See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/343778204

The effects of the Newborn Behavioral Observations (NBO) system in early

intervention: A multisite randomized controlled trial

Article  in  Infant Mental Health Journal · August 2020

DOI: 10.1002/imhj.21882

CITATIONS READS

2 277

4 authors, including:

Yvette Blanchard
Sacred Heart University
29 PUBLICATIONS   335 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

The Effect of a Newborn Behavioral Observation System-Early Intervention (NBO-EI) Model of Care. In collaboration with Kevin Nugent (PI), Children’s Hospital, Boston
and Beth McManus, University of Colorado Denver. View project

The Newborn Behavioral Observations (NBO) System View project

All content following this page was uploaded by J. Kevin Nugent on 16 January 2021.

The user has requested enhancement of the downloaded file.

DOI: 10.1002/imhj.21882

RESEARCH ARTICLE

The effects of the Newborn Behavioral Observations

System in early intervention: A multisite randomized controlled trial

Beth M. McManus1 Yvette Blanchard2 Natalie J. Murphy3 J. Kevin Nugent4

1Department of Health Systems,

Management and Policy, Colorado School
of Public Health, Aurora, Colorado
2 Department of Physical Therapy and
Human Movement Science, Sacred Heart
University, Fairfield, Connecticut
3 Physical Therapy Program, University of
Colorado School of Medicine, Aurora,
Colorado
4Division of Developmental Medicine,
Boston Children’s Hospital and Harvard
Medical School, Boston, Massachusetts
Correspondence
Beth M. McManus, Beth M. McManus,
Department of Health Systems, Manage-
ment and Policy, Colorado School of Public
Health, Aurora, CO 80045.
Email: Beth.mcmanus@cuanschutz.edu
Funding information
Noonan Medical Foundation
Abstract
The purpose of this pilot study was to evaluate the effect of an infant mental
health intervention, the Newborn Behavioral Observations system (NBO), versus
usual care (UC) on infant neurodevelopment and maternal depressive symptoms
in early intervention (EI). This multisite randomized trial enrolled newborns into
the NBO (n = 16) or UC group (n = 22) and followed them for 6 months. Out-
come measures included the Battelle Developmental Inventory (BDI-2), Bayley
Scales of Infants Development (BSID-III), and Center for Epidemiologic Stud-
ies Depression Scale (CES-D). The CES-D and BSID-III were collected at 3- and
6-months post EI entry and the BDI-2 was collected at EI entry and 6-months
post-EI entry. We estimated group differences [95% CI], adjusting for program
characteristics. At 6 months, the NBO group had greater gains in Communica-
tion (b = 1.0 [0.2, 1.8]), Self-Care (b = 2.0 [0.1, 3.9]), Perception and Concepts
(b = 2.0 [0.4, 3.6]), and Attention and Memory (b = 3.0 [0.4, 6.0]) than the UC
group. The NBO group also had greater decline in maternal postnatal depres-
sive symptoms (b = −2.0 [−3.7, −0.3]) than the UC group. Infants receiving the
NBO infant mental health intervention had greater gains in cognitive and adap-
tive functions at 6 months than infants receiving UC. Caregivers receiving NBO
care had greater improvements in maternal depressive symptoms than caregivers
receiving UC.

KEYWORDS
cognitive function, developmentally supportive care, early intervention, high-risk newborns,
NBO, parent–infant communication, parent–infant interaction, relationship-based care, self-
regulation, social–emotional function

1 INTRODUCTION of EI is to support parents’ efforts at increasing their

In the United States, infants born with diagnoses leading
to a developmental disability or with medical and social
factors placing them at risk for later developmental
delays are eligible for Early Intervention (EI) services.
These home-based services are federally funded and
protected by federal law (Individuals with Disabilities
Education Act, Reauthorization, 2004). A primary goal
infant’s early skill acquisition in order to optimize school
readiness, reduce functional limitations, and minimize
future rehabilitation service use. Although very young
infants participating in EI represent a diverse group who
may have a constellation of medical, developmental, and
social risk factors, which can present challenges for EI
providers to design appropriate interventions, a common
challenge in the first few months of life after birth is

