Clinics in Developmental Medicine No. 190
NEONATAL BEHAVIORAL ASSESSMENT
SCALE
4th edition
Clinics in Developmental Medicine No. 190
Neonatal Behavioral Assessment Scale
4th Edition
T. BERRY BRAZELTON
Harvard Medical School and Children’s Hospital, Boston,
MA, USA
and
J. KEVIN NUGENT
Children’s Hospital, Boston, Harvard Medical School, and
University of Massachusetts at Amherst, MA, USA
2011
Mac Keith Press
© 2011 Mac Keith Press
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Editor: Hilary M. Hart
Managing Director: Caroline Black
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First published in this edition 2011
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CONTENTS
AUTHORS’ APPOINTMENTS
CONTRIBUTORS
ACKNOWLEDGMENTS
PREFACE
T. Berry Brazelton
1.THE NEONATAL BEHAVIORAL ASSESSMENT SCALE (NBAS) – BACKGROUND AND CONCEPTUAL BASIS
2.THE STANDARD ADMINISTRATION OF THE NBAS
3.SCORING THE NBAS ITEMS
4.USING THE NBAS IN RESEARCH
Maggie Redshaw
5.THE PSYCHOLOGICAL CONTEXT OF THE NBAS
Nadia Bruschweiler-Stern
6.NEW ADVANCES IN THE STUDY OF MOTOR BEHAVIOR IN PRETERM AND TERM INFANTS
Fabrizio Ferrari and Natascia Bertoncelli
7.THE INTER-RELATIONSHIP BETWEEN EXAMINER, INFANT AND PARENTS IN THE USE OF THE NBAS
Claire De Vriendt-Goldman and Marie-Paule Durieux
8.THE NBAS IN DIFFERENT CONTEXTS: TRAINING, RESEARCH AND CLINICAL ISSUES
Joshua Sparrow
8.1NBAS training – lessons from the UK
Joanna Hawthorne and Betty Hutchon
8.2Neurodevelopmental assessment in young infants: a proposal for daily clinical activity and early intervention, integrating the concepts of Milani Comparetti, Brazelton and Prechtl
Gherardo Rapisardi and Adrienne Davidson
8.3The NBAS and postpartum depression: a case study
M. Barbosa, J. Gomes-Pedro, J. Justo, L. Leitão, P. Menezes, J. Rombert, R. Silveira-Machado and F. Sobral
8.4Clinical applications of the NBAS with at-risk infants within a research setting: case vignettes
Carme Costas-Moragas, Elisabet Boatella-Costa, Mª Andrea Mancera-Jiménez and Francesc Botet-Mussons
8.5The NBAS and an infant with a disability: a case study
Marie Fabre-Grenet
8.6Using the NBAS in the context of breastfeeding issues: a case study
M. Barbosa, J. Gomes-Pedro, J. Justo, L. Leitão, P. Menezes, J. Rombert, R. Silveira-Machado and F. Sobral
8.7The NBAS in pediatric care
Constance Helen Keefer
APPENDIX: NBAS SCORING FORM
REFERENCES
INDEX
AUTHORS’ APPOINTMENTS
T. Berry Brazelton |
Emeritus Professor of Pediatrics, Harvard Medical School; Founder, the Child Development Unit and Brazelton Touchpoints Center, Children’s Hospital, Boston, MA, USA |
J. Kevin Nugent |
Founder and Director, the Brazelton Institute, Division of Developmental Medicine, Children’s Hospital, Boston, MA, USA; Professor, Children, Schools, Families, University of Massachusetts at Amherst; Lecturer, Harvard Medical School |
CONTRIBUTORS
Miguel Barbosa |
PhD student, Assistant Professor at the Faculty of Medicine, University of Lisbon, Portugal |
Natascia Bertoncelli |
Developmental Therapist, Division of Neonatology and Intensive Care Unit, Azienda Ospedaliera, Universitaria di Modena, Italy |
Elisabet Boatella-Costa |
NBAS examiner accredited by the Brazelton Institute; Research Associate, Universitat Autònoma de Barcelona, Spain |
Francesc Botet-Mussons |
Professor of Pediatrics, Universitat de Barcelona; Neonatology Service, Hospital Clínic de Barcelona, Spain |
Nadia Bruschweiler-Stern |
Pediatrician and child psychiatrist, Clinique des Grangettes, Geneva; Director of the Swiss Brazelton Centre; Consultant supervisor at the University Hospital of Geneva, Switzerland |
Carme Costas-Moragas |
Director, NBAS Training/Barcelona, Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona; Professor, Psychological Assessment in Childhood, Universitat Autònoma de Barcelona, Spain |
Adrienne Davidson |
Pediatric physical therapist, developmental specialist, Head of Rehabilitation Service, Meyer Children’s Hospital, Florence. Coordinator, Pediatric Physiotherapy, University of Florence. Lecturer, Brazelton Center, Florence, Italy |
