Running Head: THOMPSON NMT IN EARLY CHILDHOOD INTERVENTION

The Neurosequential Model of Therapeutics (NMT) in Early Childhood Intervention Shauna Thompson University of Calgary

THOMPSON - NMT IN EARLY CHILDHOOD INTERVENTION

The Neurosequential Model of Therapeutics (NMT) in Early Childhood Intervention All children experience stressful events, and some of them. Many, however, grow up in kind, loving, non-abusive families and never have to experience a life-threatening disaster like a tsunami, earthquake, bombing, or military aggression. Most children never see someone killed or are present in a drive-by shooting. But as I have seen working with the Calgary Police Service, Children's Services in Alberta, and the Children's Hospital, far too many children experience repetitive, severe traumatic stress in their early years, and are overwhelmed by the traumatic events. Childhood is meant to be a time to learn and grow in the context of a safe and enlivening atmosphere. Children who suffer neglect, abuse, and maltreatment have their safe environment shattered. For many, childhood is a very violent time; childhood is permeated with unpredictability, chaos, threat, and other forms of adverse developmental experiences. For children who grow up in high-risk environments (e.g. extreme poverty, parental substance abuse, maternal health problems, and a lack of social supports) the exposure to trauma and maltreatment is well-documented and the prevalence of significant neuropsychiatric problems is high (Canada, 2006; Gilliam, 2005; Ko et al., 2008, as cited in Shaw, 2010, p.19; Ludy-Dobson & Perry, 2010; Squires & Nickel, 2003; Thompson & Cui, 2000; Webster-Stratton, 1998). Children raised in traumatized environments have a unique combination of delays, functional problems, and strengths that are determined by the quality, timing, patterns, and intensity of their developmental experiences (Perry, 2006). Piles of research describe the negative impact of childhood trauma on childrens physical, behavioural, cognitive, social, and emotional functioning (Anda, Fellitti, Walker, Whitfield, Bremner, Perry et. al., 2006; Berenson, Wieman, & McCombs, 2001; Bremner & Vermetten,

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2001; Fitzpatrick & Boldizar, 1993; Graham-Berman & Levendosky, 1998; Malinosky-Rummell &Hansen, 1993; Marolin & Gordis, 2000; Perry & Pollard, 1998; Sanders-Phillips, 1997). Many traumatized children have trouble regulating their emotions, knowing what they feel, and verbalizing their experiences and feelings (van der Kolk & Courtois, 2005). Recent studies suggest that an increasing number of young children exhibit high levels of impulsivity, aggression, and other disruptive behaviours (Barfield, Dobson, Gaskill, & Perry, 2012; Canada, 2006). These children are frequently a challenge for educators and caregivers in school settings, regularly displaying difficult behaviours and significant problems with their emotional and behavioural regulation (Gilliam, 2005), and we know that childhood trauma rates in Canada are ever increasing (Canada, 2006; Statistics Canada, 2008; Thompson & Cui, 2000; Trocme, Fallon, MacLaurin, Daciuk, Felstiner, Black, Tonmyr, et. al, 2010), suggesting a parallel increase in demand on our school and community educators and care providers. In the Fall I will begin a placement with a child and family services centre in Calgary that works with traumatized children and youths. A new therapeutic model, the Neurosequential Model of Therapeutics (NMT), (Perry, 2006; Perry & Hambrick, 2008), is currently being applied to interventions with children living in a secure treatment program in my upcoming practicum setting. Since the model is relatively new, there is a lack of research evaluating its use in practice, and I am eager to learn more about how it impacts children, and I believe this research project could be the perfect opportunity to get started. Literature Review There were (only) two recent studies (Barfield et. al, 2012) that evaluated the impact of the NMT-recommended interventions on the social-emotional development and behaviour of a number of rural Midwestern preschool children who were participating in a therapeutic preschool

