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The Neonatal Behavioural Assessment Scale

The Neonatal Behavioural Assessment Scale (NBAS) was developed by Dr T. Berry Brazelton in Boston, Mass., USA during the 1960's and first published in 1973. Dr. Brazelton is a paediatrician with training in child psychiatry, and he used the positive model of child development and parenting for the NBAS, and not the deficit model of paediatrics and child psychiatry. He also uses the systems theory of family dynamics for his view on parent-child relationships. The NBAS is a neuro-behavioural assessment of the newborn, designed to document the newborn's contribution to the parent-infant system, the competencies and individual differences of the newborn, as well as any difficulties. The main feature of the NBAS is that it is an interactive assessment, which gives a clear profile of the baby's behaviour, and how it must feel to parent the baby. The examiner's role is to facilitate the newborn's best performance. For example, the examiner will contain the newborn physically if necessary by swaddling, so that the infant can be as organised and alert as possible when tracking an object or turning to a sound.

It is now well-known that early experience has an effect on later behaviour, and that patterns of interaction are set by three months of age. It is also well-known that the newborn is no longer a passive recipient to environmental stimuli, but is capable if identifying his or her mother's voice and smell, and the mother's face compared to a stranger's face. There are many effects on newborn behaviour, such as genetic endowment, intra-uterine nutrition and infection, the effects of drug-addiction in the mother, perinatal events such as maternal medication and anaesthesia, or episodes of hypoxia. These factors will affect the newborn's capacity to interact with caregivers and the environment. The NBAS can be used with any full-term baby from birth to 2 months old. It is possible to use it with premature babies from about 35 weeks gestation, and also it can be used with developmentally delayed babies.
The concepts behind the Brazelton assessment can be applied to almost any age group:

  • Assessing the strengths and abilities of the child
  • Sharing the child's behaviour with the parents
  • Validating the parent's observations
  • Providing information on development and discussing care giving methods for the particular child
  • Forming a collaborative relationship between health professional and parent

There are now over 500 research studies worldwide that have used the NBAS. One if its most recent uses is as an intervention with parents. It has been used with postnatally depressed mothers, mothers of premature infants, mothers of babies with congenital problems or mothers with particular difficulties in interacting with their babies. As an intervention, it is seen as a collaboration between clinician and parents and it is not prescriptive, but is used as a mutual exploration of the infant's characteristics. It is a valuable way of creating a rapport with parents and alerting them to the newborn's behaviour, which can be seen as the baby's language. Observing the NBAS helps sensitise parents to the behavioural capacities of the newborn, and studies where parents have seen it done show improved mother-infant reciprocity scores, and enhanced paternal involvement. The NBAS can also be used as an educational tool for staff, as it can help them understand the caregiver's response to the infant and the kinds of interactions he or she is likely to have. When summarising the NBAS with parents and staff, there can be a discussion of caregiving implications and follow-up planning.

The Content of the NBAS

There are 28 behavioural items each scored on a 9-point scale, which assess the infant's behavioural response to positive and negative stimuli. The materials used for the assessment are a torch, bell, rattle, and a red ball to look at habituation and orientation. The examiner's face and voice are also used for orientation. There are 18 reflex items, each scored on a 4-point scale, which assess the infant's neurological status, although it is a screening tool and is not diagnostic. The seven supplementary items capture the range and quality of the behaviour of frail, high-risk infants. There are a total of 53 scoreable features, some of which are administered and some observed during the assessment, like startles, tremors, skin colour and other signs of stress or withdrawal, approach signals and smiles.

The optimal scoring on all items is either 1, 9 or 5. This was planned to avoid one overall score which can be misused (e.g. to predict future IQ). The NBAS has nothing to do with predicting IQ. Clusters of items can be analysed, such as: Habituation, Orientation, Motor Performance, Ranges of State, Autonomic regulation and Reflexes.

The NBAS should be carried out in a warm, quiet, darkened room on a medically stable infant half-way between feeds. The assessment takes 20-30 minutes. The examiner should be an experienced observer and handler of newborns, and flexible enough to bring out the infant's best performance. Examiners should be trained to reliability in the NBAS. To better understand the infant's behavioural repertoire and adaptation over time, the infant should be assessed more than once within the first four weeks of birth. For use as in intervention, the NBAS should be done three times within the first 4 weeks of birth. The most important factors of the NBAS are the infant's states (awake and asleep), habituation, state regulation, quality of alertness, and the infant's ability to self-quiet.





The Brazelton Centre
c/o
Box 226 NICU
Addenbrookes N.H.S. Trust
Hills Road
Cambridge
CB2 2QQ

phone: 01223 245791 · fax: 01223 217064
email: Joanna Hawthorne PhD



Copyright © 2002-2005, Andrew Whitaker