Introduction to Research with the NBO

A wide range of studies have been conducted with the Newborn Behavioural Observations system all over the world, looking at the benefits for parents and babies and the way it changes practitioner’s practice.

Have a look at the key points below and then explore the recent evidence summaries and check the longer reference list too!

Summary of Results using the NBO

The majority of practitioners attending the NBO course:

  • Report increased confidence and skills working with babies and their families
  • Integrate a great deal of what they learned into their practice
  • Are using the tool with fathers and mothers
  • Particularly enjoy sharing with parents their baby’s social skills and consoling strategies

Mothers, fathers, partners and co-parents who have an NBO session tend to:

  • Feel closer to their baby
  • Feel they know their baby better
  • Trust their practitioner
  • Have enhanced engagement and relationship with their baby
  • Feel more confident in reading their baby’s signals and cues

Evidence also suggests that the NBO could be an effective intervention tool in preventing postnatal depression symptoms in first-time mothers.

Several national and international studies, including randomised control trials, are currently being developed to provide us with more robust evidence regarding the effectiveness of the NBO.

Summaries of recent NBO peer reviewed published papers

These are six of the most recent publications on NBO based research. The links help you see the original paper. If you are interested in a specific aspect or topic and in specific previous studies, please contact us.


1) Supporting the newborn-parent relationship when there is parental depression or anxiety: Australian trial of the Newborn Behavioural Observations (NBO).

Susan Nicolson, Sarah Pia-Carron, Campbell Paul, Louise Newman (2022). Infant Mental Health Journal. 43(3): 455–473. Published on line 2022, May.  DOI: 10.1002/imhj.21987

In this study the Newborn Behavioral Observations (NBO) was used as a brief intervention to support the infant, the parent, and their relationship. A randomized controlled trial examined NBO effectiveness in a clinical population with antenatal distress and postnatal depression risk. Pregnant, first-time mothers with current anxiety or depression symptoms or past depression were recruited and received either three NBO sessions in the first month of life plus treatment as usual or, treatment at usual only. Outcomes assessed at age 4 months included mother-infant interaction quality; maternal anxiety, depression and stress symptoms; and depression diagnosis.

The intervention significantly improved maternal interaction emotional availability and reduced anxiety symptoms over time in the intervention group (n=40) versus the comparison group (n=34). The intervention group showed significant reductions in anxiety and depression symptoms to sub-clinical levels. Sensory processing sensitivity differentiated susceptibility to distress and intervention benefits. In summary, the NBO exerted meaningful effects on relationship quality and distress; and may enhance the infant’s interaction experience and maternal emotional adjustment in clinical populations.



2)  Practitioner views and reflections on applying the Newborn Behavioural Observations (NBO) System within an Irish Context.

Rosarii O’D. Connorton, Aine Herlihy & Ruth Cleary. Perspectives in Infant Mental Health, July, 2022

The study sought to examine practitioners’ experience of attending a Newborn Behavioural Observations (NBO) training and implementation into community services within an Irish context. Semi-structured interviews were conducted with training participants (n=6) and Thematic Analysis (TA) was used to analyse qualitative data.

The experience of receiving the training and how it was delivered were equally important: the ‘parallel’ speaks to the practitioners’ experience of the trainers, the training, the shared experience of learning with other participants and the application with the families with whom they work. At the same time the study illustrated the participant’s ‘deeper understanding of a baby’s capacities and the importance of observing the baby and adopting ‘a relational approach’ and ‘honouring’ parents as experts on their baby. ‘Obstacles’ in implementing the NBO referenced not having access to young infants and working remotely with families during the pandemic. ‘Connecting’ with other service providers, fellow trainees and mentoring support was critical. The findings suggest that, following training, practitioners felt empowered when working with babies and parents. Participants particularly identified their increased confidence and how the NBO is an extra tool to back up existing IMH informed service delivery.



3) Mentalisation amongst Maternal and Child Health Nurses using the Newborn Behavioural Observations with infant-mother dyads: A qualitative study.

