PARENT EDUCATION PROGRAMME

Learning to observe baby

behaviour: Using the
NBAS and NBO
Joanna Hawthorne
Psychologist, CEO, Brazelton Centre, UK

This article describes the reasons and techniques for observing baby behaviour closely, in order to
support parents in a strength-based, collaborative way in the first three months of their baby’s life. The
Neonatal Behavioural Assessment Scale (NBAS) and the Newborn Behavioural Observations (NBO)
provide a structured framework of observations for both practitioners and parents, so that they can
understand what care the baby is asking for. The NBAS is recommended in the 2009 UK Healthy Child
Programme, (Department of Health) and both the NBAS and the NBO are recommended in the 2013
cross UK party manifesto, ‘The 1001 Critical Days’ and the National Health Visiting Service specification
for 2014/2015.
KEYWORDS: infant mental health; baby behaviour; baby development; parenting

T
he first weeks of life are a critical transition
period for both parents and the baby (Paul,
2015; Tronick, 2007; Olds et al., 1997; Klaus et
al., 1995; Stern, 1995). Accommodating and
understanding a new baby is the task for the
whole family. Family dynamics change as they adjust
to a new member of the family. Parents explore the
characteristics of the new baby, figuring out what their
baby is telling them, and what he or she likes or doesn’t
like. If the baby is unsettled, or the baby was born pre-
term or with a disability, it can be even more difficult for
parents to understand what their baby is telling them.
Practitioners working with babies in the first months
of life may also be puzzled by a baby’s behaviour, and
may struggle to guide parents at this time. The UK
National Health Service is structured so that parents can
be seen in their own homes, or in local clinics, which
means that practitioners can provide support in a timely
manner, both antenatally and postnatally. What is an
effective way to support parents during this critical
transition to parenthood, ensuring that both parents and
baby develop a close and trusting relationship which
benefits the development of the baby? How can we
assure that the mental health of both baby and parents is
supported in the first crucial weeks of establishing their
relationship?
The importance of providing parents with information
on their child’s behavior and development so that they
can respond appropriately to their infant’s cues has been
well-documented (Young-Taffe et al., 1998; Als, 1992). It
is beneficial for practitioners to form a relationship with
parents by sharing observations of the baby together,
highlighting the positive aspects of his or her behaviour.
Parents will be more likely to share their concerns once
they share the strengths and abilities of their baby with a
practitioner (McManus & Nugent, 2014).
Additionally, early caregiving plays a critical role in
the development of the architecture of the baby’s brain,
influencing the baby’s social, emotional and cognitive
development (Shonkoff et al., 2009) and leading to a
secure attachment (Bowlby, 1969). A secure attachment
will result in a confident, motivated, stable, child
who is eager for knowledge. Parents’ brains are also
adapting to the transition to parenthood (Mayes et al.,
2012). Positive preventative effects of relationship-
based interventions for infants and their families have
been well-documented and are based on facilitating the
infant-family relationship and helping both the child and
the caregiver learn to adapt successfully to each other’s
individuality (Nugent & Brazelton, 1989).
‘WHAT BABIES DO ESPECIALLY WHEN IT LOOKS
LIKE NOTHING’
(adapted from Naomi Standlen’s book title: ‘What
Mothers Do; especially when it looks like nothing?’ 2004)
In the first three months of life, the baby is learning
fast about the world. He is learning about how people
respond to him, and he is also learning about what
sort of person he is and what people feel about him
as well as about other people’s minds (Reddy, 2008).
The mother’s face acts like a mirror to the infant. If
infants sees the mother looking lovingly and warmly
at them, they will feel, ‘I am loved and loveable’. If
the mother feels stressed and tense, the baby may feel,
‘I am difficult’. These feelings can become deeply
ingrained. Research on the development of infants has
shown that connections are made in the brain when
the baby is responded to appropriately and they learn
quickly whether or not their behaviours will bring about
a response from their caregivers. If the baby does not
get the appropriate responses, they can abandon their
expectations that their needs will be met.
COMMUNICATION BEGINS BEFORE BIRTH
During pregnancy, the fetus is already learning and
communicating and these experiences will relate to
the baby’s behaviour and development after birth
(Hepper, 2015). All behaviours mean something – arm
movements, finger movements, turning the head, facial
expressions, yawning, sneezing - and no behaviour
is random. If caregivers are supported to see these
behaviours as the baby’s language, their ability to
respond appropriately to their baby will be enhanced.
Noticing the behaviours out loud with the parents

