NBAS Studies & Publications

Selected (recent) NBAS studies 

Reduced face preference in infancy: a developmental precursor to callous-unemotional traits? Rachael Bedford, Andrew Pickles, Helen Sharp, Nicola Wright and Jonathan Hill Published in 2014 in Biological Psychiatry:


Children with callous unemotional (CU) traits, a proposed precursor to adult psychopathy, are characterized by impaired emotion recognition, reduced responsiveness to others’ distress and a lack of guilt or empathy. Reduced attention to faces, and more specifically the eye region, has been proposed to underlie these difficulties, although this has never been tested longitudinally from infancy. Attention to faces occurs within the context of dyadic caregiver interactions, and early environment such as parenting characteristics have also been associated with CU traits.

The present study tested whether infants’ preferential tracking of a face with direct gaze and levels of maternal sensitivity predict later CU traits.  The Neonatal Behavioral Assessment Scale (NBAS) was administered to the intensive sample at 5 weeks after birth in the laboratory. Because the focus of this study was face preference, we used only two subscales: 1) orientation to the human face, assessed as the extent to which the infant moves eyes and head to track the administrator’s face over a 180-degree horizontal arc and 30 degrees vertically and 2) orientation to an inanimate visual stimulus, a red ball (while the administrator keeps his or her face out of the infant’s line of vision).

Controlling for a range of confounders (e.g. deprivation) lower preferential face tracking predicted higher CU traits (p = 0.001). Higher maternal sensitivity predicted lower CU traits in girls (p = 0.009) but not boys. No significant interaction between face tracking and maternal sensitivity was found.

Conclusions: This is the first study to show that attention to social features during infancy, as well as early sensitive parenting, predict the subsequent development of CU traits. Identifying such early atypicalities offers the potential for developing parent-mediated interventions in children at-risk for developing CU traits.

Reduced Face Preference in Infancy: A Developmental Precursor to Callous-Unemotional Traits? - ResearchGate.

Neurobehavioral conditions and effects of gender, weight and severity in preterm infants according to the Neonatal Behavioral Assessment Scale. Alicia Alvarez-Garcia, Albert Fornieles-Deu, Carme Costas-Moragas, Francesc Botet-Mussons.  Published in 2014 in Anales de Psicología. 


The increasing number of preterm babies in recent years has raised interest in studying the consequences of prematurity as a risk factor. In the present paper, 30 preterm babies (at 40 weeks of gestational age) were assessed using the Neonatal Behavioral Assessment Scale and the results were compared with those of a control group of 28 full term babies. Moreover, the influence of weight, sex and gestational age was analyzed considering the Brazelton results in the preterm group.

The preterm group showed significantly lower scores than the control group for 9 of the 28 behavioral items in the Scale and for 2 of the 5 clusters. However, preterm babies performed better in habituation to disturbing stimuli (light and noise) during sleep. In relation to the influence of sex, premature girls performed better in the Social-Interactive cluster.

The preterm group has lower neurobehavioral conditions than the full term group, probably due to the abrupt interruption of their intrauterine maturation. In contrast, they showed a better ability of habituation, maybe as a consequence of a learning effect due to earlier additional extrauterine exposition.

Cord blood lead and manganese and neonatal behavior. Sharon K. Sagiv, J. Kevin Nugent, T. Berry Brazelton, David C. Bellinger, Chitra Amarasiriwardena, Paige E. Tolbert, Susan A. Korrick. Presented at the Society for Epidemiologic Research (SER), Boston, June, 2013.


788 mother-infant pairs infants born 1993-98 to mothers residing close to a PCB-contaminated harbor, New Bedford, MA for duration of pregnancy.  They were longitudinally assessed in the newborn period on the NBAS infancy, at school age (8+ years), and in adolescence (15+ years). Results showed that cord blood lead and manganese was associated with attention items, including alertness; Associations with state and motor-related outcomes less consistent and imprecise; Manganese associated with better consolability. Suggestive associations for lead and manganese and NBAS clusters, specifically habituation and regulation of state.  Low-level prenatal cord blood lead and manganese modestly related to infant behavior, particularly attention.  Protective associations (i.e., with consolability) may be explained by beneficial effect of manganese (an essential nutrient.  Identifying sensitive tests of neuropsychological function in early childhood could allow for earlier intervention. Targeting modifiable risk factors for adverse behavioral outcomes is a public health priority.

Neurobehavioral outcomes in preterm, growth-restricted infants with and without prenatal advanced signs of brain-sparing. F. Figueras, R. Cruz-Martinez, M. Sanz-Cortes, A. Arranz, M. Illa, F. Botet, C. Costas-Moragas and E. Gratacos. Ultrasound in Obstetrics & Gynecology, 2011, 38, 3, 288-294.


