The Newborn as a Person: Enabling Healthy Infant Development Worldwide

THE

NEWBORN AS A PERSON Enabling Healthy Infant Development Worldwide

Edited by

J. Kevin Nugent Bonnie J. Petrauskas T. Berry Brazelton

Enabling Healthy Infant Development Worldwide

Edited by

J. Kevin Nugent Bonnie J. Petrauskas T. Berry Brazelton

John Wiley & Sons, Inc.

This book is printed on acid-free paper. Copyright © 2009 by John Wiley & Sons, Inc. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional person should be sought. Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contact the appropriate companies for more complete information regarding trademarks and registration. For general information on our other products and services please contact our Customer Care Department within the United States at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, visit our web site at www.wiley.com. Library of Congress Cataloging-in-Publication Data: The newborn as a person: enabling healthy infant development worldwide /edited by J. Kevin Nugent, Bonnie J. Petrauskas, T. Berry Brazelton. p. cm. Includes index. ISBN 978-0-470-38645-3 (cloth) 1. Infants—Development. 2. Newborn infants—Care. 3. Parent and infant. I. Nugent, J. Kevin. II. Petrauskas, Bonnie. III. Brazelton, T. Berry, 1918– HQ774.N43 2008 305.232—dc22 2008011988 Printed in the United States of America 10

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To my family, Una, Aoife, and David, and to the many NBAS scholars and clinicians from all over the world with whom I have been fortunate to work over the years. —J. Kevin Nugent To my husband Stan for his love and support and our sons, Corey and Connor, for the gift and joys of motherhood. —Bonnie J. Petrauskas To my family and to all who have been trained in the NBAS and the families they serve. —T. Berry Brazelton

Together, we dedicate this book to all those who have guided and supported our work in the past, those with whom we work today, and the next generation of health care providers who will care for infants and their families around the world.

Contents Acknowledgments Contributors Preface

part i Chapter 1

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looking back

The Discovery of the Human Newborn: A Brief History J. Kevin Nugent

3

part ii contemporary research and practice: international perspectives Research on Newborn Behavior and Development Chapter 2

Chapter 3 Chapter 4 Chapter 5 Chapter 6

Chapter 7

Chapter 8

Predicting Development for Extremely Low Birthweight Infants: Sweden Karin Stjernqvist The Effects of Newborn Massage: United States Tiffany Field Perinatal Factors Influencing Development: Spain Carme Costas-Moragas Supporting Parents of At-Risk Infants: Japan Shohei Ohgi and Tomitaro Akiyama The Cultural Context of the Mother-Infant Relationship: Korea Yeonghee Shin and Byunghi Park Moments of Meeting: Pivotal Moments in Mother, Infant, Father Bonding: Switzerland Nadia Bruschweiler-Stern The Developmental Niche of the Newborn in Rural Kenya Charles M. Super and Sara Harkness

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Contents Early Intervention with Infants and Families

Chapter 9

Early Intervention and Fatherhood: Denmark Hanne Munck Chapter 10 A Model for Working in Community Health Settings: United Kingdom Joanna Hawthorne and Betty Hutchon Chapter 11 Using the Newborn Behavioral Observations (NBO) System with At-Risk Infants and Families: United States Yvette Blanchard Chapter 12 Early Intervention in an Australian Setting Beulah Warren Chapter 13 Reaching Out to Rural Communities: A Community Health Model: Thailand Nittaya Jirathiyut Kotchabhakdi and Naiphinich Kotchabhakdi Chapter 14 Maternal-Child and Family Nursing and Preventive Intervention: United States Kristie Brandt New Models in Training Health-Care Professionals Chapter 15 The Touchpoints Approach: United States Ann Coleman Stadtler and John Hornstein Chapter 16 The Newborn as a Touchpoint: Training Pediatricians in Portugal João Gomes-Pedro Chapter 17 Humanizing the Infant: France Drina Candilis-Huisman and Marie Fabre-Grenet Chapter 18 The NBAS in a North Carolina Clinical Setting: Hospital and Home: United States James M. Helm and Marie A. Reilly Chapter 19 Relationship-Based Practice in the Newborn Nursery: Thoughts for the Pediatric Professional: United States Constance Helen Keefer, Lise Carolyn Johnson, and Susan Minear Chapter 20 Preparing Professionals to Work with Newborns: The Brazelton Institute Experience: United States Jean Gardner Cole, Cecilia F. Matson, and Thembi Ranuga

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Contents Chapter 21 Integrating Developmental Principles into the Daily Work of Health Professionals: Italy Gherardo Rapisardi, Adrienne Davidson, Roberto Paludetto, and Giuseppina Mansi

part iii

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looking toward the future

Chapter 22 A View from the Lab Rachel Keen Chapter 23 Parent-Infant Bonding and Doula Support John H. Kennell Chapter 24 The Brazelton Baby: The Other Side of the Coin Ed Tronick Chapter 25 Evolving Family Dynamics and Neonatal Assessment Bonnie J. Petrauskas Chapter 26 Future Dialogue between the Neurosciences and the Behavioral Observation of Infants Daniel N. Stern and Nadia Bruschweiler-Stern Chapter 27 The Role of the Neonatal Behavioral Assessment Scale: Personal Reflections T. Berry Brazelton Author Index Subject Index

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Acknowledgments We would like to acknowledge the critical role of Janice Blake in the preparation and development of this book. Janice not only edited each chapter with an unfailingly careful eye for detail but she succeeded in maintaining warm, supportive relationships with authors from across the world throughout the process. We would like to acknowledge her superb skill as an editor, her personal warmth, and her dedication and commitment in bringing this book to fruition. We are grateful to our publisher John Wiley and Sons for their support in making this body of work on newborn and infant development available worldwide. We are especially grateful to the Executive Editor, Patricia Rossi, for her enthusiasm for and commitment to the book from the outset. We would also like to offer our deepest thanks to Senior Production Editor, Deborah Schindlar, for her expert advice and patient guidance in the final stages of the production of this book. We are pleased to recognize the role of colleagues whose work could not be included in this volume but whose ideas, in particular through their work with the Neonatal Behavioral Assessment Scale, have contributed to many of the themes expressed in this book. We gratefully acknowledge the seminal work of Heidelise Als and Barry Lester. We thank NBAS trainers Karen Fehringer, Jennifer Gillette, Dan Griffith, Beth Higley, Elise Holloway, John McCarthy, Susan Palmer, Joan Castellan, Elinor Harvey, and Judi Withers, in the United States; Jose and Jane Saraiva in Brazil; Alain Caron, Marie-Paule Durieux, Guy Frankard and Claire de Vreindt-Goldman, in Belgium; Chisato Kawasaki and Toshiya Tsurusaki in Japan; Maggie Redshaw, Inga Warren, and Dieter Wolke from the United Kingdom and Hellgard Rauh in Germany. To Ida Cardone and Linda Gilkerson, Donna Karl, Rebecca Kang and Kathryn Barnard, John Worobey, Barbara Myers, Catherine Donahue, Mary Grimanis, Joan Pernice, Joylene Pearson, and Zachariah Boukydis for their work with the NBAS, we offer our sincere thanks. We also would like to pay tribute to the thousands of NBAS researchers, educators, and clinicians who have passed through our training xi

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programs, who have enriched our lives, and who continue to enrich the lives of infants and families everywhere. We offer a special word of thanks to the March of Dimes for their work in promoting NBAS training over the years. This book represents many years of work with the NBAS, and such sustained effort can only be achieved in a supportive administrative environment. We acknowledge the work of Patricia Lambkin, Gillian Blake, Suzanne Otcasek, Kimberly Rose, and the late Kate Neff, who is still remembered with gratitude and fondness. Finally, we would like to thank Johnson & Johnson for the opportunity to collaborate on this publication.

Contributors Tomitaro Akiyama, MD Professor Emeritus, Nagasaki University Director, Nagasaki City Welfare Center for the Disabled Nagasaki, Japan

Drina Candilis-Huisman, PhD Psychologue Maître de Conférences, Directrice de Recherche Université de Paris Paris, France

Yvette Blanchard, ScD, PT Associate Professor of Physical Therapy University of Hartford West Hartford, Connecticut, USA Brazelton Institute Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA

Jean Gardner Cole, MS Brazelton Institute Division of Developmental Medicine Children’s Hospital Division of Neonatology Boston Medical Center Boston, Massachusetts, USA

Kristie Brandt, RN, CNM, MSN, ND Director, Parent-Infant & Child Institute Napa, California, USA T. Berry Brazelton, MD Professor of Pediatrics Emeritus, Harvard Medical School Founder and Chief Emeritus, Child Development Unit Founder, Brazelton Touchpoints Center Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA Nadia Bruschweiler-Stern, MD Directrice, Center Brazelton Suisse Clinique des Grangettes Genève, Switzerland

Ann Coleman Stadtler, MSN, CPNP Director, Collaborative Development and Training Brazelton Touchpoints Center Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA Carme Costas-Moragas, PhD Professor, Department of Clinical and Health Psychology Universitat Autònoma de Barcelona Director, NBAS Training Site Barcelona, Spain Adrienne Davidson, MS, PT Head, Physiotherapy Department Brazelton Center of Florence Anna Meyer Children’s Hospital Florence, Italy xiii

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Marie Fabre-Grenet, MD Centre d’Action Médico-Sociale Précoce Nord Centre Hospitalier Universitaire Nord Ch des Bourrelys, France Tiffany Field, PhD Professor, Departments of Pediatrics, Psychology and Psychiatry University of Miami School of Medicine Director, Touch Research Institutes Department of Pediatrics University of Miami School of Medicine Miami, Florida, USA João Gomes-Pedro, PhD, MD Professor and Director, Department of Pediatrics, University of Lisbon Hospital Santa Maria Lisbon, Portugal Sara Harkness, PhD, MPH Professor, Human Development, Pediatrics, and Anthropology Center for the Study of Culture, Health, and Human Development University of Connecticut Storrs, Connecticut, USA Joanna Hawthorne, PhD Psychologist Coordinator and Trainer, Brazelton Center in Great Britain Associate Member, Center for Family Research University of Cambridge Cambridge, England

James M. Helm, PhD Clinical Associate Professor, Pediatrics North Carolina School of Medicine Adjunct Assistant Professor, Special Education University of North Carolina–Chapel Hill Director, Carolina NBAS and NIDCAP Training Center WakeMed, Neonatology Raleigh, North Carolina, USA John Hornstein, EdD Assistant Professor, Graduate Programs in Early Childhood Education Department of Education University of New Hampshire Durham, New Hampshire Brazelton Touchpoints Center Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA Betty Hutchon, SROT Honorary Lecturer, Department of Pediatrics and Child Health Royal Free and University College Medical School Head Occupational Therapist, Royal Free Hospital London, England Lise Carolyn Johnson, MD Director, Well Newborn Nurseries Brigham and Women’s Hospital Brazelton Institute Division of Developmental Medicine Children’s Hospital Instructor in Pediatrics, Harvard Medical School Boston, Massachusetts, USA

Contributors Constance Helen Keefer, MD Assistant Professor of Pediatrics Harvard Medical School Brazelton Institute Brazelton Touchpoints Center Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA Rachel Keen, PhD Professor of Psychology, Department of Psychology University of Virginia Charlottesville, Virginia, USA John H. Kennell, MD Professor of Pediatrics Emeritus, Division of Behavioral Pediatrics and Psychology Case Western Reserve University School of Medicine Rainbow Babies and Children’s Hospital Cleveland, Ohio, USA Naiphinich Kotchabhakdi, PhD Associate Professor Director, Neuro-Behavioral Biology Center Institute of Science and Technology Mahidol University Nakhon Pathom, Thailand Nittaya Jirathiyut Kotchabhakdi, MD, MS (MCH) Associate Professor of Pediatrics Director, Brazelton Center Founder, Developmental Behavioral Division Department of Pediatrics Faculty of Medicine, Ramathibodi Hospital Mahidol University Bangkok, Thailand

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Giuseppina Mansi, PhD Clinical Psychologist, Department of Pediatrics Università “Federico II” di Napoli Naples, Italy Cecilia F. Matson, MA Child Development Specialist, Brazelton Institute Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA Susan Minear, MD Assistant Professor of Pediatrics, Boston University Medical School Brazelton Institute Division of Developmental Medicine Children’s Hospital General and Behavioral/ Developmental Medicine Department of Pediatrics Boston Medical Center Boston, Massachusetts, USA Hanne Munck, Cand. Psych. Associate Professor, Department of Psychology University Clinic University of Copenhagen Copenhagen, Denmark J. Kevin Nugent, PhD Professor, Child and Family Studies University of Massachusetts–Amherst Founder and Director, Brazelton Institute Division of Developmental Medicine Children’s Hospital Lecturer, Harvard Medical School Boston, Massachusetts, USA

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Shohei Ohgi, PhD Department of Rehabilitation Seirei Christopher College Shizuoka, Japan Roberto Paludetto, MD Professor of Pediatrics Director, Brazelton Center Chief of Neonatology Department of Pediatrics Università “Federico II” di Napoli Naples, Italy Byunghi Park, EdD Endowment Professor, Department of Early Childhood Education Keimyung College Daegu, Korea Bonnie J. Petrauskas Director, Johnson & Johnson Pediatric Institute New Brunswick, New Jersey, USA Thembi Ranuga, MPH, MS, APRN-BC Brazelton Institute Division of Developmental Medicine Children’s Hospital Boston, Massachusetts, USA Adult Nurse Practitioner, Southcoast Physicians Specialists Fall River, Massachusetts, USA Gherardo Rapisardi, MD Pediatrician and Neonatologist Director, Brazelton Center Anna Meyer Children’s Hospital Florence, Italy

Marie A. Reilly, PT, PhD Associate Professor of Physical Therapy University of North Carolina–Chapel Hill WakeMed, Neonatology Raleigh, North Carolina, USA Yeonghee Shin, RN, PhD Dean and Associate Professor of Pediatric Nursing College of Nursing Keimyung University Daegu, Korea Daniel N. Stern, MD Professor of Psychology, University of Geneva Geneva, Switzerland Adjunct Professor of Psychiatry, Cornell University Medical Center–New York Hospital, New York, USA Karin Stjernqvist, PhD Professor, Department of Psychology Director, Division of Developmental Psychology Lund University Lund, Sweden Charles M. Super, PhD Professor of Human Development and Pediatrics, Center for the Study of Culture, Health, and Human Development University of Connecticut Storrs, Connecticut, USA

Contributors Ed Tronick, PhD University Distinguished Professor, Department of Psychology University of Massachusetts–Boston Director of the Child Development Unit Division of Developmental Medicine Children’s Hospital Harvard Medical School Boston, Massachusetts, USA

Beulah Warren, MA Hons, MMH, Coordinator, Clinical Supervision NSW Institute of Psychiatry–Sydney Sydney, Australia Psychologist, Family Futures Balmain, Australia

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Preface Scientists have long been fascinated by the human newborn, intrigued by questions about the genetic origins of the infant’s behavioral repertoire and about the deft interplay of genetic and environmental factors in shaping the child’s behavior. Is the newborn baby’s repertoire inescapably genetic? How do newborn traits reach down into the double helix? Are there individual differences in behavior at birth and if so, do these individual differences persist into later childhood? Have scientists underestimated or overestimated the newborn infant’s capacity for learning or the infant’s capacity for feeling? Do early experiences actually determine the child’s future cognitive and emotional well-being? How resilient is the young infant? Are cultural differences in behavior evident from the beginning? How effective are intervention strategies that begin in the newborn period? What are the implications of our new understanding of newborn behavior and development for parents around the world? These are the kinds of questions that have engaged neuroscientists for at least three decades and this volume constitutes an attempt by researchers from around the world to address many of them. In this book we present the findings of a group of researchers and theoreticians from different countries, all of whom share a common interest in newborn behavior and development, and all of whom seem to be driven by a passionate commitment to give children and their families the best possible start in life. Despite considerable diversity in theoretical perspective and research interest, all of these authors believe that the newborn infant is a competent and complex organism and have concluded that the newborn period is a formative period in the child’s development and in the development of the parent-child relationship, while many believe that the newborn period and the early months of life may well be the intervention point par excellence across the human life span. The book begins with a brief look back at the history of newborn research and describes what we have learned about newborn behavior and early relationships over the past 3 decades. The main body of the book goes on to present a series of research and clinical xix

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studies by researchers and clinicians from countries around the world. We present studies on the effects of various pre- and perinatal influences on newborn behavior, from low birthweight and prematurity to intrauterine lead exposure. Longitudinal studies from Sweden and Japan examine the important question of the relation between newborn behavior and later development. The effects of a range of intervention practices are reported, from infant massage to relationship-based interventions, extending from rural settings in Thailand to urban settings in Denmark, Britain, Australia, and the United States, while the cultural context of infant development is described in cultures from Korea to Kenya. There are a number of chapters describing different approaches to professional education and resident training and efforts to implement a more positive model of patient care in European and North American settings. In the final section of the book, we take a look at the future and specify the challenges facing children and families everywhere, offering a series of proposals for intervention and public policy. The authors address the question of how this new body of information can help researchers, clinicians, and policymakers better understand the needs of infants and families as the twenty-first century moves ahead. These research reports attest to the role the Neonatal Behavioral Assessment Scale (NBAS) has played by expanding our understanding of newborn behavior and development. When the NBAS was first published in 1973, little was known about the remarkable capacities of the newborn. Indeed, when I first came to the Child Development Unit at the Children’s Hospital in Boston in the late 1970s to work with Berry Brazelton, I was not alone in thinking that the newborn infant was passive and incompetent, little more than a reflexive, even subcortical, organism. I was fortunate to learn about the remarkable capacities of the newborn through the NBAS under the mentorship of its creator T. Berry Brazelton and his colleagues. When I later became responsible for NBAS training, we established an international network of researchers, designed to promote the use of the NBAS in research and clinic settings around the world. The first historic meeting of that group took place in Berlin in 1985, and many of the participants in that meeting and in the subsequent meetings of the international NBAS network are key contributors to this volume. This book, then, celebrates the extraordinary advances in our understanding of newborn and infant development that have emerged over the past 3 decades. These new scientific discoveries have given the lie to the classic Lockean or Skinnerian view of the

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newborn infant as a mere tabula rasa, or blank slate, and have replaced it with a view of the newborn as possessing a wide array of mental skills and predispositions, which enable the newborn to actively engage with the world from the very beginning. Thanks to the creative ingenuity of researchers from across the world, many of whom are featured in this volume, we have come to see that the newborn infant is indeed competent in all five modalities, and we have learned that there is a wide range of individual differences in newborn behavioral profiles. There is also an emerging consensus among researchers today that while newborn behaviors do not lead inevitably to personality traits, they do set up a range of possibilities; and experience and social factors are obviously transduced into biology, although finding out how exactly our early childhood experiences reach down into our DNA is the next big challenge for neuroscientists. These studies also demonstrate that while the basic organizational processes in infancy may be universal, the range and form of these adaptations are shaped by the demands of each individual culture from the beginning. The overarching question of whether we can intervene successfully in children’s lives beginning in the newborn period is convincingly answered in these chapters and attests to the shift in emphasis toward an approach to children and families that is committed to developmental interventions that are both individualized and relationship-based and begin as early as possible in the child’s life. It is our hope that this book will not only answer some of the theoretical and empirical questions posed above, but that it will generate even more questions for future researchers and lead to the implementation of the kinds of preventive intervention programs for infants and families described in this book, ultimately resulting in more informed policies designed to protect and support children and families everywhere. Above all, we hope that the perspectives on infant behavior and development presented here from these very different cultural settings will reach down into the daily lives of practitioners and support them in their efforts to enable healthy infant development worldwide. J. Kevin Nugent

PA R T I

LOOKING BACK

CHAPTER 1

The Discovery of the Human Newborn: A Brief History J. KEVIN NUGENT

It is perhaps difficult for the twenty-first century researcher or clinician to imagine how much our understanding and appreciation of the human newborn has changed since the time the Neonatal Behavioral Assessment Scale (NBAS) was first published in 1973. The dominant view for much of the earlier part of the twentieth century, as Berry Brazelton and many authors in this volume point out, was that infants were generally passive recipients of sensory stimulation, responding to environmental input with innate reflexes. There was scant evidence that learning could be demonstrated in the first few weeks or even months of life. Newborn assessment tools reflected these assumptions, so that the earlier neonatal scales, which emerged from the field of neurology, focused on the assessment of the so-called primitive reflexes and postural reactions.1,2,3 Because it was assumed that the newborn infant was indeed a “blank slate,” a reflex organism operating at a brain-stem level, the classic tests of intelligence, such as the Gesell Developmental Schedule, the Cattell Infant Intelligence Scale, and the Griffiths Mental Development Scale, for example, did not include any items designed to assess newborn behavior. However, a number of advances, especially in the fields of psychology and psychiatry, contributed to a major shift in thinking about newborn behavior and development and, indeed, to the notion that the newborn period might be a critical time in the development of the parent-infant relationship. In the early 1960s, it was assumed that the newborn could see only shadows at birth. And then, Robert Fantz demonstrated that the newborn infant could not only see but also had clear-cut visual preferences.4 3

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Looking Back

In terms of auditory capacities, the prevailing assumption among both researchers and clinicians was that newborns’ fluid-filled ears impaired their hearing for the first few days. However, in 1963 a report appeared in Science showing that newborns could orient toward a sound as early as 8 hours after birth.5 In the previous year, Murphy and Smyth had demonstrated that infants respond to auditory stimuli even before birth.6 The notion that the baby could see, hear, and respond differentially to positive and negative stimuli inspired a new body of scientific research on newborn behavior and development. While innovative thinkers from the emerging field of infant mental health, such as John Bowlby, Donald Winnicott, and Selma Fraiberg, studied the mother ’s role in the development of early parent-infant relations, a new generation of researchers, among them Jerome Bruner, Peter Wolff, Jerome Kagan, Robert Emde, Kathryn E. Bernard, and Arnold Sameroff, stimulated by the work of Jean Piaget, began to study learning in infancy in an effort to determine how early and under what conditions infants could learn. In the 1960s and 1970s, a new body of research on newborn capabilities emerged, which provided a rich empirical database for subsequent conceptualizations of newborn and infant development. Researchers such as Lewis Lipsitt, William Kessen, T. G. R. Bower, and Rachel Keen developed innovative research methods to demonstrate that newborns could, indeed, learn from the very beginning. This new body of data, which provided evidence that the newborn infant was competent and complex, contributed significantly to the development of the NBAS. However, it was Berry Brazelton’s clinical experience with parents and his work at the Children’s Hospital in Boston that led to a pivotal concept in the thinking about how to assess newborn and infant development—the concept of individual differences. As Brazelton himself explains it, the challenge he faced was how to describe, identify, and ultimately code these differences in a reliable manner. He had provided evidence for differences in crying patterns in his own research and later presented his ideas on individual differences to a wider audience in his groundbreaking book, Infants and Mothers: Individual Differences in Development.7,8 In the preface to that book, Jerome Bruner wrote, “What delights me most is Dr. Brazelton’s unflagging sense of human individuality.” It was Brazelton’s recognition that infants were unique, with their own individual styles of responding, that prompted him to begin the quest for a scale that, on one hand, could do justice to the newborn’s capabilities and, on the other hand, could describe the full range of individual differences in newborn behavior.

The Discovery of the Human Newborn: A Brief History

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At around the same time, Peter Wolff ’s seminal work on “newborn behavioral states” led to a greater appreciation of the human newborn as a responsive organism, capable of organized behavior.9 Indeed, the idea of “state” was acknowledged as a critical matrix on which to assess all reactions, sensory as well as motor, in the newborn.3,10 The first behaviorally based scales for the assessment of the newborn appeared at this time. The Graham Scale and the Graham-Rosenblith Scale were the first to attempt to outline behavioral differences among neonates as they responded to different stimuli.11,12 Shortly after this research was published, the first iteration of the NBAS appeared—the Cambridge Scales—which Brazelton developed along with psychologist Daniel Freedman from the University of Chicago and which he now used to test out the applicability of the concept of individual differences in different settings. Intrigued by the question of how children achieve competence, Brazelton and his colleague, John Robey, went to southern Mexico, where they used the new scale with the Zinacanteco Indians, in the highlands of Chiapas. There Brazelton’s ideas on neonatal differences were confirmed. The two colleagues discovered that compared to their Caucasian counterparts, these infants could “pay attention to auditory and visual signals for 30 minutes without a break,” and their motor behavior was characterized by smooth fluid movements.13 This research was followed by a study by Freedman and Freedman that provided evidence for clear-cut differences between Caucasian and Chinese neonates.14 Working with Jerome Bruner at the Center for Cognitive Studies at Harvard University and with Mary Louise Scholl from the Department of Neurology at Massachusetts General Hospital, Brazelton began to integrate developmental theory and neurological principles into his clinical understanding of newborn behavior and development. Finally, in 1973, the first edition of the NBAS was published by Spastics International Medical Publications. In the preface of that monograph, Ronald MacKeith and Martin Bax were perceptive when they wrote that they were “happy to predict that people will be using and working with the NBAS for many years to come.”10 Since then, the NBAS has become the gold standard of newborn assessments. It has been used in many studies to examine the effects of a wide range of pre- and perinatal variables on newborn behavior. By the time I joined Brazelton and coauthored the NBAS, numerous studies had demonstrated that the scale was sensitive to variables, such as the effects of intrauterine growth restriction; the prenatal ingestion of cocaine, alcohol, caffeine, and tobacco; the exposure to environmental

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Looking Back

polychlorinated biphenyls (PCBs); the effects of different modes of delivery; or the effects of prematurity. The NBAS also stimulated the development of a number of assessment scales for use with different populations and in different settings, a testament to its theoretical richness and its generativity. Heidelise Als, Barry Lester, Berry Brazelton, and Ed Tronick, for example, used the concepts of the NBAS to develop the Assessment of Preterm Infants’ Behavior (APIB).15 Barry Lester and Ed Tronick also used the NBAS as the basis for the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS), which was designed for the neurobehavioral assessment of drug-exposed and other high-risk infants, especially preterm infants.16 While the NBAS has been used in hundreds of research studies as an outcome measure and continues to be used as a means of assessing pre- and perinatal influences on newborn behavior, we began to realize, in the 1980s, that the NBAS was a powerful teaching tool and could be used as a form of intervention. A series of studies, summarized by Nugent and Brazelton,17,18,19 showed that demonstrating the newborn infant’s behavioral capacities to parents can serve as a mechanism for helping parents learn about their new infant, thereby strengthening the relationship between parent and child and supporting family adjustment. Specifically, a number of studies consistently have reported positive effects of exposure to the NBAS on variables such as maternal confidence and self-esteem, paternal attitudes toward and involvement in caregiving, parentinfant interaction, and developmental outcome. Just as the NBAS was adapted to assess different at-risk populations, as in the case of the APIB and the NNNS, it has also been adapted or modified to render it more effective as a teaching tool for parents. A number of approaches based on the NBAS were developed for use in clinical environments as a form of parent education or intervention. The first of these modifications was by Tiffany Field and her colleagues who developed the Mother ’s Assessment of the Behavior of the Infant.20 The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) training process, developed by Heidelise Als, has profoundly changed the way in which neonatal intensive care unit (NICU) staff, particularly nurses, are trained in the observation and care of the premature infant.21 By incorporating behavioral items and concepts from the NBAS into the routine physical pediatric examination, Constance Keefer developed the Combined Physical Exam and Behavioral Exam (PEBE),22 while João Carlos Gomes-Pedro and his colleagues, in their efforts to sensitize parents to the behavior of their newborns, effectively tested a shortened version of the

The Discovery of the Human Newborn: A Brief History

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NBAS for use as the newborn pediatric discharge examination.23 Ida Cardone and Linda Gilkerson used the concepts of the NBAS to develop the Family Administered Neonatal Activities (FANA).24 Finally, the recently developed Newborn Behavioral Observations (NBO) system also comes from this tradition and was developed by myself, Constance Keefer, Susan Minear, Lise Johnson, and Yvette Blanchard, as a relationship-building instrument, to sensitize parents to the capacities and individuality of the newborn infant and to foster the relationship between parent and child and between clinician and parent.25 This brief description of the origins of research on newborn and infant development and of the transforming influence of the NBAS on clinical and research endeavors sets the stage for the wide range of reports that appear in this volume. I N T E R N AT I O N A L P E R S P E C T I V E S O N R E S E A R C H , E A R LY I N T E RV E N T I O N , A N D T R A I N I N G The chapters that follow represent many disciplines from many countries and examine the effects of different perinatal and cultural influences on behavior and the relationship between newborn behavior and later outcome. These studies also attest to the shift in emphasis toward intervention that begins ever earlier in the child’s life. These reports embrace an approach to children and families that eschews the classic deficit-seeking medical model and is committed instead to interventions that are both family-centered and relationship-based. One of the questions that continues to challenge theorists, researchers, public policymakers, and educational planners is whether there is a relationship between newborn behavior and later development, especially in the case of high-risk infants. Karin Stjernqvist from the University of Lund in Sweden examines the relationship between newborn behavior and later developmental outcomes in her longitudinal study, “Predicting Development for Extremely Low Birthweight Infants” (Chapter 2) In this chapter, she reports a positive correlation between the newborn orientation capacities at term, Developmental Quotient (DQ) at 4 years of age, and IQ at 10 years, despite the fact that in the neonatal period, instability in physical, physiological, and behavioral systems is pronounced, and neonatal assessments are thought to be less predictive. The sensitivity of the NBAS as an outcome measure has been demonstrated in numerous studies conducted by Tiffany Field and

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Looking Back

her colleagues at the University of Miami. Field, one of the pioneers in infancy research, in particular, in the role of touch, describes a series of studies in different settings, in which she and her colleagues examined the effects of infant massage on newborn behavior. She reports the effects of a recent meta-analysis of data from 19 of these studies, which revealed that 72% of the massaged infants were positively affected. Most of them experienced greater weight gain and better performance on the NBAS. In addition, she points out that the use of the NBAS seems to be an important demonstration to the parents of how their infants’ behavior can improve following massage therapy. This, in turn, seems to encourage parents to continue massage therapy at home. At the Universitat Autònoma de Barcelona, Carme CostasMoragas has established an impressive research tradition by conducting numerous research studies on the effects of a wide range of perinatal factors on developmental outcome. Chapter 4 provides a review of this body of research, describing studies on the effects of acute fetal distress, gestational and pregestational diabetes, cesarean section, intrauterine exposure to lead, neonatal hyperbilirubinemia, low birthweight, and prematurity. At the invitation of Dr. Tomitaro Akiyama from the Department of Rehabilitative Medicine at the University of Nagasaki, Berry Brazelton and I began a collaborative longitudinal study of Japanese infants in the Goto Islands in 1985. Dr. Akiyama’s research goal was to identify the origins of cerebral palsy as early as possible in a child’s life. In Chapter 5, along with his colleague, Shohei Ohgi, he describes their research on the early assessment of infants at risk for developmental disorders, such as cerebral palsy and mental retardation. In a series of longitudinal studies, Shohei Ohgi and the Nagasaki research group have provided consistent evidence for the capacity of the NBAS to identify neonates who are at high risk for later developmental disabilities, including cerebral palsy. In Korea, Yeonghee Shin and Byunghi Park designed a study to provide normative data on Korean newborn behavior. In Chapter 6 they describe the cultural context of the transition to parenthood in Korean society and discuss their study of a sample of Korean newborns, explaining what their research reveals about the universals of newborn behavior, and the behavioral characteristics that are specific to the Korean cultural setting. In her research and clinical practice in Geneva, pediatrician and psychiatrist Nadia Bruschweiler-Stern discusses the significance of what she refers to as “moments of meeting” in promoting mother-infant attachment, beginning in the newborn period.

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She defines these crucial interactions as micromoments of change in the mother-infant relationship, moments when the relationship is transformed and moves to a higher level. She goes on to describe how she promotes these moments of meeting between parent and infant and how the infant can become an “interlocutor” in this process. In a series of clinical reflections taken from her practice, Dr. Bruschweiler-Stern demonstrates how this approach can be used with a wide range of families and how fathers can be engaged in these relationship-building encounters. Anthropologist Sara Harkness and psychologist Charles Super introduced the concept of the infant’s “developmental niche” to our understanding of the relationship between child and culture. In Chapter 8, they discuss their work with Kipsigis herders and farmers in Kenya and offer some observations on research with parents and children in the United States, as well. They focus on the process of discovery of parental ethnotheories and their instantiation in parenting practices. In the developmental niche framework, the culturally constructed environment of the child is conceptualized as consisting of three components or subsystems: (1) the physical and social settings in which the child lives; (2) culturally regulated customs of child care and childbearing; and (3) the psychology of the caretakers, including parents and others, such as teachers or child-care providers. I N T E R N AT I O N A L P E R S P E C T I V E S O N E A R LY I N T E RV E N T I O N I N I T I AT I V E S The NBAS has inspired intervention initiatives in many settings around the world. In her work in Denmark, for example, psychologist Hanne Munck discusses how her research on fathers helped establish the practice of fathers being encouraged to stay in the hospital after delivery, so that they would have the opportunity to become more involved in the care of the young infant. She also describes how the NBAS and the APIB were used to demonstrate the capacities and individuality of full-term newborns and prematurely born infants. She explains how the insights from these assessments played a significant role in modernizing hospital routines and practice in Denmark as part of the preventive health-care system. In Britain, psychologist Joanna Hawthorne and occupational therapist Betty Hutchon report that, with funding from the government’s early intervention project, Sure Start, several communitybased teams in deprived areas are being trained in providing

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Looking Back

supportive intervention to mothers in deprived areas in their follow-up home visits. In a brief survey of parents who participated in follow-up professional education sessions, they report that all the parents who responded to the survey said that they found the principles of the NBAS helpful and would recommend it to other parents. The U.K. experience demonstrates that the NBAS can provide a supportive intervention to parents of premature babies, parents of babies with various syndromes, and parents with babies who may be difficult to read. Physical therapist Yvette Blanchard describes how the NBO system, which was inspired by the NBAS, is being used in early intervention settings in the United States and how the NBO neuro behavioral concepts can be integrated into Early Intervention (EI) evaluation and service planning. While many states require a score from a standardized tool in order to determine eligibility for EI, the information gathered during the NBO can be used to provide clinical information needed by the early interventionist to substantiate eligibility on the basis of clinical judgment. The integration of the NBO into the evaluation of high-risk infants allows the EI providers to meet the three goals of a developmental assessment: (1) The infant’s attempts to self-regulate and successes at self-regulation are indicators of the current level of developmental maturity and robustness; (2) the infant’s behavioral manifestations of disorganization or loss of self-regulation are indicators of developmental vulnerabilities and sensory thresholds; (3) the type and amount of support offered by the clinician forms the basis of the individualized intervention strategy and educational approach needed to support the developmental agenda and goals of this infant and to promote the relationship between the infant and his parents and the relationship between the provider and the parents. Psychologist Beulah Warren has spent her life working in early intervention settings in Australia and has devoted a great deal of that time to the training of early intervention and infant mental health specialists who work with infants and families in the first years of life. In Chapter 12 she describes her work with infants who are at risk for developmental disabilities and explains how she uses an individualized, developmentally appropriate approach to support her young patients, their parents, and even their extended families. As a young pediatrician, Nittaya Kotchabhakdi spent the first 6 months of her pediatric rotation in the northeastern province of Thailand, where she gained firsthand experience working with children and families affected by poverty, malnutrition,

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and preventable diseases. To reduce malnutrition, she initiated developmentally based breastfeeding programs for mothers and infants in these rural communities. In Chapter 13 she describes the NBAS-inspired education programs she implemented, which were designed to sensitize mothers to their babies’ interactive competencies, with a view to supporting a positive mother-infant bond and resultant success in breastfeeding. Nurse Researcher Kristie Brandt points out that for more than 3 decades, the principle underlying the NBAS has informed the discipline of nursing—guiding both the development of clinical care models and the refinement of specific intervention, facilitation, and support strategies. She explains how, in the programs she has initiated for parents in the first 8 weeks after birth, the maternal-childfamily nurse is able to “showcase and observe the newborn’s individuality as expressed in his or her mastery and clarity of cues, and other behavioral repertoire.” I N T E R N AT I O N A L P E R S P E C T I V E S O N PROFESSIONAL DEVELOPMENT In recent years, the individualized and positive-adaptive approach to infants and families, derived from the NBAS, has been used to inform curriculum development in medical education and professional development settings worldwide. The notion central to the Touchpoints Approach to professional training which was developed by Berry Brazelton and his colleagues, is that a child’s development is characterized by predictable periods of disorganization that occur prior to bursts in development. Because all development occurs within caregiving relationships, the extent to which the system supports these relationships has a direct impact on the child’s developmental potential. Brazelton Touchpoints faculty members Ann Stadtler and John Hornstein describe the newborn Touchpoint as “the prototypical touchpoint” because it is the time of greatest vulnerability, as well as the time of greatest opportunity for professionals working with parents. They go on to explain how the Touchpoints training model has been applied to different settings and how its goal of supporting providers and communities in changing the system of care for families has been implemented. The name of João Carlos Gomes-Pedro is synonymous with medical education in Portugal. In Chapter 16 Dr. Gomes-Pedro reviews the dramatic changes taking place in contemporary Portuguese society and describes how he developed an individualized

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Looking Back

behaviorally based approach to support new parents and to help health-care providers offer the kind of informational and emotional support parents need today. He also describes his approach to medical education and resident training and his efforts to implement a more positive model of patient care. Psychotherapist Drina Candilis-Huisman and pediatrician Marie Fabre-Grenet write about their approach to parents in their respective practices in France. Dr. Huisman describes her work with mothers in the maternity ward. She looks at this relationship as a threesome, in which the clinician retains a flexible and distinctly different role with both the mother and the infant. She shows that the success of this approach depends not only on the clinician’s ability to accurately assess the infant’s capacities but also on the dynamic relationship that emerges among the different partners. The clinician’s effectiveness depends on his or her flexibility, “an essential quality about which we need to conduct more research.” Dr. Grenet explains her use of the NBAS in her pediatric practice as a response to the tendency of the medical system to “hypermedicalize pregnancy.” The observation of the behavior of the neonate that is formalized in the NBAS enables the practitioner to focus on the baby as an individual. Dr. Grenet believes that the NBAS can be used during this time and that early first contact in the hospital sets the foundation of a real therapeutic alliance. In North Carolina in the United States, James Helm and Marie Reilly have been training early intervention professionals for many years. Their training programs includes NIDCAP-based, developmentally supportive, family-centered care of infants and families in the intensive care nursery (ICN), a developmental follow-up clinic, and an early intervention program that begins in the hospital and follows the family home. In Chapter 18 they describe how the NBAS contributes to each of these services and how the NBAS is also used to help identify program goals and activities with families as an integral part of the follow-up program “What is relationship-based care?” is the question posed by Constance Keefer, Lise Johnson, and Susan Minear in their discussion of the role of the pediatrician in hospital newborn care. They point out that practitioners are charged with nurturing two distinct relationships in the newborn period—that of the parent and child, and that of the clinician and family. Both are necessary components of effective medical care. Over the years, at least two important clinical tools gradually evolved from the NBAS to promote these relationships—the PEBE and the NBO systems, each of which took

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the relational aspects of the NBAS a step further. The use of these approaches is discussed, and the roles of each in fostering the bonds between parent and infant and between clinician and family are also presented. With the PEBE, the practitioner weaves observations and a narrative of the infant’s behavior into the standard newborn physical exam, which he or she performs in the presence of the parents. Meanwhile, the NBO was designed primarily as a relationship-building tool that can help sensitize parents to their newborn’s capacities and individuality. The authors go on to discuss the use of the NBO as a concrete tool for the professional clinician in training. Since the NBAS is an examination that demands an extraordinarily high level of observational and handling skill, it can be used as a model for training professionals in working with infants and their families. This challenge is specifically addressed by NBAS master trainer Jean Cole and NBAS trainers Cecilia Matson and Thembi Ranuga in Chapter 20, “Preparing Professionals to Work with Newborns.” They present their firsthand experiences as trainers and their recommendations for the training of examiners. They emphasize the importance of examiners being well versed in neuro developmental principles before they even approach the actual assessment of the infant. Then they focus on the need for examiners to have good observational and handling skills to be able to elicit the infant’s “best performance.” Finally, they describe the different training models used to prepare professionals to use the NBAS reliably and sensitively. At Anna Meyer Children’s Hospital in Florence, Italy, Gherardo Rapisardi, a neonatologist and pediatrician, and Adrienne Davidson, a pediatric physical therapist and developmental specialist, have been training a wide range of health-care specialists since the beginning of the 1980s. The training programs focus on the clinical application of a global neurodevelopmental assessment and an early intervention program that incorporate the principles of the Touchpoints model. In addition, there are training courses in the NBAS concepts for all types of health professionals throughout Italy who are involved in neonatal care. In Naples, Drs. Roberto Paludetto and Giuseppina Mansi have conducted research on the effects of neonatal jaundice, the effects of prematurity, and the effects of cigarette smoking on newborn behavior. They have incorporated the general concepts of the NBAS into the physical examination of the newborn, paying special attention to the orientation, Response Decrement, Self-Quieting, Consolability, and Cuddliness items.

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L O O K I N G T O WA R D T H E F U T U R E In the final section of the book, we look toward the future and address the question of how this new body of information can help researchers, clinicians, and policymakers better understand the needs of infants and families as the twenty-first century moves ahead. As we review the past and attempt to plan for the future, Rachel Keen, a pioneer in the infancy field and still one of its leading researchers, reminds us that that there is a great need for researchers to bring their work closer to practitioners and policymakers. She believes that the gap can be bridged, but it will take sustained, deliberate efforts on both sides. Researchers need to make their results and implications more easily available beyond their own circles, and they need to talk to social workers, pediatricians, nurses, and other personnel who intervene in children’s lives. Above all, collaborative research should be the core of continued communication. This volume is designed to promote these kinds of collaborative endeavors. To use her own words, “only when the lines of communication are freely open and flowing will we have the knowledge exchange we so badly need.” John Kennell who with Marshall Klaus introduced the concept of parent-infant bonding,26 challenges us to consider the value of simple interventions in the perinatal period, even as he acknowledges that health-care professionals and clinicians are being asked to care for an ever-larger number of children with developmental/ behavioral problems of increasing complexity. He describes doula support as a low-tech, centuries-old intervention that significantly reduces the need for cesarean delivery, analgesia, and other interventions; shortens the length of labor; enhances mother-infant interaction; and helps promote successful breastfeeding. He presents evidence from his own work that the promotion of parent-infant bonding by providing doula support results in fewer child behavior problems. Almost 40 years of research have shown that when mothers have continuous emotional support by a doula during labor, and when they have early and extended contact and interaction with their babies, significant benefits can result. After a description of his involvement in the NBAS in the early years, Ed Tronick looks toward the future and urges a word of caution in Chapter 24, “The Brazelton Baby: The Other Side of the Coin.” He points out that while the NBAS has made us aware of the infant’s competencies, we also need to recognize the anomalies and medical conditions that may disrupt development. The competent infant can also be the incompetent infant, the pathologic infant, he tells us. He challenges researchers to think about

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functional pathologies and to begin to examine the pathologic effects of functional compromises because “doing so may help us understand an often times disregarded fact: Most infants and young children with mental health, neurobehavioral, and neuropsychological problems were clinically normal newborns.” Bonnie Petrauskas addresses the challenges facing families in today’s society. She discusses the effects of poverty and the consequences of inadequate health care in many societies across the world. She then describes the challenges faced by parents today, their sense of isolation, and their need for support. She examines the changing role of fathers and the need for inclusive intervention strategies that are family centered and community based. She concludes by saying, “Healthcare professionals, educated in a strengthbased approach to neonatal assessment, can take the leadership role in providing parents with accurate, consistent, and personalized information about their children.” Daniel Stern, whose work straddles the fields of psychoanalysis, psychotherapy, philosophy, developmental psychology, neuroscience, and infant mental health, and Nadia Bruschweiler-Stern, who has also contributed elsewhere in this volume, maintain that advances in neuroscience will be enriched by the kind of behavioral observation techniques pioneered by the NBAS. As they look toward the future, they argue that Brazelton’s concept of “optimal performance” provides a unique observational approach that makes it possible to study the full complexity and unpredictability of “the present moment” in parent-child interactions, what they refer to as “the temporal dimension of experience” and the “complex melodic line of experience.” They suggest that combining the observational techniques of the NBAS and emerging imaging techniques will allow for more comprehensive exploration of brain functioning, which will tell us more about the developing nature of intersubjectivity. Finally, they acknowledge the seminal role of Berry Brazelton’s contribution to our current understanding of infancy, ending their chapter by saying that his work “will guide and provide ideas for our field in its future dialogues with the neurosciences.” In Chapter 27, Berry Brazelton himself tells his own story—the story of how he came to discover the human newborn, not only as competent and unique but also as a social organism, ready to interact with the caregiver from the very beginning. He shares his original vision for the NBAS and how it came to be realized, and he introduces the people who influenced him and those who helped him realize his dream. As Dr. Brazelton looks toward the future, his

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concern is focused on how to better prepare pediatric professionals and educators to support parents and their children, beginning in the newborn period. He presents his Touchpoints model as a framework for realizing this vision, as a way of helping the practitioner “deepen his or her relationship with parents, which means that parents and provider are better able to collaborate effectively in the care of the child.” CONCLUSION In this chapter, I have taken a look back at the field of infancy research and practice and the pivotal role played by the NBAS in its evolution and, indeed, its transformation. I have described how our understanding of the newborn infant has been enriched by Brazelton’s work and that of his colleagues and how our appreciation of the significance of early experiences has been deepened and expanded. The research and clinical work described in this volume, coming as it does from a wide range of disciplines and gathered in very different cultural settings, demonstrates how much this body of work has influenced clinical work with families across the world. These original reports—written by pediatricians, nurses, psychologists, psychiatrists, physical therapists, early education and infancy specialists, occupational therapists, and psychotherapists—also attest to the shift in emphasis toward intervention that is both family-centered and relationship-based and that begins in the newborn period and before. It is our hope that this new approach will inspire an even deeper understanding of the infant as an individual and as a person and will lead to a greater appreciation and respect for the role parents play in supporting their infants’ adaptation and development. Finally, we hope that these reports can serve as a challenge to researchers and policymakers alike to work together toward forging comprehensive family-centered social policies that support children and families everywhere. REFERENCES 1. Peiper A. Cerebral Function in Infancy and Childhood. 3rd ed. New York, NY: Consultants Bureau; 1963. 2. Andre-Thomas CI, Dargassies SS. The Neurological Examination of the Infant. London, England: Spastic Society Medical Education and Information Unit; 1960. 3. Prechtl HFR, Beintema DJ. The neurological examination of the full term newborn infant. Clin Dev Med. 1964;12:1–49.

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4. Fantz RL. The origin of form perception. Sci Am. 1961;204:66–72. 5. Wertheimer M. Psychomotor coordination of auditory and visual space at birth. Science. 1961;134:1692. 6. Murphy K, Smyth C. Response of fetus to auditory stimulation. Lancet. 1962;1:972–973. 7. Brazelton TB. Crying in infancy. Pediatrics. 1962;29:579–588. 8. Brazelton TB. Infants and Mothers: Individual Differences in Development. New York, NY: Delacorte Press; 1969. 9. Wolff PH. The Causes, Controls, and Organization of Behavior in the Neonate. New York, NY: International Universities Press; 1966. 10. Brazelton TB. Neonatal Behavioral Assessment Scale. No 50. London, England: Spastics International Medical Publications. Wm. Heinemann Medical Books; Philadelphia, PA: JB Lippincott; 1973. 11. Graham FK, Matarazzo RG, Caldwell BM. Behavioral differences between normal and traumatized newborns: The test procedures. Psychol Monogr. 1956;70(21, pt 1):17–23. 12. Rosenblith JF. The modified Graham Behavior test for neonates: Test re-test reliability, normative data, and hypotheses for future work. Biologica Neonatorum. 1961;3:174–193. 13. Brazelton TB, Robey JS, Collier GA. Infant behavior in the Zinancanteco Indians in southern Mexico. Pediatrics. 1969;44:274–281. 14. Freedman DG, Freedman N. Behavioral differences between ChineseAmerican and European-American newborns. Nature. 1969;224:122. 15. Als H, Lester BM, Tronick E, Brazelton TB. Manual for the Assessment of Preterm Infants’ Behavior (APIB). In: Fitzgerald HE, Lester BM, Yogman M, eds. Theory and Research in Behavioral Pediatrics. Vol 1. New York, NY: Plenum Press; 1982:65–132. 16. Lester BM, Tronick, EZ. (2005). NICU Network Neurobehavioral Scale (NNNS) Manual. Baltimore, MD: Paul H. Brookes Publishing Co; 2005. 17. Nugent JK, Brazelton TB. Preventive intervention with infants and families: The NBAS model. Infant Ment Health J. 1989;10:84–99. 18. Nugent JK, Brazelton TB. Preventive infant mental health: Uses of the Brazelton scale. In: Osofsky J, Fitzgerald, HE, eds. WAIMH Handbook of Infant Mental Health. Vol 2. New York, NY: John Wiley & Sons Inc; 2000:159–202. 19. Brazelton TB, Nugent JK. The Neonatal Behavioral Assessment Scale. London, England: MacKeith Press; 1995. 20. Widmayer S, Field T. Effects of Brazelton demonstrations on early interaction of preterm infants and their teenage mothers. Infant Behav Dev. 1980;3:79–89. 21. Als H, Gilkerson L, Duffy FH, et al. A three-center, randomized, controlled trial of individualized developmental care for very low birthweight preterm infants: Medical, neurodevelopmental, parenting, and caregiving effects. J Dev Behav Pediatr. 2003;24(6):399–408. 22. Keefer CH. The combined physical and behavioral neonatal examination: A parent-centered approach to pediatric care. In: Brazelton TB,

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23.

24.

25.

26.

Looking Back Nugent JK. The Neonatal Behavioral Assessment Scale. London, England: MacKeith Press; 1995: 92–101. Gomes-Pedro J, Patricio M, Carvalho A, Goldschmidt T, Torgal-Garcia F, Monteiro MB. Early intervention with Portuguese mothers: A two-year follow-up. J Dev Behav Pediatr. 1995;16:21–28. Cardone IA, Gilkerson L. Family Administered Neonatal Activities: A first step in the integration of parental perceptions and newborn behavior. Infant Ment Health J. 1990;11:127–131. Nugent JK, Keefer CH, Minear S, Johnson L, Blanchard Y. Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) System. Baltimore, MD: Paul H. Brookes Publishing Co; 2007. Klaus MH, Kennell JH, Klaus PH. Bonding. Reading, MA: Addison-Wesley Publishing Co; 1995.

PA R T I I

CONTEMPORARY RESEARCH AND PRACTICE: INTERNATIONAL PERSPECTIVES Research on Newborn Behavior and Development

CHAPTER 2

Predicting Development for Extremely Low Birthweight Infants: Sweden KARIN STJERNQVIST

The overall aim of this longitudinal study was to follow the development of a sample of tiny, extremely low birthweight (ELBW) infants born in the mid-1980s. These infants had seldom survived before. We wanted to get a comprehensive view of outcomes for the children and study the impact of their prematurity and related complications on the lives of their families.1,2,3,4,5,6 This chapter focuses on the use of the NBAS to predict neurobehavioral and cognitive outcomes at 4 and 10 years. P O P U L AT I O N In a region of southern Sweden, 32,120 infants were live-born during the period from November 1984 to October 1986. Of these, 65 (0.2%) had birthweights less than 901 g. When possible, pregnant women at risk for preterm delivery (delivery before 28 completed weeks) were transferred ante partum to the regional center. However, transfer to the regional center was not always possible. Fortytwo of the 65 ELBW infants were treated in the neonatal intensive care unit (NICU) at the University Hospital, Lund, Sweden, a regional tertiary (Level III) perinatal center with 10 referral hospitals. Twenty-three (55%) of the 42 ELBW infants at Lund survived the neonatal period, and with parental consent, 20 of the 23 survivors were enrolled in an extended follow-up program.

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The infants in the study group, 12 girls and 8 boys, had a mean birthweight of 775 g (SD
109) and were born at 26.2 (m) weeks gestational age (SD
1.8). Three infants were small for their gestational age (SGA  2 SD). Assessment of the gestational age was based on an ultrasonography examination in early pregnancy. The infants were recruited prior to the time when drug surfactant was routinely used to accelerate maturation of the lungs of premature infants. Fourteen infants (70%) had been treated with artificial ventilation. Eight of the 20 (40%), had intracranial hemorrhage (ICH), diagnosed and graded by cranial ultrasound according to Papile et al.7 Two infants had grade IV bleeding; two had grade III; two had grade II; and two had grade I. Periventricular leucomalacia (PVL) was found by ultrasound examination in two infants—one with grade IV, and one with grade III ICH, as well. The average hospitalization time was 124 days (SD
66) (range 70–334), of which an average of 51 days (SD
20) (range 10–95), were spent in the neonatal intensive care unit before the infants were moved to wards for intermediate care or to local hospitals. FULL-TERM CONTROL GROUPS Two different control groups of full-term infants were studied— one for a study conducted at term, and one for the long-term study—because the long-term follow-up study required an extensive and time-consuming matching procedure, which could not be carried out until the infants had been registered at the national child healthcare clinics. For the neurobehavioral assessment at term, a control group of 20 healthy, full-term infants—10 girls and 10 boys who all were born during 1986—were consecutively selected in the maternity clinic. The criteria were that they were born by vaginal delivery and without any neonatal complications, after a normal, uncomplicated pregnancy. All mothers who were asked consented to have their infants assessed. The average birthweight of these infants was 3,655 g (SD
370), and they were born at 40 weeks gestational age (SD
0.81) At the 1-, 4-, and 10-year assessments, a pair-matched control group was chosen at the child health-care clinics. The criteria were that the children, as infants, had been born by vaginal delivery after a normal, uncomplicated pregnancy, without any neonatal complications, and without separations between mother and infant in the neonatal period. The children were matched for gender and birth

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order, as well as for their parents’ socioeconomic status, educational level, and citizenship (native Swede or immigrant). Because the study group was small, comprising only 20 infants and families, it was essential to find close pair-matches in the control group in order to increase comparability. The children in the control group were born during a 2-year period, all between 1985 and 1986. Their birthweights were (mean
SD) 3,660 g
586, and they were born in gestational week (mean
SD) 40.1
1.3. There were 12 girls and 8 boys. The socioeconomic and educational standards were normal for a Swedish population. While the proportion of immigrant mothers (25%) was higher than we had expected, it was still the same in both the ELBW and the control families. PROCEDURE AND METHODS For all those involved in the study group, the father was usually present during the delivery. Whenever possible, the mother was given the opportunity to look at and touch her baby before it was taken to the NICU. To stress that the newborn was part of the family, the father was invited to accompany his infant to the NICU. He was also present during the first caretaking procedures, and he was thereby an important intermediary between the infant and the mother. A photograph of the infant was taken and given to the mother. Care of the ELBW infants was individualized. We had been inspired by the work of Dr. Heidelise Als, even if, at that time, full Newborn Individualized Developmental Care and Assessment Program (NIDCAP) observations were not performed.8,9 Every effort was made to minimize the amount of stimulation to which the infants were subjected, so that, for example, the light intensity was softened and the noise level kept low. As soon as possible, often within the first hour, the mother came to the NICU to be with her newborn. The neonatal unit personnel worked actively to facilitate attachment between the parents and siblings and the newborn infant. Parents and siblings could visit the baby anytime and were encouraged to take part in the care of their baby from the first day. For siblings, there was a playroom in which there was a miniature incubator with a doll and other toys. Parents got support from the nurses, doctors, and psychologist to cope with the traumatic experiences of the preterm birth and their anxiety about their infant’s survival and future impairments. Nurses helped the parents to become aware of and to interpret the weak signals of their infant and to find ways to enjoy him or her.

