Newborn Behavioural Observations System (NBO)

Original Editor - Lauren Heydenrych

Top Contributors - Lauren Heydenrych  

Introduction[edit | edit source]

Much of the literature surrounding the theory of attachment and infant development agree that the relationship between caregiver and infant is an essential component in the development of confidence, self-regulation, adaption to stress and forming future positive relationships. Furthermore, research has highlighted the importance of an attuned caregiver in aiding the positive development of a child's brain and physiology in the first year of life. [1]

Dr T Berry Brazelton first developed the Neonatal Behavioral Assessment Scale (NBAS) in 1978 as a way of assessing 1. neurological functioning in the newborn and 2. their ability to actively participate in interactions. [1] The Newborn Behavioral Observations (NBO) system is the shorter clinical variation of the NBAS and was first published in 2007.

The NBO is a strengths-based and infant-led form of assessment, with the outcome being an individualised description of an infant's neurobehavioral capabilities. [2] [1]It is currently used as an "interactive relationship-building tool to strengthen the relationship between infants and parents".[3]


Objective[edit | edit source]

The objective of the NBO is to encourage parent education and active care-giving. It is a tool used to direct a caregiver's attention to an infant's abilities to engage in visual, auditory and perceptual engagement in the world - and people around them. It aims to develop an understanding of meaningful communication through an infant's behaviour. It also allows for the development of handling and caregiving techniques that caregivers can use in the home environment to respond to infant behavioral cues.[2][1]

Through the administration of the NBO (especially if repeated) a profile of the infant's strengths and challenges can be gained. This can allow for caregiver confidence to be developed in supporting and caring for an infant's needs.[5]

The NBO is also used within the research setting to:[1]

  1. Explore the associations between observed infant behaviours and other variables
  2. Establish the effectiveness of the tool in influencing infant and caregiver outcomes.

What the NBO is not: Objective data or scoring system

Theoretical Framework[edit | edit source]

The construct of the NBO views an infant's adaption and development in the extrauterine environment as a set of hierarchical tasks of self-regulation and organisation.[5]

These tasks are summarised by the acronym AMOR.[5]

  1. Autonomic
  2. Motor
  3. Organisation of state
  4. Responsiveness
  1. The first task of an infant is to organise their autonomic or physiological behaviour. This includes breathing, maintaining temperature and minimising tremors and startles.
  2. The next task is to regulate motor control. This includes moderating tone and gaining control over movement.
  3. Organisation of state is being able to establish predictable wake and sleep patterns and includes being able to 'protect sleep' - being able to block out any stimuli which would interfere with sleep.
  4. The last task is responsiveness and involves the ability to engage with and attend to visual and auditory stimuli. This includes social interaction.

Interpreting an infant's behaviour through this theoretical framework allows meaning to be attributed to the infant's communication cues during the NBO administration.[5]

Intended Population[edit | edit source]

The NBO can be performed with healthy newborns (gestational age of 36 weeks) to 3 months "post-term". Preterm or medically fragile infants can also have the NBO administered, but need to be stable enough to be close to discharge or who are already at home, post-discharge. infants (newborns to 3 months of age) together with their caregivers.[2][1]

Both low-vulnerability and high-vulnerability families have been considered when designing the NBO system. In addition, caregiver's are not limited to mothers or fathers, but include all those who take on a care giving role of the infant.[1]

Administration[edit | edit source]

Environment/Setting[edit | edit source]

The NBO is a flexible tool that can be used in the clinical setting, at home, at the hospital or even at a children's centre.[1]

The setting should be intimate enough to limit the interruption of the outside world and allow caregivers time and space to interact with the infant.[5]

Duration of assessment[edit | edit source]

The duration of the assessment is usually 20-30 minutes. [2]

Frequency of administration[edit | edit source]

The NBO can be administered once, however, depending on the goals set for intervention and needs of the family, it can be administered weekly, fortnightly or monthly. Being able to perform more than one administration allows for a greater holistic picture of the infant and their development. It also allows caregivers and clinicians to discuss appropriate reciprocations to the baby's seeking for such things as feeding and sleeping.[1][3]

Content[edit | edit source]

The NBO consists of 18 neurobehavioral observations.