Claire De Vriendt-Goldman |
Founder and Co-Director of the Brussels Brazelton Center. Child psychiatrist at the Edith Cavell Inter-Regional Hospital Centre, Belgium. Psychoanalyst, member of the Belgian Psychoanalytic Society and of the International Psychoanalytic Association |
Marie-Paule Durieux |
Founder and Co-Director of the Brussels Brazelton Center. Child psychiatrist at the University Children’s Hospital, Queen Fabiola (HUDERF), Brussels, Belgium. Lecturer at the Free University of Brussels in Permanent Education (child and adolescent psychotherapy). Psychoanalyst; member of the Belgian Psychoanalytic Society and of the International Psychoanalytic Association |
Marie Fabre-Grenet |
Pediatrician, NBAS trainer, CAMSP Centre, Hospitalier Universitaire Nord, Marseille, France |
Fabrizio Ferrari |
Director, Division of Neonatology and Intensive Care Unit, Professor of Pediatrics, Azienda Ospedaliera, Universitaria di Modena, Italy |
João Gomes-Pedro |
Professor Emeritus at the University of Lisbon. Director, Brazelton Center, Portugal |
Joanna Hawthorne |
Psychologist, Co-Founder, Director, and Trainer, Brazelton Centre in Great Britain, Addenbrooke’s Hospital, Cambridge; Associate Member and Supervisor, Centre for Family Research, University of Cambridge, UK |
Betty Hutchon |
Co-Founder and Trainer, Brazelton Centre in Great Britain; Head Occupational Therapist, Department of Child Health, Royal Free Hospital, London; Consultant Neurodevelopmental Therapist, University College London Hospital; and Honorary Lecturer, Institute of Child Health, University College London (UCL), UK |
Constance Helen Keefer |
Faculty, Brazelton Touchpoints Center and Brazelton Institute, Division of Developmental Medicine, Children’s Hospital, Boston; Faculty, Newborn Nursery Faculty Practice, Division of Newborn Medicine, Brigham and Women’s Hospital, Boston; Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA, USA |
Andrea Mancera-Jiménez |
NBAS examiner accredited by the Brazelton Institute; PhD candidate, Research Associate, Universitat Autònoma de Barcelona, Spain |
Gherardo Rapisardi |
Director of the Neonatal and Pediatric Unit of S.M. Annunziata Hospital, Bagno a Ripoli, Florence. Director of Brazelton Center of Florence, A. Meyer Hospital, Florence, Italy |
Maggie Redshaw |
Co-Founder of Brazelton Centre, UK; Developmental and Health Psychologist; Social Scientist, National Perinatal Epidemiology Unit and Policy Research Unit – Maternal Health and Care, University of Oxford, UK |
Joshua Sparrow |
Director of Special Initiatives, Brazelton Touchpoints Center, Children’s Hospital, Boston. Assistant Professor, Harvard Medical School, Boston, MA, USA |
ACKNOWLEDGMENTS
Firstly, we would like to acknowledge the contribution of the following people who assisted in the development of the first edition of the NBAS manual: Daniel G Freedman; Frances Degan Horowitz; Barbara Koslowski; Henry Ricciuti; John S Robey; Arnold Sameroff; Edward Tronick. We would also like to express our deep gratitude and indebtedness to NBAS trainers across the world, whose work with the NBAS has confirmed its value as a unique neurobehavioral assessment and has extended our understanding of its uses in a wide range of clinical and cultural settings. As experts in the assessment of newborn behavior, their careful observations have continued to inform our scoring and administration criteria. Indeed, many of the changes included in this edition were based on recommendations of NBAS trainers who participated in the International NBAS Trainers Meeting held in Boston in 2002 and on Cape Cod in 2009. Since then, Joanna Hawthorne, in particular, has played an especially important role in the preparation of this edition of the manual. Nadia Bruschweiler-Stern also contributed ideas to the revisions included in this edition.