Objective: To evaluate the neurobehavioral outcomes of preterm infants with intrauterine growth restriction (IUGR), with and without prenatal advanced brain-sparing.

Methods: A cohort of IUGR infants (birth weight < 10th percentile with abnormal umbilical artery Doppler) born before 34 weeks of gestation was compared with a control group of appropriate-for-gestational age infants matched for gestational age at delivery. MCA pulsatility index was determined in all cases within 72 hours before delivery. Neonatal neurobehavior was evaluated at 40 weeks' ( ± 1) corrected age using the Neonatal Behavioral Assessment Scale. The effect of abnormal MCA pulsatility index (< 5th percentile) on each neurobehavioral area was adjusted for maternal smoking status and socioeconomic level, mode of delivery, gestational age at delivery, pre-eclampsia, newborn illness severity score and infant sex by multiple linear and logistic regression.

Results: A total of 126 preterm newborns (64 controls and 62 IUGR) were included. Among IUGR fetuses, the proportion of abnormal MCA Doppler parameters was 53%. Compared with appropriate-for-gestational age infants, newborns in the IUGR subgroup with abnormal MCA Doppler had significantly lower neurobehavioral scores in the areas of habituation, motor system, social-interactive and attention. Similarly, the proportion of infants with abnormal neurobehavioral scores was significantly higher in the IUGR subgroup with abnormal MCA Doppler parameters in the areas of habituation, social-interactive, motor system and attention.

Conclusion: Abnormal MCA Doppler findings are predictive of neurobehavioral impairment among preterm newborns with IUGR, which suggests that this reflects an advanced stage of brain injury with a higher risk of abnormal neurological maturation.

Increased Fetal Brain Perfusion and Neonatal Neurobehavioral Performance in Normally Grown Fetuses. Mula R., Savchev S., Parra M., Arranz A., Botet F., Costas-Moragas C., Gratacos E., Figueras F. (2013) Fetal Diagnosis and Therapy, 33:182-188 (DOI:10.1159/000350699)


Objective: To explore the association between fetal cerebroplacental ratio (CPR) and frontal brain perfusion at third trimester with neonatal neurobehavioral performance in normally grown fetuses. Methods: CPR and frontal brain perfusion measured by fractional moving blood volume (FMBV) were assessed in 258 consecutive healthy fetuses at routine third trimester scan (32-35.6 weeks). Neonates were evaluated with the Neonatal Behavioral Assessment Scale. The association between Doppler parameters and neurobehavior was analyzed by MANCOVA (multiple analysis of covariance) and logistic regression, with adjustment for smoking, socioeconomic class, mode of delivery, gestational age at birth, postnatal days at examination and gender.

Results: Fetuses with increased FMBV (in the upper quartile) had lower neurobehavioral scores in all areas, reaching significance in motor (5.6 vs. 5.8; p = 0.049), social (6 vs. 6.4; p = 0.006) and attention (5.3 vs. 5.9; p = 0.032). Fetuses with increased FMBV had higher risk of abnormal (<10th centile) motor (OR 3.3; 95% CI 1.36-8.1), social (OR 2.9; 95 CI% 1.33-6.5) and attention (OR 2.5; 95% CI 1.1-5.8) scores. Fetuses with lower CPR (in the lower quartile) did not differ in their neurobehavioral scores from those with normal values.

Conclusions: Normally grown fetuses with increased frontal brain perfusion have poorer neurobehavioral competences, suggesting a disrupted neurological maturation. The results support the existence of forms of placental insufficiency not detected by current definitions of growth restriction.

THE JOINT CONTRIBUTIONS OF MATERNAL DEPRESSION AND INFANT NEGATIVE EMOTIONALITY TO MATERNAL SENSITIVITY TO INFANT DISTRESS. Jonathan Hill1, Andrew Pickles2, Helen Sharp3, Charlotte Cecil4, 1University of Manchester, Manchester, UK, 2King's College London, Institute of Psychiatry, London, UK, 3University of Liverpool, Liverpool, UK, 4University College London, London, UK. Presented at the 14th World WAIMH Congress, Edinburgh, June 2014.


Introduction: Maternal depression and lower parenting sensitivity are often associated during infancy. Yet, little is known about (i) the role of infant emotionality and its interplay with maternal depression in the prediction of maternal sensitivity and (ii) whether these emotion-laden processes may be particularly relevant to maternal sensitivity to distress.

Method:  We studied 260 first-time mothers and their infants from a general population prospective study of families recruited in pregnancy. Infant negative emotionality was assessed at 5 weeks of age using the Neonatal Behavioral Assessment (NBAS), and mothers were interviewed for DSM Major Depressive episodes over the first 29 weeks after birth. Maternal sensitivity was observed at 29 weeks in a standardized play procedure.

