Heidelise Als – a worldwide leader who revolutionized the care of the preterm infant

It is with great sadness that we announce that Heidelise “Heidi” Als has died.  It is as if a giant oak tree has fallen.  Over the years many of us have sheltered in the amplitude of the leaf, the light and the shade of the great oak that was Heidi. Today, we are bereft in a world that is a much poorer place without that great tree.  We at the Brazelton Institute and at Newborn Behavior International want to extend our deepest sympathy to her husband, Dr. Frank Duffy and to her son Christopher, to all her family, to her colleagues and to the NIDCAP community around the world. 

Heidi dedicated her life to improving the care of the premature infant.    She was a one of the most brilliant, compassionate and beloved figures in our field, a person whose intellectual contributions were matched only by her deep humanity.  She was – and will continue to be - an inspirational figure, who almost single-handedly revolutionized the care of high-risk infants across the globe. Her work has had a profound influence on theory and practice and has served to humanize the care of newborns in Neonatal Intensive Care Units around the world. Those of us who have had the privilege of learning from her were never able to see babies in the same way again. 

Heidi began her professional life as a primary school teacher in her native Germany and it was in the classroom she learned how important it was to be able to “read” the language of children’s behavior in order to understand how they cope best, and then build on their own positive coping strategies.   The importance of being able to “read” the child’s behavior was reinforced for her when her son Christopher was born with severe brain challenges, and she had to learn to understand the language of his behavior in order to help him.  Coming to the United States to the University of Pennsylvania, she completed her doctoral research on preterm infants and their caregivers.  Her study demonstrated that the newborn infant could not only respond to a partner’s intimate social advances but could also initiate and try to elicit a response from the caregiver. She was irresistibly drawn to Boston to study newborn behavior with Berry Brazelton and was invited by Berry to join him at the Child Development Unit at Boston Children’s Hospital, in 1973.  Later she was to say, "Berry shaped my thinking, my work and my personal and professional development. He had a major impact on me as I raised my son, a young child with disabilities. He defended undauntedly the competence of each newborn, each infant and each parent, of all human beings; he valued and brought out the strengths and talents in everyone, everyone’s true goal for good”.

Heidi showed that she was a consummate observer of newborn behavior and was appointed by Berry to be the first trainer on the just published Neonatal Behavioral Assessment Scale (NBAS).  Since her goal was to improve the future for all newborns and especially those born early and/or with special challenges requiring intensive medical care, and for their families, she began to study preterm infants in intensive care.  She maintained that, although it is more challenging for them, preterm infants can also communicate “if only we know how to listen”, as she said in a Boston Globe Interview in 2019. “It takes standing next to someone and bringing down the stress, so the hands are soft and the baby relaxes and the mother blossoms.  . . .  It’s wonderful to see when it happens.”  Along with Berry, Barry Lester and Ed Tronick, Heidi extended the concepts of the NBAS to develop the Assessment of Preterm Infants' Behavior (APIB) in 1982.  The APIB is a comprehensive neurodevelopmental assessment of preterm and high-risk newborns, based in ethological – evolutionary thought and offers an in-depth conceptual framework of development, emphasizing subsystem interaction and continuous environmental interplay, which she called the Synactive Theory of Development.  

Heidi went on to develop the Newborn Individualized Developmental Care and Assessment Program, or NIDCAP  in the mid 1980s.  NIDCAP Care is based on the assumption that infants are considered individuals, persons, collaborators in care, supported and nurtured by their parents, so that parents are considered infants’ key nurturers, advocates and caregivers as well as collaborators in care decisions.  Heidi’s goal was to improve the future for all newborns and especially those born early and/or with special challenges requiring intensive medical care. In the pursuit of this goal, she encouraged busy doctors and nurses and everyone who worked with newborns to slow to a newborn’s pace, to convince them that small changes in how they work with newborn infants can make a world of difference to the developing brain.  As her colleague, Samantha Butler says, “She’s the one that brought all of this into people’s minds: that you can read an infant’s behavior and change the environment to support them, and improve their long-term outcomes”.  

As a researcher, Heidi focused her life research on investigating the effects of early experience on brain function and structure.  Along with her husband, Dr. Frank Duffy and collaborators Gloria McAnulty, Samantha Butler, Sandra Kosta and many others, she demonstrated that NIDCAP Care resulted in significant improvement in the health and neurodevelopmental outcomes of preterm infants as well as greater parent confidence and competence as compared to conventional, task- and schedule-oriented care.  Her research has changed the training and education of staff as well as the design of and care delivered in NICUs in the US and elsewhere.  NIDCAP Federation International, the professional organization representing the NIDCAP community worldwide, supports the NIDCAP model, caregiving and training approach in countries around the world.  Today Deborah Buehler, who began her professional career in 1982 on the original NIDCAP pilot study, as Dr. Heidelise Als’ first research assistant, is Director and President of NIDCAP Federation International.

Heidi’ work has had a profound influence on our work with newborns in our work at the Brazelton Institute with the NBAS and NBO.  She it was who trained many of us on the NBAS in the first place and helped us realise that every behavior no matter how subtle or fleeting is critical in helping us understand newborn infants in all their profound richness.  Her Synactive Theory shaped the AMOR conceptualization as the core theoretical foundation on which the NBO is based.  Our NBO professional training programs focus on the parents’ essential role in supporting the early life of newborn infants as well as the effects of the environment and of professionals’ care for newborns and their families – an approach reflecting the individualized family-centered relationship-based approach pioneered by Heidi and Berry Brazelton.

It is impossible to sum up what Heidi has meant to us or do justice to her contribution to the lives of babies and their families and to the training of healthcare providers everywhere but we can say without qualification that she was a remarkable human being – a devoted mother, a cherished teacher and mentor, a staunch intellectual who embodied honesty and trustworthiness, a dedicated clinician and conscientious researcher, a person committed to redressing social and health inequities in order to ensure that the voices of preterm infants and their families are not silenced.  Although she has passed away, we know that she will continue to stand by our sides, inspiring us, warming us with memories of her unforced self-effacing humor, always reminding us to observe the baby and take time to listen to parents.  In this time of sadness, we can find consolation in the realization that her spirit will continue to enlighten and inspire future generations of practitioners and will benefit generations of babies to come.

We will leave the last words to Shakespeare. In The Tempest, Miranda exclaims:

"O brave new world, that has such people in it"

J. Kevin Nugent