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program. Researchers used a new measure, the Preschool Social and Emotional Developmental Readiness Index (PSEDRI), to assess social-emotional development, and Achenbachs Child Behavior Checklist (CBCL) to assess emotional and behavioral problems in children as reported by their parents and teachers; the PSEDRI was completed by the teachers/service providers, and the CBCL was completed by parents and teachers. The first study (conducted as a pilot study), used a single group pre- or posttest design with data collected over a 6 week summer program.13 children ages 2.5 to 6 years (with an average age of 4.6) participated in the program; the program focused entirely on the NMT approach, with directed somatosensory and relational activities provided often during the week no academic content was included. The children participated in four 2-hour Filial Therapy sessions per week where the individualized somatosensory activities were the focus. The aim of the first study was to determine whether or not the NMT interventions (somatosensory and relational activities) promoted social-emotional development and improved behaviour in participants. Intervention activities were administered in the context of Filial Play Therapy as a function of the therapeutic program environment; the student-to-staff ratio was less than two students to one staff member. At home, the children all experienced multiple risk factors, among them physical abuse, runaway behaviour, a parent with a serious psychiatric illness, a sibling in an institution or other out-of-home care, and a family history of mental illness, substance abuse, or family or domestic violence. 46% of children in the first study experienced 4 or more risk factors. Study 1 found statistically significant improvements in composite PSEDRI scores from pretest to posttest (t=6.16, p<.001, d=2.34) as well as in all PSEDRI domains from pretest to posttest. When pre- or posttest ratings of the parent ratings on the CBCL were analyzed no

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significant improvement was revealed (t=1.52, p=.16, d=.58). Teacher ratings on the CBCL at posttest showed improvement, but did not show results that were statistically significant for internalizing behaviours (t=1.6, p=.135, d=.37); that being said, externalizing behaviours improved significantly (t=2.34, p=.038, d=.57) with good effect sizes. The second study used a quasi-experimental, multiple time series design to compare the 6-week NMT-based summer program with the school-year program (which did not include the NMT component). 15 children ages 4 to 7 years (with an average age of 5.2) participated; the student-to-staff ratio was approximately four to five children to one teacher. Baseline data were collected in the final 5 weeks of the school year while the children received only the school-year program; intervention phase data were collected in the 10-week summer program while the children received only the NMT program. Children in Study 2 received two 2-hour therapy sessions per week in which somatosensory activities were the focus. Three children did not fully complete the study (one missed 3 weeks, two missed 5 weeks) but were included in the study. Study 2 found significantly more improved composite PSEDRI scores during the NMT intervention phase compared to the baseline-phase (t=6.34, p=<.001, d=.61). As with Study 1, when analyzing the data from the CBCL in Study 2 there was no significant improvement in parent rating scores at posttest (Internalizing t=1.43, p=.177, d=.43; Externalizing t=1.61, p=.13, d=.28). Also like Study 1, the teachers mean Internalizing scores at posttest revealed no significant improvement (t=2.09, p=.06, d=.49) and there was a significant improvement in the Teachers mean Externalizing scores (t=2.79, p=.017, d=.67). Because the sample size in these studies was small and the researchers were unable to obtain statistically significant results as they had hoped, they cannot be looked to for definitive proof of the effectiveness of NMT in working with children with complex neuropsychological

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problems further examination is certainly warranted, and expected. The PSEDRI and Filial Therapy are relatively new in practice, and it is my opinion that too many unproven elements in a design potentially add too much uncertainty to the findings, even if they do appear to be significant (perhaps that is my low level of confidence as a new researcher!). The studies discussed above helped many interesting possibilities to surface, and serve as a great jumpingoff-point to build on for further research. In the proposed study, my objective is to obtain a reliable evaluation of the impact NMT has on 50 children ages 5-6 years participating in an outpatient therapeutic kindergarten program in a trauma treatment setting. I am interested in learning about the impact of the interventions on the childs home and school environments. Since trauma can affect a childs basic internal organization I would like to evaluate the pre- posttest functioning in the areas of executive functioning, adaptive personal skills, and adaptive social skills. Rather than pairing a new measure (the PSEDRI) with a new theory (NMT) as was done in the previous studies, I propose using the Vineland Adaptive Behavior Scales (Vineland-II) to measure adaptive behaviours (i.e. personal and social skills) and the Behavior Rating Inventory of Executive Functioning (BRIEF) to assess the domains of behavioural regulation and metacognition in the childs home and school environments. The research questions I would like to examine in this study are, (1) Does the use of NMT planned somatosensory and relational interventions improve the behavioural regulation of children participating in an outpatient therapeutic kindergarten class at the Trauma Centre? (2) Does the use of NMT planned somatosensory and relational interventions improve the metacognition of children participating in an outpatient therapeutic kindergarten class at the Trauma Centre? (3) Does the use of NMT planned somatosensory and relational interventions