Infant Ment Health J. 2020;1–13. wileyonlinelibrary.com/journal/imhj © 2020 Michigan Association for Infant Mental Health 1
2 MCMANUS et al.
Key Findings
1. This randomized controlled trial implemented
in a “real-world” community-based Early Inter-
vention (EI) setting, showed positive effects of
the NBO on infant cognitive and adaptive func-
tions in a population of infants at risk for devel-
opmental delays and disabilities.
2. This pilot study is the first to show lasting
effects of the NBO, conducted in the newborn
period, up to at least 6 months post-EI entry,
3. Mothers who participated in the NBO inter-
vention showed greater reduction in maternal
depressive symptoms over time than mothers
receiving usual care.
self-regulation. Early difficulties with self-regulation
(e.g., self-soothing), and coregulation with caregivers,
involving difficulties in mentalizing—reading baby’s cues
and responding contingently—adversely influence brain
maturation processes, which play an important role in
the development of stress-coping strategies (Fonagy, 2002;
Parsons, Young, Murray, Stein, & Kringelbach, 2010), and
possibly contributing to long-term cognitive and social–
emotional functional limitations (e.g., inability to sustain
focused attention) and participation barriers (e.g., social
interaction with parent) (Nelson, Zeanah, & Fox, 2019;
Suchman, Pajulo, Kalland, De Coste, & Mayes, 2011). For
example, attuned and well-regulated interactions between
infant and caregiver directly influence the maturation of
both the limbic system that processes and regulates social–
emotional stimuli and the autonomic nervous system that
generates the somatic aspects of emotion (Figure 1) (Rina-
man, Levitt, & Card, 2000; Schore, 2001). In this manner,
the internalized regulatory capacities of the infant develop
in relation to the caregiver, who in turn shapes the infant’s
stress coping systems (Laurent & Ablow, 2012).
For many parents of infants with complex medical
or social beginnings, birth is a nonnormative transition
fraught with vulnerability such as depressive symptoms
and anxiety. Postpartum depression (PPD) may negatively
affect the quality of the social interaction between the
infant and the primary caregiver. Compared to nonde-
pressed mothers, depressed mothers tend to be affectively
unresponsive and emotionally unavailable, provide lim-
ited language and cognitive stimulation for their children,
and display covert hostility, such as anger and criticism
(Chapin & Altenhofen, 2010; Downey & Coyne, 1990;
Lyons-Ruth, Wolfe, & Lyubchik, 2000; Murray & Cooper,
1997; Van Doesum, Hosman, & Riksen-Walraven, 2005).
Implications for practice and/or policy
The NBO provides a promising infant mental
health model of care for EI service delivery
for high-risk newborns. EI providers who work
with high-risk infants can use these findings to
develop evidence-based care plans and interven-
tion strategies to adequately address early infant
self-regulation and parent–infant interaction diffi-
culties. EI programs could consider implementing
the NBO in statewide infant mental health educa-
tion and training efforts.
Relevance to the field of early childhood men-
tal health
Early relationships play a role in brain develop-
ment and influence social–emotional, and cogni-
tive outcome. While attainment of self-regulation,
and attachment are life-course issues, the NBO is
based on the assumption that they are being nego-
tiated by the infant and parents from the begin-
ning. The newborn period presents an opportu-
nity to support parents at a stage in infant self-
regulation and individuation that involves a trans-
formation in neural functions and supports the
formation of the early parent–infant relationship.
Previous research suggests that a relationship-based
approach to care improves brain structure and function
and indeed contributes to more optimal infant cognitive
and social–emotional functional outcomes and parental
emotional health (Als et al., 2012, 2004; Kalland, Fager-
lund, von Koskull, & Pajulo, 2016; Lieberman, 2018;
Slade, Grienenberger, Bernbach, Levy, & Locker, 2005).
Therefore, interventions that bolster infant self-regulatory
skills and caregiver interaction (i.e., relationship-based
care) should be a primary focus of EI (Feldman, 2009;
Feldman & Eidelman, 2009; Landsem, Handegård,
Ulvund, Kaaresen, & Rønning, 2015; Poehlmann et al.,
2011; Shonkoff, 2010). Yet despite evidence supporting
its effectiveness, a relationship-based approach is not
standard of care for EI. There are a number of reasons for
this. EI providers often have little professional training in
infant mental health, neurobehavioral function of very
young infants, or parent–infant interaction (Blanchard
& Mouradian, 2000). As such, there are missed opportu-
nities to understand the parent–infant coregulation and
MCMANUS et al.
FIGURE 1 Conceptual model of the effects of the NBO–EI program
interaction, create care plans and goals to bolster parent–
infant functioning, and adequately support parents
and high-risk infants (Figure 1). A developmental or
relationship-based care model is strength-based and is
primarily guided by the principle that the quality of early
experiences drives brain development and functional
outcomes. Given that all experiences have meaning for
infants and parents, it is crucial that EI providers develop
an appreciation for the encounter with the infant as one
that contributes to his or her brain development at any
given time. Another reason that a relationship-based
model of care is not yet implemented as the standard of
care in EI today is the dearth of literature on relationship-
based models of care embedded in “real-world” EI
practice.
The Newborn Behavioural Observations system (NBO)
is a relationship-building intervention that focuses on
bolstering parent–infant interaction and coregulation
(Nugent, Keefer, Minear, Johnson, & Blanchard, 2007).
Specifically, the NBO involves a set of shared observations
of the infant with the parent, which includes a series of
maneuvers used to (1) elicit infant neurobehaviors and (2)
describe and interpret these neurobehaviors in the context
of the parent–infant interaction and infant self-regulation
and intentions. This interactive approach is designed to
promote mentalization or parental reflective functioning,