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Kangaroo care, where the infant is swaddled close to the mother or father ’s breast, skin-to-skin, was used frequently, even when the infants were very small. Sweden had, in the mid-1980s, 12 months’ paid parental leave, which could be shared between the mother and the father. When parents had a sick infant, they got an additional 60 days of paid parental leave per year, which could also be shared between the parents. This national insurance system made it possible for both parents to be with their newborn infant, and most of them were there, from morning until late evening every day. Also, other relatives were welcome to visit the newborn. All information about the infant’s current condition, as well as all plans for interventions, were shared with the parents. During the 10-year follow-up period of the study, the children (both ELBW and control groups) were assessed four times; the ELBW parents were interviewed three times; and the control group parents were interviewed twice. M E N TA L D E V E L O P M E N T A N D B E H AV I O R At the term assessment, the Neonatal Behavioral Assessment Scale (NBAS)10 was used. Consisting of 27 behavioral items and originally constructed for assessment of full-term newborn infants (to be used during the first 8 weeks of life), it has frequently been used to assess preterm infants as early as in the 32nd gestational week.11,12 The scale gives an estimation of the infant’s habituation to stimuli, response to auditory and visual stimuli, ability to interact, range of states, and capacity to regulate states. The NBAS assessment of the infants and the scoring were done according to the manual.10 But the ELBW infants were assessed one hour before a feeding, as recommended by Sell et al,13 instead of halfway between feedings, as recommended for full-term infants. The 27 items were reduced into six clusters of behaviors according to the Lester data reduction scheme: I: Habituation, II: Orientation, III: Motor, IV: Range of State, V: Regulation of State, and VI: Autonomic Stability.10 The raw scores were recoded so that higher scores indicated optimal responses for individual items and for clusters. At the 4-year assessments, Griffiths’ Mental Developmental Scale II was used.14,15 This method was chosen because it has been translated into Swedish and standardized for Swedish conditions. Griffiths’ Scale covers different areas of development: the locomotor scale (A), the personal-social scale (B), the hearing-and-speech scale (C), the eye-and-hand coordination scale (D), the performance

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scale (E), and a logic scale (F). The subscales are combined to give a total score. From the scores on each subscale, a mental age (MA) is calculated. The Developmental Quotient (DQ) bases on the normal curve are calculated by dividing the MA by the child’s age and multiplying by 100. The mean (M) is 100, and the SD is 15. Assessments of the children and the scoring were both done according to the manual. To assess cognitive ability at the 10-year follow-up, the Weschler Intelligence Scale for Children, WISC-III, was used.16 Ten subtests were administered, and full-scale, verbal, and performance IQ scores were calculated.

S TAT I S T I C S Differences between the two groups on continuous variables were tested with the student’s t test; and if the requirements for that test were not fulfilled, the Mann-Whitney U-test was used. For crosstables, the chi-square test was used; and when the number of individuals required for that test was not enough, the Fisher exact test was used. Correlations were studied with Pearson’s correlation coefficients (r).

R E S U LT S Neurobehavioral Development at Term Eighteen of 20 ELBW infants who were enrolled in the long-term psychological follow-up program were evaluated with the NBAS at the time of expected birth. The mean gestational age at the time of the examination was 41.3 weeks, and the mean postnatal age was 106 days. Two infants had to be excluded because one was severely ill at the time, and the other had left the area. The ELBW infants were compared with 20 full-term, healthy infants examined at the mean postnatal age of 3.3 days (mean gestational age, 40.6 weeks). Significant group differences were found for 8 of the 27 NBAS items (Table 2.1). The higher the scores, the better the performance. In seven items the ELBW infants scored significantly lower than the control group, and on one item, they scored significantly higher. The greatest differences between the groups were in the Motor performance and Regulation of State clusters. Within the latter cluster, there were significant differences in two items: The ELBW infants had more difficulty calming down when upset (Item 26) and comforting themselves by sucking on their hands (Item 27).

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Contemporary Research and Practice Table 2.1 Neonatal Behavioral Assessment Scale Items Tested in Extremely Low Birthweight and Control Full-Term Infantsa

Preterm Infants (N  18) Mean (SD)

Full-term Infants (N  20) Mean (SD)

1. Light

6.00 (1.73)

6.42 (1.93)

2. Rattle

5.54 (1.94)

6.11 (1.77)

3. Bell

5.67 (1.97)

6.39 (2.09)

4. Pinprick

1.39 (0.77)

3.58 (1.58)

5. Inanimate visual

4.00 (2.09)

3.40 (1.73)

6. Inanimate auditory

5.06 (1.73)

4.50 (1.73)

7. Inanimate visual-auditory

4.83 (1.86)

4.60 (1.70)

8. Animate visual

3.00 (1.61)

3.75 (1.69)

9. Animate auditory

5.35 (1.69)

4.15 (1.66)

10. Visual-auditory

3.44 (1.58)

3.95 (1.79)

11. Alertness

3.28 (1.27)

3.85 (1.39)

12. Tonus

4.83 (1.10)

13. Maturity

t value

P

4.64

.0001

Habituation

Orientation

–2.17

.04

5.70 (0.66)

4.59

.005

3.17 (1.10)

5.10 (1.37)

4.76

.0003

14. Pull to sit

4.78 (1.90)

5.15 (1.90)

16. Defence

5.94 (2.05)

5.35 (1.53)

21. Activity

3.50 (0.99)

4.30 (0.80)

2.76

.009

18. Peak of excitement

3.78 (0.55)

3.65 (0.99)

19. Rapidity of buildup

4.83 (1.86)

4.40 (1.35)

20. Irritability

4.56 (1.69)

4.70 (1.49)

25. Activity

3.50 (1.72)

2.50 (1.24)

Motor

Range of state

Predicting Development for Extremely Low Birthweight Infants

27

Table 2.1 (Continued ) Preterm Infants (N  18) Mean (SD)

Full-term Infants (N  20) Mean (SD)

15. Cuddliness

4.89 (1.32)

5.45 (0.89)

17. Consolability

5.41 (1.81)

5.85 (1.93)

26. Self-quieting

2.47 (1.63)

4.65 (2.03)

3.55

.001

27. Hand-to-mouth

2.56 (1.76)

5.55 (2.06)

4.78

.0001

22. Tremor

5.94 (2.24)

7.20 (1.88)

23. Startles

4.83 (1.82)

6.50 (1.10)

3.45

.001

24. Skin

4.61 (1.42)

4.65 (1.23)

t value

P

Regulation of state

Autonomic stability

a

Item numbers according to Lester system in Brazelton.10

In the Orientation cluster, the ELBW infants had better scores in three of four items on auditory measurements, one of which reached statistical significance—listening to and localizing a voice. On one item in the Habituation cluster—response to pinprick of the foot— the ELBW infants were considerably more sensitive to stimuli. In accordance with the NBAS manual, each child’s best performance was scored, with the examiner returning to the same items several times during the assessment in order to get the optimum response from the infant. The ELBW infants demanded more sensitivity from the examiner, more repeated administrations of individual items in order to achieve appropriate responses, and more pauses during testing. The stress factor expected during this examination was exhibited by the ELBW infants through signs of physiological instability, including jitteriness and short apneic spells. Usually, they recovered quickly after a short rest. The full-term infants made attempts to control the overload by, for example, gaze aversion and yawns. Parents were present at all NBAS assessments, and the examiner discussed observations of the baby’s strong and weak areas with them. F O L L O W - U P AT F O U R Y E A R S At the 4-year follow-up, the ELBW infants had significantly lower values on all subscales of the Griffiths’ test than the full-term

28

Contemporary Research and Practice Table 2.2

Correlations between the Neonatal Behavioral Assessment Scale Cluster Scores and the Griffiths’ Scale at 4 Years of Age for the Extremely Low Birthweight Children

Behavior Clusters

Developmental Quotient

Habituation

–.38

Orientation

.42*

Motor

.01

Range of state

–.63

Regulation of state

–.14

Autonomic stability

–.07

*p  .05.

control children. The developmental quotients (mean and SD) were 96.1 (8.5) and 113 (9.3), respectively (p  .001). Correlations between the results of the NBAS at calculated term (when the ELBW infants were 10–16 weeks old) and developmental quotients measured with the Griffiths’ test at 4 years of age are shown in Table 2.2. The Orientation items correlated positively with both the Griffiths’ total score, DQ (r  .42, p  .05), and the eye-and-hand coordination scale, E (r  .47, p  .05; not shown). These results indicate that it might be possible to predict development at 4 years of age from results of Orientation items of the NBAS in the neonatal period. However, further research is necessary to verify these findings.

F O L L O W - U P AT 1 0 Y E A R S All ELBW children and the full-term controls were reassessed at 10 years of age. The results on WISC full-scale IQ for the groups were (mean and SD) 87.7 (12.1) and 106 (14.9), respectively (p  .001). At the 10-year follow-up, we found an even stronger correlation between the results on the WISC full-scale IQ, and the NBAS orientation item (r  0.62, p   .01). This cluster was correlated with the Verbal IQ (r  0.51, p  .05) and the Performance IQ (r  0.62, p  .01) Regression analyses show that Orientation items explained 34% of the variance in IQ at 10 years. There were no statistically significant correlations between the other NBAS clusters and IQ at this age.

Predicting Development for Extremely Low Birthweight Infants

29

CONCLUSION The neurobehavioral differences between the ELBW infants at term and the control full-term infants in our study were not as large as reported in previous studies.11,12 Several circumstances might explain this unexpected finding. First, the control group was studied on the third day of life because the postnatal care period in the maternity ward after normal delivery in Sweden was 2 to 4 days, even though a previous study of neurobehavioral assessment of full-term Swedish infants found that the postnatal adaptation for full-term infants was not completed until after 5 days of age.17 Second, Solkoff and Matuszak have shown that with additional tactile stimulation, very low birthweight (VLBW) infants—those with weights below 1500 g—had better scores on the NBAS test for tonus, habituation to sound and light, changes of sleep-awake state, and alertness, in comparison with preterm infants without such stimulation.18 Third, several studies have shown that ELBW infants receiving individualized neonatal care require less ventilator treatment and have better mental development than ELBW infants not treated in this way.9,19,20,21,22,23 In our NICU in Lund, individualized care was given; this included low lighting and reduced sound, combined with the stimulation of parent-infant skin-to-skin contact with frequent kangaroo care. We cannot prove, although we do speculate, that such procedures may have influenced the unexpectedly high scores on some NBAS items among our ELBW infants when compared with full-term babies. It is important to note, though, that although our ELBW infants showed a wide behavioral range at term, parents had to put a lot of effort into eliciting responses from them. At the same time, they had to be observant for physiological signs of fatigue from overstimulation. If the ELBW infants became distressed during testing, they needed more comforting compared with the full-term control infants. All this indicates that parents will need detailed advice on how to give optimal support to their ELBW babies. They should be made aware of their babies’ fluctuating states of behavior and individual social needs, and, furthermore, they need to be told that the developmental process of the ELBW baby implies not only change but also instability.8 An important observation from our data—both for future neonatal care and parent counseling—is that for the very tiny preterm infant, even at term age, the periods of alertness every day when he or she is fully able to participate in social interaction, are short, but regular.

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Contemporary Research and Practice

An interesting finding of our study was the positive correlation between the Orientation items in the NBAS at term, DQ at 4 years of age, and IQ at 10 years, even though, in the neonatal period, instability in physical, physiological, and behavioral systems is pronounced, and neonatal assessments are thought to be less predictive.10 A tentative explanation for our finding might be that the early strategy for coping with environmental stimuli is essential for later perception and thereby influences development. Concerning the cognitive development for ELBW children at preschool and early school-age, our findings are in agreement with other follow-up studies of ELBW children.24,25,26 ELBW children had approximately one SD lower IQ than full-term mates.4,27 It is obvious that interventions at different levels are needed to support ELBW children’s development. Besides continuous improvements in medical care, more directed individualized developmental care in the neonatal period is needed. Long-term intervention programs aiming to give parents a better understanding of the characteristics of their ELBW children’s development are also warranted. With our very positive experiences from doing one NBAS examination and sharing our findings with the parents, we started an intervention program to support children’s development and to enhance parent-infant interaction. We recruited VLBW infants born before the 33rd gestational week who did not have major intra-cranial hemorrhages or malformations from two different hospitals in the south of Sweden. Fifty-nine infants fulfilled our criteria, and the parents of 54 infants gave their informed consent to participation. The infants were randomized into an intervention group and a control group. The interventions started in the 34th gestational week with four hospital-based interventions and was followed by eleven home-based interventions during the first six months after discharge—all performed by two trained nurses. Parts of the NBAS were used at the different intervention sessions, and the nurses’ experience of each infant’s performance and maturation over time was shared with the parents. The mothers in both the intervention group and the nonintervention group had depressive symptoms three times more often than mothers of full-term infants (38% versus 12%) during the two weeks after the birth but before the onset of the intervention, as measured using the Edinburgh Postnatal Depression Scale.28 For the mothers in the intervention group, the depressive symptoms were significantly lower when the infants were 3, 6, and 12 months old (age corrected for degree of prematurity)—7%, 4%, and 7%, respectively—while those of the mothers in the control group

Predicting Development for Extremely Low Birthweight Infants

31

remained at a higher level—22%, 19%, and 23%—for the corresponding periods. In addition, the mothers in the intervention group reported less social isolation and relationship problems with their partners than the mothers in the control group. At 12 months corrected age, there was a difference between the intervention and control groups on the mental developmental index on the Bayley Scale—92 and 87, respectively—but it did not reach statistical significance. At this age, also, the quality of the mother-child relationship was significantly better in the intervention group, as measured with the Early Relational Assessment Scale.29 With these results in hand, we gradually incorporated NBAS into our NICU discharge program and follow-up clinic, and we continue to use parts of it for intervention at different sessions. We are now reassessing the former ELBW children when they are young adults, and will soon be able to determine whether NBAS results at term is a reliable predictor of outcomes in adult life.

REFERENCES 1. Stjernqvist K, Svenningsen NW. Neurobehavioural development at term of extremely low birthweight infants (less than 901g). Dev Med Child Neurol. 1990;32:679–688. 2. Stjernqvist K, Svenningsen NW. Extremely low birth weight infants less than 901g. Growth and development after one year of life. Acta Paediatr. 1993;82:40–44. 3. Stjernqvist K, Svenningsen NW. Extremely low-birth-weight infants (less than 901g): Development and behaviour after 4 years of life. Acta Paediatr. 1995;84:500–506. 4. Stjernqvist K, Svenningsen NW. Ten-year follow-up of children born before 29 gestational weeks: Health, development and school achievement. Acta Paediatr. 1999;88:557–562. 5. Sternqvist K. Extremely low birth weight infants less than 901g: Impact on the family during the first year of life. Scand J Soc Med. 1992;20:226–233. 6. Sternqvist K. The birth of an extremely low birth weight infant (ELBW)  901g: Impact on the family after 1 and 4 years. J Repro Infant Psycho. 1996;14:2:243–264. 7. Papile LA, Burnstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: A study of infants with birth weight less than 1500g. J Pediatr. 1978;92:529–534. 8. Als H, Lawhon G, Brown E, et al. Individualized behavioral and environmental care for the very low birth weight preterm infantat high risk for bronchopulmonary dysplasia: Neonatal intensive care unit and developmental outcome. Pediatrics. 1986;78(6):1123–1132.

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9. Als H, Lawhon G, Duffy FH, McAnulty GB, Gibes-Grossman R, Blickman JG. Individualized developmental care for the very low-birth-weight preterm infant: Medical and neurofunctional effects. JAMA. 1994;272: 853–858. 10. Brazelton TB. Neonatal Behavioral Assessment Scale. No 88. 2nd ed. Philadelphia, PA: SIMP with Blackwell Scientific, Lippincott; 1984. 11. Ferrari G, Grosoli M, Fontana G, Gavazzuti G. Neurobehavioural comparison of low-risk preterm and fullterm infants at term conceptional age. Dev Med Child Neurol. 1983;25:450–458. 12. Paludetto R, Rinaldi P, Mansi G., Andolfi M, del Giudice G. Early behavioural development of preterm infants. Dev Med Child Neurol. 1984;26: 347–352. 13. Sell E, Luick A, Poison S, Hill S. Outcome of very low birth weight (VLBW) infants: Neonatal behaviour of 188 infants. J Dev Behav Pediatr. 1980;1 (pt 1):78–85. 14. Griffiths R. The Abilities of Young Children. London, England: Child Development Research Centre; 1970. 15. Ahlin-Åkerman B, Nordberg L. Griffiths’ Utvecklingsskalor I och II Psykologiförlaget [Griffiths Scale of Development I and II Psychology]. Stockholm, Sweden: Hägersten; 1980. 16. Weschler D. The Weschler Intelligence Scale for Children. 3rd ed. San Antonio, TX: Psychological Corp; 1992. Swedish translation, Psykologi Förlaget AB; 1994. 17. Leijon I. Neurological and Behavioural Assessments of Full-Term Newborn Infants. [medical dissertation no 98]. Linköping, Östergöland, Sweden: Linköping University; 1980. 18. Solkoff N, Matuszak D. Tactile stimulation and behavioural development among low-birthweight infants. Child Psychiatr Hum Dev. 1975;6:33–37. 19. Kleberg K, Westrup B, Stjernqvist K. Developmental outcome, child behaviour, and mother and child interaction at three years following NIDCAP (Newborn Individualized Developmental Care and Assessment Program) intervention. Early Hum Dev. 2000;60:123–135. 20. Westrup B, Kleberg A, von Eichwald K, Stjernqvist K, Lagercrantz H. A randomized controlled trial to evaluate the effects of the Newborn Individualized Developmental Care and Assessment Program in a Swedish setting. Pediatrics. 2000; 105:66–72. 21. Westrup B, Kleberg A, Stjernqvist K, Lagercrantz H. Indications of improved mental development at one year by NIDCAP (Newborn Individualized Developmental Care and Assessment Program). Early Hum Dev. 2002;68:83–91. 22. Westrup B, Böhm B, Lagercrantz H, Stjernqvist K. Preschool outcome in children born very preterm and cared according to the Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Acta Pediatr. 2004;93(4):498–507.

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23. Als H, Duffy F, McAnulty B, et al. Early experiences alter brain function and structure. Pediatrics. 2004;113(4):846–857. 24. Hack M, Taylor G, Klein N, Eiben R, Schatschneider C, Mercuri-Minich N. School-age outcome in children with birth weight under 750g. N Engl J Med. 1994;331(12):753–803. 25. Halsey CL, Collin MF, Anderson CL. Extremely low-birth-weight children and their peers: A comparison of school-age outcomes. Arch Pediatr Adolesc Med. 1996;150:790–794. 26. Saigal S, Szatmari P, Rosenbaum P, Campbell D, King S. Intellectual and functional status at school entry of children who weighed 1000 grams or less at birth: A regional perspective of births in the 1980s. J Pediatrics. 1990;116:409–416. 27. Wolke D, Meyer R. Cognitive status, language attainment, and prereading skills of 6-year-old very preterm children and their peers: The Bavarian Longitudinal Study. Dev Med Child Neurol. 1999;41(2):94–109. 28. Cox M. Progress and continued challenges in understanding the transition to parenthood. J Fam Issues. 1985;6(4):395–408. 29. Clark R. The parent–child early relational assessment: A factor validity study. Educational and Psychological Measurement. 1999:59(5): Handbook of Infant Mental Health. New York, NY: Guilford Press; 1993.

CHAPTER 3

The Effects of Newborn Massage: United States TIFFANY FIELD

FULL-TERM NEWBORNS Infant massage is practiced in most of the Eastern world. In many countries, including Nigeria, Uganda, Bali, Fiji, New Guinea, New Zealand (the Maori), and the Soviet Union, infants are given a massage with oil after the daily bath and before sleep time for the first several months of their lives. Infant massage is only recently being discovered in the Western world. Massage therapy schools in almost every U.S. city teach parents how to massage their infants. The techniques they teach are based on Indian massage, which is described in publications by two massage therapists who trained in India.1,2 The Indian infant massage is a daily bath time routine that begins in the first days of life. The infant is laid on his stomach on the mother ’s outstretched legs as she sits on the ground, and each body part is individually massaged. Warm water and soap are applied to the legs, arms, back, abdomen, neck, and face. The massage looks like scrubbing clothes on an old washboard and seems extremely rigorous (almost rough). After they are massaged and The author wishes to thank the parents and infants who participated in this study. This research was supported by a grant from NIMH and a Senior Scientist Award (MH No. 00331) to Tiffany Field and funding from the Johnson & Johnson Pediatric Institute. Correspondence and requests for reprints should be sent to Tiffany Field, PhD, Touch Research Institutes, University of Miami School of Medicine, Department of Pediatrics (D-820), P.O. Box 016820, Miami, FL 33101, [email protected].

34

The Effects of Newborn Massage: United States

35

swaddled, the infants sleep for prolonged periods (perhaps to recover from the stress of the massage). Although data have not yet been collected on this technique, some infant massage therapists have attributed the precocious motor development of these infants to their daily massages. They suggest that the massage provides both stimulation and relaxation, improving respiration, circulation, digestion, and elimination.3 They claim that infants who are massaged sleep more soundly and that the massage relieves gas and colic and helps the healing process during illness by easing congestion and pain. We have recently confirmed that the moderate pressure used in the Indian massage is crucial to growth effects and improved performance on the Neonatal Behavioral Assessment Scale (NBAS).4 In our study, we assessed the effects of moderate and light pressure massage on the growth and development of young infants. Mothers were instructed to massage their newborn infants once per day using either light or moderate pressure. The infants’ growth (weight, length, head circumference), sleep behavior, and performance on the NBAS were assessed soon after birth and at one month of age. Our results showed that infants in the moderate pressure group gained more weight and length than infants who received a light pressure massage, performed better on the Orientation cluster of the NBAS, had lower NBAS excitability and depression scores, and exhibited less agitated behavior during sleep. PRETERM NEWBORNS Most of the research on the effects of infant massage has been conducted with preterm (premature) infants. During the past two decades most of the studies conducted were labeled tactile/ kinesthetic stimulation because of the negative connotations of the word massage. Generally, the results have been positive. A recent meta-analysis of data from 19 of these studies revealed that 72% of the massaged infants were positively affected.5 Most of them experienced greater weight gain and better performance on the NBAS.6 Those studies that did not report significant weight gain had used the wrong kind of touch—a light stroking procedure. Infants do not respond positively to light touch, probably because it feels like tickling. The babies who gained weight had been given moderate pressure massage, which stimulated both tactile and pressure receptors. One of the studies included in the meta-analysis was conducted in our lab.7 In that study, we gave premature newborns massage

36

Contemporary Research and Practice

therapy for 45 minutes a day (in doses of three 15-minute periods) for 10 days. The infants, on average, were 9 weeks premature, weighed about 2 pounds, and had been treated in intensive care for approximately 3 weeks before the study. The massages were started as the infants graduated from the “grower nursery” at a time when their primary reason for being in the nursery was to gain weight. The massage therapy sessions were divided into three phases. For the first and third phases of the massage, the newborns were placed on their stomachs and gently stroked for five, 1-minute periods (six back-and-forth strokes at approximately 10 seconds each for each of the 1-minute periods) over each region in the following sequence: (1) from the top of the head to the neck and back to the top of the head, (2) from the nape of the neck across to the end of the shoulders and back to the neck, (3) from the upper back to the waist and back to the upper back, (4) from the top of the thigh to the foot and back to the thigh on both legs, and (5) from the shoulder to the hand and back to the shoulder on both arms. As already noted, moderate pressure was applied. During the second 5-minute phase, the infants’ arms and legs were moved back and forth much like bicycling motions (into flexion and extension) while the infants were lying on their backs. First the right arm, then the left arm, then the right leg, then the left, and finally both legs were moved again in slow motion for 1 minute each for a total of 5 minutes. By the end of the 10-day treatment period, the massaged preterm infants in this study had gained 47% more weight than the control group, even though both groups consumed the same amount of formula. The massaged infants were surprisingly awake and active more of the time, even though we expected they would sleep more. In addition, they performed better than the control group on the Habituation, Orientation, Motor, and Range of State clusters on the NBAS. Further, they were discharged from the hospital 6 days sooner, saving approximately $3,000 per infant in hospital costs. Today, the comparable cost savings would be $10,000, which means that if the 470,000 premature infants born each year in the United States were massaged, $4.7 billion in hospital costs would be saved annually. In a similar study conducted over a 5-day, instead of a 10-day, period, we also noted a 47% greater increase in weight gain in the massaged preterm infants, suggesting that 5-day treatment periods would be even more cost effective.8 In other parts of the world, researchers have used the same massage procedure and have reported similar effects. In the Philippines, Dr. Cifra and her colleagues reported nearly the same weight gain

The Effects of Newborn Massage: United States

37

(45%);9 and in Taiwan, another group of neonatologists reported increased weight gain—as well as increased growth (length and head circumference)—in their massaged preterm infants. In Israel, the same massage was used, but the infants’ mothers performed the massages instead of the massage therapists.10 The Israeli researchers also reported infant weight gain; in addition, the mothers benefited by decreased postpartum depression. Finally, a decrease in stress hormones has been reported for massaged newborns: In a study conducted in London,11 blood samples were obtained for cortisol (stress hormone) levels. Cortisol levels significantly decreased after massage, and there was also a slight decrease in skin temperature. MASSAGE THERAPY WITH OTHER HIGH-RISK NEWBORNS Cocaine-exposed preterm infants also benefit from massage therapy.12 After receiving the massage described previously (three times daily for a 10-day period), the massaged cocaine-exposed preterm infants experienced fewer medical complications and showed less irritability than cocaine-exposed infants not massaged. They also gained 28% more weight, on average, than the control group, and they performed better on the NBAS, especially on the Orientation and Motor clusters. Finally, they showed fewer stress behaviors on a Neonatal Stress Scale.13 The Neonatal Stress Scale was developed to characterize the stress behaviors that cocaineexposed neonates show during NBAS assessments. The scale comprises 11 items that are operationally defined in terms of the specific behaviors/signs that occur either during particular NBAS items or during the NBAS in general. They include tremors, restlessness, irritability, excessive high-pitched crying, hypertonia, abnormal reflex behavior, abnormal Moro reflex, excessive mouthing, tachypnea, autonomic instability, and gastrointestinal signs (such as vomiting and diarrhea), and these behaviors are scored positive if present. HIV exposure is another risk factor for less optimal performance on the NBAS. Increasing numbers of newborns have been exposed to HIV perinatally. In a study on HIV-exposed newborns, we taught mothers how to massage their infants, and we experienced almost 100% cooperation.14 This unusually high compliance rate might have occurred because the mothers felt guilty for exposing their infants to HIV. After two weeks of massage therapy, these HIV-exposed infants experienced greater weight gain, and they showed better performance on the Habituation, Motor, Range of State, and Autonomic Stability scales of the NBAS.

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Contemporary Research and Practice

PA R E N T S A N D V O L U N T E E R S A S MASSAGE THERAPISTS In order to provide massages to all newborns on a daily basis, and at no cost, we have been teaching mothers, fathers, and volunteers to massage the infants. To our surprise, the massagers also benefit. In one study, for example, we taught depressed mothers to massage their infants.15 We expected the mothers’ depression to decrease and their infants’ distress behavior and disturbed sleep patterns to decrease. The mothers gave their infants 15-minute massages daily for a 2-week period. At the end of that time, the infants fell asleep faster and slept longer, and they showed less fussiness. The mothers also benefited by this face-to-face interaction, showing better behaviors with their infants. In another study, we taught fathers to massage their infants. We had demonstrated father massage for an Australian television network because the producer “wanted to get Australian fathers more involved in caregiving.” Following the television airing, an Australian research group studied the effects of Australian fathers massaging their infants. In this study, at a 3-month home observation, the fathers who massaged their infants showed greater involvement with their infants than fathers who did not massage their infants. The massaged infants also showed more eye contact, smiling, and vocalizing with their fathers. We subsequently conducted a similar study, and again, the fathers who massaged their infants for a month had better interactions with their babies than fathers who did not.16 We also taught infant massage to grandparent-age volunteers.17 The “grandparent” volunteers then massaged neglected and abused infants in a shelter. After giving the massages for one month, these volunteers reported less anxiety and fewer depression symptoms. Their cortisol (stress hormone) levels also decreased, and their lifestyles improved, including more social contacts and fewer visits to their physicians. Thus, massage therapy not only helped the infants, but also helped the adults who massaged the infants. F O L L O W- U P S T U D I E S The only follow-up study we have conducted assessed preterm infants 8 to 12 months after they had been massaged as newborns.18 Although clinicians are most impressed by the weight gain effects of massage, parents may be more impressed by the behavioral effects as measured by the NBAS. This possibility was highlighted by the follow-up data showing that preterm infants who had been

The Effects of Newborn Massage: United States

39

massaged as newborns were performing better on the Bayley Scales later in the first year. The massage therapy helped the newborns be more responsive, behaviorally, as evidenced by their better NBAS performance. In turn, the newborns were better able to interact with their parents, who then were better interaction partners. Because of this snowball effect, the infants showed better performance on developmental assessments (at one year). Thus, the weight gain following massage therapy may help the infants go home sooner, while the improved behavior as manifested on the NBAS may help the infants elicit better stimulation from their parents and, in turn, achieve superior development. These pathways, of course, need further research. At this point, our experience shows us that the use of the NBAS seems to be an important demonstration to the parents of how their infants’ behavior can improve following massage therapy. This, in turn, seems to encourage parents to continue massage therapy at home.

REFERENCES 1. Auckett AD, Baby Massage. New York, NY: Newmarket Press; 1981. 2. McClure VS. Infant Massage. New York, NY: Bantam Books; 1979. 3. Grossman R. The Other Medicines: An Invitation to Understanding and Using Them for Health and Healing. Garden City, NY: Doubleday and Co; 1985. 4. Field T, Hernandez-Reif M, Diego M, Feijo L, Vera Y, Gil K. Massage therapy by parents improves early growth and development. Infant Behav Dev. 2004;27:435–442. 5. Ottenbacher KJ, Muller L, Brandt D, Heintzelman A, Hojem P, Sharpe P. The effectiveness of tactile stimulation as a form of early intervention: A quantitative evaluation. J Dev Behav Pediatr. 1987;8:68–76. 6. Brazelton TB. Neonatal Behavior Assessment Scale. No 88. 2nd ed. London, England: Spastics International Medical Publications; 1984. 7. Field TM, Schanberg S, Scadifi F, et al. Tactile/kinesthetic stimulation effects on preterm neonates. Pediatrics. 1986;77:654–658. 8. Dieter JN, Field T, Hernandez-Reif M, Emory EK, Redzepi M. Stable preterm infants gain more weight and sleep less following 5 days of massage therapy. J Pediatr Psycho. 2003;28(6):403–411. 9. Cifra HL, Sancho MN. Massage therapy with preterm infants and children with chronic illnesses. In: T. Field, ed. Touch and Massage Therapy in Early Development. Skillman, NJ: Johnson & Johnson Pediatric Institute LLC; 2003:211–226. 10. Ferber SG, Kuint J, Weller A, et al. Massage therapy by mothers and trained professionals enhances weight gain in premature infants. Early Hum Dev. 2002;67:37–45.

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11. Acolet D, Giannakoulopoulos X, Bond C, Weg W, Clow A, Glover V. Changes in plasma cortisol and catecholamine concentrations in response to massage in preterm infants. Arch Dis Child. 1993;68:29–31. 12. Scafidi F, Field TM, Wheeden A, et al. Cocaine exposed preterm neonates show behavioral and hormonal differences. Pediatrics. 1996;97:851–855. 13. Eisen LN, Field TM, Bandstra ES, et al. Perinatal cocaine effects on neonatal stress behavior and performance on the Brazelton Scale. Pediatrics. 1991;88:477–480. 14. Scafidi F, Field TM. Massage therapy improves behavior in neonates born to HIV positive mothers. J Pediatr Psycho. 1997;21:889–897. 15. Field TM, Grizzle N, Scafidi F, Abrams S, Richardson S. Massage therapy for infants of depressed mothers. Infant Behav Dev. 1996;19:109–114. 16. Cullen C, Field T, Escalona A, Hartshorn K. Father-infant interactions are enhanced by massage therapy. Early Child Dev Care. 2000;164:41–47. 17. Field T, Hernandez-Reif M, Quintino O, Schanberg S, Kuhn C. Elder retired volunteers benefit from giving massage therapy to infants. J Appl Gerontol. 1998;17(2):229–239. 18. Field TM, Schanberg S, Scadifi F. Massage of preterm newborns to improve growth and development. Pediatr Nurs. 1987;13:385–387.

CHAPTER 4

Perinatal Factors Influencing Development: Spain CARME COSTAS -MORAGAS

Catalonia, with Barcelona as its capital city, is located on the east coast of the Iberian Peninsula. It covers an area of 31.895 km, and, as of 2007 had a population of 7,210,508. In 2006, the birth rate in Catalonia was 11.69 per 1,000 inhabitants, and the infant mortality rate was 2.66 per 1,000 live births. The government of Catalonia provides free public health services to everyone (as occurs in the rest of Spain) and has developed a network of 80 early intervention clinics for children from 0 to 6 years of age. It was in this setting that I began working with a group of psychology professors at the Universitat Autònoma de Barcelona. In collaboration with neonatology pediatricians at the Hospital Clínic de Barcelona, we initiated research to examine a range of perinatal factors affecting development in the neonatal period. The Hospital Clínic is a level III university hospital, affiliated with the Universitat de Barcelona, at which there were 4,100 births in 2007. We decided that our first step would be to familiarize ourselves with the Neonatal Behavioral Assessment Scale (NBAS) to see how it could be applied to our unique research setting in Barcelona. Our initial results provided vital data on the reliability of the NBAS (our analysis indicated consistent interrater agreement among examiners). In addition, there were numerous aspects of its theoretical framework that convinced us that the NBAS would be the most appropriate instrument for our clinical research.1,2 Our main research objective was (and still is) to examine various risk factors and their effects on neonatal development, so we could provide clinically relevant information that would enable clinics to improve

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conditions for newborns in neonatology units. In addition to facilitating our formal research program, the NBAS has been extremely valuable in helping us understand the complexities of neonatal psychic structure. For this reason, another of our primary academic activities is to offer training courses on the NBAS for psychologists, pediatricians, and nurses throughout Catalonia and Spain, with the result that the NBAS is being used in different early intervention settings across the country.

B E H AV I O R A L S T U D I E S O F AT - R I S K N E W B O R N S From the moment of birth, there are a series of factors—both biological and psychological—that can affect a child’s development. While advances in modern medicine have reduced the impact of many perinatal risk factors, there are many others—such as the adverse effects of prenatal toxic substances, low birthweight and prematurity—that have remained unchanged or have even increased. In order to address these issues, we have studied the immediate effects on neonatal behavior of such factors, including birthweight (both low and high), serum bilirubin levels, umbilical cord lead levels, acute fetal distress, and gestational and pregestational diabetes, as well as cesarean delivery and prematurity in order to thereby improve future early intervention programs. All the children in these studies were assessed on the third day after birth (when they were between 60 and 84 hours old) because this immediate postnatal period is considered the most reliable age for conducting a single NBAS evaluation. The evaluations took place in the Neonatology Unit at the Hospital Clínic de Barcelona, with the prior agreement of the parents. They were always conducted in a quiet room, with very low lighting, at a room temperature of 25˚C to 26˚C, and, as recommended by the NBAS manual, midway between feedings. The examinations were carried out by examiners trained to a 90% to 100% interrater reliability level of agreement, often with two examiners scoring the examination. We used the first and second editions of the NBAS until 1995; from then on, we used the third edition, which was translated into Spanish by our team.3,4,5 With the exception of the low birthweight study, we analyzed the results according to the seven clusters proposed by Lester et al: Habituation, Orientation, Motor, Range of State, Regulation of State, Autonomic Stability, and Reflexes.6

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E F F E C T S O F L O W B I RT H W E I G H T A N D H I G H B I RT H W E I G H T Low Birthweight Children born with birthweights below normal—small-for-dates newborns—are considered to be at risk because they have experienced intrauterine growth retardation. Clinical experience has proven that as they grow older, they are likely to exhibit different types of problems that affect not only their physical health, but also their learning abilities. For this study, two groups of full-term infants were selected. The underweight group comprised 41 smallfor-dates, full-term newborns whose birthweights were below the 10th percentile, based on postmenstrual age. The infants had a mean birthweight of 2,598 g, with none showing severe signs of undernourishment. The control group comprised a matched sample of 41 full-term neonates whose birthweights were between the 25th and 75th percentiles, with a mean of 3,392 g. Six clusters of neonatal behavior were derived from the NBAS5 raw scores: Interaction, Orientation, Motor, Range of State, Consolability, and Energy. Analysis of variance demonstrated that underweight infants scored lower than the control group on the Interaction and Orientation clusters (p
.01) as well as the Motor and Energy clusters (p
.001). However, no differences were found on the Range of State cluster, and there was a small but significant difference found on the Consolability cluster (p
.05). Underweight infants also scored lower on elicited responses, especially on the Rooting reflex (p
.01), the Crawling and Moro reflexes (p
.05), and the Passive Movement (p
.001). From these data, we can conclude that the behavior of low birthweight newborns, in comparison with newborns of appropriate birthweight, is characterized by greater difficulty in attending to stimuli, poorer response to interpersonal interactions, poorer tonic-postural adaptation, and greater difficulty with self-quieting and consolability. Considering the impact of this behavioral profile on caregiving adults, it is possible that underweight infants offer less positive reinforcement than do infants of average weight.2,7 High Birthweight Newborns Children born with birthweights above normal—large for gestational age (LGA)—are also at risk. They have higher morbidity and mortality rates than newborns of appropriate weight, as well as a greater incidence of morbidity caused by factors such as neonatal

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asphyxia and metabolic and hematological problems. For our study of high birthweight infants, the study group comprised 20 full-term newborns with weights between 4,000 and 4,920 g, which is above the 90th percentile, based on postmenstrual age. The control group comprised 35 full-term newborns of appropriate weight, between 3,000 and 3,770 g. LGA newborns performed less well than newborns in the control group on the NBAS Orientation cluster (p
.01) and on the Regulation of State cluster (p
.05).8 In another study comparing low and high birthweight infants, the results suggest poor NBAS performance in both groups. However, among low birthweight infants, we observed lower scores on the items relating to the Motor and Autonomic Stability clusters, probably influenced by the nutritional state of the organism.9 SERUM BILIRUBIN LEVELS AND N E O N ATA L B E H AV I O R Neonatal hyperbilirubinemia is one of the most common clinical problems in the first days of life. There are a range of negative outcomes associated with hyperbilirubinemia, such as disorders of motor development in the first year and alterations of neurological development and hypoacusia in the first decade of life. In this study, we used the NBAS5 to conduct a blind evaluation of 73 newborns. Total bilirubin was determined at 72 hours of life. The mean bilirubin value was 123.12 mol/L (7.2 mg/dL); the standard deviation, 71.8 mol/L (4.2 mg/dL); and the range, 17.1 to 273.6 mol/L (1–16 mg/dL). In order to avoid unnecessary tests, blood extracted for early endocrine-metabolic screening was used (at that point no child in the sample had been subject to phototherapy or any other therapeutic measure). The relationship between bilirubin levels and NBAS scores for behavioral variables was established using the Pearson correlation test. Results showed an inverse correlation between elevated bilirubin levels and scores on the following NBAS clusters: Habituation to tactile stimuli (p  .03); Orientation, especially to auditory stimuli (p  .000); and Motor (p  .0051). These data may be compatible with disorders previously mentioned.10 UMBILICAL CORD BLOOD LEAD LEVELS AND N E O N ATA L B E H AV I O R There are numerous studies that highlight the negative impact of lead on children’s cognitive development, especially as it affects their visual-motor and visual-spatial coordination. Our umbilical cord lead study was designed to evaluate possible short-term

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neurobehavioral consequences for the newborn exposed to lead in utero at levels that, today, are regarded as safe. Thirty healthy newborns (13 girls and 17 boys) were recruited for the study. Special emphasis was put on ascertaining that the mothers had no medical problems in their histories; newborns of mothers with a history of smoking, alcohol consumption, or other drug use were excluded. Lead levels were measured in cord blood specimens. Cord blood samples were obtained in the delivery room, collected in plastic tubes with heparinlithium as an anticoagulant, and kept in the refrigerator at 4˚C until processed. Lead levels were measured by atomic absorption spectrophotometry and processed in the Laboratory of Toxicology at the Hospital Clínic of the University of Barcelona. Cord blood lead was detected in all subjects: The frequency distribution ranged from 1.9 to 15 g/dL (mean 6.48, median 5.8, standard deviation 3.24). Negative correlations have previously been found between cord blood lead levels and scores on the NBAS.4 Using an alternative method of analysis, a comparison of NBAS cluster scores was carried out after the subjects were classified into two subgroups, according to their lead levels (above or below the median). Mean NBAS scores in both groups were compared and differences evaluated by a two-tailed t test for differences between means. No significant differences between the two groups were found based on gender ratio, postmenstrual age, or somatic characteristics of the infants with lead levels above or below the median (5.8 g/dL). However, significant differences were found when the NBAS cluster scores of the two groups were compared. For all NBAS clusters, except for Range of State, the neonates with lead levels above the median obtained significantly lower scores than those in the group with lead levels below the median. In addition, the correlation between lead levels and the Habituation, Orientation, Regulation of State, Range of State, and Autonomic Stability clusters showed a statistically significant negative correlation with blood lead levels. Behavior scores of neonates evaluated in this investigation were all within the normal range. However, newborns with higher cord blood lead levels showed lower scores in the Habituation, Orientation, and Regulation of State clusters, and they seemed to have more difficulty in self-quieting and in their self-regulatory activity and were less well able to habituate to auditory stimuli.11 E F F E C T S O F A C U T E F E TA L D I S T R E S S Acute fetal distress is common during the neonatal period (occurring in 2% to 5% of newborns). Generally, it occurs during

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birth and is a high-risk situation because of the lesions that can be caused, particularly to the central nervous system. This study evaluated the effects of fetal distress associated with metabolic acidosis (pH
7.15 and BE
8 in blood samples from the umbilical artery) on neonatal behavior. We compared 15 anoxic neonates with a sample of 87 newborns with the same characteristics, but whose pH and BE levels were normal (pH  7.25 and BE  5). Statistically significant differences were found between the two groups. The control group performed much better than the hypoxic group on almost all of the NBAS clusters.6 The following results were obtained with Student’s t test: Habituation (p
.001), Orientation (p
.001), Autonomic Stability (p
.001), Regulation of State (p
.01), and Motor (p
.001). These data indicate that hypoxic neonates exhibit greater irritability and hypersensitivity to stimuli than nonhypoxic newborns. This means they have more difficulty in habituating to repetitive disturbing stimuli, as well as more difficulty remaining attentive and responding to external sensory stimuli. In addition, infants who have experienced fetal distress at the time of birth are less predisposed to interaction, have poorer general motor aptitude, and have lower capability for internal organization and regulation of states. In general, then, it seems that these babies lack the resources to recover their internal equilibrium after a phase of irritation, such as crying, because they find it more difficult to console themselves. In addition, there is evidence to suggest that they have a poor capacity to respond appropriately to situations of stress that require readjustment of the autonomous nervous system.12

NEWBORNS OF DIABETIC MOTHERS Nowadays, with correct metabolic and obstetric control, the most likely prognosis in cases of gestational and pregestational diabetes is a normal outcome for both the mother and her child. To determine whether neonates born to mothers with gestational and pregestational diabetes show any differences in behavior from those born to healthy mothers, the NBAS4 was administered to 50 newborns. The study group comprised 15 neonates born to mothers with gestational diabetes (A1 and A2) and 3 born to mothers with pregestational diabetes mellitus Type 1. The control group comprised 32 neonates born to healthy mothers. Diabetes control was determined by means of glycohemoglobin plasma levels (HbA1) and the absence of macrosomia.

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The results showed no significant differences among groups in any of the NBAS clusters that make up the scale. Apart from that, HbA1 levels of the mothers during gestation were always within normal limits. Thus, as was expected, in this case, the NBAS detected no differences in the behavior of neonates born to mothers with gestational diabetes that was correctly controlled during pregnancy.13 FULL-TERM CESAREAN SECTION N E W B O R N I N FA N T S The objective of this research was to study the behavior of normal, full-term newborns delivered by cesarean section and to compare their behavior with that of normal full-term newborn infants delivered vaginally. The study included two groups of 15 neonates whose mothers had been given epidural or intradural analgesia and had similar characteristics. The infants in the study group had been delivered by cesarean section, while those in the control group had been delivered vaginally. Comparison of the neonates’ behavior showed no statistically significant differences in any of the NBAS clusters.5 The scores of infants born by cesarean section were, in fact, higher—although not significantly so—than those of the infants born by vaginal delivery. From an analysis of the individual items, a significant difference was observed for Pull-to-Sit in the Motor cluster, favoring those born by cesarean (5.73 versus 3.93; p
.05), but this difference is not clinically significant. Given these results, it may be concluded that, in this case, cesarean section, practiced with epidural or intradural analgesia, did not influence neonatal behavior, as evaluated on the third day of age, on the NBAS.14 B E H AV I O R O F P R E M AT U R E N E W B O R N S AT 4 0 P O S T M E N S T R U A L W E E K S A newborn is considered premature when it is born before 37 postmenstrual weeks. Studies of the risks associated with prematurity at the psychopathological level look at different aspects, both cognitive and psychomotor (or behavioral) in nature. The objective of this research was the detection of the earliest signs of such problems. The study compared a group of 30 premature infants born between 27 and 34 weeks with a control group of 30 healthy, full-term newborn infants. The assessment of neonatal behavior with the NBAS5 was carried out at 38 to 40 postmenstrual weeks for the study group and at 60 to 84 hours after birth for the control group.

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In comparing the behaviors of the two groups, we found statistically significant differences, with lower scores in the State Organization (p  .021) and State Regulation (p  .003) clusters for the prematurely born newborns. We found no differences for the other clusters, except in the case of the Habituation cluster, where the results for premature neonates exceeded those of the control group, specifically in the case of their response to auditory stimuli. The lowest scores observed in premature neonates—that is, in the State Organization and State Regulation clusters—include items related to control and self-regulation mechanisms in response to stimulation from their surroundings. In this case, it is plausible that premature neonates have already learned to cope with auditory stimulation in the NICU, and this is demonstrated by better results for Habituation, since they had to develop this capacity throughout their extrauterine experience of between 6 and 13 weeks. However, they have few resources with which to control their states, and so are poorly equipped to defend themselves against the indiscriminate stimulation of their environment.15 CONCLUSION In our work in Barcelona, the NBAS has proven to be a very sensitive technique for detecting deficits in at-risk newborns. As we had expected, in almost all cases, the groups of at-risk neonates we studied scored consistently lower than the control groups (the exceptions were the babies of diabetic mothers and those born by cesarean section). It is important to remember that these results must be treated and applied with caution, since their statistical significance may not always be clinically meaningful. That being said, the score profiles of at-risk neonates in our series of studies indicated a fragility that was reflected in the behavioral parameters we observed. The infants’ poor ability to respond to external stimuli and their lack of resources to defend themselves from persistent environmental stimulation seem to compromise their stability. Yet the behavioral disturbances, which can affect the future development of these newborns, are not readily noticeable in a routine physical examination during their early days of life. Fortunately, we now know that they can be detected using very sensitive methods, such as the NBAS. All of the data provided by our research indicate that the NBAS is a most appropriate instrument for revealing behavioral deficits, as well as developmental disorders caused by adverse perinatal factors. It provides clinicians with a description of the neonate’s behavioral profile that is vital in order

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to be able to develop appropriate programs of early intervention for each individual child, beginning at birth.

REFERENCES 1. Costas C, Castells M, Domènech E. Evaluación conductual de un grupo de recién nacidos con una forma abreviada de la escala de Brazelton [Behavioral evaluation of a group of newborns using an abbreviated version of the Brazelton scale]. Poster presented at: First Congress of Psychological Assessment; September 25–28 1984; Madrid, Spain. 2. Costas C, Domènech E. Análisis de la escala para la evaluación del comportamiento neonatal de T. B. Brazelton: Valoración de la conducta del recién nacido de bajo peso [Analysis of T. B. Brazelton’s Neonatal Behavioral Assessment scale: Evaluation of low birth weight newborns’ behavior]. Evaluación Psicológica. 1987;3(3):383–407. 3. Brazelton TB. Neonatal Behavioral Assessment Scale. No 50. London, England: Spastics International Medical Publications; 1973. Clinics in Developmental Medicine No. 50. 4. Brazelton TB. Neonatal Behavioral Assessment Scale. No 88. 2nd ed. London, England: Spastics International Medical Publications; 1984. Clinics in Developmental Medicine No. 88. 5. Brazelton TB, Nugent JK. Escala para la evaluación del comportamiento neonatal [Neonatal Behavioral Assessment Scale]. Barcelona, Spain: Paidós; 1997. 6. Lester BM. Data analysis and prediction. In: Brazelton TB. Neonatal Behavioral Assessment Scale. 2nd ed. London, England: Spastics International Medical Publications; 1984:85–96. 7. Costas C, Botet F, Ortolà ME. Comportamiento del neonato de bajo peso nacido a término, según la escala de Brazelton [Behavior of the small-fordate newborn, according to the Brazelton Scale]. Anales Españoles de Pediatría. 1989;1:37–40. 8. Castells M, Domènech E. Estudio de la conducta del recién nacido de peso elevado para la EG: Análisis con la escala de Brazelton [Behavioral study of high weight newborns: Analysis using the Brazelton scale]. Acta Pediátr Española. 1987;45:315–322. 9. Costas C, Castells M, Domènech E. Comparación entre la conducta de recién nacidos de peso elevado y bajo [A comparison of behavior between high and low birth weight newborns]. Acta Pediátr Española. 1988;46:501–506. 10. de Cáceres, ML, Costas C, Botet F, Rosales S. Niveles fisiológicos de bilirrubina y conducta en el período neonatal en recién nacidos normales [Assessment of newborn behavior and serum bilirubin levels]. Anales Españoles de Pediatría. 1991;37:466–468. 11. de Cáceres ML, Botet F, Costas C, Rosales S. Umbilical cord lead levels and neonatal behaviour. Behav Neurol. 1995;8:39–41.

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12. Jirón P, Costas C, Botet F, de Cáceres, ML. Estudio del comportamiento neonatal en el sufrimiento fetal agudo [A study of the effects of fetal distress on neonatal behavior]. Anales Españoles de Pediatría. 1998;48:163–166. 13. Botet F, de Cáceres ML, Rosales S. Costas C. Behavioral assessment of newborns from diabetic mothers. Behav Neurol. 1996;9:1–4. 14. Botet F, Lleonart I, Costas C, Figueras J. Estudio del comportamiento del neonato a término nacido mediante cesárea con analgesia epidural, según la Escala de Brazelton [Study of the behavior of neonates born full term via cesarean section with epidural analgesic, according to the Brazelton scale] [abstract 132]. Revista Latinoamericana de Neonatología. 1999(suppl 2): 13–55. 15. Costas C, Lleonart I, Botet F, de Cáceres ML. Behavior of the newborn premature infant according to the Brazelton scale (NBAS) Infant Ment Health J. 2000;4–5:344.