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improve the adaptive personal skills of children participating in an outpatient therapeutic kindergarten class at the Trauma Centre? And (4) Does the use of NMT planned somatosensory and relational interventions improve the adaptive social skills of children participating in an outpatient therapeutic kindergarten class at the Trauma Centre? The Neurosequential Model of Therapeutics (NMT) Before getting into description of the methods, I think it is necessary to give a brief introduction to NMT. According to Bruce Perry, one of the people responsible for the development of the model, NMT integrates several core principles of neurodevelopment and traumatology into a comprehensive approach to the child and their interpersonal system (e.g. family, school, community); NMT) is a developmentally sensitive, neurobiologically informed approach to clinical work (Perry, 2006). Trauma impacts the growth and development of the brain depending on when and how traumatic events occur. The brain develops from the most basic (brainstem and diencephalon) to the most complex (cortex and frontal cortex), and with the right combination of timing, intensity, and pattern of traumatic experiences the brain can become frozen in development (e.g. preventing the person from accessing higher functions as needed). Since we cannot just look at an fMRI of a childs brain and know where, when, and how things went badly, the initial assessment process of NMT creates a functional map of the childs brain based on the status of several brain-driven functions (Perry, 2009). The map serves as a visual tool to understand the status of each area of the brain according to their present level of functioning (e.g. brainstem - respiration, suck/swallow/gag; diencephalon - feeding/appetite, sleep; limbic affect regulation/mood; cortex/frontal cortex self awareness, abstract/conceptual cognition) (Barfield et. al, 2012). It outlines the childs unique strengths and vulnerabilities in the areas of sensory integration, self-regulation, relational, and cognitive

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domains of functioning so the clinician and educator can apply the unique selection and timing of NMT activities appropriate to the childs unique developmental needs (Barfield et. al, 2012; Perry & Hambrick, 2008). Methods Participants In September of this year, 50 children will be joining 4 therapeutic kindergarten classes in the citys Trauma Centre. Children are referred to the program through hospital pediatricians, psychologists, and psychiatrists if they have experienced an impactful traumatic event(s) that are affecting their quality of life at home and at school. The target population is English-speaking kindergarten-aged children who have experienced an impactful traumatic event(s), and the accessible population is the children scheduled to attend the clinic this Fall. The population is multicultural, composed primarily of Caucasian children, Asian children, East Indian children, and aboriginal children. Instruments Vineland Adaptive Behavior Scales, Second Edition (Vineland-II). The Vineland-II is a short questionnaire that will be used to measure adaptive behaviour (personal skills and social skills) in kindergarten children (Sparrow, Cichetti & Balla, 2005). It consists of five domains each with subdomains including (1) Communication (Receptive, Expressive, and Written), (2) Daily Living Skills (Personal, Domestic, and Community), (3) Socialization (Interpersonal Relationships, Play and Leisure Time, and Coping Skills, (4) Motor Skills (Gross Motor and Fine Motor), and (5) Maladaptive Behavior Domain (Maladaptive Behavior Index and Maladaptive Behavior Critical Items). The tool also provides an Adaptive Behavior Composite of the four main domains (excluding Maladaptive Behavior). The Vineland-II has been found to

