Understanding Newborn Behavior and Early Relationships

The Newborn Behavioral Observations (NBO) System Handbook

J. Kevin Nugent, Constance Keefer, Susan Minear, Lise Johnson, Yvette Blanchard

• Publisher: Brookes Publishing
• Year: 2021
• ISBN:
  9781681255071
• Topic: Medicina
• Subtopic: Perinatologia e neonatologia

Giving babies a "voice" helps parents understand their baby's unique strengths and needs. This observational tool and handbook, complete with beautiful four-color photographs by a Pulitzer prize-winning photographer, gives professionals a systematic way to help parents respond with confidence to their baby's individual needs—and build positive parent–professional relationships in the process. Flexible, easy to integrate into everyday practice, and based on more than 25 years of research, this system includes

• A short, easy-to-use, interactive observational tool. With the Newborn Behavioral Observations (NBO) system, professionals will have a structured set of 18 observations for infants from birth to approximately 3 months. Including parents as partners, professionals guide the observation, discuss the baby's abilities and behaviors with parents, encourage parent insights and questions, and suggest specific ways to support the child's development. (Appropriate use of the NBO tool in clinical practice requires training through the NBO training program.)
• A complete guide to the NBO system. Through realistic case studies, step-by-step how-to instructions, and color photos illustrating each NBO item, professionals will understand how to use the NBO effectively with a wide variety of families.
• Invaluable professional guidance. More than a tool, the handbook helps professionals improve their daily work with in-depth information on infant and parent development, cultural competence, premature and at-risk infants, family–centered care, and more.

An essential resource from the co-author of the highly regarded Neonatal Behavioral Assessment Scale (NBAS) and his colleagues, this system is just what clinicians in hospital, clinic, or home settings need to help new mothers and fathers get to know their baby, increase their confidence and competence as parents, and support their child's growth and development.

1

AN INTRODUCTION TO THE NEWBORN BEHAVIORAL OBSERVATIONS SYSTEM

This chapter is divided into three sections. The first section describes the history, content, and uses of the Newborn Behavioral Observations (NBO) system; the second section presents the underlying theoretical assumptions of the NBO; and the third section presents a series of clinical principles that govern the use of the NBO.

BACKGROUND OF THE NEWBORN BEHAVIORAL OBSERVATIONS SYSTEM

This section describes the history, content, and uses of the Newborn Behavioral Observations (NBO) system.

History

The development of the NBO is based on more than 30 years of research and clinical practice with the Neonatal Behavioral Assessment Scale (NBAS) and was shaped by the authors’ clinical work in a variety of environments working with infants and families. It also was inspired by the formative influence of T. Berry Brazelton, whose teaching and mentoring have shaped the authors’ understanding and appreciation of newborn behavior on the one hand and molded their clinical stance toward parents and families on the other hand. His pioneering work with the NBAS on the nature of individual differences in newborn behavior and his respectful, nonjudgmental clinical stance toward parents in his clinical teaching influenced both the content and the clinical approach of the NBO.

In terms of helping both scientists and practitioners understand the newborn infant, it is widely recognized that the single most important advance in the study and the assessment of the newborn infant was the development and publication of the NBAS by Dr. Brazelton and his colleagues in 1973 (Brazelton, 1973, 1984; Brazelton & Nugent, 1995). For much of the 20th century, it had been assumed that the newborn infant was a blank slate—a reflex organism that operates at a brain stem level. However, a new body of research on newborn capabilities in the 1960s and 1970s and the introduction of the concept of newborn behavioral state by Wolff (1966) led to a greater appreciation of the human newborn as a responsive organism capable of organized behavior, which, in turn, contributed to the development of a new generation of neonatal scales. Because it yields a comprehensive description of newborn competencies on the one hand and identifies individual differences in newborn behavior on the other hand, the NBAS can be said to have begun where other scales left off.

Extensive research has shown that the NBAS is sensitive to a wide range of perinatal variables, such as the effects of intrauterine growth restriction; the prenatal ingestion of cocaine, alcohol, caffeine, and tobacco; or the effects of prematurity. The NBAS remains the most comprehensive assessment of newborn behavior available; as such, it can be said to have played a major role in expanding the understanding of the phenomenology of newborn behavior.

