Newborn Behavioral Observations (NBO)

What is the NBO? 

The Newborn Behavioral Observations (NBO) system is a relationship-based tool that offers individualized information to parents about their baby's communication strategies and overall development, with a view to strengthening the parent-infant relationship. The NBO describes the infant's capacities in such a way that the parents can begin to see their baby as a person and learn to understand and respond to their baby in a way that meets the baby's unique developmental needs. It consists of 18 neurobehavioral observations and is designed for use from birth through the third month of life. Inspired by the Neonatal Behavioral Assessment Scale, the NBO items are designed to show that newborns possess a wide range of visual, auditory, and perceptual abilities that allow them to explore the world around them and to engage in face­ to-face, eye-to-eye mutual exchange.

The NBO is useful in a range of clinical and cultural settings and with families facing diverse challenges. It can easily be integrated into a range of clinical practices and is used in hospital, clinic, or home visit settings by pediatric professionals such as nurses, doctors, psychologists, social workers, midwives, physical and occupational therapists, doulas, communication specialists, child life specialists, lactation specialists, home visitors, and other early intervention professionals.

A Strength-Based Approach

The NBO system was developed as an interactive relationship-building tool to strengthen the relationship between infants and parents beginning in the newborn period , so that the NBO is above all, strength-based and is primarily guided by the princi­ple that the quality of early experiences drives brain development and functional outcomes.   

The First Months of Life

The newborn period and the first months of life make up a significant stage in the development of the parent–infant relationship and in infants’ behavioral adaptation to their new environment. Because it is a major transition stage in the lives of both infants and their parents, it presents clinicians with a unique opportunity to affect change at what can be called a critical transition stage in the development of the parent–infant relationship and, indeed, in the development of the family itself. It can be used to support parents at a time when the very bases for parental functioning are being established.

AMOR - Theoretical Framework

Over the first few months of life, newborns face a series of hierarchically organized tasks in self-regulation that are in some ways similar to stages. From this developmental perspective, the newborn infant is seen to confront a series of tasks or challenges as she attempts to adapt to her new extrauterine world, both the world or objects and the world of people. These tasks are summarized by the acronym AMOR, for Autonomic, Motor, Organization of State, and Responsiveness.

  • A - Autonomic/physiological stability: stabilization of breathing, temperature regulation, reducing tremors and startles, etc.

  • M - Motor regulation: development of good motor control and feeding skills; ability to maintain a controlled activity level

  • O - Organization of State: the ability to cope with stress; to be able to regulate state and develop predictable sleep-wake patterns

  • R - Responsiveness: development of a growing awareness of the environment and the capacity to process visual and social information and engage in social interaction

The Parent AMOR

Every parent is in a state of potential disequilibrium and reorganization through the transition to parenthood with the attendant possibility of crisis and opportunity for development. The Parent AMOR acronym is intended as an aide memoire for key psychic regulatory processes in parents that promote reciprocity in the relationship. These challenges are: Affect regulation, Mentalizing, Openness, and Responsiveness.

  • A - Affect regulation: firstly there is the need to re-settle heightened emotions, such as anxiety, sadness, anger.

  • M - Mentalise: then the parent needs to understand the baby’s mental state and be able to scaffold the baby’s mental state.

  • O - Openness: or being curious about “the real baby” enables the parent to become more aware of the baby’s as an individual person, whereby the parent is “in the present moment”, with more awareness, acceptance and availability to being surprised. The parent is thereby psychologically poised for

  • R - Responsiveness: to communication from the baby.

Over the first months of life, parent and developing infant find their way together, either without or with professional support. Parent AMOR regulatory functioning develops so the parents become increasingly responsive to their baby, and infant AMOR regulatory capacities develop such that they are able to be quiet alert state and socially responsive for greater periods. The scene is set for the emergence of reciprocity in the parent-infant relationship through increasingly visible moments of affective attunement, synchrony, and mutually rewarding interaction or co-regulation between infant and parent.