CHAPTER 5

Supporting Parents of At-Risk Infants: Japan SHOHEI OHGI and TOMITARO AKIYAMA

We have been using the Neonatal Behavioral Assessment Scale (NBAS) for early assessment of infants at high risk for developmental disorders such as cerebral palsy and mental retardation and have found it to be a valuable tool for managing early intervention.1,2 The NBAS is the best instrument we know of for objectively assessing high-risk infants because its fundamental principle is to identify the individual characteristics and capabilities of each infant—information that is extremely useful in planning early intervention.3,4 At the heart of caring for at-risk infants is the necessity of seeing each one as a unique person, with a unique set of personality traits, responses, and behaviors. In assessing infants with cerebral palsy and/or mental retardation, we believe it is more important to find out what they can do (their positive abilities) than to identify what is abnormal. A core principle of our treatment is that appropriate assessment of ability is essential for optimal care. We present here a summary of our work in Japan, as well as the clinical and research implications of what we have learned. P R E D I C T I O N S T U D I E S O F L AT E R D E V E L O P M E N TA L D I S A B I L I T I E S It is important to understand the neonatal neurobehavioral characteristics of at-risk infants in order to formulate appropriate intervention plans for their developmental care. Care plans that center on the neonatal behavioral organization of these infants facilitate 51

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development by enhancing parenting skills, improving parental recognition of their infants’ abilities, and promoting the parentinfant relationship. The NBAS has been widely used for this purpose. When the NBAS examination is administered to assess a behaviorally disorganized, high-risk infant, it can provide information to guide the clinician in planning intervention and can also support both the infant and the family by helping parents recognize and understand their infant’s behavioral characteristics. Neonatal Behavioral Assessment Scale and Later Developmental Disabilities in Low Birthweight Infants From the clinical standpoint, we have analyzed the relationship between NBAS scores and developmental outcomes in low birthweight infants, and find the NBAS to be a useful tool in assessing the risk of future developmental disabilities.5 This study analyzed the relationship between NBAS scores during the neonatal period and developmental outcomes at 5 years of age. It included 209 eligible low birthweight infants. The NBAS assessment was performed three times: at the postmenstrual age of 36 to 38 weeks (preterm), 40 to 42 weeks (term), and 44 to 46 weeks (postterm). The 5-year outcome was assessed using neurological examinations, imaging techniques, intelligence development tests (McCarthy Scales),6 and behavioral problems questionnaires. Developmental outcomes were categorized in three groups: Normal, Mild Disability, and Severe Disability. The Normal group included children with no distinguishable motor, mental, or behavioral problems. The Mild Disability group included children with motor delay and/or slight mental development and/or behavioral problems. The Severe Disability group included those with cerebral palsy and/or mental delay and/ or epilepsy and/or visual-auditory impairment. The NBAS cluster scores at each assessment period were compared among the three groups. Behavioral cluster scores (Habituation, Orientation, Motor, Range of State, State Regulation, Autonomic Stability) were significantly lower, and Reflexes cluster scores were significantly higher in the Mild and Severe Disability groups than in the Normal group. These results suggest that lower scores on the Behavioral clusters, and higher scores on the Reflexes cluster in the neonatal period, are reliable predictors of later developmental disabilities. These results also suggest that, in the neonatal period, infants with developmental disabilities have poorer motor control, less responsiveness to environmental stimuli, less regulatory capacity, poorer state regulation,

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and depressed reflexes, compared to developmentally normal infants. The results of multinomial logistic regression analysis show that at postterm age, the risk of later Mild Disability is more closely related to lower Behavioral cluster scores, such as Motor, Orientation, and State systems; whereas the risk of Severe Disability is strongly associated with neurological abnormality (higher Reflexes cluster scores). Signs of abnormality were more apparent in the Behavioral clusters for the Mild Disability group, while the Reflexes cluster at postterm age was the best predictor of the Severe Disability group. Comparing predictions of developmental outcomes based on the multinomial logistic model with actual outcomes, results show that 94% to 97% of the subjects in the Normal group, 50% to 78% in the Mild Disability group, and 71% to 85% in the Severe Disability group were correctly classified by the model. The overall proportion of correct prediction was highest—reaching 91.7%—at postterm age, suggesting that it is possible to differentiate the Normal group from the Mild or Severe Disability groups with a high degree of accuracy at term age. This high level of accuracy suggests the usefulness of the NBAS as a method for predicting developmental disabilities. Neonatal Behavioral Characteristics and Later Behavioral Problems With a view to developing an early intervention plan for infants at risk of later behavioral problems, the aims of this study were: (a) to evaluate the usefulness of the NBAS as a tool to assess the risk of later behavioral problems; and (b) to carry out an analysis of the relationship between neonatal behavioral characteristics and behavioral problems in childhood.7 Seventy-seven very low birthweight infants made up the final sample. For children 7 to 8 years of age, behavior problems were diagnosed based on the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.)8 and the Strengths and Difficulties Questionnaire (SDQ).9 In comparing NBAS cluster scores of infants with and without later behavioral problems, we found that Orientation, Motor, and State Control cluster scores were significantly lower in those with later behavioral problems than in those without behavioral problems. In other words, infants with later behavioral problems had deficiencies that were identified in their neonatal behavioral developmental systems, as compared to infants without such problems. These results suggest that weak behavioral regulation systems in the neonatal period are predictors of later behavioral problems. The odds ratios estimated by the logistic regression model at selected terms showed that lower Motor, State Control

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(average of the Range of State and State Regulation cluster scores) and Orientation cluster scores were associated with a significantly increased risk of later behavioral problems. The results of this study show that neonatal behavioral characteristics, such as poor motor performance, poor state regulation and poor interaction ability in the neonatal developmental stage are risk factors of behavioral problems in later childhood. In summary, these results suggest that the NBAS, when used serially in the postnatal period, can help clinicians develop a management protocol for infants at risk for later developmental disabilities, as well as identify neonates who are at high risk of later developmental disabilities. E A R LY I N T E RV E N T I O N F O R I N FA N T S A N D M O T H E R S AT R I S K Previous studies of early, family-centered intervention based on the NBAS—for both healthy newborns and premature infants— have shown positive effects on infant-mother interactions and developmental outcomes.3,4,10,11,12,13 This NBAS-based intervention was designed to facilitate the development of infants by enhancing parenting skills and improving parental recognition of infants’ abilities. We believe a family-centered approach based on the NBAS should take precedence over a disabilities-focused approach in the first stage of planning early intervention for at-risk infants. Strategy for Early Intervention Early intervention planning for at-risk infants has conventionally been centered on the infants’ disabilities, rather than on the family’s adjustment. In at-risk groups, it is especially important for parents to be able to adapt their parenting styles based on the infant’s behavioral repertoire and the severity of the infant’s symptoms. Our intervention strategy has two major components (Table 5.1). The first is to facilitate infant-mother interactions using NBAS-based intervention. NBAS-based intervention requires the parent(s) to observe the baby during a demonstration of the NBAS examination. The infant specialist then comments on—and discusses—the baby’s behavior (strengths and weaknesses, attempts at self-regulation) and demonstrates how parents can recognize and support their infant’s coping strategies and respond to their infant in ways that will be developmentally beneficial. The goal is to optimize caregiving interactions by enhancing the mother ’s adjustment to her infant’s

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Table 5.1 The Goal of the Early Intervention Strategy

First Component (NBAS-Based Intervention)

Second Component (Advising a Mother about Care and Developmental Support Program)

1. To enable the mother to appreciate her baby’s specific behavioral characteristics

1. To adapt the immediate physical and sensory environment to her infant’s thresholds (handling, positioning, swaddling, adjusting light and noise levels)

2. To sensitize her to the baby’s cues

2. To modulate the infant’s state modulation

3. To highlight optimal ways of responding to infants’ cues

3. To promote the infant’s feeding ability

4. To share with parents concerns about the baby’s future development

4. To allow the infant to experience normal sensorymotor development (tactile/ kinesthetic stimulation through massage therapy, vestibular stimulation, orientation toward visual-auditory stimulation)

5. To promote a positive collaborative relationship between the clinician and family

5. To promote the development of normal posture and muscle tone while inhibiting abnormal postural reactions (e.g., neurodevelopmental therapy)

behavior. The second component of our intervention strategy is to advise the mother on specific ways to handle her infant based on the child’s abilities and developmental needs. Figure 5.1 summarizes the early intervention program for at-risk infants and their parents. It is performed three to four times, lasts about 30 minutes per session prior to discharge from the NICU, typically taking place at 36 to 40 weeks postmenstrual age. Advising a mother about caring for her infant is begun with rooming in, and then continues at a follow-up clinic, at the rehabilitation unit, and/or with home visits once every week or every other week after discharge. Effects of an Early Intervention Program on Low Birthweight Infants with Cerebral Injuries This study was carried out to determine whether the Early Intervention Program (EIP, described in the previous section) effectively

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Contemporary Research and Practice

NICU

Hospital

Home

Rooming-in

Follow–up clinic rehabilitation unit home visiting

Discharge

NBAS-based intervention Advising a mother about care Developmental support program

Figure 5.1 Early Intervention Program (EIP) for Infants and Their Parents.

promotes maternal mental health as well as the developmental progress of low birthweight infants with cerebral injuries.14 Subjects were 23 high-risk, low birthweight infants (15 with preventricular leukomalacia, 5 with intraventricular hemorrhage, and 3 with both). Subjects were randomly assigned, 12 to the EIP group, and 11 to the control group. Participants in the EIP group received an NBAS-based intervention combined with developmental support designed to enhance the infants’ development and the quality of the parent-infant relationship. The control group received routine medical-nursing care without the EIP. The EIP began prior to discharge from the NICU and lasted until 6 months of corrected age. All children were examined using the NBAS preintervention and again at 44 weeks postmenstrual age. Maternal anxiety status (State-Trait Anxiety Inventory [STAI])15 and maternal feelings of confidence in dealing with her baby (Lack of Confidence in Caregiving [LCC] items of the Mother and Baby Scale)16 were measured pre- and postintervention. Mental and motor development were assessed postintervention using the Bayley Scale of Infant Development.17 Orientation and State Regulation behavioral profiles, as well as the STAI and LCC scores, significantly improved in the EIP group, but not in the control group. The Bayley Mental Development Index (MDI) score in the EIP group was higher than

Supporting Parents of At-Risk Infants: Japan

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in the control group, but there was no statistically significant difference between the two groups. Overall, then, our results indicated that the EIP had beneficial effects on neonatal neurobehavioral development and maternal mental health of low birthweight infants with cerebral injuries. This evidence suggests that shortterm changes in maternal mental health and infant neurobehavior promoted by an EIP may serve to initiate a positive interaction between parents and infants. NBAS-Based Intervention for Infants with Developmental Disabilities We studied infants with developmental disabilities and their mothers in order to investigate the effectiveness of the same NBAS-based intervention described in the previous section, to enhance infant neurobehavioral organization, maternal self-efficacy, and motherinfant interaction.18 A time-series study design was used, with the intervention trial consisting of a 2-week observation at baseline, which was followed by the NBAS-based intervention. The study was designed to examine the efficacy of the NBAS-based intervention on infants’ neurobehavior, on maternal self-efficacy, and on mother-infant interaction. Study subjects consisted of 13 infants with disabilities (6 with cystic periventricular leukomalacia, 3 with chromosomal anomaly, 1 with birth asphyxia, 1 with holoprosencephaly, 1 with congenital multiple arthrogryposis, 1 with RussellSilver syndrome) and their mothers. The NBAS, LCC, and the Nursing Child Assessment Teaching Scale (NCATS)19 were used to assess neonatal neurobehavior, maternal self-efficacy, and the quality of mother-infant interaction, respectively, at three time points: at intake, preintervention, and postintervention. The NBAS-based intervention consisted of parental observation of the NBAS exam conducted by the infant specialist, followed by discussion of the infant’s behavioral characteristics, and demonstration of intervention strategies to attune mothers to their infants’ behaviors. Intervention sessions were held six to eight times, 30 minutes per session, during the intervention period. Results showed that the NBAS Orientation and State Regulation cluster scores, the LCC score, and the NCATS Caregiver Total and Subscale scores (Sensitivity to Cues and Social-Emotional Growth Fostering) were significantly improved postintervention. This study suggests that the NBAS-based intervention has beneficial effects on neonatal neurobehavioral organization of infants with developmental disabilities and on the quality of mother-infant interaction skills and maternal self-efficacy

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in caring for such infants. The study also shows that attunement of mothers to their infants’ behaviors early in life may promote a positive cycle of interaction between parents and infants. CONCLUSION Our studies provide strong evidence that the NBAS is a reliable tool for predicting later developmental disabilities in low birthweight and premature infants. Further, we found that, when used serially in the postnatal period, the NBAS can help clinicians not only to identify neonates who are at high risk of behavioral problems in childhood, but also to develop individualized management protocols for infants at risk for later developmental disabilities. REFERENCES 1. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale [CDM No 137]. 3rd ed. Cambridge, MA: Cambridge University Press; 1995. 2. Nugent JK. Research use of the NBAS. In: Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale [CD-ROM No 137]. 3rd ed. Cambridge, MA: Cambridge University Press; 1995:67–83. 3. Nugent JK. The Brazelton Neonatal Behavioral Assessment Scale: Implications for intervention. J Pediatr Nurs. 1981;3:18–21, 67. 4. Nugent, JK, Brazelton TB. Preventive mental health. In: Osofsky J, Fitzgerald H, eds. The Handbook of Infant Mental Health. Vol 2. New York, NY: John Wiley & Sons Inc; 2000:159-202. 5. Ohgi S, Arisawa K, Takahashi T, et al. Neonatal Behavioral Assessment Scale as a predictor of later developmental disabilities of low birth weight and/or premature infants. Brain Dev. 2003;25:313–321. 6. McCarthy D. McCarthy Scales of Children’s Abilities. New York, NY: Psychological Corp; 1990. 7. Ohgi S, Takahashi T, Nugent JK, Arisawa K, Akiyama T. Neonatal behavioral characteristics and later behavioral problems. Clin Pediatr. 2003:42;679–686. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994. 9. Goodman R. The strengths and difficulties questionnaire: A research note. J Child Psychol Psychiatry. 1997;38:581–586. 10. Widmayer SM, Field TM. Effects of Brazelton demonstrations for mothers on the development of preterm infants. Pediatrics. 1981:67(5):711–714. 11. Rauh VA, Achenbach TM, Nurcombe B, Howell CT, Teti DM. Minimizing adverse effects of low birth weight: Four-year results of an early intervention program. Child Dev. 1988;59(3):544–553.

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12. Beeghly M, Brazelton TB, Flannery KA, Nugent JK, Barrett DE, Tronick EZ. Specificity of preventative pediatric intervention effects in early infancy. J Dev Behav Pediatr. 1995;16(3):158–166. 13. Hart S, Field T, Nearing G. Depressed mothers’ neonates improve following the MABI and a Brazelton demonstration. J Pediatr Psychol. 1998;23(6):351–356. 14. Ohgi S, Akiyama T, Fukuda M, Kusumoto T. Randomized controlled trial of an early intervention on low birth weight infants with or at risk for cerebral injuries. J Paediatr Child Health. 2004;40:689–695. 15. Spielberg CD, Gorsuch RL, Lushene RE. STAI Manual. Palo Alto, CA: Consulting Psychologist Press;1970:23–49. 16. Wolke D, St James-Roberts, I. Multi-method measurement of the early parent-infant system with easy and difficult newborns. In: Rauh H, Steinhausen HC, eds. Psychobiology and Early Development. Amsterdam, Netherlands: North-Holland/Elsevier; 1987:49–70. 17. Bayley N. Manual for the Bayley Scales of Infant Development. New York, NY: Psychological Corp; 1969. 18. Ohgi S, Gima H, Akiyama T, Loo, KK. NBAS-based intervention for infants with developmental disabilities: Its short-term effects on infant neurobehavior, maternal self-efficacy, and mother-infant interaction. In: Proceedings of the Pediatric Academic Societies’ Annual Meeting; May 14–17, 2005; Washington, DC. 19. Barnard, K. NCAST Caregiver/parent-child interaction teaching manual. Seattle: NCAST Publications, University of Washington, School of Nursing; 1994.

CHAPTER 6

The Cultural Context of the Mother-Infant Relationship: Korea YEONGHEE SHIN and BYUNGHI PARK

Considering how little of the literature on Korean practices of childbearing and childrearing is known to Western society, it seems appropriate to begin with a historical perspective. There are three major influences affecting pregnancy, birth, and neonatal care in Korea—shamanistic beliefs, ancient Chinese philosophy, and Western medical philosophy. Theories and practices of Chinese medical arts heavily influenced ancient Korean culture. Among these are acupuncture and chi theory yin-yang theory and the arts of medicine, numerology, and astrology. These became a part of Korean heritage and remain so today in the form of several research institutes and schools of oriental medicine. In 1884, the North American Presbyterian Church sent medical missionaries to establish a hospital and medical school in Seoul; this was the beginning of Western medical practice in Korea.1 From 1910 to 1945, Korea survived 36 years of annexation to Japan, and after that, two devastating wars in succession—World War II and the Korean War. In the decades since, Korea has been reborn as a technological society. Yet, ancient folk beliefs and traditions toward pregnancy, birth, and postpartum practices were retained until well into the 1980s.2 Traditional cultural practices related to childbearing and childrearing that are unique to Korea included Tae Mong (a conception dream), Tae Kyo (a set of rules for safe childbirth), and instructions for postpartum-newborn care and breastfeeding.2 Ancient Koreans believed in Tae Mong, a dream in which a woman would see various 60

The Cultural Context of the Mother-Infant Relationship: Korea

61

images before conceiving. The oldest Tae Mong story was recorded during the Three Dynasty period—Kokuryo (20 bc to ad 668), Baekjae (19 bc to ad 660), and Silla (57 bc to ad 935). According to this story, a man prayed to Buddha for a son whom he pledged to dedicate to a temple. After his pious prayer, his wife had a dream in which “a star had fallen from the sky and into her arms.” Later, she had a son who became a famous monk in ancient Korea. There is a similar legend about Genghis Kahn. His mother had a Tae Mong in which she saw “the sun had fallen from the sky into her womb.” Many Korean women respect Tae Mong and practice the Tae Kyo ritual for pregnancy. Tae Kyo (the literal translation is “fetal education”) is a set of rules for safe childbirth, most of which are derived from ancient Chinese medical philosophy; however, some may have derived from Buddhism or shamanism. Tae Kyo is meant to maintain physical, as well as mental, well-being during pregnancy in order to protect the fetus. The pregnant woman has to meticulously observe various taboos, such as avoid killing any living creature and avoid having contact with anything considered unclean. As parturition approaches, even more taboos are imposed on the woman and her family. The pregnant woman must avoid sexual intercourse and must not consume any sacrificial food; and no type of repair or construction on the home where she lives is allowed. The belief is that if these taboos are broken, an easy and safe childbirth may not be assured, the fetus may contract a disease or be born retarded, or a stillbirth may result. Some of these taboos have a rationale in terms of contemporary Western medical concepts. Today, Korean woman observe Tae Kyo with varying degrees of strictness. Part of current Tae Kyo practice includes reading classical literature, appreciating art objects, and keeping a serene and optimistic attitude during pregnancy. In former times, when all Tae Kyo traditions were strictly followed, males and childless women were not allowed to be in the room during labor and delivery. After childbirth, the new mother typically would eat seaweed soup and rice. Any food other than seaweed soup was believed to be harmful for the new mother. A sound basis for this tradition is probably the fact that seaweed soup supplements salts (Na, K, Cl, Ca, Mg, and I), as well as the water lost during labor; and replacing these helps prepare the new mother ’s body for lactation. Cold beverages were absolutely forbidden because they were thought to harm the mother ’s teeth. No household members except those responsible for the care of the mother and the infant were allowed to enter the birth chamber for 7 days, and both mother and infant were usually confined to bed for from

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3 to 21 days after birth. Any members of the family who had traveled before the infant was born were not permitted to enter the new mother ’s room until 21 days postpartum. This rule seems to be equivalent to the concept of quarantine. Traditionally, mothers were always encouraged to begin breastfeeding as early as possible because early lactation was known to be critical for the safety and survival of the infant. However, the rate of breastfeeding in Korea has declined steadily since the 1980s. By the early 1990s, only one in four mothers breastfed their babies.3 Even worse, by the year 2000, particularly among highly educated middleclass women, even fewer women were breastfeeding their infants.4,5 The decline of breastfeeding has been attributed to a number of factors: the industrialization of Korea, the improvement of women’s social status, the migration of the population into metropolitan areas, and the shift away from the extended family structure, leaving young mothers isolated and more independent in their small nuclear families. Without the kind of social support that used to exist, far fewer young women breastfeed. Despite the campaigns of both nurses’ and physicians’ academic societies, the trend away from breastfeeding is difficult to reverse. Historically, the merits of breastfeeding have been appreciated in Korea—not only the immunological benefits but also the emotional benefits of the interaction between mother and infant. In 1995, Elizabeth Chong Choi lamented the fact that the influence of Western medicine has altered traditional perinatal care practice in Korea, to the detriment of both infants’ and mothers’ well-being.2

E VA L U AT I N G N E W B O R N S W I T H N B A S A N D OTHER SCALES The mother-infant dyad is the primary relationship on which all other social relationships are built. The nature and importance of mother-infant interaction, therefore, has been studied extensively. In particular, the work of both Bowlby and Ainsworth has inspired and greatly influenced subsequent researchers. This dyadic motherinfant relationship apparently starts long before the birth. Recent evidence from basic research shows that the fetus remembers the mother ’s voice (the fetus responds to sounds as early as 22 to 24 weeks in utero), and newborns demonstrate a remarkable ability to recognize their mothers’ faces shortly after birth.6 Even before these basic research results were reported, Brazelton, in his seminal work, recognized the neonate’s role in the mother-infant relationship.7

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Behavioral studies of Korean newborns and mother-infant interactions are relatively few. In 2004, Shin and colleagues conducted a study of Korean newborns by examining a sample of 50 full-term newborns using the Neonatal Behavioral Assessment Scale (NBAS).8 We found that overall similarities with other behavioral investigations suggested both universal and culture-specific characteristics of Korean newborns.9,10 As shown in Table 6.1, our findings reinforced the overall profile of Korean neonates as having moderate levels of ability in shutting out disturbing stimuli and in responding to social stimulation; they also showed high levels of ability in State Organization, State Regulation, and Autonomic Stability. We found that Korean newborns appeared less skilled in shutting out disturbing stimuli and in taking part in social interaction than other study groups including Indonesian,11 CaucasianAmerican,12 and Swedish neonates.13 As for the State organization and State Regulation clusters, Korean neonates did not demonstrate hyper- or hypoactive responses to stimulation. Their responses to disturbing stimuli were tolerant, rarely reaching a crying state. This suggests that Korean newborns are agreeable and manageable, which may make them easier to care for, a characteristic that may, in turn, promote attachment. Performance on Motor, State Organization, State Regulation, and Autonomic stability clusters was similar to, or even better than, those of other cultural groups, for which we have comparable data.11,12,13 Another notable finding was that a significant number of Korean newborns showed poor walking and standing reflexes. Notable, too, was the fact that newborns whose mothers worked during pregnancy showed significantly higher scores on Social Interactive scores. It is likely that these working mothers had more active lives, both mentally and socially, during their pregnancies than nonworking mothers. Thus, the mothers’ active lifestyles may have affected neonatal behavior performance. In 2003, Shin and colleagues conducted a pilot research project in which a group of orphaned infants were screened for physical abnormalities using the NBAS.14 Although these infants were free of any physical defects, we observed that their facial expressions were blank and lacked emotion. We decided to study the effects of daily multiple-sensory stimulation (auditory, visual, tactile, and vestibular) on their development. Within only 4 weeks, we found the faces of infants in this intervention group to be bright, with responsive smiles. Furthermore, when compared to the control group at 1 and 6 months, the intervention group showed significantly higher weight gain, an increase of head circumference, and

64

Contemporary Research and Practice Table 6.1 Korean Infants’ Behavioral Responses

Cluster/Items

Mean

SD

Range

Response decrement

4.87

1.03

Light

5.19

1.69

3–9

Rattle

5.26

1.72

1–9

Bell

6.50

1.82

3–9

Foot

3.15

1.34

1–5

Social interactive

5.34

1.40

Animate visual

4.76

2.00

1–8

Animate visual and auditory

5.95

1.81

1–9

Inaminate visual

5.70

2.29

1–9

Inanimate visual and auditory

5.84

1.70

1–8

Animate auditory

5.62

1.63

2–8

Inanimate auditory

4.81

1.43

2–8

Alertness

4.76

1.65

1–8

Motor system

4.90

.66

General tone

5.34

.91

3–6

Motor maturity

4.32

1.63

2–9

Pull to sit

5.84

1.54

2–8

Defensive movement

5.28

1.81

2–9

Activity level

4.12

.68

3–5

State organization

3.86

.49

Peak of excitement

3.64

.66

2–5

Rapidity of buildup

3.38

1.15

1–6

Irritability

4.74

1.35

2–6

Lability of state

3.70

.78

2–5

State regulation

5.60

.87

Cuddliness

4.84

1.01

3–6

Consolability

5.69

1.45

3–9

Self-quieting

5.62

1.61

2–9

Hand-to-mouth

6.62

1.49

2–9

Autonomic stability

5.83

.87

Tremulousness

8.40

1.14

5–9

Startles

5.56

1.68

2–8

Lability of skin color

3.52

.61

3–6

The Cultural Context of the Mother-Infant Relationship: Korea

65

fewer illnesses and hospital visits. In summary, we found that the multiple-sensory stimulation and human contact provided by a caregiver on a daily basis seemed helpful for the development of orphaned newborns, perhaps compensating, on some basic level, for the lack of a mother. Korean investigators have observed mother-infant interactions in several different studies. In 2003, Seon-Ah Lee and Shin educated primipara mothers about their infants’ behavioral characteristics by demonstrating the NBAS and subsequently measured the effects on the mother-infant play interaction using the scale developed by Walker and colleagues.9,15 As shown in Table 6.2, there was a significant difference between the scores of the intervention and control groups on the measure of mother-child interaction, with the intervention mothers scoring higher on the overall quality of their interactions with their infants. Similar results had been reported in earlier studies.8,16 Our investigation further showed that when maternal education was factored in, the demonstration of the NBAS improved not just mother-infant interaction but infant behavior, too: The behavioral scores of the infants in the intervention group were significantly higher than those of the infants in the control group in specific behavioral domains.9 Social Interaction and State Regulation scores of intervention group were significantly higher than those of the control group. The Habituation score was also higher, but not to a degree that was statistically significant. Overall, our study results are consistent with the results earlier reported by Hae-Kyung Lim.8 Therefore, we concluded that inexperienced young mothers and their children benefit significantly from an NBAS-based maternal education program. CONTRIBUTION OF THE NBAS TO KOREAN MOTHERS AND CHILDREN In October of 1997, Dr. Brazelton and Dr. Kevin Nugent made their first visit to Keimyung University at the invitation of President Synn and held the first Brazelton conference and NBAS workshop in Daegu, Korea. Similar conferences held subsequently, along with the translation of the NBAS manual into Korean 17 elicited considerable interest in neonatal behavioral research among nurse researchers. However, many nurses and physicians found that the NBAS required too much delicate handling of newborn babies, to the point where it was not easy to complete the examination reliably in a short time period without very good skills. Nevertheless, despite the extra time and effort that the NBAS requires, we have found that the

66

Contemporary Research and Practice Table 6.2 Mother-Infant Interaction Scores after Intervention

Interaction

Intervention Mean (SD)

Control Mean (SD)

Tt

Pp

Mother response Holding style

4.12 (0.44)

4.00 (0.58)

0.82

.413

Expression of affect

4.00 (0.29)

3.75 (0.73)

1.54

.133

Expression of affecta

4.33 (0.56)

3.91 (0.50)

2.69

.010*

Caregiving style

3.70 (0.85)

3.50 (0.65)

0.94

.351

Visual interaction

4.50 (0.51)

3.96 (0.62)

3.29

.002

Style of play interaction

4.04 (0.55)

3.79 (0.41)

1.77

.082

Vocalization style (general tone and content)

4.16 (0.76)

3.95 (0.62)

1.03

.306

Vocalization stylea

4.00 (0.93)

3.45 (0.72)

2.25

.029*

Attempts at smile elicitation

3.04 (1.04)

2.25 (1.03)

2.64

.011*

Kinesthetic quality of interaction

3.88 (0.53)

3.46 (0.59)

2.56

.014*

39.79 (3.97)

36.04 (2.62)

3.85

.000**

Predominant response level

4.17 (0.70)

3.96 (0.75)

0.99

.325

Predominant mood/affect

3.79 (0.88)

3.58 (0.71)

0.89

.374

Visual interaction

4.21 (0.59)

3.63 (0.57)

3.47

.001**

12.16 (1.71)

11.16 (1.66)

2.05

.045

Overall dyadic quality of interaction

4.13 (0.79)

3.41 (0.50)

3.91

.001*

Synchrony of affect

3.70 (0.85)

3.29 (0.46)

2.09

.043*

Subtotal (max score 10)

7.83 (1.49)

6.71 (0.85)

3.19

.003**

59.79 (6.63)

53.91 (3.88)

3.74

.001**

Subtotal (max score 50) Infant response

Subtotal (max score 15) Mother-infant synchrony response

Total (max score 75)

*p ⬍ .05;**p ⬍ .01. a Quantity of contingency to infant.

The Cultural Context of the Mother-Infant Relationship: Korea

67

NBAS can be effective in identifying any abnormalities or behavioral problems that have been overlooked prior to discharge. Therefore, this exam may be the best simple and cost-effective screening method available in a variety of clinical settings. Industrialization-induced population drift to urban areas, an increase of women’s employment, and improvement in women’s status have all contributed to an erosion of traditional cultural practices related to childbearing and childrearing in Korea. A young couple in their own small nuclear family does not have anyone to bother them with anachronistic preaching. By the same token, they also have no one to advise them about breastfeeding or newborn care. Bottle-feeding in Korea is now at its highest recorded level. In the past several years, education related to pregnancy, labor, and delivery has been left primarily to nurses, physicians, and other experts in the field, with family members playing a less important role in advising and guiding new parents. In addition, many informational resources such as books and pamphlets are available. We are not suggesting that the age of technology is necessarily a bad thing. Educational television channels and Internet sites (such as www.momilk. co.kr) provide helpful information and a variety of good programs; some of these discuss Tae Mong, Tae Kyo, and a variety of ancient traditions, as well as providing up-to-date medical information. We believe that the education of expectant mothers or primiparas through the NBAS is an ideal way of increasing each mother ’s sensitivity to understanding her baby’s cues. This sensitivity may, in turn, enhance physical and emotional bonding between mothers and their newborns. In addition, we have found that the NBAS can be a wonderful tool for identifying developmental disabilities among premature infants, institutionalized infants, or infants from families with low socioeconomic status. Early intervention with NBAS for high-risk babies offers significant benefits. A large and consistent body of research proves the efficacy of this kind of early intervention.18,19,20,21

REFERENCES 1. Hwang SI. A biographical history of medicine: Horace Allen, MD, the first Presbyterian missionary in Korea. Seoul Korea: Ryo Moon Gak Publishing Co; 2004:333-336. 2. Choi EC. Unique aspects of Korean-American mothers. J Obstet Gynecol Neonatal Nurs. 1986;15:394–440. 3. Kim HZ, Park, YS. A survey of infant feeding practices in Seoul. Korean Soc Nurs Sci. 1993;23:377–396.

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4. Windsor JE. Korean women and breastfeeding. Assoc Womens Health, Obstet Neonatal Nurses Lifelines. 2003;7:61–64. 5. http://www.momilk.co.kr [website operated by the Korean Association for the Promotion of Breastfeeding]. Accessed Feb 11, 2005. 6. Hepper P. Prenatal development. In: Slater A, Lewis M, eds. Introduction to Infant Development. Oxford, England: Oxford University Press; 2002:39–60. 7. Brazelton, TB. Psychophysiologic reactions in the neonate: The value of the observation of the neonate. J Pediatr. 1961;58(pt 1):508–152. 8. Shin Y, Bozzette M, Kanner C Kim TI. Evaluation of Korean newborns with the Brazelton Neonatal Behavioral Assessment scale. J Obstet Gynecol Neonatal Nurs. 2004;33(5):589–596. 9. Lim H. Effects of Demonstration of Neonatal Behavioral Assessment on Reciprocity between Mother and Infant [dissertation]. Seoul, Korea: Yonsei University.1999. 10. Shin Y, Lee SA. Effects of maternal education using Brazelton Neonatal Behavioral Assessment Scale on the mother-infant interaction and infant behavior. Korean Acad Child Health Nurs. 2003;9(1):74–84. 11. Piessens, PW. Newborn behavior and development in Indonesia. In Nugent JK, Lester, BM, Brazelton, TB, eds. The Cultural Context of Infancy. Vol 2. Norwood, NJ: Ablex Publishing Co; 1991:271–298. 12. Als, H, Tronick, E, Lester, BM, Brazelton TB. Specific neonatal measures: The Brazelton Neonatal Behavioral Assessment Scale. In: Osofsky JD, ed. Handbook of Infant Development. New York, NY: John Wiley & Sons Inc; 1979:185–215. 13. Welles-Nystrom BL. The mature primipara and her infant in Sweden: A life course study. In: Nugent JK, Lester, BM, Brazelton, TB, eds. The Cultural Context of Infancy. Vol 2. Norwood, NJ: Ablex Publishing Co, 1991:145–168. 14. Kim TI, Shin Y, White-Traut RC. Multi-sensory intervention improves physical growth and illness rates in Korean orphaned newborn infants. Res Nurs Health. 2003;26(6):424–433. 15. Walker, LO. Neonatal perception inventories. In: Humenick SS, ed. Analysis of Current Assessment Strategies in the Health Care of Young Children and Childbearing Families. Norwalk, CT: Appleton-Century-Crofts; 1982:161–170. 16. Kim, TI. Primiparous Mothers’ Perceptions of Their Infants, Childrearing Attitudes and Mother-Infant Interactions during Early Feeding Experiences [dissertation]. Seoul, Korea: Ewha Woman’s University. 1992. 17. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. 3rd. ed. Shin Y, Park B, Kim C. trans. Daegu, Korea: Keimyung University Press; 1999. 18. Carnegie Task Force on Meeting the Needs of Young Children. Starting Points: Meeting the Needs of Our Youngest Children. New York, NY: Carnegie Corp; 1994.

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19. Ramey CT, Ramey SL. Early intervention and early experience. Am Psychol. 1998;53:109–120. 20. Ramey CT, Ramey SL. Right from Birth: Building Your Child’s Foundation for Life. New York, NY: Goddard Press; 1999. 21. Ramey CT, Ramey SL. Early educational intervention with disadvantaged children: To what effect? J Appl Prev Psychol. 2001;1(3):131–140.

ADDITIONAL REFERENCES Ainsworth MD, Blehar MC, Waters E, Wall S. Patterns of Attachment. Hillsdale, NJ: Lawrence Erlbaum; 1978. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. 3rd ed. London, England: MacKeith Press; 1995. Choi, EC. Unique aspects of Korean-American mothers. J Obstet Gynecol Neonatal Nurs. 1984;15:394–400. Kim KH, Lee G, Kim CH, et al. The survey of breastfeeding in Korean infants. J Korean Pediatr. 1985; 28:8–12. Lee SA, Shin Y, Kim TI. Effects of prenatal education using NBAS on maternal perception of their infants. J Parent-Child Health. 2003;6(1):46–58. Lester BM, Brazelton TB. Cross-cultural assessment of neonatal behavior. In: Wagner DA, Stephenson HW, eds. Cultural Perspectives on Child Development. San Francisco, CA: WH Freeman; 1982:20–53. Nugent JK, Brazelton, TB. Preventive infant mental health: Uses of the Brazelton scale. In: Osofsky JD, Fitzgerald HE, eds. WAIMH Handbook of Infant Mental Health. New York, NY: John Wiley & Sons Inc; 1999:159–202.

CHAPTER 7

Moments of Meeting: Pivotal Moments in Mother, Infant, Father Bonding: Switzerland NADIA BRUSCHWEILER-STERN

This chapter addresses the therapeutic effect of neonatal intervention with the Neonatal Behavioral Assessment Scale (NBAS) and, more specifically, very particular moments of the consultation known as “moments of meeting.”1,2 A moment of meeting is a moment of change in the relational process, as described in the work of the Boston Change Process Study Group (BCPSG) when studying the therapeutic process.3,4,5 The focus here will be on moments of meeting between mother and infant, moments which, in our Western societies, typically occur during the first days or weeks of life. I see them as a sign of recognition between the partners that jumps the relationship and their attachment to a higher level and as an important step in establishing the new family triad.

NOW MOMENTS—MOMENTS OF MEETING In a relationship, a tension is generated when an unpredictable event arises that disturbs the current equilibrium. This creates a “now moment.”(NM). Attention is drawn to the present. How will I deal with this situation? What do I do? Fight? Flee? Or freeze? This is a moment of change. Right before a change, the elements of the old equilibrium are not steady anymore; they are volatile and can easily go wrong. 70

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To best relieve this tension, it is necessary to have a moment of meeting. Such moments have the potential not only to reequilibrate the relationship, but to jump it to a higher level. Birth is such a crisis, since the arrival of a baby upsets the previous equilibrium and, as a result, natural tensions arise for mother, baby, and father. A moment of meeting among them resolves these tensions and moves them to a new state. What I am addressing here are tiny instants on the order of seconds.1,6 It is at this microlevel that life is lived and gets inscribed intimately as a whole in the body and in the mind at once. Whether a meeting is achieved can be the beginning of a spiral—either positive or negative—that may become a characteristic pattern of the relationship. N AT U R E O F T E N S I O N S I N M O T H E R , B A B Y, A N D FAT H E R For the mother, two essential elements of the Motherhood Constellation are at play.7,8,9,10 First is the new and permanent sense of responsibility for ensuring the survival, the growth, and the wellbeing of her baby. A mother asks herself questions such as: How will I know when he hungry? Or when he has had enough? Why does he cry? What does he need? Is he in pain? When do I take him to the doctor? Second is the need to establish unique ties of attachment and love with her baby: Will I be able to love him? Will he love me in return? Will I be able to connect with him? Will I feel he is my own? These questions preoccupy new mothers. Accordingly, they will experience a certain level of alertness, vigilance, and anxiety that reflects their emotional investment in the baby. On the baby’s side, the newborn seems to have an impulse and a disposition to connect with his mother, to get to know her, to make her a coherent and familiar other. He is equipped to be interested in and oriented toward her: • He began this work in utero. He has already learned the sound of her voice, the distinctive cadence of her way of speaking, as well as her taste and odor, so that when he is born, he can immediately recognize her as familiar. • When he hears his mother ’s voice, he will mobilize himself to visually find the source of this familiar sound. • His visual system is built to best see things that occur at a short distance away, where most mothering activity takes place.

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His mother will naturally be in his field of vision. In this way, he learns to associate the voice, which he already knows, with a face, a touch, and a rhythm of motion. • The maternal voice is particularly stimulating for the baby. He emerges from his drowsiness, searches to discover where the sound comes from, tones his body up, turns his head, and seeks the voice until his gaze finds the eyes of his mother. • The click of a mutual gaze between baby and mother is a moment of meeting, a sign of recognition that changes the inner and interpersonal states of both. As far as the father is concerned, although he has initiated the future life and is co-responsible for it, he remains a spectator—a witness to the pregnancy and delivery. He may be more or less active and involved in the events surrounding birth, depending on circumstances, his choice, and his culture. Regardless, the jump into his new role as a father can feel surrealistic and scary. As he faces a continuation of his life in the life of this child, which he will have to help raise, he finds himself in charge of the security of the family nest. He needs to be gainfully employed. He must also find his place in the family triad, where suddenly he seems less important because the mother-baby axis has become predominant. He must remain available to participate without taking the mother ’s place and must develop his own tie with the baby, regulate their contacts with the surrounding world, and become a solid and stable base while his wife undergoes the highs and lows that result from the physical, hormonal, and emotional effects of becoming a mother. These paternal tasks require a good deal of flexibility, a certain understanding of what the mother is going through, and good communication between the partners. Because they are so complex and important, the early processes of triadic interactions are an active area of study.11

B E G I N N I N G M AT E R N A L B O N D I N G Maternal attachment and bonding does not start at birth, but well before. From a psychological point of view, the attachment system is being prepared before and during the pregnancy by the mother ’s imaginary exploration of her child-to-be and his place in the family. At the moment of birth, the mother usually progresses through certain steps. Observing situations where these steps could not be

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fully lived through and resolved has taught me the most about their importance. Three of these steps are as follows: 1. Survival of the baby emerges as the mother ’s first preoccupation. Accordingly, at the moment her baby is born, she first needs to make sure he is alive. She needs to make him her own, at an animal level—to physically experience the weight of his little body on hers, its smell, its texture, to feel him warm and well, alive on her. It is the end point of the delivery. The mothers of preterm babies have the same urge to have their babies in their arms. In the recent past, they had to wait for weeks for that moment, which brings such a huge relief that for many mothers that is the moment when he is finally born. 2. Then, the mother needs to know that everything is fine, that her baby is anatomically intact and in good health. Seeing her newborn naked—looking at the face, the genitals, the back, counting the fingers—and assessing the physical status of the baby answers her questions and meets this essential need. 3. Once she has been reassured that the baby is normal and healthy, the mother wants to make the baby her own. She seeks to meet this new member of the family as a person in the continuity of her and her husband’s families. She will search to appropriate him through physical resemblances (“He has his father ’s forehead and eyes, but he has my mouth!”) and through behavioral similarities (“When he is hungry, you’ve got to be there right away! He is demanding like my father,” or “He sleeps a lot. In my family, we are all great sleepers.”). These steps seem to free the mother to invest in her child. However, this is not yet a relationship.

C O N S U LTAT I O N U S I N G T H E N B A S 1 2 During my consultations using the NBAS, I aim to release the tensions described earlier and foster the establishment of a relationship by promoting moments of meeting where the baby will become a real interlocutor (see Figure 7.1).12 The parents are my first interlocutors (a); in their presence, the baby will be my next interlocutor (b); and then in my presence, the parents will discover the baby as an interlocutor for both of them (c).

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T

P

T

P

T

P

B

M

B

M

B

M

(a)

(b)

(c)

Figure 7.1 Axes of Interaction.

I try to create a protective environment for the parents that is open and spontaneous enough to let them feel free to ask their questions and let their emotions flow. I begin by listening to them narrate their respective experiences of the pregnancy and delivery. Sharing the emotional and practical details of their experience helps establish a trusting relationship between them and me. I also listen to their description of their baby as they see him. Only then do I invite them to see with me what their infant has to tell us about himself. I get closer to the baby and explain what I will do with him as I begin to administer the NBAS. The behavior of the infant as he interacts with me, as well as the parents’ reactions, will guide the unfolding of the consultation. I aim for the discovery of the baby at this moment, paying peripheral attention to the parents’ reactions and their interaction. So my dialogue with them goes on during the NBAS examination. This early intervention can create moments of meeting that promote or strengthen the bonding process among mother and infant and father.

Clinical Examples Bianca and Her Mother Bianca was filmed with her mother for a television program about the newborn competencies revealed through the NBAS. Unfortunately, the father couldn’t be there. The mother hadn’t asked for a consultation; this is the reason why I am not engaging with her as fully as I usually do in a consultation setting. Bianca is a 4-day-old, full-term baby, awake and alert. She follows my voice as I am talking to her, all the way from one side to the other. At some point, the camera lens comes into her line

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of vision and captures her gaze. Her mother and I talk about this, and I resume the exam, offering Bianca the red ball to follow. The mother murmurs, “Incredible! It is incredible!” She pauses, then adds, “How wonderful!” Next, I present my face to Bianca and she follows my face as I move it slowly. “Do you see how attentive she is?” I ask, and we join in admiring Bianca’s capacity, so early in life, to maintain her attention and to follow with such harmony. Her mother comments. Bianca hears her mother, and she turns right toward her. I explain this reaction: “Notice how your voice has stimulated her. Did you see how she looked past my face to find you? She reacted to your voice.” Bianca’s mother listens to me, looks at her daughter, totally in love, and starts talking to her, “Bianca, are you listening to me, my little one? Are you listening to Mommy?” “Had you noticed before that she would turn toward you when hearing your voice?” I ask. “When I am talking, even if she is lying down like this, she looks at me,” the mother answers. Once again, Bianca turns her head toward her mother. Bianca’s attention, senses, and body all turn toward her mother. “Look! She is turning toward you,” I point out. “Yes. Yes. Yes. She turns to my husband, too. She stares at him,” the mother tells me. There is silence as mother and child gaze at one another. After a few seconds during which the mother is immersed in her baby’s eyes, she says, “It’s Mommy, my angel. He-ey!” There is silence, until I speak. “She is wonderful,” I say. The moment of meeting occurs when the mother realizes that her baby’s behavior is specifically aimed toward her. This literally changes the mother. It would be interesting to see brain imaging of these particular moments. This change in the mother translates into the fact that she goes from commenting about the baby from the outside, as an observer (“It is incredible! How wonderful!”), to speaking directly to her baby, as a partner in their exchange (“Bianca, are you listening to me, my little one? Are you listening to Mommy?”), even introducing herself to the baby as her mother.

Lucas and His Parents Lucas was born following an uncomplicated pregnancy and birth. Soon after the birth, his parents discovered that their baby had a minor deformation of one foot; it was turned to the outside (in a valgus position). This discovery was a shock and killed their joy in having a son who was otherwise in good health. His deformed foot was all they could see. During the Orientation interaction of the NBAS, Lucas showed a capacity to maintain a prolonged alert state and a strong attraction to the face, which he followed attentively from left to right, and up and down. When his mother expressed the realization that he could see, (Continued )

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Lucas immediately oriented his gaze toward her and repeated this behavior an instant later. These responses elicited intense emotion in his mother, who took him in her arms and looked at him as if she had never realized until that moment that, behind his deformed foot, there was a little guy eager for her attention and her care. Another moment of meeting. This situation illustrates the unfolding of the attachment process along the steps described earlier. The discovery of an imperfect baby stopped the attachment process in its tracks. The parents were paralyzed. Having discovered that their infant was alive, the discovery of a baby who was not totally intact froze the unfolding of the attachment process (fight, flight, or freeze). The question of the utility of such a defense in the case of a very grave pathology remains open. In this case of a very minor physical malformation, it was urgent to unblock the situation by revealing to the parents the clear and quiet signals that their infant is a whole person. This step allowed them to resume the attachment process and start relating to Lucas as their son.

Anton and His Parents This third baby was filmed for the same television program mentioned earlier. Anton has a twin brother, Daniel. They are slightly preterm and in good health. As I began to administer the NBAS, the mother stayed quite far away and made some comparisons with the other twin that were not favorable to Anton. I begin the Reflexes item of the NBAS. The mother is receptive but a little anxious; she moves around. [My thoughts are presented in italics.] I sense that there is a tension to relieve, but I’m not sure where it’s coming from. I speak to the baby: “You have the hiccups!” I pause. I wonder if this infant gets easily overwhelmed and whether I will be able to proceed very far into the exam. During the pull-to-sit maneuver, the mother remarks that Anton doesn’t hold his head as well as his brother, Daniel. I answer, “Yes, and here, have you seen? He also makes an effort to bring it forward.” The mother is worried about her baby not being strong enough. Is Daniel seen as the half full glass and Anton as the half empty one? The father watches the exam attentively, and he acts supportive toward his wife; he puts his arm around her after her anxious utterance. I am trying to have a contact with Anton. I position him facing me and say, “Hello! Are you going to wake up?” He has the hiccups again. I pause again. Anton’s father encourages him briefly. The mother goes behind me and comes back to my other side, away from her husband. The mother is anxious. She asks, “Why does one of the twins open his eyes a lot and the other one much less?” I listen, and she goes on, “Because the other baby keeps his eyes open all the time, but not him. When I feed Daniel, he gazes at me all the time, but not Anton.” The mother feels recognized by Daniel and bound with him, but not in the same way with Anton; and this may be what is behind her anxiety.

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Anton had just opened his eyes upon hearing his mother ’s voice. I seize the opportunity and show her, “Yes . . . yes . . . and did you see now? He opened his eyes, too, to look where you were!” The mother watches the baby, bends forward and begins to speak melodiously, “Anton! Anton, hello! Hello, darling, are you awake?” Anton opens his eyes again and raises his gaze toward his mother. He searches for her for almost 10 seconds. Then he becomes more animated and raises his head. I congratulate him: “Good! Here we go!” The mother praises him and calms him down. “Did you see that?” I ask. Both parents nod. Anton begins to crawl, and I suggest to the mother, “If you stand at the other side of the bed, he will come to you.” This is an opportunity for a moment of meeting! The mother moves to the other side of the bed, and Anton does crawl toward her. She congratulates him and kisses him. I admire this feat, too, “Look at this! Do you want to take him in your arms?” I want to help the moment of meeting to bloom. The mother gathers him in her arms; her mood has lightened noticeably. “How nice my baby is!” she says. “My nice baby!” With a gesture of his hand, the father joins this moment of meeting and also admires his son. “Brave!” he says simply. I notice that this is his way of being part of the meeting, joining in with his own thoughts, but allowing the central place to remain the mother ’s. The mother hugs her son . . . kisses him and talks to him. The father participates quietly in this intense moment. I comment, “This is the greatest happiness!” The mother keeps her son close in her arms and smothers him with kisses. I give time for the moment of meeting to unfold. I feel happy and relieved, even though I am not done with the NBAS and will resume it when the mother ’s emotions recede a bit from this crest. This is a four-person moment of meeting. At the beginning of the exam, the mother expressed her anxiety when she said that Anton didn’t open his eyes, didn’t hold his head as well as his brother, and didn’t look toward her when being breastfed. Through the NBAS, Anton responded to his mother ’s concern by acting. He was indeed able to emerge from his sleep. Attracted by his mother ’s voice, he summoned up all his energy to hold his head and look at her and to crawl toward her. Deeply relieved, she expressed a deep surge of love and sought closeness with her baby. All four of us had shared a positive experience that is now registered in the family’s history.

General Commentary on the Clinical Examples The orientation behavior of the baby toward his mother is a strong trigger for the mother ’s attachment. The baby crawls toward her; when she picks him up, he molds his warm little body against her; he twists his neck to look at her and listens to her with great

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attention when she speaks. This behavior delivers a message that the mother understands at a psychological level; it makes the mother feel that he is interested in her, that he has chosen her, and that he loves her. Effectively, when the baby’s gaze finds his mother ’s, this moment of meeting releases a flow of love. One can feel it; it is almost palpable. It is the clinician’s reward. This moment of meeting answers the mother ’s question, which is the second theme of the Motherhood Constellation—wondering if she will be able to bond with her child. “Will I love you? Will you love me? Will I know that you love me? Will you recognize me? Will we click? Will we connect?” The infant’s behavior is one more building block nature puts into place in order to construct a positive bond that feeds representations of the baby as being gratifying, of the mother as being competent, and of the father as having a competent and harmonious family that he feels good about. The NBAS consultation always includes the father; he is part of the team. When he witnesses a moment of meeting between the baby and his mother, the father is usually relieved to discover his partner ’s competencies, the harmony of her communication and relationship with their child. It pulls him closer to her. It can also trigger a moment of meeting between mother and father in their new role of co-parents. Even though moments of meeting between father and baby are much less frequent, the father may often be inspired by witnessing one of them; and he may try, later, to connect with his infant in the same way. For all these reasons, the father ’s presence is essential. Beyond the establishment of the bond, what I find fascinating is the mother ’s discovery of her baby as an interlocutor, someone who listens to her and with whom she can communicate. He is no more considered only as a beloved object of care, but as a life companion with whom she can share her thoughts because she has discovered that he is endowed with affective receptivity. And the same is valid for the father. This early openness to affective and fuller communication may allow for more fluid exchanges later on. U N D E R LY I N G T H E O RY It is now understood that the process of establishing the parent-infant tie, the attachment process, is vital for survival and for mental health. These processes begin at birth, and for this reason my work focuses on their initial steps in the neonatal period. The quality of early

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attachment and the coherence of the transmitted and remembered experience starts to form from the very beginning. The ties and attachment form mostly in a nonverbal language (only the parents have words). Accordingly, attachment is situated in the implicit domain. This nonverbal language is made up of the affects—the rhythms of interaction and their transitions, the play of gaze, the facial expressions, the gestures, the physical positions, the vocalizations, and everything the body expresses. It is in this interactive space that the baby constructs the world of his knowledge of how to be with others and how they are with him—the style of exchanges with others. This is called “implicit relational knowing.”6,13,14 One of the central concerns here is how and when changes occur that advance the attachment process. It is recognized that such changes are usually unpredictable and occur in a leap, not in a continual progression. What is the best way to describe such discontinuous phenomena? The BCPSG explores the change process on a scale of seconds during development and in psychotherapy. We define an NM as a moment of crisis where all energy is mobilized in managing the very moment. The NM arises at the crossroad marked by a time-limited opportunity for the individual to act. He can grapple with his destiny, flee it, or do nothing (fight, flight, or freeze). Whichever course he takes will change his destiny. Such a time window for action is called kairos by the ancient Greeks. An individual can let himself be carried by the events and submit to them passively, or he can act on them, adequately or not. He can let himself be guided by his instinct or by the advice of others. In any case, he is the agent of his own destiny, and his destiny is being played out now. The birth of one’s own infant is an NM or a moment of kairos par excellence. It involves a challenge to who you are and an opportunity to become who you want to be. This realization can help parents take their destiny in hand, especially in situations when their own infancy has been difficult. It gives them a chance to correct a trajectory initiated in the past. Steps in the advancement of the attachment process occur not only in the infant’s and parents’ behavior, but also in their minds— their representations of themselves, of the others, and of their relationships. It is thus necessary to have a model that can deal with these parallel but interrelated changes within the triad. Figure 7.2 provides an example of such a model.15 The representations are the result of past and present experiences; these determine, in large part, the behavior of each parent.

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Father Behavior

Interactions Baby Representations

Baby Behavior

Mother Behavior

Mother Representations

Figure 7.2 Schema of the Interactions and of the Representations of Mother, Father, and Baby.

On his side, the baby constructs his representational world from the experience lived in his interactions. Certain aspects of the parents’ representational world will influence their triadic interactions, including: • The recent past history of the baby (the pregnancy, the delivery, first contacts, breastfeeding) and his current state (his physical state and health status, his state of alertness and activity). • The history of each parent, which may include assisted procreation, an undesired pregnancy or one with much ambivalence, mourning over a previous pregnancy, other traumatic experiences of loss or damage to another baby, step-children from a previous marriage, a handicap in the family, meaningful loss, and so forth. It also includes the quality of attachment with their own parents (the nature of the mother ’s attachment to her own mother, which is particularly active at this time, and with her own father; and, similarly, the father ’s attachment with his parents). • The relationship of the couple, including their culture of origin, preexisting level of harmony, marital state, and so forth. • The richness and harmony of ties to the extended family and friends. • Work and economic means as they affect child care. The presence of the examiner multiplies the complexity of all this considerably. She brings her own personal history (Does she have children?), her professional training (pediatrician, psychologist,

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nurse), her clinical experience, and, importantly, her personality and style. This model argues for the presence of both parents during the NBAS. It requires attention to their affects, behaviors, and representations. It is this combination of information sources that helps inform the intervention. W H Y E A R LY I N T E RV E N T I O N ? Bringing a baby into the world is, for the mother, a profound upheaval. For the rest of her life, she will be responsible for him. The Motherhood Constellation takes place and acts on the mother ’s psychology. It is a sort of mutation into another form of herself, with no possible return. This is a normal maturational life crisis that is extremely demanding. Understanding the new forces within the mother brought about by the Motherhood Constellation throws light on maternal anxiety. Her concern for her baby is due to a high level of maternal vigilance, which is probably biologically programmed to protect the infant and ensure his survival. The stress of their personal transformation mobilizes a lot of energy from the parents. They need consideration and strong support. However, the time surrounding birth is commonly considered as one of the happiest times in life. Given the fact that, as time passes, memories of difficulties are often erased, the family and social environment doesn’t appreciate the frailty of the new parents and their necessary adjustment process. The environment often underestimates this very real difficulty and doesn’t offer the needed support. All the ancient rituals around birth and the welcoming of the baby have almost disappeared, such as the relevailles, which is the ceremony performed at church when a woman first returns after the birth of her child; the presentation to the family; the baptism; and so forth. They served as acts of acknowledgment and support for the new parents. The transition to parenthood, like all transformations, implies a lot of uncertainties and opens the way to many misunderstandings and inaccurate attributions. It is hard to build a parent’s new identity without the benevolent regard of experienced others who take the time to revisit with them the paths of their own metamorphoses. The construction of a coherent family history about the foundational event of the birth puts in place a solid base for the construction of the attachment between the family members and for their life together. It is a communal experience to which they can refer in the future.

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The encounter with their baby, long awaited, is a decisive moment for the parents. This little person, all new, still unknown, will become part of their lives forever. They have dreamed of him, thought about him, and sometimes been apprehensive of his coming. They need to discover who he is, to feel that he is coming toward them to meet, to feel him responding to them in order to enhance their ties and mutual love. The period surrounding a birth rides on a crest of happiness where the balance is uncertain, even very fragile. Many times, the meeting fails or is delayed. Sometime these troubles are easy to surmount thanks to a constellation of favorable factors. But if not, even a banal event can be misunderstood and can lead the family triad into a negative spiral that will leave a mark on its history. The emergence of new responsibility for the life and the well-being of a newborn, which has not been learned, adds additional pressure to the other difficulties. Under these circumstances, when feelings of confusion, exhaustion, and impotence accumulate, it is easy to slip toward and get submerged in anxiety, panic, feelings of isolation, depression, marital conflicts, or desperate enactments. One of the aims of the intervention described here is to act on the moments that can correct a downward spiral and open the way to a positive one.16 Without going into all the therapeutic targets of this complex time in life, the main guidelines of this approach and the objectives of the intervention are: 1. To establish a coherent sense of self with competencies for autonomy, as an agent, an entity, a whole person. 2. To feel related through shared experiences. To feel attached through interpersonal events and connected through intersubjective experiences. Moments of meeting contribute to building this sense of relatedness. These two paths show the basic bipolarity of social life, namely to feel autonomous and attached at the same time. CONCLUSION This view is based on the notion that the development of relatedness is not something that grows progressively like a tree. Rather, it is a discontinuous process made up of NMs and moments of meeting. Moments of meeting are special moments that permit the relationship to jump to a higher level. My intervention with the NBAS aims

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to facilitate and promote such moments and attempts to use them clinically for the purpose of early bonding and attachment. The baby has the competencies to establish ties with his parents and, at the same time, to develop his own autonomy. When they recognize the bipolarity of his competencies, the parents are in a better position to understand their baby and to build harmonious ties with him. Finally, in this approach emphasizing moments of meeting, I try to bring to light one of the main objectives of the NBAS as I have described my use of it. It is an aspect of Brazelton’s work—implicit in his practice—that he uses intuitively and informally. When he does a rapid demonstration of the Scale, he may omit certain items. But he never forgets to ask the mother to speak to her baby, so that she has the pleasure (and he does, too) of seeing the baby turn his head toward her. However, this gesture, which is perhaps the most important of the whole intervention, has not yet been formally integrated in the administration of the test. In this chapter, I have tried to show some of the theory and practice that underlies such relation-building moments in the use of the NBAS. They can be very powerful. REFERENCES 1. Brazelton TB. Neonatal Behavioral Assessment Scale. No 50. Philadelphia, PA: J.B. Lippincott; 1973. 2. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. 3rd ed. London, England: MacKeith Press; 1995. 3. Boston Change Process Study Group: Bruschweiler-Stern N, Harrison AM, Lyons-Ruth K, et al. The Something More than Interpretation: Sloppiness and Co-Construction in the Psychoanalytical Encounter. Boston, MA: JAPA; 2003. Report No 4. 4. Boston Change Process Study Group: Bruschweiler-Stern N, Harrison AM, Lyons-Ruth K, et al. Non-interpretive Mechanisms in Psychoanalytic Therapy. Int J Psychoanal. 1998;79:903–921. 5. Bruschweiler-Stern, N, Member of Boston Change Process Study Group. Reflections on the Process of Psychotherapeutic Change as Applied to Medical Situations. Infant Ment Health J. 1998;19(3, theme issue). 6. Boston Change Process Study Group: Bruschweiler-Stern N, Harrison AM, Lyons-Ruth K, et al. Explicating the implicit: The local level and the microprocess of change in the analytic situation. Int J Psychoanal. 2003;83:1051–1062. 7. Bruschweiler-Stern N. The psychological pregnancy and the role of the obstetrician. Gynaecol Forum. 2002;7(4):14–17. 8. Bruschweiler-Stern, N. The Concept of Maternal Representations: Clinical Implications for Perinatology. Ab Initio. 1997;4:1–4.

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9. Stern, DN. The Motherhood Constellation: A Unified View of Parent-Infant Psychotherapy. New York, NY: Basic Books; 1995. 10. Stern, DN, Bruschweiler-Stern N. The Birth of a Mother: How the motherhood experience changes you forever. London, England: Basic Books Publishing; 1998. 11. Fivaz E, Corboz A. The Primary Triangle. New York, NY: Basic Books; 2000. 12. Bruschweiler-Stern N. Neonatal interventions for relationship problems. In: Sameroff AJ, McDonough SC, Rosenblum KL, eds. Treating Parent-Infant Relationship Problems: Strategies for Intervention. New York, NY: Guilford Press; 2003:188–212. 13. Stern DN. The Present Moment. New York, NY: WW Norton; 2003. 14. Lyons-Ruth K. The two-person unconscious: Intersubjective dialogue, enactive relational representation, and the emergence of new forms of relational organization. Psychoanal Inquiry. 1999;19(4):576–617. 15. Stern-Bruschweiler N, Stern DN. A model for conceptualizing the role of the mother ’s representational world in various mother-infant therapies. Infant Ment Health J. 1989;10(3):16–25. 16. Bruschweiler-Stern N. Modèle d’intervention préventive au cours de la période néonatale [A model for preventive intervention during the neonatal period]. Prisme. 2000;33:126–139.

CHAPTER 8

The Developmental Niche of the Newborn in Rural Kenya CHARLES M. SUPER and SARA HARKNESS

There was a time—as many contributors to this volume will remember—when it was possible to think of the newborn as a purely biological creature, free, for at least a little time, from human culture. Prenatal influences were acknowledged, but they were generally considered isolated variables operating at the biological level. Culture entered the developmental equation only as part of socialization, a process of little apparent importance in the early months of life. It is now increasingly recognized, however, that culture permeates all aspects of human development, from the act of conception through the ceremonies surrounding death. Progress in understanding how this is true, and by what means culture influences development, depends ultimately on appropriately focused comparative research. In this age of globalization, there is an urgency to the pursuit of that research because our theories of development need greater perspective to accommodate the broader reality that is now difficult to ignore.1,2 In addition, social policies that unwittingly rest on the expectation of a homogeneous population are rapidly becoming obsolete and counterproductive.3 The

The original research discussed here was supported in part by the W. T. Grant Foundation, the Spencer Foundation, the Carnegie Foundation, and the National Institutes (United States) of Mental Health and of Child Health and Human Development (grants R01 MH 33285 and R01 HD 38357). All statements made and views expressed are the sole responsibility of the authors.