by enabling the parent to think about and understand
their child’s feelings and experiences and see the child as
an individual, thus enhancing the parent–infant relation-
3
ship, the cornerstone of optimal infant neurodevelopment
and function (Feldman, 2009; Fonagy, 2002; Kalland et al.,
2016). In sum, the NBO is a relationship-based intervention
that could serve as a new standard of care.
Because the newborn period is a time of particular
vulnerability for both parents and their infants, PPD
can impair a mother’s ability to respond contingently to
her infant’s cues and to engage in sensitive and respon-
sive interactions with her infant (Mertesacker, Bade,
Haverkock, & Pauli-Pott, 2004; Murray et al., 2016; Musser,
Ablow, & Measelle, 2012; Tronick, 2007). The NBO is based
on the assumption that newborns have a rich repertoire of
social responses and rudimentary intentions and emotions
that are evolutionarily designed to draw out parental care-
giving and thus ensure the infant’s survival and develop-
ment (Brazelton & Nugent, 2011). The NBO is used there-
fore to sensitize parents to their infant’s social cues, in
order to engage the caregiver and motivate the kind of con-
tingent parent–infant interactions deemed essential not
only for the baby’s survival but for the establishment of
secure attachments and healthy development. Thus, for
mothers who are depressed, the baby can be a powerful cat-
alyst for growth and positive change, because the newborn
infant has the emerging capacity for shared attentiveness
and social engagement.
In our previous work, we found that the NBO was
associated with reduced PPD symptoms in mothers of
healthy term infants (Nugent, Bartlett, & Valim, 2014),
while Shah (2018) reported that the NBO was effective in
4 MCMANUS et al.
ameliorating maternal perinatal anxiety symptoms in a
sample of women diagnosed with anxiety during preg-
nancy. Previous literature also suggests that the NBO
promotes parents’ ability to read their infant’s cues (Dittz,
Alves, Duarte, & Magalhães, 2017; Guimarães, Lindgren
Alves, Cardoso, Penido, & de Castro Magalhães, 2017;
McManus & Nugent, 2014; Simkin-Tran, Harman, &
Nicolson, 2020) and improve provider confidence to work
with medically fragile newborns (Kristensen, Vinter,
Nickell, & Kronborg, 2019; McManus & Nugent, 2011). In
a nonrandomised cluster-controlled design, Høifødt et al.
(2020) found that in a well-functioning, well-educated
sample of mothers of full-term infants, mothers learned
significantly more from the follow-up about the baby’s
signals and needs in relation to sleep/wake patterns,
social interaction, and crying/fussiness, but the NBO was
not associated with lower levels of depressive symptoms
and parenting stress at 4 months postpartum. Yet, to our
knowledge, the long-term effects of the NBO on infant
neurodevelopment in at-risk infants and their families
remain to be evaluated. Thus, more information is needed
about the long-term effects of the NBO on maternal
emotional well-being, particularly with families of infants
at risk for developmental delays.
In this pilot study, we describe a study designed to
address the current knowledge gap on the effects of the
NBO as an infant mental health intervention on infant
and maternal outcomes. The aims of this study were to
test the effectiveness of the NBO as a model of care on
infant neurodevelopment, with a particular focus on cogni-
tive and social development and on symptoms of maternal
depression. Understanding effective strategies to improve
self-regulatory difficulties in high-risk infants has impor-
tant clinical and programmatic implications for designing
and implementing developmentally supportive interven-
tions for infants and toddlers.
2 METHODS
2.1 Population and recruitment
The study sample was drawn from five EI programs in
Massachusetts. Most of these programs serve low-income,
underserved communities. Children were enrolled in the
study if they were less than 6 weeks old (corrected for ges-
tational age), eligible for EI services based upon medical
and social factors, and had a primary caregiver over the age
of 18 who spoke or wrote English, Spanish, or French flu-
ently (as materials were available only in these languages),
and resided with their biological parent. The EI program
director identified eligible infants and caregivers between
February 1, 2016 and August 31, 2016. All eligible par-
ents received Institutional Review Board approved mate-
rial about the study from their EI service provider. Parents
who agreed to participate completed written informed con-
sent forms with a member of the study team, and infants
were randomly assigned using cluster randomization pro-
cedures (i.e., randomized within EI program) to receive the
NBO intervention or usual care (UC) EI. Specifically, the
study lead researcher created a blocked random list (Sealed
Envelope Ltd. 2016. Create a blocked randomisation
list. [Online] Available from: https://www.sealedenvelope.
com/simple-randomiser/v1/lists [AccessedMay 16, 2016]
including the five EI sites (i.e., blocks) and allowing for bal-
ance between the study arms. The sample size calculation
was performed in SAS v9.4 and estimated that 15 infants
per group would allow detection of clinically meaningful
differences in the outcome measures of interest with 80%
power. Study infants were followed for up to 6 months,
corrected gestational age, with outcome measurements
(described below) at EI entry, 3-months corrected age, and
6-months corrected age.
2.2 NBO intervention
The NBO is a shared observation of the infant with the
parents and provider that is designed to elicit the infant’s
responses and regulatory abilities through the administra-
tion of items that involve infant handling and social inter-
action. The NBO session typically begins with an obser-
vation of the baby’s initial state. If the baby is asleep, the
clinician (or parent) then administers the light and sound
stimuli to observe the infant’s capacity for sleep protection
(i.e., habituation). When the baby becomes more alert,
the clinician then elicits—or guides the parents to elicit—
motor behaviors such as hand-grasp, sucking and root-
ing, pull-to-sit, and crawling. The quality of motor tone
and activity level is observed, followed by observations
of the infant’s capacity to respond to the face and voice