We are equally indebted to NBAS trainers Jean Gardner Cole, Elizabeth Higley, Thembi Ranuga, Yvette Blanchard, Jennifer Gillette, Cecilia Matson, James Helm, Marie Reilly, Elise Holloway and Karen Fehringer in the United States; Beulah Warren in Australia; Jane and Jose Saraiva in Brazil; Alain Caron, Claire De Vriendt-Goldman and Marie-Paule Durieux in Belgium; Hanne Munck in Denmark; Drina Huisman and Marie Fabre-Grenet in France; Gherardo Rapisardi, Adrienne Davidson and Roberto Paludetto in Italy; Tomitaro Akiyama, Chisato Kawasaki, Shohei Ohgi, Toshiya Tsurusaki, Masako Nagata and Sachiyo Nagai in Japan; Joao Gomes Pedro in Portugal; Carme Costas-Moragas in Spain; Karin Stjernqvist in Sweden; Nadia Bruschweiler-Stern in Switzerland; Nittaya Kotchabkadi in Thailand; and Joanna Hawthorne, Betty Hutchon, Dieter Wolke and Associate Trainers Jeanette Appleton and Alison Pritchard in the UK. Many of their ideas on administration, scoring and training have been integrated into this edition of the Scale.
We would also like to take this opportunity to pay tribute to the many researchers and clinicians who have used the Scale in their research and practice over the years. We have incorporated many of their observations and critiques into the Scale and we realize that it is because of their efforts that the NBAS has made such a formidable contribution to the field of infant development.
We offer our thanks to Elizabeth Higley for her work in compiling the list of administration guidelines and eliciting strategies that are included in Chapter 3 of this manual. She was assisted in this task by NBAS Trainer Emeritus Jean Gardner Cole and NBAS Trainer, Thembi Ranuga, with the help of Ethan Howland.
We also thank Barbara Dorant, Suzanne Otcasek and Ajejandra Viloria, who helped in the preparation of this manuscript.
We would like to express our heartfelt gratitude to our publisher Mac Keith Press for their support in making the Scale available worldwide, since the first edition was published in 1973. We are especially grateful to Caroline Black, our editor, for her enthusiasm and commitment to making this fourth edition possible. We want to add our thanks to Martin Bax of Mac Keith Press, whose backing for the NBAS from the beginning has contributed greatly to its introduction in settings across the world.
Finally, we would like to acknowledge the individual infants and parents who have taught us so much about newborn behavior and development over the years and who made the development of the NBAS possible in the first place. This edition is dedicated to them with gratitude and deep affection.
The photographs used in this edition were taken by Emily Burrows (2.4-2.7, 2.11, 2.15, 2.16, 2.18, 3.1-3.6), Edward Tronick and Denise Zwhalen (2.8), and the March of Dimes Birth Defects Foundation (2.2, 2.9, 2.10, 2.12-2.14, 2.17, 3.8).
PREFACE
T. Berry Brazelton
Since the publication of the first edition of the Neonatal Behavioral Assessment Scale (NBAS) in 1973, we have learned so much. Yet there is still much more to learn about newborn behavior and newborn interactions with their adult caregivers. With this fourth edition of the NBAS manual, it is time to review what we have learned and to establish the NBAS as a necessary instrument in evaluating newborns in every nursery in the US and abroad. This new edition of the NBAS records many changes that trainers in the different training sites in Europe, Asia and North and South America have proposed for the administration and scoring of the scale, as well as for training. The chapters by professionals who have been using the Scale for many years will alert readers to the many possibilities for use of the NBAS in research and clinical settings, and to some of the new knowledge that the Scale has generated.
I like to think that the NBAS has changed the way everyone thinks about babies and the effect babies have on their parents. Before it was published in 1973, the common belief was that newborn babies couldn’t see or hear, and that they were ‘lumps of clay’, ready to be shaped by their environment (Brazelton 1973). As a result, we blamed the parents for everything that went wrong. I called this ‘blaming the victim’. But parents knew that their babies could respond to auditory and visual signals at birth. Many others had always been aware that the fetus was responsive to changes in the uterus and its surroundings all through the last trimester. Why did we try to deny this and interfere with parents’ belief in their babies from the first? Maybe it was because of higher infant mortality rates in those days, and the resulting need to prepare for possible loss. But that is no longer the case and it is time to change.
Now, owing to better obstetrical practices and more knowledge of the physical requirements for their recovery, the vast majority of babies will recover from the trauma of labor and delivery. It is time to begin to think about the competence and the excitement that a newborn brings to his or her parents; and to prepare parents for understanding their baby’s individuality at birth so that they can combine their passion with their baby’s competence to give him or her the most promising future that they can. We know how to do that, now that we understand so much about the baby’s behavior and individuality thanks to the NBAS.
When the NBAS was first published, there were several objections to its use as an assessment.
Since then we have been able to respond to these objections.
