Examining Child Maltreatment

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no plagiarize, spell check, and check your grammar. Please only use the attached below. Only 250 words.

The Perry Study is a detailed analysis that focuses on the development of a person while using the NMT model for therapeutics. The study targeted children and adults who have been abused or mistreated. After reading the study twice, it is to my understanding that the NMT model is broken down into three parts. Out of the three parts, I found the developmental history of the child to be an essential step in the therapeutic process. Often in therapy, it is noted about what age the abuse happens, but not physically to the brain (Perry, 2009). Perry makes an interesting connection; he states that repetitive neural input to the mind and neural networks are the reason for a child behavior for abuse might exist. For example, if a child in mentally, physically, or emotionally abused repetitively their brain will make neural connections translating the mistreatment and the reactions. I found this to strength in the study because it provides the client with a visual description of their brain as they are progressing through therapy. This can give the client reassurance that they are improving. The weakness in this approach is that it requires more than one outside professional and longer time in therapy. Perry states this in the study that 1- hour once a week in treatment is not enough to help change the neural development in a person's brain after being abuse (Perry, 2009). Another weakness to this form of therapy is that the by age two most of our basic neuro patterns are formed and hard to re-wire (Walker, 2009).

A personal story I do have that sheds some light on Perry findings is about a student of mine. I once taught kindergarten for a summer camp. It was told to me by the principle that the little girl was raped as at one year old. The little girl would share with me that she was hurt by her mother’s boyfriend a child. I would ask her if she was okay every day as well. Even though the young girl was too little to


Perry, B. D. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential mode of therapeutics. Journal of Loss and Trauma, 14(4), 240-255. doi: 10.1080/15325020903004350 (PsychINFO: 2009-10040-002)

