What is the NBO?

understandingnewbornbehaviorThe Newborn Behavioral Observations (NBO) system – which was inspired by our work with the Neonatal Behavioral Assessment Scale (NBAS) – consists of 18 neurobehavioral observations, which capture the baby’s autonomic, motor, state, and social interactive behaviors in a way that is highly individualized (Nugent, J. K., Keefer, C.H., Minear, S., Johnson, L., Blanchard, Y, 2007).  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 focus of the NBO is on relationship-building rather than on assessment per se and so that we hope it meets the needs of pediatric professionals who strive for a more relational or family-centered model of care to replace the traditional pathology-seeking biomedical model of care.


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.

NBO Home visit with Tanya

NBO Home visit with Tanya

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 as a mechanism for helping parents learn about their new baby, thereby strengthening the relationship between parent and child and supporting the family adjustment. Specifically, a number of studies have consistently reported positive effects of exposure to the Neonatal Behavioral Assessment Scale on variables such as maternal confidence and self-esteem, paternal attitudes toward and involvement in caretaking, parent-infant interaction, and developmental outcome (Brazelton & Nugent, 2011).

Dad with Dr. Lise Johnson in hospital setting

Dr. Lise Johnson with Dad in hospital setting

The Newborn Behavioral Observations (NBO) system, developed by Nugent, Keefer, Minear, Johnson and Blanchard, 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 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.  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.  The NBO is conceived of, therefore, 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 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.

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. 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 et al., 2014; Sanders and Buckner, 2006; Alvarez-Gomez, 2007; Kashiwabara, 2012).



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