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The Brazelton Neonatal Behavioral Assessment Scale detects differences among

newborn infants of optimal health

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Journal of Pediatric Psychology, Vol. 25, No. 8, 2000, pp. 577–582

Brief Report: The Brazelton Neonatal Behavioral

Assessment Scale Detects Differences Among
Newborn Infants of Optimal Health
Cristina Lundqvist,1 MS, and Karl-Göran Sabel,2 MD, PhD
1
Lund University and 2Borås Hospital

Objective: To determine whether the Brazelton Neonatal Behavioral Assessment Scale (NBAS) can detect
behavioral differences in newborn infants of optimal health and, if such differences appear, also detect
gender differences among those neonates.
Methods: Participants were a group of healthy Swedish neonates, 20 boys and 18 girls. The infants were as-
sessed by the NBAS under standardized conditions at 48–72 hours of age, at the midpoint between two
meals.
Results: All items except those in the dimensions Autonomic System and Motor System had a wide inter-
quartile range. The trend was that girls had higher median item profiles, which means a higher level of
functioning than boys. Four out of seven median values in the dimension Social Interactive Organization, as
well as the median value in the self-quieting item in the dimension State Regulation, were significantly
higher for girls. The interquartile range of the items seemed wider for boys than for girls.
Conclusions: The results indicate behavioral variability among healthy neonates. Gender differences were
also observed with girls showing higher levels of functioning than boys.

Key words: assessment; neonates; infant development; infant health.

Investigators have been attracted recently to the be-
havioral repertoire and functioning of the newborn
infant. Despite many studies addressing the impact
of prenatal events and the risks of prematurity,
there are still many unanswered questions related
to early prevention of later developmental difficul-
ties. For example, according to Kadesjö and Gillberg
(1998), children apparently are born healthy and
develop dysfunctional behaviors later on.
Scientists have stressed different requirements
for successful development. Brazelton and Cramer
All correspondence should be sent to Cristina Lundqvist, Department
of Paediatrics, Borås Hospital, 501 82 Borås, Sweden. E-mail: cristina.
lundqvist@psychology.lu.se.
(1990) emphasized the importance of caring for the
parent and infant as a unit since the infant develops
within this system and suggested a transdisciplinary
approach. Schore (1994) suggested that failures in
the dyadic processes of affect regulation lead to de-
velopmental psychopathology. Many researchers
(e.g., Nordberg, 1995) have demonstrated that the
quality of social-interactive experiences has impor-
tant implications for children’s mental develop-
ment. Some researchers have focused on the baby’s
contribution to this interactive process (Murray,
1994) whereas others have focused on the impor-
tance of the parents’ behaviors, especially the moth-
er’s. Thompson (1990) stated the fundamental