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newborn period is not too early a place to examine the role of culture in development. What should we be looking for? LeVine4 has suggested that seeking and describing variation in child development is an opening phase of the comparative enterprise, and many neonatal reports from around the globe—found here and in earlier volumes— contribute to that phase. Subsequent and more difficult, however, is the challenge of accounting for differences and similarities in a way that advances a deeper theoretical understanding of development.5 That challenge requires developing an insightful tool for parsing the child’s cultural surround. C U LT U R E Culture has been conceptualized in many ways by anthropologists, varying in focus on historical continuity, physical artifacts, patterns of daily life, organized variation, and shared systems of knowledge and meaning.6,7,8,9,10 For the developmentalist, the key insight concerns the integrative aspects of culture—a complex of particular beliefs and practices that function as a system and that are shared by a group of people who recognize each other as members of the same group. The coordinating aspect of culture organizes a child’s environment, and the power of culture to shape human development is a direct result of this organizing role.11,12,13,14,15 More than any momentary event or single environmental feature, it is the coordinated repetition of experiences over time, directly and indirectly, in ways large and small, that ensures that the message of culture is conveyed to the next generation.12 We have found it helpful to think of the child’s cultural environment as being structured by three interlocking subsystems: the physical and social settings that are the stage of everyday life;10 the customs of child care and education (in the broadest sense) that are routinely employed and considered normal by adults in the community;16 and the psychology of the caretakers, especially their ethnotheories, or motivating beliefs and concepts that are shared with other caretakers.17 Together, this structure is referred to as the developmental niche (see Figure 8.1). Three critical features of the niche highlight its dynamics.12,13,18 First, there is pressure for the three subsystems to operate in harmony. For example, parents do not want to put their children in settings they believe harmful, and customary routines of care are supported by the ethnotheories shared by various caretakers. Second, the child and the niche are subject to constant mutual influence and adaptation. The child, at the center of the niche, has his or her own particular characteristics,

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Aspects of the Larger Culture

Aspects of the Larger Culture

Settings

Child Caretaker psychology

Customs

Aspects of the Larger Culture

Figure 8.1 The Developmental Niche.

including sex, age, temperamental disposition, likes and dislikes, and a range of abilities and disabilities; with those characteristics, the child elicits and creates a specific context. Similarly, characteristics of the niche provide both opportunities and constraints to the child. A very active child, for example, may choose to spend more time at the playground than a quiet one—but only if such play spaces are available. Finally, all three elements of the niche—settings, customs, and caretaker psychology—are in constant interaction with the larger culture. As new information, technologies, or fashions are introduced through media, social networks, and relevant professionals, the developmental niche will evolve over time and generation.19 The concept of developmental niche can be used to delineate the environment of a particular child at a particular developmental stage.20 More powerfully for research purposes, aspects of the niche commonly found in one community can be summarized and contrasted with those in another. Thus, we can compare the developmental niche for children of differing social class in the United States with regard to their acquisition of mathematics,21 or, as we will do here, compare the niches of infants in rural Kenya with those of urban New England. The results provide a useful context

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for understanding the behavior of infants and children, and the role of culturally structured environments in shaping development. T H E D E V E L O P M E N TA L N I C H E O F I N FA N T S I N K O K W E T Kokwet is a farming community in western Kenya, about 200 miles west of Nairobi, in the fertile, rolling hills where the western highlands slope down toward the Mara savannah lands. The 54 homesteads of Kokwet (a pseudonym) are spread out over about 6 square miles, each cluster of grass- or tin-roofed houses surrounded by pastures and fields. At the time of this research (1972–1975), the typical household consisted of a husband and wife and about five children; in one-quarter of the homesteads a second wife and her children formed a second household. The people of Kokwet are Kipsigis, a highland Nilotic people numbering about half a million.22 Their traditional life at the beginning of the twentieth century was seminomadic; its economic base was pastoral, with some simple agriculture. More permanent residence and land tenure became common as a result of increasing contact with British settlers, missionaries, and colonial administrators.23 A newborn in Kokwet leaves the mother ’s womb and enters a world of women. The process of birth is attended by other women, typically two or three relatives or neighbors. On rare occasions of distress (perhaps 1% of births) senior men may be called in to “blow into the mother ’s mouth to push the baby out,” as one senior woman explained. Also rarely (about 3 cases per 100), but salient to the residents of Kokwet, a mother would fail to reach home as she rushed from her garden fields, or would be waiting in desperation for transportation to the missionary hospital, when the time for birth arrived, and whoever was around, women or men, would lend assistance. More typically, new life in Kokwet arrives in the semidarkness of the mother ’s hut, and the neonate will stay there for at least 1 week with the mother, visited only by close neighbor women and female relatives. After 7 days, more women visit with gifts of water or milk. At 1 month, women bring maize, flour, and firewood. At 3 months, when the baby is no longer referred to as a chereret (monkey), the women bring milk and honey, sometimes as part of a larger greeting ceremony, reminiscent of an older tradition that includes beer and instruction by the father ’s mother in the ways of the clan. At this point, the mother resumes all her farm work and begins to carry the baby on her back.

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S TAT U S O F T H E N E W B O R N I N K O K W E T Eighty infants were born during our residence in Kokwet. One of us (CMS) was able to examine 32 of them on the fifth day after birth, using the Neonatal Behavioral Assessment Scale (NBAS).24 (In the other 48 cases, either we learned too late of the babies’ arrivals, we were absent from the community on the necessary day, or the mothers declined to allow our presence.) Just over half of the women had attended the prenatal clinic at a missionary hospital at least once, and all but two of the pregnancies were described as having been uneventful. All infants were born at home or (in two instances) on one of the paths leading home from the fields. Eight of the deliveries were described by the mothers as difficult. The babies appeared normal and in good health at the time of examination, except one with a cleft palate, and three with symptoms of upper respiratory infection. Other characteristics of the sample, including gestational age as estimated by the method of Dubowitz, Dubowitz, and Goldberg,25 are included in Table 8.1. Table 8.1 Sample Characteristics and Neonatal Behavioral Assessment Scale Lester Cluster Means (and Standard Deviations)

Measure/Scale

Kokwet

Boston

n (percent male)

32 (47%)

17 (59%)

24 (58%)

Median parity (range)***

3.4 (1–10)

1.4 (1–4)

1.0 (1–3)

Median gestational age (range)

38.9 (35.2–40.7)

39.5 (37.5–42.0)

40.0 (38.0–42.1)

Medication***

none

none or minimal

varied

Median labor in hours

9.5

7.5

11.3

Median weight kg (age) (range)

3.21 (day 5) (2.15–4.07)

3.29 (birth) (2.55–4.62)

3.70 (birth) (2.80–6.36)

Autonomic stability

4.40 (1.92)

3.78 (1.54)

3.50 (0.90)

Habituation

7.10 (1.04)

7.10 (1.55)

6.74 (1.73)

Motor performance*

4.59 (0.88)

5.23 (1.30)

5.10 (0.72)

Orientation**

5.18 (1.25)

6.36 (1.37)

5.08 (1.46)

Reflex

0.29 (0.14)

0.26 (0.29)

0.33 (0.23)

State range

3.96 (1.00)

3.58 (0.71)

3.82 (0.61)

State regulation*

6.37 (1.19)

5.58 (1.93)

5.33 (1.70)

***p ⬍ .0001; **p ⬍ .01; *p ⬍ .05.

Connecticut

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Because of the low level of light, ambient noise, presence of the mother, lack of furniture, and patterns of newborn care, the standard examination procedures were modified somewhat; primarily, modifications consisted of underplaying the aversive procedures—especially the incurvation, Moro, and defensive reflexes—in deference to the mothers’ concern with their infants’ perceived fragility.26 Nevertheless, the exam was generally comparable to the standard procedure, and the results can be meaningfully summarized (Table 8.1) using the clusters developed by Lester and colleagues.27(p70) Table 8.1 also includes results from two other samples for the purpose of comparison. The first was constructed shortly after the African fieldwork to provide a comparison group with minimal medication, and consists of 17 Euro-American infants from middle- and upper middle-class families in metropolitan Boston. Mothers were recruited through two obstetric practices offering a modification of LeBoyer ’s “low stress” approach to delivery.28 Parents attended childbirth classes, and fathers were present at the hospital delivery in all but one case. Seven births were without any medication, six involved local anesthetic only, and in four cases a mild sedative was used. All infants were in good health at the time of examination (by CMS), which was carried out at home on day 5 with the same modifications as used in Kokwet (darkened room, mother present, and so forth). The second comparison group was drawn more recently (2001–2006) from suburbs and small towns in central and eastern Connecticut, and represents a broader range of parent income and education. Participants in this second group were recruited through pediatric and obstetric practices and by the “snowball” method. Six infants were delivered by cesarean section; 7 of the mothers who delivered vaginally received both an epidural and an opiate analgesic (usually Stadol), 13 received only an epidural, and 9 delivered without any medication. All infants were in good health at the time of examination, which again was carried out at home on day 5, by one of us (CMS) in half the cases, or by one of two other trained examiners. Statistical analysis indicates no effect of maternal medication on newborn behavior within this group. Overall, the three samples reported here are surprisingly similar in their physical status at birth, and the biggest status difference indicated in Table 8.1 is the greater parity of the African sample. At the behavioral level, rank-order analysis of variance indicates overall group differences for three of the seven clusters (see Table 8.1). The largest difference concerns Orientation, on which

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the Boston infants performed exceptionally well, perhaps reflecting their excellent health and unimpaired deliveries, whereas the infants in Kokwet and Connecticut generally scored lower. The Kipsigis infants, in turn, have the highest scores on State Regulation. Examination of the individual items contributing to this cluster reveals that only Hand-to-Mouth varies significantly in its own right, although Consolability and Self-Quieting contribute strongly to the overall contrast. Finally, it appears that the Kipsigis infants scored lower on the Motor Performance cluster than the U.S. groups, but a closer examination of the individual items reveals a more complex picture. There are no significant differences in the component items of Pullto-Sit, Activity, or Defensive Movements; only on Tonus and Motor Maturity do the groups differ significantly. Like Keefer and colleagues,29 we perceived a qualitative difference in the motor tone of many Kipsigis infants, namely that the tone tested stronger but was still flexible, without signs of hypertonicity. Toward the end of this fieldwork, we conducted a joint examination with Keefer of one Kipsigis infant, confirming the similarity in our qualitative judgments. Unlike Keefer ’s research group, however, we had not devised new scores; rather we had coded on motor tone and simply noted, when appropriate, the poor fit with the hypertonic criterion. Thus, when the present data are prepared for making the summary clusters by folding this scale at the midpoint,27 high (even though not hypertonic) scores pull down the final cluster score, making it appear as a less good performance. In contrast, the Motor Maturity item is not changed for the Motor Performance cluster; the Kokwet sample, in general, displayed more restricted and jerky movements than the Boston sample (and to a lesser degree, than the Connecticut sample), properly leading to a lower total on the Motor Performance cluster. In summary, then, there are two significantly differing motor items, pointing in opposite directions: The infants in Kokwet showed stronger muscle tone than either of the U.S. samples but at the same time slightly less mature motor movements. E T H N O T H E O R I E S O F I N FA N T B E H AV I O R These are the observations of an American researcher, trained by the Brazelton group to elicit and attend to certain characteristics of neonatal behavior. The newborn’s niche, however, is formed by the mother ’s ethnotheories, which guide her behavior and are shared with other women in the community. What do Kipsigis mothers

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see in their newborns’ behavior? What ideas about babies do they share with each other as part of their culture, and how do these ethnotheories shape the developmental niche of their infants? We approached this question by asking the mothers to judge the association, or similarity, of key items on the NBAS. If a baby likes to look at a face, for example, how likely is it that this baby will also turn his head toward the sound of a voice? Will it be easy to soothe such a baby when she is upset? Twenty-two of the 27 behavioral items on the NBAS were included in this systematic pairing, and the resulting matrix of similarities was subjected to multidimensional scaling, a mathematical procedure that organizes the items spatially such that “similarity” is represented by physical proximity. This same procedure was carried out with several other groups, including the Boston mothers, and a sample of NBAS-trained and certified researchers. The results demonstrate that these three groups, when thinking of the same behaviors, use different ideas, or cognitive schema, to organize their judgments (C. M. Super, PhD, and S. Harkness, PhD, unpublished data, 2008). The Kipsigis mothers were especially attuned to motor integrity and responsiveness (e.g., Defensive Movements), and these characteristics weighed heavily in their judgments of similarity. The Boston mothers, in contrast, used an organizational scheme focused on cognitive competence, as seen by them, for example, in Orientation and Habituation. The difference between the way the two groups of mothers interpret newborn behavior is nicely illustrated by the comment of one U.S. mother that her newborn son was very “alert and attentive.” Asked to elaborate, she replied, “Well, I can tell because he holds his head up, you know, with his neck straight.” For her, the cognitive, attentional element in a controlled orienting of the head was more salient than the underlying neuromuscular skill. A Kipsigis mother would have built her interpretation around the integrity and smoothness of the motor act. The NBAS experts, in contrast to both groups of mothers, were particularly sensitive to the Regulation of Arousal state, that is, for example, Consolability and Alertness compared to Startles and High Activity Level. No one familiar with the examination will be surprised at this result, because assessing the infant’s state and adjusting one’s own behavior accordingly is a central part of the procedure and is emphasized in training. The theme of motor integrity and responsiveness is woven throughout Kipsigis ethnotheories of infant development in several ways. Initially, intact infants are calm, and although capable of making known their needs for food and warmth, they are not prone

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to uncontrolled and unresponsive crying. Both symbolically and protectively, quiet is good.30 Too much excitement or arousal might attract unwanted attention; and just as the condition of pregnancy is virtually a taboo subject for discussion, in part to avoid the witchcraft of jealousy, so young infants are best kept calm and quiet. More obviously, especially as the baby gains in strength and maturity, the successful accomplishment of motor milestones is taken as evidence of robust development and competent mothering—a promise of strong help in the fields and at home. A common greeting to a mother whom one has not seen for a period is, with obvious reference to the child on her back, “Tianná?” (”What has he or she learned?”) and it is answered, “He is sitting now” or “She walks.” When asked as part of a child-rearing interview, virtually all mothers in Kokwet said they made an effort to teach their babies to sit, stand, and walk. What would happen, they were asked further, if a mother somewhere, for some reason, did not teach these things? The common answer, after a moment to assimilate such an outrageous idea, was that the child would not learn them. The more thoughtful mothers suggested, “Perhaps they would only learn these things later”; but for all of them, such a scenario seemed bizarre. C U S T O M S O F I N FA N T C A R E The customary care of newborns and infants in Kokwet directly reflects these ethnotheories. From the first days of life, the stepping reflex is exercised on the outstretched legs of the mother or grandmother sitting on the floor of the hut or, after a week, outside in the sun on a cool day, or in the shade when the sunshine is too bright and hot. This activity, called keguldó, is evidently an enjoyable way to play with the baby, but in addition, the bouncing is thought of as developing the muscles and skills for walking. The frequency of keguldó can be estimated by averaging over nearly 2,000 spot observations and quick interviews, which indicate the activity takes place two or three times per week during the first month, increases in frequency to nearly every day at 4 and 5 months, and then decreases only as a more directed “teaching to walk” (kitwalse) is begun around 6 months (C. M. Super, PhD, and S. Harkness, PhD, unpublished data, 2008). There are other customs that stimulate or support motor development but are not particularly carried out for that purpose. During the newborn period, for example, most babies are massaged twice a day with butter or Vaseline; this is to keep the skin from drying

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and to help the baby sleep. When awake, the baby is being held nearly 80% of the time, usually in the arms or lap. Although these positions do not provide as much muscle stimulation as the traditional back-carrying (which does not become common until around 4 months), they do nevertheless require more postural adjustment on the baby’s part than lying down, the predominant position (59%) for infants in the U.S. sample (C. M. Super, PhD, and S. Harkness, PhD, unpublished data, 2008). S E T T I N G S O F I N FA N T L I F E Many of the customs that are not specifically oriented toward strengthening motor development, but are nevertheless supportive of it, follow naturally from the physical and social settings of newborn life in Kokwet. The one-room hut, which serves as birthing room, kitchen, dining room, and family room, is typically made in the mud-and-wattle style: wooden posts placed in a circle with saplings woven around them to form walls, and topped with a thatched conical roof. The walls and contoured floor are coated with mud mixed with cow dung, which dries to a smooth hard surface. A recessed fire pit usually lies toward one side, and slightly raised areas for bedding on another. Furniture is minimal, with a small cupboard, perhaps a table and a few chairs. The space is relatively warm and cozy (and smoky) during the cold wet season, and cool and dark when it is hot outside. It is not, however, a safe place for infants to be on the floor, or even unattended in the sleeping area. On the other hand, there are usually several people around— the mother, grandmother, preadolescent siblings, and perhaps neighbor women or other visitors. There is always a lap or pair of arms to keep the baby safe and warm and not “alone.” CONCLUSION The setting and customs that surround the opening weeks of life work systematically with local ethnotheories to promote optimal development as it is conceived by the mothers of Kokwet. These cultural factors are in play at birth, and an examination 5 days after birth probably reflects some effect of their shaping of behavior. The behavioral differences are subtle in that healthy babies are seen to be so similar in these culturally divergent samples. The small but specific differences in NBAS scores demonstrated here are consonant with the respective developmental niches. The Boston sample, in the best health and delivered without

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medication, showed the best performance on Orientation. The infants in Kokwet demonstrated a modest advance in State Regulation, which probably reflects their relatively subdued environment and treatment (even during the exam). Finally, we can reasonably speculate that the daily massages and frequent elicitation of walking and stepping reflexes in Kokwet, starting from the first day of life, resulted in superior motor tone on day 5. Given the prominence of motor performance in the Kipsigis mothers’ ethnotheories of infant development, and its facilitation through the settings and customs of care, it is not surprising that the Kokwet infants (and many other traditionally reared infants in Africa) reach many of the motor milestones earlier than is typically true in the United States, in particular the various markers of advanced sitting and walking.31,32,33,34 Ironically, but understandably, the mothers of Kokwet are not aware of this difference, and most believe that “European” (White) children walk earlier than their own. For one thing, they point out, Europeans live in towns, where it is easier to get to a doctor if you need one. Also, European mothers don’t work in the fields and stay home more, the Kipsigis women say; hence European mothers are never delayed by work in feeding the child, and they have more time to teach their babies to walk, as any good mother would. The women of Kokwet are correct in imagining that cultural groups shape their infants’ development from the earliest days, even if they lack comparative data to specify and evaluate the differences. As developmental science continues to incorporate the perspectives and tools of multiple disciplines, including anthropology as well as developmental pediatrics, we can all come to see more clearly that newborns, like other persons, live and grow in a cultural environment. REFERENCES 1. Nsamenang AB. Human ontogenesis: An indigenous African view on development and intelligence. Int J Psycho. 2006;41(4):293–297. 2. Super CM. The globalization of developmental psychology. In: Pillemer D, White SH, eds. Developmental Psychology and Social Change: Research, History, and Policy. Cambridge, England: Cambridge University Press; 2005: 11–33. 3. van Oorschot W. Culture and social policy: A developing field of study. Int J Soc Welfare. 2007;16:129–139. 4. LeVine RA. Cross-cultural study in child psychology. In: Mussen P, ed. Carmichael’s Manual of Child Psychology. Vol 2. 3rd ed. New York, NY: John Wiley & Sons Inc; 1970: 559–612.

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5. LeVine RA. Child rearing as cultural adaptation. In: Leiderman PH, Tulkin SR, Rosenfeld A, eds. Culture and Infancy: Variations in the Human Experience. New York, NY: Academic Press; 1977:10–26. 6. Geertz C. The Interpretation of Cultures. New York, NY: Basic Books; 1973. 7. Handwerker WP. The construct validity of cultures: Cultural diversity, culture theory, and a method for ethnography. Am Anthropol. 2002;104(1): 106–122. 8. Harkness S. Human development in psychological anthropology. In: Schwartz T, White GM, Lutz CA, eds. New Directions in Psychological Anthropology. New York, NY: Cambridge University Press; 1992:102–121. 9. LeVine RA. Culture, Behavior, and Personality. Chicago, IL: Aldine; 1973. 10. Whiting BB, Edwards CP. Children of Different Worlds: The Formation of Social Behavior. Cambridge, MA: Harvard University Press; 1988. 11. Rogoff B, Angelillo C. Investigating the coordinated functioning of multifaceted cultural practices in human development. Hum Dev. 2002;45(4): 211–225. 12. Super CM, Harkness S. The environment as culture in developmental research. In: Wachs T, Friedman S, eds. Measurement of the Environment in Developmental Research. Washington, DC: American Psychological Association; 1999:279–323. 13. Super CM, Harkness S. Culture structures the environment for development. Hum Dev. 2002;45(4):270–274. 14. Weisner TS. Ecocultural understanding of children’s developmental pathways. Hum Dev. 2002;45(4):275–281. 15. Worthman CM. Developmental microniche: A concept for modeling relationships of biology, behavior, and culture in development. Am J Phys Anthropol. 1994;18(suppl):210. 16. Goodnow JJ, Miller PJ, Kessel F, eds. Cultural Practices as Contexts for Development: New Directions for Child Development. Vol 67. San Francisco: JosseyBass; 1995. 17. D’Andrade R, Strauss C. Human Motives and Cultural Models. Cambridge, England: Cambridge University Press; 1992. 18. Harkness S, Super CM. Themes and variations: Parental ethnotheories in western cultures. In: Rubin KH, Chung O-B, eds. Parental Beliefs, Parenting, and Child Development in Cross-Cultural Perspective. New York, NY: Psychology Press; 2005:61–79. 19. Harkness S, Super CM, Keefer CH. Learning to be an American parent: How cultural models gain directive force. In: D’Andrade RG, Strauss C, eds. Human Motives and Cultural Models. New York, NY: Cambridge University Press; 1992:163–178. 20. Super CM, Harkness S. Temperament and the developmental niche. In: Carey WB, McDevitt SA, eds. Prevention and Early Intervention: Individual Differences as Risk Factors for the Mental Health of Children—A Festschrift for Stella Chess and Alexander Thomas. New York, NY: Brunner/Mazel; 1994:15–25.

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21. Pellegrini AD, Stanic GMA. Locating children’s mathematical competence: Application of the developmental niche. J App Dev Psychol.1993;14: 501–520. 22. Sutton JEG. The settlement of East Africa. In: Ogot BA, ed. Zamani: A Survey of East African History. Nairobi, Kenya: East African Publishing House and Longman Group; 1968:53–81. 23. Manners RA. The Kipsigis of Kenya: Culture change in a “model” East African tribe. In: Steward JH, ed. Three African Tribes in Transition. Urbana, IL: University of Illinois Press; 1967:207–359. 24. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. 3rd ed. London, England: MacKeith; 1995. 25. Dubowitz LMS, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. J Pediatr. 1970;77(1):1–10. 26. deVries M, Super CM. Contextual influences on the Brazelton Neonatal Behavioral Assessment scale and implications for its cross-cultural use. Monogr Soc Res Child Dev. 1979;43(43, serial no 177). 27. Lester BM, Als H, Brazelton TB. Scoring criteria for seven clusters of the Brazelton scale. Unpublished manuscript, Boston, MA. 1978. Cited by: Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. 3rd ed. London, England: MacKeith; 1995. 28. Oliver CM, Oliver GM. Gentle birth: Its safety and its effect on neonatal behavior. J Obstet Gynecol Neonatal Nurs. 1978;7(5):35–40. 29. Keefer CH, Tronick E, Dixon S, Brazelton TB. Specific differences in motor performance between Gusii and American newborns and a modification of the Neonatal Behavioral Assessment Scale. Child Dev. 1982;53(3): 754–759. 30. Harkness S, Super CM. Child-environment transactions in the socialization of affect. In: Lewis M, Saarni C, eds. The Socialization of Emotions. New York, NY: Plenum Press; 1985:21–36. 31. Kilbride JE, Kilbride PL. Sitting and smiling behavior of BaGanda infants: The influence of culturally constituted experience. J Cross-Cultural Psychol. 1975;6:88–107. 32. Kilbride JE, Kilbride PL. Sociocultural factors and perinatal development of BaGanda infants: The precocity issue. J Prenat Perinat Psychol Health. 1990;4(4):281–300. 33. Super CM. Environmental effects on motor development: The case of African infant precocity. Dev Med Child Neurol. 1976;18:561–567. 34. Super CM. Cross-cultural studies of infancy. In: Triandis HC, Heron A, Kroeger E, eds. Handbook of Cross-Cultural Psychology. Vol 4. Boston, MA: Allyn & Bacon; 1981:17–54.

PA R T I I

CONTEMPORARY RESEARCH AND PRACTICE: INTERNATIONAL PERSPECTIVES Early Intervention with Infants and Families

CHAPTER 9

Early Intervention and Fatherhood: Denmark HANNE MUNCK

In 1975, at the University of Copenhagen, we started using the Neonatal Behavioral Assessment Scale (NBAS) in teaching and research. The NBAS,1 and from 1982 the Assessment of Preterm Infants’ Behavior (APIB)2 helped us demonstrate the capacities and individuality of newborns and prematurely born infants. These scales have played a role in modernizing hospital routines and practice.3,4,5 In 1989, after more than 15 years of research and clinical work with the families of newborns, we established the center for Infants and Their Families under the leadership of the author at the Institute of Psychology in Copenhagen. The work at the center is cross-disciplinary, with two psychologists, a social worker, a relaxation therapist, a specially trained educationist, and eight students of psychology. Being a university clinic, the center is engaged in graduate, as well as postgraduate, training in early intervention and infant observation. From its beginning, the center worked in close and intense collaboration with six public health nurses from the local district. During the infants’ first years, the nurses pay regular home visits to all new families in the district, regardless of need. The visits are part of the public preventive health-care system and are received by almost every family in Denmark, irrespective of social status.6 The nurses advise each family on everything concerning their infant’s health and development. The number of visits depends on the family’s particular situation. A great many research studies have been undertaken by the center, most recently focusing on fathers and their relation to their infants. 101

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The three functions of the center—running a clinic for treatment of families, educating students, and doing research (often in collaboration with institutions outside the university clinic)—are closely integrated into daily working routines. This chapter draws on clinical therapeutic experiences as well as results from some of our studies at the center. We discuss three topics: (1) the advantages of a primary prophylactic approach compared with focusing on traditional risk groups, (2) the growing focus on fathers, and (3) the advantages of infant observation as an integrated aspect of early intervention and as part of the therapeutic training of the young clinician. FA M I L I E S A N D T H E I R N E E D S In order to explore the kind and amount of problems in families during the first year of their infants’ lives, we conducted a demographic study of all infants born in a particular year—1990—in our local district.7 This area of Copenhagen has a population of 45,000, with approximately 400 births per annum. In 1990, the number of newborns was 389. The study was carried out retrospectively, two years after the infants’ births, to make possible the comparison of situations for referred families with those of families not in need of referral. The six public health nurses in the district filled out an extensive questionnaire based on their records of the 389 families with newborns. The families were divided into four groups according to the number, character, and seriousness of their problems. The amount of difficulty they experienced must be considered in context: These families live in a welfare society with a high social, economic, and educational level and a paid, 12-month maternity leave for the mother (the last half taken either by the mother or by the father) and a 2-week leave for the father right after the delivery of the infant. Also, the rate of wanted and planned pregnancies in Denmark is extremely high because there is free access to abortion. The four groups were: Group A: This group consisted of families who fit the standard visiting profile. (In 1990, the recommended number of visits to a family without problems was seven in the first year of the infant’s life.) These families were described by the nurses as having infants who were developing well and parents who demonstrated good parenting skills without any need for further assistance. The number of families in this group was 166 (44.7%).

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Group B: These families had minor problems of a moderate and well-defined nature, such as breastfeeding difficulties, weight/ diet problems, and/or mild parental insecurity. There was a need for an extra effort (extra visits, telephone calls) by the nurse, but there was no reason for concern about the future development of the family or the infant. The number of families in this group was 141(34.2%). Group C: This group consisted of a small group of families who had greater problems and needed more intensive intervention. There might have been several factors (physical, psychological, social) jeopardizing the family situation. The nurses described their main task as motivating these families to accept further help, without which the development of the infant would be imminently at risk. The number of families in this group was 57(14.7%). Group D: This group was made up of an even smaller group of families, who had very serious and complex problems, such as alcohol or drug abuse, domestic violence, child maltreatment or neglect, or serious emotional problems. These families, and especially the development of their infants, were endangered. The efforts of the nurses alone would never be sufficient. The number of families in this group was 25 (6.4%). E A R LY P R O P H Y L A C T I C A P P R O A C H A N D THE CONCEPT OF RISK GROUP Somewhat surprisingly, we found that a great proportion of families that traditionally would be considered at risk were doing quite well without any professional help other than that offered to all families by the public health nurses. This was the case for almost two-thirds of those parents (all mothers) who were living alone with their infants; the extra help to those who needed it in this group consisted, for the most part, of more visits from the nurse. This does not mean it is easy to be a single parent, but it does show that these mothers could cope with their social and psychological situation and were able to give their infants what was required for their healthy development and overall well-being. Another group traditionally considered to be at high risk were families with prematurely born infants. In cooperation with the neonatal intensive care unit at the University Hospital, Rigshospitalet, we carried out two extensive follow-up projects with very premature children (those with birthweights below 1,500g) and extremely premature children (those with birthweights

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below 1,000g). Each group comprised about 400 families, which were examined when the children were 4 and 5 years old.8,9 We found that, as a group, parents of both groups were well-functioning in their relationships with their children; we assessed their relationships with respect to sensitivity, appreciation, and loving attention.8 These results contradict the often-made argument that the strain put on families with very low birthweight infants renders the parents less able to react in a sensitive manner later in their children’s lives. Despite the strain of giving birth very prematurely, and in spite of the stress caused by prolonged hospitalization of the newborn infant, the parents of both groups of prematurely born children in our studies were just as sensitive as the control parents. We think that these results are explained partly by the fact that in Denmark there is no significant connection between preterm delivery and a typical socioeconomic profile of poor living conditions (as is the case in the United States and the United Kingdom) and partly as a result of the tremendous change that had already taken place in Denmark and comparable countries with respect to the parents’ active participation in the care of their infants in the neonatal intensive care units.10 Negative social history, combined with massive problems involving alcohol, violence, and child abuse, are well-known risk factors to infants’ development in young families, and this was the case for the 6.4% in our study who were referred to various social agencies—half of them also to our center. A great many of these families were the second generation or more with massive difficulties. But apart from these obviously troubled families, the public health nurses found that about 10% of the 389 families had a private social network that was lacking, inadequate, or strained in much more subtle and discrete ways. In fact, their situations were so burdening to these families that the functioning of the parents was influenced to a worrying degree. Only through personal and frequent contact did the nurses learn about these problems (which otherwise might easily have been overlooked) and help the family further by paying them extra visits or making appropriate referrals. The quality of the families’ private social network was the single most significant factor distinguishing referred families from families not referred to our center. There are two important dangers in focusing too much on risk groups: one is that of overlooking difficulties in families that do not belong to the traditionally defined risk groups; the other is that of stigmatizing and having expectations that are too negative

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based solely on the basis of well and easily defined outward circumstances. FAT H E R S A N D T H E I R I N FA N T S There is a common complaint among health-care professionals that in the growing area of early intervention, the focus on fathers is rather sparse, with most offers of intervention (and most research interest) given to the mother-infant relationship.11,12 At our center, we always suggest that both parents participate in treatment. Analyzing the families who were referred to our center in the first three years of the center ’s existence, we found that in 67% of our two-parent families, the fathers participated in our treatment. However, the public health nurses mentioned fathers’ problems as the reason for referrals in only 7% of the cases, and only in combination with mothers’ problems (which were mentioned in more than 80% of the cases) or in combination with the infants’ problems (mentioned in 39% of the referrals). Nevertheless, in the course of the ensuing therapeutic process, we estimated that 25% of the participating fathers exhibited problems that required treatment. We discovered that fathers’ psychological problems are easily overlooked, even if the fathers are in contact with the primary healthcare system: In 80% of all families, the fathers had participated in the visits from the public health nurses.13 Our clinical work with both parents led to an increased interest in fatherhood and in fathers’ relationships with their infants. So for the past 5 years, we have conducted a series of studies on fathers in cooperation with the University Hospital of Copenhagen, Rigshospitalet. The main study consisted of extensive interviews with 42 fathers 4 weeks before delivery, 2 weeks after the birth of their infants, and again when the infants were 5 months old. The fathers were asked about their expectations, feelings, and reflections on their fatherhood, their relationships to their own parents, and their relations with their infants. Other studies concentrated on their expectations, thoughts, wishes, fears, and actual experiences around the delivery. Results from our studies show that 77% of fathers interviewed during pregnancy spontaneously talked about how worried, anxious, and troubled they felt. They were concerned about their infants’ well-being, the delivery, their own capacities for parenting, and whether they would have enough time for their children as well as for themselves. Five months after delivery, 60% of the

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fathers in their first, spontaneous statements were eager to talk about joy, love, pleasure, and delight in being fathers. There was an interesting difference between the fathers’ representations of their infants as time went on. Before delivery, 65% of the fathers’ representations of their expected infants referred to an older child (and not to an infant). But 5 months after delivery, 85% of the fathers talked only about imaginings and representations of an infant; and 54% of the fathers’ descriptions demonstrated sensitivity—the ability to identify with the infant’s life, feelings, and experiences of his or her world.14 From our studies using questionnaires, we found that 75% of the fathers participated in the prophylactic consultations during pregnancy. Almost all of them found it beneficial. Two-thirds of the fathers felt personally welcome, but 54% did not feel directly invited, and 40% did not experience being directly addressed by the midwives during the consultations. Ninety-seven percent of Danish fathers are present at the delivery of their babies. In one study, 165 fathers completed questionnaires, both before and after delivery, about their expectations and experiences. They stated that they wanted to be present not only to support their partners, but for their own sakes; they appreciated having been there (98%) and felt they had played an important role.13,15,16 Our findings showed a strong involvement on the part of the fathers during pregnancy and delivery, but, at the same time, an apparent discrepancy between the attitude of the official health authorities (the Danish Health Board) and the families, concerning the father ’s role and the importance of his participation in the birth of his child. The Danish Health Board hardly mentions the father in their publications and general directives. Likewise, in contrast to the wishes of both fathers and mothers, traditional hospital routines do not allow the father to stay overnight at the hospital with the mother and the newborn infant after delivery. Such a policy indirectly supports a view of fathers’ presence as being of little importance, ignoring the significance of the fathers’ involvement, which is clearly shown in our study and is currently being confirmed by experiences from our therapeutic intervention. Attitudes seem to have been changing, following a period of much public discussion. Several Danish hospitals now offer fathers the opportunity to stay the first night after delivery. And in January 2004, a large Copenhagen hospital, Hvidovre, announced that it would be the first in Denmark to allow the father to stay overnight

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Table 9.1 Activities of 41 Fathers with Their Infantsa

“How often do you do the following?” Bathing

Daily (%) 12

Often (%)

Sometimes (%)

Never (%)

57

24

5

Playing

98

2

0

0

Feeding

61

24

7

7

Changing diapers

83

15

2

0

Putting to bed

32

39

12

17

Getting up in the night

20

20

24

37

a

Data from Madsen S Aa, Munck H, Tolstrup M.15

with the mother and infant during the whole hospitalization period. As an illustration of the fathers’ involvement, Table 9.1 describes how often fathers participate in specific caregiving activities when their infants are 5 months old. E A R LY I N T E RV E N T I O N A N D T H E I M P O RTA N C E O F I N FA N T O B S E RVAT I O N At the Center for Infants and Their Families, we see families very early; more than 60% are referred before the infant reaches 3 months of age. Most often, we have mother, father, and infant together in our therapeutic sessions. Because the majority of Danish women breastfeed their infants (more than 60% for more than 6 months), it is convenient for the mothers to bring their infants; and having the infant in the therapy sessions is of tremendous value. We see, as did Selma Fraiberg in 1980, that the infant acts as a catalyst for change and in most cases intensifies the therapeutic process.17 As argued previously, we also see it as a pronounced advantage, in most cases, to have the father participate in the intervention, as well. Even if it is the mother who seems in greater need of help, who shows signs of depression or ambivalence, or who expresses feelings of serious inadequacy, it is our experience that the dynamic between the parents plays a greater role in the whole family’s functioning than is usually considered. Even if the father has no psychological problems himself, other than worry for his wife, we

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find that the father ’s presence and the participation of the intact family provides a better outcome and leads to more permanent changes and stability. Perhaps this finding is connected with the previously mentioned sharing of responsibilities and the equality of involvement of Danish parents in coping with daily life. We still need a more structured assessment to test this impression of a better outcome. However, we share with the public health nurses who continue to follow the families the point of view that the fathers’ participation in therapy is beneficial. In our interventional treatment models, we mainly use two tools. One is observation (of infants and of parent-infant interaction); the other is traditional psychodynamic psychotherapy (focused on the parents individually or as a couple). We usually work with an integration of these approaches. Combining our skills in observation and psychotherapy, we can follow each family in its individuality; and we are able to shift focus flexibly, according to the needs encountered.18 This integrated approach offers special opportunities and at the same time makes special demands on the therapist. When dealing with families with small infants, it is easy to be overwhelmed by all the input, and difficult to witness the pain and suffering stemming from unhappy and unsatisfying interactions. The urge to act, to do something, to try to make the situation better at once, is common, especially among our young therapists. In the sessions, however, it is important to keep our balance in observing without necessarily intervening, to concentrate on what the parents say and feel without overlooking what they actually do and how the baby is doing. In order to keep this balance, we find it necessary for the therapist to have both therapeutic training and elaborate skills in observing infants. The therapist’s patient, observant, nonjudgmental position is crucial; and therefore, such concepts as containing, holding, reflecting, and timing are at the core of our training. Our training models consist of training in infant observation, and training in psychotherapy under supervision; we use co-therapeutic models, one-way screen observations, and video recordings. Questions That Guide Our Work • What do we see? Seeing and observing play a crucial role. The obstacles against being able to see are numerous and complex. Why was the infant not seen as an individual in the professional world for so long? Preconceived knowledge and theory did not allow the space or expectation for being attentive. Perhaps

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•

•

•

•

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also there is a feeling in primary health care of powerlessness, of not knowing what to do. (The public health nurses report that after they began working with our center they also began to dare to see more difficulties. They allowed themselves to acknowledge the problems they saw because now they could do something to help: They could tell us about a family’s situation and receive appropriate guidance, or they could give the family a referral to our center for further treatment.) What do we feel? Contact with a troubled family arouses many feelings. It is urgent to be attentive to these feelings and not just to suppress them—to allow them to be there and, within the context of the supervision process, to clarify them. It is essential to resonate and to contain the pain, anger, fear, sadness (and, more seldom, joy) stemming from the family. What do we understand? How do we understand the situation of a family? Why are they doing the things they do in their lives and in the sessions? In this work, we need to be able to stay with and endure a position of not-knowing and doubt for quite a while. How do we describe? We try to be aware of the ways and the words we use to describe. We find tremendous advantages in using plain, normal, common words in our descriptions of concrete activities and in quoting the words used by the parents as accurately as possible. We defer the use of the more interpretive and diagnostic terms for theoretical discussions. What do we do? What do we want to do? What does the family want us to do? What does the family allow us to do? What are the possibilities? Changes occur only through the family’s own activity. Are our expectations realistic? Do our interventions have any side effects? Or, rather, what will the side effects of our interventions be?

These are the questions we often put to ourselves when working in this sensitive area.

CONCLUSION So far, our studies in fatherhood indicate that the inner turmoil and external adaptations of new fathers put them in a psychological state very much like that of new mothers (described by Daniel Stern as the “Motherhood Constellation”)19 and that the transition to fatherhood is a unique psychological constellation that contains

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not only energy and capacities to attach and attune to an infant but also vulnerability. The rather new, but so far very promising, approach to involve fathers in early intervention will undoubtedly be more developed in the near future. As this happens, our knowledge about fathers, and therefore our capacity to help families, will improve. We believe that giving more attention in theory, research, and clinical practice to fathers, their experiences with their infants, and their transition to fatherhood is a necessity for development of the capacities embodied in fatherhood; and we hope, with our work, to facilitate and contribute to this development. REFERENCES 1. Brazelton TB. Neonatal Behavioral Assessment Scale. Clinics in Developmental Medicine. No 50. London, England: Spastics International Medical Publications; 1973. 2. Als H, Lester BM, Tronick EZ, Brazelton TB. Manual for the Assessment of Preterm Infants’ Behavior (APIB). In: Fitzgerald HE, Lester BM, Yogman M, eds. Theory and Research in Behavioral Pediatrics. Vol 1. New York, NY: Plenum Press; 1982. 3. Gøtzsche V, Lier L, Munck H. Graviditet, Fødsel, og det Første Leveår: Forældres og Børns Behov i Perioden Omkring Graviditet, Fødsel og Barnets Første Leveår, Specielt Med Henblik På Barselsorlov [Pregnancy, Birth, and the First Year of Life: Parents’ and Children’s Needs during the Period Surrounding Pregnancy, Birth, and the Child’s First Year of Life, Especially Concerning Maternity Leave]. Stockholm, Sweden: Nordisk Utredningsserie B:10; 1979. 4. Munck H. Psykologisk anvendelse af Brazelton skalaen [Psychological use of the Brazelton scale]. Tidsskrift for Jordemødre. 1984;6:8–14. 5. Munck H, Mirdal GM, Marner L. Mother-infant interaction in Denmark. In: Nugent JK, Lester MB, Brazelton TB, eds. Cultural Context of Infancy. Vol 2. Norwood, NJ: Ablex Publishing Corp; 1991:169–199. 6. Munck H. The primary prophylactic approach in Denmark: In symposium— Scandinavian models for early prevention within the general health system. In: Proceedings of the 6th World Congress of the World Association for Infant Mental Health; July 1996; Tampere, Finland. 7. Munck H, Dutton Poulsen I, Matejka P, et al. An early clinical Intervention project with “newborn” families at the University Clinic in Copenhagen. In: Proceedings of the 5th World Congress of Infant Psychiatry and Allied Disciplines; August 1992; Chicago, IL. 8. Petersen MB, Greisen G, Kovacs R, Munck H, Friis-Hansen B. Status at four years of age in 280 children weighing 2,300g or less at birth. Dan Med Bull. 1990;37(6):546–552.

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9. Hoff B, Munck H, Greisen G. Assessment of parental sensivity towards pre-school children born with very low birth weight. Scand J Psychol. 2004;45:83–87. 10. Munck H. Intervencão Hospitalar com Pais de Bebés Prematuros I [Hospital Intervention with Parents of Premature Babies]. In: BEBÉ XXI, Crianca e familia na viragem do século [Children and family at the turn of the century. Portuguese] Lisboa, Portugal: Fundacäo Calouste Gulbenkian; 1995. 11. Socialstyrelsen. Samspelsbehandling i Spädbarnsfamilier: En Beskrivning av Spädbarnsverksamheter i Sverige [Interactive Treatment in Families with Infants: A Description of Infant Institutions in Sweden]. SOS-rapport 14. Stockholm, Sweden; 1993. 12. Phares V. Fathers and Developmental Psychopathology. New York, NY: John Wiley & Sons Inc; 1996. 13. Munck H, Lind D, Madsen S Aa. Fædre og tidlig intervention [Fathers and early intervention]. In: Elsass P, Lunn S, eds. Psykologi i Forvandling: Et Jubilæumsskrift fra Institut for Klinisk Psykologi [Psychology in Transformation: A Jubilee Publication from the Institute for Clinical Psychology]. København, Denmark: Københavns Universitet; 2000. pp: 159–172. 14. Madsen S Aa, Lind D, Munck H. Fædres Tilknytning til Spædbørn [Fathers Attachment to Infants]. København, Denmark: Hans Reitzels Forlag; 2002. 15. Madsen S Aa, Munck H, Tolstrup M. Fædre og Fødsler [Fathers and Births]. København, Denmark: Frydenlund Grafisk; 1999. 16. Madsen S Aa, Munck H. Une étude au Danemark: La présence des pères à l’accouchement [A study in Denmark: Fathers’ attendance at childbirth]. Santé Mentale au Québec. 2001;26(1):27–38. 17. Fraiberg, S. Clinical Studies in Infant Mental Health: The First Year of Life. New York, NY: Basic Books; 1980. 18. Munck H. Using the NBAS with Families: A psychotherapeutic approach. In: Brazelton TB, Nugent JK, eds. Neonatal Behavioral Assessment Scale. No 137. London, England: MacKeith Press; 1995:108–116. 19. Stern D. The Motherhood Constellation. New York, NY: Basic Books; 1995.

CHAPTER 10

A Model for Working in Community Health Settings: United Kingdom JOANNA HAWTHORNE and BETTY HUTCHON

Recently in the United Kingdom, the Neonatal Behavioral Assessment Scale (NBAS) has become popular with health professionals as a supportive intervention for parents of all newborns—especially when newborns are preterm or have developmental issues, or when parents have concerns or there are relationship difficulties. It helps parents come to terms with their babies, validates their observations of their young infants, and strengthens relationships between health professionals and families. With funding from the government’s early intervention project, Sure Start, several community-based teams in deprived areas are being trained in using the NBAS as a supportive intervention. When using the NBAS in a community setting, the goals are similar to those in a hospital setting, namely: • To sensitize parents to their newborn’s capacities • To describe positive behavior as well as difficult behavior • To help parents read their infant’s behavioral cues as meaningful communication At present, the NBAS is not widely available in either hospital or community settings in the United Kingdom, although 164 people are fully trained, and 100 are in the process of training, particularly Sure Start, UK, and Flying Start, Wales, personnel. These are healthcare workers whose brief is health promotion and education and, above all, providing support for mothers in deprived areas, to enable them to develop healthy relationships with their infants. 112

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In this chapter, we describe the use of the NBAS with preterm babies in a neonatal unit and on follow-up in the community, and illustrate with two examples from the community, one using the NBAS with a full-term baby, and the other using the NBAS with a baby who has Prader Willi syndrome. G O I N G H O M E F R O M T H E N E O N ATA L U N I T — C A M B R I D G E S U RV E Y Parents who have a sick or premature baby can take time adjusting to the baby they have. The baby in the incubator may be very different from the baby they envisaged throughout pregnancy. The mother ’s pregnancy may have been cut short by a premature birth, and her baby may not look like the chubby full-term baby she and her partner imagined. Parents can have difficulties getting to know their baby in the public atmosphere of the neonatal unit, and if the baby is very ill, access can be hampered by tubes and monitors. The baby may also be very fragile and sensitive to touch, so often parents cannot stroke and hold their baby as much as they would like because doing so could be overstimulating for the baby. Once the baby is 36 weeks gestation, medically stable, and almost ready to go home, the NBAS can be used as a preventive intervention. It can demonstrate to parents their baby’s skills and help them read their baby’s signals and cues. It can guide parents in learning to figure out ways to help their baby be comfortable and self-regulated. Several studies have shown that parents need increased support when they have a premature baby. Counseling is available in several U.K. neonatal units, and a few units have multidisciplinary teams—including, physiotherapists, occupational therapists, speech therapists nutritionists, and psychologists—that care for all aspects of the premature babies’ development. In a few units in the United Kingdom, nurses use the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP). Some units use the Neonatal Assessment for Premature Infants (NAPI), and a few use the NBAS. In Cambridge, England, the Community Neonatal Nursing team was established at Addenbrookes Hospital in 2002 to provide medical and feeding support at home. It was decided to set up a supportive intervention using the NBAS. The aim was to provide an intervention to support parents whose babies sometimes had to wait for some time between discharge from the neonatal unit and their first appointment with the Child Development Center.

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Once the intervention was concluded, 22 families were surveyed by a postal questionnaire, which asked them about the intervention. Protocol for Intervention Using the NBAS • Weekly visits to parents in the NICU observing, discussing, and sharing baby behavior • First NBAS: baby over 35 weeks gestation and medically stable • Second and third NBAS exams: 2 and 4 weeks after discharge home • Postal questionnaire: 2 weeks after last NBAS Brazelton Concepts Over the course of the baby’s time in the NICU and Special Care Baby Unit (SCBU), the psychologist discusses the following points with the parents as they sit beside the baby and all observe the baby together: 1. What is your baby like? How would you describe his or her personality? 2. What does your baby like to do/look at? 3. How does your baby react to noise and light? 4. How does your baby react to handling? 5. What position does your baby like to be in? 6. How does your baby manage his or her sleep and awake states? 7. How does your baby comfort him- or herself? 8. Is your baby cuddly? 9. Is your baby strong? 10. How does your baby show you he or she knows you? Of the 22 families surveyed in the follow-up study, 14 mothers responded. Of these, almost half (46%) reported that the NBAS helped them notice something about their babies they had not noticed before. Most mothers (64%) felt the sessions had helped them adjust to their baby’s behavior, and 57% felt that their babies had benefited from the NBAS. Sixty-two percent of the mothers felt that their needs and their babies’ needs for emotional support were being met. All the parents who responded to the survey said that they found the NBAS helpful and would recommend it to other parents.

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Many parents wrote comments about the intervention expressing their thoughts: • “Bonding is difficult in the NICU. The baby does not feel like your own. The assessment helps to affirm you do know your baby.” • “Gave us the ability to see him as a ‘normal’ developing baby and not seem like a medical patient.” • “Sessions helped us relax and enjoy time spent with him rather than anticipating the worst.” • “Hadn’t previously realized how much it was possible to interact with her and therefore played with her much more following sessions.” • “Amazing to me to see someone being so positive about my baby who was so sick.” • “I do now spend longer watching her and adapt my behavior depending on hers.” The staff reported that they felt the parents were more confident, less hostile, and more accepting of their baby’s situation. Using the NBAS at Home Babies from the NICU and SCBU are more likely to have challenging behaviors compared to full-term babies, and the NBAS can help parents understand their baby’s signals and cues and work out strategies to support their babies’ development. Performing the NBAS twice in each home gave parents a chance to discuss their baby’s behavior first in relation to the baby’s homecoming, and later in terms of the concerns that developed once the family had been at home for a while. The NBAS intervention offered nonmedical support that bolstered parental efforts to regain control over the care of their baby after a long stay in the neonatal unit, where the parents may have felt de-skilled. The community neonatal nurses continued to visit the family until feeding was well-established. Interventions in the early weeks have been shown to be effective in supporting the developing parent-baby relationship. Early interventions have also been shown to improve collaboration between parents and the hospital staff and among members of staff. Using the NBAS in the NICU/SCBU has continued to take place in the hospital in Cambridge. A community neonatal nurse, midwives, and health visitors are training in the NBAS, and the neonatologists are keen to support this work.

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The following examples illustrate the use of the NBAS in supporting parents and their efforts to understand their baby’s behavior.

Clinical Examples Baby A Baby A’s birth had been a planned home birth, but due to complications, his mother was transferred to the hospital labor ward. Following delivery, the infant was transferred to the SCBU. He was a full-term newborn, but not the healthy baby his parents had anticipated. He was very sleepy, had problems feeding, and had low muscle tone. The medical staff broke the news to his parents that it was very likely that Baby A had something the parents had probably never heard of—Prader Willi syndrome. The parents were distraught. The occupational therapist initially approached the parents while in SCBU but, feeling that they were still coming to grips with the diagnosis, decided that a follow-up visit on discharge at home would be more beneficial. The occupational therapist administered the first NBAS in Baby A’s home when he was one week postterm. His parents’ primary concern, at this point, was his poor feeding; and he continued to be fed mainly through a nasogastric tube. His mother had planned on breastfeeding and was still keen to pursue this goal. Throughout the administration of the NBAS, the parents watched intently. Baby A remained mostly in States 2 and 3. He showed no fussing or irritability in response to any of the maneuvers or stimuli. His muscle tone was low, and his reflexes were weak—in particular, the suck reflex. During the Orientation items, he showed an emerging State 4 and tried desperately to fix and follow. His parents were very excited by this. They said it was the first time they had seen him respond in this way. Upon completing the NBAS, the occupational therapist sat with the parents and explained in more detail how the behaviors observed during its administration could now be used to help plan some short-term goals. Discussion focused largely on the range of states available to a strong newborn and how Baby A, while not showing the full six states at this stage, could be helped to achieve them. The occupational therapist provided ideas and suggestions regarding appropriate stimulation to help promote a wider range of states and, in particular, State 4. The parents were very encouraged by this discussion and were able to make the association between more alert, robust states and better feeding. It also gave them hope that they could help their baby play and learn. They were glad to have the structure of the NBAS in order to see and understand their child’s strengths, as well as his vulnerabilities. Baby A’s parents commented that it was their first positive experience since their child’s birth. They were a well-educated, articulate

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couple, and they appreciated the systematic approach of the NBAS. It helped provide goals and gave them some positive ideas for things they could do with their baby to help promote his development. The occupational therapist continued weekly home visits to Baby A throughout his first few months and administered the NBAS on several more occasions. His parents continued to find it the most positive experience of any other intervention. They established a close and trusting relationship with the therapist and continue to send Christmas cards from Baby A, who is now 7 years old.

Baby B Baby B was referred to the occupational therapist by the Health Visitor (public health nurse) who specifically requested that the NBAS be administered. The Health Visitor had heard of the NBAS at a professional seminar and had been particularly impressed by a case study that illustrated its use with irritable babies. Baby B was described as one of twins who were born at term and who were now 7 weeks old. The difficulty with Baby B was that he kept crying despite much comforting and consoling, and his mother was finding it increasingly difficult to cope. There appeared to be no reason for the persistent crying. His twin sister was described as doing well, and there were no reported concerns about any aspect of her development. The occupational therapist visited the family with the Health Visitor the day after the referral. The mother was very pleased because the nurse had explained previously that the therapist had a technique that could be very helpful in identifying the source of a baby’s irritability. The occupational therapist felt slightly anxious about this introduction, worried that the mother might feel badly let down if these expectations were not met. Baby B was asleep in his seat in the living room. The occupational therapist, after giving the mother some information about the NBAS and what might happen, proceeded to administer the Habituation items. Baby B responded to these items with classic “textbook” habituation: he initially responded to the items while asleep, but was able to decrease and eventually cut out his responses after several administrations. He continued to sleep soundly in his chair, and showed no sign of irritability. The therapist followed the Habituation items by gently picking up Baby B, undressing him a little, placing him on his changing mat, and administering the Reflex items. These items normally help to wake a sleeping baby, but Baby B continued to sleep and had to be helped to wake up. At this point, Baby B had already demonstrated robust States 1, 2, and 3; but now went immediately to a State 6—the crying state. Baby B’s mother explained this was typical behavior whenever he was awake. She described him as only sleeping and crying. Baby B made (Continued )

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some serious efforts to comfort himself but didn’t succeed in bringing himself to a quieter state. Neither did any of the consoling maneuvers result in a State 4. Baby B’s mother said she would often have to leave him in this crying state because he wouldn’t stop and eventually he would wear himself out and fall asleep again. The occupational therapist attempted to get Baby B interested in the Orientation items by talking to him and playing with the rattle. Baby B settled down momentarily and showed wide-eyed State 4 interest in the rattle but quickly became upset again and looked away. Once or twice more it was possible to get some purposeful fixing and following and an alert State 4; but Baby B seemed to be unable to sustain it, instead protesting loudly and again going to a State 6. A lengthy discussion followed, involving the mother, the Health Visitor, and the occupational therapist. The NBAS had shown a profile of a baby who had a full range of strong robust states. He did not show any hypersensitivities to the environment, nor to the items presented. It seemed clear he was communicating another need, which the therapist felt might be hunger. However, the mother and the Health Visitor disagreed, explaining that because he was a twin, Baby B was being fed every four hours (this schedule was felt to be more manageable for his mother); and he was putting on weight appropriately and progressing up his weight chart. The occupational therapist felt that further investigation of his crying might be helpful because both Baby B and his mother were distressed. Baby B’s mother was anxious to be given ideas about responding to her baby in ways that would be helpful, but because demand feeding did not seem to be an option, the therapist suggested she visit her general practitioner for further advice. The occupational therapist arranged a follow-up visit to the home in 2 weeks time. On this second occasion, a very different Baby B was found. He was happy, playful, and alert. The therapist was surprised and asked the mother what had changed. The mother explained that following the administration of the NBAS, which had ruled out any hypersensitivities being the source of the crying, she reconsidered the program of feeding Baby B every 4 hours and decided to feed him whenever he cried. He immediately became quieter, happier, and more content; and she now had a baby who was happy to be awake and play. The occupational therapist and the mother discussed the fact that babies are not aware of weight charts, and some babies just like to feed more than others. The mother was very grateful that the NBAS had facilitated a systematic assessment of her baby, and while it was not able to pinpoint definitely that his protest was about food, it was able to rule out other possibilities. This insight, provided by the NBAS, appears to have helped the mother gain confidence in understanding her baby and inspired her to try another approach to feeding.

