SaintA has been committed toimplementing the NeurosequentialModel of Therapeutics™ (NMT™)since 2008, working closely with Dr. Bruce Perry and the ChildTraumaAcademy staff, as well as its NMT™

partners and colleagues. Our journeyhas been demanding and yet remark-ably rewarding, teaching all of us aboutchildren, their families and the commu-nities in which they grow up. We havelearned a few lessons along the way:

• Trauma is important but not all-inclusive. Neglect, relational interac-tions, neurobiological capability andother developmental opportunities arealso very salient

• Resilience is primarily fostered by the strength of a child’s connectionto his core groups (family, community,system)

• The capability of parents/care-givers is the most significant variable in child well-being

• The children and families we serveare our best teachers and resources fortheir own healing

• Hope is indeed possible H’s story below illustrates the unique

perspective that the NMT™ process

offers. It is a story of hurt and hope,and how dedication and compassioncreated opportunities to heal and grow.

H came to his current SaintA treat-ment foster home after multiple place-ments and disruptions. This home wasH’s fourth foster home, followingremoval from his birth parent’s custodyfor the second time. At only sevenyears old, H had spent the majority ofhis life in foster care. Throughout hislife, H experienced significant adverseevents without the buffering of a sta-ble, healthy adult. His parents strug-gled with mental health disorders diag-nosed as schizophrenia and depression,ADOA and their own chaotic/neglect-ful childhood experiences, all of whichimpeded their ability to respond to H’sneeds and provide an optimal environ-ment for development. In addition, Hwitnessed domestic violence, experi-enced the loss of his father’s involve-ment in his life, homelessness, medicaltrauma, and several transitions, such asthe removal from his family of origin.With this lack of consistency and pre-dictability in his life, H displayed manychallenging behaviors when placedwith SaintA. These behaviors created

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A onTrauma-Informed

Care*

*Articles will become available to non-members on a biweekly basis

FOCUS

Implementing the Neurosequential Model ofTherapeutics™ by Kathleen Ayala, MSW and Tim Grove, MSW

EDITOR’S COLUMN

— by Gretchen Test, MSWsignificant difficulty in stabilizing and maintaining him safely in thehome and community. His diagnoses included ADHD, reactiveattachment disorder (RAD) and post-traumatic stress disorder(PTSD). He was having multiple explosive tantrums each week thatinvolved property destruction as well as verbal and physical aggres-sion. In addition, H had put himself at significant risk for harm,which required the foster parent to provide line-of-sight supervision.If she needed to be away from the home, alternate programming hadto be arranged for H, because he was not able to be safely main-tained with another adult for periods of more than 30 minutes. H’sbiggest triggers appeared to be transitions and intimacy. It was verydifficult to prevent H’s tantrums; however, the foster parent had setup the home in a way that allowed H to be safe during the tantrums.He destroyed property with his tantrums, but he had become accus-tomed to using his bedroom as a more appropriate place to releasehis physical aggression. The foster mother had developed a processwithin her home that, to ensure safety, required all other children toleave the area when H started to escalate. H’s explosive behavioralso continued to be dangerous when he was in the community. Thecombination of his intense behaviors (themselves the result of a verysensitized stress response system) and a poorly matched medicationregiment from his pediatrician resulted in a hospitalization stay. Hehad lost 30% of his body weight and was officially labeled with fail-ure to thrive. The team had run the traditional course: individualtherapy, medication management, day treatment services, etc. H was very much at risk for a residential stay. The silver lining of H’shospitalization was that it brought the opportunity for H’s team tore-group and consider a different approach.

On behalf of the Foster Family-basedTreatment Association (FFTA) board of direc-tors, we are excited to release FOCUS, ourquarterly newsletter, to all stakeholders inthe field of child welfare. For years, the FFTAEditorial Committee has sought outadvanced-level articles from its broad mem-bership. Until now, these articles have beenavailable only to member agencies of theFFTA. In making FOCUS available to all, wehope to reach a wider audience and involveeven more dedicated professionals in thevital work that we support every day. Ourhope is that these articles inspire a reneweddedication to the field and generate newideas. We encourage you to share and discuss these articles widely amongst yourcolleagues.