The NBO Clinician - Creating a Safe Space for Parents

Whether the NBO takes place in a bustling hospital ward or a busy apartment, the clinician creates a psychologically safe holding environment for the parents, a space that is respectful and non-judgmental and where the outside world ­ for now at least - is set aside, as parents, siblings, grandparents, family, and friends are invited to gather around and "meet" the baby. The baby remains at center-stage throughout the NBO. The clinician, by eliciting the baby's behaviors, is the choreographer, who not only draws out the baby's capacities through sensitive handling but also draws in the parents as the baby's primary caregivers, as part of the baby's on-stage supportive cast. Although the NBO is designed to capture the "baby's story”, clinicians provide parents with the relational space so that they feel free in sharing "the family story". The NBO is, therefore, infant-focused and family - and community -centered.

Research

Although the NBO is still in its infancy as a clinical intervention approach, a number of randomized control studies have demonstrated its effectiveness as a form of support. Infants receiving the NBO infant mental health intervention had greater gains in cognitive and adaptive functions at 6 months (McManus et al. 2020). In a number of studies, the NBO was associated with enhanced mother–infant engagement (McManus and Nugent, 2012; Nicolson et al. 2020; Nugent et al. 2017) and was effective in helping parents be more responsive to their infant’s communication cues (Kristensen et al. 2020; Høifødt et al., 2020). Studies have also shown that mothers who participated in the NBO sessions demonstrated a reduction in postpartum depressive symptomatology and reduced anxiety symptoms (McManus et al. 2020; Nicolson et al. 2022; Nugent et al. 2014). A study in Norway demonstrated that the NBO conducted in home visits is a feasible and acceptable intervention for both parents and healthcare workers within the well‐baby clinic services (Greve, Braarud, Skotheim, Slinning, 2018). Moreover, NBO practitioners demonstrated higher perceived confidence in working with low- and high-risk newborns and their families (McManus and Nugent, 2011).

In a series of non-randomized observational studies the NBO has been associated with enhanced mother–infant engagement, a greater understanding of the baby’s communication cues, increased levels of confidence among parents, positive parental perceptions of their interactions with their high-risk infants, increased levels of father involvement, and higher perceived confidence and enhanced practitioner mentalization among service providers in working with low- and high-risk newborns and their families (Alvarez- Gomez, 2014; Appleton, Nickell & Nicolau, 2016; Cheetham & Hanssen, 2014; Connorton et al. 2022; Hawthorne & Nicolau, 2017; Holland & Watkins, 2015; Kashiwibara, 2012; Nugent & Alhaffer, 2006; Sanders & Buckner, 2006; Savage-McGlynn & Hawthorne, 2014; Shah, 2018; Simkin-Tran et al. 2020; Windarti and Suryawan, 2021; Zhang et al. 2021). Congdon, Nugent, McManus, Coccia & Bush (2020) provided evidence for the reliability and validity of the NBO by demonstrating sub-scale associations with infant salivary cortisol reactivity and maternal report of infant temperament. Finally, a number of RCT studies using the NBO as a form of relationship-support are now in progress in different countries - China, Hong Kong, Japan, Brazil, Iceland, South Africa, the UK and the United States.

NBO System Items

  1. Habituation to light (sleep state)
  2. Habituation to sound (sleep state)
  3. Muscle tone in legs and arms
  4. Rooting
  5. Sucking
  6. Hand grasp
  7. Shoulder and neck tone
  8. Crawling response
  9. Visual tracking (red ball)
  10. Visual response to face
  11. Visual response to face and voice
  12. Orientation to sound (rattle)
  13. Orientation to voice
  14. Crying
  15. Soothability
  16. State regulation
  17. Response to stress- color change, startles, tremors
  18. Activity level

Source: Adapted from Nugent, Keefer, Minear, Johnson, & Blanchard (2007), Understanding newborn behavior and early relationships: The Newborn Behavioral Observations (NBD) system handbook. Baltimore, MD: Brookes.