Introduction to Research with the 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.

Rosarii O’D. Connorton, Aine Herlihy & Ruth Cleary. Perspectives in Infant Mental Health, July, 2022 https://perspectives.waimh.org/2022/06/17/practitioner-views-and-reflections-on-applying-the-newborn-behavioural-observations-nbo-system-within-an-irish-context/

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.

Kim Simkin-Tran, Bronwyn Harman, Susan Nicolson (2020).  Journal of Pediatric Nursing, Feb, 2020. https://doi.org/10.1016/j.pedn.2020.01.018

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.

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):https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-020-02669-y

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.

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.

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.

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

Esther Sokoloff-Rubin, Jessica Dym Bartlett, Katherine Paschall, Allison Hebert, Lianne Woodward, J. Kevin Nugent, Sylva Yeghiayan, Rachel Suttin, Lise C. Johnson.  Mothers of Preterm Infants’ Subjective Experiences of a Newborn Behavioral Observations (NBO) Parenting Support Intervention. Presented at the 35th Annual Gravens Conference on the Environment Of Care For High-Risk Newborns. Clearwater Florida, March 12, 2022.

Huiping Zhang, Ze’en Zhu, Shan Wang, Xiaoqin Nan, Jinhua Huang, Dan Yao, Shuya Shao, Shengquan Chen, Tawali Shah, Hui Li. Effect of Newborn Behavioral Observations (NBO) intervention on insecure parent-child attachment following maternal perinatal depressive symptoms: a prospective cohort study.  Presented at the 17^th World Association for Infant Mental Health, Brisbane, 2021.

Yuka Urata, Masako Nagata. Effect of an NBO Introduction to mothers in a maternity clinic (Japan).  Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Susan Nicolson, Alex Harrison, Katharine Frost, Nicki Dawson, Kathy Crouch, J. Kevin Nugent.  Towards cultural safety, family access, infant wellbeing: Global stories of early parent-infant relationship support using the Newborn Behavioral Observations (NBO)(Susan Nicolson, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Alexandra Murray Harrison. The NBO (Newborn Behavioral Observations) in Asia and Latin America.  Presentation in Symposium entitled: Towards cultural safety, family access, infant wellbeing: Global stories of early parent-infant relationship support using the Newborn Behavioral Observations (NBO)(Susan Nicolson, Chair). WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Kathy Crouch & Susan Nicolson. Baby’s First Yarn: Cultural co-design of a baby-led, infant mental health support for Aboriginal families in the first 100 days. Presentation within Symposium entitled: Towards cultural safety, family access, infant wellbeing: Global stories of early parent-infant relationship support using the Newborn Behavioral Observations (NBO) (Susan Nicolson, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Nicki Dawson, Katherine Frost, Susan Nicolson. “She is now beautiful”, seeing and being seen, and the power of the Newborn Behavioural Observations (NBO). Presentation within Symposium Titled: Towards cultural safety, family access, infant wellbeing: Global stories of early parent-infant relationship support using the Newborn Behavioral Observations (NBO)(Susan Nicolson, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

1. Kevin Nugent, Maggie Redshaw, Susan Nicolson, Ingeborg H. Kristensen, Inge Nickell, Eiko SAITO, Lise Johnson. Randomized Controlled Trials testing the efficacy of the Newborn Behavioral Observations (NBO) system in Australia, Denmark, Japan and the US. (J. Kevin Nugent, Chair, Maggie Redshaw, respondent). Symposium presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia. Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Lise C. Johnson, Jessica Bartlett, J. Kevin Nugent, Lianne Woodward. The impact of an NBO-based intervention on the mental health of mothers with late preterm infants. Presentation within Symposium entitled: Randomized Controlled Trials testing the efficacy of the Newborn Behavioral Observations (NBO) system in Australia, Denmark, Japan and the US (Kevin Nugent, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Susan Nicolson, Pia Carron, Campbell Paul, Louise Newman. Supporting the newborn-parent relationship when there is parental depression or anxiety: Australian trial of the Newborn Behavioural Observations (NBO). Presentation within Symposium titled: Randomized Controlled Trials testing the efficacy of the Newborn Behavioral Observations (NBO) system in Australia, Denmark, Japan and the US. (Kevin Nugent, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Ingeborg H. Kristensen, Merethe Vinter, Inge K. Nickell, Hanne Kronborg. Health visitors’ competences before and after implementing the Newborn Behavioral Observations (NBO) in a community setting: A cluster randomised study. Presentation within Symposium titled: Randomized Controlled Trials testing the efficacy of the Newborn Behavioral Observations (NBO) system in Australia, Denmark, Japan and the US. (Kevin Nugent, chair).Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Beth McManus Yvette Blanchard, Natalie Murphy, J. Kevin Nugent. The Effects of the Newborn Behavioral Observations (NBO) system with at-risk infants in Early Intervention: a Multi-site Randomized Controlled Trial.  Presentation within Symposium titled: Randomized Controlled Trials testing the efficacy of the Newborn Behavioral Observations (NBO) system in Australia, Denmark, Japan and the US. (Kevin Nugent, chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Eiko Saito, Emi Tsukamoto, Takako Hirose, Maiko Nakamoto, Saori Minagawa, Masae Hasegawa, Mariko Iwayama. A randomized controlled trial on the efficacy of an early parenting relationship-building intervention using the Newborn Behavioral Observations in Japan. Presentation within Symposium titled: Randomized Controlled Trials testing the efficacy of the Newborn Behavioral Observations (NBO) system in Australia, Denmark, Japan and the US. (Kevin Nugent, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Lise Johnson. Notes from the field: The NBAS and NBO in practice around the world (Lise Johnson, Chair). Symposium presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia. 2020, “Creating stories in Infant Mental Health: research, recovery and regeneration”, presenters will be asked to share an illustrative story or case report that captures the essence of their work with the NBAS and/or NBO. At the conclusion of the session we hope that participants will have a sense of both the diversity and the unifying themes that characterize contemporary work using the NBAS and NBO