Each issue of FOCUS is dedicated to a specific relevant theme. In the latest issue,we explore trauma-informed care. Just a fewyears ago, this theme seemed like a “hottopic” and has now become integrated intoour everyday lexicon and incorporated intothe fabric of our organizations. According tothe National Child Traumatic Stress Network,“child traumatic stress occurs when childrenand adolescents are exposed to traumaticevents or traumatic situations, and when thisexposure overwhelms their ability to copewith what they have experienced.” 1It canbe the results of acute traumatic events(such as sudden loss of a loved one or physi-cal assault) or due to chronic traumatic situa-tions (such as longstanding sexual abuse).Children can react differently to traumadepending on many factors, and healingapproaches that are tailored to a child’s age,experience, culture, gender, etc. are critical.Thanks to a growing body of brain science

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Implementing the NeurosequentialModel of Therapeutics™ | continued from pg. 1

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Table 1 (left) represents H’s(Client) brain “map” at thebeginning of services. The“map” is a part of the NMTprocess that approximatesdevelopmental capabilityacross 32 functional itemslike cardiovascular/ANS, temperature regulation/metabolism, attention/track-ing, sleep-sensory integration,attunement/empathy, speech/articulation, reading/verbal,etc. A numerical score isgiven by the clinician in col-laboration with the team foreach of the 32 items with 1being the lowest score andup to 12 being the highestscore. When you compare H’s“map” to an age typical map,the effect of H’s developmen-tal experiences is evident.

Using the NMT™ core principles and H’s NMT™ metric as a guidefor understanding the challenges H faced, the team began to createtheir sequential priorities. The first priority was to figure out how toengage H’s foster parent, recognizing that she was going to be the dif-ference-maker. She committed to a 30-day plan that involved workingwith an occupational therapist and treatment foster care specialist toenhance H’s regulatory capacity through exposure to a variety ofsomatosensory activities. Such activities included whole-body activities(riding bikes, playing basketball, swimming); oral activities (chewinggum, blowing bubbles, using a vibrating toothbrush); cognitive andfine motor activities (doing crossword puzzles, building Legos, playingchess). This process also involved the larger Wraparound Milwaukeeteam, which included seven formal supports and one informal support— H’s mom. All of these team members agreed to learn all of the reg-ulatory activities and used them during their time with H. Ongoingpsycho-education happened with the foster parent, as she started tomake the connection between H’s adverse history and the importanceof regulation.

As H started to show small signs of progress, he also began to havemoments where he would allow relational interactions to pass throughthe protective barrier he had erected. This was a remarkable NMT™-related discovery — that some kids have such a high degree of rela-tional sensitivity that the focus must be on enhancing their regulationbefore attempts are made at relational connection. The foster parentwas taught about H’s “intimacy barrier” and learned ways to benefitfrom his regulatory capacity and interact with him to help him feelsafe. These activities were completed the majority of the time in thecontext of a relationship. At first, the foster mom and other teammembers conducted the activities in parallel, with H slowly working toclose the intimacy barrier. As time went on, the team remained com-mitted to utilizing these activities as a way to reduce negative behav-iors and increase H’s ability to appropriately interact with others.

Editor’s Column | continued from pg. 2

and child development research, as well asemergence of more evidence based pro-grams, we know much more about how tohelp kids who’ve experience trauma to heal,grow and thrive.

In this FOCUS you’ll learn just what trau-ma-informed care looks like for an organiza-tion, its staff, families and youth. We beginwith a wonderful and hopeful story byKathleen Ayala and Tim Grove of SaintA in Wisconsin about “H”, a young boy whohad experienced many traumas. Using anapproach called Neurosequential Model of Therapeutics™ (NMT™) “H” improved significantly and, well, you have to read thearticle for the happy ending!

In Kasserian Ingera we learn about FFTAmember PATH’s trauma-informed care for ayoung child who has experienced multipleand severe traumas including witnessingdomestic violence and experiencing sexualabuse. This story highlights the role of expertconsultant Dr. Bruce Perry in working withthe team of clinicians and foster parents tohelp Cheyenne build a set of six corestrengths in her path to wellness.

J. Kellie Evans and Ronnie Gehring of TheUp Center in Virginia describe a deliberateprocess of organizational transformation,with a specific focus on what changed forresource parents, from recruitment andassessment, to the home study and training,to improved foster family supports and serv-ices and involvement in quality improvement.