We have learned so much about newborns and their influence on how their parents nurture them that it is time for us to demand that all neonatal units share each neonate’s behavior with his parents before discharge. We now have data to show the following:
With all of these data to demonstrate how important it is for a professional to share each neonate’s behavior with parents – using the NBAS or NBO – in the first few days, it seems to me that it is time that we demand that all newborn units be staffed by professionals who are trained reliably to demonstrate each baby to his or her parents before discharge. It is time to let parents know that they should expect this. It is my hope that the NBAS and NBO will be widely implemented as standards for newborn assessment and care.
1
THE NEONATAL BEHAVIORAL ASSESSMENT SCALE (NBAS) – BACKGROUND AND CONCEPTUAL BASIS
History
The dominant view for much of the earlier part of the twentieth century was that infants were generally passive recipients of sensory stimulation, responding to environmental input with innate reflexes, as Berry Brazelton points out in the Preface. There was scant evidence that learning could be demonstrated in the first few weeks or even months of life. Newborn assessment tools reflected these assumptions, so that the earlier neonatal scales, which emerged from the field of neurology, focused on the assessment of the so-called ‘primitive reflexes’ and ‘postural reactions’ (e.g. Andre-Thomas and Dargassies 1960, Peiper 1963, Prechtl and Beintema 1968). These scales were designed specifically to assess brain functioning by examining newborn reflexes. In clinical settings, the assessment of neonates was confined to Apgar scores and pediatric examinations of physical competence.
However, a number of advances, especially in the fields of psychology and psychiatry, contributed to a major shift in thinking about newborn behavior and development. Back in the early 1960s, it was still assumed that the newborn could not see at birth or could see shadows at best. And then, Robert Fantz demonstrated that the newborn infant could not only see but also had clear-cut visual preferences (Fantz 1961). In terms of auditory capacities, the prevailing assumption among both researchers and clinicians was that newborns’ fluid-filled ears impaired their hearing for the first few days. However, in 1963 a report appeared in the journal Science showing that newborns could orient towards a sound as early as 8 hours of age (Wertheimer 1961). The notion that the baby could indeed see, hear, and respond differentially to positive and negative stimuli stimulated a new body of scientific research on newborn behavior and development.
INFLUENCES
While innovative thinkers such as John Bowlby, Erik Erikson, Donald Winnicott and Selma Fraiberg, from the emerging field of infant mental health, studied the mother’s role in the development of early parent–infant relations, a new generation of researchers, among them Jerome Bruner, Peter Wolff, Jerome Kagan, Robert Emde and Arnold Sameroff, stimulated by the work of Jean Piaget, began to study learning in infancy in an effort to determine how early and under what conditions infants could learn. In the 1960s and 1970s, a new body of research on newborn capabilities began to emerge, which provided a rich empirical database for subsequent conceptualizations of newborn and infant development. Researchers such as Lewis Lipsitt, Louis Sander, T.G.R. Bower and Rachel Keen developed innovative research methods to demonstrate that newborns could, indeed, learn from the very beginning. This new body of data, which provided evidence to show that the newborn infant was competent and complex, contributed significantly to the development of the NBAS.
However, it was Berry Brazelton’s own clinical experience with parents and his work at the Children’s Hospital in Boston which led to a breakthrough in our understanding of newborn and infant development. It was his contention that newborn infants were unique, with their own individual styles of responding, and it was this discovery which prompted him to begin the quest for a scale that, on the one hand, could do justice to the newborn’s capabilities and, on the other, could describe the full range of individual differences in newborn behavior.
He first provided evidence for differences in crying patterns in his own research (Brazelton 1962a, 1962b), and later he presented his ideas on individual differences to a wider audience in his groundbreaking book, Infants and Mothers: Differences in Development. Then, at the Center for Cognitive Studies at Harvard, he worked with Jerome Bruner, Tom Bower, Martin Richards, Colwyn Trevarthen and Edward Tronick on new microanalytic observational techniques in an effort to develop a more detailed and complex understanding of individual differences in infant behavior and early infant–parent transactions. This body of research confirmed his hypothesis that newborns were equipped with powerful innate reciprocal communicative abilities and moreover that this could be reliably coded. He could see that they were also capable of the kind of ‘organized’ behavioral responses Peter Wolff had demonstrated earlier in his seminal work on ‘newborn behavioral states’ (Wolff 1959). Indeed, the idea of ‘state’ was to become a critical matrix on which to assess all reactions, sensory as well as motor, in the newborn. Working with Mary Louise Scholl from the Department of Neurology at Massachusetts General Hospital, Berry Brazelton also began to integrate developmental and neurological principles into his clinical understanding of newborn behavior and development. These ideas and discoveries provided a conceptual foundation for the development of the Neonatal Behavioral Assessment Scale.