Although the NBAS has been used primarily as a research instrument, it also has been used as a clinical or educational tool to attune parents to their infant's capabilities (Nugent, 1985; Nugent & Brazelton, 1989, 2000). The scale has been adapted or modified to render it more effective as a teaching tool for parents. A number of scales were developed for use in clinical environments, as a form of parent education or intervention. Field et al. (1978) developed the Mother's Assessment of the Behavior of the Infant to involve mothers actively in the assessment of their child. By incorporating behavioral items and concepts from the NBAS into the routine physical pediatric examination, Keefer (1995) developed the combined physical and behavioral neonatal examination to help promote a more parent-centered approach to pediatric care. Gomes-Pedro et al. (1995), in their efforts to sensitize parents to the behavior of their newborns, effectively tested a shortened version of the NBAS for use as the newborn pediatric discharge examination. Cardone and Gilkerson (1990) also used the concepts of the NBAS to develop the Family Administered Neonatal Activities.

With the growing recognition of the importance of the newborn period as a unique opportunity for preventive intervention with families, Nugent (1985) developed a manual for clinicians, providing guidelines on how to use the NBAS as a teaching tool in clinical environments. The approach itself and the manual can be said to be the precursor to or the first iteration of the NBO and the training material described in this handbook. A series of studies, summarized by Brazelton and Nugent (1995) and Nugent and Brazelton (1989, 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. Specifically, a number of studies consistently have reported positive effects of exposure to the NBAS on variables such as maternal confidence and self-esteem, paternal attitudes toward and involvement in caregiving, parent–infant interaction, and developmental outcome. Parker, Zahr, Cole, and Brecht (1992), for example, invited mothers to participate actively in the behavioral assessment of the infant in the neonatal intensive care unit environment, and Rauh, Achenbach, Nurcombe, Howell, and Teti (1988) used the NBAS serially in the neonatal intensive care unit as a teaching tool with mothers of low birth weight infants. Studies by Anderson and Sawin (1983), Beeghly et al. (1995), Gomes-Pedro et al. (1995), Hawthorne-Amick (1989), Myers (1982), Rauh et al. (1988), Widmayer and Field (1981), and Worobey and Belsky (1982) and the meta-analysis by Das Eiden and Reifman (1996) all reported positive effects of the NBAS on various developmental and parenting outcomes. The results from these controlled studies encouraged us to develop the Newborn Behavioral Observations system as a tool clinicians could use to support parents and strengthen their relationship with their infant.

Content and Uses of the NBO

The NBO system, initially known as the Clinical Neonatal Behavioral Assessment Scale, comes from this tradition and grew from the authors’ desire to provide clinicians with a scale that retained the conceptual richness of the NBAS but shifted the focus from assessment and diagnosis to observation and relationship building. The underlying concepts of newborn behavior, therefore, are complemented by theoretical principles that describe the transition to parenthood and the nature of the parent–infant relationship and by clinical principles that describe the nature of relationship building in clinical practice. Moreover, the NBO was designed to be flexible and easy to use so that it could be integrated easily into the care of newborn families, whether in hospital, clinic, or home environments.

The NBO was created to sensitize parents to their infant's competencies, with a view to helping them understand their infant's behavior and thereby promote positive interactions between parents and their new infant and contribute to the development of a positive parent–infant relationship. It is conceived of as an interactive system, one in which parents play an active role in both the observations of their infant's behavior and the identification of appropriate caregiving strategies. Therefore, although the theoretical principles that guide the use of the NBO and the accompanying training program include many of the conceptual themes that informed the NBAS, they also are informed by theoretical and clinical principles from the fields of child development, behavioral pediatrics, nursing, developmental and clinical psychology, physical and occupational therapy, early intervention, and infant mental health.