Kim Simkin-Tran, Bronwyn Harman, Susan Nicolson (2020).  Journal of Pediatric Nursing, Feb, 2020.

This qualitative study explored Maternal and Child Health Nurses’ (MCHN) mentalisation processes in working with infant-mother dyads when using the Newborn Behavioural Observations (NBO) system in practice. Ten Australian MCHNs who had used the NBO clinically within the last 12 months, were recruited from a database of NBO-trained practitioners. Interpretative phenomenological analysis (IPA) of individual semi-structured interviews explored MCHNs experiential meaning-making.

Data analysis produced 4 main themes: reflections regarding the dyad, personal reflections, reflection into action, and professional identity and future practice. The NBO focus on the pre-verbal infant adds a dynamic to consultations outside the practitioner-caregiver relationship. Caregivers were able to provide holistic and collaborative relationship support to infant-mother dyads. Emotional satisfaction and pride in profession were reported, factors which have been found to reduce burnout in primary care providers. The NBO appears to promote practitioner mentalisation, offering a framework and supporting confidence in applying infant mental health theory practically and potential benefits to child and family health nursing practice. Other primary care providers offering infant mental health and relationship support  benefit while working with families during the first three months benefit. The NBO also facilitates a shift from prescriptive to mentalisation-based, infant-inclusive, individualised practice.



4) Newborn Behavioral Observation, maternal stress, depressive symptoms and the mother-infant relationship: results from the Northern Babies Longitudinal Study (NorBaby).

Ragnhild Sørensen Høifødt, Dag Nordahl, Inger Pauline Landsem, Gábor Csifcsák, Agnes Bohne, Gerit Pfuhl, Kamilla Rognmo, Hanne C. Braarud, Arnold Goksøyr, Vibeke Moe, Kari Slinning & Catharina Elisabeth Arfwedson Wang (2020). BMC Psychiatry, 20, 300 (2020):

In this paper it is acknowledged that families can experience the postpartum period as overwhelming with many reporting a special need for support. This study aimed to evaluate the NBO as a universal preventive intervention within the regular well-baby clinic service on measures of maternal depressive symptoms, parental stress, the mother-infant relationship and satisfaction or benefit of the postpartum follow-up. It is part of a larger longitudinal study with women and their partners recruited between 2015 and 2017 in a non-randomised cluster-controlled design. This article is based on 196 women using data from gestational weeks 13–39, 5–15 weeks and 3–9 months postpartum with allocation to receiving the NBO (n = 82) and a care as usual comparison group (n = 114). Maternal depressive symptoms and parental stress were measured, and the mother-infant relationship, maternal postnatal attachment and maternal confidence assessed.

The NBO-group learned significantly more than the comparison group about the baby’s signals in relation to sleep/sleep patterns, social interaction and crying/fussiness. Significant differences between the groups in terms of the mother-infant relationship domain were not found and few differences in depressive symptoms and parental stress. However, the study sample was generally well-functioning, and the results indicate that the benefits of the NBO may be limited within such a sample.



5) The Effects of the Newborn Behavioral Observations (NBO) system on Sensitivity of Mother-Infant Interactions.

Nugent, J. K. Dym-Bartlett, J., Vonende, A., Valim, C. (2017) Infants and Young Children, 30, 4, 257-268. DOI: 10.1097/IYC.0000000000000103

The Newborn Behavioral Observations (NBO) system is as the lead author Kevin Nugent describes it, a neurobehavioral observation tool designed to sensitize parents to infants’ capacities and individuality, enhancing the parent–infant relationship by strengthening parents’ confidence and practical skills in caring for their babies. The focus on relationship-building is intended for infant mental health professionals who strive for a relational, family-centered model of care in contrast to a pathology-based model. The study assessed the impact of the NBO on the sensitivity of mother–infant interaction in the first 4 months of life. Primiparous mothers and their full-term infants were randomized into experimental and control groups. The intervention group participated in the NBO in the hospital within 2 days of birth and again at home at 1 month. At 4 months, dyads (n = 35) were videotaped during semi-structured play episodes, with coding to assess parent–child sensitivity in interaction.