THE CAMBRIDGE SCALES
The Graham Scale (Graham et al 1956) and the Graham-Rosenblith Scale (Rosenblith 1961) were the first scales to attempt to outline behavioral differences among neonates. Shortly thereafter, the first iteration of the NBAS appeared – The Cambridge Neonatal Scales – developed by Berry Brazelton and Daniel Freedman (Brazelton and Freedman 1971). Using this scale, Freedman and his colleague were able to identify behavioral differences between Caucasian and Chinese neonates (Freedman and Freedman 1969). Intrigued by these findings, Brazelton and John Robey then went to southern Mexico to study the Zinacanteco Indians, in the highlands of Chiapas (Brazelton et al 1969). Here, their ideas on neonatal differences were confirmed. They discovered that, compared to their Caucasian counterparts, these infants, even after delivery, ‘lay quietly on the blanket looking around the room with alert faces for an entire hour’ (Brazelton et al 1969: 279).
Confident that the scale could capture individual differences in newborn behavior, the next challenge was to refine the scoring system in a way that could describe, identify, and ultimately code these differences with a high degree of inter-rater reliability (Brazelton 1973, 2009). With the help of Daniel Freedman, Frances Degan Horowitz, Barbara Koslowski, Henry Riciutti, John Robey, Arnold Sameroff and Edward Tronick, Berry Brazelton developed a new scoring system, which was incorporated into the first edition of the Scale, which was published in 1973 by Spastics International Medical Publications in London. In the preface to that volume, Ronald Mac Keith and Martin Bax were perceptive when they wrote that they were ‘happy to predict that people will be using and working with the NBAS for many years to come’. The second edition, which appeared in 1983, added the ‘supplementary items’, which were adapted from the NBAS-K (Kansas version) (Horowitz et al 1978) and the then newly developed Assessment of Premature Infant Behavior (Als et al 1982a), and provided additional scoring criteria for use of the Scale with at-risk infants. The usefulness of these items has been supported by studies of high-risk infants (e.g. Dreher et al 1994, Eyler et al 1998, Sagiv et al 2008). Thirteen years later, the third edition appeared, in which J. Kevin Nugent joined Berry Brazelton as co-author and added a new set of guidelines on the clinical uses of the NBAS. This current edition expands the scope of the previous editions by highlighting the wide range of research and clinical contexts in which the NBAS can be used.
Conceptual basis
In developing the Scale, we were impressed from the beginning by the newborn infants’ ability to interact with the environment and by their capacity to deal selectively with environmental stimuli. The NBAS assumes that the newborn is a social organism, predisposed to interact with her caregiver from the beginning and able to elicit the kind of caregiving necessary for her species-specific survival and adaptation. The Scale was conceptualized, therefore, not as a series of discrete stimulus–response presentations simply to assess the baby in isolation, but rather as an interactive assessment, in which the examiner plays a major role in facilitating the performance and organizational skills of the infant. We therefore wanted a scale that could yield a comprehensive profile of neonatal functioning by describing the full range of neonatal behavior including competencies and strengths as well as identifying areas of difficulty or deviation. The NBAS does not merely provide a catalogue of newborn competencies, but over the course of the first four weeks of life it allows us to see how the baby’s discrete behaviors are integrated into coherent patterns of behavior. It enables us to identify what role the caregiver can play in facilitating the infant’s adaptation and development. Above all, the goal of the NBAS was to identify and describe individual differences in neonatal behavioral adaptation.
THE COMPETENT NEWBORN
The NBAS is based on the assumption that the newborn infant is both competent and complexly organized. Over the past 25 years, an ever-expanding body of research has yielded an extensive taxonomy of newborn and infant behavior, showing that, for example, the newborn can visually track (Slater et al 1985, Dannemiller and Freedland 1991, Laplante et al 1996), can hear and locate sounds (Muir and Field 1979) and seems to prefer to look at faces (Walton et al 1998, Farroni et al 2004). This body of research also demonstrates that the newborn infant is a social organism; infants are predisposed to interact with their caregivers from the beginning and able to elicit the kind of caregiving necessary for their successful adaptation (Trevarthen 2001). The newborn is drawn to the mother’s voice (deCasper and Spence 1991, Spence and Freeman 1996), can imitate facial expressions (Field et al 1982, Meltzoff and Moore 1983, Nagy 2006), and can clearly discriminate her mother’s face from that of a stranger (Nazzi et al 1998). After three decades of intensive research on newborn behavior and development, newborn human infants have emerged as competent, as complexly organized and as playing an active role in shaping their own development.
