homework, tutoring,
the role of sensory processing in emotional regulation and or therapy. These can be tailored to a child's particular tal-
bring the body into both the treatment plan for child and ents and interests. Many know the story that the cham-
family and within clinical visit itself. pionship swimmer Michael Phelps struggled terribly with
ADHD. Swimming can be a very regulating activity, but
REGULATING IN RELATIONSHIPS. As Perry articulates in some kids with learning and behavior problems also have
the NMT, the relational context of treatment is central. sensory processing difficulties and can't stand to have
Perry highlights the fact that our brains "prefer" a relation- their head under water. Clearly swimming isn't the right
ally enriched environment. The brain grows and develops choice for them.
in the context of caregiving relationships. Thus, attending Occupational therapy that focuses on sensory integra-
not only to the activities that promote emotional regulation tion for young children can accomplish this goal of using
but also to the relational milieu in which these activities the body to help the brain. But as children get older and
occur is important to successful treatment. can learn to express their feelings, parents can help them
120 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequential Model of Therapeutics 121
,

identify age-appropriate activities that work in a simi- her and hitting her in the face, she understandably
lar way. One boy in my practice had a creative tutor who became angry. Used Perry's model, I explained that
discovered that he did better in his early morning tutor- the nap, with the impending separation, might pre-
ing sessions at school if she let him ride a scooter down cipitate just the kind of stress that would cause his
the hall to the classroom. This same boy, several years brain to revert to lower levels of functioning. Alex had
later, learned to recognize that when he was feeling over- experienced multiple traumatic losses in his short life,
whelmed, going down to the basement to play his drums including loss of his mother at one year of age. The
helped him to regroup. This kind of awareness, of both stress of separation, together with his adoptive moth-
mind and body, can serve kids well not only in childhood er's anger, likely signified in his mind a repetition of
but also over a lifetime as they learn to adapt to their par- abandonment. Thus, a nap, which from Jane's per-
ticular vulnerabilities. spective was a typical everyday experience, became
a frightening, if not terrifying, event for Alex. In this
high state of arousal, he regressed to a lower level of
Case vignette: Alex brain function. His behavior was ruled by the lower
Alex's mother was despairing that she and her husband regulatory centers of his brain. Even though he looked
were having trouble connecting with their adopted like a bright, articulate three-year-old, at that moment
son. At three he was bright and engaging, having mas- he was developmentally more like an infant. While
tered English in less than a year following his adop- Alex had spent a year in a stable and loving home, the
tion from Cambodia a year earlier, just after his second fact that the lower centers of the brain had developed
birthday. The contrast with his typical behavior and in an environment of unpredictability and absence of
his "outbursts," as his mother called them, was alarm- a mutually regulating primary caregiving relationship
ing and bewildering to his parents, Jane and Michael. meant that he was vulnerable to regression to a level of
He would spit, bite, kick, and scream at what seemed dysregulation that reflected his early trauma.
to them a minor provocation, such as being told it was I suggested that, in the moment when Alex was totally
naptime. out-of-control, she try to visualize him as a baby who
At our third visit, after I had learned the story and could be held and even swaddled. Even though she could
then met Alex, I asked Jane to tell me in detail all not literally do this, by thinking of the containing experi-
of the events around the nap. She saw how, as his ence of swaddling a baby, she could visualize what it was
resistance escalated, her frustration escalated in par- that Alex needed in that moment. He might at first resist
allel as she became increasingly enraged. Then when physical contact. But she found that as she deescalated
her usually bright and loving child began spitting at the situation by speaking to him with a soft, gentle voice,
122 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequential Model of Therapeutics 123

letting the sense of threat gradually subside, he would than confronting him as she might an older child, she
soon allowher to hold him. was in a sense helping to regrow the pathways that
Jane needed to acknowledge her own legitimate had been disrupted earlier. This simple intervention
reaction of anger and, in a sense, override it as she rec- opened up a path to healing.
ognized the complex meaning of her son's behavior.
Recognizing. the difficulty of this task, I said to Jane,
"You need to be the most generous when you feel the
most angry." NMT FOR PARENT AND CHILD. As we see in Alex's story, a
At first Jane did not understand why this prob- child's behavior may provoke a parent to regress to lower
lem was still present after a year of living in a loving levels of brain function. This is more likely if the parent
home. But when she thought about the disruptions that has a history of trauma. While Perry's model focuses on
occurred in infancy, when the lower centers ofhis brain the child, it is equally applicable to understanding what
were forming, she saw how Alex could still be vulner- is going on for a parent in a moment of disruption. Just
able when stressed, even though most of the time he as we recognize that in a moment of stress a child feels
was adaptive and high functioning. out of control, a parent in this situation has a similar
When I saw the family a few weeks after this visit, experience, especially if a history of trauma is involved.
Jane described a complete transformation in their Parents with a history of being physically abused may
relationship. Because I had spent some time in non- experience a surge of stress and rage when their own
judgmental listening during this and the previous vis- child hits them.
its, Jane herself was calm and could take in what I was Even when a child behaves aggressively in a way that
saying. She said that phrase about needing to be most is developmentally normal (though limits must be set), a
calm when she felt most angry had really made sense parent with a history of early life trauma may have a surge
to her and had transformed the way she interacted of stress hormones that affect brain functioning: think-
with him. ing is impaired and a kind of fight-or-flight reaction may
Over the coming weeks she learned not only how ensue, which in turn may lead to aggression. Another
to deescalate his behavior during a meltdown but also alternative, as I describe in detail in Chapter 6, is to shut
how to anticipate these moments before his higher cor- down or, in psychological language, to dissociate. This
tical centers were completely offline. She could see his leads to a sense of being emotionally disconnected. Nei-
stress level rising and ask him, "Do you need a hug?" ther state in a parent is good for a child. Focusing exclu-
while he could still hear her and take in what she was sively on the child's behavior will accomplish little in this
saying. By repeating this type of scaffolding rather situation. Repeated exposure to an angry, out-of-control,
124 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequential Model of Therapeutics 125
,