The NBO is made up of 18 behavioral observations. These items were selected to operationalize the theoretical framework on which the NBO was based. They draw on the understanding of the richness of the newborn's behavioral repertoire, on the appreciation of the wide range of variability in newborn behavior, on the understanding of the developmental agenda of the human newborn across the first months of life, and on the understanding of the developmental challenges that parents face in these early months. The items that are included in the NBO also incorporate the understanding of the ontogeny of the parent–infant relationship in the transition to parenthood and the influence of the infant on the parent–child relationship. The NBO items include observations of the infant in sleep, awake, and crying states and the degree to which the states are integrated or organized. The individual behaviors were selected to represent the developmental tasks that newborns face across the first months of life and were designed to capture the process by which the autonomic, motor, organization of state, and responsivity (AMOR) domains become integrated. The autonomic domain is represented by observations of the infant's response to stress, such as the amount of color change, startles, or tremulousness. Observations of motor tone in the arms and legs, activity level, the crawl response, and sucking and rooting reflexes represent the motor domain. The infant's state regulation, or the organization of state domain, is captured by observations of the infant's capacity for habituation or sleep protection, the amount of crying, and the ease with which he or she can be consoled or his or her capacity for self-consoling and the nature of transitions between states. Finally, the infant's response to visual and auditory stimulation, including social interaction, represents the attentional-interactive domain, or the responsivity domain.

The NBO may take between 5 and 10 minutes to administer if all of the 18 behaviors can be observed, but its length and, indeed, its focus will be shaped not only by the infant's behavior and the needs of the parents but also by the nature and the clinical goals of each particular session. For that reason, it may take 5 minutes or 1 hour, depending on the goals of the clinician, the needs of the family, and the nature of the relationship between the clinician and the family. The NBO is appropriate for use from birth to the third month of life and can be used in a range of clinical environments, including in-hospital, outpatient, and in-home environments.

Administration of the NBO must be flexible, and the administration sequence is always driven by the infant's state. Therefore, if the infant is sleeping at the beginning of the session, then the NBO begins with the administration and discussion of the habituation items. If, however, the infant is crying, then the session begins with the soothability item, as befits the infant's state. In general, the administration is shaped by a number of factors, including the robustness or frailty of the infant, the focus or concerns of the parents, and the goals and the purpose of the NBO session itself. Most important, the parents’ participation is central to the administration of the NBO. Their own previous observations of their infant's behavior, such as crying or soothing experiences, and their interpretation of these behaviors all inform and shape the direction of the session. Parents can be invited to administer parts of the NBO, such as eliciting the infant's response to the parents’ voices or soothability, as a way of drawing parents further into the center of the interaction. The following are the NBO items:

Introduction and observation of infant state with parents

1.Habituation to light (flashlight)

2.Habituation to sound (rattle)

Uncover and undress (optional)

3.Muscle tone: legs and arms

4.Rooting

5.Sucking

6.Hand grasp

7.Shoulder and neck tone (pull-to-sit)

8.Crawling response

9.Response to face and voice

10.Visual response (to face)

11.Orientation to voice

12.Orientation to sound (rattle)

13.Visual tracking (red ball)

14.Crying

15.Soothability

16.State regulation

17.Response to stress (color changes, tremors, and startles)

18.Activity level

Although these 18 observations make up the full set of NBO observations, it should be pointed out that some of them are summary observations, such as crying, state regulation, response to stress (color change, startles, and tremors), and activity level.

In sum, the NBO can be described as an individualized, infant-focused, family-centered observational system that is designed for use by practitioners to elicit and describe the infant's competencies and individuality, with the explicit goal of strengthening the relationship between the parent and the child and promoting the development of a supportive relationship between the clinician and the family.

UNDERLYING THEORETICAL ASSUMPTIONS

The theoretical assumptions underlying the NBO, which will be expanded and elaborated on throughout this volume, provide the clinician with a framework within which to understand newborn and infant behavior and development, on the one hand, and parent and family development, on the other, so that he or she can use the NBO in a way that is individualized, theoretically robust, and developmentally sound. Here, we will summarize some of the key theoretical principles on which the NBO is based.

The Competent Infant

The NBO is based on the assumption that newborns come into the world with a wide array of mental skills and predispositions and a set of abilities that are uniquely suited to the critical needs of early life. Recent research has yielded an extensive taxonomy of newborn and infant behavior. The newborn infant not only can see but also has clear-cut visual preferences, as Fantz (1961) pointed out many years ago. Fantz reported that infants preferred to look at visual patterns that they had never seen before in contrast to patterns that they had seen. This has been confirmed by a number of more recent studies demonstrating that newborns can focus and visually track stimuli (Dannemiller & Freedland, 1991; Laplante, Orr, Neville, Vorkapich, & Sasso, 1996; Slater, Morison, Town, & Rose, 1985). Newborns have certain scanning preferences and are sensitive to eye gaze from the beginning. Not only can newborns track visually, but they also prefer the mother's face and can even discriminate their mother's face from that of a stranger (Pascalis, de Schonen, Morton, Deruelle, & Fabre-Grenet, 1995).

