The ChildTrauma Academy
The ChildTrauma Academy Newsletter
June 2010
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June CTA Newsletter
    This summer the CTA will be taking a major step forward in our efforts to provide useful tools to clinicians and clinical settings working with traumatized and maltreated children.  A set of web-based tools, including a set of "metrics" that will allow the clinician to create a functional brain map to aid in the application of the Neurosequential Model of Therapeutics (NMT) will be beta tested for six months by our Individual Certification and Site Certification partners.  This process will ultimately lead to a wider distribution of this set of useful clinical tools.  Interest in the NMT continues to grow.  In the last several months we have started program partnerships with multiple new group including: North American Family Services (NFI) in Vermont, St. Aemilian - Lakeside, Inc.,in Wisconsin, a collaborative group in Valencia County, New Mexico sponsored by New Mexico Children Youth, and Families Department, and the Addictions and Mental Health Branch of DHS in Oregon.   Registration is now open for the second class of Individual Certification Participants in the NMT.  Read more in this month's newsletter about this opportunity.

Rumination Disorder - Attachment, Reward and Abnormal Self-Soothing Mechanisms
           One of the most common findings in very maltreated infants and toddlers is a set of oropharyngeal problems - normal suck, swallow and gag functions are dysregulated.  In one review of 100 of sequential admissions to a residential treatment center serving children in the CPS system, 46% had histories of rumination behaviors or outright Rumination Disorder (RD).  RD is classified as a disorder usually diagnosed in infancy, early childhood or adolescence. However, it can be diagnosed throughout the lifespan, especially in adults with Mental Retardation or Pervasive Developmental Disorders (e.g., Autism). Those with RD voluntarily regurgitate their food a few seconds to about an hour after eating. Usually, the food has not yet been digested, and many people with RD re-chew their food and swallow it again. Others will spit out the regurgitated food. This regurgitation is not due to a gastrointestinal or other medical condition and is not usually accompanied by nausea or pain. However, some people with chronic RD eventually develop nausea, bloating, dental erosion, and complications due to malnutrition. Seemingly, those with RD receive some type of soothing stimulation from rumination and are thus compelled to continue ruminating.
            Due to the hypothesized soothing/stimulating nature of rumination, it is not surprising that many infants and children diagnosed with RD have been severely neglected, or that the onset of RD often occurs around times of stress (e.g., divorce, the beginning of school). RD is often co-morbid with anxiety, depression, and Obsessive-Compulsive Disorder (with rumination being the compulsion). As with many other primitive self-soothing behaviors this disorder is most commonly observed in those with Mental Retardation or Pervasive Developmental Disorders.
            Most people with RD are misdiagnosed for many years, as they are forced to undergo a significant amount of medical testing to rule out an organic cause (Chial et al., 2003). Further complicating the diagnostic picture is the fact that approximately 25-50% of all infants and/or children have some sort of transient feeding disorder that usually remits naturally. However, research suggests that when clinical symptoms are consistent with a diagnosis of RD and have lasted for one month following a period of normal functioning, early behavioral treatment is indicated, even if all medical conditions have not been completely ruled out.
            No clinical trials have been conducted on treatment for RD, as it is an uncommon disorder. However, several case studies have shown that behavioral treatment can be effective (Chial et al., 2003). Treatments that require the client to engage in a non-compatible response during times when rumination usually occurs are particularly successful.  For example, when performing deep diaphragmatic breathing, it is impossible to engage the same muscles that are used during rumination. Therefore, rewarding clients for performing deep breathing during times when rumination is likely results in a decrease of rumination.  Other behavioral strategies have also been used, such as increasing one's satiety (or feelings of "fullness") during times when rumination is likely (Thibadeau et al., 1999). Increasing satiety is hypothesized to be effective when rumination seems to be caused by the client's lack of satiety following meals. Clearly, disrupted attachment could lead to this abnormal "reward/soothing" mechanism. It is possible that increasing caregiver attention and physical contact with infants and young children who ruminate could cause symptoms to decrease. Though this hypothesis has not been empirically tested, because RD is common in neglected children, changes in the environment could produce therapeutic gains. In brief, while a great deal is not know about rumination, when found, the association with early attachment and maltreatment are important to explore.

Further Reading:

Chial, H. J., Camilleri, M., Williams, D. E., Litzinger, K., & Perrault, J. (2003). Rumination             syndrome in children and adolescents: Diagnosis, treatment, and prognosis.  Pediatrics, 111, 158-162.

Thibadeau, S., Blew, P., Reedy, P., & Luiselli, J. K. (1999). Access to white bread as an             intervention for chronic ruminative vomiting. Journal of Behavior Therapy and Experimental Psychiatry, 30, 137-144.

Individual Certification in the NMT - Begins September 27th
The ChildTrauma Academy is now accepting applications for our second Neurosequential Model of Therapeutics (NMT) Individual Training Certification (IC) class.  Due to overwhelming interest in the NMT from clinicians in private practice and from small organizations the CTA began offering training certification for individuals in 2009 (visit our website to see participants in our current IC class).  Phase I for Individuals offers an introduction to the core NMT concepts, use of NMT metrics and staffing approach.  Phase II of the IC program will start this fall and includes a Train-the-Trainer component to allow the IC Phase II certified participants to begin teaching the NMT approach. This initial level of certification is limited to 15 people and is slated to begin this September.  

In order for clinicians to be eligible to participate in the NMT Individual Training Certification process individuals must first meet certain requirements.  The requirements for participants include: (a) at least a master's degree in social sciences or equivalent, a current license, current practice working with children and families, and participation in at least 1 NMT Case-based Staffing Series (may be waived if clinician has participated in other CTA trainings).  Cost for Phase I is $5,000/per person and includes 10 Individual Certification NMT Case-based Staffings, access to the 30 NMT Staffings in the 3 NMT Case-based Staffing Series - Fall, Winter, Spring/Summer; CTA Videos - Series 1 & 3 and Early Childhood and Brain Development; Series 1 Educator's Package and Reading Materials.

Each staffing is tentatively set for the last Monday of the month at 2pm to 3:30 PM CST:

Sept 27                                                                                
Nov 1
Nov 22
Dec 27
Jan 24
Feb 28
Mar 28
April 25
May 23
June 27
July 25 ** make up date
August 22 ** make up date

Learn more about the NMT, Individual Certification, and program registration on our website.

Upcoming On-site Presentations
We know that many of you are interested in upcoming on-site presentations by Dr. Perry and CTA Fellows.  We have now added a list of upcoming talks to our new website, and we are posting announcements weekly on Facebook and Twitter.  Below is a brief list of summer 2010 trainings, but check out our complete list by clicking here.  We attempt to update this list monthly.

Date          Fellow        Location                Contact                       Email

6/17           Perry         Brooklyn                Sarah Cheesman
                                    Center, MN

6/24           Perry         New Orleans         DeeDee Bandy 

6/25           Perry         Dallas                   Antonia LoVersa          Antonia@internationalspeakers.

7/14           Perry         Edmonton, AB      Deborah Landry 

7/26           Brandt       Jackson, WY        Tiernan McIlwaine

8/19           Dobson     Austin, TX             Kim Schenck      

8/20           Perry         Houston, TX         Karen Kennard   
Special thanks to Erin Hambrick for preparing the mini-review of Rumination. Our best to you for a safe and happy summer. 

Bruce D. Perry, M.D., Ph.D.
The ChildTrauma Academy

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