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Journal of Loss and Trauma, 14:240–255, 2009 Copyright # Taylor & Francis Group, LLC ISSN: 1532-5024 print=1532-5032 online DOI: 10.1080/15325020903004350 Examining Child Maltreatment Through a Neurodevelopmental Lens: Clinical Applications of the Neurosequential Model of Therapeutics BRUCE D. PERRY Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 ChildTrauma Academy, Houston, Texas, USA and Department of Psychiatry and Behavioral Sciences, Northwestern University, Chicago, Illinois, USA This article provides the theoretical rationale and overview of a neurodevelopmentally-informed approach to therapeutic work with maltreated and traumatized children and youth. Rather than focusing on any specific therapeutic technique, the Neurosequential Model of Therapeutics (NMT) allows identification of the key systems and areas in the brain which have been impacted by adverse developmental experiences and helps target the selection and sequence of therapeutic, enrichment, and educational activities. In the preliminary applications of this approach in a variety of clinical settings, the outcomes have been positive. More in depth evaluation of this approach is warranted, and is underway. Over the last 30 years, key findings in developmental neurobiology have informed and influenced practice in several clinical disciplines, including pediatrics, psychology, social work, and psychiatry. Despite this influence, the capacity of these large clinical fields to incorporate and translate key neurobiological principles into practice, program, and policy has been inefficient and inconsistent. The purpose of this article is to present preliminary efforts to integrate core concepts of neurodevelopment into a practical clinical approach with maltreated children. This neurosequential model of therapeutics (NMT) has been utilized in a variety of clinical settings such as therapeutic preschools, outpatient mental health clinics, and residential treatment centers with promising results (Perry, 2006; Barfield et al., 2009). Received 23 March 2009; accepted 28 April 2009. Address correspondence to Bruce D. Perry, ChildTrauma Academy, 800 Gessner, Suite 230, Houston, TX 77024, USA. E-mail: BDPerry@ChildTraumaAcademy.org 240 Examining Child Maltreatment Through a Neurodevelopmental Lens 241 Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 CONTEXT AND CURRENT STATUS Development is a complex and dynamic process involving billions of interactions across multiple micro (e.g., the synapse) and macro domains (e.g., maternal-child interactions). These interactions result in a unique expression of an individual’s genetic potential and create a miracle of dynamic organization in the trillions of component parts (e.g., neurons, glia, synapses) comprising the human brain. Maltreatment disrupts this hardy process; trauma, neglect, and related experiences of maltreatment such as prenatal exposure to drugs or alcohol and impaired early bonding all influence the developing brain. These adverse experiences interfere with normal patterns of experience-guided neurodevelopment by creating extreme and abnormal patterns of neural and neurohormonal activity. The resulting negative functional impact of impaired or abusive caregiving on the developing child has been well documented (e.g., Malinosky-Rummell & Hansen, 1993; Margolin & Gordis, 2000). As expected, in any brain-mediated function examined—from speech to motor functioning to social, emotional, or behavioral regulation—developmental trauma and maltreatment increase risk of dysfunction (see also Perry & Pollard, 1998; Bremner & Vermetten, 2001; Perry, 2001, 2002; Anda et al., 2006). In the United States alone, there are millions of maltreated children and youth in the educational, mental health, child protective, and juvenile justice systems (Fitzpatrick & Boldizar, 1993; Graham-Berman & Levendosky, 1998). The majority of these children do not receive adequate mental health services; indeed, most are not even known to be maltreated or traumatized. While current policy efforts to create trauma-informed practices and programs are a welcome start, for children and youth, focusing on trauma alone is insufficient. Practice, program, and policy must become substance abuse, attachment, and neglect informed as well; we must become fully ‘‘developmentally informed’’ to understand and address the range of problems related to maltreatment. The following sampling of some principles of neurodevelopment illustrates the value of this broader view for clinical practice. PRINCIPLES OF NEURODEVELOPMENT There are many well-documented and emerging findings regarding the genetics, epigenetics, and experience-determined elements of neurodevelopment. Only a few are listed below to serve as examples of how these facts and concepts can inform our understanding of maltreated children and therapeutic work. More complete reviews are available elsewhere (e.g., Perry, 2001, 2002, 2006, 2008). Sequential Development The brain is organized in a hierarchical fashion with four main anatomically distinct regions: brainstem, diencephalon, limbic system, and cortex. During Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 242 B. D. Perry development the brain organizes itself from the bottom up, from the least (brainstem) to the most complex (limbic, cortical) areas. While significantly interconnected, each of these regions mediates distinct functions, with the lower, structurally simpler areas mediating basic regulatory functions and the highest, most complex structures (cortical) mediating the most complex functions. Each of these main regions develops, organizes, and becomes fully functional at different times during childhood. At birth, for example, the brainstem areas responsible for regulating cardiovascular and respiratory function must be intact for the infant to survive, and any malfunction is immediately observable. The neural networks involved, therefore, must be mostly organized in utero in order to become functional at birth. In contrast, the cortical areas responsible for abstract cognition have years before they will become fully organized and functional. Each brain area has its own timetable for development. Microneurodevelopmental processes such as synaptogenesis will be most active in different brain areas at different times and, thereby, be more sensitive to organizing or disruptive experiences during these times (sensitive periods). As the brain is developing from the bottom to the top, the process is influenced by a host of neurotransmitter, neurohormone, and neuromodulator signals. These signals help target cells migrate, differentiate, sprout dendritic trees, and form synaptic connections. Some of the most important of