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CONCLUSION These examples show how the NBAS can provide a supportive intervention to parents of premature babies, parents of babies with different syndromes, and parents with babies who may be difficult to read. There is an advantage in providing community follow-up, as parents tend to be more comfortable in their own homes than in the hospital, and as they spend more time with their babies, they can feel more in charge. Support in the community also allows the health professional to see the parent for a more extended followup. The Health Service in the United Kingdom is structured to allow for support in the community, and the NBAS is gradually becoming a vital component of its early intervention strategy. ADDITIONAL READINGS Brazelton TB, Cramer BG. The Earliest Relationship. London, England: Karnac; 1991. Cooper PJ, Landman M, Tomlinson M, Molteno C, Murray L, Swartz L. Impact of a mother-infant intervention in an indigent peri-urban South African context. Br J Psychiatry. 2002;180:6–81. Cohen M. Sent before My Time: A Child Psychotherapist’s View of Life on a Neonatal Intensive Care Unit. London, England: Karnac; 2003. McFadyen A. Special Care Babies and Their Developing Relationships. London, England: Routledge; 1994. Murray L, Cooper PJ. The role of infant and maternal factors in postpartum depression, mother-infant interactions, and infant outcomes. In: Murray L, Cooper PJ, eds. Postpartum Depression and Child Development. New York, NY: Guilford Press; 1997. Nugent JK, Brazelton TB. Preventive infant mental health: Uses of the Brazelton Scale. In: Osofsky JD, Fitzgerald HE, eds. WAIMH Handbook of Infant Mental Health: Early intervention, Evaluation and Assessment. Vol 2. New York, NY: John Wiley & Sons Inc; 2000. Rauh V. Achenbach T, Nurcombe B, Howell C, Teti D. Minimizing adverse effects of low birthweight: Four-year results of an early intervention program. Child Dev. 1988;59:544–553.

CHAPTER 11

Using the Newborn Behavioral Observations (NBO) System with At-Risk Infants and Families: United States YVETTE BLANCHARD

Eric was born at 24 weeks of gestation weighing 620 g. He suffered a severe brain hemorrhage (grade IV) soon after birth and has been diagnosed with Stage 2 retinopathy of prematurity. Finally home after 4 long months in the hospital, he is off oxygen during the day but still requires it at night. He is bottle-fed but tires easily and can only take up to 2 ounces per feeding. His neonatal intensive care unit discharge nurse referred him to early intervention (EI). After he was home 1 week, Eric’s mother received a phone call from the EI program coordinator and scheduled a convenient time for his initial eligibility evaluation.

When an infant is referred to EI, the first point of contact between the family and the EI service providers is often in the context of the initial eligibility evaluation. As those involved in this process know, completing a developmental assessment and service plan on such a young and medically fragile infant is no small task. Interventionists often leave an initial eligibility evaluation session feeling that they have missed valuable information and have not been as helpful to parents as they would like to have been. On the other 120

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hand, parents may not have received the kind of developmental information and support they need in the early weeks and months following homecoming. The clinician’s ability to establish a relationship of support with the family seems compromised from the beginning. While there are many possible reasons to explain why both parties feel their needs are not met, two of the main reasons are: (1) a lack of evaluation instruments designed to capture the early signs of developmental competencies and vulnerabilities in the very young infant, and (2) a need for specialized training in very early infant development and neurobehavioral functioning for EI providers. To support the efforts of EI service providers in determining eligibility and subsequent individual developmental goals of infants and families, the developmental assessment of a very young infant should accomplish three major goals:1 1. Determine the level of developmental maturity. 2. Identify the areas of developmental vulnerabilities. 3. Offer guidance to families for immediate individualized developmental intervention. In order to reach these goals, the assessment model used for the very young and sensitive infant should be designed to examine the level of competency of very early developmental skills and be able to identify immediate and individualized intervention strategies for infants and their families. This chapter provides an overview of the evaluation process in EI and describes how the integration of the Newborn Behavioral Observations (NBO) system into the eligibility evaluation will assist EI providers in conducting improved assessment and program planning for young infants while meeting the needs of families for individualized attention and services.2 M E E T I N G T H E N E E D S O F FA M I L I E S O F V E RY Y O U N G I N FA N T S I N E A R LY I N T E RV E N T I O N The mission of most EI programs is to strengthen the capacity of families to meet the developmental needs of their infants and toddlers who have, or are at risk of having, delays or disabilities. Guided by the philosophy of such a mission statement, the evaluation process should reflect the ongoing collaboration between clinicians and parents in understanding the child and his family and

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should be viewed as the first step in a potential intervention process.3 Given that a service plan will be written from the findings of the evaluation, it becomes critical that those findings capture the infant’s unique developmental strengths and challenges and also give the parents an opportunity to see and further understand the developmental issues concerning their child. The evaluation experience should provide the structure for the upcoming short-term intervention goals and strategies and is obviously not complete unless it also incorporates the parents’ own concerns and goals for their child. With the evaluation itself, intervention has already begun because, given the right evaluation tools—the testing abilities of the service provider and the active involvement of the family—all the ingredients needed for the determination of an individualized service plan are present. Unfortunately, most of the traditional screening and evaluation instruments used in EI are limited in their ability to capture the early signs of developmental vulnerabilities in the very young infant because they were not designed to document the qualitative aspects of early infant behavior and development. In order to improve eligibility evaluation procedures, EI providers need to appreciate the complex behavioral repertoire and the dynamic, reciprocal interactions that newborns and young infants bring to the world.4 Integrating a neurobehaviorally based assessment, such as the NBO, into the eligibility evaluation and ongoing assessment of the very young child will provide early interventionists and families with the best model to meet the needs of families and their infants in this very early phase of intervention. Only then can we begin to understand the early developmental agenda of a very young infant who has had a complex medical history. N E U R O B E H AV I O R A L M O D E L S The neurobehavioral models proposed by Brazelton5 in his work with full-term infants, and Als,3,6,7 in her work with preterm infants, provide a framework for the understanding of neurobehavioral functioning of the very young infant. Within the framework of these models, the newborn infant’s capacity to organize his behavior so that he is able to play an active role in influencing his caregiving environment and eliciting the support he needs for his development is among the earliest developmental tasks accomplished.3,8 In order to understand how this model applies to work in EI, the first step is to learn about infant behavior and early neurobehavioral functioning. Als elaborated on Brazelton’s neurobehavioral

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model of the full-term infant by proposing the synactive theory of behavioral development, which categorizes behaviors into three different subsystems: the autonomic system, the motor system, and the state system. The synactive theory proposes a dynamic interaction of the subsystems with each other and, simultaneously, with the environment, and so these subsystems are viewed as being both interdependent and mutually supportive of one another.3,6 Within this behavioral framework, infants’ behaviors are seen as meaningful, communicative, and indicative of the infant’s efforts, successes, and failures at self-regulation. For each of the subsystems, Als has identified behavioral channels of communication and describes behaviors as either approach/self-regulatory behaviors or avoidance/stress behaviors. An infant is described as organized when his self-regulatory abilities are able to support the demands placed on him as demonstrated by his approach behaviors. Conversely, a child is described as disorganized when his threshold to self-regulation is exceeded and avoidance behaviors are observed, indicating stress.3,9 For example, respiratory rate, color, and visceral signals are the behavioral channels of the autonomic system. A regular respiratory rate, good color, and stable digestion are noted in well-organized infants while infants who are showing signs of disorganization may have irregular breathing, poor color, and signs of unstable digestion. Within the motor subsystem, organization and disorganization are observed through muscle tone, postures, and movement patterns. Smooth movements and balanced flexor-extensor tone would be considered organized behaviors, while jerky movement quality and overuse of extensor movements would be considered disorganized. The state system is observed in terms of the range of states of consciousness available to the infant, the robustness and stability of each state, and the patterns of transition from state to state. An infant with a well-organized state system has a broad range of well-defined states available with smooth transitions from one state to the next. A less well-organized infant may have a narrower range of states; states may be more diffuse; and the infant may have rapid state changes. Attention-interaction is considered an outgrowth of the state subsystem and is observed through the infant’s ability to respond and interact with animate and inanimate objects. Infants with well-organized attention-interaction can achieve and maintain shiny-eyed alertness and well-modulated interactive periods at least briefly. A less well-organized infant may have strained, low level alertness or, conversely, may be hyper-alert and unable to break away from interaction that may be too intense.

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For an infant with well-organized self-regulation, the subsystems are well integrated and function in smooth synchrony, supporting and facilitating each other. An infant with less well-organized self-regulation requires more assistance from adults and the environment to achieve and maintain subsystem interaction and integration. The kind and intensity of facilitation required to achieve behavioral organization becomes instructive for early interventionists and parents, and can form the basis for individualized goals and strategies for that infant.3,5,6 I N T E G R AT I N G N B O N E U R O B E H AV I O R A L C O N C E P T S I N T O E I E VA L U AT I O N A N D S E RV I C E P L A N N I N G The NBO, designed to promote the parent-infant relationship through behavioral observation, contains several key concepts of neurobehavioral assessment grounded on synactive theory that can be integrated into the initial eligibility evaluation and subsequent assessments conducted by EI providers. First, observing the infant’s behaviors before, during, and following an event (NBO or home visit), while paying attention to the physical and social contexts, will help the EI provider understand how a particular infant responds over time and will provide information on his ability to maintain an organized state when disturbed and to recover after disorganization. Therefore, behavioral observation begins the moment the EI provider enters an infant’s home and ends when he or she leaves. The infant’s behaviors across the subsystems described previously are first noted when the EI provider observes the child before the assessment begins. Notation is made of these baseline behaviors and of the physical environment and social surroundings of the child. The NBO maneuvers become the event against which the infant’s neurobehavioral responses will be challenged. In other words, the demands of the evaluation itself become the structured setting against which stable neurobehavioral functioning is challenged and measured. The behavioral observation continues throughout the duration of the evaluation with concurrent observation of specific environmental events, or aspects of the evaluation itself, that challenge self-regulatory control. Once the formal evaluation or NBO is completed, the observation is continued for some time in order to document the infant’s recovery from the stresses of the interaction. The observation of the infant’s behavior over time will later help the EI provider tell the story of the event from the infant’s perspective and develop a behavioral

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profile of the infant. This evaluation write-up describes the infant’s neurobehavioral profile and allows the parents and caregivers to better understand the individual pattern of response and reactivity demonstrated by their infant. A second concept that can be taken from neurobehavioral assessment is the importance of capturing the moment at which the first signs of disorganization occur. This allows caregivers to identify key events during the NBO, such as handling or social demands, that trigger loss of self-regulation and subsequently lead to disorganization. Understanding and identifying infant sensory thresholds can allow caregivers to modify environmental and social demands to be more supportive of infants’ self-regulatory limits. In order for the NBO to be pursued from this point on, however, EI providers need to be able to support the infant’s attempts at self-regulation as soon as signs of disorganization are observed. This brings us to a third concept of neurobehavioral assessment that relies on the provider ’s ability to offer well-timed individual assistance and support to the infant that matches his own style and his attempts at self-regulation. Within this perspective, intervention is aimed at facilitating prolonged periods of organization, thus decreasing the manifestation of disorganized behaviors while recognizing and reinforcing the infant’s individual self-regulatory style. For example, well-organized full-term newborns and infants may be observed bringing themselves into sleep by placing one hand against the back of the head or behind the ear with the other hand close to the mouth. Less well-organized infants, such as infants born prematurely, drug-exposed, or with medical complications may attempt to do the same, but may not be as successful at maintaining these comfort postures by themselves. Building on these observations, the caregiver, parent, or service provider can assist the infant by positioning him sideways (within boundaries to brace against), by bringing the hand close to the mouth, by offering a finger to hold, by tucking the legs and allowing the infant to brace his feet against a hand until he settles down, and in these ways helping him maintain a state of organized functioning. CONCLUSION Although many states require a score from a standardized tool in order to determine eligibility for EI, the information gathered during the NBO may provide clinical information needed by the early interventionist to substantiate eligibility on the basis of clinical judgment. Behavioral descriptors may be used when infants

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receive a passing score on a standardized tool but show qualitative dimensions of functioning that are clinically concerning.1 For example, one infant may track a red ring with low alertness, paling, and facial flaccidity, while another infant may track the same red ring with shiny-eyed alertness, good color, and good muscle tone. While both infants would receive a passing score on the test item, the behavioral descriptors give a very different picture of these infants that would not be available on the basis of scores alone. The integration of the NBO into the evaluation of high-risk infants will allow EI providers to meet the three goals of a developmental assessment stated earlier: 1. The infant’s attempts to self-regulate and successes at selfregulation are indicators of the current level of developmental maturity and robustness. 2. The infant’s behavioral manifestations of disorganization or loss of self-regulation are indicators of developmental vulnerabilities and sensory thresholds. 3. The type and amount of support offered by the examiner forms the basis of the individualized intervention strategy and educational approach needed to support the developmental agenda and goals of this infant and promote the relationship between the infant and his parents and the relationship between the provider and the parents.

Clinical Example The following example illustrates how the neurobehavioral information gathered through the NBO provides the EI provider and the parents with a richer understanding of the infant’s developmental strengths and vulnerabilities. When I arrived at Eric’s house to conduct his eligibility evaluation, he was sleeping in his crib. His mother told me that he sleeps all day and is rarely awake. I told her to let him sleep because I was interested in his sleep and his waking up. After explaining the content of the evaluation that was to take place, I flashed a light in Eric’s eyes and then shook a rattle near his ear for up to 10 times each. Eric responded to the first four lights by squirming slightly, but then stopped responding to the subsequent light presentations. He showed a similar reaction pattern to the rattle presentations. His mother was very interested in learning about his ability to protect his sleep even when disturbed by the light and rattle. I then placed Eric on his back and

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uncovered him. He stretched his back, arms, and legs for close to 1 minute. He grimaced and fussed but kept his eyes closed. Eric’s mother commented on Eric’s difficulty in waking up, which almost always ends in crying after a period of stretching and fussing. This provided an opportunity for me to talk about state control and state transition with the mother and explain how some infants show difficulty in this area of their development in the first months of life. I shared strategies and offered guidance for developmental expectations. I then examined the tone in his arms and legs. Eric showed a strong response in all his reflexes; he held his head up during the pull-to-sit maneuver, and crawled forward by kicking his legs when placed on his stomach. Because his eyes were still closed, I suggested closing the curtains on the large living room window to see if less light would make a difference for him. As soon as the curtains were drawn, Eric opened his eyes. His mother mentioned she had noticed that he seemed to be most awake during his night feeding but was not aware that lighting might have played a role in his ability to be more awake. Even though Eric remained awake, he showed his sensitivities by needing to shut out a lot of activity around him; he did so by closing his eyes often. I picked him up and held him sitting on my lap. When I shook a rattle next to his ear, he opened his eyes and turned his head slightly toward the sound of the rattle. His mother then called his name, and he listened to her voice by quieting his body movement and becoming very relaxed. His mother mentioned that he quiets to her voice when he becomes fussy. With slow vertical rocking and removal of the sweater he had on over his pajamas, Eric gradually became more awake and was able to turn his head toward his mother ’s voice and look at her. It was the first time she had seen him respond to her voice with such deliberate action. Soon thereafter, Eric became tired and fussy, letting us know he needed to rest in his crib. The session ended with a discussion summarizing Eric’s accomplishments and challenges. Eric’s mother was able to identify her infant’s needs by saying she would assist his efforts at becoming more alert and stimulate his interest in her voice while giving him opportunities for quiet sleep when tired. Eric’s mother and I, as the EI provider, both felt a lot was accomplished during this first visit. I had the information I needed to develop an individualized service plan that would meet EI administrative requirements, and Eric’s mother felt she was better informed about her child’s developmental strengths and challenges.

REFERENCES 1. Blanchard Y, Mouradian L. Integrating neurobehavioral concepts into early intervention eligibility evaluation. Infants Young Child. 2000;13(2): 41–50.

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2. Nugent JK, Keefer CH, Minear S, Johnson L, Blanchard Y. Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) System. Baltimore, MD: Paul H. Brookes Publishing Co; 2007. 3. Greenspan SI, Meisels SJ. Toward a new vision for the developmental assessment of infants and young children. In: Meisels SJ, Fenichel E, eds. New Visions for the Developmental Assessment of Infants and Young Children. Washington, DC: Zero to Three; 1996:11–26. 4. Als H. Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Ment Health J. 1982;3(4):229–243. 5. Brazelton TB. Neonatal Behavioral Assessment Scale. London, England: Spastics International Medical Publications; 1973. 6. Als H. A synactive model of neonatal behavioral organization: Framework for the assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care unit. In: Sweeney JK, ed. The High-Risk Neonate: Developmental Therapy Perspectives. New York: Haworth Press; 1986:3–55. 7. Als H. Reading the premature infant. In: Goldson E, ed. Nurturing the Premature Infant. New York, NY: Oxford University Press; 1999:18–85. 8. Brazelton TB. Observations of the neonate. J Am Acad Child Psychiatry. 1962;1:38–58. 9. D’Apolito K. What is an organized infant? Neonatal Netw. 1991;10(1):23–29.

CHAPTER 12

Early Intervention in an Australian Setting BEULAH WARREN

Although Australia is geographically isolated from most of the Western world—New Zealand being its only western neighbor— the familial roots of most of the population for a long time have been in Western Europe, Eastern Europe, and North America. In recent years, with an increase in Asian migration, that pattern has begun to change. Much has been written of “the tyranny of distance” and its consequences for life in Australia, both socially and economically. The distance referred to is not only external— isolation from neighboring countries. It is also internal, for within Australia a great number of families and communities are geographically isolated and live great distances from many resources, such as educational facilities and medical expertise, and from the emotional support of extended family. In 2000, I wrote: The emotional threads that are woven through the history of Australia have relevance to our understanding of infant mental health in Australia at the end of the twentieth century. There has been a pervasive denial of the pain of loss: • Succeeding generations of Australians have struggled with issues of separation and loss from their birthplaces. Sometimes it was a relief to be in a new country. For example, for some of the early convicts and later refugees, Australia represented a new start, but for most there has been considerable pain at separation from the familiar. For many there was also the reality of an entirely different, harsh landscape, and a pioneering culture lacking refinement—true culture shock. • Children have been separated from their parents “for their own good” since the earliest days of the European colony. It was assumed that

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convicts were not appropriate parents, and therefore that their children needed to be raised by others so that they would become responsible, skilled citizens. In addition, the initial nonexistence of extended family meant that many of the illegitimate and orphaned children of the colony were institutionalized. I might add that aboriginal children were also deliberately separated from their parents; they became known as “the stolen generation.” • Within rural families many children were sent to board in country towns or to boarding school, in particular for secondary education, although some went as young as five or six. In the cities, children of more affluent families have been separated from their parents and sent to board at one of the elite private, single-sex schools. Once again, some for both primary and secondary education. • It has not been acceptable to own or talk about feelings. Instead, the expected behavior following separation or loss was to get on with the task at hand, not dwell on the pain, except to dull it with alcohol or other substances.1

This denial of pain began to slowly change in the latter half of the last century. It is as if, in the discovery of the baby and the importance of infancy, the lid was lifted off the nation’s emotions. In Australia during the 1960s, 1970s, and 1980s, comparable with what was happening in North America (see Chapter 1), there was increasing societal and professional awareness that the infant’s experiences, early interactions, and particularly early human relationships within the family were all significant to later development of the individual. Babies became a focus for clinicians and researchers. The practice of infant observation as part of psychoanalytic training began in 1968 and within a few years was available to a wider group of professionals. Infant behavior per se became a focus of investigation. Dr. Ann Murray, for example, studied crying.2 This new area of research and clinical observation of the individual characteristics of the infant was consolidated in Australia by the visit of Dr. T. Berry Brazelton in 1978 and his training of local professionals on the Neonatal Behavioral Assessment Scale (NBAS).3 Two psychologists who were trained by Dr. Brazelton—Dr. Murray and Dr. Robyn Dolby—were given permission to train others and immediately began to do so. The NBAS was embraced by researchers initially, and within a short while by clinicians as well. Some of the earliest research with the NBAS was in response to concerns about the consequences of childbirth being considered an illness and of increasing intervention in the birth process. The medical profession was looking at the effects of birthing practices on newborns. Research into the effects of medication was conducted

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in the 1970s. For example, Drs. Murray and Dolby and their colleagues studied the effects of epidural anesthesia on newborns and their mothers.4 It was not simply the biological or physical consequences of these practices that were studied, but also the behavioral outcomes for mothers and infants. The NBAS distinguished the differences between the medicated and unmedicated babies in terms of motor, state control, and physiological response clusters, as well as enabled comparisons of their total NBAS scores. Although the differences between the two groups was less dramatic by the time of discharge on the fifth day, the medicated babies continued to show poorer state organization, with a labile pattern in the epidural group and a flat pattern in the oxytocin-epidural group. In addition, the unmedicated group showed better scores on the state control items, and they appeared to be well organized. At one month, the examiners observed few differences between the groups; in fact, the examiners’ NBAS assessments showed no statistically significant differences between the groups, implying that drug effects had worn off by 1 month. However, according to the mothers’ reports, there were subtle behavioral differences, with mothers of medicated infants reporting their babies to be less adaptable, more intense, and more bothersome in their behavior. These mothers also rated their babies on the MABI as having poor overall performance.5 In discussing the results, the authors wondered at the dominance of the baby’s initial behavior in shaping maternal expectations and interactive styles, and the potential for this temporary picture to interfere with the development of a reciprocal relationship between mother and baby. These findings had clinical implications for professionals working with parents and infants in the early postbirth period. By the end of the 1970s, research was being conducted into the consequences of medical practices on infant development, in particular, the consequences of premature birth on later development.6,7 Publication of studies on the battered child syndrome had awakened the world to the disturbing realities of child abuse, and one of the identified at-risk groups was premature infants.8 Methods of intervention to reduce the risks associated with prematurity were investigated. In Australia, for example, Dr. Dolby and her associates found that parents of premature newborns identified as difficult infants appeared to benefit dramatically from early support. At 6-month follow-up, parents of these infants who had received support were more affectionate and verbally responsive toward their infants, as well as more aware and active in meeting their infants’ developmental needs.9

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It was at this time that I joined Dr. Dolby’s team of researchers, having gained my reliability on the NBAS in 1979. My entry into this field followed the birth of our third baby. My overall childbirth experience, especially in the prenatal classes, where there was little or no emphasis on the baby, was an epiphany for me. I changed the topic of my Master ’s thesis so I could investigate how professionals could help parents prepare for the reality of the newborn as a unique individual: How to get to know their baby. Dr. Dolby’s team received a grant to evaluate a preventive care program that could be incorporated into any basic follow-up service for low birthweight infants over the first year. The intervention flowed from assessment, incorporated parents’ perceptions of their infants’ behavior, and was implemented through day-to-day handling, for which parents took responsibility. The NBAS was used as a baseline measure and initial intervention tool at 36, 40, and 44 weeks. In 1983, Dr. Dolby and I visited Boston and worked with Kevin Nugent and Berry Brazelton, obtaining our qualifications as trainers, and with Heidelise Als, from whom we gained valuable insights for our work with premature infants. Then in 1985, Dr. Dolby and I were appointed to the NICU at Westmead Hospital, a new tertiary hospital in a fast-growing area of Sydney; there, we were given the opportunity to implement an intervention program. Our task was to develop a Growth and Development Clinic for the graduates of the NICU—premature infants less than 1,500 g at birth and other at-risk infants. The NBAS was used to assess the babies prior to discharge and at 1-month after discharge. The goal was to help parents in two ways: first, to help them understand the behavior of their small, often fragile infants; and second, to address their concerns. The parents were grateful to be shown their babies’ unique characteristics, to be told what extra help their infants required, and to find out what their babies’ strengths were. Parents grew in confidence as their observations of their babies were validated. They felt less anxious as their questions were answered and they were able to recognize their newborns’ capabilities. The infants were scheduled to return at key points of development over the first 3 years, when assessments were used to identify risks and strengths, and parents once again had the opportunity to raise questions they had regarding their children’s progress. Parents were provided with guidance as to how they could help their children meet the next developmental challenges, and referrals to additional services were made, as necessary.

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For the past 20 years, my primary professional focus has been as a clinician, thus my experience with the NBAS has been training professionals in its use, and using it clinically as an early intervention tool. Many professionals, both clinicians and researchers, have requested training and completed the 1-day orientation to the NBAS. Some have gained the required experience and returned to complete the NBAS certification process. Among these have been a neonatolgist and allied health team members in neonatal nurseries, as well as other health professionals working with infants in maternity and children’s hospitals and postbirth mother-and-baby units. In 1988, I took the position of foundation coordinator of the Early Intervention Program (EIP) at the Royal Hospital for Women, Sydney. This was a home-visiting program for infants at risk, from 0 to 3 years. A multidisciplinary team of six clinicians and an administrative assistant staffed the program. It was a parent-infant unit based on the Child Development Unit model of Dr. Selma Fraiberg.10 The focus was the relationship between parent and infant and the importance of being conscious of the contribution of each. No matter what their disciplines, all of the EIP clinicians were trained on the NBAS because there is no better tool to gain an awareness of the specific attributes of a baby and how those attributes will influence the baby’s contribution to interaction with his or her mother or father. The Royal Hospital for Women had a level III NICU. One third of the referrals to the EIP were families with premature infants. We met the families in the nursery, using the NBAS to reinforce parents’ knowledge of their babies. The families were visited at regular intervals, as necessary, over the early years. For a number of families, the NBAS was a key factor in the intervention. Following are two examples that illustrate this point.

Clinical Examples Alicia and Her Family Alicia was born at 28 weeks gestational age to parents who were both professionals in their mid-30s. The mother, Gayle, had had a miscarriage a short time before becoming pregnant with Alicia. Her pregnancy had been difficult and, at 28 weeks, following a visit to the obstetrician, Gayle was admitted to hospital with hypertension. She was transferred to the tertiary hospital, and the following morning Alicia was born by emergency cesarean section, weighing 825 g, with Apgar scores of 4 and 9. Alicia’s progress in the nursery was not easy. She had hyaline membrane disease, apnea, chronic lung disease, and necrotizing (Continued )

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enterocolitis, but no periventricular hemorrhage. She required mechanical ventilation for 36 days, multiple peripheral arterial lines, and phototherapy because her bilirubin level rose to 117 (mc mol/1); in addition, she received a blood transfusion and total parenteral nutrition (TPN) for 10 days. Alicia was a very active baby and was slow to gain weight. By the time discharge was planned, she was 16 weeks postbirth, 3.5 weeks corrected age, having been in the hospital for 108 days. Her weight was 2,260 g. The nursery staff referred the family to the EIP because of the parents’ anxiety, describing them as “the most anxious parents” they had ever seen. Alicia was described as “hard to settle” and a “wound-up” baby. I met Gayle in the rooming-in facility where we discussed Alicia and her progress to date. Alicia was sleeping, so we talked a little about how Alicia had been since being moved into Gayle’s room. Gayle said that Alicia had been restless that morning, not settling down to sleep. I explained that Alicia may need assistance to get into a curled posture that would enable her to be still and get into a deep sleep. I demonstrated how Alicia could be wrapped to keep her flexed, and encouraged Gayle to hold Alicia until she felt her body become still before placing her in the bassinette. Gayle responded with great interest and invited me to meet her husband, John, the following day, prior to their departure. The next day, I stopped by the room only to discover that Alicia was back in the nursery. “She was a bit snuffly,” Gayle said, explaining that they were not taking her home that day because she had the flu. She commented that they had “waited so long, another few days won’t matter.” I commiserated, and we talked for a few moments. Gayle told me that the baby was booked in until the following Monday. I said that she would probably only stay the one night. Gayle gasped. I realized, then, how terrified Gayle was to take her baby home, and that the staff, both nursing and medical, were all caught up in the family’s anxiety. Babies 4 weeks post due date, doing well medically, did not usually stay another week because they were “snuffly.” I sat down with the mother and father and said quietly, “It is a pretty scary prospect, isn’t it, taking home a new small baby?” With this, Gayle burst into tears and sobbed while she told me the extent of her fears and her sense of helplessness. We looked at possible supports. I assured her that I would visit her at her home—some considerable distance from the hospital. When we met the following week, we focused on how Gayle had managed her care of Alicia while rooming in, what she had discovered about her new baby, and what strategies had worked to settle Alicia. We talked about wrapping Alicia to contain her movement for quiet times and also for sleep. I stressed that most premature babies prefer stimulation with one modality at a time in the early months. John was taking the week off, and they agreed to return the following week so we could do an assessment using the NBAS.

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By the time they returned, John had already learned that if he curled Alicia in his arms, she could snuggle in and relax her tight little body. John filmed the assessment and we reviewed the film together. The parents saw from the assessment that their little girl was relatively robust, and also that she was very responsive to voices. Gayle told me some months later that they took her home that day and talked to her, using their voices to soothe and settle her and also to provide stimulation in quiet alert times. She also reported that in those first weeks Alicia’s cries didn’t seem like crying, but more like a bleating demand, “I want to be held.” And so they held her, wrapped and curled. In being held, Alicia gained control of her body and was able to be still and settle. Gayle gained confidence in knowing she could bring her baby back to a calm base. The tightness in Alicia’s muscular system relaxed, and by 9 months she had made good progress.

Emily and Her Family Emily was born by an emergency cesarean section at 38 weeks because of pregnancy-induced hypertension. She was admitted to the Neonatal Care Nursery for birth asphyxia, absent fetal movement (10 hours), profound hypoglycemia, and her poor condition following birth. In the nursery, she was intubated and monitored. Her Apgar scores were 1 and 6; her birthweight 2,610 g; and her initial head circumference, 34.5 cm. The pathological disease processes documented in the NICU indicated hypoxic brain damage with definite neonatal seizures. In treating Emily in the NICU, the following procedures were required: parenteral nutrition; headbox oxygen; a head ultrasound, which showed cerebral edema and apneic spells; an EEG, which revealed frontal sharp activity and good background rhythm; and a CAT scan, which showed computerized tomography consistent with ischemic insult in the frontal lobe. Emily was the second child of Meg and Graham. Their first child, Toby, was 2 years and 6 months at the time of Emily’s birth. Meg and Graham had been married for approximately 6 years when Emily was born. The referral to EIP was made by Emily’s pediatrician who explained that prior to the birth the mother, Meg, had presented to her obstetrician at 38 weeks, saying she had not felt any movements that day. The reasons for the referral were to provide emotional support to the parents, to give them an opportunity to share their anxiety about the uncertain outcome for their infant, and to conduct a neonatal assessment of the infant and provide developmental guidance to the parents. When the pediatrician phoned, Emily was 2 weeks old and doing well. She was medicated. He asked me to come to the nursery to meet the parents. The pediatrician wanted Emily followed because he was uncertain of her prognosis. The NBAS assessment in the nursery showed that Emily had solid sleep states; however, she moved rapidly from deep sleep to a fussy awake state. Robust crying was observed. In fact, she was predominantly (Continued )

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fussing and crying. Because Emily became very distressed, the more invasive items of the NBAS were not completed. When she was quietly active, Emily tried to get her hand to her mouth to calm herself. Once upset—although she tried to quiet herself at the sound of a voice—Emily needed to be picked up, wrapped, and given the pacifier before she quieted. When dressed, wrapped, and sucking on the pacifier, Emily was able to focus briefly and follow a face and voice for 30 degrees to the left and right before becoming overloaded. The infant’s muscle tone was variable; she was very active, especially when upset, and her movements were jerky. She was very red when crying, from early in the examination. No tremors or startles were noticed. I shared the assessment with the parents, explaining that all infants want to establish an equilibrium of regular sleep, wakefulness, and feeding routines. Establishing this kind of balance was particularly difficult for Emily because of her birth trauma. I shared with Meg and Graham suggestions for handling their baby: wrapping her for sleep and quiet times; encouraging sleep for 14 to 18 hours in 24; talking to Emily to contain her extra movement and distressed states and to help her settle; and, finally, encouraging flexion by wrapping and holding her in a flexed position. Three days later, the family took Emily home. Initially, she was relatively easy, sleeping and eating regularly. The family returned to EIP 2 weeks postdischarge. During the postdischarge NBAS, Emily became very upset, and once again the more invasive items were not completed. However, she also had periods of quiet alertness, when she focused and responded to several stimuli by following for 60 degrees to the left and right. She was able to quiet herself when active, but not when very distressed (State 6). In short, there had been considerable improvement in Emily’s orientation, regulation of state, and motor regularity in 2 weeks, although some tremulousness was observed, and her color changes were still marked. Meg and Graham were pleased with Emily’s progress. The family lived about 50 kilometers from the hospital, but Meg’s mother lived in a closer suburb; and because Meg visited her mother regularly, we agreed to meet at her mother ’s home as the need arose. A third NBAS was completed a short time later, and the orientation cluster was noticeably improved. Emily responded to all items, and there was less tremulousness and more stable color. However, her range of state, regulation of state, and motor control did not show improvement from the second assessment. She did show increased motor tone and stronger extension on handling. Emily worked hard on self-regulation; she tried to use her power of concentration to keep herself calm by locking onto someone or something with her eyes. Meg and Graham spoke of increased irritability during the day but said that Emily was sleeping longer at night. They both used a sling to carry her. As phenobarbitone was reduced, Emily became more unsettled, crying for long periods during the day. Over the ensuing weeks, Emily continued to be extremely sensitive, not allowing the pediatrician or others to assess her because of her

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irritability—initially allowing only her mother to hold and settle her. Her parents clung to the image of Emily as an alert baby, and to the fact that over time she had shown some improvement in her efforts to quiet herself. At around 4 months, Graham phoned to say he was worried about Meg, wondering whether she was depressed. He talked about how difficult it was for Meg to not be getting enough sleep and to have Emily be so demanding, still not settling for anyone else. I reassured him that they were going through an extraordinarily difficult time; that they were not doing anything wrong; that they were good parents; and that Toby, their 2-year-old son, was evidence of this. I agreed to meet Meg at her mother ’s home every 2 weeks. At Meg’s mother ’s home, because of Emily’s sensitivity to handling, we would make a hammock from a sheet and rock her to sleep. Graham decided to take a long service leave, and during that period, Emily began to let him settle her as well. At 9 months, Jan, the physiotherapist on the team, performed a motor assessment. Her approach was to work with a doll and let the parent handle the child. As Jan talked with Meg, little Toby quietly played with the doll. Jan looked down and saw that in his play, Toby had taken a cotton band and placed it across the doll’s mouth. Toby was telling us of his experience with his little sister. It was about this time that Meg phoned to say that Toby’s behavior had deteriorated. He had been so cooperative during the early months of Emily’s life but was now being cheeky and defiant. I said we could discuss what might be happening during my next visit. When I arrived, Meg said that Toby had asked if he could talk with me, too. So from then on, during each visit, Toby and I would talk about his feelings toward his little sister, and how hard it was not being able to do the things he wanted to with mum and dad. Emily continued to slowly improve. Developmentally, she was progressing well, but behavioral regulation remained a challenge. It was not until Emily was about 11 months that she would let her grandmother hold and comfort her. Meg learned to manage Emily’s sensitivity. She spoke about taking Emily, then 10 or 11 months, to be fitted for her first pair of shoes. Emily screamed every time the shop assistant tried to measure her foot, or fit a shoe; the assistant suggested returning on another day, but Meg assured him it would make no difference. Meg took the shoes home. Over the next few weeks, she worked on increasing Emily’s tolerance to them, at first putting them on and taking them off almost immediately, then keeping the shoes on for a few minutes while Emily sat in the high chair, then increasing the time the shoes were kept on, until finally, Emily fell in love with her new shoes. As Emily’s development improved, Meg managed to get more sleep, and Toby’s behavior settled down again. However, when Emily was around 16 months, Graham phoned and asked to come and see me. He was feeling very depressed and, in fact, suicidal. The months of holding the family together had taken their toll, and he finally recognized that (Continued )

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he also needed help. After meeting with him, I recommended he see a psychiatrist for medication and a short term of therapy, which he did. At 12 months, Emily’s score on the Bayley Mental Scales (MDI) was 122 and on the Motor Scale (PDI) was 80. The assessment at 18 months was a joy to do. Emily’s Bayley scores were MDI 123, PDI 107. At 3, Emily went to preschool. Meg reported that Emily loved school, but still had certain sensitivities; for example, she preferred a little distance between herself and her playmates. She managed this by being the organizer and taking charge of the games. My last contact with the family was a photo I received showing Emily, 5 years, with Toby, on the day she started at the local school.

CONCLUSION The essential elements of the NBAS can be summarized in the following way: • Observing babies and infants provides information about their unique characteristics, as well as their needs and strengths. This capacity to observe infants is a crucial skill in all infant-parent work, just as observation is crucial in working with older children. • Focusing on the best performance of the infant, rather than a deficit model, allows the parents to maximize the baby’s development. • The NBAS’s capacity to elicit the individuality of the baby allows the parents to focus on their baby, rather than on how she compares with another baby. • The message of the NBAS—that infants communicate and that their behavior can tell us about their needs—is still a mystery to most new parents, not just to parents of at-risk infants. Sharing this message with the widest possible audience is the challenge for all professionals with an understanding of infants’ needs and is the focus of my own teaching and practice.

REFERENCES 1. Warren BE. Cross-cultural perspectives on Infant Mental Health: Development of Infant Mental Health in Australia. In: Osofsky JD, Fitzgerald HE, eds. Perspectives on Infant Mental Health. Vol 1. New York, NY: John Wiley & Sons Inc; 2000:91–122.

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2. Murray AD. Infant crying as an elicitor of parental behavior: An examination of two models. Psychol Bull. 1979;86:191–215. 3. Brazelton TB. Neonatal Behavioral Assessment Scale. No 50. London, England: Spastics International Medical Publications; 1973. 4. Murray AD, Dolby RM, Nation RL, Thomas DB. Effects of epidural anesthesia on newborns and their mothers. Child Dev. 1981;52:71–82. 5. Field T, Dempsey J, Hallock N, Shuman H. The mother ’s assessment of the behavior of her infant. Infant Behav Dev. 1978;1:156–167. 6. Kitchen WH, Ryan MM, Rickards A, et al. A longitudinal study of very low birth-weight infants: An overview of performance at eight years of age. Dev Med Child Neurol. 1980;22(pt 4):172–188. 7. Yu VY, Wood C. Perinatal asphyxia and outcome of very low birth-weight infants. Med J Aust. 1978;2:578–581. 8. Kempe CH, Silverman FN, Steele BF, Droegemuller W, Silver HK. The battered child syndrome. JAMA. 1962;181:17–24. 9. Dolby RM, English B, Murray A. Hospital practices that strengthen parentinfant attachment. In: Oates K., ed. Child Abuse: A Community Concern. Sydney, Australia: Butterworths; 1982:57–73. 10. Fraiberg, S, ed. Clinical Studies in Infant Mental Health: The First Year of Life. New York, NY: Basic Books; 1980.

CHAPTER 13

Reaching Out to Rural Communities: A Community Health Model: Thailand NITTAYA JIRATHIYUT KOTCHABHAKDI and NAIPHINICH KOTCHABHAKDI

In 1974, as a young pediatrician, I (NJK) spent my community pediatric rotation in the northeastern province of Thailand, Ubonrajathanee. This experience gave me a firsthand opportunity to work with children and families affected by poverty, malnutrition, and preventable diseases. During my pediatric training at the Faculty of Medicine, Ramathibodi Hospital, Mahidol University, I had learned that there was a 60% prevalence of protein energy malnutrition in children under the age of 5 among rural and poor urban populations in Thailand. Troubled by this reality, I was puzzled by some traditional practices that seemed detrimental to the healthy growth and development of babies, especially the taboo against nutritious food for pregnant and new mothers. In addition, it was believed that early yellowish breast milk, or colostrum, was “unripe” or inadequate for the nutritional needs of the new baby. As a result, breastfeeding was not properly practiced, and that led to early feeding of semi-solid food, mostly mashed banana and chewed glutinous rice, beginning in the first few weeks of life. Moreover, there was a belief that no one should show affection for or admire new babies in case the evil spirits might “take the baby away.” Instead, it was believed that those looking at a newborn for the first time should say that the baby was ugly—to deceive the “ghosts/evil spirits” and to prevent them from taking the baby. These traditional practices and this belief in “the evil eye” was a longstanding cultural adaptation to historically high incidences of 140

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maternal and infant mortality. I decided there needed to be a more constructive solution to address this fear—a completely different approach to conventional maternal health education. More knowledge was needed. After completing my rotation in the northeast in 1978, I attended the first International Brain Research Organization training workshop in basic neuroscience, which had been organized by Naiphinich (Nick) Kotchabhakdi in Bangkok. It was here that I was exposed to new research on the contrasting effects of enriched and impoverished environments on the developing brains of experimental animals. I was impressed and wanted to know if there was any research on the effects of early environment on human infants. This led me to the work of Berry Brazelton on the Neonatal Behavioral Assessment Scale (NBAS) and the research of Brazelton and Tronick on the interaction between mother and young infant, the “face-to-face paradigm.” What Brazelton described was totally new and different from the conventional pediatric textbooks, which said, for example, that infants only began to see by the age of about 3 months. I made up my mind that I would find a way to learn more about babies’ behavior and this amazing scale. Nine months at the Harvard School of Public Health and Graduate School of Education gave me this opportunity. There, I was able to develop broader perspectives on issues of health, nutrition, and child development when considered in the varied contexts of the ecological system, social policy, and health system management. Several weeks after arriving in Boston, I began to learn about NBAS with Dr. Brazelton and Kevin Nugent at the Child Development Unit at the Children’s Hospital in Boston and became certified in the use of the NBAS. Learning the NBAS had a greater impact on me than I had anticipated. It sharpened my observation skills with newborn infants and their parents. Above all, it helped me better understand myself. The systematic observation and recording of the behavior of individual newborn infants helped me understand the newborn as a person. At the same time, the concept of “best performance” and using the baby’s behavior as a language made each encounter with children and families an opportunity to learn and to share. I realized that my patients had much to teach me, yet I also became more confident in my ability to understand and communicate with newborn infants and, in fact, with every person I encountered. Returning to Thailand in 1980, I established the Child Development Unit in the Department of Pediatrics at the Faculty of Medicine, Ramathibodi Hospital, Mahidol University, and introduced the NBAS to my pediatric and OB-GYN colleagues, nurses, and residents.

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Later, I was invited to join the research team on a project that was designed to reduce protein energy malnutrition among young children under the age of 5. Pattanee Winichakul, a nutritionist colleague, and I spent time in remote villages among people with the lowest incomes. When we visited a 4-month-old baby’s home, the baby became involved in a wonderful, reciprocal vocal and social interaction with me. The mother became interested and observed with pride that her baby knew and played with me, the doctor from Bangkok. I turned to her, put the baby in her arms, and said, “Let’s see how the baby will respond to you.” The baby made eye contact, smiled, and cooed with his mother; and the mother-baby dyad began to “dance” merrily in reciprocal interaction. The mother ’s face lit up as much as the baby’s. When the father approached and the baby looked away, I explained that the baby needed to take a break. After a while, the father and the baby played and interacted; then the older siblings also participated. It was beyond my expectations that the atmosphere of this house could be so quickly and totally changed into a joyful and lively place. It also took me by surprise that these parents had completely overlooked their baby’s competence and the importance of one-to-one positive interaction with their infant, even though this was their fourth child. That experience led me to collaborate with colleagues from the Institute of Nutrition, Mahidol University (INMU), and design a series of educational videos for parents that included the perception and orientation components of the NBAS, in addition to nutrition components. Five of those titles are described briefly here: 1. Our Beloved Children compared the development of two 15-month-old boys, one malnourished, the other well nourished. 2. BreastFeeding emphasized the value of breastfeeding (nutrients and other benefits) and provided instructions on how to breastfeed. 3. Supplemental Feeding described the ingredients of good supplementary food, how to cook to preserve nutrients, and how to feed a child at different ages. It also promoted a nutritious combination of rice, beans, and sesame. 4. Dr. Nitt Is Coming focused on newborn perceptual and interactive ability, mother-infant interaction and breastfeeding, the growth of attachment, and how to read a child’s communication cues. 5. Moo Baan Saen Som Boon used animated puppets to present the five food groups in the context of a battle in a village that was fighting the “malnutrition devil.”

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To test the effectiveness of this form of educational outreach, a controlled study was conducted in 16 villages in the northeastern area of Thailand. The video series was shown in a mobile van twice a week in two groups of four villages. In the first group of villages, the videos were reinforced with radio spots; in the second group of villages, there were no radio spots. The third group, which included four other villages, was exposed to the radio spots only, while the fourth group of four villages, which served as a control group, was not exposed to any of these educational media. In this controlled follow-up study, the findings after 18 months revealed that in villages exposed to the interactive video, more mothers fed their babies colostrum, continued breastfeeding more successfully, and introduced semisolid supplementary food at 4 to 6 months.1 The mothers’ nutritional knowledge, attitudes, and practices (KAP) were recorded and were found to be significantly different among the four groups. Increased exposure to educational messages (video and radio > video alone > radio alone) were related to more positive parent-child interactions and more successful breastfeeding.2 As a result, between 1988 and 1992, the video Dr. Nitt Is Coming was used in health centers in prenatal and well child–care clinics throughout Thailand. It was broadcast on national television and used for training a range of groups, including medical students, nurses, and child-care providers. The Department of Health incorporated the concept in its comprehensive well child–care program, integrating the early childhood development component with promotion of immunization and growth monitoring. Child developmental monitoring and promotion has been included in the Home-Based Child Health Record. Since 2000, a nutrition and child development corner has been established in all 7,000 health centers and 600 district hospitals throughout Thailand, with more effective programming for family empowerment. Moreover, parts of VTR number 1 and 4 were used in the Unicef training package on Early Childhood Care and Development in developing countries. Later in 1990, there was a wonderful opportunity to introduce newborn behavior and competence to the world’s leaders. At the United Nations’ World Summit Education for All in Jom Tien, Thailand, I (NJK) collaborated with Robert Myers and the Consultative Group on ECCD and presented “Foundation of Human Learning,” a VTR along with the symposium to emphasize the concept that learning begins at birth, not in primary schools, and the implications for programming. Subsequently, Unicef and UNESCO made the VTR available for related organizations in many countries.

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In 1995, I (NJK) became an NBAS instructor and established the NBAS training center at Ramathibodi Hospital in affiliation with the Brazelton Institute in Boston. The National Institute for Child and Family Development was established in Mahidol University Salaya campus in 1997, for research, higher education and model development. The Salaya community participatory project for the betterment in child health and development has been one of the successful models for local capacity building and empowerment of families. Another channel to disseminate the information about newborn behavior and early learning has been the inclusion in the Thai versions of “Facts for Life”3 and eventually in the third international version. In 2005, 25 years after establishing the first child development unit in Thailand, and after 13 years of unofficial fellowship training, the field of Developmental-Behavioral Pediatrics (DBP) was granted official status as a subspecialty of Pediatrics by the Royal College of Pediatricians of Thailand and the Medical Council of Thailand. The first national DBP sub-board examination took place in June 2007, with 19 applicants. The NBAS and the Touchpoints concepts were included in the DBP fellowship training. In the future, it is hoped that the NBAS and the Neonatal Behavioral Observations (NBO) training will help parents understand their newborn infants’ behavior and thus promote positive relationships between parents and infants from the beginning in the understaffed hospitals in Thailand. As of December 2007, Thailand has a new public law for the promotion of development of children and youth and also a national policy to enhance early childhood care and development. The recognition of the newborn as a person will certainly support the implementations for future social development and human security.

REFERENCES 1. Dhanamitta S, Winichakoon P, Kotchabhakdi NJ, Smitasiri S, Valyasevi A. Communication for behavioral change: Radio vs. video van. In: Tanphaichitra V, Dahlan W, Suphakarn V, Valyasevi A, eds. Human Nutrition: Better Nutrition, Better Life. In: Proceedings of the 4th Asian Congress on Nutrition. Bangkok, Thailand: Aksornsamai Press; 1985:124–128. 2. Kotchabhakdi NJ, Winichakoon P, Smitasiri S, Dhanamitta S, Valyasevi A. The integration of psychosocial components in nutrition education in northeastern Thai villages. Asia Pacific J Public Health. 1987; 2:16–25. 3. Fact for Life. 3rd. ed. downloadable from http://www.unicef.org

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ADDITIONAL READINGS Dhanamitta S, Kotchabhakdi NJ, Winichakoon P. Thai case study. In: Asian Regional Workshop on Effective Communications for Nutrition in Primary Health Care; October 3–7, 1983; Bangkok, Thailand. Kotchabhakdi NJ. Developmental Issues in Child Health. In: Proceedings of the 4th International Congress of Tropical Pediatrics; July 7–11, 1995; Kuala Lumpur, Malaysia.

CHAPTER 14

Maternal-Child and Family Nursing and Preventive Intervention: United States KRISTIE BRANDT

Assisted by a supportive nurse and attentive nurse-midwife, a woman and her partner have worked through a challenging and arduous labor to bring their young daughter into the world. Exhausted and exhilarated, they hold their daughter and lift her into the air in front of them. In this moment, every movement, physical characteristic, sound, smell, taste, and touch of their infant has intense meaning. This baby’s life is dependent on her ability to entice these parents into caring for her, meeting her primary needs for food, warmth, and safety, and her basic need for love and human connectedness. She has been born uniquely prepared for this important task with a repertoire of behaviors and other capacities to draw in and captivate her parents. Of this phenomenon, Bowlby wrote, “It is fortunate for their survival that babies are so designed by nature that they beguile and enslave mothers.”1 Suspended in this moment and accompanied by parental joy, mourning, and readjustment is the fading fantasy baby of pregnancy, that is gradually being replaced by the real baby at birth, as each new characteristic of the newborn is assimilated.2 This process will be fueled by such overt observations and experiences as the physical appearance or crying of the infant, and those that are virtually imperceptible, such as the infant’s ability to synchronize movements in rhythm with the mother ’s voice.3 These all have a powerful impact and meaning for the new parent, and—coupled with the neonate’s ability to look at, mimic, reach for, and respond

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to the parent—provide the repertoire and capacities for the beguilement described by Bowlby. The baby searches the unfamiliar faces of her parents and they search back, each recording every movement and sound. As they attend to postdelivery work, the RN and nurse-midwife watch too, and they are also taking note of every movement and sound. Highly skilled in observation, one nurse whispers to the new mother, “Look how she turns toward your face when you talk,” and the other comments on the nice Moro reflex exhibited by the baby when a hallway door closes a little too loudly. Subtly, these health-care professionals are implementing a vital, lifesaving, and life-changing intervention that will impact this infant, her family, and the public health of her community throughout her lifetime. By pointing out the cues and behaviors of the baby and assisting the parents to see and understand their daughter ’s behavioral language, the nurses are working to ensure the baby’s health, wellbeing, safety, and optimal development. When the capacities of the newborn match the expectations of the parent in this sensitive period after birth, innate caregiving responses are elicited that fuel the process of attachment.2 Gradually the baby becomes more familiar, behavioral language more meaningful, and the parents are falling in love with her—an essential ingredient of assuring that they will work hard at helping their baby thrive.4 While the art and science of nursing is focused on protecting, promoting, and optimizing health and abilities,5 the specialty of Maternal-Child and Family (MCF) nursing is principally concerned with the health, development, and functioning of: the mother (throughout pregnancy, the intrapartum period, and the postpartum experience); the fetus, newborn, and young child; and, the family as the unit that will nurture the child. After the obvious first objective of securing a safe passage for the dyad through the pregnancy and birth, the most important MCF nursing objective is to support the process of the parent and child “falling in love” with one another. In a practical sense, this helps secure the survival of the infant, but in a more expansive view, it fosters the optimal development of both parent and child and simultaneously builds the foundation for caretaking behaviors by the parent and positive biological responses in the infant that are fundamental to lifelong health and well-being.6,7,8 From a public health perspective, this scaffolding of the parentchild relationship is likely the second most important intervention for the young child (the first being the physical health and survival of the newborn), because the success of any future parental or

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systems-based public health interventions on behalf of the infant or focused on the child in the context of the larger community will rely heavily on the strength and functionality of the parent-child relationship. For example, parents who know their baby’s cues, are invested in seeing their child thrive, and develop functional parenting patterns, are far more likely to engage in positive and preventative health practices on behalf of the child (well-child visits, breastfeeding, immunizations, child safety practices, etc.), thus contributing to the health of both the infant and the community at large.9,10,11,12,13,14,15 Research in the past two decades increasingly suggests an association between adverse childhood experiences (abuse, neglect, or dysfunctional parenting) and negative childhood and adult health outcomes, including a greater incidence of depression and chronic fatigue, as well as a lower subjective rating of overall health and well-being.16,17,18 Many studies have found a strong relationship between child maltreatment or childhood household dysfunction and serious, chronic adult health problems, including cigarette smoking, ischemic heart disease, obesity, physical inactivity, and substance abuse.18,19,20 Staggering amounts of money are spent each year in responding to the long-term consequences of problems in the parent-child relationship, and Dallam (2001) concludes that “the cost of doing nothing is simply too great.”21,22 So what are the preventive interventions that nurses can employ to enhance the protective factors for a child? In Neurons to Neighborhoods, Shonkoff and Phillips quote T. Berry Brazelton, Robert Emde, and Daniel Stern: “When young children and their caregivers are tuned in to each other, and when caregivers can read the child’s emotional cues and respond appropriately to his or her needs in a timely fashion, their interactions tend to be successful and the relationship is likely to support healthy development in multiple domains.” The two authors go on to conclude that “Most successful interventions, whether they are primarily preventive or therapeutic, are based on facilitating that relationship and helping both the child and the caregiver learn to adapt successfully to each other ’s individuality.”23 The lifelong risks are obvious, and the primary preventive intervention clear: Scaffold and facilitate the early relationship between parent and child by supporting parents in seeing and responding to the behavioral cues of their newborn. In the first 8 weeks after birth, the Neonatal Behavioral Assessment Scale (NBAS) offers the MCF nurse a stellar tool for showcasing and observing the newborn’s individuality as expressed in his or her mastery and clarity of cues and other behavioral repertoire,

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and parental meaning-making. This sophisticated interventive strategy consists of eliciting and showcasing the infant’s behaviors, observing parental response to the behaviors, and exploring with parents the meaning they make of the behaviors, and it affords the provider insight into the parents’ experience and understanding of the baby. This positions the parent as the expert on the child, and scaffolds parent and infant as their relationship and ways of being together expand. With a look of awe and pleasure on their faces, a woman and her partner watch the nurse as she conducts the NBAS at the bedside. When doing the Pull-to-Sit maneuver, the nurse gently pulls on the newborn’s hands and arms to bring her from a reclining to a sitting position. As the baby comes upright, her head moves forward and the parents’ expressions change to fear and concern. Reflexively, the mother reaches for the baby with an exclamation of, “Oh!” The baby looks up toward the mother, pulls her head more solidly to midline, and stabilizes her head so she can stare at her mother. The nurse lowers the baby back to the reclining position and asks the mother, “What do you make of that?” The mother explains how she was worried the baby’s head would “flop over and hurt her neck,” but she goes on to say that she didn’t know the baby was so strong, remarking, “She just lifted her head up and looked right at me.” The nurse hands the baby back to the mother who cradles the baby close to her body and brushes her hand across the baby’s head. The baby relaxes, opens her eyes, and stares into her mother ’s face again. The mother ’s expression softens, and she smiles at her daughter. In this brief and seemingly insignificant interaction, powerful messages have been exchanged. The baby has seen that something she did (looking at her mother during the Pull-to-Sit maneuver, then staring at her mother ’s face when being cuddled) changed something about her mother (the mother reached for the baby when their eyes met in the Pull-to-Sit, and the mother smiled when the baby looked at her while being cuddled). The mother has learned that something she did (an exclamation, reaching for the baby, then cuddling her baby) changed something about the baby (she relaxed, stayed in a quiet alert state, and stared at her mother). Exchanges such as these awaken a deep sense of caring and a desire to protect the infant.2 It is this very connection that is called on when the parent is engaged on behalf of the child in any of a host of behaviors that will contribute to the child’s health and development: Sitting down to read to her daughter (early literacy), securing her in a car seat (child safety), breastfeeding her and later

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making certain she has other quality food to eat (nutrition), taking her for well-child examinations and immunizations (preventive health), going for walks with her (physical activity and exercise), providing warm and nurturing care (relationships and socialemotional development), and so on. The Pull-to-Sit episode described was an actual encounter, and the dialogue continues: Nurse: “She worked really hard at that task.” Mother: “I know. I really do think she’s strong, don’t you?” Nurse: “I do, too. And, she looked right at you when you said ‘Oh.’” Mother: “I know. I think she knows I’m her mom.” Nurse: “I think she does, too. And, when you cuddled her, she relaxed and looked right at you again.” Mother: “I know. I love it when she looks at me.” (The new mother looks back down at her baby and smiles.) Nurse: “I thought she might cry after I pulled her up to sit, but she didn’t. She had a sort of worried look like she might cry, but she really relaxed when you cuddled her. And, now she’s looking at you with such interest.” Mother: “I just can’t believe she knows me already.” The Pull-to-Sit maneuver, just one element of the 28 behavioral and 18 reflex items of the NBAS, provided the opportunity for this simple yet powerful intervention. The baby has been credited with physical strength, with the ability to regulate her state, and with relaxing in response to her mother ’s caregiving efforts. The mother is credited with being a source of comfort and security for her baby; plus, her sense that her baby is strong and knows who her mother is has been affirmed. Such exchanges strengthen the parent-child relationship, enhance the protective factor of a secure attachment, and bode well for the baby’s future. Since its development, the NBAS has provided a tool for observing, assessing, understanding, and transmitting information on the capacities of the newborn. While it is first a systematized, rigorous, and uniform research tool, the hidden value of the NBAS is the respect, appreciation, and wonder it engenders in both provider and parent for the newborn’s characteristics, behavioral language, and repertoire for interacting. For more than 3 decades now, the NBAS has informed the discipline of nursing and contributed to both the development of clinical care models and the refinement of specific intervention,

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facilitation, and support strategies. It has contributed immeasurably to nursing knowledge and the implementation of “best practices” in the care of newborns, pregnant women, and parenting families in a variety of situations, including: (1) newborns prenatally exposed to drugs or alcohol,24 (2) infants with colic,25 (3) the role of fathers,26 (4) attachment,27 (5) caring for infants with macrosomia,28 (6) primary care of the infant and family,29 (7) parental caretaking tasks,30 (8) routine neonatal nursing care31; and very significantly to an understanding of the cultural variations relative to both the newborn’s behavioral repertoire and the meaning of infant behavior to the parent.32 In addition, the NBAS has influenced programs that have dramatically advanced MCF nursing in the past 20 years. For example, the Newborn Individualized Developmental Care and Assessment Program training process (NIDCAP), developed by Heidelise Als, Ph.D., has profoundly changed the way in which neonatal intensive care unit (NICU) staff, particularly nurses, are trained, and the environment and care provided for preterm, low birthweight, and other infants in the NICU.33,34,35 The remarkable work of Kathryn Barnard, RN, Ph.D. and the Barnard Model of caregiver-infant interaction, with the NCAST Parent-Child Interaction (PCI) Feeding and Teaching Assessments and the Keys to Caregiving training series, has elevated the practice and impact of MCF nursing by providing nurses and other professionals with new knowledge, skill and expertise for working with newborns, young infants and their caregivers.37,38,39As colleagues of many years, Brazelton and Barnard have had substantial influence on one another ’s contribution to this field. It is worth noting that 2 years before it was first published, Brazelton and his colleagues presented an unpublished paper on the NBAS for Dr. Barnard’s Nursing Child Assessment Project at the University of Washington in February 1971.36,37,38 The rigor of the NBAS, including the time required for training, developing expertise in, and administering this tool, has limited its use in the United States and internationally. Recently, the Newborn Behavioral Observations (NBO) system was developed by Nugent, Keefer, Minear, Johnson, and Blanchard to address this.40 The NBO can be learned quickly, and use of this observational system can be implemented rapidly in delivering hospitals, perinatal home visiting units, and health-care offices. Incorporation of this tool should be a critical goal for MCF nursing services in any setting where nurses work with infants and their families in the first 8 weeks after birth. The NBO is probably best implemented in settings where

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providers using the system can work in collaboration with a colleague who is skilled and certified in use of the NBAS, and can provide appropriate consultation if the NBO reveals responses or behaviors that the observer is unfamiliar with or believes to be problematic. From the perspective of the discipline of nursing, “best practice” in the care of children and their families lies in a multidisciplinary approach. In 1971, Reeder wrote that “health professionals find themselves in the center of a revolution in the health-care system,” and “only by multidisciplinary collaboration will they be able to rise to the occasion and provide adequate health services” for children and their families.41(18) More than 30 years since that was written, a multidisciplinary approach remains at the heart of a functional system of care that meets the needs of families. Perhaps this is the greatest contribution of the NBAS to the health and wellbeing of infants and families everywhere, to the profession of nursing, and to the other professionals who work with parents and their young infants: In the first 8 weeks after birth, the NBAS provides a powerful pandisciplinary tool, with specific observations, a common language, and a uniformity of approach for providers in supporting and observing infants as they reveal their unique capacities, cues, and vulnerabilities; observing and exploring the meaning of these behaviors with parents; and supporting parent and newborn as they co-create the relationship that will impact their lives forever.