Results: Controlling for a range of potential confounders, neither maternal depression nor infant negative emotionality independently predicted maternal sensitivity, but the interaction between them was statistically significant (p = .01). Increasing infant negative emotionality predicted decreasing maternal sensitivity to distress, only in mothers who experienced an episode of Major Depressive Disorder during the post natal period. This effect was not seen for sensitivity to non-distress, although the test of the difference between the effects was not statistically significant (p = .07).

Conclusions: These findings suggest that maternal depression during the first months of infant life may create an affective and cognitive vulnerability to the effects of frequent intense infant negative emotions. The findings have implications for our understanding of psychological processes underlying maternal sensitivity, and hence for early interventions.

EXPOSURE TO MATERNAL CHILDHOOD ABUSE AND DEPRESSION IN UTERO: EFFECTS ON NEONATAL BEHAVIORAL REGULATION AND THE HYPOTHALAMIC-PITUITARY-ADRENAL (HPA) AXIS Carmine M Pariante, Susan Conroy, Enrica Fantini, Sarah Osborne, Susan Pawlby, Patricia Zunszain, King's College London, Institute of Psychiatry, London, UK. Presented at the 14th World WAIMH Congress, Edinburgh, June 2014.


Introduction: Childhood abuse predicts maternal depression at vulnerable times such as the perinatal period. Furthermore maternal depression in pregnancy is associated with poor neonatal outcome. Here we examine the effect of a mother's own experience of childhood abuse and of a major depressive disorder in pregnancy on the neonate's regulatory behavior.

Method:  Sixty-six women were assessed at 25-weeks' gestation for Major Depressive Disorder (MDD; SCID-I) and for childhood abuse (CA; CECA-Q: Bifulco, 2005). Fifty-five neonates (15 offspring of mothers with neither MDD nor CA; 10 of mothers with MDD only; 8 of mothers with CA only; 22 of mothers with MDD and CA) were assessed with the Neonatal Behavioral Assessment Scale (NBAS). Neonatal salivary cortisol was measured before and after the assessment.

Results:  Group differences were found in the NBAS scores (alertness:  KW(3)=13.40, p=.004; irritability: K-W(3)=8.24, p=.04). Compared with offspring of CA only mothers, those with MDD only mothers were less alert (z=2.89; p<.05) and more irritable (z=2.22; p<.05); likewise, offspring of mothers with MDD and CA were less alert (z=3.47; p<.05) and more irritable (z=2.52; p<.05). No differences were found in the NBAS scores of offspring of mothers with neither MDD nor CA compared with the other groups. Difficulties in neonatal regulatory behavior were significantly correlated with increased cortisol levels following the NBAS (alertness: r=-.41, p=.002; irritability: r=.39, p=.005).

Conclusions: Prenatal exposure to MDD with or without maternal CA is associated with dysregulated neonatal behavior and increased HPA axis activity following the stress of being handled. One explanation why offspring exposed to maternal CA only had high alert and low irritability scores may be their over-regulation and unresponsivity to stress.

The relationship between newborn behavior patterns and reactivity categories at four months of age: implications for emotional-self regulation.   J. K. Nugent, Snidman, N., Kagan,J., Shih, M.C. C. Matson, S. Bujoreanu, J. Gillette, S. Ming. Presented at the 14th World WAIMH Congress, Edinburgh, June 2014.


The purpose of this prospective study was to examine the relationship between specific newborn behavior patterns that are involved in developing self-regulation and infant temperament at four months of age.  Previous research has suggested that behaviors at four months of age relate to behavioral profiles in the second year of life as well as to twelve and fifteen years of age (Kagan and Snidman, 1991, 2004; Kagan et al. 2007; Snidman and Kagan, 2007).   The present study was designed to extend these findings to the newborn period.  

Methods: Seventy-two Caucasian healthy full-term newborns were observed and evaluated on the revised Neonatal Behavioral Assessment Scale (NBAS-R) between 24-72 hours after birth. Each infant was classified as High or Low Cry, based on the number of crying episodes and as Easy or Difficult to Console, based on the capacity of the infant to be consoled during the administration of the NBAS. At four months, fifty-eight of the newborns (30 males) returned to the laboratory for a behavioral temperament assessment.  Three temperament categories were derived from the assessment: High Reactive (high cry-high motor), Low Reactive (low cry-low motor) and Other (high cry-low motor and low cry-high motor).  Also at one and four months of age, mothers filled out the Behavioral Observation Questionnaire (BOQ), a measure of cry and motor activity. 

