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NBO

The Newborn Behavioral Observations (NBO) system

The Newborn Behavioral Observations system (NBO) is an infant-focused, family-centered relationship-based tool, designed to sensitize parents to their baby's competencies and individuality, in order to foster positive parent-infant interactions and thus contribute to the development of a positive parent-infant relationship from the very beginning (Nugent, Keefer, Minear, Johnson & Blanchard, 2007).   

It is a structured set of observations designed to help the clinician and parent together, to observe the infant's behavioral capacities and identify the kind of support the infant needs for his successful growth and development. The NBO is therefore inherently interactive and family-centered, so that parents are involved as partners in the NBO session.  The clinician maintains a collaborative stance towards the parents during the session, which ends with the clinician and parents developing a joint infant caregiving plan, by identifying techniques most likely to foster positive parent-infant interaction. Click here to read an article by J. Kevin Nugent on the NBO, which appeared in the Zero to Three Journal.

The NBO system consists of a set of 18 neurobehavioral observations, which describe the newborn's capacities and behavioral adaptation from birth to the third month of life. While it describes the infant's capacities, the NBO provides parents with individualized information about their infant's behavior, so that they can appreciate their baby's unique competencies and vulnerabilities and thereby understand and respond to their baby, in a way that meets her/his developmental needs. The 18 NBO items include observations of the infant's

  • capacity to habituate to external light and sound stimuli (sleep protection)
  • the quality of motor tone and activity leveltracking face copy
  • capacity for self-regulation (including crying and consolability)
  • response to stress (indices of the infant's threshold for stimulation)
  • visual, auditory and social-interactive capacities (degree of alertness and response to both human and non-human stimuli)

While the NBO attempts to reveal the full richness of the newborn's behavioral repertoire, the clinical focus is on the infant's individuality, on the aspects of behavior that make the baby unique and different. In other words, the NBO provides the baby with a "voice", with a "signature". It gives the baby an opportunity to tell the caregiver who he or she is, if you will, what her preferences are and what her vulnerabilities might be and in what areas she may need support. By providing this behavioral profile of the infant's strengths and challenges, the NBO can provide clinicians with the kind of individualized guidance that can help parents meet their baby's needs. This, in turn, will help the parents develop the kind of confidence they need to support their baby's development and enjoy the experience of being a new parent.

The NBO was designed to meet the needs of pediatric professionals who want a more relational or family-centered model of care to replace the traditional pathology-seeking biomedical model of care (Brazelton and Cramer, 1990; Stewart et. al. 1995). It is flexible and can easily integrated into hospital, clinical or home visits. The NBO offers individualized information to parents about their baby, with a view to promoting a positive bond between parent and child and between themselves and the parents and family. For that reason, the NBO is best understood as inherently interactive and family-centered, because parents are involved as partners in the NBO session throughout. So, while the NBO aims at fostering positive parent-infant interaction, it also aims at promoting a positive relationship - a partnership - between clinician and parents.

The NBO describes the newborn's capacities and behavioral adaptation from birth to the third month of life and is based on the assumption that the developmental challenges facing the newborn center on the process of self-regulation and mutual regulation.  It is designed to help the clinician and parent together, to observe the infant's self-regulation efforts and identify the kind of support the infant needs for his successful growth and development and thus strengthen parents’ confidence, and practical skills in caring for their children.   The NBO grew from our desire to provide clinicians with a tool that retained the conceptual richness of the NBAS but shifted the focus from assessment and diagnosis to observation and relationship-building.  Above all it is designed to give the baby a "voice" and to identify the baby's communication cues and language. 

While the theoretical principles guiding the use of the NBO and the accompanying training program, include many of the conceptual themes that informed our work with the NBAS, they are influenced by theoretical and clinical principles from the fields of infant mental health, child development, brain development, behavioral pediatrics, systems theory, communication studies, nursing, early intervention and cultural studies, among its influences.  Above all, the NBO was designed to be accessible and flexible so that it could be easily integrated into the care of newborn families, whether in hospital, clinic or home settings. Recent studies show that the NBO is associated with more optimal parent-infant interaction, provider confidence in meeting family needs, increased father involvement and reduction in post-partum depression symptoms (McManus and Nugent, 2011; 2012; Nugent and Dym-Bartlett, 2014, Sanders and Buckner, 2006; Alvarez-Gomez, 2007; Kashiwabara, 2012).

The NBO - origins and background

The development of the NBO is based on over 30 years of research and clinical practice with the Neonatal Behavioral Assessment Scale (NBAS) and was shaped by our clinical work in a variety of clinical settings, working with infants and families. It was also inspired by the formative influence of T. Berry Brazelton, whose teaching and mentoring has informed our understanding and appreciation of newborn behavior, on the one hand, and has molded our clinical stance towards parents and families, on the other. His pioneering work with the NBAS on the nature of individual differences in newborn behavior and his respectful non-judgmental clinical stance towards parents in his clinical teaching, influenced both the content and clinical approach of the NBO. 

With the growing recognition of the importance of the newborn period as a unique opportunity for preventative intervention with families, Nugent developed a manual for clinicians, with guidelines on how to utilize the NBAS as a teaching tool for use in clinical settings (Nugent, 1985). The approach itself and the manual can be said to be the precursor or the first iteration of the NBO system. A series of studies, summarized in Brazelton and Nugent (1995, 2011) and Nugent and Brazelton (1989, 2000), have shown that demonstrating the newborn infant's behavioral capacities to parents can serve asa mechanism for helping parents learn about their new baby, thereby strengthening the relationship between parent and child and supporting the family adjustment. The Newborn Behavioral Observations (NBO) system, comes from this tradition and grew from our 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 concepts underlying newborn behavior are, therefore, complemented by theoretical principles describing the transition to parenthood and the nature of the parent-infant relationship and by clinical principles describing 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 easily integrated into the care of newborn families, whether on hospital, clinic or home settings. We created the NBO to sensitize parents to their baby's competencies, in order to foster positive parent-infant interactions between parents and their new infant and thus contribute to the development of a positive parent-infant relationship. (Photos below shoe the NBO being used in Bangkok and Oslo, respectively)

NBO

The Newborn Behavioral Observations (NBO) system, comes from this tradition and grew from our 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 concepts underlying newborn behavior are, therefore, complemented by theoretical principles describing the transition to parenthood and the nature of the parent-infant relationship and by clinical principles describing 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 easily integrated into the care of newborn families, whether on hospital, clinic or home settings. We created the NBO to sensitize parents to their baby's competencies, in order to foster positive parent-infant interactions between parents and their new infant and thus contribute to the development of a positive parent-infant relationship. 

The NBO is conceived of as an interactive system, one in which parents play an active role in both the observations of their baby's behavior and in the identification of appropriate caregiving strategies. Therefore, while the theoretical principles guiding the use of the NBO and the accompanying training program, include many of the conceptual themes that informed the NBAS, they are informed by theoretical and clinical principles from the fields of child development, behavioral pediatrics, nursing, early intervention and infant mental health.

Recent studies show that the NBO is associated with more optimal parent-infant interaction, provider confidence in meeting family needs, increased father involvement and reduction in post-partum depression symptoms (Alvarez-Gomez, 2007Kashiwabara, 2012, McManus and Nugent, 2011; 2012; Nugent, Dym-Bartlett & Valim, 2014; Sanders and Buckner, 2006)

NBO system Training Evaluation


Professor Hui Li demonstrates the NBO to neonatologists and pediatricians at Xi'an Children's Hospital. 

In a national trial, 222 pediatric professionals from ten settings around the United States, representing inner-city, suburban, and small city sites, were trained to use the NBO. Pre- and post-training evaluations, conducted by the Philliber Research Associates, showed that 98% of the trainees agreed that the NBO was excellent or good in helping parents learn about their newborns and that it fostered parents' interest in their baby, while 97% of the trainees believed that the NBO could enhance the clinician's partnership with parents. One month after the training, trainees (n=102) continued to rate the NBO as excellent or good in providing information to parents, and a comparison of pre-training and one month responses (n=72) revealed that parents became better observers of their infants (p<.001), learned new information about their infants (p<.01) and practitioners were more "connected to" or "tuned in" to parents as a result of the NBO (p<.05). Parents themselves (n=31) reported that their understanding of their infant increased significantly as a result of the NBO (p<.001). (See Ab Initio International for more reports on the use of the NBO in clinical settings.)


Reference:  Nugent, J. K., Keefer, C., Minear, S., Johnson, L., Blanchard, Y. (2007). Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) system Handbook. Basltimore, Maryland: Paul H. Brookes. 
 



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