Ze’en Zhu , Shan Wang , Xiaoqin Nan , Jinhua Huang , Dan Yao, Huiping,  Zhang, Shuya Shao , Shengquan Chen, Tawali Shah, Hui Li. Effect of Newborn Behavioral Observations (NBO) intervention on insecure parent-child attachment following maternal perinatal depressive symptoms: a prospective cohort study. Presentation within the symposium titled; Notes from the field: The NBAS and NBO in practice around the world (Lise Johnson, Chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Jayne Singer. Facilitating Newborn Behavioral Observations in the context of maternal-infant substance exposures and recovery. Presentation in the Symposium entitled: Notes from the field: The NBAS and NBO in practice around the world (Lise Johnson, chair).  Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Claire Favrot-Meunier. “Leila, a hearing baby with her deaf parents: talking together”. Presentation within the symposium entitled “Notes from the field: The NBAS and NBO in practice around the world” (Lise Johnson, chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Deanna Gibbs. Transforming relationships: Using the NBO in the neonatal unit to enhance infant communication and parent understanding. Presentation within the symposium entitled; “Notes from the field: The NBAS and NBO in practice around the world” (Lise Johnson, chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Eiko Saito, Yukiyo Nagai , Masako Nagata , Shohei Ohgi , Mariko Iwayama. The uses of the NBO in Japanese cultural settings. Presentation within the symposium entitled “Notes from the field: The NBAS and NBO in practice around the world”. Dr Lise Johnson (Chair).  Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Campbell Paul, Masako Nagata. Using the Newborn Behavioural Observation (NBO) to support parents and staff in meeting the needs of extremely premature babies. Presentation within the symposium entitled “Notes from the field: The NBAS and NBO in practice around the world”. (Lise Johnson, chair). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Alexandra Harrison, Kevin Nugent & Lise Johnson. The NBO in Covid Times: How can the NBO be conducted virtually to build a strong parent-infant relationship? Lessons from Pakistan, Australia, Norway and the United States.  Symposium presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Alexandra Harrison, Shazia Parveen, Muhammad Zeshan. Zooming in to Support Families of Infants: Practicing the Remote NBO. Presentation with the symposium titled; The NBO in Covid Times: How can the NBO be conducted virtually to build a strong parent-infant relationship? Lessons from Pakistan, Australia, Norway, and the United States  (Chair: Alexandra Harrison). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Susan Nicolson & Campbell Paul. Necessity is the mother of invention: Newborn Behavioral Observations in perinatal and infant mental telehealth. Presentation within the symposium titled: The NBO in Covid Times: How can the NBO be conducted virtually to build a strong parent-infant relationship? Lessons from Pakistan, Australia, Norway, and the United States (Alexandra Harrison, Chair).  Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.Lise Johnson, Kevin Nugent, Aditi Subramaniam, Maria Henrikson,