Intervention group infants were 2.8 times more likely to be classified as “cooperative” (sensitive) than control group infants and intervention mothers were 2.5 times more likely to be classified as sensitive than control mothers. The findings highlight the potential to promote positive maternal–infant relations by influencing early behaviour, suggesting that the NBO appears to be an effective, time-limited intervention for strengthening relationships between parents and infants.



6) Use of the Newborn Behavioral Observations System as an early intervention for infants and their parents: A scoping review.

Early Satoshi Yago, Yuki Takahashi, Emi Tsukamoto, Asuka Saito, Eiko Saito (2023). Hum Dev. 2023 Aug; 183:105811. DOI: 10.1016/j.earlhumdev.2023.105811 Epub 2023 Jun 19. PMID: 37385114.

This paper is a recent review of NBO studies aimed to provide an overview of the key characteristics of the research and evidence accumulated over the past 17 years on the early NBO intervention for infants and their parents to identify research gaps and inform future directions. The review used six databases (PubMed, CINAHL, MEDLINE, Google Scholar, Ichushi-Web, and CiNii) and was limited to English and Japanese language articles from January 2006, when the NBO was developed, to September 2022.

A total of 29 articles were identified. In the analysis of those included, four overarching themes were identified: (1) usage pattern of the NBO; (2) participants, setting, duration, and frequency of the NBO intervention; (3) outcome measures and effects of the NBO intervention; and (4) findings from a qualitative perspective. The review of research in a variety of cultures and settings suggested that early NBO intervention had a positive impact on maternal mental health and sensitivity to the infant, confidence and knowledge of practitioners, and infant development. However, evaluation of the long-term effects of this intervention on a wider range of participants is needed.



Other recent NBO research-based papers

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Lise C. Johnson, Beth McManus, Yvette Blanchard, J. Kevin Nugent (in press). The Newborn Behavioral Observations System (NBO): A relationship-based intervention to support infants and parents in the Neonatal Intensive Care Unit. IN PRESS To appear in Acta Paediatrica.

Lise C. Johnson, Jessica Dym Bartlett, J. Kevin Nugent (2023). Gravens by Design: The Newborn Behavioral Observations system to support early parent-infant relationships in the NICU. Neonatology Today, 18, 9, 77-82.

Greve, R.A., Braarud, H, Skotheim, S., & Slinning, K. (2018). Feasibility and acceptability of an early home visit intervention aimed at supporting a positive mother-infant relationship for mothers at risk of postpartum depression. Scandinavian Journal of Caring Sciences. 10.1111/scs.12589

Guimarães, M.A., Alves, C.R., Cardoso, A.A., Penido, M.G., & Magalhães, L.C. (2018) Clinical application of the Newborn Behavioral Observation (NBO) System to characterize the behavioral pattern of newborns at biological and social risk. J Pediatr (Rio J). 94:300–7

Høifødt, R.S., Nordahl, D., Pfuhl, G., et al. (2017) Protocol for the Northern babies longitudinal study: predicting postpartum depression and improving parent–infant interaction with The Newborn Behavioral Observation. BMJ Open;7:e016005. doi:10.1136/bmjopen-2017-016005

Kristensen, I.H., & Kronborg, H. (2018) What are the effects of supporting early parenting by enhancing parents’ understanding of the infant? Study protocol for a cluster-randomized community-based trial of the Newborn Behavioral Observation (NBO) method. BMC Public Health.  BMC Public Health. 4;18(1):832. doi: 10.1186/s12889-018-5747-4

NBO Books

Nugent, J. K., Keefer, C. H., Minear, S., Johnson, L. C., & Blanchard, Y. (2007). Understanding newborn behavior and early relationships: The Newborn Behavioral Observations (NBO) system handbook. Baltimore, MD, US: Paul H Brookes Publishing.

Improving our Evidence

Developing our tools and training courses based on robust evidence is vital to us. We are especially interested in more culturally appropriate research in the UK, with parents and newborn babies. Are you or your organisation interested in developing a research project with our tools? We’d love to hear from you! Please get in touch using the form below.

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