Research with the NBAS also reveals that the neonate’s behavior can no longer be assumed to be biologically determined. Infant behavior at birth is phenotypic, not genotypic, so that intrauterine nutrition and infection (Lester and Brazelton 1982, Oyemade et al 1994) and drugs (Fried and Makin 1986, Chasnoff and Griffith 1989, Coles et al 1992, Beeghly and Tronick 1994, Dreher et al 1994, Eyler et al 1998, Morrow et al 2001), to name but a few possible influences, are affecting the fetus throughout pregnancy, interacting with genetic endowment to shape newborn behavior. There is rapidly accumulating evidence that the newborn infant is powerfully shaped before delivery, and routine perinatal events, such as maternal medication and anesthesia, and episodes of hypoxia, further influence his or her reactions (Sepkoski et al 1992). Research shows that extrauterine stimulation which involves the pregnant mother may also be shaping the neonate’s learning in utero and may be influencing prenatal brain development (Dobbing 1990, Als et al 2003). This has led to the recognition that the infant has well-established behavioral endowments at birth and that the infant’s development is influenced by both biological and environmental influences from the beginning.
THE DEVELOPMENTAL AGENDA OF THE NEWBORN PERIOD
The scope of the Scale extends from birth to the end of the second month of life and is designed to describe the infant’s adaptation and development, specifically the capacity for self-regulation over that period of time. From this developmental systems perspective, the NBAS enables us to study behavioral changes systematically over time by describing the process of hierarchical integration of the different domains or systems of behavior over the first two months. Newborn infants are seen to face a series of hierarchically organized developmental challenges as they attempt to adapt to their new extrauterine world, both the inanimate and animate world (Brazelton 1982). This includes their capacity to first regulate their physiological or autonomic system, then their state behavior, their motor behavior and finally their affective interactive behavior, which develops in a stage-like epigenetic progression over the first two months of life (Als et al 1982a, 1982b). The NBAS items cover these four domains of neurobehavioral functioning:
The first – and basic – task for newborn infants is to organize their autonomic or physiologic behavior. This involves dealing with stress related to homeostatic adjustments of the central nervous system. It involves the task of stabilizing their breathing, of reducing the number of startles and tremors and being able to maintain temperature control. When this homeostatic adjustment has been achieved, newborn infants can move on to the second task – that of regulating or controlling their motor behavior. This means gaining control over and inhibiting random motor movements, developing better muscle tone, and reducing excessive motor activity. Although these challenges may not develop in an absolute sequence and they may be contemporaneous, there is an assumption of a hierarchical progression, such that each precedes the next.
The third challenge of this period is state regulation. This is the ability to modulate his/her states of consciousness. This includes the ability to develop robust and predictable sleep and wake states and what could be called sleep protection, or the ability to screen out negative stimuli while asleep. State control means that the infant is able to deal with stress, either through self-regulation strategies such as hand to mouth maneuvers, or through being able to communicate with the caregiver through crying and being consoled with the caregiver’s help.
The final task for newborn infants is the regulation of their affective interactive or social behavior. This involves the capacity to maintain prolonged alert periods, the ability to attend to visual and auditory stimuli within their range, and the ability to seek out and engage in social interaction with the caregiver. The NBAS can reveal where along this hierarchical continuum the individual baby falls and in which domain she needs support and what kind of support she may need.
The Scale can therefore be used to describe the current status of the individual infant’s autonomic, motor, state and social-attentional systems as they interact with each other and become integrated during the neonatal period (Als et al 1982a, Nugent and Brazelton 2000). Serial observations with the NBAS can reveal how the systems are being integrated over time and how they are being affected by environmental factors. This integrative task proceeds in a hierarchical fashion, with autonomic regulation preceding motor organization, followed by the task of state regulation and finally social interactive tasks. Moreover, the model of development on which the NBAS is based assumes that developmental outcome is a function of the interaction of organismic and environmental factors, so that most researchers who have used the NBAS to examine the relationship between newborn behavior and later outcome have combined the NBAS scores with measures of the infant’s environment (e.g. Nugent 1991, Van den Boom 1991, Stjernqvist and Svenningsen 1995, Ohgi et al 2003).
Content and uses
The NBAS can be described as a neurobehavioral assessment scale, designed to describe newborn infants’ responses to their new extrauterine environment and to document the contribution of the newborn infant to the development of the emerging parent–child relationship (Brazelton 1973, 1984, Brazelton and Nugent 1995). The NBAS assesses the newborn’s behavioral repertoire with 28 behavioral items, each scored on a nine-point scale. It also includes an assessment of the infant’s neurological status on 20 items, each scored on a four-point scale. The reflex items are used to identify gross neurological abnormalities through deviant scores or patterns of scores, but they are not designed to provide a neurological diagnosis. In the two previous editions of the NBAS (Brazelton 1984, Brazelton and Nugent 1995), a set of supplementary items was added in an attempt to better capture the range and quality of the behavior of fragile high-risk infants. The usefulness of these items has been confirmed by studies of high-risk infants (e.g. Dreher et al 1994, Eyler et al 1998, Sagiv et al 2008).