these signals come from the monoamine neural systems (i.e., norepinephrine, dopamine, and serotonin). These crucial sets of widely distributed neural networks originate in the lower brain areas (brainstem and diencephalon) and project to every other part of the developing brain. This architecture allows these systems the unique capacity to communicate across multiple regions simultaneously and therefore provide an organizing and orchestrating role during development and later in life. Due to their wide distribution throughout the brain, and their role in mediating and modulating a huge array of functions, impairment in the organization and functioning of these monoamine neurotransmitter systems can result in a cascade of dysfunction from lower regions (where these system originate) up to all of the target areas higher in the brain. If the impairment occurs in utero (e.g., prenatal exposure to drugs or alcohol) or in early childhood (e.g., emotional neglect or trauma), this cascade of dysfunction can disrupt normal development. Simply put, the organization of higher parts of the brain depends upon input from the lower parts of the brain. If the patterns or incoming neural activity in these monoamine systems is regulated, synchronous, patterned, and of ‘‘normal’’ intensity, the higher areas will organize in healthier ways; if the patterns are extreme, dysregulated, and asynchronous, the higher areas will organize to reflect these abnormal patterns. The clinical implications of this principle speak to the importance of the timing of developmental experience; the very same traumatic experience will impact an 18-month-old child differently than a 5-year-old. Similar traumatic experiences occurring at different times in the life of the same child will Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 Examining Child Maltreatment Through a Neurodevelopmental Lens 243 influence the brain in different ways; in many cases, the previous exposure has sensitized the child, making him or her more vulnerable to future events. And so it is with the timing of positive experience; the developmental stage of a child has a profound impact on how an educational, caregiving, or therapeutic experience will influence the brain; somatosensory nurturing, for example, will more quickly and efficiently shape the attachment neurobiology of the infant in comparison to the adolescent. A more subtle clinical implication is that in order to most efficiently influence a higher function such as speech and language or socioemotional communication, the lower innervating neural networks (e.g., locus coeruleus norepinephrine systems) must be intact and well regulated. An overanxious, impulsive, dysregulated child will have a difficult time participating in, and benefiting from, services targeting social skills, self-esteem, and reading, for example. The field of restorative neurology has for many years emphasized the positive impact of repetitive motor activity in cognitive recovery from stroke. This principle suggests that therapeutic massage, yoga, balancing exercises, and music and movement, as well as similar somatosensory interventions that provide patterned, repetitive neural input to the brainstem and diencephalon monoamine neural networks, would be organizing and regulating input that would likely diminish anxiety, impulsivity, and other trauma-related symptoms that have their origins in dysregulation of these systems. Our preliminary findings, and those of others (B. van der Kolk, personal communication, June 2008) with maltreated children with such self-regulation problems, suggest that this is the case (Barfield et al., 2009). Activity-Dependent Organization: Use-Dependent Modification The brain organizes in a use-dependent fashion. In the developing brain, undifferentiated neural systems are critically dependent upon sets of environmental and micro-environmental cues (e.g., neurotransmitters, cellular adhesion molecules, neurohormones, amino acids, ions) in order for them to appropriately organize from their undifferentiated, immature forms (for reviews, see Perry, 2001, 2008). The molecular cues that guide development are dependent, in part, upon the experiences of the developing child. The quantity, pattern of activity, and nature of the activation from these neurochemical and neurotrophic factors depend upon the presence and the nature of the total sensory experience of the child. When the child has adverse experiences—loss, threat, neglect, and injury—there can be disruptions of neurodevelopment leading to compromised functioning (see below). This principle has many clinical implications. Primary is the role this principle plays in psychopathology. Use-dependent changes in the brain are the origin of neuropsychiatric symptoms related to exposure to threat, fear, chaos, stress, and trauma. The monoamine systems mentioned earlier are crucial components of the stress-response neural networks in the brain. Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 244 B. D. Perry When a child (or an adult) is threatened and activates this stress response in an extremely prolonged or repetitive fashion, the neural networks involved in this adaptive response will undergo a ‘‘use-dependent’’ alteration. The very molecular characteristics of individual neurons, synaptic distributions, dendritic trees, and a host of other microstructural and microchemical aspects of these important neural networks will change. And the end effect is an alteration in the baseline activity and reactivity of the stress response systems in the traumatized individual. The brain will ‘‘reset’’—acting as if the individual is under persistent threat. The details of this process have been well described elsewhere (Perry & Pollard, 1998; Perry, 2001). The principle of use dependence is at the heart of effective therapy. Therapy seeks to change the brain. Any efforts to change the brain or systems in the brain must provide experiences that can create patterned, repetitive activation in the neural systems that mediate the function=dysfunction that is the target of therapy. In many cases, this will mean (as mentioned above) that the target of the intervention should be the innervating neural systems and not the area or system that is the final mediator of the function= dysfunction (e.g., physical exercise helps stroke victims recover speech). This is a significant problem in the conventional mental health approach to maltreated children; many of their problems are related to disorganized or poorly regulated networks (e.g., the monoamines) originating lower in the brain. Yet, our clinical interventions often provide experiences that primarily target the innervated cortical or limbic (i.e., cognitive and relational interactions) regions