REFERENCES 1. Bowlby J. Attachment. New York, NY: Basic Books; 1982. Attachment and Loss. Vol 1. 2. Brazelton TB, Cramer B. The earliest relationship: Parents, infants, and the drama of early attachment. Reading, MA: Addison-Wesley Publishing Co; 1990. 3. Condon WS, Sander LW. Neonate movement is synchronized with adult speech. Interactional participation and language acquisition. Science. 1974; 183:98–101. 4. Stern DN, Bruschweiller-Stern N. The Birth of a Mother: How the Motherhood Experience Changes You Forever. New York, NY: Basic Books; 1998. 5. American Nurses Association. Nursing’s Social Policy Statement. 2nd ed. Atlanta, GA: American Nurses Publishing; 2003. 6. Beckwith L. Prevention science and prevention programs. In: Zeanah CH, ed. Handbook of Infant Mental Health. 2nd ed. New York, NY: Guilford Press; 2000:439–456.

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7. Guralnick MJ. The effectiveness of early intervention for vulnerable children: A developmental perspective. Am J Ment Retard. 1998;102:319–345. 8. Sameroff AJ, Fiese BH. Transactional regulation and early intervention. In: Meisels JS, Shonkoff JP, eds. Handbook of Early Childhood Intervention. New York, NY: Cambridge University Press; 2000:119–149. 9. Brandt KA, Andrews CM, Kvale J. Mother-infant interaction and breastfeeding outcome 6 weeks after birth. J Obstet Gynecol Neonatal Nurs. 1998; 27(2):169–174. 10. Beckwith L, Parmelee AH. EEG patterns of preterm infants, home environments, and later IQ. Child Dev. 1986;57:777–789. 11. Cohn DA. Child-mother attachment of six-year-olds and social competence at school. Child Dev. 1990;61:152–162. 12. Erickson MF, Sroufe LA, Egeland B. The relationship between quality of attachment and behavior problems in preschool in a high-risk sample. In: I. Bretherton & E. Waters, eds. Monogr Soc Res Child Dev. 1985; 50(1–2):147–166. 13. Shonkoff JP, Phillips DA, eds. Nurturing Relationships In: From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academy of Sciences Press; 2000:229. 14. Sroufe LA. Infant-caregiver attachment and patterns of adaptation in preschool: The roots of maladaptation and competence. In: Perlmutter M., ed., Minnesota Symposium in Child Psychology. Vol 16. Hillsdale, NJ: Lawrence Erlbaum. 15. Vietze PM, Anderson BJ. Styles of parent-child interaction. In: Hegab, M., Haywood, HC, Garber H. eds.. Psych-Social Influences in Retarded Performance. Baltimore, MD: University Park Press; 1980:225–283. 16. Brown J, Cohen P, Johnson JG, Smailes EM. Childhood abuse and neglect: Specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry. 1999;38:1490–1496. 17. Heim C, Ehlert U, Hellhammer DH. The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology. 2000;25:1–35. 18. Moeller TP, Bachmann GA. The combined effects of physical, sexual, and emotional abuse during childhood: Long-term health consequences for women. Child Abuse Negl. 1993;17:623–640. 19. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–258. 20. Anda RF, Croft JB, Felitti VJ, et al. Adverse childhood experiences and smoking during adolescence and adulthood. JAMA. 1999; 282(17):1652–1658. 21. Dallam, SJ. The long-term medical consequences of childhood trauma. In: Franey K, Geffner R, Falconer R, eds. The Cost of Child Maltreatment: Who Pays? We All Do. San Diego, CA: FVSAI Publications; 2001:1–14.

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22. Walker EA, Unutzer J, Rutter C, et al. Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry. 1999;56:609–613. 23. Shonkoff JP, Phillips DA, eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academy of Sciences Press; 2000:28. 24. Choi ES, Hamilton RK. The effects of culture on mother-infant interaction. J Obstet Gynecol Neonatal Nurs. 1986;15:256–261. 25. Covington C, Cronenwett L, Loveland-Cherry C. Newborn behavioral performance in colic and noncolic infants. Nurs Res. 1991;40:292–296. 26. Beal JA. The effect on father-infant interaction of demonstrating the Neonatal Behavioral Assessment Scale: A tool to enhance parental attachment. Birth. 1989;16:18–22. 27. Beal JA. The Brazelton Neonatal Behavioral Assessment Scale: A tool to enhance parental attachment. J Pediatr Nurs. 1986;1:170–177. 28. Pressler JL. Strategies useful in caring for macrosomic newborns. J Pediatr Nurs. 1991;6:149–153. 29. Tedder JL. Using the Brazelton Neonatal Assessment Scale to facilitate the parent-infant relationship in a primary care setting. Nurse Pract. 1991;16: 26–30, 35–36. 30. Jones LC, Heermann JA. Parental division of infant care: Contextual influences and infant characteristics. Nurs Res. 1992;41:228–234. 31. Anderson CJ. Integration of the Brazelton Neonatal Behavioral Assessment Scale into routine neonatal nursing care. Issues Compr Pediatr Nurs. 1986;9:341–351. 32. Nugent JK, Lester BM, Brazelton, TB. The Cultural Context of Infancy: Multicultural and Interdisciplinary Approaches to Parent-Infant Relations. Norwood, NJ: Ablex; 1991. 33. Als H, Brazelton TB. A new model of assessing the behavioral organization in preterm and full-term infants. J Am Acad Child Psychiatry. 1981; 20:239–263. 34. Als H, Lester BM, Tronick EZ, Brazelton TB. Manual for the assessment of preterm infants’ behavior (APIB). In: Fitzgerald HE, Lester BM, Yogman MW, eds. Theory and Research in Behavioral Pediatrics. Vol 1. New York, NY: Plenum Press; 1982:35–63. 35. Als H, Duffy FH. The behavior of the premature infant. A theoretical framework for a systematic assessment. In: Brazelton TB, Lester BM, eds. New Approaches for Developmental Screening of Infants. New York, NY: Elsevier North Holland; 1983:153–173. 36. Barnard KE, Douglas HB. A Literature Review. Seattle: University of Washington Press; 1983. Child Health Assessment; pt 1. 37. Barnard KE, Hammond MA, Booth CL, Mitchell SK, Spieker SJ. Measurement and meaning of parent-child interaction. In: Morrison FJ, Lord CE, Keating DP, eds. Applied Developmental Psychology. Vol 3. New York, NY: Academic Press; 1989.

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38. Sumner G, Spietz A. NCAST Caregiver/Parent-Infant Interaction Feeding Manual. Seattle: NCAST Publications, University of Washington, School of Nursing; 1994. 39. Brazelton TB, Freedman DG, Horowitz FD, et al. Neonatal behavioral assessment scale. Paper presented at: Nursing Child Assessment Project; February 1971; University of Washington, Seattle. 40. Nugent JK, Keefer CH, Minear S, Johnson L, Blanchard Y. Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) System. Baltimore, MD: Paul H. Brookes Publishing Co; 2007. 41. Reeder S, Mastroianni L, Martin L, Fitzpatrick E. Maternity Nursing. 13th ed. Philadelphia, PA: Lippincott; 1971.

ADDITIONAL REFERENCE Brandt KA, Murphy MJ. Empowering parents through nursing home visits: The Napa County Touchpoints Model. In: Lamb-Parker F, Hagen J, Robinson R, eds. Developmental and Contextual Transitions of Children and Families: Implications for Research, Policy, and Practice. In: Head Start’s Fifth National Research Conference; New York, NY: Columbia University’s Mailman School of Public Health Press; 2000:674–676.

PA R T I I

CONTEMPORARY RESEARCH AND PRACTICE: INTERNATIONAL PERSPECTIVES New Models in Training Health-Care Professionals

CHAPTER 15

The Touchpoints Approach: United States ANN COLEMAN STADTLER and JOHN HORNSTEIN

The Touchpoints Approach to working with families of young children has its origin in the pediatric practice of T. Berry Brazelton. Initially, the term Touchpoints referred to a body of specific observations about how children develop, and to less specific (but effective) ways of establishing relationships with parents. Many of these insights are addressed in Brazelton’s earliest books including: Infants and Mothers: Differences in Development1 and Toddlers and Parents: A Declaration of Independence.2 Brazelton’s ideas about development come from several sources, including his direct work with the families in his practice, as well as his collaborative research on infant capabilities. The notion central to the Touchpoints Approach is that a child’s development is characterized by predictable periods of disorganization that occur prior to bursts in development. This concept evolved, in large part, from thousands of interactions with—and observations of—young children and their parents over decades of pediatric care. Discussions about feeding concerns at 4 months, sleep problems at 7 months, and tantrums at 2 years became data for a view of development. This view goes beyond a simple mapping of developmental milestones to a more complex and dynamic insight into the forces that energize a child’s progress over time. Further, this view takes into account both the individuality each child brings to the world and the meaning parents make of their child’s unique personhood. Three sources of energy fuel development: the developing nervous system, the child’s internal feedback system (“I did it myself—I can keep going”), and the external feedback system that includes the family and greater caregiving community (“Good job—keep 159

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going!”). All three, in combination, stimulate the child to reach his developmental potential. This dynamic process of development is multidimensional, with each area of development affecting others. For example, when a child is learning to walk, he directs his energy toward the acquisition of this new skill, and this concentration on walking has an inhibiting effect on other areas of development. The child’s previous interest in words may wane. He now practices his new skill during light sleep, which disturbs his sleep. Eating becomes an unwelcome interruption to his practice of walking. This disruption in language, eating, sleeping, and behavior is confusing to parents and can undermine their confidence, creating what we call parental vulnerability. As the child gets older, the impact of development becomes less transparent. For instance, when a child’s imagination becomes more complex, it may have an impact on his emerging control over toileting. A parent may not see the child’s new level of complex thinking as it relates to toileting, but merely the fact that the child is now having accidents, or has lost interest in toileting (Figure 15.1). Since all development occurs within caregiving relationships, the extent to which the system supports these relationships has a direct impact on the child’s developmental potential. The periods of disorganization that accompany developmental progress (Touchpoints) have an impact on the parent’s sense of self as a parent and create parental vulnerability. Each of these Touchpoints

Functional and Developmental Status

Motor

Speech Cognitive Emotional

Time

Months

Figure 15.1 Disorganization in One System Can Disorganize Others. Copyright 2000 Brazelton Touchpoints C.

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offers the professional working with parents an opportunity to support the parent’s self-esteem and, ultimately, the parent-child relationship. The idea that a child’s development progresses through stable and tumultuous periods is not entirely new. Piaget,3 Freud,4 and Erickson,5 along with countless other clinicians and researchers, have described such discontinuity. What the Touchpoints Approach adds to this understanding is to tie these periods specifically to the day-to-day child-rearing challenges experienced by parents. In doing so, Touchpoints offers professionals additional tools that they can use to establish authentic alliances with parents. According to this model, parents experience parallel disorganization when confronting disorganization in their child’s progress and behavior. Concurrent with the emergence of these understandings from direct practice with families was the creation of the Neonatal Behavioral Assessment Scale (NBAS). In the Touchpoints Approach, along with the notion that disorganization is characteristic of a child’s development is the notion that each child brings a unique set of capabilities to his interactions with the world. Further, in eliciting those capacities using the NBAS or the Newborn Behavioral Observations (NBO) system, professionals can utilize specific and carefully guided observations to help parents understand their baby and their baby’s capabilities. In describing the relationship of the NBAS to the Touchpoints Approach, we often say that the newborn Touchpoint is the prototypical Touchpoint. It is the time of greatest vulnerability, as well as the time of greatest opportunity. Parents of newborns are receptive to—and in need of—support. Using the language of the child’s behavior via the newborn assessment, we come to know the child and the new family, and they come to know us as part of the available helping community. The NBAS offers us an organized approach to describing the child and sharing our observations with the parents. By observing the newborn in the parents’ presence, describing the child’s behaviors, and observing and listening to the parents’ meaning-making of the behavior, we come to know the parents and support their sense of confidence in their ability to parent their baby. In supporting parental competence, forming a relationship with the parents, and conversing with them about child-rearing challenges, we return to observation of the child as the means through which we join the system of care around that child. The birth of Touchpoints as an articulated professional approach to working with families occurred when Brazelton and a group of researchers and clinicians at the Children’s Hospital in Boston took

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this understanding about development and considered how to use it in supporting parent-child relationships and parental mastery. In her description of expert practice, Benner6 describes expert practitioners in any discipline as those who seem to do their work automatically and invent language for how they do this work. Experts are able to create their own guidelines for how they do their work, but they do not always articulate these guidelines to others. As a group, and through simulated practitioner-parent-child interactions, we extricated the principles and assumptions of Touchpoints practice. We have used the annotated transcript of a year-long roleplay, The Shelly Manual,7 in our training program. We have encouraged others to use role-play to practice and grow in the Touchpoints principles and to better understand what they bring to their interactions with families. Central to the extracted principles, again, is the concept of using the behavior of the child as one’s language. When encountering parents in practice, the currency of communication with them is what the professional observes in the child. Describing the child’s behavior as it happens, predicting where it might go, discussing how to manage it, understanding what it means to the parent—all these points are part of the larger conversation that exists within the professional-parent partnership. At the newborn Touchpoint, the NBAS provides us with a comprehensive, wellresearched lexicon of behavior in facilitating this conversation. Using the language of the child’s behavior is one of eight principles that serve as a framework for training in the Touchpoints Approach: Touchpoints Principles 1. Value and understand the relationship between you and the parent. 2. Use the behavior of the child as your language. 3. Recognize what you bring to the interaction. 4. Be willing to discuss matters that go beyond your traditional role. 5. Value passion wherever you find it. 6. Focus on the parent-child relationship. 7. Look for opportunity to support parental mastery. 8. Value disorganization and vulnerability as an opportunity. Touchpoints training utilizes these principles, along with specific themes of development at particular ages, to help professionals

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retool how they interact with families. Practitioners can use each of these principles to guide and reflect on their work with families. For example, “Value passion wherever you find it.” Passion is the energy that an individual brings to the parenting role, and it leads us to what is important to that parent. The principle of valuing passion offers strategies for understanding and joining a parent in what is important to the parent. Useful to this understanding are the parental themes described at each Touchpoint: Parental Themes Pregnancy: The “ideal” baby, the “damaged” baby, and the prospects of being a parent Newborn: The real baby and the reality of this baby’s presence 3 Weeks: The exhaustion of childbirth and newborn care 6 Weeks: Relationships within the new family and altered relationships with others 4 Months: The baby’s interest in the outside world 7 Months: The need to establish a parental style 9 Months: The baby’s ability to make his needs known (pointing, saying, calling) 12 Months: The need for vigilance as the toddler learns to walk . . . and run 15 Months: Interpreting signals that switch from clinginess to independence 18 Months: The impact of the child’s battles for control 24 Months: Making sense of the child’s rituals and rigidity 36 Months: Coping with the 3-year-old’s complex thinking The professional uses knowledge of these common themes and an observation of the parent’s emotional shifts (both positive and negative) to come to know the meaning of the child’s behavior/ development for the parent. A key concept of the Touchpoints Approach is anticipatory guidance—guidance that is not prescriptive, but rather collaborative (Figure 15.2). The goal is to build a supportive structure (a “scaffold”) that will keep the parent and the parent-child relationship strong through periods of vulnerability. In this process of scaffolding, professionals and parents have equal power and engage in discussions that value the expertise of each. Anticipatory guidance can facilitate a knowledgeable parental response. For example, at 9 months, the infant begins to understand permanence; in response, it is typical for parental issues related to

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Functional and Developmental Status

Practitioner’s Anticipatory Guidance

Child

Time

Derailment

Months

Figure 15.2 Anticipatory Guidance Can Facilitate Parental Response. Copyright 2000 Brazelton Touchpoints C.

separation and loss to emerge. How we come to understand a particular parent’s perspective on these issues is based on our understanding of that parent. As we reflect on the parent’s prior experience with separation and loss, we can anticipate her reaction to the coming period of vulnerability. We can recall her reaction at 4 months (when the child’s interest in the outside world typically triggers a sense of loss and separation for a parent) and apply that reaction to the present disruption when once again the parent will be dealing with these issues. By using a description of the child’s behavior, we allow the parent, through her reflection on the observed behavior, to reveal her understanding of her child and the impact of her child’s behavior on herself. In supporting the parent’s reflection on past and present successes, past and present dilemmas, and future dilemmas, we enhance the parent’s trust in herself and her ability to cope with the issue successfully. By using information from the parent and family’s past adaptations to disruptions (Touchpoints), we learn how we might help in problem-solving the present dilemma. We set the stage for a working collaboration by supporting the parent’s competence and demonstrating the system’s availability to collaborate and help parents. With the map of Touchpoints as a guide, we can anticipate the next Touchpoint and its associated predictable disorganization. In doing so we can collaboratively problem-solve with the parent in a strength-based manner in order to support the parent’s emerging

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sense of competence. Building on the successful navigation of each of these Touchpoints, we promote successful parenting: Touchpoints Pregnancy

The Ideal Baby

Newborn

The Real Baby

3 Weeks

The Energy Sink

6–8 Weeks

The Rewarding Baby

4 Months

Looking Outward

7 Months

Up All Night

9 Months

The Pointer

12 Months

The Walker

15 Months

The Clinger

18 Months

Rebel with a Cause

2 Years

Getting to “No!”

3 Years

“Why?”

There are at least 12 opportunities in the first 3 years for medical providers to support parents through vulnerable times, or to provide anticipatory guidance regarding upcoming Touchpoints. In child-care and early education, there are daily opportunities for care providers to join parental vulnerability. Other professionals have varying amounts of opportunity to join in also. In 1995, we piloted training and mentorship in the Touchpoints Approach with nine nurse practitioners and pediatricians. These highly experienced clinicians from the Boston area played a major role in the design of the professional development program still in use today. At first, these providers told us they did not have time to focus on their relationships with families because the issues within the families they cared for were so complex that as providers they could focus only on survival issues. By the end of the training, however, they reported that they did not have time not to focus on their relationships with the families. They also reported that they did not realize how close they were to burnout, and how often they distanced themselves from their families because they were depleted by the problems these families faced. Since the initial pilot, we have trained, mentored, and collaborated with multidisciplinary professionals throughout the country. Some have focused on their individual practices with families,

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while others—participating on a training team—have focused on developing a seamless multidisciplinary system of care for a particular population of families. These Touchpoints teams, in turn, train, mentor, and change the system of care for the families in their communities and are part of the Touchpoints National Site Network. The training itself contains both didactic and experiential components. Presentations include an overview of the approach, descriptions of specific Touchpoints with a dual focus on the child’s development and the related parental issues, as well as anticipatory guidance and additional relevant information. Role-play and other activities in which participants practice using elements of the Touchpoints Approach are essential. Issues of cultural and economic diversity are proactively addressed. The Touchpoints Approach, by definition, is sensitive to unique, culturally formed parental interpretations of children’s development. Demonstration visits, including a newborn exam, are used to explore how the approach can be applied in various settings. We see the trainings themselves as opportunities to support reflective practice, as well as collaborative relationships among practitioners that parallel direct work with families. There are now over 70 Touchpoints Sites in the Touchpoints National Site Network. The goal of the network is to build a web of sites across the country that share a common vision of strengthening communities, strengthening families, and supporting the optimal growth and development of children. Sites include organizations, programs such as WIC and Healthy Families, agencies, hospitals, universities, towns, counties, and even states. Each of these sites integrates the common Touchpoints Approach into its existing work. Touchpoints is not a stand-alone program. Therefore, each site looks quite different. Most training teams are multidisciplinary, composed of members from health care, child care/early education, and social service agencies. More recently, several training teams have been entirely composed of early childhood educators. The Touchpoints Approach was originally adapted from medical practice and there is no question that it enhances medical practice. Within the realm of medicine, trainers work in a diversity of settings—from public health departments to hospitals, clinics, and private practice. Not surprisingly, nurses have played a large role in these various settings, often as site coordinators. In fact, several hospitals have trained their entire nursing departments and consider attitudes that are compatible with the Touchpoints

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Approach in their hiring decisions, core competency requirements, and performance reviews. Many teams focus on a city or county’s effort to provide effective, comprehensive care for its families. Three goals for local systems of care are that professionals within the community use a common language, engage in multidisciplinary collaboration, and promote each family’s feeling that they have power within a system of care that is responsive to their needs. Several sites are university-based and are integrating the Touchpoints Approach into the preservice training of professionals who work with families. The challenges for emergent professionals are multifold. The material is new, and supervision is, by necessity, highly directive. Students tend to focus on learning the technical aspects of care, rather than on forming relationships with families. The integration of a Touchpoints Approach, which emphasizes collaborative, sensitive, strength-based care presents an additional challenge when the learner is engaged in simultaneously acquiring the entire body of working knowledge necessary for the practice of a particular discipline. Child-care and early education professionals see the Touchpoints Approach as very useful. However, unlike many health-care professionals, these early care providers have longstanding, ongoing relationships with children. Hence, the dynamics of their relationships with children and families are uniquely different than those of other providers. A child care/early education working group was established to explore these issues and suggest ways to train and mentor these professionals. This group, in collaboration with the site network, modified the training program to be sensitive to the unique role of child-care and early education professionals. A central theme of this training is that early care providers need to join the family system, rather than expecting children to join the existing early care system. Issues such as gate-keeping between parents and professionals (e.g., competitive feelings of affection for the child) and establishing working relationships with parents are essential topics. We review all of the issues that are important in understanding the relationship between the family and the providers, and we integrate these issues into the training of child-care and early education professionals. Two years ago Touchpoints launched an American Indian/ Alaskan Native (AI/AN) Initiative. A goal in these communities is “to optimize child development and support the social and emotional well-being of children within the family while at the same time learning about and utilizing the unique culture and strengths

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of AI/AN communities.”8 Based on our work with American Indians, we are expanding our understanding of the Touchpoints principle of using the language of the child’s behavior. In our work with families, we often gain understanding through questioning and listening. While this standard approach works well in most situations, it is less effective when working with American Indians and is often perceived by them as disrespectful. However, “using the language of the child’s behavior” with these families is both respectful and fruitful. Through conversations that focus on shared observations, the provider comes to understand the parents’ perspective, motivations, and culture. Reflective practice and reflective supervision through journaling is working in mentoring and supporting AI/AN Early Head Start/Head Start teachers as they strive to understand their interactions with parents. This process helps providers gain valuable insights into the relationships between themselves and the parents they serve. Many sites are effectively utilizing the Touchpoints Approach in various parent groups. In these groups, the role of the Touchpoints facilitator is to join parents rather than lead them. The parents’ agenda inevitably emerges in response to the facilitator ’s use of the Touchpoints principles in guiding the group discussions. For example, in our work with families with asthma, a curriculum for parallel parent-and-child groups has been developed. The goal is to empower both the child and the parent in the management of the child’s asthma. Recently, a parent who talked about her child’s medication at the first group session told us at week 3 that she was not giving her child necessary medicine on a daily basis. She said she was afraid her child would become dependent. Through the strength-based collaboration within the group, she was able to reveal the meaning of having her child on daily medication. We came to know her perspective, and she, in turn, was more open to understanding the purpose of daily medication. At the same time, her child developed a better understanding of her asthma, the medications she was taking, and the importance of the medication in the control of her asthma symptoms. We have also developed a parallel parent-child group curriculum for delayed toilet training called “toilet school.” Toilet school is a 6-week, 1-hour-per-week program for children over 4 who are not toilet trained. Both the child group and the parent group share their perspectives on where they are in the process of toilet training and the impact of the delay on their lives. Through a carefully

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designed step-by-step approach, both parents and children are empowered to find solutions to the dilemma. In both chronic illness and delayed developmental skill attainment, it is easy to imagine how the parent-child relationship can be derailed. When this happens, a much more expensive intervention may be necessary. One goal of the Touchpoints Approach is to prevent these derailments by anticipating them. For families who are exposed to professionals from a variety of disciplines, major issues are the complexity of the system and lack of collaboration. In general, most professionals miss the opportunity for multidisciplinary collaboration in the service of families. One reason is that they have a limited awareness of or contact with the other professionals working with the same family, and so the opportunity to build a seamless scaffolding of support simply doesn’t exist.

CONCLUSION The Touchpoints Approach has developed into a national training and mentorship program that aims to support providers and communities in changing the system of care for families. The paradigm shift at the center of this approach requires providers to focus on strengths rather than problems, to value parental expertise as essential in developing an understanding of the child and family’s needs, to provide anticipatory guidance where the parent feels joined rather than instructed, and to strive for multidisciplinary collaboration in order to form a seamless system of care for families. Paradigm Shift From

To

Deficit Model

Positive Model

Linear Development

Multidimensional Development

Prescriptive Guidance

Collaborative Guidance

Objective Involvement

Empathic Involvement

Strict Discipline Boundaries

Flexible Discipline Boundaries

For more information about the Touchpoints Approach, its training offerings and the Touchpoints National Site Network, visit Touchpoints.org.

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1. Brazelton TB. Infants and Mothers: Individual Differences in Development. New York, NY: Delacorte Press; 1969. 2. Brazelton TB. Toddlers and Parents: A Declaration of Independence. New York, NY: Delacorte Press; 1974. 3. Piaget J, Inhelder B. The Psychology of the Child. New York, NY: Basic Books; 1969. 4. Freud S. Psychopathology of everyday life. 1901. In: Strachey J, Strachey A, Tyson A, eds. The Standard Edition of the Complete Psychological Works of Sigmund Freud. London, England: Hogarth Press; 1953–1974. 5. Erickson E. Childhood and Society. New York, NY: WW Norton; 1963. 6. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Co; 1984. 7. Brazelton Touchpoints Center. The Shelly Manual. Boston, MA: Brazelton Touchpoints Center; 1996. 8. Mayo-Willis L, Hornstein J. Joining American Indian system of care: The complexities of culturally appropriate practice. Zero to Three. 2003;23:5.

ADDITIONAL REFERENCES Brazelton TB. Touchpoints: Your Child’s Emotional and Behavioral Development. Reading, MA: Addison-Wesley Publishing Co; 1992. Brazelton, TB, Christophersen, ER, Frauman AC, Gorski PA, Poole JM, Stadtler AC. Instruction, timeliness, and medical influences affecting toilet training. Pediatrics. 1999;103(6, pt 2):1353–1358. Hornstein J, O’Brien M, Stadtler AC. Touchpoints practice: Lessons learned from training and implementation. Zero to Three. 1997;17(6):26–33. Percy, M, Stadtler, AC, Sands, D. Touchpoints: Changing the face of pediatric nurse practitioner education. Matern Child Nurs. 2002;27(4):222–228. Stadtler AC. Using the language of the child’s behavior in your work with families. J Ped Health Care. 1999;13:S13–S16. Stadtler AC, Burke P. A group treatment approach to failure to toilet train: The case of Max. Clin Excell Nurse Pract. 1998;2(2):83–87. Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions and recommendations. Pediatrics. 1999;103:1359–1361. Stadtler AC, O’Brien M, Hornstein J. The touchpoints model: Building supportive alliances between parents and professionals. Zero to Three. 1995; 16(1):24–28. Stadtler AC, Tronick EZ, Brazelton TB. The Touchpoints pediatric asthma program. Ped Nurs. 2001;27(5):459–461.

CHAPTER 16

The Newborn as a Touchpoint: Training Pediatricians in Portugal JOÃO GOMES -PEDRO

The sense of belonging and the quest for coherence are the forces that shape an individual’s destiny, especially in light of the changes in family life today. As a pediatrician, clinician, and educator, I would like to share my efforts to better understand the origins and the development of this quest. In this chapter, I describe some of the results of our research. My hope is that, together, we may exchange ideas that will contribute to a greater understanding of the importance of research on infant development. Today, we possess a tremendous amount of knowledge about the infant, especially compared to the knowledge we had little more than half a century ago. In the 1920s, behavioral research concerning children below school age appeared for the first time. Up until then, very little was known about this age group. In the 1930s, adolescence became another focus of interest, as adults began to express concern about all the risks so prevalent during this short period of a young person’s life. It was not until the 1940s that infancy came to the forefront as an area of interest for researchers and clinicians. As professionals in different fields sought more scientific knowledge about infants and how they changed during infancy, behavior and development became a “must” in university curricula all over the world. The important influence of mothers on children had long been recognized, and as a result, maternal behavior became a major subject of research. After the 1950s, the child-rearing practices of mothers became the focus of empirical research for the first time. 171

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Soon scholars “discovered” that there was also a father in the home who, both directly and indirectly, influenced the baby’s behavior and development. And so, the topic of parent-child interaction and the variables influencing parent behavior became research priorities. In fact, the very first studies on infant behavior changed the direction and meaning of modern research in our field. The new view of the infant comes, very significantly, from our awareness of the infant’s social and transactional role. Recent research about fetal behavior shows us that babies are social even before birth. Knowing this, it is no longer possible to view them simply as passive recipients of parental caregiving. Human babies are genetically endowed with capacities that ensure their survival, so they are able to respond adequately to sensory and social stimuli. From birth, they are capable of complex integrative behavior; and with each passing minute, hour, and day, they become progressively competent as interactive partners and are able to influence the way their environment will affect them. In order to be accepted as a unique social partner, the human baby uses her behavior as a primary mode of communication, particularly with her parents. Recognizing the significance of infant behavior, parents, clinicians, and educators all understand that reading and interpreting babies’ communication signals is a fundamental challenge, so sharing these discoveries has become a priority for researchers and clinicians alike. Neuroscience has given us evidence about how the infant organizes her emotions in order to build her feelings and, ultimately, her consciousness. However, I am committed to learning more about how we can help the infant build her sense of values, that is, her moral sense. Today, Portugal is experiencing problems of child abuse and neglect, which manifest themselves differently in different regions of the country. In fact, the indicators of family turmoil and dysfunction in Portugal are one of the highest in Europe. The Portuguese crude divorce rate is about 2.7 per thousand, with the majority of divorces occurring in the first years of marriage. This means that here—in a country which is a historic model of maritime adventure and courage, with traditional customs that value stability, loyalty, and faithfulness—vulnerability is emerging in the very places where respect, passion, and commitment should be firmly rooted—the family. When it comes to infant mortality, Portugal is a model in Europe with an infant mortality rate of only 3.3 per thousand. However, infant mortality is no longer the only indicator by which we assess

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health in a country. We need to also look at the rates of school failure, teenage pregnancy, drug abuse, maternal depression, ADHD, the emotional resilience of youth and families, and the prevalence of family dysfunction. Furthermore, our pediatric residents are still influenced by a pathological model of teaching/ learning medicine and are, therefore, not trained to understand and interpret child behavior. This means they would probably be unable to recognize the distinctly different behavioral patterns of two newborns, one of whom was born to a heroin-dependent mother, and therefore, the practitioner would be unlikely to take steps to adequately intervene on behalf of the more vulnerable baby. Using findings based on the assessment of residents’ comments on a 3-minute film of the Neonatal Behavioral Assessment Scale (NBAS) administered to two newborns (one normal and the other with a deprivation syndrome), we saw that aspects of behavior like alertness, control of states, consolability, and self-calming, as well as manifestations of physical conditions, like tremors and color changes, were not reported by the residents. Not surprisingly, the more subjective reactions, such as “vulnerability” or “resilience” were also not mentioned in the residents’ comments. We concluded, therefore, that our residents still lack discriminative ability in terms of the neurobehavioral assessment of the newborn, particularly those aspects of behavior related to the organizational abilities that indicate stress control, alertness, and interactive communication. I am increasingly convinced that the evolution of moral development depends on the dynamic acquisition of emotions that build character. From sympathy to empathy, moral sense emerges based on the initial trust acquired when first attachments are formed and fulfilled. Nature has provided for the acquisition of these essential emotions through the trust that is inherent in a healthy mother-infant relationship. In its first days and weeks of life, a baby needs to experience acceptance, nurturance, respect, and empathy. If this is the reality, then the baby views herself as worthy of love as she becomes a child and later an adult. In contrast, babies who experience rejection, overstimulation, or unpredictability in terms of their parent’s responsivity, will be more likely to view themselves as unworthy of love, and then it will be more difficult for them to become good caregivers themselves. The cycle of respect and coherence experienced by the baby as responsive care, consistently and reliably provided, is the main source of energy for development. However, it is not only the early relationship between mother and child that will influence later development, but rather how the mother and child “read” the

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coherence that is the essence of good communication. The spiderweb model may explain how interpersonal relationships are spawned from early experiences. The spider builds its web in a progressive and consistent way. The central structure of the web is organized at the base of the principal threads, through which the spider intertwines other secondary threads that provide elasticity, lightness, and resistance. In the same way, babies build relationships with other family members and an ever-widening circle of additional people, based on the success of their relationships with their primary caregivers. All babies are inherently good and sympathetic and are predisposed to seek from the environment this same goodness and sympathy. This helps the parents, especially the mother, to build an image of “the imaginary baby” during pregnancy. The crying baby, the baby with feeding difficulties, the baby with sleeping difficulties—all of these babies betray the parents’ expectations, and thus parental disappointment is sometimes the reason for a maladjustment in the organization of first attachments. Such an unfortunate consequence demands special attention on the part of the pediatrician and other care providers, as well as those who educate them. Each baby’s first relationship is built on an initial feeling of trust—an original state of grace—that is the state of mutual sympathy between mother and baby. Subsequent relationships are all built on, and follow, this initial pattern. Our moral feelings originate in our most primitive social interactions based on our emotions. Our emotions, in turn, are the source of greater or lesser empathy, and our ability to empathize is a key influence in all of our relationships. Social morality is profoundly determined by individual morality, and the origins of individual morality can be found within each baby, through the use of the NBAS.1 The NBAS represents, essentially, a philosophy through which one discovers a person—the baby—with all her abilities and individual strengths, as well as vulnerabilities. These strengths and vulnerabilities, as a whole, are the basis of her temperament and present a reliable behavioral profile, which can inspire the attitudes through which the parents teach their child about life. In administering the NBAS, the examiner works to get the baby’s “best performance.” In other words, through his or her sensitive handling and clinical expertise, the examiner tries to elicit the full range of the baby’s behavioral repertoire, to see what this particular baby is programmed by nature to do and to learn and what parents

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can most effectively do in an attempt to help her organize her responses. The careful observer may, through the NBAS, discover the baby as a person. This process of discovery represents the best fundamental use of the NBAS as an intervention tool, particularly where vulnerability is the case. During the assessment, a full dynamic evaluation of the baby’s abilities is roughly sketched, based on positive social stimulation quite similar to that which is likely to be provided by the baby’s own parents in their daily routines. We travel with the baby from stage to stage, from sleep to crying, trying to reach the summit of the journey, when the baby, in a full state of alertness, interacts and plays with us. When we obtain a prolonged state of alertness and a contingent interaction, it is then possible for the baby to imitate us on different occasions and in different states of this affective harmony, which we call empathy. Empathy implies the alignment of emotions and expectations, an alignment that is, after all, necessary for the attunement of any relationship. Why? Because the fundamental basis of the relationship makes sense to both partners. The baby is unknown to us until, using the NBAS, we mutually develop an empathic relationship with her. This kind of relationship can only be established by one whom the baby recognizes as being a provider of a sense of coherence. We think it is essential for parents to discover and share this relationship early. When the baby is someone with whom we have already established a contingent intercompatibility of shared affects, imitation becomes even more complex and, also, richer, because it corresponds with our already compatible states of spirit. This is the empathy of affect, which determines the successive stages of moral development. I believe, more and more, that antisocial behaviors have their origin in the inadequate development of empathy. Empathy or—to use a “Brazeltonian” expression—passion, is what should inspire each of our interventions at the main Touchpoints of infancy and childhood. Our deepest concern in our clinical work is to find strategies that can strengthen babies and their families in terms of their passion because this passion is the basis of each family’s sense of identity. In terms of child development, identity is deeply related to intimacy and trust—basic needs that are essential for the emergence of self-esteem and the establishment of structural relationships.2 Today, clinicians recognize human development as a dynamic process influenced by determining factors that are both endogenous and exogenous. These factors, functioning together through the maturation of the central nervous system, contribute to the

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individual’s processes of development. The goal of development is to reach a sense of competence identified as the total realization of humanness. I see a parallel between identity and competence, as well as between empathy and moral sense. In clinical terms, it is relevant that the philosophy and strategies of intervention proposed by Brazelton attempt to highlight the flux of empathy between the child and her parents or grandparents and between clinicians and families. This is particularly critical when Touchpoints principles are used as guidelines for our intervention.3 Development is not, in fact, a continuous chain of events, but rather a journey of starts and stops. The map of child development is predictable and serves as the base for identifying entry points for early intervention. Before each spurt of development—cognitive, motor, emotional, or moral— there is a short period of regression. Parents need to understand that these periods are part of the normal development of each child. Each of these periods is a unique opportunity to reinforce an indispensable climate of trust between parents and professionals. This sense of trust is the core philosophical principle of Touchpoints. The first of these Touchpoints, planned to strengthen identity and to reduce risks in the critical perinatal period, is the prenatal visit that occurs in the pediatrician’s office. To be expecting a baby— especially a first baby—is one of the most important events in a woman’s life and clearly represents a challenge to the expectant mother ’s maturity and to the structure of her personality. It is also a time of taking on new responsibilities. In the face of these responsibilities, the woman is—from the beginning—involved in a relationship of mutual dependence and progressive attunement. The most dramatic changes in the lifestyle of the woman who has become pregnant come from an awareness that she has stopped being a girl and has begun assuming the responsibility for her baby. A sharing of responsibility is also progressively assumed by the couple, to the extent that both become aware that they have begun to divide time and attention with another person—real, even if not yet present—in their world. In very little time, a pediatrician or a family doctor is able to enter into a significant relationship with the parents-to-be. Health-care providers have excellent opportunities, particularly at the time of each Touchpoint, to reduce the stress of new parenthood, facilitate the development of more secure attachments between parents and child, and encourage development of a child’s secure sense of identity through the passion of an empathic intervention.

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In Portugal, as in many other countries, some important positive patterns of child care face the risk of being discarded as cultural standards. One of these patterns is for mothers to continue breastfeeding their babies throughout the first months. (With almost a full 100% of mothers breastfeeding at birth, we found that only 18% were still breastfeeding at 4 months.) Another pattern is for fathers to be present at health visits; unfortunately, anecdotal evidence indicates that their attendance has been dropping off considerably. Yet, it has been possible to reverse these disappointing trends. Tracking these two patterns of parental behavior in a middle-class Portuguese sample, we observed significant changes with new parents who had both attended 15- to 20-minute interviews with their pediatricians while they were still parents-to-be, compared with new parents who did not attend such prenatal pediatric visits.4 Examining the rate of breastfeeding, 74% of the mothers who had come to the prenatal visit were still breastfeeding their babies at 4 months (a sharp contrast to the 18% in the control group). Similarly, 76% of the fathers who had participated in the prenatal visit came to at least four of their babies’ routine visits during the first year of the infant’s life. Only 23% of the fathers in the control group did the same. Very probably, passion was the secret to these changes. In fact, it is the passion that comes from our own empathy that inspires us, as practitioners, to intervene in these crucial Touchpoints in the lives of young families. There is no question that the structure of the family is changing very rapidly in Western cultures. The traditional nuclear twoparent family is disappearing, and this fact has to inspire new strategies in our interventions. Today single-parent families are prevalent in Portugal. There are also many couples who, while not divorcing, are experiencing severe stress related to dysfunction in their marriages. In addition, many parents feel poorly prepared, and their behavior, when responding to the needs of their sons and daughters, reflects their lack of confidence and lack of skill. In short, much of their behavior reflects the stress that society has placed on them in their parenting roles. In Portugal, more and more parents and children are faced with the abrupt separation that occurs when a baby is handed over to a day care system where the baby will remain from morning until night. Approximately 80% of women in the reproductive age group work. Within this group, about 65% who have a child under 10 years are employed, with only 10% of these having part-time

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jobs. This figure represents the second highest level of working mothers of young children in the European Union, and it should lead to a completely different policy concerning educational and child-care services in Portugal. Bronfenbrenner and his colleagues wrote that what we need is a “humanism of science” to address all these realities, particularly in the early periods of life when children are most vulnerable.5 Vulnerability, in this context, does not imply inevitable fatality. Rather, it means distress, discouragement, and despair. What we have to do is change despair into hope. In Portugal, we have been working on this transformation since the 1970s, very much influenced by the passionate principles articulated by Berry Brazelton. We are aware of the voids that have been created by new habits—habits that, in anthropological terms, are destroying societal foundations that have existed for centuries. One of these foundations is the stable arrangement of the mother and baby together, without a break, following birth. About 20 years ago, we became convinced that the separation of mother and baby in our maternity wards after delivery was a determining factor in increasing vulnerability in the early postpartum period. Using identical rooming-in conditions, we studied the influence of extended early contact on both newborn infants’ and their mothers’ behavior. This experimental “postpartum contact” group was compared to a control group of infants and mothers who were separated immediately after birth in the way that was traditional then—with the baby kept in a newborn nursery except for brief stays in the mother ’s room for feeding or the father ’s visit. One of the main findings of our study was that interactive items of Orientation, which assess the baby’s social interactive capacities on the NBAS, were significantly better for the postpartum contact group.6 As for the mothers’ behavior, it was meaningful that the group with early contact got better results in the Affectionate Behavior items. Birth is a primary Touchpoint for clinicians working with new parents, providing a unique opportunity for inspiring empathy and coherence. Over the past 2 decades, an increasing body of research has emerged stressing early childhood as a primary period for interventions. In Portugal, in another study, we examined whether a change in parents’ attitudes would influence subsequent parent-infant interactions. While one control group of mothers, on the third day of their babies’ lives, had a 7-minute talk about routine issues of infant health, one experimental group underwent a structural intervention, also about 7 minutes in duration, which

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was inspired by the Brazelton model. The same pediatrician told mothers in the experimental group, “We have been observing your baby so as to get to know her, as well as her abilities. We would like you to observe and experience some of your baby’s abilities, too. Have you noticed that she can see and hear?” At this point, the NBAS items of Animated Visual and Auditory Sensory Orientation were demonstrated. Then, each mother was invited to elicit the responses from her baby. She was reinforced by being told that she, the infant’s mother, had elicited her infant’s best performance. The pediatrician then spoke about the baby’s good reflexes and elicited the Moro reflex. He then demonstrated the infant’s response to being consoled, through the NBAS Consolability item. The mother was invited to talk to the baby and taught how to console her child. In this way, the mother became aware of both her baby’s ability to recover from stress and her own ability to promote this recovery. Finally, the mother was asked to hold her baby after the pediatrician had first demonstrated the newborn’s cuddliness. The last part of the intervention consisted of a short dialogue with the mother about the observed competencies of the neonate as well as her role as the baby’s partner. Although Sensory Orientation, Consolability, and Cuddliness are all common behaviors, these were the three NBAS items chosen for this intervention because Portuguese mothers of low and middle socioeconomic status are generally not aware of them. Our results support the view that mothers become aware of their newborns’ behavioral competencies when an appropriate intervention is designed with this purpose in mind.7 Using the NBAS as an assessment instrument, we observed that the infants in the experimental group were more responsive to visual and auditory stimuli, as measured by the NBAS Orientation cluster. This group also had a more favorable interactive pattern as measured through a specific interactive assessment—the “stillface” procedure—which was repeated nine times during the first two years of the babies’ lives. Noticeable differences between the two groups were highlighted when we began using the “still-face”* procedure at 12 months. By the time the babies were 6 years old,

*The “still-face” is a well-known procedure designed by Tronick and Brazelton to study the infant’s response to a stressful event by making eye contact and interacting with the baby and then presenting the baby with a stony, unmoving, unspeaking, inexpressive face; infants’ differing reactions can be indicators of eventual behavioral differences.

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however, no differences were evident between the groups. This result suggests the hypothesis that the follow-up itself may have acted as a significant intervention for both groups by unintentionally combining them into a single intervention sample. From research of this kind, we are learning to better predict developmental outcomes, a responsibility that should be imperative for clinicians in their everyday practices. Belief in this imperative guides us in our practice, and that is why we intervene at every one of the Touchpoints suggested in Brazelton’s Touchpoints Approach. The impact of the Touchpoints Approach was suggested to us when, at the 9-year follow-up, mothers from the experimental group were better able to recall what the pediatrician had talked about with them when initially sharing the discovery of their newborn babies—9 years previously. We already know through well-documented evidence that each individual is affected not only by his experiences, but even more so by the way he feels events or behaviors ought to be. We believe that this perception of the rightness of a situation underlies the development of moral sense in each culture. In addition, we learn from Ortega Y. Gasset that each person is a combination of his or her own unique selfhood. Each child’s development is shaped first of all by the family, and then by its extensions—by the child’s other relatives, friends, neighbors, teachers, and even pets. Brazelton’s view of Touchpoints is very much based on the constructs of circumstance and change, which make it much easier to develop comprehensive strategies for clinical intervention. The circumstances or the environment in which the child lives, however, is not a stable factor. This is particularly true when there is a disturbance in relationships. We provoked this disturbance experimentally using the still-face paradigm at different ages. We could see that the inexpressive, emotionless face caused extreme distress to the baby in the newborn period. We could see the same emotional catastrophe in the child’s reactions at 12 months. But even more impressive than the child’s distress was the adaptive effort of the baby to reestablish the balance—that is, the child’s efforts to recover the sense of coherence that was lost through this experimentally induced disturbance, namely by crying, closing her eyes, looking away, or going to sleep. In observing the still-face situation, we recognize the frustration of a baby whose major expectation is to be able to be engaged in affective exchanges with someone very special to her. Every baby is

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“programmed” to be loved, to feel that she belongs, and to have a sense of coherence in whatever happens to her. If a child builds a strong self-image because all these programmed expectations are fulfilled, then she is able to be empathic and altruistic, and able to believe in others. Following the logic of this basic observation, the development of moral sense and the prevention of violence in our society begins here. Bearing all this in mind, what are we doing in Portugal? We are using the Touchpoints Approach in our clinical work. We are using the NBAS as an opportunity for early intervention with families, particularly with families at risk. At our university hospital, we have begun to use the prenatal Touchpoint with parents at risk. Before each mother ’s maternity discharge, we share the discovery of neonatal behavior with both parents. Overall, we attempt to invest, primarily, in education. We meet every week to plan Touchpoints interventions. We practice Touchpoints together, once a month. We teach Touchpoints once a year through a 1-week course given by a multidisciplinary team. We teach the NBAS to researchers and the Newborn Behavioral Observations (NBO) system to clinicians.8 We teach our young neonatologists Touchpoints and NBAS through an intensive postgraduate course. In the first year of our medical curricula, we teach our students neurobehavior and development, and they have the opportunity to visit nurseries, kindergartens, old-age homes, prisons, and centers for handicapped children. In their pediatric curriculum, our students follow a family through pregnancy, the delivery, and the first health visit. They evaluate what happens during this first follow-up visit in terms of neurodevelopment and prevention. On the whole, we teach Touchpoints and the NBAS as models for intervention; we teach early intervention; and we teach the cycle of moral sense—sympathy, communication, empathy, altruism, tolerance, and respect—as opposed to the adversity cycle, particularly in families at risk. Our challenge now is to establish a national program for a preventive family intervention using the Touchpoints philosophy. All this is centered in our university department and at our medical school that is affiliated with a central hospital. This is part of a dream. Maybe it is still only a dream. Let me recall, however, the words of Fernando Pessoa, one of our great Portuguese poets: Perhaps I will take to the other world what I have dreamed, but will I be able to take to that world what I forgot to dream?9

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1. Brazelton TB. Neonatal Behavioral Assessment Scale. London, England: SIMP/William Heinemann Medical Book Ltd;1976. 2. Gomes-Pedro J. The child in the twenty-first century. In: Gomes-Pedro J, Nugent JK, Young G, Brazelton TB, ed. The Infant and Family in the Twenty-First Century. Boston, MA: Brunner-Routledge;2001:3–21. 3. Brazelton TB. Touchpoints: The Essential Reference. Cambridge, MA: Addison-Wesley Publishing Co; 1993. 4. Gomes-Pedro J, Monteiro MB, Carvalho A, Patrício M, Torgal-Garcia F, Fiadeiro I. Meaning and effects of early intervention on mothers. In: Gomes-Pedro J, ed. Biopsychology of Early Parent-Infant Communication. Lisbon, Portugal: Calouste Gulbenkian Foundation; 1987:47–61. 5. Bronfenbrenner U, Crouter AC. The evolution of environmental models in developmental research. In: Kassen W, ed. History, Theories, and Methods. 4th ed. New York, NY: John Wiley & Sons Inc; 1983:357–414. Mussen P, ed. Handbook of Child Psychology: Vol 1. 6. Gomes-Pedro J, Almeida JB, Costa CS, Barbosa A. Influence of early mother-infant contact on dyadic behaviour during the first months of life. Dev Med Child Neurol. 1984;26:657–664. 7. Gomes-Pedro J, Patrício M, Carvalho A, Goldschmidt T, Torgal-Garcia F, Monteiro MB. Early intervention with Portuguese mothers: A 2-year follow-up. J Dev Behav Pediatr. 1995;16:21–28. 8. Gomes-Pedro J. CLNBAS as a Clinical Tool in Pediatrics. Acta Pediatr Port. 2003;34(6):389–391. 9. Pessoa F. Obras Completas: Poemas [Complete Works: Poetry]. Lisbon, Portugal: Edições Ática; 1952.

CHAPTER 17

Humanizing the Infant: France DRINA CANDILIS -HUISMAN and MARIE FABRE -GRENET

The Neonatal Behavioral Assessment Scale (NBAS) is a powerful tool for clinicians, researchers, and teachers—for all of us who work with neonates and their parents. Although it is a clinical tool, it is not only a clinical tool. It is a research tool and an intervention tool. Why are these multiple purposes so important? The power of the NBAS, we believe, is due to the different research, educational, and clinical approaches advocated by T. Berry Brazelton and the team that has worked with him to develop the NBAS and oversee its evolution. Each professional has a different set of tasks and, therefore, each has a different point of view. It is not only pediatricians who administer, teach, and utilize the NBAS in their work; the NBAS is also used by psychiatrists, psychologists, nurses, and others whose goal is to support parents, to focus on the baby as a unique individual, and to work together to promote and support the development of this individual. The NBAS, therefore, is baby-centered, with the strong involvement of the parents. T H E R A P E U T I C C O N S U LTAT I O N S I N T H E M AT E R N I T Y WA R D I (DCH) want to share with you some thoughts about the use of the NBAS as a clinical intervention tool from a psychotherapist’s point of view. In general, I am called on as an expert to intervene, as a Drina Candilis-Huisman wrote the first part of the chapter, “Therapeutic Consultations in the Maternity Ward,” and Marie Fabre-Grenet wrote the second part, starting with “Contribution of NBAS to the Practice of Neonatology.”