or emotionally removed parent has significant impact on they understand the nature of the flip, they can appre-
the child's development. ciate that they have control over the situation and they
Alex's mother, during those episodes of biting and no longer feel helpless. The following vignette shows how
spitting, was likely in a similar state of concrete or even to make use of Perry's model in real time in the clinical
reflexive thinking. The goal of my work with Alex's encounter.
mother was to. first get her brain functioning in a more
regulated way, to help her regain her own capacity for
abstract thinking. This was accomplished in part simply Cose vignette: Mora
by giving her the space and time to tell her story in a Ellen and John were concerned that their three-year-
nonjudgmental setting. She could speak of the intense old daughter, Mara, had bipolar disorder. As I do as part
rage she felt toward him in those moments. Her thinking of every assessment, I asked them to tell me about a spe-
was in a sense paralyzed by the rage and guilt. Freed of cific moment of disruption. What started as a story of
these feelings by sharing them, she could begin to think Mara throwing a toy at her older sister ended up being a
clearly. She was able to hear and take in my idea about story of daily chaos from the moment Ellen came home
being most generous when she felt most angry. Only then from work until the battle around bedtime ended many
could she help Alex. hours later in complete exhaustion.
Parents need to find ways to become calm in their own As soon as Ellen walked in the door from her high-
body to be able to help their child shift out of a primi- stress job, she explained, both Maraand her sister would
tive level of brain functioning. Psychotherapy may help to be physically on her, demanding her attention. But she
accomplish this task, but that can take time. Supporting had to get dinner ready and was in no state to engagewith
parents in finding tools for self-regulation that have a more them, so they would chase each other around the house,
immediate effect, such as yoga or meditation, can be an getting more and more wound up. Ellen, in turn, would
essential part of the treatment of a family. get angry, and inevitably the scene would degenerate,
with Mara having a screaming tantrum.
USING NMT WHEN BEHAVIOR SHIFTS RAPIDLY. Parents As Ellen tried to tell me this story, we were able to
often speak of a "flipped switch" when describing behav- experience it in real time. Mara climbed on her father,
ior that is alarming to them. With that observation comes with increasing silliness, poking him in the face and
the question of bipolar disorder. But Perry's NMT helps jumping on the couch despite the availability of a vast
us reconceptualize the switch as a shift from higher to array of toys in the office. While he tried to swat her
lower levels of brain function. This switch is within a par- away, Ellen intermittently interrupted her story to say,
ent's control once they learn to recognize it as such. Once "Stop poking, Daddy."
126 THE DEVELOPMENTAL SCIENCE OF EARLY CHILDHOOD The Neurosequentiai Model of Therapeutics 127
..,!

Observing Mara's increasingly out-of-control behav- erless in the face of her extreme behavior, Ellen and
ior, I suggested we try another approach. "For five min- John had a way not only to:findmeaning in her behavior
utes," I said, looking at my watch, ':let'sjust play." Ellen but also to help her.
and John came offthe couch and sat on the floor. Imme-
diately Mara calmed down and engaged in imaginary
play with the dollhouse, including both of her parents. PUTTING IT ALL TOGETHER: NMT, MENTALIZATION, AND
When the five minutes were up, I asked Mara to resume MUTUAL REGULATION. The preceding chapters described
her play on her own so her mother could finish telling how parental reflective functioning is an entry point to
me the story. mutual regulation. Perry's NMT helps us see that, for men-
Mara played on her own for four minutes and then, talization and mutual regulation to occur, the parents'
just as her parents had described, it was like a switch brain must be working at the level of the higher cortical
was flipped. We sat through another few minutes of centers. To facilitate parental reflective functioning, we
Mara's increasingly agitated behavior, with Ellen trying need to first to support a parent's ability for thinking. This
in vain to continue talking with me, stopping repeatedly is accomplished by providing a safe, containing, nonjudg-
to tell Mara, in an increasingly aggravated tone, to calm mental space for listening.
down. Atthe :first visit both John and Marahad described When a child's behavior precipitates an understand-
howthey had a shared love of music, so now I suggested able reaction of anger in a parent, the child, who is already
that, instead ofplay, we use music. Singinga song did not stressed, may become terrified and descend into more
calm Mara. I asked Ellen if she had any other ideas, and primitive levels of brain function. When both parent and
Ellen brought out her phone and turned on a favorite child are in a similar state of distress, a downward spiral of
song.Marasat in rapt attention, her wholebeing absorbed mutual dysregulation occurs.
in listening to the music. Once a parent's higher cortical centers are online,
I took this as an opportunity to validate Ellen and the parent can think about the meaning of the child's
John's experience that Mara's behavior could turn like behavior. The parent is then able to recognize how the
a flipped switch. But I reframed the question from, "Is child is in fact not defiant but helpless. The parent can
there something wrong with her?" to "Why does her work toward developing tools to support the child's brain
mood shift so suddenly?" and "How can we help her functioning at a higher level that is consistent with his
to return to a calm state?" The withdrawal of her par- chronological age. With this more advance level of brain
ents' attention seemed to be, at least in part, the cause. function comes the capacity for reflective thinking, self-
But we saw that both play and music could help flip the regulation, cognitive resourcefulness, and social compe-
switch to the healthy position. Rather than feeling pow- tence that are central to mental health.