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have good internal reliability (.93 to .97 across age groups), test-retest reliability (.76 to .92), and inter-rater reliability (.71 to .81) as well as good face and content validity. It takes approximately 20 minutes to complete; items were constructed at a 4th grade reading level. The parent/caregiver rating form will be administered 14 times (at the beginning of each week once before the class begins, every second week (e.g. week 3, week 5, week 7) through the final week of the class, and for follow-up one month, three months, and six months after the class is complete. The teacher rating form will follow the same pattern with the exclusion of the first week, as they will not yet be familiar with the child at that point. The questionnaires take approximately 10-15 minutes to complete and 5 minutes each to score using simple data entry on the computer. Behavior Rating Inventory of Executive Function (BRIEF). The BRIEF is an 86-item questionnaire for people ages 5-18 years that will be used to measure executive functioning (Gioia, Isquith, Guy, & Kenworthy, (2005). It consists of eight non-overlapping clinical scales that are sorted into two Indexes each with their own Clinical Scales including Behavioral Regulation (Inhibit, Shift, and Emotional Control), and Metacognition (Initiate, Working Memory, Plan/Organize, Organization of Materials, and Monitor), and two validity scales that measure negativity and inconsistent responses. The BRIEF has high internal consistency (.80 to .98), test-retest reliability (.82 for parents and .88 for teachers), and moderate correlations between teacher and parent ratings (.32 to .34). According to test authors, convergent validity is established with other measures of inattention, impulsivity, and learning skills; divergent validity demonstrated against measures of emotional and behavioral functioning; Working Memory and Inhibit scales differentiate among ADHD subtypes.

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The parent/caregiver rating form will be administered 14 times (at the beginning of each week once before the class begins, every second week (e.g. week 3, week 5, week 7) through the final week of the class, and for follow-up one month, three months, and six months after the class is complete. The teacher rating form will follow the same pattern with the exclusion of the first week, as they will not yet be familiar with the child at that point. The questionnaires take approximately 10-15 minutes to complete and 5 minutes each to score using simple data entry on the computer. Design The design of this study will be an A-B-A single-subject sample. I chose this design because it is typically used to study the behavioural changes an individual exhibits as a result of some treatment. In this study I want to look at the changes children make in their executive functioning and adaptive functioning before, during, and after participating in a therapeutic program that includes the use of NMT activities. The independent variables will be the application of NMT techniques with children in the program in three 2-hour sessions each week during the treatment phase of the study; the dependent variables will be the scores obtained on the BRIEF and Vineland-II parents/caregiver and teacher reports that reflect changes in the childs executive functioning and adaptive behaviours. In this design each participant serves as his or her own control. In the 20-week therapeutic program NMT will be used in weeks 3 through 15, and regular therapeutic programming (no NMT) will continue all other weeks. Parent questionnaires will be administered at the start of weeks 1, 3, 5, 7, 9, 11, 13, 15, 17, 19, and 20; teacher questionnaires will follow the same pattern with the exception of week 1. Follow-up questionnaires will be

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administered 1-month, 3-months, and 6-months after the program has been completed to evaluate the lasting effects of any changes that may result from the intervention. Procedure All parents with children in the Trauma Centres outpatient kindergarten program will be included in the sample. When a child is referred for placement in the class parents are informed about the study and asked to participate; those who do not wish to do so are referred to a similar program at the Alberta Childrens Hospital, as it would be unethical to deny their child treatment because the parent did not want to participate in the study. All staff will receive training in the NMT core concepts. Children will be assigned to attend one of four time-slots for the kindergarten program based on their parental availability. Two classes will run concurrently in the morning and two will run concurrently in the afternoon. Each class will have 12 to 13 students, 2 teachers, and 2 educational assistants. Staff will receive training in the impact of developmental trauma on early brain development and to understand that activities they provide with the children must always be developmentally relevant, repetitive, and patterned, rewarding, and rhythmic, while being respectful of the family, child, and culture of each student (Barfield et. al., 2012, p. 35). Pre-test measures will be given out at a parent meeting in the last week of August. All parents (one from each family) will be required to attend a coffee and cookies meeting to learn about the program and ask any questions they might have before the class begins. Questionnaires will be explained and completed at the end of the meeting. We will also discuss the format of further assessment (e.g. schedule of completion). Questionnaires will be given to parents Monday mornings when they drop off their children; teachers will complete them Monday mornings before class begins. A locked box will be available at the centres reception desk where