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supplement to the routine care provided by the maternity ward team and its usual partners. In adding my own contribution to all of this team’s work, I come to the maternity ward with a one-time consultation as my only chance to help. I know that, generally, there will be no other opportunity to meet with this mother and her infant. As a working hypothesis, I look at the NBAS assessment as part of a triadic situation, with three different partners: the mother; the baby; and myself, the examiner. When I say three partners, I nevertheless want to underscore the heterogeneous positions of the three, the examiner being external, quite separate from the initial motherchild dyad. It is the actual involvement of each of these three partners that confers special characteristics to this examination during the perinatal period. The structure of the NBAS as a framework for consultation brings an energetic impulse to this triadic schema in order to influence, in some way, the future direction of this mother-infant relationship. I speak from the dual viewpoint of someone who has experience both as a child therapist and as an NBAS trainer. These two different perspectives make me particularly aware of the importance and the strength of intervention during these first moments of an infant’s life. In our maternity wards in France, a pregnant woman typically meets 20 to 30 different people in, or related to, the institution of the maternity ward during her journey from pregnancy to new motherhood. A clinician must make a very strong impression in order to introduce something new and uniquely memorable in a woman’s maternity ward experience. That is why I am continuously surprised to find that when I administer the NBAS, I remain a figure of reference for a very long time for the family. I remember Tom, for instance, whose father regularly sent me photographs and written notes about his son’s developmental milestones: first smile, first steps, first words, and so forth. And I had seen this infant just once! Promoting the kind of triadic situation that has this kind of positive long-term impact is the examiner ’s main task. With this goal in mind, I next discuss the examination in three different phases, which I believe summarize the emotional dynamics of the three partners. Examiner’s Point of View There is always a feeling of excitement before going into a new mother ’s room. It is probably a mixture of fear and desire—fear of being refused and the desire to be useful. (S. Stoleru1 compared this

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to the struggle against the envy fantasy described by the famous Freudian child psychoanalyst, Melanie Klein, that envisioned stealing the baby from the mother ’s womb.2) The other aspect is that the examiner has to gain the trust of the mother and the baby and, finally, win over their confidence. Does this first meeting require specific skills? At first, it might seem so, but in considering past experiences, I am not completely sure. In France, we work in an environment where specific guidance about parenting and infant care is not usually provided by a psychologist, but by a rotating team of nurses, each one having a very specific point of view. For instance, one nurse might say to a mother, “You should breastfeed your baby.” But a few minutes later, a second nurse might come into the room and advise the mother to feed her baby with a bottle. Understandably, in this kind of situation, mothers are both eager and apprehensive about receiving any advice at all about their babies. For this reason, I am very careful about the impact of what I tell a mother as we discover her baby together through the NBAS. This brings us to the second partner: the mother. Mother’s Point of View The new mother vacillates between two different identities: an image of herself as a baby and an image of herself as a mother. (We are grateful to Dan and Nadia Stern for describing this special and unique ambivalence.3) We need to empathize with both of these two persons in one. How does the mother first react to the prospect of participating in the NBAS assessment? She might be worried or, on the contrary, quite confident. If we pay attention to her attitudes—how worried or how confident, how concerned or unconcerned she is—we will have our first hint of what is likely to be her typical way of projecting her feelings onto her baby. A mother ’s worries might indicate that she views the baby as a personification of her own unhappy inner world. In contrast, those very same worries could indicate her desire to build a genuine realm of emotional protection for her infant and for herself. I often meet this latter kind of situation with immigrant mothers. Unconcerned women may have very different profiles. Sometimes, mothers are overwhelmed by all the medical requirements of the hospital, and so they are distracted from focusing on their child’s developmental profile. Sometimes they are hiding the emergence of depressive feelings.

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And what about confidence? I am very often struck by an attitude of immediate—sometimes exaggerated—confidence. This is frequently the case with mothers who come from foster homes. Overconfidence indicates to me that I will need a lot of time to get these mothers to trust me; however, often, I cannot get them to trust me in one session. It would be necessary to share two or three sessions with such a mother and her baby in order to make it possible for her to be able and willing to observe her baby with someone else—with me—in this case. Usually, this kind of mother is just too emotionally fragile to allow herself to acknowledge the fragilities, as well as the strengths, of her child. In France, mothers usually stay in the maternity ward for only 3 days after delivery. I consider this to be too short a time for the clinician to establish a deep, confident relationship with emotionally fragile mothers; and this kind of confidence is necessary for us to be able to observe the baby together in a meaningful way. It would take at least two or three different sessions for us to be able to establish such a relationship. And so, in response to the special needs of these kinds of mothers, we have established an intervention program at a mother and baby care center. Here we meet with these mothers and babies on an ongoing basis after they leave the hospital. In this setting, we help the mothers focus on only one aspect of their babies’ development at a time—for instance, motor organization, sleep, or orientation abilities. I think it is necessary to progress step by step with these kinds of mothers in order to respect their lack of self-confidence. A situation that requires very special sensitivity is the mother who has delivered a healthy baby after previously experiencing a stillbirth. Normally, most mothers in this situation are defiant at first, but extremely rewarding to work with by the end of the NBAS session. It takes a special effort to help them get past their very understandable fear that even though this infant has survived, it may have some long-dreaded defect or abnormality. The difficulty with a mother in this situation is not only to ignore her lack of self-confidence, but also to deeply understand and validate her feelings of guilt for having lost a previous baby. This guilt is sometimes the reason for a delay in this mother ’s ability to develop an appropriate bond with her new, healthy baby. Baby’s Point of View We can consider the entire encounter as a play in three different acts, just like a drama on a stage, with three different actors—the

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baby and the examiner in the spotlight and then, very near but slightly out of the limelight, the mother. Phase I: The Beginning

All of us trained to administer the NBAS assessment know that the ideal situation is to begin when the baby is asleep so that it’s possible to get a complete picture of the full range of her competencies. The Habituation items are difficult to assess accurately (or must be eliminated entirely) when the baby is alert, active, or crying. In general, neither the mother nor the examiner really likes to wake up a sleeping baby. It is obvious that sleep protects the infant’s internal world. Nevertheless, when mother and examiner do have the opportunity to administer the recommended NBAS items during sleep, it is fascinating to observe how powerful the infant’s ability is to resist being awakened; it’s as if, somehow, this tiny being were convinced of the usefulness of sleep. Phase II: The Middle If the baby was asleep when the assessment started, she is not asleep anymore. The question now is: Will the mother allow someone else to discover her baby with her? She could observe her infant by herself; most mothers do. But because of the sort of “noise” that inevitably accompanies a mother ’s personal interpretation of her infant’s behavior (projective identification), observing her infant in the company of another person who will offer support, yet require her to look at her baby more objectively is a novel and challenging concept. Looking at her infant more objectively, within the first few days of its life is anticipating the kind of observation that would normally occur a little later during the process of establishing her relationship with the baby. The NBAS enables the new mother to discover two different people: She observes her baby and discovers a new person, and she observes herself observing the baby; in this way, she discovers herself as a new person, too. It is necessary to firmly and tactfully support this adventure. The process of discovery is a risky one that needs careful attention. As facilitators, we need to help guide this process in a way that is as unobtrusive as possible. In fact, this is a very sophisticated job. That’s one reason we have to carefully examine the thoroughness and sensitivity of our training. We also have the responsibility of offering an appropriate way of handling a newborn. Brazelton, in Saving the Bathwater, explained his concept of “best performance” in a very interesting way: “We believe that the best performance represents a form of pushing

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limits which may be a better estimate of future performance than a modal performance.”4 I totally agree, with a small restriction. I think we have to be very careful in our attempts to search for the best performance in a baby who has a handicap or deficiency. In this realm, especially, the issue of how—and even whether—to seek best performance remains an open question. Phase III: The Conclusion

Does the NBAS experience leave the mother and the examiner feeling happy or puzzled? When we feel that we have contributed to understanding how the baby is best able to organize herself, even in a small way, we, as examiners, feel rewarded; and we can feel the same sense of reward in the mother. When a mother understands how to read her baby’s cues, the baby is empowered and the mother is, too. Their interactions are more satisfying on both sides, and their relationship gets off to a solid start. At this very earliest period of life, the NBAS examination has a dual goal—both to link the mother and the baby, and to separate them. This endeavor is not always successful. Sometimes I go out of the room puzzled. The exam has been meaningful, of course. Yet it is clear that this particular mother-infant dyad is going to need further support. Sometimes it is necessary to respect the mother and infant’s self-protective emotional need to work out the future of their relationship for themselves. Sometimes it is more useful to try to find a network of support for the mother. Inevitably, building the necessary kind of network requires multidisciplinary teamwork. The resources for supporting mothers and infants vary greatly from one country to the next. Yet even in our rich Western countries, the means for building a powerful and effective support network during this early period of life is woefully inadequate. I want to emphasize that both the framework of the NBAS and the guidelines for successfully administering the examination are based on the hypothesis that neonatal behavior is immediately set amid a complex relational system. René Spitz, in his book The First Year of Life,5 describes the mother-infant relationship as a “crowd of two.” I look at this relationship as a threesome, in which the clinician retains a flexible and distinctly different role with both the mother and the infant. I believe that the quality of the examination depends not only on the ability to accurately assess the infant’s capacities but also on the dynamic relationship that emerges among the different partners. The clinician’s effectiveness relies on his or her flexibility, an essential quality about which we need to conduct more research.

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CONTRIBUTION OF NBAS TO THE PRACTICE O F N E O N AT O L O G Y When I (MFG) meet at-risk babies who have been hospitalized and their parents, the NBAS is an important Touchpoint in follow-up care. Since 1991, I have met many mothers (and fathers, too, but unfortunately, fewer fathers) around their babies’ incubators. As I follow these families during the early years of their children’s lives, it seems to me very important to offer these parents a space for listening around the baby. The kind of intervention that I offer usually occurs just prior to discharge, midway between the neonatology unit and CAMSP (Centre d’Action Medico-Sociale Précoce, the early medicalsocial intervention center). My approach, looking at the baby as an individual person at a particular point in development—and an integral part of the infant-parents-caregiver system—requires a deliberate shift to a more global kind of medicine: developmental medicine. Context The tendency to hypermedicalize pregnancy is not going to slow down—because of the increased medicalization of procreation, which has led to more premature births; an increasing number of multiple births; and an increasing number of late-in-life pregnancies. Thus there is a paradox. We have succeeded in reducing the rates of infant mortality, but we have induced new causes of prematurity and morbidity by creating situations where shorter gestation periods threaten viability. Thus our neonatal units are always crowded. Medical techniques of intensive care—and neonatal survival rates— are improving every day. We are saving babies, allowing them to live, but we have to take a long-term look at what is going on here and ask the question: What is the cost of this? The organizational structure of CAMSP as an integral part of a mother-infant hospital allows us to initiate intervention and provide comprehensive follow-up care of at-risk infants and their families in an ideal setting. We can start following them in the neonatology unit, sometimes before birth in the high-risk pregnancy unit, or at birth. Taking care of and following babies born prematurely or hospitalized at birth (and their parents) is a long-term story. This story begins with a pregnancy, often at risk, but sometimes not. Often conception has been spontaneous, but sometimes it has been induced (or in vitro). Then one day, nothing is going as

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expected: the fruit is falling from the tree while it is still green, and suddenly this mother is living with violence, the emergence of danger, death, disability, and dispossession of her body—a body that is no longer playing its role. Her uterus has become dangerous instead of protective. The psychological process of the pregnancy is broken: Can this mother recover and become a premature-mother? Bruschweiler-Stern has described “the premature-mother” concept by pointing out that a pregnancy takes 9 months in the mother ’s head, too.6 When a baby is born prematurely, the mother feels that she does not control anything and that her pregnancy has been disposed of by the “powerful doctors” on whom her child’s survival seems to depend; she often feels diminished by not having been able to give birth normally. She will have to do successive grieving. She will grieve a normal pregnancy, a normal delivery, and an ideal newborn. Add to this the disappointment of a baby who may look like a “shrimp”— skinny, red, and (often in the beginning) living with the assistance of machines in her boat-like incubator. It is all so strange to her. All these situations raise psychological issues that will have to be addressed in an integrated way in the course of providing the prevention and support care that this new infant, and new family, needs. It will require real teamwork. Different fields of thinking orient our multidisciplinary response: • The medical field: It’s crucial to care for various transitory pathologies caused by immaturity, which can become chronic and, as a result, cause real pathologies—reflux, respiratory diseases, developmental delay, and so forth. All this can result in a baby that is difficult to handle—a baby that resists being held in your arms because of painful reflux, a baby who will not look at people spontaneously. Another concern is early medical intervention. Definitive brain lesions, for example, will result in a very different outcome if follow-up starts as soon as possible, even in the neonatology unit, rather than being delayed until 4 months of corrected age—and 4 months late! • The psychosocial field: A variety of difficult psychological and social issues are often added to the challenges a new family faces solely on the basis of the baby’s prematurity. • The preventive field: This is the true mission of the CAMSP: the prevention of relationship troubles, developmental troubles, and postural abnormalities. The prevention of all the sequelae caused by prematurity is the primary goal of all the caregivers who are a part of, or who work with, the neonatology team.

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How We Work with Families Understanding neonatal development and behavior in accordance with the approach of Brazelton and his colleagues, like Als, has proven really meaningful for us in the care and the following of premature babies. The spirit of this approach is to challenge our preconceived notions and push us to question our habitual ways of thinking and acting. It can often be uncomfortable but, at the same time, it is very enriching. Spending time with newborns and observing their behavior leads us to touch the never-ending richness of human behavior. The possibility of following their progress for the long term allows a real support of parents, but perhaps of caregivers, too, for they also experience the rewards of their investment. In this way, the babies are supporting us just as we are supporting them. Up until now, the predominant medical model has been a pathological one; but the time has come to expand both our point of view and our diagnostic tools as we consider the “normal” model of child health in the context of developmental issues. The observation of the behavior of the neonate that Brazelton formalized in the NBAS has led us to focus on the baby as an individual. Understanding the baby’s language by observing and interpreting her reactions allows us to adapt her environment, including interactions with her caregivers. That means the people who take care of the infant—parents, the mother in particular, and the medical staff—make deliberate adjustments in the way they interact with her; it also means making adjustments to her physical environment—light and noise levels, and even the selection of accessories and equipment used in her care. It is enriching to observe how adapting the environment to each baby helps her to structure and develop herself. But in reverse, an unadapted environment—for example, one that is too intrusive, too stimulating or not stimulating enough, or for too long or too short a period of time—is going to disturb her development or have no positive effect. When stimulation is adjusted to what the baby seems to need and want, it really helps and supports her. Throughout the administration of the scale, we can see the baby awakening, organizing herself, controlling her physiology, and becoming stronger. I never observe bradycardiae or decrease of oxygen level during the administration of the NBAS with fragile babies. The challenge is for us to open our eyes, identify the relationship between the stress reactions of every baby and her environment, and figure out how to modify the environment to support the development of each infant. Sharing our observations with the parents

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allows them to be partners in the care of their baby; they become familiar with her universe. Considering the baby as a full partner, we are able to take advantage of all her resources and interpret her reactions. During the assessment, the baby will “lead the game” by participating or withdrawing in accordance with her capabilities and her unique individuality. Sometimes she is withdrawn, and it is up to the examiner to adapt the stimulation of the exam, decreasing the intensity, giving her a little break, or interrupting the administration of the scale if continuing becomes inopportune. Flexibility is the master word to us: Flexibility means changing our understanding, as “best performance” tends to achieve surprising outcomes when compared to a classical examination. This is particularly evident in the pull-to-sit item; during a normal neurological examination, we are obtaining a reflection of the basic axial tone. During the NBAS, it seems to be the will of the baby to display a superior brain function. For example, when the baby has a brain impairment (most typically, bleeding), we expect to see a floppy baby, then suddenly she contracts her muscles, holds her head in midline, and looks at you for a while; this stabilization and deliberate gaze seems to be accomplished through sheer force of will. Scoring the NBAS enables us to get a better sense of perspective and look at the baby more objectively; the NBAS encourages us to analyze the baby’s behaviors. What we learn will complete our medical analysis and also guide us in the care of this baby. What We Do Before discharge (sometimes even before delivery), the midwife meets mothers in the high-risk pregnancy unit or in the maternity ward. She asks questions about the pregnancy, provides information about what to expect postpartum, and serves as the mother ’s liaison to our team. Whenever possible, I try to meet parents and their babies around the NBAS when the baby is off life supports and is ready, or nearly ready, for discharge. Sometimes we have met before, in an informal way around the incubator or in the corridor; perhaps we have been introduced by the psychologist or one of the nurses; but most of the time, this is our first contact. I often ask whether the parents have ever heard about the NBAS or Dr. Brazelton. My intervention takes place as part of a follow-up framework established by the CAMSP team in collaboration with the neonatology unit. The NBAS is an opportunity to open the door to discharge. The time I spend listening to the parents allows them to talk about

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their living situation, about the traumatic events surrounding their child’s birth, and to ask questions they have inside. I give them specific advice about the care of their infant and introduce the follow-up plan we are offering to them. This early first contact in the hospital sets the foundation for a real therapeutic alliance; because of this solid start, we have observed a better adherence to our follow-up recommendations. The administration of the NBAS takes place either while the baby is still in the hospital or at the first formal visit as part of the baby’s follow-up program. In either case, this first visit, during which we share the NBAS together, establishes the way we are going to get along together for a quite a while. The exam and our conversation can easily take more than half an hour. In our clinical practice, we believe that spending this amount of time is important. Even if there is a psychologist on the team and the family knows he or she is available, the first visit (or a visit prior to discharge) is often too early for them to ask for psychological counseling. Some will never ask. In that case, they will only speak about the troubling experiences surrounding their child’s birth a long time afterward, when problems begin to appear. I am a pediatrician, and I realize that sometimes this first meeting with me might be the only time parents will be open enough to speak about their infant’s premature delivery, the intensive care their baby required, and their fears. Sharing observations around the NBAS, and allowing parents to discuss their special concerns, is the first step in our follow-up, a process that often lasts for up to 6 years. How Families Respond To illustrate the effect of the NBAS experience, I would like to tell you about the findings of a young midwife who conducted nondirected interviews with families who had observed the NBAS being administered to their newborns. The question was, “Do you remember the NBAS exam that Dr. Fabre-Grenet administered to your baby before discharge from the neonatology unit? Please tell me about it.” Here is a sampling of the responses from a variety of parents; for some, the NBAS had been administered quite recently; for others, it had been several months, or even years: • “I was happy that someone was taking care of my baby differently. The exam was less on the medical side, more on the human one; the doctor was available for me and my baby. She took time, more than half an hour for us.” This mother said

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that she had also been reassured about the capacities of her son (his twin had died in NICU during the first week), despite the fact that he had a small periventricular hemorrhage. I followed him for 3 years, and he did well. • Another mother said she had discovered that even though her daughter was premature (born at 26 weeks of gestation), she was able to do a lot of things “like a term baby.” She said the NBAS experience had reassured her about her baby’s competencies, which she had been doubtful about beforehand. “I saw her as a baby, not as a preemie. . . . She was not a frail thing anymore; she was my baby.” This mother also said that she, herself, felt more confident about taking care of her baby because she saw the baby as less fragile. She saw that the baby could be handled and had capacities she had never seen before. She was less anxious about taking her baby home. • “The doctor was listening. She told me a lot about my daughter and changed the way I looked at her. After 4 months spent in the hospital, I needed that exam.” I remember that this baby was extremely weak and easily overstimulated. This mother learned to recognize the signs of her infant’s stress and learned the maneuvers that were effective in supporting her. She also said, “This exam took us out of the strictly medical realm. It focused more on our humanity, and with that shift my relationship to my baby became sealed.” Over and over, in their own words, these mothers expressed the wonder of discovering their babies, especially through the NBAS Orientation items—where it becomes clear that the baby recognizes the mother ’s voice and gazes steadily at the mother ’s face—and the items that demonstrate the baby’s self-protection capacities. “Humanization,” “decrease of anxiety about discharge,” “the time spent listening”—these memories are constantly brought up in the interviews with these mothers, even 2 years after the NBAS experience. CONCLUSION Why do we sense such positive responses, such relief, when mothers consistently describe the NBAS experience as “one that humanizes the infant—finally”? It’s as though those mothers had accepted the pathological model of the medical staff because they knew that the nurses and doctors were dedicated to the physiological needs

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of the baby and often lacked the time and opportunity to meet with them around their needs, even if they wanted to. Setting aside this special time, as discharge nears, seems to have a specific, useful, and perhaps necessary function. This is the time we can share with the parents what their babies can teach us. By doing this in a structured and supportive way, we can support the development of the baby and support the mother-infant team— a step that we believe is necessary to improve the quality and effectiveness of the medical care we provide. REFERENCES 1. Stoleru S. Obstacles pré-contre-transférentiels lors de l’apprentissage de l’échelle de Brazelton [Pre-counter-transferal obstacles when training in the use of the Brazelton scale]. Devenir. 1997;9(4):43–54. 2. Klein M. The Psycho-analysis of Children. London, England: Hogarth Press; 1932. 3. Stern DN, Bruschweiller-Stern N. The Birth of a Mother: How the Motherhood Experience Changes You Forever. New York, NY: Basic Books; 1998. 4. Brazelton TB. Saving the bathwater. Child Dev. 1991;61:1661–1671. 5. Spitz R. The First Year of Life. New York, NY: IUP; 1963. Ch VIII. 6. Bruschweiler-Stern N. Que Sont les Bébés Devennus? [What’s Become of the Babies?] Eres, France; 1997. Col: Mille et un Bébés [Collection: A Thousand and One Babies].

CHAPTER 18

The NBAS in a North Carolina Clinical Setting: Hospital and Home: United States JAMES M. HELM and MARIE A. REILLY

Our approach to supporting high-risk infants and their families is deeply rooted in the work of T. Berry Brazelton, Heidelise Als, and the theoretical traditions they have richly enhanced and advanced. Our emphasis is on supporting the emerging infant-family relationship, helping both hospital staff and families in the hospital and at home understand infant behaviors, support self-regulatory efforts made by babies, and structure both the infant’s environment and the parents’ care practices with the goal of reducing stress and maintaining controlled, organized behavior. This chapter focuses on our use of the Neonatal Behavioral Assessment Scale (NBAS)1 for multiple purposes. We offer an array of services that includes Newborn Individualized Developmental Care and Assessment Program (NIDCAP)based, developmentally supportive, family-centered care of infants and families in the intensive care nursery (ICN)2,3; a developmental follow-up clinic; and an early intervention program that begins in the hospital and follows the family home. The NBAS contributes to each of these services, and we consider it important for families and for our follow-up program. The NBAS also helps us identify program goals and activities throughout our association with families. Most of the babies we examine are those who have been in the ICN, born prematurely, or who were sick or traumatized at birth. We are part of a Developmental Team that is multidisciplinary and 196

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includes trainers on the NIDCAP approach, the NBAS, a developer of the Family Infant Relationship Support Training (FIRST)4 program and trainees on the Brazelton Touchpoints Approach (a program of the Brazelton Touchpoints Center, an affiliate of the Children’s Hospital in Boston). Members of the team are certified or trained on the Assessment of Preterm Infants’ Behavior (APIB),5 the Test of Infant Motor Performance (TIMP),6 and other infant assessment protocols. These all influence our clinical practice, and with all these tools available, our approach to each exam and each family varies according to the circumstances. This depth and breadth of resources allows us to draw from a rich background. When we conduct an NBAS-based exam, we prefer supporting parents to use the items from the exam much like the Family Administered Neonatal Activities (FANA).7 At times, however, we also conduct the exam with parents observing, or even examine babies when families are unable to attend. We often don’t score exams; rather we use the exams as a basis for clinical observations that are documented in ways that meet early intervention requirements or that lead to suggested activities for families or other interventionists. We are also often able to conduct repeated exams. The following sections briefly discuss our uses of the NBAS. F O R FA M I L I E S As many others have done, we use the NBAS with families close to the time their babies are discharged from the ICN, and do the exam either in the hospital before discharge, in families’ homes, or during a follow-up clinic visit. We find the discharge exam helps families focus much more on the behavior of their babies rather than on medical issues, such as grams of daily weight gain or oxygen settings. For families who have been in the ICN, this discharge exam is frequently quite confirming for them, and it gives us an opportunity to discuss developmental processes and offer anticipatory guidance. For families who have been less able to be with their babies, the exam helps us talk about their baby’s competencies, as well as behaviors that might reflect how fragile or robust they are. In many ways, the process of examining the baby and discussing observations helps open our relationships with parents. It encourages them to discuss behavior, development, and caregiving. When we’re able to do multiple exams over the course of several days or weeks, the benefits seem to multiply as well. As we approach an exam with a family, we often characterize it as a way to look at how their baby responds to the world and to the routine kinds of stimulation that he or she is likely to encounter at

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home. We explain that the exam can be viewed as a systematic presentation of routine care; for example, testing reflexes of the feet and legs is similar to putting on socks and pants; Pull-to-Sit is similar to getting a baby up off a changing table; orientation items are like social play, and so forth. Besides allaying fears about a “test,” this approach opens for discussion a wide range of potential topics related to a baby’s behavior and responses, such as sleep-wake states and state control, stability of the autonomic system, regulatory efforts and supports needed for the baby to be successful, availability of the alert state, tolerance for stimulation, control of posture and movements, and many others. The examiner always encourages parents to express their observations and ask questions. Examiners have the opportunity to express their observations, as well. Throughout the exam, the baby’s responses act as a catalyst for discussions that are important for each parent’s understanding and adjustment—important for their role as parents. The exam supports mothers and fathers in becoming more competent parents. D E V E L O P M E N TA L F O L L O W - U P At our hospital, we have a follow-up clinic for babies from the ICN for up to 3 years. The purpose is to help coordinate complicated medical care; to monitor and evaluate behavior and development; to support families, offer suggestions and anticipatory guidance; and to make appropriate referrals. NBAS exams at discharge give us good baseline information on the child’s behavior and the family’s issues. At times the discharge exams are done in the clinic, but whether the first NBAS exam is done in the hospital or clinic, follow-up allows multiple exams (NBAS or partial NBAS) timed according to how closely the child is monitored. The theoretical constructs on which the NBAS was developed and through which observations have been interpreted inform our understanding of babies for some time beyond the age range for the scale. Behaviors are seen both as current indicators of a baby’s status and in the context of earlier observations, thereby helping us appreciate change and progress. In Touchpoint terms, we can use the baby’s behavior as his or her language to communicate current status and needs. These behaviors give us a focus to continue discussions on regulatory competencies and the developmental process, as well as individual expressions of temperament or personality, the baby’s robustness or fragility, and the integration of the new baby into the family.

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COMMUNITY PROGRAMS In the United States, early intervention (EI) for children with disabilities can start at birth. Each state has the right to interpret and implement this program within the national guidelines, and in North Carolina, children can be made eligible for EI if they have a developmental delay or any condition included under the category of “Established Conditions.” This category includes congenital or neonatal conditions that are most frequently associated with delays. As of July 1, 2006 neonatal conditions and associated complications include birth at less than 27 weeks, or birthweight less than 1000 g, neurologic disease or damage, neonatal seizures, intrauterine growth retardation, necrotizing enterocolitis requiring surgery, broncho pulmonary dysplasia that requires supplemental oxygen at discharge from the hospital and others. Even though a variety of conditions can make a child eligible for services, there is still the requirement for assessment to determine needs. It is required that a child has an evaluation of his or her: Present level of development, unique strengths, and needs in the following areas: 1. Cognitive development 2. Physical development, including gross and fine motor, vision, and hearing 3. Communication development 4. Social-emotional development 5. Adaptive development In addition, the evaluation must include a medical component.8

The state recognizes there are no standardized or normed evaluations for these domains of development for babies born prematurely or at the ages that babies are discharged from the ICN, and therefore allows clinical observations. We use the NBAS and adaptations as the basis for clinical observations and then organize our evaluation summaries to meet the needs of the EI system, as well as to guide development of intervention goals and activities. If a Summary of Existing Assessment Information* is required early in a premature infant’s stay in the hospital, we use information gained through the NIDCAP’s Naturalistic Observation of Newborn * The Summary of Existing Assessment Information is required by the EI system as part of the process of developing an education plan. The timing for setting this process in motion varies, being determined somewhat by parental readiness and preferences.

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Behavior (NONB) activity9; and if it’s due around the time of discharge, we usually use the NBAS. Using the synactive framework and either of these two neurobehavioral observations, we can characterize the baby’s physiological stability, motor control, and state control, as well as regulatory efforts, energy, sensitivities, and support needed to maintain organized behavior.10 These descriptions help parents and caregivers understand infant behaviors, appreciate competencies, and formulate goals and strategies that can foster continued development and strengthen family relationships. Once observations are made, insights can be formulated to meet the requirement that each of the five developmental domains is addressed, as required by EI guidelines. Since the behavioral expression of these domains in infants overlaps so much, a long discussion could ensue. For example, a description of regulatory efforts may fit under the adaptive behavior section for some children, but under the communication or cognitive sections for others; and physiological stability might be of particular importance in describing a baby’s adaptive skills (e.g., turns pale during feeding), as well as his or her ability to get alert and attentive (e.g., turns pale with increased respiratory efforts after short periods of faceto-face interaction). The domains may be artificial separations for babies, but the important information about neurobehavioral organization gained from an NBAS-based observation can be used Table 18.1 How Observation Informs Developmental Intervention Planning

A—Assessment Description: Baby was born at 25 weeks gestation, weighed 2 lb. 2oz. (960 g), and is now 3 months old or 39 weeks gestational age. Communication development: Baby was most available for interaction when gently swaddled in blankets and stimulation was soft. Her ability to get alert is just emerging, and when alert, she readily averted her gaze or went into a drowsy state to control input. She cried or went to sleep in response to too many demands. During feeding she did best when looking off into the room rather than at the feeder. B—Intervention Plan Goal: Baby will be able to sustain relaxed social interaction for 5–10 minutes. Activities: Family will provide a low level of stimulation when engaging Baby in social play. Baby will be gently swaddled in a blanket during feeding with low lighting and a quiet room.

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to meaningfully describe the baby in meeting state and federal requirements. An example of a brief description of communication skills is provided in Table 18.1. H O S P I TA L - H O M E E A R LY I N T E RV E N T I O N Our EI program—WakeMed’s Hospital-Home Intervention Program (HHIP)—is currently grant funded (Wake County SmartStart) and allows us to provide continuity for families from the ICN through their discharge home and for another 5 to 6 months (until approximately 4 months post–due date). At that point, we work with families to identify their needs and other community programs that might best serve them. The referral process can start as early as a few days after birth but is also modified to meet the needs of each family, so that the process is sensitive to the critical nature of the ICN. Services are blended with the developmentally supportive, family-centered care that is part of the ICN’s approach to families. Once families enter the EI system, the formal process of evaluation and IFSP (Individualized Family Service Plan, required by EI) development begins. All of the NBAS-based observations described previously can both meet the evaluation requirements and also lead directly to functional goals and activities that support the baby’s development and each family’s relationship with their baby. For example, in Table 18.1 the description in Section A can lead to suggested activities in Section B. The information used to describe communication is also clearly of potential importance for describing social-emotional or cognitive development. The work of Brazelton on the NBAS has led to a cascade of work that has expanded and enriched our ability to understand infant behavior. Als and her colleagues expanded the work to help us understand premature babies; and the work of both, along with various expansions and adaptations (e.g., FIRST, Touchpoints) have guided our clinical efforts to support families in meeting the sometimes daunting challenge of raising at-risk babies. REFERENCES 1. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. No 137. 3rd ed. New York, NY: Cambridge University Press; 1995. 2. Als H. Program Guide: Newborn Individualized Developmental Care and Assessment Program (NIDCAP). Cambridge, MA: Harvard Medical School, Children’s Hospital Boston; 2003.

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3. Als H, Gilkerson L. Developmentally supportive care in the neonatal intensive care unit. Zero to Three. 1995;15:1–10. 4. Browne JV, MacLeod AM, Smith-Sharp S. Family Infant Relationship Support Training (FIRST). Denver, CO: The Children’s Hospital Association Center for Family and Infant Interaction; 1999. 5. Als H, Lester B, Tronick EZ, Brazelton, TB. Manual for the assessment of preterm infant’s behavior (APIB). In: Fitzgerald HE, Lester BM, Yogman MW, eds. Theory and Research in Behavioral Pediatrics. Vol 1. New York, NY: Plenum; 1982:64–133. 6. Campbell, SK, Girolami G, Kolobe T, Osten E, Lenke M. Test of Infant Motor Performance (TIMP). Chicago, IL: Infant Motor Performance Scales, LLC; 2001. 7. Cardone IA, Gilkerson L. Family Administered Neonatal Activities (FANA). In: Brazelton TB, Nugent JK, Neonatal Behavioral Assessment Scale. No 137. 3rd ed. New York, NY: Cambridge University Press; 1995:11–117. 8. Children’s Developmental Services Agencies, Early Intervention Branch,Women’s and Children’s Health Section, Division of Public Health, North Carolina Department of Human Services. In: NC Infant-Toddler Program Policy and Procedure Manual. Bulletin #18 Eligibility Categories, Bulletin #21 Evaluations and Assessments. Raleigh, NC: North Carolina Department of Human Services; 2006. 9. Als, H. Naturalistic Observation of Newborn Behavior. Boston, MA: Boston Children’s Hospital; 2000. 10. Als H. Toward a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Ment Health J. 1982;3(4):229–243.

CHAPTER 19

Relationship-Based Practice in the Newborn Nursery: Thoughts for the Pediatric Professional: United States CONSTANCE HELEN KEEFER, LISE CAROLYN JOHNSON, and SUSAN MINEAR

Soon after the introduction of the Neonatal Behavioral Assessment Scale (NBAS) in 1973, it became apparent that this comprehensive research tool could be the foundation for creating a powerful clinical tool. The NBAS gave clinicians a structure for looking at the baby, a language for talking about the baby, and, perhaps most importantly, it modeled behaviors for interaction with the baby. These qualities suggested strategies for bringing effective relationship-based care to infants and their families. The fundamental concepts underlying the NBAS exam are to follow the baby’s lead, to allow her to show her strengths, to be respectful of her individuality and her needs, and to bring her to her own best level of performance. They encourage the examiner to look for the baby’s strengths and allow the baby to set the pace. In addition, the NBAS requires the examiner to be very present in the exam. At its heart, the NBAS is a relational care tool because it gives professionals a way to interact on a relational basis with the newborn infant and her parents right from the start. Over the years, two important clinical tools gradually evolved from the NBAS—the Combined Physical Exam and Behavioral Exam (PEBE) and the Newborn Behavioral Observations system (NBO), each of which took the relational aspects of the NBAS a step further. With the PEBE, the practitioner weaves observations and a narrative of the infant’s behavior into the standard newborn physical 203

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exam which he or she performs in the presence of the parents.1 The development of the NBO drew on our 25 years of research and training with the NBAS and our NBAS-informed clinical work, and thus reflects a wide range of theoretical and clinical perspectives.2,3,4 The NBO is based on the assumptions, first, that the newborn infant is behaviorally organized and capable of social interaction from the very beginning and, second, that the newborn period is a significant stage in the parent-child relationship. We designed the NBO primarily as a relationship-building tool that could help sensitize parents to their newborn’s capacities and individuality. Our goal was to foster the bonds between parent and infant and between clinician and family. The NBO consists of 18 neurobehavioral observations that describe the newborn’s capacities and behavioral adaptations from birth to the third month of life; it provides parents with individualized guidance on caregiving based on these behavioral observations. Behaviors included in the NBO are those deemed to be of relevance to parental caregiving, so the NBO provides information on the baby’s sleep, feeding, and motor behavior, threshold for stimulation, crying, consolability, and social/interactive behavior. In this way, the NBO is used with parents to create a profile of their baby’s behavioral repertoire. Thus, it enables the clinician to provide important information to parents about their baby and identify the kind of support and stimulation optimal for development. This profile of the infant’s capacities describes the infant’s strengths, as well as her areas of vulnerability. Moving the NBAS into the clinical arena was a natural transition. Those of us who had experience with NBAS research often carried those little red rattles filled with popcorn kernels (used for auditory and visual orientation) in the pockets of our white coats. Unconsciously—perhaps preoccupied with our thoughts as we were studying a newborn—we would take those rattles out and shake them. As the baby responded, suddenly we had something of substance to say to this infant’s mother standing nearby: “Look, your baby can see and follow this object as it moves. Watch as she turns her head toward the sound.” Suddenly, this baby was fascinating. Suddenly, we were much more than nice pediatricians because now we could say so much more than, “Isn’t she cute!” or “Her eyes are so bright and pretty.” Now we had a tool that enabled us to understand this baby, and we were able to share this understanding with the parents. We could explain what this bright-eyedness meant. We could give parents a framework to help them make sense of their own astute observations about their baby.

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Utilizing other aspects of the NBAS, we could explain how this particular child seemed to have a very fragile autonomic system. Or, we could say more than just that the baby seemed to have a mature motor system; we could say, “See how smooth and graceful her hand movements are—almost like a ballerina. The way she moves shows me that she has recovered from the stress she experienced during labor.” The NBAS gave us a vocabulary of infant behavior that is not routinely taught to pediatric clinicians. It allowed us to see the baby as a real individual at a particular point on her developmental trajectory. Further, we could orient the parents to what we observed together in ways that were meaningful and would help give predictability to this new baby’s behavior. With the NBO, the clinician now has the time and the tool to focus on key aspects of newborn development that are clinically relevant and also meaningful to families. The astute clinician recognizes that families do know about their newborns and that newborns are not tabulae rasae but complex persons with a whole repertoire of abilities. Now, rather than only explaining babies’ behavior to parents, the clinician is able to adopt an attitude of partnership and invite the parents to share in the experience of discovering who this unique baby is. As much as he or she works to keep the baby in the center of the encounter, the clinician also works to recognize the parents as central and the medical community as supportive. The clinician’s language is simple, supportive, and uncoded. He or she strives to notice and share information with parents rather than to teach and lecture. In short, the NBO helps the clinician transform the traditional medical encounter from one that is hierarchical and focused on pathology to one that is authentic and centered on the whole person, the whole family. W H AT I S R E L AT I O N S H I P - B A S E D C A R E ? When we speak of the clinician fostering relationship in the newborn period, we refer to two distinct relationships—that of the parent and child, which we are charged with nurturing, and that of the clinician and family, a necessary component of effective medical care. The importance of developing each of these relationships must not be underestimated. Fostering the Parent-Infant Relationship Observing the new baby in the context of the NBO helps parents see their child as a person, separate and distinct from any other.

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Parents of newborns are beginning to develop a genuine relationship with that child, reconciling the dreams of the baby they had hoped for during pregnancy and the nightmares of the baby they had feared. This reconciliation of polar subconscious fantasies into the vision of a baby they can love is important. Recent research on newborn behavioral and brain development demonstrates the fact that if babies experience positive responses from their primary caregivers when they are very young, they actually develop larger, healthier, more dynamic parts of the brain with which to experience pleasure, a strong, affirmative sense of self—joy. Why is this important? Because it means they are more likely to become capable, more likely to exhibit cheerfulness, competence, and confidence, more likely to behave in positive ways, and, ultimately, more likely to have a positive impact on the world they inhabit. At one time, ideas like this were shrugged of as mere idealism. Today, these theories about the genesis of positive human behavior are firmly grounded in science.5 The NBO gives us a framework for supporting families as they get to know and understand their new babies; it helps us build a collaborative relationship based on the language of the baby; and perhaps most important, it gives us a powerful tool for informing and empowering every new parent to feel more confident and competent about his or her ability to nurture the new baby. New parents know that their baby will someday learn to crawl, to walk, to say words. These developmental tasks are easily identified and recognized. In contrast, the skills developed in the first weeks of life, specifically the organization of the autonomic, motor, state, and environmental responsiveness systems, are more subtle, less universally understood, and prone to misinterpretation. The framework of the NBO is a powerful tool in helping parents appreciate the unique individuality and developmental path of their newborn during these early weeks. But let us be clear: The goal of the NBO is not to hand the family a complete understanding of who this baby is and what this baby’s individual personality is like, but to look at the baby with them and help illuminate what they are looking at and what they are looking for. The early weeks of an infant’s life can go so much better when parents can be helped to understand what their baby is trying to tell them. For example, we frequently use the NBO as a way of helping parents of near-term newborns understand their babies. One mother was working very hard in the first days to help her baby (born at 36 weeks of gestation) learn to breastfeed. Though the baby had a mature suck-swallow ability, her feeding was inconsistent. While observing an attempt at feeding, the clinician noticed that the baby

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alternated between crying and sleepy staring and explained to the mother that this was an example of how the baby’s ability to regulate her state was still immature, still developing. Admitting that she had been totally perplexed, the mother said that the clinician’s explanation of the behavior—and suggestions for what to do about it—made sense. The next day, the mother told the clinician, “She did that same crying-staring thing again last night, so I just let her chill out on my chest for a while, and she was able to feed better a little later.” This mother understood the concept of state regulation in the context of her baby and was able to adapt her caregiving accordingly; the result was successful breastfeeding. Fostering the Clinician-Family Relationship More than ever, clinicians face challenges in their efforts to establish strong relationships with their patients. The demand to see more patients in less time, the fragmentation of care with a family often seeing different providers within a primary care setting, the use of the tort system to compensate patients for medical failures—all these threaten clinicians’ ability to connect with their patients. This connection, however, is one of the most important aspects of the clinician’s role with families, equal at least to knowledge or technical skill. When relationship is sacrificed, patient care suffers, clinician morale plummets, burnout occurs, and lawsuits become more likely.6,7 Because the NBO is predicated on the shared observations of the clinician and parent, with the infant at the center of the interaction, it serves as an ideal tool to promote a strong relationship between the clinician and the family. THE NBO: A CONCRETE TOOL FOR THE PROFESSIONAL CLINICIAN IN TRAINING As clinicians confront the challenges to their time and energy, the NBO is a concrete tool to help them build relationships with their patients and to foster parent-child relationships. Though all clinicians can find this useful, such a tool is particularly important for clinicians in training. Indeed, a key component of clinician training must be to maintain the integrity of the clinician-patient relationship even in the face of a myriad of other responsibilities that constantly compete for the clinician’s time and attention. The NBO can be used as an organizing agent for clinicians in training who want the doctor-patient relationship to be pivotal

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in their practice. In our nurseries, physicians in training are introduced to the principles of newborn neurodevelopment and the NBO at the beginning of their rotations. Throughout the following weeks, they practice the structure of the assessment and learn to incorporate the language of the NBO into their practice. Each resident is encouraged to develop his or her own style because the NBO is not rote or mechanical. In addition, residents are encouraged to experiment with the NBO in a variety of situations, such as the loss of a previous pregnancy, postpartum depression, first-time parents, near-term or otherwise developmentally fragile infants, and others. The residents learn that there is something in the NBO for every family and that every family is unique. Through practicing the NBO, the clinician in training has the opportunity to incorporate several core principles of good medicine: (1) being a keen observer; (2) meeting the patient, in this case the baby, where one finds her and keeping her at the center of the interaction; (3) taking a sincere interest in the family and respecting their knowledge about their own baby; and (4) valuing the concept of a continued relationship, what we call “keeping the family in mind.” Being a Keen Observer Keen observation is central to the NBO. The clinician must first understand the concepts of developmental organization as they apply to the various systems of the newborn—autonomic, motor, state, and social/interactive. He or she must then learn to use the NBO to assess the baby’s level of organization in each of these realms in order to generate a behavioral profile of the baby. Most importantly, the clinician must learn how to share these observations with parents in a meaningful way. As an example, the clinician who is a keen observer and who practices the four principles listed previously may walk into a mother ’s room and see her struggling to breastfeed an infant who is wailing. The clinician, who has come in to begin discharge teaching, observes the infant’s flailing arms and legs and sees the mother ’s angst. The clinician puts her own agenda aside and begins her interaction where she finds this mother and baby—struggling over the attempt to breastfeed. Rather than immediately pointing out the positioning problems she sees, the clinician sensitively begins by asking the mother what she thinks: “You’re working very hard! How is it going?” The mother exclaims in frustration, “He’s hungry, and I don’t have enough milk!” Instead of refuting the mother ’s opinion with a recitation of medical knowledge about colostrum

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and sufficiency of human milk, the clinician gently draws attention to the baby’s behavior. She notes his flailing feet and suggests swaddling to help him get organized. She notes his beautiful cry and suggests a little break to help him calm down. The clinician strikes up a conversation with the mother about normal baby states and hunger cues. With the baby and mother a little calmer, the clinician is able to make a few more recommendations—she swaddles the infant and begins to help the mother position him at the breast. The mother learns as she listens to the clinician explain infant behavior and cues, using her own baby as an example. She is affirmed as the clinician recognizes her hard work, and she is empowered as the clinician describes the baby’s cues and proposes possible solutions. Helping the baby latch, the clinician can now talk about the first week and how the baby will learn—and how it will not always be this difficult. The mother is now open to hearing the clinician talk about colostrum and the sufficiency of the mother ’s milk. As the baby latches, the mother is more likely to be open to the possibility of her breastfeeding being a success, and therefore is more likely to persevere. After this brief encounter, a trust is established between the clinician and the mother. The next day, the clinician returns to the mother ’s bedside. She makes sure to mention the previous day. Knowing that the baby’s alertness, and therefore feeding, should be significantly improved after the first 24 hours of life, the clinician asks the mother how things have been. She affirms the mother for her hard work and offers support where needed. In this way, the clinician serves as a partner. She finds that her skills and expertise are welcomed, rather than unintentionally discouraged because she did not overwhelm the mother with generic advice, but rather approached her gently through her own baby’s behavior. Being “Baby-Centered” By its nature, the NBO must be carried out in the presence of and, ideally, with the participation of, the family. The baby must be at the center of the interaction so that observations can be shared. In fact, such shared observation can be very powerful, both for relieving anxiety and for giving parents the authority to refer back to the shared observations in future conversations with their child’s healthcare professional. Clinicians in training learn to take the baby where they find her. This is an example of setting aside the clinician’s agenda and putting the baby first. Having learned the skills needed for both behavioral and physical assessment of the newborn, the

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clinician in training has the flexibility to move smoothly from one component to another, allowing the baby to lead. He or she can observe and describe aspects of the infant’s behavior, complete the physical examination, and focus on anticipatory guidance—all while observing and responding to the infant’s cues. If the infant is crying, the clinician talks about the healthiness of infant cry, different kinds of crying, ways to soothe a crying baby, and self-soothing. If the infant is sleeping, the clinician talks about habituation, how the baby uses this ability to shut out unwanted noises and light, and how parents can help the baby protect his or her sleep. As the infant moves from state to state during the examination, the clinician explains regulation, the importance of organization, the baby’s cues for overstimulation, and her need for support. As the clinician fluidly moves through the examination, pointing out and naming the various aspects of normal newborn behavior, the parents learn about and have the opportunity to see how the clinician copes with each. In this way, the NBO models behavior for other aspects of the young clinician’s work with newborn families. This use of the NBO is quite similar to Keefer ’s description of the PEBE.1 In addition to learning to take cues from the baby, the clinician must also learn to recognize the behavioral cues of the parent. In one case, for example, the clinician sees, upon entering a mother ’s room, that she is anxious about taking her newborn twins home. The clinician stops her discharge teaching to explore the mother ’s anxieties. The mother expresses her concern that her twins aren’t ready to go home. The clinician is perplexed because, looking at the medical record, the infants are healthy full-term babies who have transitioned well and are medically stable for hospital discharge after 48 hours of life. Rather than explaining the medical reasons why the babies are ready to go home, the clinician listens. She proposes to the mother that the two of them undress the babies and look at them together. Immediately, the clinician senses the mother ’s anxiety decrease, as she perceives that her concerns are being taken seriously. The clinician uses the language and structure of the NBO to share with the mother all the aspects of her own babies’ physical examinations that are healthy and normal. The two also discuss those important areas of the babies’ physical and developmental stage that will require extra care, such as attention to head control and swaddling to prevent their arms and legs from flailing. At the end of this brief encounter, the mother is visibly open to the clinician’s opinion regarding the twins’ readiness for discharge. Recognizing the clinician’s genuine interest in her and her infants, the mother volunteers her fear: She talks about a friend whose infant died at

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home. The clinician acknowledges the mother ’s fear and does not meet it with superficial assurances that these babies are normal. Instead, she proposes another option—a visiting nurse to check on the mother and babies after discharge. Relieved at the prospect of ongoing support and reassured about the health of her babies, the mother is now mentally available to take in important anticipatory guidance. Having been actually shown the evidence of her infants’ health, she is less likely to be anxious at home and to convey that anxiety to them. Moreover, in the brief minutes that the clinician spent during this encounter, her relationship with this mother has been strengthened, and a key trust has been established. Taking a Sincere Interest in the Family It has been our observation that newborns are often examined in the hospital nursery, away from parents, who are given a verbal report after the exam is completed. This likely occurs for a variety of reasons—clinician convenience and time constraints, better lighting, force of habit, discomfort with the possibility that an abnormal finding will need to be thought through in the presence of family members. What is lost, however, is a powerful opportunity to allow the family to see all the ways in which the clinician has examined their newborn, to remind them of little questions they had that the exam triggers, to share the baby with the parents, as a caring provider—in short, to build a relationship. If instead, the family merely hears from the clinician, “I looked at her in the nursery and she looks fine,” there is no sense of participation, empowerment, or partnership. As an exercise, our pediatric residents are asked to consciously compare the quality of their experience with two families, one whose baby they examined alone in the nursery and one whose baby they examined in an interactive manner with the family. The residents report consistently that the difference between the two encounters is clear, based not only on the reactions of the families but also on the amount of satisfaction the clinician is able to glean. The NBO provides a wonderful vehicle for the clinician to demonstrate a sincere interest in and respect for a newborn and her family. The clinician learns to open the encounter with a question that is most likely to be meaningful to the parents, putting his or her own agenda aside in order to put the parents and the newborn first: “What is her name? How did you choose it?” Most parents care deeply about the name they have chosen for their new baby. Usually much thought has gone into their decision. There are

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frequently stories that spring from the parents as they recount the process of choosing their baby’s name. It is not unusual for parents to smile, chuckle, and look at one another as the clinician asks the question about the baby’s name. Listening carefully to the answer, the clinician can elicit important social and family history without asking uncomfortable or intrusive questions. And within seconds of their telling the story about the name, a relationship is formed between the parents and the clinician. The clinician learns the importance of language; using words like sharing instead of teaching puts the relationship on the level of partnership rather than paternalism. Words chosen carefully and thoughtfully can reinforce the parents’ position of legitimate authority. Sensitively chosen words affirm and can reinforce selfesteem that is sometimes vulnerable. As the clinician observes the infant with the parents, he or she asks them what they have seen. Rather than expecting that the parents do not know their infant and do not understand newborn care, the clinician adopts an attitude that parents do know their infant, and, in some cases, they know their infant better than anyone else. Not uncommonly, when asked what parents have noticed about their newborn, mothers will laugh and describe the infant as though she has been with her for years—even though the baby is less than 24 hours old. Many mothers even say something like, “Oh, she has always been like that!” In another typical scenario, the clinician may invite a teenage father to call to his baby, asking if he has noticed his baby turning to voices yet. The father states, “Yeah, yesterday I was talking, and I saw she was looking right at me.” If the newborn is sufficiently organized and alert, she will turn once again, in the presence of the clinician, to her father ’s voice and gaze at his face. Much is accomplished in these few moments. The father swells with love and pride at his baby’s competence. The baby shows that she knows and recognizes her father. The father, who is often marginalized in postpartum settings, feels validated in the observations he has made about his baby. In encouraging, affirming, and valuing the parents’ knowledge of their own infant, the clinician has begun to build a relationship of trust and mutual respect. Keeping the Family in Mind Finally, the clinician in training is always learning the importance of continuity of care, a fundamental component of pediatrics. Using the NBO, he or she has an opportunity to plant a seed in the nursery that will establish a continuous relationship with parents and allow

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them to see that they and their infant are held in the clinician’s mind as distinct individuals with a unique story. In noticing key aspects of the infant’s behavior or the infant’s talents at birth, the clinician remarks, “Won’t it be interesting to see what she is doing when I see you next!” At the next visit, noting the same aspect of the assessment (e.g., head control), the clinician says, “Look what she is able to do now! Remember what she did in the nursery? Now she can control her head so much better!” This seamless thread that the clinician has created between one encounter and the next serves to establish a trust in the parents’ minds that the clinician is caring for their infant and does remember her. With this trust as a foundation, the relationship grows. CONCLUSION There are contrasting ways to view hospital newborn care. One view is that the pediatrician’s job is to make sure the baby has all its parts and that the parents have enough information to keep the baby alive until they come in for their first appointment. Our view is quite different. We see the birth of a new child as a normative crisis, one that is a different experience for every family. There are vulnerabilities in being a newborn on that first, second, third, or fourth day of life. At the same time, whether the child is a first baby or not, the parents are also developing—physically, emotionally, and socially. There are new responsibilities, new financial issues, and concerns about other family members who will also need to make adjustments for this new person in their midst. We believe the physician’s role is to watch over that normative crisis, to be available to it, to be whatever it is that the parents need us to be through this all-too-brief hospital stay. The challenge is that you never know which family is going to need what. You can scan your list of patients and dismiss a particular family, thinking, “Well, they won’t need me.” Then you discover that the mother, who seemed so capable and so “together,” is suddenly traumatized by the way her 3-year-old is responding to the new sibling. Collectively, as pediatric care providers, it is our role to be available to address whatever issues may arise surrounding the newborn, and our families respond very positively. In fact, their responses reinforce the philosophy that underlies our approach—a healthy family is the ideal environment in which to safeguard and nurture the healthy development of a newborn. Instead of making assumptions, we try to recognize what this experience is like for each family. We’ve learned that our being

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available is particularly important for first-time parents. They need to know our support is there when they need it during this unique life stage. It’s a time when parents need a hovering guardian angel ready to answer questions and provide encouragement and positive reinforcement—to provide a scaffolding (“That was great. Should we look at something else?”). It’s not an exaggeration to say that the parent-clinician interaction can be a model for caregiving itself, for the kind of positive reinforcement and careful skillbuilding that we know to be the framework on which healthy infant development is built. Given the real world, a pediatric clinician who comes to see a particular baby the first day after birth might not expect to see the same family the next day or later in the outpatient setting. We believe that’s all the more reason to make the time we do have with that family as rich an experience as possible. There are many things we can do to help the parents of healthy thriving infants in that initial visit. We can help them get to know and understand their new baby. We can help build their confidence about their ability to care for their child. We can help them feel comfortable about calling us if they do have questions. We can remind them that someone, whether ourselves or someone else, is expecting to see them in a few days or a week, whenever that first well baby visit is to be scheduled. As clinicians who recognize the importance of relationship as fundamental in medicine, we also recognize the need to instill this awareness in clinicians in training. Clinicians in training today need a concrete tool, complete with language, to help them learn and practice the art of building relationships. The NBO serves as such a tool; it is a valuable organizing agent for clinicians in training and other professionals who choose to make relationship a key component of newborn care. When we hear back from families we met in the hospital, they often express gratitude for what we have done for them and their babies. Sometimes our medical and technical skills have been important. But almost always they thank us for supporting them and for understanding the anxieties and confusion that almost always accompany the birth of a new baby. They say, “Thank you for listening,” and “Thank you for helping me understand my baby.” REFERENCES 1. Keefer CH. The combined physical and behavioral neonatal examination: A parent-centered approach to pediatric care. In: Brazelton TB, Nugent JK. The Neonatal Behavioral Assessment Scale. 3rd ed. London, England: MacKeith Press; 1995:92–101.

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2. Brazelton TB, Nugent JK. The Neonatal Behavioral Assessment Scale. 3rd ed. London, England: MacKeith Press; 1995. 3. Nugent JK, Brazelton TB. Preventive infant mental health: Uses of the Brazelton Scale. In: Fitzgerald HE, Osofsky JD, eds. Handbook of Infant Mental Health. Vol 2. New York, NY: John Wiley & Sons Inc; 2000:159–202. 4. Nugent JK, Keefer CH, Minear S, Johnson L, Blanchard Y. Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) System. Baltimore, MD: Paul H. Brookes Publishing Co; 2007. 5. Shonkoff JP, Phillips DA, eds. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, DC: National Academy of Sciences Press; 2000. 6. Levinson W, Roter DL, Mulloly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–599. 7. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

CHAPTER 20

Preparing Professionals to Work with Newborns: The Brazelton Institute Experience: United States JEAN GARDNER COLE, CECILIA F. MATSON, and THEMBI RANUGA

Clinical Example During the NBAS examination, the baby’s family looked on—mother, father, three siblings, ages 7, 10, and 12, and a 12-year-old cousin. Maggie was just 12 hours old. Her mother had been on bed rest for the previous 5 months due to risk of premature labor. As the examiner checked Maggie’s Habituation responses, Maggie’s mother sighed with relief: “It’s so good that she can sleep through noise!” Then, as the examiner checked Maggie’s walking reflex, her mother excitedly instructed the rest of the family: “Watch! See her walking!” The Orientation segment of the exam was the first time Maggie’s siblings had seen her with her eyes open. Maggie’s focused alertness was superb, and her audience was captivated: “Look! Oh, she’s turning to look at your face!” By the time the exam was over, Maggie’s mother had tears in her eyes. “You’ve made my day,” she said, “I feel so much more confident about her now than I did before. Look how much she can do, even though she’s so little.” Maggie’s father was less emotional, but equally impressed: “It really surprised me to see how she could follow the toys with her eyes, and turn toward the sounds of the rattle.” Before the NBAS examiner could leave the room, Maggie’s mother asked her to be in a picture with all of them. She was delighted to become part of this joyful family memory.