in the brain and not the innervating source of the dysregulation (lower stress-response networks). Even when targeting the appropriate systems in the brain, we rarely provide the repetitions necessary to modify organized neural networks; 1 hour of therapy a week is insufficient to alter the accumulated impact of years of chaos, threat, loss, and humiliation. Inadequate ‘‘targeting’’ of our therapeutic activities to brain areas that are not the source of the symptoms and insufficient ‘‘repetitions’’ combine to make conventional mental health services for maltreated children ineffective. The origins of—and therapeutic recovery from—neglect are manifestations of the principle of use dependence as well. Neglect, from a neurodevelopmental perspective, is the absence of the necessary timing, frequency, pattern, and nature of experience (and the patterns of neural activation caused by these experiences) required to express the genetic potential of a core capability (e.g., self-regulation, speech and language, capacity for healthy relational interactions). Neglect-related disruptions of experiencedependent neural signals during early life lead to a range of abnormalities or deficits in function (see Perry, 2001, 2006). As discussed above, the malleability of the brain shifts during development, and therefore the timing and specific ‘‘pattern’’ of neglect influence the final functional outcome. A child deprived of consistent, attentive, and attuned nurturing for the first 3 Examining Child Maltreatment Through a Neurodevelopmental Lens 245 Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 years of life who is then adopted and begins to receive attention, love, and nurturing may not be capable of benefiting from these experiences with the same malleability as an infant. In some cases, this later love is insufficient to overcome the dysfunctional organization of the neural systems mediating socioemotional interactions. With little appreciation of neurodevelopment, neglect-related problems in maltreated children are missed (in over 80% of children under the age of 6 removed by child protective services, there are significant developmental problems, yet this population rarely receives a developmental assessment in most states), ignored (a minority of children in child protective service care with mental health, learning, speech and language, or developmental problems receive consistent services), or lumped into the overinclusive current label of ‘‘complex’’ trauma or, worse, bipolar disorder. Even when children do receive mental health services, neglect-related issues are rarely appreciated as having a distinct pathophysiology and pathogenesis related to but different from trauma. Disproportional Valence of Early Childhood Experience The sequential development of the brain and the activity dependence of neurodevelopment create times during development when a given neural system is more sensitive to experience than others. In healthy development, that sensitivity allows the brain to rapidly and efficiently organize in response to the unique demands of a given environment to express from its broad genetic potential those characteristics that best fit the child’s world; different genes can be expressed, and different neural networks can be organized from the child’s potential to best fit that family, culture, and environment. We all are aware of how rapidly young children can learn language, develop new behaviors, and master new tasks. The very same neurodevelopmental sensitivity that allows amazing developmental advances in response to predictable, nurturing, repetitive, and enriching experiences makes the developing child vulnerable to adverse experiences. The simple and unavoidable conclusion of these neurodevelopmental principles is that the organizing, sensitive brain of an infant or young child is more malleable to experience than a mature brain. While experience may alter the behavior of an adult, experience literally provides the organizing framework for an infant and child. Because the brain is most plastic (receptive to environmental input) in early childhood, the child is most vulnerable to variance of experience during this time. Again, the clinical, practice, and policy implications are profound. Early identification and aggressive early interventions are more effective than reactive services. Despite solid research documentation on early intervention and effective therapeutic services targeting young mothers, infant mental health, home visitation programs, and high-quality child care programs, support for these programs is scant and inadequate. 246 B. D. Perry Downloaded By: [Perry, Bruce] At: 05:07 2 July 2009 Relational Mediation of Major Developmental Experiences Life is full of novelty, unpredictability, challenges, stressors, and, often, trauma. There are individual differences in how we cope with and overcome stress and trauma. Much is yet to be understood; genetic factors, for example, appear to influence hardiness or sensitivity. Yet, one recurring observation about resilience and coping with trauma is the power of healthy relationships to protect from and heal following stress, distress, and trauma. This relational modulation of stress is mediated by two interrelated and broadly distributed systems in the human brain: the stress response systems and neural networks involved in bonding, attachment, social communication, and affiliation. To best understand the intimate interdependence of these systems in the brain, it is useful to examine the conditions into which the human brain evolved. For the vast majority of the last 200,000 years, humans have lived in hunter-gatherer clans in the natural world. The size of our living groups was small—40 to 60 people. These multigenerational, multifamily groups were the main source of safety from the dangers of the world. Our survival depended upon the ability to communicate, bond, share, and receive from other members of our family and clan. Without others, the individual could not survive in the natural world. Then, and today, the presence of familiar people projecting the social-emotional cues of acceptance, compassion, caring, and safety calms the stress response of the individual: ‘‘You are one of us, you are welcome, you are safe.’’ This powerful positive ...
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School: UCLA



Examining Child Maltreatment
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I support the idea that highlights constant exposure to mental, physical or emotional pain
as the cause for a child's behavior for abuse. A child can be inclined to a specific reaction as a
result of the minds exposure to a routine of mistreatment. The mind h...

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