The NBAS is appropriate for use without adaptation for term infants, and can be applied until the end of the second month of life. With the addition of the supplementary items it can also be used for apparently healthy preterm (who have reached 37 weeks gestational age) or late preterm infants, and for them, depending on the degree of immaturity, its application is still possible at 2 months corrected age. It will be obvious that the NBAS should not be attempted for infants requiring neonatal intensive care with multichannel monitoring, oxygen therapy and intravenous or gavage feedings. A baby who is either immature or recovering from illness may become over-stressed by the examination.
TABLE 1.1
Behavioral, supplementary and reflex items on the NBAS
Behavioral items |
Supplementary items |
Response Decrement to Light |
Quality of Alertness |
Response Decrement to Rattle |
Cost of Attention |
Response Decrement to Bell |
Examiner Facilitation |
Response Decrement to Tactile Stimulation of the Foot |
General Irritability |
Orientation Inanimate Visual |
Robustness and Endurance |
Orientation Inanimate Auditory |
State Regulation |
Orientation Inanimate Visual and Auditory |
Examiner’s Emotional Response |
Orientation Animate Visual |
|
Orientation Animate Auditory |
Reflex items |
Orientation Animate Visual and Auditory |
Plantar Grasp |
Alertness |
Babinski |
General Tonus |
Ankle Clonus |
Motor Maturity |
Rooting |
Pull-to-Sit |
Sucking |
Defensive Movements |
Glabella |
Activity Level |
Passive Movements – Arms |
Peak of Excitement |
Passive Movements – Legs |
Rapidity of Build-up |
Palmar Grasp |
Irritability |
Placing |
Lability of States |
Standing |
Cuddliness |
Walking |
Consolability |
Crawling |
Self-Quieting |
Incurvation (Gallant Response) |
Hand-to-Mouth |
Tonic Deviation of Head and Eyes |
Tremulousness |
Nystagmus |
Startles |
Tonic Neck Reflex |
Lability of Skin Color |
Moro |
Smiles |
Because it is sensitive to even subtle environmental effects, the NBAS has demonstrated that newborn behavior and development can be affected by many variables, including intrauterine growth restriction, low birthweight, and preterm birth (e.g. Costas et al 1989, Eyler et al 1998); environmental polychlorinated biphenyls (PCBs) (e.g. Lonky et al 1996, Sagiv et al 2008); different modes of delivery and obstetric medication (e.g. Lester et al 1982, Sepkoski et al 1992); gestational and pregestational diabetes (e.g. Botet et al 1996); infant massage (e.g. Field 2009); neonatal hyperbilirubinemia (e.g. deCaceres et al 1991) and maternal ingestion of toxins – cocaine, tobacco, alcohol and caffeine (e.g. Mayes et al 1993, Datta-Bhutada et al 1998, Morrow et al 2001, Lewis et al 2007, Mansi et al 2007).
DATA REDUCTION AND ANALYSIS
Since the NBAS contains 28 behavioral items and 20 reflex items, the search for the most effective data reduction and data analysis procedures challenged researchers from the beginning. Item-by-item comparisons across the individual NBAS items have given way to approaches based on factor analysis (e.g. Jacobson et al 1984, Lester 1984, Sostek 1985, Azuma et al 1991), but it is Lester’s seven-cluster system which has become the most widely used system among researchers (e.g. Mayes et al 1993, Sagiv et al 2008). Chapter 4 describes research uses and the different data reduction procedures used with the NBAS in more detail.
USES IN DIFFERENT CULTURAL SETTINGS
From the time it was first published, the NBAS has been used to examine neonatal differences and their natural variations in different cultural settings. These studies have been reviewed by Lester and Brazelton (1982) and Super and Harkness (1982), while Nugent, Lester and Brazelton (1989, 1991) later presented a series of NBAS studies from 24 different cultures in Europe, Asia, North and South America and Africa. While this body of cross-cultural research constitutes a fraction of the canon of cultural and cross-cultural studies, the NBAS studies have made a unique contribution to the field by showing that while the basic organizational processes in infancy may be universal, the range and form of these adaptations are shaped by the demands of each individual culture. Moreover, these studies expand our understanding of the range of variability in newborn behavioral patterns and the diversity of child-rearing practices and belief systems (Nugent et al 2009).