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“The NBAS has changed my life!” This dramatic comment expressed by a newborn nursery nurse is not unique. The Newborn Behavioral Assessment Scale (NBAS)1 and the Newborn Behavioral Observations (NBO) system have indeed changed the practices of many professionals around the country and abroad.2 In teaching these assessment scales to a variety of professionals— nurses, physicians, and therapists—we find that this kind of comment is more the rule than the exception. The NBAS and related tools, such as the NBO, completely change the way people who work with babies interact with them. NBAS and NBO training enhances all existing skills and supplements them with new methods of observation and intervention when caring for infants. Less task oriented than the more widely used Dubowitz newborn assessment, the NBAS focuses on interpreting the newborn’s behavior based on his neurological maturity. It is quite instructive to observe a physician trained in the NBAS or the NBO perform a routine physical examination of an infant. The concepts that originally inspired development of the NBAS are seamlessly incorporated into the exam and are a delight to observe.3 Because the concept of “best performance” is a guiding principle of the exam, the physician will take great care to help the baby stay calm and comfortable. For example, the infant need not be totally undressed; only the parts of the body to be examined are uncovered, one at a time. This is because most young infants simply do not like the sensation of being completely uncovered. When the infant frets, the NBAS-trained physician consoles him by cradling the baby with his or her hands, providing a brief time-out in order to let the infant become calm before continuing with the examination. The examiner will explain to the parents that when a baby cries he has used all of his own self-soothing resources and is seeking help; he may be asking to be held or fed or changed; he may want a pacifier; or he may simply want to be left undisturbed for a while. (Sometimes the examiner can provide comfort so effectively that the baby actually falls asleep.) Explaining and demonstrating this kind of responsiveness supports the infant and reassures the parent. Further reassuring the parent are the gentle techniques used to trigger reflexes. For example, when eliciting the asymmetrical tonic neck reflex (ATNR), it makes sense to elicit the rooting reflex first, thereby stimulating the head-turning movement of the ATNR.4 To the parent—and family—who might be observing the exam, this maneuver demonstrates sensitivity, gentleness, and competence— serving to both inspire and model confidence. Imagine, in contrast, a parent’s reaction if the examiner were to grasp the infant’s head

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and turn it firmly, a maneuver often used in the usual physical exam, which—not surprisingly—can be upsetting for the infant. A thorough introduction to the amazing abilities of the average newborn is the cornerstone of the NBAS-based training model we use at the Brazelton Institute. By attending didactic lectures and PowerPoint presentations, and participating in guided examinations of newborns, the professional becomes skilled in reading behavioral cues of infants and learning how infants communicate through their behavior. Few early intervention professionals, including doctors, nurses, and physical and occupational therapists, have had extensive training in neurobehavioral assessment, which is the core of the NBAS and the NBO. Training in these concepts becomes essential if the professional is to work effectively with infants and their families, especially high-risk infants.5,6 Because many of these infants are very sensitive to external environmental stimuli, an NBAS-trained examiner will always proceed with caution, interpreting the infant’s responses carefully, and adjusting his or her way of handling the child in order to meet the infant’s immediate needs. The key point is that behavior is never random; it is always externally or internally caused, and the infant’s reaction to a stimulus is how he communicates his need for support. Learning to observe minute changes in color, respiration and heart rate, tonus and posture, and quality of movement, as well as changes in states of consciousness, deepens the professional’s understanding of how complex the newborn infant is, and how he is attempting to deal with his environment. This method of observing infants can be life-changing for professionals, and they will never again look at babies in the same way. Learning how to communicate this information to the infant’s parents is part of the training. It often confirms the parents’ own observations of their infant and enhances the parent-child relationship.7,8 Professionals trained in NBAS concepts change their practices as they reflect on what they have learned from the exam and what the infant has communicated to them. They learn that the behavior of the infant is the language of the infant. A behavioral profile—what Brazelton calls “the infant’s signature”—can be written delineating the infant’s strengths and vulnerabilities. From that point, a plan of intervention can be designed appropriate for both the infant’s needs and those of his parents. When used in the postpartum period, “this assessment offers health-care professionals an opportunity to support parents in the important phases of an evolving relationship with their child. Participation in the exam helps

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reinforce new parents’ instincts about their newborn infant while encouraging them to ask questions about important items such as feeding, social issues, home and family environment, and so on.”2 SPECIFIC TRAINING MODELS Several training models have been developed by the Brazelton Institute in preparing professionals to work with infants and their families in various settings. The classic model is quite intensive and introduces the trainee to the newborn infant’s amazing abilities to communicate neurobehaviorally with his environment and with his caregivers. Trainees are shown a video of the NBAS exam, which gives them an overall view of the scale being administered and allows them to observe the infant’s responses, thus acquiring a good baseline knowledge of neurobehavioral responses and their meaning. After the video, a presentation focusing on specific items in the exam is given. The item could be, for example, Habituation to the sound of a rattle. A discussion ensues exploring how the infant uses Habituation to shut out disturbing sounds or other sensory stimulation to ensure restful sleep, and what a valuable technique this is for long-term development. Next, Reflexes are shown and discussed, with an explanation of all the primitive reflexes found in the newborn, how to elicit them, and how they are part of the marvelous central nervous system of the newborn and can be indicators of normalcy. The slides cover all the items in the scale and describe them in great detail. The various subsystems of the infant—state, motor, autonomic, and self-regulatory—are discussed from the perspective of how they appear when the infant is stressed, as well as how they appear when the infant is stable. Also, techniques are demonstrated for consoling, and for eliciting interaction—both animate (with a person) and inanimate (with an object). The point is made that the examiner decides which item to use for beginning the exam depending on the infant’s state of consciousness, and from that point is led by the infant to decide which item to move to next. For example, if the infant is asleep, Habituation can be evaluated. If the infant is awake, interaction is attempted; and if the infant is crying, consoling is done. The slides present much in-depth information about the exam, its administration, and the infant’s responses and how to interpret them.1,9,10 After reviewing all this material and the NBAS manual, trainees are ready to start practicing on their own. The next segment of training occurs at the hospital, where the trainer examines an infant with the trainee, discussing and describing

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all of the infant’s responses and demonstrating holding, handling, and elicitation of the items in the scale. Together, trainer and trainee reflect on what they saw the baby communicate in this exam, and the trainer explains in detail and how to write up the infant’s behavioral profile based on their observations.1 The trainee has the opportunity to administer one or two exams with the guidance of the trainer, practicing his or her newly acquired infant handling and examination skills, and improving them through feedback, suggestions, and demonstrations provided by the trainer. In becoming more attuned to the language of the newborn, the trainee learns to interpret the infant’s cues and respond accordingly. A newborn, for example, who is flailing wildly with arms and legs, is often begging for help with quieting his motor system. The experienced examiner will gently cradle the baby, bringing his arms in close to his body, supporting and containing his legs and feet so he can feel the familiar enclosed comfort of the fetal position. H O S P I TA L - B A S E D M O D E L S There are several hospital-based models of training using both the NBAS and the NBO. One model, designed for staff nurses in neonatal intensive care units (NICU) and special care units (SCN), teaches staff nurses how to read the behavioral cues of the infants and adjust their nursing care accordingly. A direct example of this developmentally focused approach is the way a nurse prepares an infant for hands-on care—speaking to the baby and gently laying his or her hands on the infant before beginning. In this way, the sensitive infant is allowed to awaken gradually and is prepared gently for caregiving, rather than being awakened abruptly and having the procedure begin without any advance warning—which can be quite disorienting for a fragile infant. A nurse who understands how to do so can pace all care according to the behavioral and developmental needs of the infant, with lots of time-out breaks allowed for the infant to reorganize and recover some stamina in order to deal with the caregiving. An indirect example of developmental care is the change in the NICU/SCN environment. Nurseries are more dimly lighted; sound levels of both mechanical equipment and staff voices are muted; and activity levels are quieter and more respectful of the infant’s need to experience restful sleep, which is restorative. Research studies have shown that this approach is beneficial for the infant in terms of improved medical and developmental outcome, and can lead to shorter hospital stays.11

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Other hospital-based models train newborn nursery nurses to incorporate NBAS concepts into the newborn bath experience. In one training model, the nurses are taught how to use the concepts of slow gentle handling and positioning—allowing the sides of an oval tub to support the infant in flexion while gently bathing the infant immersed in warm water up to his chin in the tub. Many infants become so relaxed, they fall asleep in the tub. The nurses learn to be led by the infant’s behavioral cues—states of consciousness, color, tonus, and motor activity—and to adjust their care accordingly. The infant stays very calm during the bath. Once the bath is completed, the infant is gently lifted out onto a warm towel prepositioned on the shoulder of the nurse. The nurse wraps the infant in the towel and dries him by patting him gently inside the wrapping of the towel. His lower body is slowly unwrapped to put on a diaper, while his upper body is kept wrapped in the towel, then his upper body is slowly unwrapped to put on his shirt. A study evaluating the effects of this bath method showed positive results.12 In another model using NBAS concepts during bathing, the nurse describes the infant’s behavior to the mother during the bath using NBAS behavioral terms: states of consciousness; sucking and grasping for self-consoling; the infant’s response to the Pull-to-Sit, and to stand, step, and crawl; the vigor of his cry; and what he needs to be consoled. The interactive bath is a mini-NBAS experience, providing the parent with much information about her infant—and all done within the context of the newborn bath.13 A third model incorporating NBAS concepts and used in hospitals and in educational settings is the Parent Infant Pathways (PIP) program. This model is both a teaching guide for professionals and a parent education curriculum addressing the first months of the infant’s life. This model provides professionals with a powerful way to demonstrate and discuss a newborn infant’s many capabilities and helps facilitate the acquisition of positive parenting skills . . . through the use of seven key vantage points or Pathways. PIP gives professionals dynamic ways to impart important information about infant development, and to support new parents and their babies. It has been proven to be an excellent tool for training professionals in how to educate parents about newborn development, provide parents with anticipatory guidance, and connect families to community resources.14

It is always gratifying to see firsthand how learning to understand their newborn’s amazing resources and unique patterns of behavior

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can help new parents quickly gain confidence—and competence. A skilled examiner encourages the mother to discover her baby’s individuality for herself, confirming and interpreting what she has noticed. Parents come to the NBAS having already observed many things about their babies. The examiner facilitates further discoveries and also provides important insights that will guide the mother in caring for her child. Perhaps one of the most valuable benefits of the NBAS experience is the degree to which it can relieve much of the distress that almost all first-time parents feel when their babies cry. By explaining that crying is meaningful behavior and suggesting strategies for soothing the crying infant, NBAS examiners help parents feel confident about their ability to respond appropriately. Utilizing NBAS concepts in work with infants is enormously gratifying. Infants are so much more responsive than new parents realize, and it is very exciting to be able to confirm for parents the amazing abilities of their newborn infant and provide intervention, if needed.7 The NBAS or the NBO may not actually change the lives of every professional we train, but certainly it will change forever their clinical practices. REFERENCES 1. Brazelton TB, Nugent JK. Neonatal Behavioral Assessment Scale. 3rd ed. Cambridge, England: MacKeith Press; 1995. 2. Nugent JK, Keefer CH, Minear S, Johnson L, Blanchard Y. Understanding Newborn Behavior and Early Relationships: The Newborn Behavioral Observations (NBO) System. Baltimore, MD: Paul H. Brookes Publishing Co; 2007. 3. Keefer, CH. The combined physical and behavioral neonatal examination: A parent-centered approach to pediatric care. In: Brazelton TB, Nugent JK. The Neonatal Behavioral Assessment Scale. London, England: MacKeith Press; 1995:92–101. 4. Cole JG, Als H. Incorporating developmental care concepts into the physical exam of the high risk infant: A tutorial program for house officers. In press. 5. Cole JG. Infants at Risk: Readings in Child Development. Lauter-Klatell N, ed. CA: Mayfield Publishing Co; 1991:36–41. 6. Cole JG. Using the Brazelton Neonatal Behavioral Assessment Scale with high risk infants. In: Brazelton TB, Nugent JK, eds. Neonatal Behavioral Assessment Scale. 3rd ed. Cambridge, England: MacKeith Press; 1995: 126–132. 7. Als, H. Towards a synactive theory of development: Promise for the assessment and support of infant individuality. Infant Ment Health J. 1982;3(4):229–243.

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8. Cole JG. The amazing abilities of the newborn infant. Mother Baby J. 1998;3(1):40–43. 9. Nugent JK, Brazelton TB. Preventive infant mental health: Uses of the Brazelton Scale. In: Osofsky J, Fitzgerald HE. WAIMH Handbook of Infant Mental Health: Early Intervention, Evaluation and Assessment. New York, NY: John Wiley & Sons Inc; 2000:159–202. 10. Nugent JK. Using the NBAS with Infants and Families. White Plains, NY: March of Dimes; 1985. 11. Cole JG, Gilkerson L. Developmental consultation: The role of the parentinfant educator in a hospital/community coordinated program for high risk premature infants. In: Waldstein A, ed. Issues in Neonatal Care. Monmouth, OR: Technical Assistance Development System (TADS)/Western States Technical Assistance Resource (WESTAR); 1982:107–122. 12. Cole JG, Brissette N, Lunardi B. Tub baths or sponge baths for newborn infants? Mother Baby J. 1999;3(4):39–43. 13. Karl D. The interactive newborn bath. Am J Matern Child Nurs. 1999;24(6):280–286. 14. Pearson J. Parent Infant Pathways (PIP). Minneapolis, MN: Baker Multimedia; 2000.

CHAPTER 21

Integrating Developmental Principles into the Daily Work of Health Professionals: Italy GHERARDO RAPISARDI, ADRIENNE DAVIDSON, ROBERTO PALUDETTO, and GIUSEPPINA MANSI

Two Brazelton Centers have been functioning in Italy since 1996: one in Florence, directed by Dr. Gherardo Rapisardi, and the other in Naples, directed by Dr. Roberto Paludetto. Both directors have extensive experience in the use of the Brazelton concepts and in assessing newborns and promoting both neonatal and child health. The activities of the two centers differ in accordance with the specificity of the professional curricula and the everyday clinical environments in the two locations. EXPERIENCE IN FLORENCE Dr. Rapisardi, a neonatologist and pediatrician, works in collaboration with Adrienne Davidson, a pediatric physical therapist and developmental specialist. Both trained in infant neurological assessment and intervention with Professor Adriano Milani Comparetti in the 1970s, and they have been working together at Anna Meyer Children’s Hospital since the beginning of the 1980s. In Florence, the efforts of the Brazelton Center have focused on: (1) the clinical application of a global neurodevelopmental (ND) assessment and an early intervention program that incorporate the principles of the Neonatal Behavioral Assessment Scale (NBAS) and

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the Touchpoints Approach; (2) training courses in the Brazelton concepts for all types of health professionals throughout Italy who are involved in neonatal care; (3) diffusion of the Brazelton concepts through the publication of written articles, translation of English texts, and so forth. Clinical Application The Florence-based authors were trained in Boston in 1985 and 1986, respectively, learning to administer the NBAS directly from T. Berry Brazelton and J. Kevin Nugent, learning about individualized developmental intervention in the NICU directly from Heidelise Als, and also completing the Touchpoints training. Since then, Rapisardi and Davidson have worked to integrate these diagnostic/analytical tools with Milani-Comparetti’s model.1 Their evaluations also include the General Movements (GM) assessment2,3,4 proposed by Prechtl and his group (including Giovanni Cioni from Pisa and Fabrizio Ferrari from Modena). The integration of these approaches (from Milani-Comparetti, Brazelton, Als, and Prechtl) has led to the development of a practical neurobehavioral assessment tool5 which is now used for early evaluation of at-risk newborns in the NICU, in the neonatal follow-up service, and in the early intervention clinic 0 to 3 years, where infants are sent for consultation by health professionals, mainly pediatricians, working in other departments of this hospital, in other hospitals, or in community pediatric and rehabilitation services. This assessment tool focuses on the observation of spontaneous motor and interactive behavioral activity during the four different phases of development in the first year of life: 0 to 3, 3 to 6, 6 to 9, and 9 to 12 months, according to the stages of the separationindividuation process. Three main parameters are assessed: (1) autonomic stability, particularly in the first trimester; (2) motor activity, divided into the nonfunctional spontaneous movement repertoire and the adaptive functional motor repertoire; and (3) behavioral modulation in relation to interactions with people, objects, and the environment. The items assessed in the 0-to-3-month phase are illustrated in Table 21.1. This model of ND evaluation allows for the early assessment of normality and includes an assessment of the competencies of the individual infant within his family system, as well as an early diagnosis of cerebral palsy (CP) and other severe ND impairments (sensory deficits and interactive disturbances) within the first 3 to 4

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Autonomic systems

Stability of respiration, skin color, visceral functions, and motor signs

Nonfunctional motor repertoire

Quality of general movements, richness of motor patterns, distal segmental movements

Functional motor repertoire

Postural variability, ability to stay still, head and trunk control, flexion movements to midline

Behavioral modulation

Quality of alertness, visual interaction, auditory interaction, cuddliness, energy and endurance; cry and consolability; self-regulatory abilities

months of corrected age6,7,8; it can also be used to assess the emergence of competencies within an individual’s impaired development. A basic principle of this model is the differentiation between a nonfunctional motor repertoire, which is primarily affected in central motor disturbances, and its functional adaptive use (functional motor repertoire), which is only secondarily affected. The nonfunctional motor repertoire is assessed by GMs until 4 to 5 months postterm, and then by the richness and variability of the motor patterns and the distal segmental movements of the hands and feet. The ND assessment tool that we use is a simple, nonintrusive method, intended to be included within routine assessment by different professionals (neonatologist, pediatrician, child neurologist, physical therapist). The overall main goal is to enable them, through the assessment of the normality of the central nervous system, to reveal the strengths and the difficulties/problems in the infant’s development, as well as any deficit needing more investigation. The information collected in this way then serves as the basis for developing a plan based on the main principles of family-centered ND intervention that are focused on the promotion of subsystem development and the enrichment of the family environment in which the baby is growing and maturing. All therapists working in the pediatric rehabilitation service at the hospital have received the Brazelton training; and the Brazelton concepts are integrated into all the clinical work with small babies carried out in the various clinics within the department, including the pathological cases in neonatal follow-up, and within

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the 0 to 3 years early intervention consultations requested by the community pediatric and rehabilitation services. These concepts are particularly useful as a base for supporting parents of children with developmental problems, even as they grow beyond the first months of life. Training in the Brazelton Concepts The education of health professionals working with neonates and their families is the main goal of our venter. Since 1996, five different multiprofessional courses incorporating the Brazelton and Touchpoints concepts have gradually been developed to promote continuous education in behavioral and ND assessment and family-centered intervention in the NICU and in the first year of life. The courses are as follows: • Behavioral Assessment and Family-Centered Developmental Support of the Term Newborn • Neurodevelopmental Assessment in the First Year of Life • Individualized Neurodevelopmental Care in the NICU • Neurodevelopmental Follow-Up and Intervention for the Preterm Infant in the First Year of Life • Communication and Counseling in the Support of Families Up to mid-November, 2005, 83 interdisciplinary courses had been held in Florence and throughout Italy, with a total of 3,138 participants (40% pediatricians/neonatologists, 24% physiotherapists, 17% pediatric nurses, 8% child neurologists, 6% psychologists, 4% midwives, 1% other developmental therapists). The first course, Behavioral Assessment and Family-Centered Developmental Support of the Term Newborn, is considered the foundation; its main goal is to promote the integration of the NBAS concepts into the everyday clinical routines of all the variety of health professionals working with neonates and their families. As an everyday tool, we propose the use of a simplified version of the NBAS associated with the basic facilitation techniques of newborn behavior and the application of the principles of family-centered developmental intervention. The focus is on the use of the baby’s behavior as a means of relating to the parents—sharing the baby’s language to create and strengthen the partnership between the professional and the family. This relationship is then proposed as a channel to support the parents and to discover together their personal approaches to effective baby care. The possible risks of

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diminishing parental self-esteem by appearing, for example, to be an expert or a teacher are examined, as is the risk of being prescriptive rather than collaborative. The multidisciplinary participation in the course provides opportunities to experiment with a transdisciplinary approach to problem solving, both in small groups and in the plenary discussion. Recently, we carried out a small trial investigation on the effectiveness of the training 3 months after the course; through an anonymous questionnaire, participants were asked to describe the positive effects on their professional routines, as well as the difficulties they had experienced in trying to apply what they learned during the course. We also asked this study group to send short videos showing examples of their practical use of the assessment and intervention with families. Positive aspects reported were enhanced interest in understanding newborn behavior and in the understanding of the neonate’s abilities (to self-regulate and to influence his environment), improved abilities to recognize neurovegetative signs, and increased appreciation of the concept of providing anticipatory guidance. Other positives were increased tendencies—and preferences—to listen rather than intervene, and to promote informed choices rather than provide solutions. Other positive effects mentioned were improvements in the clinical setting and in working together with other professionals (“sharing the new tool for an interdisciplinary approach to baby care”). At the same time, difficulties encountered dealt mostly with interdisciplinary communication, inadequate settings in the working environment, especially in hospitals, and the lack of an opportunity to verify skills in the assessment items under supervision, at a distance of time. Through the videos, we managed to identify the general abilities of the professionals and their difficulties. Both the feedback and our observations resulted in a revision of course (content and time distribution), as well as our teaching methods. We also made changes to offer better support to participants in order to improve their interactive skills with the newborn and his or her family. Dissemination of the Brazelton Concepts To promote knowledge of the Brazelton concepts in Italy, the Brazelton Center in Florence supports the publication of original and translated articles and texts; an Italian version of the third edition of the NBAS manual and the two books on Touchpoints (0 to 3 years

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and 3 to 6 years) are available.9,10,11,12 As a result, in the past 10 years, knowledge of the Brazelton concepts has spread throughout Italy. Unfortunately, it is still not part of the curriculum studiorum of all health professionals working with infants. Yet, more and more teaching and training programs are recognizing the value of the Brazelton approach and are including it in postgraduate training within programs for continuing education. We observe that as this approach becomes more widely used, its value for the promotion of child health in the early years is being acknowledged, especially by family pediatricians. EXPERIENCE IN NAPLES The Brazelton Center in Naples, led by Drs. Paludetto and Mansi, has utilized the Brazelton NBAS with both term and preterm newborns. The NBAS has facilitated both our research and our care of newborn infants and their families, particularly preterm infants. As far as full-term newborns are concerned, interest has mainly focused on jaundiced neonates. Our first study was performed in order to evaluate possible changes in behavior in jaundiced infants without perinatal complications other than hyperbilirubinemia treated with phototherapy. Thirty jaundiced infants (mean bilirubinemia 13.3 mg/dL) and 30 of a comparison group were examined during the third day of life according to the NBAS. We demonstrated that the jaundiced subjects were less responsive to stimuli, mainly in the visual orientation responses area. Moreover, we showed that such responses were compromised up to at least 1 month of age.13 In a second study, we tried to reduce the effects of phototherapy on the newborns’ behavior by protecting the eyes with an opaque screen suspended over the head instead of using the usual blindfold in order to avoid covering the newborn’s eyes during treatment. However, we obtained no statistically significant improvements in the newborns’ neurobehavioral development.14 In a third study, we focused our attention on the effects of low levels of bilirubin. We selected term newborns with a mean serum bilirubin concentration equal to 10mg/100 mL, therefore studying newborns who did not undergo phototherapy. These levels of bilirubin did not significantly influence the behavior of this group of term newborns.15 In recent years, less aggressive protocols for the treatment of neonatal jaundice have been formulated. Such protocols recommend

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starting phototherapy when serum bilirubin levels are higher than 17 mg/100 mL. This revision has allowed us to publish a new study16 that investigates the behavioral changes induced by moderate hyperbilirubinemia in the otherwise healthy, untreated newborn infant. Fifty term neonates with untreated moderate hyperbilirubinemia (median 14.3 mg/dL, range 13.2–20 mg/dL) and 50 matched controls with lower bilirubin concentrations (median 9.1 mg/dL, range 5.3–12 mg/dL) were evaluated using the NBAS at 87 hours of life (range 72–110 hours). A subgroup analysis was also performed at 104 hours of life (range 96–134 hours) and at 3 weeks of age. The first examination showed that all behavioral clusters were significantly altered in the group with moderate hyperbilirubinemia. After 24 hours, a decrease in serum bilirubin within the moderate hyperbilirubinemic group was associated with improved scores. At 3 weeks of age, the behavioral assessment of the two groups did not show significant differences. Our conclusion, then, is that untreated moderate hyperbilirubinemia is associated with a transient, and apparently reversible, alteration of neonatal behavior, particularly in the social-interactive area. Stretching the scale’s rules a little, we have also worked with preterm newborns who showed no serious diseases and who did not need mechanical ventilation, in order to study the maturation of their sensory and interactive abilities. On the whole, we found more evident maturation in the areas of Motor Performance and Orientation during the 35 to 44 weeks of postmenstrual age.17 With such methodology, this study was among the first to indicate the early development of Auditory Orientation (which is similar to that of the term newborn at 35 weeks of postmenstrual age), as opposed to the development of Visual Orientation, which is slower. Moreover, an evident delay was demonstrated in the ability to bring the hand to the mouth; this skill was very much compromised in our preterm newborns even after they reached term age (40 weeks of postmenstrual age).18 We hypothesized that this was probably due to the absence of the physiological intrauterine stimuli that enhance sucking and the movements that help centralize the limbs on the median axis (liquid environment, containment by uterine wall, and so forth). As a matter of fact, these infants have obliged postures in the incubator; they are exposed to gravity, which constrains them to the mattress; sometimes, the obliged postures are kept for a long time, and may be due to immobilization procedures. What we’ve learned through the NBAS has prompted us to carry out more specific interventions with parents. In our NICU,

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parents have been actively participating in the care of their infants in incubators since 1976.19 Our goal has been to help parents strengthen their relationships with their small premature infants by suggesting the most appropriate sensorial communication techniques, such as postures, manipulations, and cuddling. These simple interactions between newborn and parent represent a very early form of care, which has been increasingly implemented in most Italian centers during the past several years. Our group has also investigated the effects of nonnutritive sucking in the preterm infant. We have demonstrated for the first time that nonnutritive sucking alleviates behavioral distress (resulting in a reduction of crying) during invasive procedures.20 Presently, our attention is focused on the effects of maternal smoking during pregnancy on the neurobehavioral development of the healthy, term neonate. The aim of our study is to correlate in detail the newborn’s neurobehavioral abilities with the biological markers of maternal smoking (urinary cotinine).21 Last, we have used and are still using the NBAS in routine clinical practice both in the NICU, which has been opened to parents since 1976, and in the nursery, where rooming-in has always been the norm. We have incorporated the general concepts of the scale with the physical examination of the newborn, with special attention to a few specific items–Orientation, Decrement to Stimuli, Self-Quieting, Consolability, and Cuddliness. Although we have not evaluated its impact in detail, our experience with the NBAS has proven it to be a useful tool for the professional enrichment of all providers dealing with the care of the neonate.

REFERENCES 1. Milani-Comparetti A. Semeiotica neuroevolutiva [Neurodevelopmental semiotics]. Prospettive in Pediatria. 1982;48:305–314. 2. Prechtl HFR. Qualitative changes of spontaneous movements in fetus and preterm infant are a marker of neurological dysfunction. Early Hum Dev. 1990;23:151–158. 3. Prechtl HFR, Ferrari F, Cioni G. Predictive value of general movements in asphyxiated full-term infants. Early Hum Dev. 1993;35:91–120. 4. Prechtl HFR, Einspieler C, Cioni G, Bos A, Ferrari F, Sontheimer D. An early marker for neurological deficits after perinatal brain lesions. Lancet. 1997;349:1361–1363.

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5. Rapisardi G. La valutazione dello sviluppo psicomotorio nel I anno di vita [The evaluation of psychomotor development in the first year of life]. Medico Bambino. 1999;18:27–33. 6. Rapisardi G, Cioni ML, Mattei P, Scarano E, Donzelli GP. Early motor repertoire assessment and the diagnosis of cerebral palsy in NICU graduates. International Symposium on Qualitative Assessment of General Movements and Cerebral Palsy; November 26–28, 1998; Graz, Switzerland. 7. Guzzetta A, Mercuri E, Rapisardi G, et al. General movements detect predictive signs of hemiplegia in term infants with neonatal cerebral infarction. Neuropediatrics. 2003;34:61–66. 8. Cioni G, Bos AF, Einspieler C, et al. Early neurological signs in preterm infants with unilateral intraparenchymal echodensity. Neuropediatrics. 2000;31:240–251. 9. Rapisardi G, Davidson A. La promozione dello sviluppo neonatale ed infantile: l’ “approccio Brazelton” [The promotion of child and infant neonatal development: The “Brazelton Approach”]. Medico Bambino. 2003;22:171–176. 10. Brazelton TB, Nugent K. La Scala di Valutazione del Comportamento del Neonato: Edizione Italiana Della III Edizione Americana [The Evaluation Scale of Newborn Behavior: Italian edition of the 3rd American Edition]. Rapisardi G, ed. Masson, Milano, Italy; 1997. 11. Brazelton TB. Il Bambino da 0 a 3 Anni: Guida allo Sviluppo Fisico, Emotivo e Comportamentale del Bambino [The Child between the Ages of 0 and 3: A Guide to Physical, Emotional and Behavioral Development]. Fabbri, Milano, Italy: RCS Libri SpA; 2003. 12. Brazelton TB, Sparrow JD. Il Bambino da 3 a 6 Anni [The Child between the Ages of 3 and 6]. Fabbri, ed. Milano, Italy: RCS Libri SpA, 2004. 13. Paludetto R, Mansi G, Rinaldi P, De Curtis M, Ciccimarra F. The behavior of jaundiced infants treated with phototherapy. Early Hum Dev. 1983;8:259–267. 14. Paludetto R, Mansi G, Rinaldi P, Saporito M, DeCurtis M, Ciccimarra F. Effects of different ways of covering the eyes on behavior of jaundiced infants treated with phototherapy. Biol Neonate. 1985;47:1–8. 15. Paludetto R, Mansi G, Rinaldi P, Ariola P, Cascioli CF. Moderate hyperbilirubinemia does not influence the behavior of jaundiced infants. Biol Neonate. 1986;50:43–47. 16. Paludetto R, Mansi G, Raimondi F, Romano A, Crivaro V, Bussi M, D’Ambrosio G. Moderate hyperbilirubinemia induces a transient alteration in neonatal behavior. Pediatrics. 2002;110:50e. 17. Paludetto R, Rinaldi P, Mansi G, Andolfi M, Del Giudice G. Early behavioural development of preterm infants. Dev Med Child Neurol. 1984;26:347–352. 18. Paludetto R, Mansi G, Rinaldi P, et al. Behavior of preterm newborns reaching term without any serious disorders. Early Hum Dev. 1982;6:357–363.

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19. Paludetto R, Mansi G, Rinaldi P, Margara-Paludetto P, Faggiano-Perfetto M. Working toward a humanized neonatal care system in Naples: Interactions between parents, infants and health care personnel. In: Nugent JK, Lester BM, Brazelton TB, eds. Multicultural and Interdisciplinary Approaches to ParentInfant Relations. Norwood, NJ: Ablex, 1991:239–270. The Cultural Context of Infancy. Vol 2. 20. Corbo MG, Mansi G, Stagni A, et al. Nonnutritive sucking during heelstick procedures decreases behavioural distress in the newborn infant. Biol Neonate. 2000;77:162–17. 21. Mansi G, Sarno M, De Maio C, et al. Importanza del fumo materno in gravidanza sul comportamento del neonato: Dati preliminari [The importance of maternal smoking during pregnancy on the newborn’s behavior: Preliminary data]. Paper presented at: 9th Congresso Nazionale SIN; May 21–24, 2003; Naples, Italy.

PA R T I I I

LOOKING TOWARD THE FUTURE

CHAPTER 22

A View from the Lab RACHEL KEEN

When I was in graduate school at the Institute of Child Development, University of Minnesota, in the early 1960s, my professors advised the graduate students to avoid giving advice to parents. Although we were getting our doctorates in child psychology, we were not to advise the public on child rearing. “We don’t know enough to comfortably tell people how to raise their children,” was the word we got. I think this was somewhat in reaction to the Institute’s past history of being very much in the forefront of giving parents advice, some of it ill-founded. But in the 1960s, there was a retreat back to the laboratory, with no pretense that we knew something that in fact we did not. I took this advice to heart in my research and teaching in the 1960s and 1970s, so I was extremely cautious when answering students who asked for child-rearing advice. My plan of action was to show all sides of an argument, describe pro and con research, and then leave it to the students to take from it what they would. While this may have suited some, one day a student emerged out of a large class of 500 to confront me with the following accusation: “You never say anything for sure!” It was a comment that elicited profound pondering on my part. Beginning with my dissertation, I have been studying infant behavior for around 40 years. I began with newborns, and over the years have studied various aspects of infant behavior throughout the first 2 years of life. As a graduate student scouring the literature

Preparation of this manuscript was supported by Grant HD27714 from the National Institutes of Health and Human Development to Rachel K. Clifton (now Rachel Keen).

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in the early days, it struck me how little we knew about infants, especially newborns. Their hearing, their vision, their sensitivity to pain, their responses to caretakers, their capacity to learn—all seemed unknown territory. Space is too short to cover all aspects of infant behavior, so I will concentrate on what we have learned about infant hearing because it has direct implications for infants’ care and well-being. When I researched the literature for my dissertation in 1963, the dominant view was that infants were generally passive recipients of sensory stimulation, responding to environmental input with innate reflexes. There was scant evidence that learning could be demonstrated in the first few weeks of life. The literature suggested that newborns’ fluid-filled ears impair their hearing for the first few days. No one remotely suggested that the fetus of 7 to 9 months might be responsive to sound. Forty-something years later there is a ton of evidence that in the last month before birth, immediately after birth, and continuing thereafter, the infant hears quite well and can make amazingly fine discriminations between sounds.1,2 The Neonatal Behavioral Assessment Scale (NBAS) was one of the first ways that parents could be shown directly how responsive their newborn baby was to sensory stimulation, including light and sound. The NBAS influenced my own hearing research very directly. Around 1978, I wanted to study whether newborns could localize sound. Prior to this, I had tested newborns lying in their hospital cribs, delivering sound through speakers and measuring heart rate change. Now an interest in sound localization made me seek a directional response like head turning. We adapted the Brazelton rattle (popcorn kernels shaken in a plastic container) as our stimulus and the NBAS procedure of holding the baby with head centered rather than lying in a crib with head to one side. With back, neck, and head well supported, the newborns turned readily to the tape-recorded rattle presented laterally.3 We progressed through a series of studies, manipulating duration of the rattle stimulus from very short (less than 1 second) to several seconds, and manipulating its repetition rate.4 We discovered that not every sound is so attractive to newborns. We concluded that the rattle sound is effective in eliciting head turns because of its broad bandwidth, covering frequencies from 50 to 7000 Hz. However, the newborn must hear the sound for a duration of at least 1 second for it to be effective. If the sound’s duration is shorter than 1 second but repeated at a rate of 2/second, the newborn will orient toward the sound. The NBAS uses two extremely effective stimuli to elicit head turning—the shaken rattle and the human

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voice. Both have broad bandwidths and rhythmic properties, making them useful stimuli for researchers interested in determining the parameters of newborn hearing. Not only are newborns sensitive to sound, but they appear to remember sounds from one day to the next. To test memory for sound, we presented newborns with the same sound several times until they stopped responding. This decrease in responding to a repeated stimulus is known as habituation, and all normal infants show it. When we presented the same newborns with the same sound 24 hours later, they responded less than a control group who were hearing the sound for the first time.5 Many years later, we tested the specificity of this habituation.6 On Day 1, a group of newborns was exposed to a recording of a female voice repeating a single word. The newborns readily turned toward the voice, and after several repetitions, they habituated. On Day 2, the group was divided so that one subgroup heard the same word they heard on Day 1, and the other group heard the same voice repeating a new word. There were two interesting effects: (1) The group hearing the same word failed to turn toward the side the voice was coming from as much as the group hearing a new word, and (2) in fact, the group hearing the same word actually began turning away from the side the sound was coming from, as though seeking to avoid hearing it repeated. In this case, novelty seemed to be more attractive, and the familiar, repeated word became less attractive. The important point is that newborns remembered or recognized the word that they had heard on Day 1, retaining this specific information for at least 24 hours. Work from other labs has shown retention of auditory information over even longer periods—spanning from fetal life to postnatal life. DeCasper and Fifer gave newborns pacifiers that were hooked up to a device whereby a change in the rate of sucking would produce a recording of the mother ’s voice or a stranger ’s voice.7 Newborn infants learned to suck appropriately at the rate (either slower or faster) that would produce the mother ’s voice. This is apparently due to the experience of hearing the mother ’s voice in utero and recognizing its familiar cadence, rhythm, intonation, or some other property. Should scientists have suspected this sensitivity to sound before the research showed it with certainty? As mothers brought their infants to my lab to participate in hearing research, I would often engage them in conversation. No mother seemed surprised to learn that infants were extremely sensitive to sound. Some told charming stories of playing certain music when they were pregnant and then realizing that their babies responded to that same music after they

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were born. In retrospect, no one should have been surprised at DeCasper and Fifer ’s finding that newborns prefer to hear their mothers’ voices over strangers’ voices, but it was big news at the time. Infants’ sensitivity extends to music. Trehub and Trainor have studied infants’ reaction to “good” versus “bad” musical patterns and have shown they can detect pitch contours of rising and falling melodies.8 There is a great deal of data indicating that infants’ most exquisite sensitivity to sound is reserved for speech. I next review briefly what we have learned about infants’ discrimination and sensitivity to speech sounds. Very young infants, soon after birth, can discriminate phonemes, the basic units of speech sounds. Infants are universal discriminators, meaning they can detect differences in speech sounds that you and I cannot. As adults, our ears are now tuned to our native languages. In learning certain languages that use a set of phonemes that are distinctly different from those of our native language, we will have difficulty. For example, Japanese speakers have trouble with the English distinction between /r/ and /l/, and English speakers cannot hear contrasts between certain phonemes in Czech or Thai. Infants have no problems with any of these contrasts. Their powers of discrimination are better than ours. (See Jusczyk for an excellent review of this literature.)9 We now know that the “tuning up” process comes late in the second half of the first year of life. That is, as infants start to understand the meaning of words and also begin to produce speech themselves, this universal discrimination ability declines.10 However, the ability to learn new language sounds remains very plastic, and children can pick up a second language easily during preschool and early childhood. As we age, learning a foreign language gets harder, all of which implies that we should not wait until high school or college to teach students a new language. Because hearing and speech are so much at the core of human nature, knowing about infants’ exquisite sensitivity to the sounds of language and music can make them seem more mature and more human to parents and, in fact, to all those who work with infants. “Motherese” is the term for the special way mothers and other caretakers speak to infants. It has been studied crossculturally and has been found to have commonalities across many languages.11 We can say with great confidence to parents, “It is extremely important to talk to your infant right from birth.” It will be many months before the meaning of the words is understood, but from the beginning, infants can distinguish among different sounds; they are

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sensitive to cadence, rhythm, and modulation of speech; and they need to hear speech directed toward them. In addition to exposing infants to “good” sounds, we need to be concerned about exposing infants to sounds too loud and environments with continual noisy backgrounds. The former can damage hearing, and the latter can fatigue hearing, making it more difficult to detect important sounds over ongoing noise. Early assessment of auditory impairment is also critical because amelioration through hearing aids and early exposure to sign language are available and effective. Exciting work has shown the ease with which infants, either deaf or hearing, can pick up sign language from their caretakers.12 We need to educate parents about how normal infants respond to sound, coupled with prompt assessment if hearing loss is suspected, in order to ensure that every infant experiences good communication in the first year of life. There is a great need for researchers to bring their work closer to practitioners and policymakers. The gap can be bridged, but it will take sustained, deliberate efforts on both sides. First, researchers need to make their results and implications more easily available beyond their own circles. This can be done through special publications that both researchers and practitioners would read and write for. This volume is exactly the type of vehicle for this interchange and should inspire similar volumes in the future. Second, researchers need to deeply ponder the implications of their findings for practical problems, but to do this, they need to talk to social workers, pediatricians, nurses, and other personnel who intervene in children’s lives. Symposiums that provide a forum for the needed interchange between researchers and clinicians are one way to ensure that the dialogue is undertaken—and continues. Third, collaborative research should be the core of continued communication. One way to facilitate this would be to bring together researchers and clinicians in workshops whose purpose is to design collaborative studies. The studies would then be carried out by those attending the workshop. Only when the lines of communication are freely open and flowing will we have the knowledge exchange we so badly need. REFERENCES 1. Aslin RN, Jusczyk PW, Pisoni DB. Speech and auditory processing during infancy: Constraints on and precursors to language. In: Kuhn D, Siegler R, eds. Cognition, Perception, and Language. 5th ed. New York, NY: John Wiley & Sons Inc; 1998. Damon W, ed. Handbook of Child Psychology. Vol 2. 147–198.

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2. Werner LA, Rubel EW. Developmental Psychoacoustics. Washington, DC: American Psychological Association; 1992. 3. Clifton RK, Morrongiello BA, Kulig J, Dowd J. Newborns’ orientation toward sound: Possible implications for cortical development. Child Dev. 1981;52:833–838. 4. Clarkson MG, Clifton RK. Acoustic determinants of newborn orienting. In: Weiss MJS, Zelazo PR, eds. Newborn Attention: Biological Constraints and the Influence of Experience. Norwood, NJ: Ablex; 1991:99–119. 5. Keen R, Chase H, Graham F. Twenty-four hour retention by neonates of an habituated heart rate response. Psychonomic Science. 1965;2:265–266. 6. Swain I, Zelazo P, Clifton R. Newborn memory for speech sounds retained over 24 hours. Dev Psychol. 1993;29:312–323. 7. DeCasper A, Fifer W. Of human bonding: Newborns prefer their mothers’ voices. Science. 1980;208:1174–1176. 8. Trehub S, Trainor L. Listening strategies in infancy: The roots of music and language development. In: McAdams S, Bigand E, eds. Thinking in Sound: The Cognitive Psychology of Human Audition. Oxford, England: Oxford University Press; 1993:278–327. 9. Jusczyk P. The Discovery of Spoken Language. Cambridge, MA: MIT Press; 1997. 10. Werker J. Becoming a native listener. Am Sci. 1989;77:54–59. 11. Fernald A, Taeschner T, Dunn J, Papousek M, Boysson-Bardies B, Fukui I. A cross-language study of prosodic modifications in mothers’ and fathers’ speech to preverbal infants. J Child Lang. 1989;16:477–501. 12. Petitto L, Marentette P. Babbling in the manual mode: Evidence for the ontogeny of language. Science. 1991;251:1493–1496.

CHAPTER 23

Parent-Infant Bonding and Doula Support JOHN H. KENNELL

P R E FA C E F O R T H E H E A LT H - C A R E P R O V I D E R In a period when health-care professionals and clinicians caring for children are asked to prevent and/or manage an ever-increasing number of children with developmental/behavioral problems of increasing complexity, it is heartening to know that simple interventions in the perinatal period might prevent or modify these problems. Almost 40 years of research have shown that when mothers have continuous emotional support by a doula during labor, and when they have early and extended contact and interaction with their babies, significant benefits can result. To emphasize the value of a woman companion who is warm, supportive, and caring, the Greek word doula was chosen for a laywoman caregiver who provides continuous physical, emotional, and informational support to the mother during labor and delivery. Results can be even better when contact is skin-to-skin, with privacy for the mother and father, if the baby can crawl to the breast and self-attach, and if the mother and baby can live in together through the hospital stay. Research studies show further benefits if the perinatal caregivers are positive and supportive and show the parents some of the amazing abilities of the newborn, and if the mother breastfeeds through the first year. Special efforts to avoid separating mother and baby during the hospital stay immediately after birth are often necessary because separating mothers, fathers, babies, and families has been so ingrained in maternity units for the past 100 years. For the past 25 years, in the majority of hospitals, families are no longer 243

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separated, but it is still difficult to keep mothers and babies together. The perinatal period—from the onset of labor to several days after the baby’s birth—is a remarkable time, the so-called maternal sensitive period, because events during that time (what is said, what is done) can have remarkably strong positive effects on the later behavior of the mother and father, effects that might not be possible to achieve at a later time. From the evidence presented in this chapter about parent-infant bonding and doula support, it appears that returning to many of the childbirth practices followed by our ancestors for hundreds of thousands of years should result in many fewer child behavior problems. Many more children will be on the path to becoming securely attached to their caregivers by 12 to 14 months. We now know that securely attached children usually relate well to parents, peers, and teachers and make relatively smooth progress through childhood and into early adult life. PA R E N T - I N FA N T B O N D I N G The term bonding refers to the feelings of love and commitment parents develop for their infant. This feeling of deep, emotional connection can occur at various times. Some women experience this bond during pregnancy when they begin to feel movement. Some, even earlier, because today, with ultrasound, the mother and father can see their child’s first heartbeats and begin to fantasize about who this baby will be. Other parents feel this emotion at the birth of their infant, and still other perfectly normal parents take a week or longer to sense this bond. A number of factors influence how parents perceive their infant. In the past 30 years, numerous studies have explored how mothers and fathers develop a special tie to their infants. This curiosity about bonding was stimulated by the fact that some parents have difficulty “taking on” their newborn baby, especially if the infant had a problem or the parents had unresolved issues from their own childhoods or from current life stressors. Research has also identified hospital practices that make it harder for mothers to feel close to their babies. As an example, taking the baby away shortly after birth and keeping the baby in the newborn nursery has inhibited many mothers from getting to know and feel at ease with their newborns. One of the changes being made as a result of this research is the phasing out of the newborn nursery. The baby is kept in the mother ’s room during the hospital stay, so she can get to know her baby and begin to breastfeed and suckle her infant when he or she is

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hungry. The UNICEF/WHO Baby Friendly Initiative (BFI) requires breastfeeding within one hour, rooming-in, and no bottles. Babies who were cared for in accordance with the BFI recommendations breastfed longer than control babies. More significantly, the BFI reduced infant abandonment in hospitals in three countries. When the baby is ill and needs special care, it is imperative that the mother and father are involved as soon as possible with their infant in order to avoid estrangement or fear that the baby will die. It is helpful to recognize the powerful physiological forces at work, as well as the psychological ones, to enhance bonding. When giving birth without medication and without an epidural, the mother produces the hormone oxytocin. This naturally produced hormone has a variety of important functions. It strengthens the labor contractions. Oxytocin is extremely helpful in reducing the mother ’s pain both during and after labor by raising the pain threshold. After the birth, it helps contract the uterus to eject the placenta and prevent bleeding. When the baby breastfeeds, suckling creates an oxytocin spike in the mother that produces the milk letdown. Oxytocin produces strong feelings of calmness, and women with elevated oxytocin levels feel more relaxed, and often sleepy. This hormone (often called the “cuddle” hormone) helps mother and baby feel closer. In addition, oxytocin is a major nonstress hormone, which helps shift the stress system (sympathetic nervous system) to the nonstress system (parasympathetic system). Oxytocin helps activate 19 gastrointestinal (GI) hormones in both the mother and the baby. Some of these GI hormones, in turn, produce longer villae in the intestines—those tiny hairlike structures that increase food absorption in the breastfed baby and in the mother. When artificial oxytocin (pitocin) is given to the mother during labor, it does not get into the mother ’s brain and, therefore, it does not produce the same effects. In fact, pitocin has been seen to interfere with the naturally produced hormone and can cause more painful contractions. Research has shown that the calm presence and help a doula provides—with her caring touch, appropriate massage, visualizations, and so forth—also enhance the mother ’s oxytocin levels. This type of support helps avoid factors that can make a birth traumatic for parents. A traumatic birth, one in which the mother feels helpless, with no sense of control, inadequate, demeaned or humiliated, betrayed or damaged, can greatly affect the mother ’s perception of her infant. If a normal bond does not occur, parents may project onto the baby their own distress; they may not see the baby for himself, but rather as a manifestation of distress in their own lives. When natural bonding is prevented, parents may not pick up their baby’s signals

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that would otherwise help guide them in figuring out what they should be doing to meet the baby’s needs. These signals indicate not only the baby’s basic physical requirements but also the emotional responses the baby needs. Babies are motivated by emotion and affect and, therefore, the emotional responses from their parents form a foundation for the infant’s sense of self. Understanding the six states of consciousness or awakeness can help parents recognize what signals or needs the baby may indicate in each state. There are two sleep states (quiet and active); then the third state, drowsiness; the fourth state, quiet alert; the fifth state, active alert, where the baby shows interest in looking around rather than just looking quietly at the parent’s face; and finally, the sixth state, crying. The parent-infant bond is enhanced by early and continuous contact. The longest period of the quiet alert state in those early days occurs right after birth. In this state, the baby is especially interested in seeing the faces of his mother and father, hearing their voices, smelling them, and feeling their touch while he is acclimatizing to the outside world. Parents can be helped to learn about and appreciate their baby’s natural abilities in this state, in which the baby can imitate the mother ’s tongue protrusion, follow the parents’ faces or an object, turn to the mother ’s voice, and stop crying when held by the mother or father. Most health-care institutions have made changes in the care of healthy newborns and their parents to support parent-infant bonding. Usually fathers, other family members or friends provide continuous support during labor. Early contact of the baby with the mother—skin to skin on her chest with an opportunity to crawl, self-attach to the nipple and have the first feeding—is the ideal start for early and long term benefits. In the delivery room, after the feeding or when the nurse is attending to the mother, the father will have a chance to hold and interact with his baby. Mother and baby are kept together throughout the hospitalization. Breastfeeding guidance from nurses and lactation consultants and roomingin help the parents to learn about the abilities of their infant and make decisions about the care and feeding of the new member of the family at home. C O N T I N U O U S L A B O R S U P P O RT B Y A D O U L A More than 30 years ago, Dr. Marshall Klaus and I were studying breastfeeding at a maternity hospital in Guatemala. Most women coming to that hospital were separated from family and friends

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and labored alone with no analgesia. We were dismayed by the distress and pain of the laboring women, but observed the calming effect when we asked a female Guatemalan research worker to enter a labor room to talk with one of the women. This serendipitous observation has led to more than 20 years of research in the United States on the perinatal effects of continuous support provided by a trained labor companion—a doula. Meta-Analysis of the First Randomized Trials Management of obstetric patients in Guatemala in the late 1970s was quite different from current U.S. practices. While Guatemalan women labored alone without our present-day obstetric technology, American women are rarely alone during childbirth. In spite of well-trained and experienced obstetric teams, childbirth practice involves increasing emphasis on intervention, medication, and technology while the human elements of comfort and support are often deemphasized, or left out entirely. The demands on labor and delivery nurses are so great that they can spend less than 10% of their time providing supportive services. By adding continuous doula support to the labor experience, we and other researchers found remarkable positive perinatal effects. This result was demonstrated in a meta-analysis of the first six randomized controlled trials conducted—two in Guatemala and one each in Canada, South Africa, Finland, and the United States (Houston, Texas). With the continuous support of a doula: cesarean deliveries decreased by 50%, use of forceps by 40%, requests for epidural analgesia by 60%, need for pain medication by 30%, pitocin use by 40%, and, perhaps most significant of all, labor length decreased by 25%. These first six randomized clinical trials were conducted in hospitals that did not permit family members or friends to be present with the laboring woman, or allowed only brief visits. Randomized Trial: Doula Support for Couples At this point in the investigation of the effects of doula support, questions remained about the generalizability of the positive effects for middle, or upper, income groups or for women accompanied by their husbands or other family members during labor and delivery. As a result, a study was conducted involving 555 healthy women expecting to be supported by their male partners through labor for their first baby; the women were randomly assigned to either the control or the doula group. They received routine

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obstetric care from their personal obstetricians or from the hospital’s obstetric staff. All were permitted to have family members present during labor and delivery. Of the women accompanied only by their male partners, 22.5% required a cesarean delivery compared to 14.2% of those supported by both the father and a doula. This study showed the value of doula support for all mothers, whether laboring alone or with a partner. The doula does not displace the father, but supports him—showing him how he can be helpful, and relieving much of his anxiety. Fathers, as well as mothers, say they could not have managed the labor without the doula’s support. Randomized Trial: Management of Labor Pain Another study compared epidural analgesia, narcotic analgesia, and doula support as alternate methods of managing labor pain. Four hundred and twenty-seven low-risk primigravidas in active labor were randomly placed in one of three groups. At the first indication of pain, patients in the control group received narcotic analgesia, and epidural analgesia was given if requested by the patient. Patients in the doula group continued with the support of their doulas (which had begun at the time they entered the study) and other comfort measures.* Meanwhile, patients in the epidural group received epidural analgesia at the first indication of pain after they were 4 centimeters dilated. For all pertinent demographic variables, the three groups (narcotic analgesia, doula, and epidural) did not display any significant differences. All of the patients were considered low income; 87% were Hispanic, and 83% were born outside the United States. The average age of the women was 21 years, with a range of 14 through 37. Average maternal education was 9 years. The day after delivery, women in the study, using a visual analog scale, were asked to rate their pain before and after receiving a pain intervention—either narcotic analgesia, epidural analgesia, or doula support. Women in all three groups reported a significant decrease in pain after receiving intervention. Women in the epidural group reported the greatest decrease, and women in the control (or narcotic analgesia) group reported the least change in pain level. Doulasupported patients fell between these two groups in the decrease in pain that they reported. On 10 items related to the experience of labor, *If the mother required pain management beyond the comfort provided by the doula, a small dose of narcotic medication or epidural analgesia was administered.

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the patients in the doula group consistently responded most positively, with a statistically significant difference on 6 of the 10 items. They reported more pride in themselves, a greater sense of accomplishment, more positive feelings about their coping ability, and a better overall labor experience—a great start for a new mother. Mechanisms for Effectiveness of Doula Support A review of anthropologic data about birthing practices in 128 representative nonindustrialized societies indicated that in all but one, support was provided by a woman. Studies in human and primate mothers have indicated the association between acute anxiety and arrests of labor, and that increased levels of catecholamines (epinephrine and norepinephrine) decrease uterine contractibility and result in a long labor. One possible mechanism to account for the results in the doula studies is the effect of the doula as a source of strength and confidence to relax the laboring woman, reduce her anxiety, and, as a result, reduce her catecholamine levels. Another possible mechanism to explain the effect of the doula is that the close contact—touch and massage—provided by the doula may stimulate the production of oxytocin in the mother ’s brain, resulting in slight drowsiness, euphoria, and an increased pain threshold, all of which help the mother relax and allow the labor to progress more easily. Doula Support Benefits the Baby The long-term advantages of doula support may be even greater for the baby as demonstrated in three separate studies that examined changes in mother-infant interaction following doula support during labor. In addition to the direct effects of the doula on the course of labor and delivery, there are effects manifested after the birth of the baby that are of special interest to those who care for children and families. In the first study of doula support in Guatemala, both control and supported mothers and their babies were observed in a standardized situation through a one-way mirror in the first 25 minutes after leaving the delivery room. The doula-supported mothers showed more affectionate interaction with their infants, with significantly more smiling, talking, and stroking than the mothers who did not have a doula. Investigators in Johannesburg observed the physiological health of the women and infants in both the control and supported groups

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for 6 weeks after the delivery. There were favorable effects of doula support on the subsequent psychological health of the women and infants. At 6 weeks, there were also impressive behavioral differences postpartum. A significantly greater proportion of women in the doula group were breastfeeding (51% compared with 29%). Mothers in the doula group said that during the first 6 weeks after delivery they spent 1.7 hours a week away from their babies, in contrast to those in the no-doula group, who spent 8.6 hours away. The doula mothers noted that it took an average of 2.9 days for them to develop a relationship with their babies, compared with 9.8 days for the no-doula mothers. These results suggest that support during labor expedited the doula group mothers’ readiness to fall in love and bond with their babies, and they spent less time away from them. At 6 weeks, mothers in the doula group remained significantly less anxious, had scores on a test of depression that were significantly lower than the control group, and had higher levels of self-esteem. These maternal qualities are all favorable indicators for the development of the infants. The doula mothers also felt significantly more satisfied with their partners 6 weeks postterm (71% compared with 30%). Not only did these supported mothers show more positive behaviors with their babies, but they more often rated their babies as better than a standard baby—more beautiful, more clever, and easier to manage—than did the control mothers, who perceived that their babies were slightly less beautiful and less clever than a standard infant. The third evidence of doula support favorably affecting the mothers’ interaction with their babies comes from the narcotic analgesia–doula–epidural study. Primigravida mothers with uncomplicated vaginal deliveries were randomly assigned to a doula (n = 33) or one of two no-doula (n = 71) groups (control or epidural) as described previously. A home visit was made to observe the mothers’ interactions with their infants. Mother-infant (M-I) interaction was scored on a scale of 1 to 7 that included operational definitions of the mother ’s physical contact, visual attention, and affectionate behaviors toward her child. The M-I interaction was assessed at five predefined points during the visit: (1) when the examiner entered the mother ’s house, (2) while a Bayley exam was being set up, (3) while the exam was being scored, (4) during a feeding, and (5) while the mother changed the baby. Interrater reliability was .91 across two examiners who were blind to group assignment. The M-I interaction scores revealed significant differences between the doula-supported and no-doula group of mothers. The doula-supported mothers’ mean interaction score

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was significantly higher than the no-doula group of mothers for 4 of 5 observation points (p