Hawthorne, IJBPE, vol 3, issue 1 23

 KNOWLEDGE BASE
and reflecting on what they mean is a way to join with
the parents in their exploration of their baby
(Nicholson, 2015).
Babies learn very fast about themselves and their
caregiving environment (Tronick, 2007; Gopnick, 2001;
Trevarthen, 2001) and work to make sense of the world
and their caregivers. They can imitate, and attempt to
understand others’ minds. Nagy & Molnar (2004) show
how a newborn at one hour old in an alert state can
imitate the examiner who holds up from one to three
fingers. Observing the individual baby with a framework
for observations in mind, provides information that all
practitioners can share. A structured framework also
gives parents the information they need about the baby’s
behaviour and self-regulatory abilities so that they can
make better informed decisions about caregiving. By
sharing these observations with parents, and also giving
them up to date information on their baby’s development,
it seems that a stronger relationship can exist between
practitioner and parent (MacManus & Nugent, 2011).
WHAT DO PARENTS WANT TO KNOW?
Parents with a new baby have many questions. They
may wonder if their baby is all right, and whether what
their baby is doing is typical:
• Can my baby see?
• What can she see?
• Does my baby recognise my voice?
• What kind of stimulation does my baby need?
• How do I know when she is hungry?
• How much will she sleep?
• Is there something wrong if my baby cries a lot?
• What can I expect over the next few weeks?
• What are newborns doing?
Parents want to learn about their baby’s development
and knowing that babies have a developmental agenda
can help parents understand that their baby is developing
and learning all the time. Using the Neonatal Behavioural
Assessment Scale (NBAS) and the Newborn Behavioural
Observations (NBO) can provide parents and practitioners
with all the necessary information and insight into what
kind of caregiving the baby is asking for.
THE NBAS AND NBO
The task for babies in the first year of life is to regulate
their behavioural states (from deep sleep to crying)
(Table 1), and also to stabilise their four domains of
neuro-behavioural functioning: autonomic, motor, state
and social interactive (Als et al.,1982). Both the Neonatal
Behavioural Assessment Scale (NBAS) (Brazelton &
Nugent,1973) and the Newborn Behavioural Observations
(NBO), (Nugent et al., 2007) were developed for
practitioners to share with parents the wonderful abilities
of their baby from birth to three months old. The NBAS
is a detailed assessment of infant behaviour, focusing
on the baby’s individuality, and their strengths, but also
noting the baby’s difficulties in order to put in place a plan
for caregiving (Brazelton & Nugent, 2011). The NBO
is derived from the NBAS, using the same theory and
concepts, but it is a relationship-building tool to enhance
the parent/baby and the parent/practitioner relationship.
It is brief and more accessible for busy practitioners
24 Hawthorne, IJBPE, vol 3, issue 1
to learn. Practising with 20 -25 babies is required for
learning the NBAS, as it is important to learn how
individual babies manage self-regulation and to interact
with a variety of babies in order to understand the range
of possible behaviours. Also, practice helps to identify
often very subtle behaviours that indicate why a baby may
need more support in self-management.
Both the NBAS and the NBO can be used as
interventions or in research. The NBAS has been used
in over 600 studies worldwide and provides a detailed
assessment of the individual baby’s functioning and
reactions to handling, crying, sleeping and waking
from birth to two months old, producing a behavioural
profile. The NBAS can be used as a baseline measure
or an outcome measure of infant functioning (Redshaw,
2011). It has been shown to increase maternal confidence
(Myers, 1982), to be effective as an intervention with
parents (Nugent, 1985), to increase confidence and reduce
the anxiety of parents of pre-terms (Ohgi et al., 2004) and
to increase father involvement in caregiving (Beal 1989).
It has beneficial effects on the quality of later parenting
(Das Eiden & Reifman, 1996) and contributes to a
prediction of developmental outcomes of healthy full-term
(Canals et al., 2011) and low birthweight/premature (Ohgi
et al., 2003) babies and can be used as an intervention
for relationship problems (Bruschweiler-Stern, 2003).
In a questionnaire survey in Wales, mothers who were
supported by NBAS trained health visitors showed more
enjoyment in parenting, less hostility towards the baby,
and a better quality of attachment than mothers supported
by generic health visitors (McGlynn et al., 2012).
The Newborn Behavioural Observations (NBO) uses
NBAS strength-based concepts and theories and provides
an introduction to newborn behaviour to sensitise parents
to their newborn’s abilities, while building collaborative
relationships between health professionals and parents
(Nugent, 2015). The NBO is appropriate for work with
families with babies from birth to three months old.
Studies using the NBO have shown less postpartum
depression symptomatology (Nugent et al., 2014), higher
parent-perceived quality of home visiting care (McManus
& Nugent, 2014), greater confidence in clinicians when
working with high-risk infants (McManus & Nugent, 2011)
and increased maternal sensitivity (Nugent et al., 2015).
Practitioners working with babies in the UK show an
increase in confidence in discussing newborn behaviour
with parents after the NBAS or NBO course (Foley &
Hawthorne, 2014). Analysis of 543 questionnaires given
to parents after an NBO session, showed that parents’
perception of their infant improves and they learn more
about their baby during the session (Brandt. 2014; Savage-
McGlynn & Hawthorne, 2014).
The NBAS and NBO can be offered to parents at the
new birth visit by health visitors, or earlier by midwives.
In fact, these tools are used by professionals and also
family workers in Children’s Centres, all working with
babies and parents under three months old.
BEHAVIOURAL STATES
Parents and practitioners find that understanding
behavioural states (Wolff, 1987, 1959; Brazelton &
Nugent, 1973) makes it very clear when to interact with a
baby or leave them to sleep.