It therefore is clear that biology has programmed the human newborn to be a prosocial organism that actively seeks contact with the social and physical world, and the biological competencies at birth guarantee that the infant is able to interact with the physical and social environment. Newborns not only can distinguish between contrasting physical patterns but also are able to explore the internal features of the face and to gather cues about the partner's emotions (Blass & Camp, 2003; Trevarthen, 1993). Newborn infants seem to prefer the human face over all other stimuli, and are sensitive to eye gaze from the beginning. Farroni, Massaccesi, Pividori, and Johnson (2004), for example, showed that newborns looked significantly more at a face with direct gaze than at a face with averted gaze. The infant's gaze behavior not only regulates his or her internal physiological state but also signals his or her readiness to engage in communication. The infant's visual system, therefore, serves to elicit a dyadic form of interchange, which helps a parent recognize that the infant indeed is a fully responsive human being—a person with an individual personality.

In terms of sensitivity to the interpersonal context of their new world, there is evidence that infants are able to discriminate between different affective facial expressions (e.g., happy, sad, surprised) and even are capable of imitating these expressions (Field, Woodson, Greenberg, & Cohen, 1982). Indeed, newborns can imitate both in the visual and auditory modalities, which include not only mouth, tongue, and other facial movements but also eye blinking and sequential finger movements (Meltzoff & Moore, 1999). An equally important finding for the clinician who uses the NBO is the discovery by Als in her work with the Assessment of Preterm Infant Behavior and the current authors’ work with the NBAS that gaze aversion suggests the need to withdraw from an overly demanding situation or the need to recover from the excitement of the interaction (Als, 1982, 1986; Brazelton et al., 1974; Brazelton & Nugent, 1995). The NBO is based on the assumption, therefore, that the main task or challenge that the newborn faces is to organize and integrate the new world of sights, sounds, faces, and voices in a way that is both understandable and predictable. In other words, the newborn seems to come into the world with a set of social capabilities that enable him or her to read and decipher the emotional expressions of the caregiver as well as to interact with the caregiver, playing a vital role in the development of the parent–infant bond (Klaus, Kennell, & Klaus, 1995).

The newborn also can hear and locate sounds (Muir & Field, 1979) and seems to prefer higher pitched voices or, more specifically, the mother's voice (Clarkson & Clifton, 1995; deCasper & Fifer, 1980; deCasper & Spence, 1991; Ecklund-Flores & Turkewitz, 1996; Fifer, 1993; Fifer & Moon, 1994; Moon, Cooper, & Fifer 1993; Morrongiello, Fenwick, Hillier, & Chance, 2004; Querleu, Renard, Boutteville, & Crepin, 1989; Spence & Freeman, 1996). Indeed, newborns can detect the overall patterns of rhythm and pitch that differentiate one person's voice from another's and can discriminate between languages (Nazzi, Floccia, & Bertoncini, 1998). There even is evidence to suggest that newborns can discriminate between two vowels (Moon et al., 1993) and between unfamiliar whispered voices (Spence & Freeman, 1996). Newborns can remember speech sounds (Swain, Zelazo, & Clifton, 1993) and specific musical sounds (Hepper, 1991). Newborns also seem to be able to detect the sounds of any language and can make fine-grained distinctions between many speech sounds (e.g., “ba” and “ga,” “ma” and “na”) and show a greater sensitivity to low-frequency sounds as compared with adults, who show maximum sensitivity to high frequencies (Aldridge, Stillman, & Bower, 2001). It is their adaptive value that renders these remarkable capacities so important to the newborn because, taken together, they serve one of the major developmental functions of the infancy period, namely, the promotion of mother–infant attachment.

Although infants have very specific visual and auditory capabilities, it is evident that they are competent in all five sensory modalities. Revie...