䉷 2000 Society of Pediatric Psychology

578
principle that others initially regulate emotions, but
the baby, as development proceeds, becomes in-
creasingly self-regulated because of neurophysiolog-
ical maturation.
With insights from clinical pediatrics, psychia-
try, and developmental and clinical psychology,
Brazelton and his colleagues (1973) constructed the
Neonatal Behavioral Assessment Scale (NBAS) to
demonstrate both positive and negative characteris-
tics of behavior. In contrast to the pathological
models evaluating deficits, Brazelton, Lester, and
their colleagues (1976) considered the baby’s whole
behavioral repertoire as an important factor in his
or her development. The NBAS has been revised
twice, in 1984 and 1995. The scale combines neuro-
logical items with an extended behavioral repertoire
of the infant in an interactional process. It measures
the coping capacities and adaptive strategies of the
infant. The optimal interactional process is de-
scribed as a condition wherein the newborn baby
uses most of his or her energy to interact with the
environment, has physiological control, and is con-
trolling his or her motor activity and state
(Brazelton, 1990). These integrative tasks proceed in
a developmentally hierarchical manner with Auto-
nomic Regulation preceding Motor Organization,
followed by the task of State Regulation and finally
Social Interaction (Als, 1982).
Gender-based behavioral differences have been
established in studies on young children. Trevar-
then (1996) found that asymmetries in emotional
and communicative gestures are seen earlier among
girls. Lindahl and Heimann (1997) reported that
among 9-month-old children mother-daughter dy-
ads displayed significantly higher degrees of social
proximity than mother-son dyads, measured
through nine items focusing on both communica-
tion and social interaction. Nordberg, Rydelius, and
Zetterström (1991) found that boys at 1 year and 4
years of age were more vulnerable to psychosocial
stress. Davis and Emory (1995) found that boys had
a lower threshold for stress reactivity. Gender-based
differences have been found among certain groups
of children with dysfunctional behaviors and dis-
eases; that is, a higher percentage of boys have prob-
lems related to attention, perception, and motor
control (Kadesjö & Gillberg, 1998). Also, more boys
than girls die in Sudden Infant Death Syndrome
(SIDS) (McLaughlin et al., 1995).
The aim of this study was to explore whether
the NBAS would detect behavioral variations in
an optimally healthy group of Swedish newborn
Lundqvist and Sabel
infants and whether such possible variations are
gender-related. Specifically, we hypothesized that
behavioral differences among newborn infants are
gender-related.
Method
Participants
Thirty-eight neonates participated in this study (20
boys and 18 girls). The mean weight of the girls was
3455 g (SD ⫽ 396 g) and of the boys 3605 g (SD ⫽
434 g). The mean length of the girls was 50.5 cm
(SD ⫽ 1.5 cm) and of the boys 51.3 cm (SD ⫽ 2.0
cm). The mean gestational age at birth for the girls
was 39.5 weeks (SD ⫽ 0.9) and for the boys 39.6
weeks (SD ⫽ 0.9). Gestational age was determined
from the date of the last menstrual period and by
ultrasound verification at 15–16 weeks of gestation.
Procedure
Very healthy infants were recruited for the study to
reduce the impact of perinatal factors. Midwives at
the maternity ward were asked to register healthy
3-day-old infants on the mornings of prespecified
days. To be classified as “very healthy,” the baby
had to fulfill certain requirements: (1) an Apgar
score (Apgar, 1954) of at least eight points at 5 min-
utes; (2) the baby must not have been instrumen-
tally delivered; (3) the baby must not have a twin;
(4) the baby must have had a minimum gestational
age of 37 weeks; (5) the baby must have had a birth
weight of at least 2500 g yet not more than 4500 g;
(6) the baby’s mother must not have been given any
analgesics during labor.
These infants were then checked in accordance
to Kyllerman and Hagberg’s optimal health condi-
tions, a modification of Prechtl’s optimal concept
(Kyllerman & Hagberg, 1983). The optimal health
conditions included prepartal, partal, and postpar-
tal items. Examples of prepartal items are maternal
age of 18–30 years, mother’s pregnancy number 4
or less, and no maternal disorders in pregnancy (in-
fection, diabetes, surgery, anemia-Hb 8.0g/ml, etc.).
Examples of partal items are amniotic fluid clear
and no pathological labor (duration less than 1/2 or
more than 24 hours). Examples of postpartal items
are no apnea, no hypoglycemia, and blood sugar
levels ⬍30 mg/100 ml. The postpartal items were
recorded on the third day of life. Optimal health
Behavioral Differences in Newborns
in this study was defined as scoring positive to all
optimal conditions except the age of the mother
(our upper limit is 35 years instead of 30 years).
The infants were examined at 48–72 hours of
age to minimize the influences of the delivery. The
aim was to examine the baby at the midpoint be-
tween two meals. This goal was not always achieved
since breastfed infants often are fed at irregular in-
tervals.
No more than three babies were examined per
day and if there were more babies fulfilling the re-
quirements that day, the ones examined were cho-
sen consecutively. All parents gave their consent to
the assessment. All of the babies were examined by
one of the authors (CL), who has been trained and
certified to be reliable in administering and scoring
the NBAS by the Boston group at Harvard Medical
School. The babies were examined in a small and
quiet room, in daylight, and in the presence of at
least one parent. Complete assessment was not pos-
sible for five of the infants. Three babies, one boy
and two girls, woke up during the measurement of
the responses decrement to light, rattle, bell, and
tactile stimulation. One boy and one girl fell asleep
during the orientation items.
Materials
The NBAS is a multidimensional, multi-item scale
(Brazelton & Nugent, 1995). The basic score sheet
includes 28 behavioral items, 18 reflex items, and 6
supplementary items. The supplementary items
were constructed to measure the quality of the ba-
by’s responsiveness, the help the examiner has to
invest to get the infant’s optimal performance, and
also the response of the examiner to the infants. In
order to compare the evaluations of the infants’ be-
havior, the items that interact in similar ways have
been grouped into seven clusters describing global
functions, following Lester, Als, and Brazelton
(1982). The clusters are as follows: (1) reflexes (e.g.,
plantar grasp, babinski, ankle tonus); (2) motor sys-
tem (which includes tonus, motor maturity, pull-
to-sit, defensive movements and level of activity);
(3) autonomic stability (which includes tremors,
startles and skin color); (4) habituation (which in-
cludes response decrement to light, bell, and tactile
stimulation); (5) social interactive organization
(which includes animate and inanimate visual, au-
ditory orientation items, and alertness); (6) range of
states (which includes peak of excitement, rapidity
of build-up, irritability, lability of states and the
579
cluster); (7) regulation of states (which includes
cuddliness, consolability, self-quieting activity, and
hand-to-mouth activity).
The interactive character of the scale distin-
guishes it from other assessments. It demands thor-
ough knowledge of newborn babies and of an
infant’s developmental course as well as examiner
flexibility. Examiner training procedures contain
both a training phase and a reliability phase.
This study used two of the supplementary items,
specifically examiner facilitation and examiner’s
emotional response to that infant. These were cho-
sen with regard to their theoretical connection to
attachment behavior and also because neonatal so-
cial behavior with an examiner during the NBAS ex-
amination has been found to be related to neonatal
social behavior with the mother and to maternal
functional stimulation (Arco, DeMeis, Self, & Gu-
trecht, 1984).
The behavioral items, including the supplemen-
tary items, are scored on 9-point scales, and reflexes
are scored on a 4-point scale. The infant’s reflex
score is the total number of diverging scores. In
some of the behavioral items the end-point score 1
or 9 represents the optimal status of function, in
others the central score of 5 represents it. The rea-
son for this is that Brazelton did not want to give
the baby a sum score, which may be misused. In
this study the item scores have been transformed to
labels (italicized numbers) representing an in-
creased level of functioning, where 9 means a high
level of functioning and 1 a very low level of func-
tioning. The item consolability, which measures the
number of maneuvers the examiner has to utilize in
order to bring the baby to a quite state, may serve
as an example. In that case, 1 point stands for the
baby not being consolable at all and 9 points means
that simply seeing the examiner’s face consoles the
baby. The measurement level of data is ordinal,
meaning that there is a defined rank order of the
category levels, but the levels do not represent any
mathematical values. Furthermore, there are no de-
fined distances between adjacent levels. These prop-
erties mean that arithmetic that creates sum scores
cannot be applied (Coste, Fermanian, & Venot,
1995).
Analysis
Since normal distribution of data was not assumed,
median values and nonparametric statistical meth-
ods were used. Gender differences in the median
580 Lundqvist and Sabel

values for each item of the clusters reflexes, auto- Table I. Clusters and Behavioral Items
nomic system, motor system, habituation, state Clusters Boys Girls
organization, state regulation, social interactive or-
Reflexes
ganization, and two of the supplementary items
Diverging score 4 (2–5) 3 (1–5)
have been analyzed by applying the Wilcoxon- Motor system
Mann Whitney test. In order to obtain an overall General tone 5 (5–6) 5 (5–5)
significance level of at least .05, the p values within Motor maturity 5 (5–6) 6 (5–6)
a cluster have been adjusted according to Holm’s Pull to sit 6 (5–8) 8 (6–8)
(1979) multiple test procedure. Defensive movements 5 (5–6) 6 (5–6)
Activity level 4 (3–5) 5 (4–5)
Autonomic stability

Results Tremulousness 8 (8–8) 8 (8–8)

Startles 8 (8–8) 8 (8–8)
Lability of skin color 5 (3–5) 5 (4–5)
Except the items startle, tremulousness, and most
Habituation
of the motor items, the other behavioral items had
Response decrement to light 6 (4–7) 6 (4–7)
a wide interquartile range (see Table I). The median Response decrement to rattle 4 (3–7) 5 (4–7)
profiles of the girls were in general higher than Response decrement to bell 6 (3–7) 5 (5–6)
those of the boys (see Table I). According to the Response decrement to foot stimulation 5 (4–6) 5 (4–6)
Wilcoxon-Mann Whitney test, four median values Social interactive organization
in the social interactive organization cluster were Animate visual 3 (2–7) 6 (5–7)
significantly higher for girls (the orientation items Animate visual and auditory 5 (3–7) 7 (6–8)*
animate auditory, p ⬍ .01; animate visual and audi- Inanimate visual 5 (3–7) 6 (4–7)

tory, p ⬍ .05; inanimate auditory, p ⬍ .05; inani- Inanimate visual and auditory 4 (3–7) 8 (7–8)**
Animate auditory 4 (3–6) 7 (6–8)**
mate visual and auditory, p ⬍ .01). Girls’ median
Inanimate auditory 4 (4–7) 7 (4–8)*
value in the item self-quieting (cluster state regula-
Alertness 5 (4–6) 6 (5–8)
tion) was also significantly higher than that for boys
Range of states
( p ⬍ .01). Further, most of the interquartile ranges Peak of excitement 3 (2–4) 4 (3–4)
of the items seemed wider for boys (see Table I). Rapidity of build-up 5 (3–7) 5 (5–7)
Irritability 4 (2–6) 6 (5–8)
Lability of states 6 (4–8) 7 (6–8)
Discussion Regulation of states
Cuddliness 4 (4–5) 5 (5–7)
The aim of this study was to explore whether the Consolability 5 (2–6) 6 (5–7)

NBAS could discover behavioral differences among Self-quieting 4 (2–6) 6 (6–7)**

medically very healthy infants and demonstrate
that a baby may be healthy and seem strong and
robust yet may also be vulnerable. For example,
even healthy babies may have difficulties in self-
regulation and therefore be hard to interact with.
The study indicated that the NBAS detects behav-
ioral differences among optimally healthy infants.
The fact that the supplementary items examiner
facilitation and examiner’s emotional response had
a wide interquartile range emphasized that babies
of optimal health need different amounts of help to
organize themselves and provoke different feelings.
This in turn has an impact on the interactive pro-
cesses, attachment behavior, and infant develop-
ment (Murray, Fiori-Cowlley, Hooper, & Cooper,
1996).
Further, the study confirmed the hypothesis
that there are behavioral differences between girls
Hand to mouth 4 (2–7) 7 (5–8)
Supplementary items
Examiner facilitation 6 (4–7) 6 (5–8)
Examiner’s emotional response 5 (3–6) 6 (5–8)
The values represent median and interquartile ranges.
*p ⬍ .05.
**p ⬍ .01.
and boys. The girls had higher functioning scores,
especially in the social interactive organization clus-
ter. This result is in accordance with Trevarthen
(1996) and points in the direction of gender-based
behavioral differences as innate. Since a higher per-
centage of boys develop dysfunctional behaviors
and are overrepresented among certain diseases,
such as nervous disorders and lower respiratory
tract infections (van den Bosch, Huygen, van den
Hoogen, & van Weel, 1992), we suggest it would be
Behavioral Differences in Newborns
valuable to further explore qualitative gender-
based differences.
As clinicians, we see a demand for a diagnostic
instrument that discriminates between immaturity,
stress effects, and individual characteristics in neo-
natal wards, maternity wards, and health care cen-
ters. It seems that the NBAS is a satisfactory tool in
this work. The results of this study are parsimonious
to previous research that has demonstrated the ef-
fectiveness of the NBAS (Brazelton & Nugent, 1995).
Therefore, we suggest that the NBAS be used com-
plementary to neurological and pediatric examina-
tion when specific questions about the baby exist
and when the baby already has been identified as
an infant at risk. Infants who show considerable de-
viations should be monitored with repeated assess-
ments.
A simplified and shorter screening instrument
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