These 18 items assess an infant's ability to habituate to light and sound (indicative of sleep protection), quality of motor tone and activity level, capacity for self-regulation, response to stress (indicating threshold for stimulation) and the infant's visual, auditory and social-interactive capacities.

  1. Habituation to light.
  2. Habituation to sound.
  3. Muscle tone in legs and arms.
  4. Rooting.
  5. Sucking.
  6. Hand grasp.
  7. Shoulder and neck tone.
  8. Crawling response.
  9. Visual tracking.
  10. Visual response to face.
  11. visual response to face and voice.
  12. Orientation to sound.
  13. Orientation to voice.
  14. Crying.
  15. Soothability.
  16. State regulation.
  17. Response to stress.
  18. Activity level.

Introducing the NBO[edit | edit source]

Administration of the NBO places the infant in "center-stage" as described by Nugent (2015). Items of administration are not simply a set of tasks to be performed but help in revealing the infant's nature and personality to caregivers. From the beginning, the clinician needs to be aware and sensitive to the communication and behaviour of the infant and provide support and reciprocation.[5]

The invitation to participants of the NBO is usually framed as "Lets see what this little baby can tell us about herself."

Progression of the NBO[edit | edit source]

The administration of the NBO is infant-led, so it will not always follow items in their presented order.[5]

The session usually begins with a shared observation of the initial state of the infant. The session then progresses to items involving more awake or alert states. It may be that the infant remains asleep throughout. In these scenarios, repeated administration aids in the evaluation of changes in sleep patterns and levels of organisation. [5]

Wherever possible, caregivers are encouraged to aid in eliciting or guiding of items.[5]


Evidence[edit | edit source]

In a Cochrane review evaluating the effectiveness of both the NBAS and NBO, it was concluded that current studies (1981-2015) were of low-quality evidence. and that more studies of better quality were needed to establish the effectiveness in supporting caregivers in neonatal support[1]

Positive results have been documented in various studies, although few in number.

A study undertaken in Ireland sought to gain an understanding of participants who had completed the NBO training and then implemented it into their community services. The study found that participants felt more confident and empowered to treat infants and communicate with parents following NBO training. It was also highlighted that ongoing peer support groups may be a good way to support continued learning and development within the NBO. [7]

In another study where interviews were done with mothers in a rural Pakistan context, high satisfaction was expressed by the mothers. Not only did they feel more confident in the care of their infant, but they also related a better understanding of their infant's behavioural cues and a stronger attachment.[8]

Links[edit | edit source]

The Newborn Behavioral International site has links to research dealing with the NBO.

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Bartram SC, Barlow J, Wolke D. The Neonatal Behavioral Assessment Scale (NBAS) and Newborn Behavioral Observations system (NBO) for supporting caregivers and improving outcomes in caregivers and their infants. Cochrane Database of Systematic Reviews. 2015 Jun 21(6).
  2. 2.0 2.1 2.2 2.3 Lean RE, Smyser CD, Rogers CE. Assessment: the newborn. Child and Adolescent Psychiatric Clinics. 2017 Jul 1;26(3):427-40.
  3. 3.0 3.1 Yago S, Takahashi Y, Tsukamoto E, Saito A, Saito E. Use of the Newborn Behavioral Observations System as an early intervention for infants and their parents: A scoping review. Early Human Development. 2023 Jun 19:105811.
  4. Brazelton Centre UK. The Newborn Behavioural Observations . Available from: [last accessed 21/11/2023]
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Nugent JK. The newborn behavioral observations (NBO) system as a form of intervention and support for new parents. Zero to Three Journal. 2015 Sep 1;36(1):2-10.
  6. Brazelton Centre UK. Listening to babies...from the Moment of Birth. Available from: [last accessed 21/11/2023]
  7. Connorton R. Herlihy A. Cleary R. Practitioner views and reflections on applying the Newborn Behavioural Observations (NBO) system within an Irish Context. World Association for Infant Mental Health. 2022
  8. Parveen S, Zeshan M, Naveed S, Levey E, Jahan N, Harrison AM. Newborn behavioral observations system in rural Pakistan: A feasibility and acceptability study. Infant Mental Health Journal. 2023 Jan;44(1):125-32.