Baby States
Deep sleep – State 1
Eyes are firmly closed; breathing is deep and
regular with no motor activity; this state give the
baby time to rest and grow, and organise the
immature nervous system.
Active sleep – State 2
Eyes are firmly closed, but slow rotating
movements can be seen; there may be twitches;
breaging is irregular and even shallow; facial
movements include grimaces, frowns, mouth
movements.
Drowsy – State 3
Eyes may open and close but look glazed in
appearance; arms and legs may move smoothly;
breathing is regular but faster and shallower than
in sleep; babies in this state may be susceptible to
being aroused to a more alert, responsive state.
Alert, awake – State 4
Body and face are relatively quiet and inactive
with bright shining eyes. Sights and sounds will
produce responses; in this state the baby can be
very rewarding for parents.
Alert, active – State 5
Transitional state to crying; available to external
stimuli and may be soothed or brought to an alert
state by attractive stimuli; if stimuli are too much,
may break down to fussiness; movements are jerky,
disorganised, and may startle the infant.
Crying – State 6
Communicates hunger, pain, boredom, discomfort,
tiredness, setting off automatic responses of
concern and responsibility in parents; this is the
most effective mode for attracting a caregiver.
(Brazelton & Cramer, 1991)
In the early weeks, the baby moves from sleeping and
waking states apparently at random, although typically,
waking and sleeping will occur in cycles of three or four
hours (Murray & Andrews, 2000; Brazelton & Cramer,
1991). If the baby has an erratic sleeping pattern or
sleeps little, it is not the result of being ‘naughty’. As
babies grow older, their sleeping and waking periods
lengthen.
Feeding patterns can also sometimes seem chaotic,
but these too will even out over time. The baby is not
deliberately trying to cause problems by wanting to feed
frequently, but is showing their need to feel they have a
full stomach, and their need to suck which is the most
soothing thing a baby can do.
CONTENT OF THE NBAS
There are 53 scorable items on the NBAS, which is
a systematic way of looking at the baby’s reaction to
stimulation. Every item has to be presented to the baby
when he is in the correct sleep or awake state. The
KNOWLEDGE BASE
habituation items are presented when the baby is in a
state 1, 2 or 3. The interactive items are presented when
the baby is in an alert state 4. The other items can be
presented in a state 3, 4 or 5 usually. When the baby is
in a crying state 6, consolability can be tried in a step-by-
step approach to see how much help the baby needs to
stop crying.
HABITUATION
The NBAS starts when the baby is asleep, half-way
between feeds. A torch is shone on his closed eyelids
and his reactions are observed. Some babies manage to
get used to the stimulus quite quickly and stop moving,
and some babies continue to move or are woken by the
stimulus. The same thing is done with a rattle and a bell.
If a baby gets used to the stimulus and stays asleep, we
can say he has habituated to the stimulus. Observing
how a baby habituates can be especially helpful if the
baby seems to have trouble getting to sleep. If he is a
light sleeper, he may need to be put in a quiet corner. If
he habituates easily, he can sleep through interruptions
such as the noise of the vacuum cleaner or a door
slamming.
MOTOR TONE AND REFLEXES
The NBAS is considered to be a screening tool for
any major abnormalities in tone and reflexes.
However, parents also consider the baby’s reflexes to
be a skill, such as the stepping, standing, walking and
crawling reflex.
STATE ORGANISATION AND REGULATION
There is a big difference between babies who have many
state changes in the 30 minute assessment, and those
who have very few. If the baby wakes up slowly into
an alert state 4 and stays there throughout the exam, this
is different from a baby who moves straight from a deep
sleep (state 1) into a crying state (state 6) for instance. A
baby who finds transitions between states overwhelming