Results: 78% of the infants classified as High Reactive at four months had been classified as High Cry in the newborn period, while only 38% of the other two groups were coded as High Cry in the newborn period (p.<03).  In addition, 67% of infants classified as High Reactive at four months were classified as Difficult to Console in the newborn period, compared to 21% in the low-reactive and other categories (p.<01). There was no relation between newborn cry and consolability scores with BOQ scores at one month or 4 months.

Conclusion: these results demonstrate a relationship between behavioral profiles important to self-regulation observed during the newborn period and temperamental categories at four months of age based on observed behaviors but no relation between the two ages based on mother report.

Crying and Behavioral Characteristics in Premature Infants. Kusaka, R., Ohgi, S., Shigemori, K., Fujimoto, T. (2008). J Jpn Phys Ther Assoc, 11(1): 15–21.


The aims of this study were to analyze 1) whether there was the relationship between the neonatal behavioral characteristics and amount of crying in premature infants at term age, and 2) what kind of difference between infants with high levels of crying and cry less on neonatal behavioral characteristics using the Neonatal Behavioral Assessment Scale (NBAS). 

Methods: The study participants consisted of 69 healthy low birth-weight infants who were admitted to the NICU at the Nagasaki University Hospital, Nagasaki, Japan. This study analyzed the relationship between NBAS scores measured neonatal behavioral performance and crying at term age. 

Results: This study results indicate that there was significant statistical negative correlation between the amount of total daily crying and Habituation, Range of state, Regulation of state, and Autonomic stability cluster scores and some individual items scores (Response decrement to light, Response decrement to tactile of foot, Alert responsiveness, Examiner persistence, Motor maturity, Irritability, General irritability, Cuddliness, Consolability, Self-quieting activity, and State regulation). The high levels crying group also showed higher responsivity than less crying group in the items of Peak of excitement, Rapidity of build-up, Irritability and General irritability. 

Conclusion: In conclusion, neonatal behavioral characteristics such as poor inhibit discrete stimuli while asleep, hyper-responsivity and poor state regulation abilities were risk factors of high levels of crying.

Psychometric evaluation of the Brazelton Scale in a sample of Spanish newborns. Costas Moragas, C., Fornieles Deu, A., Botet Mussons, F., Boatella Costa, E., de Caceres Zurita, M.L. (2007). Psicothema, 19, 1, 140-149.   


This study analyses the data obtained from a sample of 220 healthy full-term neonates evaluated with the Neonatal Behavioral Assessment Scale, NBAS, 3rd edition. Standard scores were obtained for each of the 35 behavioral items and analysis of the main components of all the clusters was performed. Similarly to the original scale, the five following factors were obtained: Autonomic and Motor Systems, Habituation, State Organization, State Regulation, and Social Interactive. The analysis of the reliability of these groupings reveals that it is between moderate and high (the average Cronbach's alpha coefficient was.78).

Neurobehavioural profile of low- birthweight infants with cystic periventricular leukomalacia. Ohgi S., Akiyama, T., Fukuda, M. (2005). Developmental Medicine & Child Neurology, 47: 221–228


Twenty-three low-birthweight infants (17 males, six females) diagnosed with cystic periventricular leukomalacia (PVL; median gestational age 30wks, postmenstrual age range 25 to 36wks; median birthweight 1365g, range 680 to 2010g) were evaluated and compared with 209 comparison infants (117 males, 92 females; median gestational age 33wks, postmenstrual age range 25 to 39wks; birthweight 1771g, range 670 to 2460g). There were three assessment times: 36 to 38 weeks (preterm), 40 to 42 weeks (term), and 44 to 46 weeks (post-term); the Neonatal Behavioral Assessment Scale (NBAS) was used for assessment. Outcome at 2 years was assessed on the basis of a neurological examination, magnetic resonance imaging, computerized tomography, electroencephalography, and the Mental and Psychomotor Development Indices of the Bayley Scales of Infant Development. All infants in the PVL group were found to have evidence of cerebral palsy, whereas all infants in the comparison group were normally developing. Infants with PVL performed more poorly on all elements of the NBAS examination at all three assessment times compared with the comparison group. They demonstrated poorer motor control, less responsiveness to environmental stimuli, less regulatory capacity, and more abnormal reflexes compared with the comparison group. These results suggest that LBW infants with PVL show dysfunction and/or disorganization in their neurobehavioural systems in the neonatal period. Assessment of neonatal neurobehavioural characteristics using the NBAS may assist clinicians in identifying LBW infants with PVL, and in formulating plans for the developmental care of these infants.

Correspondence to first author at Department of Rehabilitation, Seirei Christopher College, 3453 Mikatabara-cho, Hamamatsu, Shizuoka 433-8558, Japan. E-mail: