Save self-assessment
Generate self-assessment report
The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Click on each segment for more details
Core Components
The Newborn Behavioural Observational (NBO) System is a strength-based interactive relationship-building tool which aims to strengthen the relationship between infants and their parents in the newborn period. It can be used with families of infants from birth to 3 months old. It is primarily guided by the principle that the quality of early experiences drives brain development and functional outcomes. It aims to help support parents to see their infant’s capacities and help them see the baby’s uniqueness, competencies and vulnerabilities and to help them respond to their baby in a way that is meeting their baby’s needs.
The NBO is not designed as a test or examination but to help parents and practitioners understand the uniqueness of the baby and gain an understanding of their communication by observing their behaviours. It helps identify the kind of support the infant needs for successful growth and development. It is based on 3 assumptions; infants are social beings ready to communicate, babies communicate through their behaviour and infant communication is not random.
The NBO is used in a range of clinical practices such as hospitals, clinics or home visits. It can be utilised by a range of professionals such as nurses, doctors, psychologists, social workers, midwives, occupational therapists, doulas, lactation specialists, home visitors, and other early intervention professionals.
The NBO consists of 18 neurobehavioural observations, which describe the newborn’s capacities and behavioural adaptions and helps parents understand their child’s unique competencies and vulnerabilities and therefore, understand how to respond to their baby in a way that meets their developmental needs. The 18 items include observations of the infant’s:
Capacity to habituate to light and sound (sleep protection) Motor and tone activity level Capacity for self-regulation (including crying and consoling)
Response to stress (indices of the infant’s threshold for stimulation) Visual, auditory and social interactive capacities (degree of alertness and response to stimuli)
The tool is baby-led, the baby’s behaviour guides which items are administered and in what order.
The NBO can be used as a targeted approach by using it with families in specialist services, targeting parents in, for example, Mother and Baby Units or Neonatal Units. It can also be delivered universally by, for example, all Health Visitors using it on their Newborn Visit. It can then be used at each visit or as needed in follow up appointments. The practitioner can be guided by the parents and use it to help understand the infant when the parents raise a concern or question about their baby, for example about management of sleep, feeding and crying. The NBO takes 10-30 minutes to administer. Certain items can be selected to administer based on the needs of the family and the baby’s state. It can be incorporated into practitioner’s normal contacts with families.
Every practitioner receives a manual prior to training to support the use of the NBO and they have access to online resources, including a summary form which can be completed with parents noting the observations made.
Fidelity
Fidelity of the NBO is maintained by ensuring trainers are rigorously trained with standardised training. Practitioners are strongly encouraged to participate in supervision to regularly review their skills and ensure they remain focused on maintaining effective ways of delivering. Fidelity is also supported with the use of standardised kits, a training book and recording guidelines and forms. Materials are available to practitioners through an online central training platform.
Modifiable Components
The NBO can be used in a highly flexible way to suit need and circumstances with individual elements of the tool being used in isolation as required. It can be delivered in a range of different environments: community settings, hospitals, home visits. The items covered in each session can be modified to meet the needs of each individual family and based on the baby’s state (i.e. sleeping, alert etc). Once practitioners are certified and skilled with the approach it can be adapted for use antenatally, it can also be delivered remotely over a video call. Further support with these adaptions can be discussed during supervision sessions offered by The Brazelton Centre UK.
The NBO has been used by practitioners across the world in different cultures, practitioners are trained to approach every family with respect and curiosity, taking into account any cultural differences.
The Brazelton Centre UK is a national charity which is part of a network of training centres across the world dedicated to the teaching and certification of the Newborn Behavioural Observational (NBO) System and Neonatal Behavioral Assessment Scale (NBAS). The parent centre, the Brazelton Institute is based in Boston, USA.
Support for Organisation/Practice
Implementation Support
The Brazelton Centre UK offers training and certification in the NBO to professionals across the UK. NBO trainers have been trained and approved by the Brazelton Centre.
Implementation supports are available on request. This can include support around staff selection and data collection, as well as how to integrate the NBO into services, processes and record keeping. They are also able to support connections with similar services already using the NBO.
Licence Requirements
No licence required.
Start-up Costs
Training for one practitioner in the NBO costs £465. This includes the 2-day training course, certification, NBO kit (book and handouts), post training support supervision and access to resources on the online training platform.
If practitioners have previously completed the NBAS training in the UK the cost is reduced to £233.
On site trainings are also available for groups of 13 – 20 individuals. Online training is also available for groups of 15 or 16 people. Group trainings cost £465 per person for groups of 15 – 39. The cost reduces the more staff are trained; 40 – 100 people costs £445 per person, 101 – 199 people is £419 per person and 200+ is £395 per person.
Building Staff Competency
Qualifications Required
Practitioners training in the NBO need to be working with infants and families from birth to 3 months, have an understanding of newborn behaviour and development and have a professional qualification involved in work with infants (e.g. midwives, Neonatal Unit staff, health visitors, neonatal doctors, perinatal mental health practitioners, paediatricians, psychologists, physiotherapists etc.).
Training Requirements
Practitioners attending the Newborn Behavioural Observational (NBO) System TM training course are required to do some pre-reading from the manual. They then attend the 2-day training course either online or in person (content is the same for both). This training covers the background and content of the NBO and is delivered through presentations, interactive exercises and live or video demonstration with a newborn baby and their parents. The course aims are:
Understand how newborn babies communicate Know about different behavioural states of infants Understand infants’ self-regulatory behaviours Know the signs of overstimulation or need for a break Learn soothing techniques to console the baby Understand how to support parent in a strength-based way, taking into consideration the parents’ needs
Following training practitioners are required to work towards certification. To become certified practitioners must carry out 5 practice NBO sessions with families, which requires the trainee to submit 5 recording forms and 5 parent questionnaires. This is all reviewed by a Neonatal Evaluation Officer who will ensure practitioners understand the tool. Once approved practitioners receive a certificate.
Supervision Requirements
The Brazelton Centre UK offers ongoing supervision sessions at no extra fee, delivered via Zoom. NBO supervision sessions are run twice a month for 1 hour each and are open to practitioners who have attended the training course and are working towards certification, and practitioners who have completed their certification. These sessions are optional and can be attended as frequently as required.
Theory of Change
The Newborn Behavioural Observational (NBO) System is based on key assumptions; infants are social beings ready to communicate, babies communicate through their behaviour and infants’ communication is not random, their rich repertoire of social responses, intentions and emotions are evolutionary designed to draw out caregiving from parents. The NBO therefore, is designed to help sensitise parents to their infant’s cues in order to engage the caregiver and motivate the kind of contingent parent-infant interaction deemed essential not only for the baby’s survival but for the establishment of secure attachments and healthy development.
Antenatal / Perinatal: from conception to birth - Rating: 4+
Research Design & Number of Studies
The best evidence for the NBO comes from four Randomised Controlled Trials (RCT), three conducted with involvement of the developers (McManus et al. 2020, Nugent et al. 2014 and Nugent et al. 2017) and one without involvement (Nicolson et al. 2022). The first two studies recruited 112 families (Nugent et al. 2014) and 40 families (Nugent et al. 2017) from postpartum units in a large urban hospital and community hospitals in North-eastern USA. The infants were all 2 days or younger when the NBO was conducted, then followed up at 1 month. The third study recruited 38 parents of children under 6 weeks old. All were from low-income, underserved communities in Massachusetts, USA (McManus et al. 2020). The fourth study recruited 90 new mothers, all reporting significant distress symptoms of depression or anxiety or had a history of mental illness (Nicolson et al. 2022). Mothers were recruited from metropolitan hospitals and a regional hospital in the state of Victoria, Australia.
Outcomes Achieved
Child Outcomes
Infants who received the intervention were 2.8 times more likely to be rated as cooperative than infants in the care as usual group (Nugent et al. 2017) At six month follow up, infants receiving the NBO had marginally significantly higher scores on measures of neurodevelopment (Social Role and Gross Motor domains) than the usual care group (McManus et al. 2020)
Parent Outcomes
At 1-month post-partum significantly fewer mothers in the intervention group had elevated depression symptoms than in the usual care group (Nugent et al. 2014) Significant between-group reduction in anxiety symptoms (Nicolson et al. 2022) Within-group analysis found a significant decrease in depression symptoms in the intervention group from pre-intervention to post-intervention (Nicolson et al. 2022) At 6-month follow up mothers in the group receiving the NBO had significantly greater improvements in maternal postnatal depressive symptoms than the usual care group (McManus et al. 2020) At 4 month follow up the intervention group demonstrated significantly higher sensitivity and non-intrusiveness than the comparison group (Nicolson et al. 2022) Intervention mothers were 2.5 times more likely to be rated as sensitive in their interactions with their infants, than mothers in the control group (Nugent et al. 2017) Maternal knowledge of infant development at 4 months follow up was significantly greater in the intervention versus the comparison group (Nicolson et al. 2022)
Key References
McManus, B., Blanchard, Y., Murphy, N., & Nugent, J.K. (2020) The effects of the Newborn Behavioral Observations (NBO) system in early intervention: A multisite randonized controlled trial. Infant mental Health Journal , 41, 757-769
Nicolson, S., Carron, S.P., & Paul, C. (2022) Supporting early infant relationships and reducing maternal distress with the Newborn Behavioral Observations: A randomized controlled effectiveness trial. Infant Mental Health Journal , 43:3, 455-473
Nugent, Bartlett & Valim (2014) Effects of an Infant-Focused relationship-based Hospital and Home Visiting Intervention on reducing Symptoms of Postpartum maternal Depression: A Pilot Study. Infants & Young Children , 27:4 292-304
Nugent, J. K., Bartlett, J., Von Ende, A., & Valim, C. (2017) The effects of the Newborn Behavioral Observations (NBO) system on sensitivity in mother-infant interactions. Infants & Young Children , 30:4, 257-268
Infants and Toddlers: 0-36 months - Rating:
Need
Comparable Population
The Newborn Behavioural Observational (NBO) System is designed for all families across cultures and countries and can be used universally with all families with infants up to 3 months old. It can also be used as a targeted approach in specialist services with families with specific needs (e.g in Mother and Baby Units or Neonatal intensive care units) or with specific, targeted families in universal services.
Research showing the effectiveness of the NBO were conducted with families from both urban and rural environments, in USA and in Europe.
Is this comparable to the population your organisation would like to serve?
Desired Outcome
The NBO aims to support parents to develop a deeper understanding of their child’s competencies, vulnerabilities and to help them respond to their baby in a way that is meeting their baby’s needs. It also aims to strengthen the relationship between infants and their parents in the newborn period.
Research has found the NBO to be effective in reducing postnatal depression in mothers, increasing sensitivity in parent interactions with their infant and developing parent’s knowledge concerning their infant’s communication skills. For the child it has been found to increase the cooperative interactions and neurodevelopment.
Do the above outcomes align with the desired outcomes of your organisation? Does your organisation have other initiatives in place that already effectively and efficiently address the above outcomes? Does the NBO approach and outcomes align well with other approaches or intervention offered to the population you serve?
Need Score
Select a rating
1
2
3
4
5
Fit
Values
The Newborn Behavioural Observational (NBO) System takes a strength-based interactive relationship-building approach. It values the parents’ knowledge about their child, treating them as the expert. In addition, they emphasise the need for the approach to be guided by the infant, always being led by them and giving them a voice.
Does taking a strength-based interactive relationship-building approach fit with the key values of your organisation? Is treating parents as the expert on their newborn, and being led by the infant a key value for your organisation’s approach?
Priorities
The NBO can be used with any family, universally or as a targeted approach in specialist services. It has been designed to be used with any or all families to support a deeper understanding of their child’s competencies, vulnerabilities and to help them respond to their baby in a way that is meeting their baby’s needs. The approach aims to strengthen the relationship between infants and their parents in the newborn period.
Is a universally, or targeted approach to strengthen the relationship between infants (0 – 3 months old) and their parents in the newborn period a priority for your organisation?
Existing Initiatives
Does your service already provide a universal or targeted approach, to support parents of infants, to understanding of their child’s competencies and vulnerabilities? Does your service already provide an approach with aims to strengthen the relationship between infants and their parents in the newborn period? Are existing initiatives effective and acceptable to families? Are there components in the NBO that are not met by existing interventions or approaches?
Fit Score
Select a rating
1
2
3
4
5
Capacity
Workforce
The number of practitioners required to implement The Newborn Behavioural Observational (NBO) System is one, but the numbers a service chooses to train should depend on the needs of the population they are serving. Although only one practitioner is required to deliver the approach, Brazelton UK recommended that services train more than one practitioner, as this can support the reflection and competency development of practitioners.
How many families does your organisation intend to support using this approach in the first year? Based on this number do you have the required number of staff to train in this approach?
Practitioners training to use the NBO should be working with infants and families from birth to 3 months, have an understanding of newborn behaviour and development and have a professional qualification involved in work with infants (e.g. midwives, Neonatal Unit staff, health visitors, neonatal doctors, perinatal mental health practitioners, paediatricians, psychologists, physiotherapists etc.).
Do you have practitioners with the required qualifications and skills, who are able to deliver this approach? Do you have practitioners who work with the relevant population to deliver this intervention?
The time commitment required for each practitioner involves time for the training (pre reading, 2 days training) and implementation. Using the NBO with a family can take from 5 minutes to 20 minutes depending on the items administered, based on needs of the parents and state of the baby. The use of the NBO can be integrated into a practitioner’s ongoing clinical contact with a family.
Can your organisation support the time commitment required for practitioner training and delivery of this approach?
Technology Support
To train and deliver the NBO, no technology support is required. If practitioners are engaging in online training, supervision, or delivery they require a device with the relevant software and internet connection. Practitioners can also access online resources through the Brazelton UK’s training platform
Do your practitioners have the required technology to access the training platform, supervision, training and delivery of the approach?
Administrative Support
No additional administration support is required over a services usual support for practitioners.
Financial Support
Practitioner training costs £465, this includes resources required for training and delivery of the approach.
Does your organisation have funds available to train the required number of practitioners?
Capacity Score
Select a rating
1
2
3
4
5