CLINICAL USES
While the NBAS has been used in many research studies as an outcome measure and continues to be used as a means of assessing the effects of a wide range of pre- and perinatal influences on newborn behavior, we began to realize in the 1980s that the NBAS was a powerful teaching tool and could be used as a form of intervention (Nugent 1985). A series of studies, summarized by Nugent and Brazelton (Nugent and Brazelton 1989, Brazelton and Nugent 1995, Nugent and Brazelton 2000), showed that demonstrating the newborn infant’s behavioral capacities to parents can serve as a mechanism for helping parents learn about their new infant, thereby strengthening the relationship between parent and child and supporting the family adjustment. A number of follow-up studies have consistently reported positive effects of exposure to the NBAS on variables such as maternal confidence and self-esteem, parent–infant interaction and developmental outcome (e.g. Myers 1982, Rauh et al 1988, Parker et al 1992, Achenbach et al 1993, Beeghly et al 1995, Gomes-Pedro et al 1995, Kaaresen et al 2006).
CALESNSPIRED BY THE
The NBAS has also stimulated the development of a number of assessment scales for use with different populations and in different settings – a testament to its theoretical richness and generativity. The NBAS-K (Kansas version) was developed by Horowitz and colleagues ‘to identify individual “outlier” infants whose behavioral organization can be said to be very different from normal’ (Horowitz and Linn 1984: 97). The Assessment of Premature Infant Behavior was derived from the NBAS and has become the most widely used instrument to assess preterm infant behavior (Als et al 1982a). The Neonatal Intensive Care Unit Network Neurobehavioral Assessment Scale (Lester and Tronick 2004) was designed for the neurobehavioral assessment of drug-exposed and other high-risk infants, including preterm infants. A number of clinical approaches based on the NBAS were also developed as a form of parent support or intervention. The Mother’s Assessment of the Behavior of her Infant (Widmayer and Field 1980) and the Family Administered Neonatal Activities (Cardone and Gilkerson 1990) were adapted from the NBAS, while Keefer (1995; see also Chapter 8.7 in this volume) based the combined Physical and Behavioral Neonatal Examination (PEBE) on the NBAS. The recently developed Newborn Behavioral Observations (NBO) system (Nugent et al 2007) was also inspired by the clinical uses of the NBAS. The NBO is a flexible, interactive relationship-building instrument and is used extensively in clinical settings as a means of sensitizing parents to the capacities and individuality of the newborn infant and fostering the relationship between parent and child and between clinician and parent.
In sum, the newborn period can be considered a major transition stage in the newborn’s adaptation and development. It is a period defined by specific developmental challenges as the newborn attempts to make a successful transition to his or her new extrauterine environment. What the NBAS has revealed is that this process is highly individualized and there is a wide range of variability in how newborn infants adapt to their new environment over these first two months. This period can also be considered a major transition stage in the development of the parent–infant relationship. From an interventionist point of view, it has become clear that this transition period provides clinicians with a remarkable opportunity to play a supportive role in promoting the baby’s self-regulation, on the one hand, and facilitating the mutual affective regulation process between parent and infant, on the other.
Conclusion
The NBAS has now established itself as an invaluable neurobehavioral assessment tool in research and clinical settings across the world (Nugent et al 2009, Lester and Sparrow 2010, Nugent 2010). It remains the most comprehensive examination of newborn behavior available. Because it yields a comprehensive description of newborn competencies, on the one hand, and is able to identify individual differences in newborn behavior, on the other, the NBAS can be said to have begun where other scales left off. The NBAS has enriched our understanding of the competencies and complexities of newborn behavior and helped us identify the multiplicity of variables which influence newborn behavior and development. It adds to our understanding of what can be considered normal or typical, and can broaden our appreciation of the range of variability of newborn behavior and the relationship between prenatal influences and newborn behavior, on the one hand, and the relationship between newborn behavior and later development, on the other.
With the growing interest in viewing development through the lens of developmental psychobiology, the history of the NBAS suggests that it can play a key role in the emerging field of cognitive neuroscience. Combining NBAS observations with emerging neuroimaging techniques, such as event-related potentials and functional magnetic resonance imaging, should make possible a more comprehensive exploration of newborn behavioral functioning and a greater understanding of the neural underpinnings of newborn behavioral patterns (Nelson et al 2006, Nugent 2010). Finally, because the model on which the NBAS is based is, by nature, both flexible and adaptable, it can be predicted that the NBAS will continue to enrich the lives of researchers, clinicians and parents in years to come and make a unique contribution to the field.