Sylva Yeghiayan, Leah Koretz, Nancy Macalaster , Laurie Foster, Rachel Suttin.  The urgent need for ‘Holding’ mothers and their late preterm infants in mind: Creative adaptations in the Baby AMOR study. Presentation with the symposium titled; The NBO in Covid Times: How can the NBO be conducted virtually to build a strong parent-infant relationship? Lessons from Pakistan, Australia, Norway, and the United States (Chair, Alexandra Harrison). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Unni Tranaas-Vannebo & Kari Slinning. When the NBO practitioner takes the role as a coach: Some experiences from Norway during the Covid-19 situation. Presentation with the symposium entitled: The NBO in Covid Times: How can the NBO be conducted virtually to build a strong parent-infant relationship? Lessons from Pakistan, Australia, Norway, and the United States, (Chair, Alexandra Harrison). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Roseanne Clark, Sarah Strong, Gretchen Becker Crabb. Remote NBO Training and Implementation in the Context of the Global Pandemic in a University Post-Graduate Infant Mental Health Program: Challenges and Benefits.  Presentation within the symposium entitled: The NBO in Covid Times: How can the NBO be conducted virtually to build a strong parent-infant relationship? Lessons from Pakistan, Australia, Norway, and the United States (Chair, Alexandra Harrison). Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

Maggie Redshaw  & Michaela Vigarova. Changing practice: developing the skills of practitioners working with infants and families during the postnatal period.  Presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

1. Kevin Nugent. AMOR – Giving babies and their parents their own voice through the NBO. Master Class presented at WAIMH 2021, 17^th World Congress, Brisbane, Australia.

McManus, Yvette Blanchard, Natalie Murphy, J. Kevin Nugent. (2019). The Effects of the Newborn Behavioral Observation (NBO) System in Early Intervention: a Multi-Site Randomized Controlled Trial.  Presented at the APTA Academy of Pediatric Physical Therapy Annual Conference (APPTAC), Omaha, Nebraska, Nov 13-15, 2019.

Braden, J., Paul, C., Nicolson, S., Paul, J., Buist, A. (2018). Experiences of Maternal and Child Health Nurses in using the Newborn Behavioral Observation (NBO) system.  Presented at the 16th World Congress of the World Association for Infant Mental Health, Rome, May 2018.

Shah, Tawali (2018).  The Effects of the NBO on breastfeeding mothers with high levels of perinatal maternal anxiety.  Presented at the 16th World Congress of the World Association for Infant Mental Health, Rome, May 2018

Halliday, J. (2017). A closer look. Community Practitioner, January, 2017.

Greve, R., Braarud, H. C., Slinning, K. (2016). Feasibility and Acceptability of the Newborn Behavioral Observations (NBO) system in well-baby clinics. Presented at the 15^th World Congress of WAIMH, Prague, June 2016.

Appleton, J., Nickell, I., Nicolau, S. (2016) Evaluating the impact of preparation for health visitors prior to attending the NBO (Newborn Behavioural Observations) training on later use with families. Presented at the 15^th World Congress of WAIMH, Prague, June 2016.

Magalhaes, L., Dittz, E., Guimaraes, M. A. P., Lindgren Alves, C. (2016). The Newborn Behavioral Observation as relationships building tool In Brazil: the perspective of mothers and professionals. Presented at the 15^th World Congress of WAIMH, Prague, June 2016.

Nugent, J. K., Dym-Bartlett, J., Von Ende, A., Killough, J., Valim, C., A Randomized Study of the Effects of the Newborn Behavioral Observations (NBO) System on Mother-Infant Interaction. Presented at the Society for Research in Child Development (SRCD) Biannual Meeting, Philadelphia, March 2015.

Saito, E. Effectiveness of a nursing intervention for relationship-building between Japanese parents and their problematic breast-feeders, using the newborn behavioral observations system.  Presented at WAIMH, Edinburgh, 2014

Jayne Singer, Using the NBO with infants treated for congenital heart defects.  Presented at the Understanding the Baby and Supporting Parents using the NBO and NBAS. Pre-WAIMH Poster session, Edinburgh, 2014.

Paul, C., Nicolson, S., Thomas, N., Chapman, M, Salo, F., Judd, F. Introducing the newborn behavioral observation into a maternity hospital: the power of babies meeting their mothers and fathers. Presented at WAIMH, Edinburgh, 2014.

Savage-McGlynn, E., & Hawthorne, J. The effects of the neonatal behavioral observation (NBO) on parent perception and enhancement of the parent-infant relationship. Presented at WAIMH, Edinburgh, 2014.

Alvarez, M. A. The baby as a person not as a patient: using the NBO in paediatric primary care in an urban Spanish setting. Presented at WAIMH, Edinburgh, 2014.