and inanimate visual (red ball) and auditory stimuli (rat-
tle) and the opportunity to engage in a face-to-face inter-
action with parent and or clinician. If the infant cries,
the amount of crying and the ease or difficulty of con-
solability is observed while particular attention is paid to
the infant’s threshold levels and signs of stress throughout
the NBO session. The 18 observed or elicited items high-
light the robustness of infants’ physiologic (e.g., observing
color changes, tremors, and startles), motor (e.g., flexion
recoil), state regulation (e.g., observing frequency and pre-
dictability of state transitions), and social interaction func-
tion (e.g., visual or auditory responses to animate or inan-
imate stimuli). Items are recorded on a three-point scale
reflecting the degree of the infants’ robustness with the
observed or elicited activity. During the NBO, EI providers
MCMANUS et al.
and parents engage in a shared observation in order
to develop an understanding of the infant’s strengths
and needs for support in the context of the parent–
infant relationship. At the end of the NBO encounter,
the provider and parent reflect on the shared observation
and jointly develop strategies to assist the infant in bol-
stering self-regulation and to promote the parent–infant
relationship.
2.3 Procedures
NBO home visits typically consist of intervention strate-
gies guided by the NBO. At each home visit, the EI ser-
vice provider conducted the NBO with the parents and
discussed (1) the infant’s attempts and successes at self-
regulation and signals for support, (2) how the infant’s
neurobehaviors contribute to the parent–infant social
interactional encounter, parental meaning-making, and
infant–caregiver bonding. To improve intervention fidelity,
NBO interventionists and site directors attended a 2-day
advanced NBO training course prior to the start of the
study. The course reviewed details on recruitment and
informed consent procedures, the intervention protocol to
ensure standardized delivery of the intervention, and data
collection procedures. Both off-site and on-site mentoring
of NBO interventionists was made available including con-
ference calls and webinars.
Infants in the intervention group received weekly home
visits from an EI provider certified in the NBO system,
which was used up to 12 weeks corrected gestational age.
The UC group received traditional EI home-based ser-
vice delivery from an EI provider not certified in the
NBO. These home visits typically consist of therapeutic
and developmental activities deemed appropriate for the
infant’s adjusted age and typically include visual track-
ing, reaching and grasping toys of a variety of textures,
and tolerance of developmental play. Infants in both treat-
ment arms received at least three 1-hr study visits and some
infants received four.
To minimize bias, providers were selected into the UC
and NBO groups to have similarity in terms of professional
discipline, education, and years of experience. In our previ-
ous pilot NBO research, we observed minimal differences
across provider groups with regard to professional disci-
pline, years of experience, and education level (McManus
and Nugent, 2012).
2.4 Outcome variables
The primary outcomes of interest were (a) infant’s neu-
rodevelopment, with a focus on adaptive skills, and
5
cognitive and social–emotional function and (b) symptoms
of maternal depression.
Infant neurodevelopment was measured using scaled
(i.e., age-adjusted) scores from two different instruments,
the Bayley Scales of Infant Development-III (BSID-III)
Adaptive and Social Emotional Scales (Bayley, 1993) and
the full Batelle Developmental Inventory, second edition
(BDI-2: Newborg, 2005).
BSID-III. The BSID-III is a widely used assessment of
function appropriate for children ages 1–42 months, and
items are scored dichotomously (1 = able to complete or
0 = not able to complete). For this study, we used the BSID-
III Adaptive Scale which includes seven subscales relevant
to newborns: Communication (e.g., makes eye contact,
laughs, cries when upset), Health (e.g., cries when upset,
swallows liquid medicines, avoids bumping into things
when mobile), Leisure (e.g., engaging with a toy, looking
at a picture in a book), Self-Care (e.g., feeds/swallows well,
sleeps through the night), Self-Direction (e.g., focuses on
a toy, calms when picked up), Social (e.g., smiles, snug-
gles, lifts arms to be picked up), and Motor (e.g., lifts head,
shakes a rattle). Additionally, we used the BSID-III Social
Emotional Scale. Specifically, we used the 3-month and 6-
month modules which assess self-regulation skills and use
of emotions in an interactive, purposeful manner, respec-
tively. Specific items include infant’s ability to calm, engage
with an adult, respond to touch, and voice. The BSID-III
Adaptive and Social Emotional Scales were administered
via phone interview at the 3-month and 6-month follow-
up time, by an independent member of the study team who
was blinded to the infant’s intervention group assignment.
BDI-2. The BDI-2 is appropriate for children birth to 7
years of age and includes five subscales that evaluate the
core developmental domains of adaptive, motor, commu-
nication, personal–social, and cognitive function. BDI-2
items are scored on a three-point scale to capture emerg-
ing functional performance (Bliss, 2007). The BDI-2 has
been shown to have good sensitivity and specificity to clas-
sify infants and toddlers with developmental delay and to
be a valid measure of change in developmental function
over time (Elbaum, Gattamorta, & Penfield, 2010). Since
the study programs used the BDI-2 for EI eligibility pur-
poses, study providers completed the BDI at EI entry and
6-months (corrected for gestational age) per EI protocol
and scores were sent to the research team. We used scaled
BSID-III and BDI-2 scores, which both have a mean of 10
and a standard deviation of 3.
Maternal depressive symptoms were collected using the
Center for Epidemiologic Studies Depression Scale (CES-
D) (Radloff, 1977). The CES-D asks mothers to report, on
a four-point scale (0 = rarely/none of the time to 4 = all
of the time), their frequency of symptoms for 20 scale
items. Scores of 16 or greater indicate clinically significant
6 MCMANUS et al.

depressive symptoms. The CES-D has been used exten-

sively in psychological and epidemiologic studies of post-
natal women and demonstrated high reliability (McManus
& Poehlmann, 2012). The CES-D was collected via phone
interview at the 3-month and 6-month follow-up time,
by an independent member of the study team who was
blinded to the infant’s intervention group assignment.

2.5 Analysis

We calculated sample means, standard deviations (SD),

and proportions for child characteristic. The outcome vari-
ables were skewed, and we accordingly report them as
median [interquartile range (IQR)]. We calculated the
change in each outcome measure between study entry and
3-months and study entry and 6-months. Then, we esti-
mated unadjusted group differences between EI entry and
6-months (i.e., change over time) in each outcome measure
using median quantile regression models. Quantile regres-
sion models estimate the median rather than the mean
and are more appropriate for skewed outcome data. Then,
we used adjusted quantile median regression to estimate
group differences in the change in each outcome measure
between EI entry and (1) 3 months and (2) 6 months. There
was significant variability with respect to program sites as
some served more urban, socially diverse populations. To
address the impact of the small sample size and EI program
variability and to account for the low intraclass correla-
tion (i.e., clustering), we included a program-fixed effect to
account for these differences and not overspecify the ana-
lytic models. We performed intention-to treat analyses, and
all analyses were conducted in SAS v9.4 with an alpha level
set at .05.
FIGURE 2 CONSORT Flow Diagram
3.1 Group differences at baseline
The descriptive statistics in Table 1 show that the UC and
NBO groups were comparable, with the exception of gesta-
tional age. 64.7% of infants in the NBO group were born at
less than 34 weeks gestational age, whereas 77.3% of the UC
group fell into this category; however, the median (SD) ges-
tational ages were more similar, with 33.6 (4.5) in the NBO
group and 32.5 (3.9) in the UC group. Moreover, there were
no group differences in BDI-2 scores in any developmen-
tal domain at baseline (Table 2). we estimated unadjusted
(Table 3) and adjusted (Table 4) group differences in out-
comes between study timepoints.
3.2 Group differences at 3 months

There were no statistically significant differences in CES-

3 RESULTS
Overall, 49 newborns were referred to the five study EI pro-
grams during the recruitment period. Of those, 46 (94%)
were eligible for the study. Of the eligible infants, 38 (83%)
enrolled and were followed until 6-months corrected age.
Despite the relatively high rate of enrollment among eli-
gible infants, we acknowledge the overall low number of
participants, which highlights the unique challenges of
conducting intervention trials in “real-world” community-
based settings, particularly among families of infants at
high medical and/or social risk for developmental delays
and disabilities. We further discuss these challenges later
in the paper. Five declined participation, and three were
lost to follow up (Figure 2). Total enrollment was n = 16
for NBO and n = 22 for UC for a total sample size of 38
infant–mother dyads.
D or BSID scores at 3 months although BSID Motor scores
(b = 1.0 [−0.2, 2.2]) were higher in the NBO group, which
approached statistical significance (p = .10, Table 4).
3.3 Group differences at 6 months
In adjusted models, the NBO group had greater gains in
BSID-III Communication (b = 1 [0.2, 1.8]), BSID-III Self-
Care (b = 2 [0.1, 3.9]), BDI-2 Perception and Concepts
(b = 2 [0.4, 3.6]), and BDI-2 Attention and Memory (b = 3
[0.4, 6]) scores than the UC group (Table 5). Of note, these
group differences represent a clinically meaningful gain
(i.e., 0.67 effect size). Additionally, BDI Social Role (b = 1.5
[−0.8, 2.9]) and Gross Motor (b = 2.1 [−0.6, 4.8]) were
marginally statistically significantly higher in the NBO
group. The NBO group also had greater decline in maternal
MCMANUS et al. 7