Kimberley Bradley of Seneca Falls Family ofAgencies in California discusses practiceapproaches and principles for supportingcaregivers and birth parents, including par-enting unconditionally, understanding andacknowledgement of their own emotional ortraumatic experiences. By better understand-ing themselves, Bradley argues, parents canbetter help the children they care for.

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Implementing the NeurosequentialModel of Therapeutics™ | continued from pg. 2

Table 2 (left) represents The IntimacyBarrier. The general premise is thatchildren who have early experiencesthat are positive, safe & nurturingdevelop a broader capacity forengaging in interactions that rangefrom casual to intimate and respondaccordingly. Children with early expe-riences that are marked by fear,threat and insecurity often prioritizesafety which restricts the risk they arewilling to take in the same relationalcontexts. Like H, these childrenrequire patience, repetition andattuned caregiving so that theircapacity for more intimate interac-tions can be gradually enhanced.

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H’s progress now moved forwardat a much quicker pace. H’s stressresponse system began to experi-ence some much-needed regulation.This resulted in a reduction of theintensity and frequency of hisaggressive episodes, from severaltimes a week to once or twice amonth. H no longer destroyedproperty. H began to learn to trustadults and seek out affection. Hemade improvements with listeningto rules both at home and in thecommunity (i.e., previously he hadtried to run into the streets or leavethe adults he was with, but he wasnow no longer considered a flightrisk). His school also accepted therecommended adaptations, and sen-sory activities were added to hisfunctional behavioral plan. He wasable to successfully discharge fromday treatment, remain on a minimalamount of medications and bedescribed as a model student. He stabilized and is now placed with a pre-adoptivefamily, where he will be able to achieve permanency in several months.

H’s story is one of many that are taking place in our community. A group of dedi-cated foster parents, professionals and teams are learning how to apply core develop-mental concepts to create hope and healing for the people we serve.

Kathleen Ayala, MSW, has been a social worker in the Treatment Foster Care Program with SaintA, Inc.for last 5 years.

Tim Grove, MSW, is the Chief Clinical Officer at SaintA. He spearheaded SaintA’s trauma-informed carephilosophy and practices, including implementing Dr. Bruce Perry’s Neurosequential Model of Therapeutics™.

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Get in FOCUSFOCUS is the newsletter distributed to all Foster Family-basedTreatment Association agency members. Articles of the newsletterare made available to the general public on a staggered basis.

To receive the full FOCUS, consider joining FFTA.

FFTA Headquarters, 294 Union Street, Hackensack, NJ 07601

phone: (800) 414-FFTA, fax: (201) 489-6719, e-mail: ffta@ffta.org. Visit our Web site at www.ffta.org.

Phone: (800) 414-3382 Fax: (201) 489-6719 E-mail: ffta@ffta.org Web: www.ffta.org

Newsletter of the Foster Family-based Treatment Association

The Foster Family-based Treatment Association strengthensagencies that support families caring for vulnerable children.

Christine Bowlby of Right Turnof Nebraska stresses the impor-tance of vicarious trauma and its impact on staff well-being,behavior and job performance,and offers practical tips forsupervisors and agency leadersto recognize that “it’s there”and create a supportive environ-ment that will help staff andstrengthen the agency.

These articles are just a sam-pling of the expertise of ourmembers. Thanks to all of ourauthors for giving of their valu-able time and writing skills. Doyou want to learn more abouttrauma-informed care? We have also included some onlineresources for you to explore.Hope you enjoy…

1 National Child Traumatic Stress Network,Defining Trauma and Child TraumaticStress, http://www.nctsnet.org/content/defining-trauma-and-child-traumatic-stress

Gretchen Test, MSW, is a Senior Associate atthe Annie E. Casey Foundation, located inBaltimore, MD. She serves on the FFTA Boardof Directors and is the Chair of the EditorialCommittee.

Editor’s Column |continued from pg. 3

Table 3 (above) represents H’s brain “map” as scoredby his clinician and team 18 months later, again com-pared to an age typical child. Notice the absence of reditems compared to his first “map” and also a significantreduction in pink items. These changes suggest that thecollective efforts of H’s team contributed to significantgains in developmental capacity, which usually translatesto positive changes in behavioral outcomes.

Implementing the Neurosequential Model of Therapeutics™ | continued from pg. 3