needs support and gentle handling. Parents will soon
see the baby’s pattern and how much help their babies
need to maintain a calm alert state for feeding or playing.
If the baby wants to sleep, it is best to let him do so
so that he can strengthen his ability to stay asleep by
himself. If the baby is wide-eyed and alert, this is the
ideal moment for looking at the baby face to face and
talking, smiling and laughing, singing and reading.
AUTONOMIC SYSTEM
If the baby is having trouble with startles and tremors,
changing colour and has rapid respirations, this means
the baby’s autonomic system is still adjusting to the world
outside the womb. This baby needs to be helped and
protected until adjustment is achieved. This might be
especially true for a baby who was born prematurely,
was small for gestational age at birth, or was born with
anomalies.
SOCIAL-INTERACTIVE SYSTEM
The best state for talking and playing is when the baby
is in an alert, quiet state 4. The baby will track your face
and voice, an object (a shiny red ball, for instance), and
turn to your voice or the parent’s voice, or the sound
of a rattle. The baby might even smile as he is having
Hawthorne, IJBPE, vol 3, issue 1 25
 KNOWLEDGE BASE
pleasurable sensations. The baby has facial movements in
utero and from birth. If these movements are in relation
to a nice feeling, or a face and voice, they are the
beginnings of a social smile, and they can be reinforced
by the caregiver.
CRYING
When a baby cries, the practitioner can observe to see
what kind of support he or she would like to have.
The baby is put down for a few seconds to observe
the techniques that he or she may be using to calm
themselves, such as finding something to look at, putting
a hand near the mouth, inserting a finger or hand into
the mouth, or changing position. If the baby makes no
attempt to calm themselves, certain techniques can be
employed to see how much help the baby needs.
Consolability techniques from the NBAS
(Brazelton & Nugent, 2011)
1) Look at the baby so he can see you
2) Talk to the baby in a calming way (talk calmly
throughout all steps)
3) Continue to talk and look, but put your hand
across his chest to help him feel secure
4) Continue the above, and also contain his arms
and legs if they are still moving
5) Pick him up and hold him still in your arms
6) Add rocking gently (swaying)
7) Add dressing or wrapping, with hands to face
8) Add giving the baby a finger or pacifier to suck
The NBO includes several of the items on the NBAS,
such as habituation, consolability, some reflexes and
social interaction. It therefore addresses any issues with
sleep, crying or feeding, similar to the NBAS, but not in
such detail. The NBO can be used universally at the new
birth visit, with the NBAS used as a universal plus if more
support is needed (Lee & Mee, 2015).
CONCLUSION
Both the NBAS and NBO are recommended in the UK
for use in the early weeks of the baby’s life (Hawthorne,
2015). Collaborating with parents to observe their
baby’s behavioural abilities, cues and signals has been
shown to be an effective way of supporting parents.
The NBAS and NBO inform practitioners and parents
about development and behaviour so they become good
observers. Some babies are challenging to read as their
cues are subtle. Practitioners and parents alike learn to
look at babies in detail, developing a behavioural profile
of the baby in order to focus on the individual needs of
the baby. The information from these tools results in a
tailored programme of support for the individual baby
and their parents.
NBAS AND NBO TRAINING
For NBAS and NBO training courses, please visit:
www.brazelton.co.uk
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September 2015>
Cost: £45.00 AIMH UK members;
Wolff, P.H. (1959) Observations on human infants. Psychosomatic £65 for non-members
Medicine, 221, 110-118.
Wolff, P.H. (1987) Behavioral States and the expression of
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emotion in early infancy. Chicago, University of Chicago Press.
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