TA B L E 1 Characteristics of the study sample (n = 38) of infants enrolled in an EI program

Characteristics NBO (n = 16) Usual Care (n = 22) p
% (n)
Maternal education .89
Some College or less 37.5 (6) 36.4 (8)
College 62.5 (10) 63.6 (14)
Gestational Age .21
Less than 34 weeks 68.8 (11) 77.3 (17)
Greater than or equal to 34 weeks 31.3 (5) 22.7 (5)
Child’s sex .81
Male 56.3 (9) 52.4 (11)
Female 43.8 (7) 47.6 (10)
Median (SD)
Gestational age (weeks) 33.6 (4.5) 32.5 (3.9)

TA B L E 2 Unadjusted median (IQR) scores for each outcome measure at each time point for the NBO (n = 16) and Usual Care (n = 22)
infants
NBO (n = 16) Usual Care (n = 22)
Batelle Developmental Inventory
Subscale Scaled Scores EI entry 6-Months EI Entry 6-Months
Cognitive
Attention and Memory 2 [2, 2] 9 [9, 9] 2 [2, 4] 9 (0.1)
Perception and Concepts 6 [6, 8] 10 [10, 10] 8 [8, 9] 10 (0.1)
Adaptive/Behavioral
Adult Interaction 7 [7,7] 7 [4, 7] 7 [6, 8] 7 [7, 8]
Social Role 2 [2, 3] 9 [9, 9] 2 [2, 4] 9 [8, 9]
Communication
Expressive Language 6 [4, 6] 6 [5, 6] 6 [5, 6] 6 [6, 7]
Receptive Language 7 [6,8] 4, [4, 5] 7 [6, 8] 4 [2, 4]
Motor Skills
Fine Motor 5 [4, 6] 6 [6, 6] 5 [4, 6] 6 [5, 7]
Gross Motor 2 [2, 6] 8 [8, 8] 2 [2, 6] 8 [8, 8]
Self-Care 7 [6, 8] 8 [8, 9] 7 [6, 8] 8 [5, 8]
Bayley Scales of Infant Development
Subscale Scaled Scores 3 months 6 Months 3 months 6 Months
Communication 9 [8,9] 7 [6.5, 8] 8.5 [8,9] 7 [6,8]
Health 10 [9,10] 8 [7,9] 9.5 [7,10] 7 [6,8]
Leisure 10 [7,11] 8 [7,9] 10 [9,11] 9 [8,9]
Self-Care 6 [4,7] 4.5 [3.5,6] 4 [3,7] 5 [2,6]
Self-Direction 7 [7,9] 6 [4.5, 7.5] 8.5 [7,11] 7 [7,8]
Social 5 [5,6] 8 [5,8.5] 6 [5,6] 7 [5,10]
Motor 6 [5,7] 4.5 [4,5] 5.5 [5,7] 5 [4,7]
Social Emotional Skills 61 [54, 65] 70 [65,75] 59 [56, 64] 66 [63,70]
3 months 6 Months 3 months 6 Months
Centers for Epidemiologic 6 [5, 12] 3 [3, 9] 5 [2, 7] 3 [0, 4]
Studies-Depression
8 MCMANUS et al.

TA B L E 3 Unadjusted median (IQR) difference in CES-D, BSID-III, and BDI-2, scores between the NBO and Usual Care groups between
time points
Median change
NBO (n = 16) Usual Care (n = 22)
Batelle Developmental Inventory Subscalesa
Cognitive
Attention and Memory 7 [4, 7.5] 5 [3, 7]
Perception and Concepts 3.5 [2.5, 5] 1 [0, 3]
Adaptive/Behavioral
Adult Interaction –1 [–3, 5.2] 0 [–1, 2]
Social Role 6 [3, 5.7] 5.5 [4, 7]
Communication
Expressive Language 0 [–1.5, 2.5] 1 [–2, 2]
Receptive Language –3 [−4.5, −0.5] –3 [–4, –2]
Motor Skills
Fine Motor 1 [–0.5,4.5] 1 [–1, 4]
Gross Motor 5.5 [–0.5, 6.5] 3 [1, 6]
Self-Care 1.5 [–2, 3] 0 [−2, 3]
Bayley Scales of Infant Development Subscalesb
Communication –1 [−2, –1] –1 [–2, 0]
Health –2 [–3, –2] –2 [–2, 0]
Leisure –1 [−3, 0] −2, [−3, 0]
Self-Care 0 [–1, 1] 0 [–1,1]
Self-Direction –1 [–1, 0] –2 [–3, 0]
Social 2.5 [1, 4] 2 [0, 4]
Motor –1.5 [–3, –1] 0 [–1, 1]
Social Emotional Skills 9.5 [1, 13] 10 [3, 15]
c
Centers for Epidemiologic Studies-Depression –2.5 [−3, –1] –1 [–2, 1]
a
Differences in Battelle Developmental Inventory scores between EI entry and 6 months, adjusted for prematurity,
b
Differences in Bayley Scales of Infant Development scores between 3 and 6 months, adjusted for prematurity,
c
Differences in Centers for Epidemiologic Studies-Depression scores between 3-months and 6-months, adjusted for prematurity

postnatal depressive symptoms (b = −2.0 [−3.7, −0.3])
than the UC group (Table 5).
4 DISCUSSION
In this pilot pragmatic trial, we found that infants
who were randomized to receive the NBO, a stan-
dardized, developmentally supportive, relationship-based
infant mental health intervention, every week during the
newborn period, had improved neurodevelopment at 6
months, and their mothers had greater improvement in
postnatal depressive symptoms compared to parent–infant
dyads receiving usual EI care. These findings are novel
because, to our knowledge, this is the first study to show
that the NBO can be an effective infant mental health inter-
vention to bolster infant neurodevelopment and mater-
nal well-being in “real-world” community-based EI set-
tings. However, we acknowledge the small study sam-
ple size and the results should therefore be interpreted
accordingly.
Infants at risk for developmental delays and disabili-
ties due to medical and/or social factors are predisposed
to have difficulties with self-regulation, which interrupts
successful integration of social, emotional, and cognitive
functions (Als et al., 2012, 2004; Blanchard & Mouradian,
2000; Blanchard & Oberg, 2015; Nugent, Blanchard, &
Stewart, 2008). Thus, understanding self-regulatory diffi-
culties in high-risk infants has important clinical and pro-
grammatic implications for designing and implementing
developmentally supportive interventions.
To this end, the first main finding of the paper is that
infants in the NBO group demonstrated greater gains cog-
nitive and adaptive function between EI entry and 6-
months post EI-entry. Specifically, infants receiving the
NBO demonstrated better gains in visual attention with
caregivers (i.e., BDI-2 Attention and Memory) sensorimo-
tor interactions (BDI-2 Perceptions and Concepts). Infants
MCMANUS et al.
T A B L E 4 Adjusteda median (95% CI) difference in CES-D and
BSID-III scores between the NBO and Usual Care groups at 3
months
Developmental outcome Median group
measure difference (95% CI)
Centers for Epidemiologic 0.82 [–2.2, 3.8]
Studies-Depression
Bayley Scales of Infant
Development Adaptive
Scale
Social 0 [–0.62, 0.6]
Communication 0 [–0.63, 0.63]
Health 0 [–1.23, 1.23]
Leisure 0.6 [–1.8, 3.0]
Self-Care 0 [–3.1, 3.1]
Self-Direction 0.1 [–2.9, 2.8]
Motor 1 [–.2, 2.2]
Social Emotional Scale 0 [–2.9, 2.48]
a
Models adjusted for early intervention program.
*
p = 0.10.
receiving the NBO infant health intervention also demon-
strated greater gains in their adaptive function. Specifi-
cally, infants receiving the NBO infant mental health inter-
vention showed greater improvements in eye contact with
caregivers, crying, using different voice tones to get care-
givers’ attention (i.e., BSID-III Adaptive Scale, Communi-
cation subscale), and feeding skills (i.e., BSID-III Adap-
tive Scale, Self-Care subscale). Study findings are comple-
mentary to previous literature examining the effect of the
NBO. For example, the NBO has been shown to be asso-
ciated with improvements in parent’s ability to read their
baby’s cues [McManus & Nugent, 2014] and providers’
confidence to provide relationship-based, developmentally
supportive care to high-risk infants receiving EI services.
Arguably, parent–infant coregulation and provider confi-
dence are mechanisms through which the NBO influences
infant cognitive, adaptive, and social function. The current
study builds upon previous literature in confirming longer-
term neurodevelopmental effects of the NBO.
There is growing research to support the role of
relationship-based, infant mental health interventions like
the NBO on improving early self-regulatory difficulties
in high-risk newborns and later cognitive and social–
emotional function (Figure 1).
These findings are promising in terms of the benefits of
the NBO as a mental health intervention in “real-world”
community-based EI settings. State EI programs in the
United States serve about 350,000 infants and their fami-
lies annually. The evidence supporting links between early
self-regulatory difficulties and later development and func-
tion are derived from clinical research in controlled set-
9
tings (Als et al., 1994, 2004, 2012). To our knowledge, the
current study is the first to demonstrate the positive infant
neurodevelopmental effects of an infant mental health
intervention, the NBO, in “real-world” community-based
EI settings. The findings from this pilot study have the
potential to improve EI service delivery and quality of life
for families with infants at risk for developmental disabil-
ities and delays. The significant findings around improved
infant self-care after NBO intervention are particularly
salient for quality of life improvement at an early age as
this subscale is closely related to feeding. Indeed, there is a
significant body of literature (Thoyre, Hubbard, Park, Prid-
ham, & McKechnie, 2016; Thoyre, Park, Pados, & Hubbard,
2013; Weber & Harrison, 2014) underscoring the impor-
tance of relationship-based, developmentally supportive
care to promote optimal oral feeding skills in high-risk
newborns. It is likely that the NBO intervention effects on
bolstering infant self-regulation and parent–infant interac-
tion had spillover effects on improving infant oral-feeding
skills.
The final main finding of this pilot study is that we
also found positive intervention effects for mothers sug-
gesting that this individualized, developmentally support-
ive relationship-based intervention has promising effects
at reducing symptoms of maternal depression and anxiety
at 6 months post-EI entry. This finding is particularly pow-
erful because the mothers in the NBO group had much
higher CES-D scores at the 3-month measurement. This
finding extends the results of another randomized con-
trolled study of first-time mothers and their babies, which
showed that the NBO was associated with lowering the
odds of depressive symptomatology by approximately 75%
during the first month after delivery (Nugent et al., 2014).
Because it is strength-based, can be easily integrated into
clinical practice and is cost-effective, the NBO could be an
effective intervention tool in preventing PPD in first-time
mothers. However, further research to determine whether
these effects hold up over time and explore underlying
mechanisms of the NBO’s effect on PPD will be important
to establishing the NBO’s effectiveness in reducing PPD
symptoms.
This pilot study has important clinical, program-
matic, and policy implications for developing a sustain-
able model of NBO-EI service delivery and serve as a
research framework for other NBO studies. EI providers
can use these findings to develop evidence-based care
plans and intervention strategies to adequately address
early self-regulatory and parent–infant interactions dif-
ficulties among the families with high-risk infants they
serve. EI program directors and state EI leadership could
consider implementing statewide education and train-
ing efforts related to infant mental health interven-
tions such as the NBO. Such training efforts could be
10 MCMANUS et al.