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both teachers and parents may drop off completed questionnaires at the beginning of each week. If questionnaires are not received teachers or educational assistants will make follow-up phone calls to the family. At the end of each day questionnaires will be collected from the locked box and scored; scores will be printed and kept in the student file labelled with the students initials and student ID number; the files will be kept in a locked cabinet in a locked office in the Trauma Centre (which is also locked against outside access after-hours). Children will attend class daily, and in the first 2 weeks will attend the regular academicbased kindergarten programming without the use of any NMT techniques unless the situation demands it. In the third week of class the initial NMT Assessments will be done by one of 4 psychologists (one will be assigned to each class) with the help of the staff who work directly with the children. The treatment team will then develop a plan to use NMT in a way that best meets the needs of each child assessed. Each child will be engaged in a 2-hour session where NMT activities are the focus of the session; these sessions will occur 3 times per week. Class will run September through December, excluding the week of Christmas vacation. In week 17 there will be a parent meeting to discuss the possibility of their child attending another clinic to continue with NMT if they would like; it will also be possible to make alternative referrals at that time to ensure parents are not left unsupported after four months of intervention. Where needed the psychologists will follow up with parents in transition planning. Assumptions and limitations. In designing this study it is assumed that none of the students have been involved in working with NMT before. It is assumed that families can speak and read English at minimum grade 4 level. It is also assumed that parents were attentive to the information they received regarding the study parameters, and that they will ask questions if they are unsure of anything. With regard to limitations of the study, only 50 children are available to

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participate; all work must be completed in the Centre by the end of December, and follow-up done from the researchers community office. There is a possibility that questionnaires will not be regularly returned by the parents and teachers; it is also possible that parents could withdraw their child from the study for their own reasons. Finally, in an ideal situation children should be able to participate in the experimental treatment until such time that they no longer need it; however, all face-to-face contact must be completed at the Centre by the end of December. All parents will be offered a referral to a subsidized community program to continue the NMT treatment if they so desire upon completion of the program. Data Analysis The appropriate t-tests will be conducted with a confidence value of .05. T-tests could be used to look at the differences between mean scores of boys vs. girls, or 5-year olds vs. 6-year olds, or Vineland-II vs. BRIEF scores. ANOVAs will be done to test for multiple group comparisons each data-set entry to determine if any found differences in childrens BRIEF and Vineland-II scores are significantly different at the appropriate probability level. Effect sizes will be calculated to look at practical significance and magnitude. Due to the small sample size that is likely, the primary criterion to consider is the clinical significance of the results. Effects that are small but statistically significant might not show up as a useful difference in the behaviour of a student (Gay, Mills, & Airasian, 2009). Results It is expected that NMT will indeed have a positive impact on both the level of each childs executive function and their adaptive behaviours over the 4 months of the study. Though there may initially be a slight decline in scores when the class has ended, it is also expected that

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children will maintain the gains they make over the 4 months in the 6 months of follow-up that are to be conducted. If the researchers hypotheses are supported by this study it will benefit the body of research that is currently building around NMT. Though the sample size in this study is small, several small studies that produce the same results give legitimacy to methods over time. If the design works well, perhaps the study could be replicated in other areas of the country, with different age groups, with children who have different presenting problems. It would be excellent to have more reason in the literature to support the Neurosequential Model of Therapeutics in working with children who have experienced trauma in their lifetimes. Discussion Brain growth and development happens in a use-dependent fashion; when a developing child experiences patterned, repetitive activities (both good and bad) this shapes and changes the brain, particularly in their first four years of life (Perry, 2002a, 2002b, 2006). As a result, traumatic or chaotic experiences that occur repetitively during sensitive times in a childs developmental process can create chaotic, developmentally delayed dysfunctional organization, leading to a wide range of physical, mental, and emotional illnesses in later life (AAP, 2012, Perry, 2002a, 2002b). Millions of children today remain scarred by childhood trauma and maltreatment, expressing only a fraction of their full potential. The developmental insults create a lifetime of vulnerability to emotional, physical, and social health problems (Anda et al., 2006). Although negative early experiences in life have the ability to shape a childs developing bring, relationships can also be protective and reparative. A solid healthy attachment with significant people during infancy and early childhood predicts healthy relationships with others as the child

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grows. (Ludy-Dobson & Perry, 2010). Perhaps by producing more evidence in favour of the use of NMT in a variety of settings such as daycares and playschools, educational settings, and therapy situations I believe we will have a very powerful tool to reverse the terrible impact of trauma on the brain and development, allowing children to flow and bloom into their full potential. In helping children build stable bonds with safe and nurturing caregivers we help set them up to be successful in future relationship with friends, family members, and others in their lives. By helping children strengthen their executive functioning skills and build adaptive behaviours into their daily lives we set them up for success in the arenas of school and community activities.