TA B L E 5 Adjusteda median difference (95% CI) in CES-D, BSID-III, and BDI-2, scores between the NBO and Usual Care groups between
time points
Developmental outcome measure Median group difference (95% CI) Effect size
Centers for Epidemiologic Studies-Depressionb –2.0 [–3.7, –0.3]a 0.50
c
Bayley Scales of Infant Development
Adaptive Scale
Social 0 [–2.4, 2.4]
Communication 1.0 [0.2, 1.8]a
Health 0 [–1.2, 1.2]
Leisure –1.0 [−2.8, 0.8] 0.33
a
Self-Care 2.0 [0.1, 3.9]
Self-Direction –1.0 [–3.4, 1.4]
Motor –2.0 [-–.8, –0.2]a 0.67
Social Emotional Scale –1.0 [–4.7, 2.7]
Battelle Developmental Inventoryd
Cognitive
Attention and Memory 3.0 [0.4, 6.0]* 1.0
Perception and Concepts 2.0 [0.4, 3.6]*a 0.67
Personal-Social
Adult Interaction –2.0 [–4.0, 0.04]
Social Role 1.5 [–0.8, 2.9]
Communication
Expressive Language –1.0 [–2.8, 0.8]
Receptive Language 0 [–1.2, 1.2]
Motor Skills
Fine Motor 1.0 [–0.4, 2.4]
Gross Motor 2.1 [–0.6, 4.8]
Self-Care 1.0 [–1.4, 3.4]
a
Models adjusted for early intervention program.
b
Differences in Centers for Epidemiologic Studies-Depression scores between 3 and 6 months, adjusted for prematurity.
c
Differences in Bayley Scales of Infant Development scores between 3 and 6 months, adjusted for prematurity.
d
Differences in Battelle Developmental Inventory scores between EI entry and 6 months, adjusted for prematurity.
*
p < .05.

incorporated into statewide quality assurance initiatives
to improve EI service delivery and outcomes for high-
risk infants and their families. For example, the State
of Ohio has dedicated funding to train all EI develop-
mental specialists and infant mental health providers on
the NBO as a statewide approach to delivering evidence-
based infant mental health services to high-risk new-
borns and their families. Such statewide initiatives pro-
vide the opportunity for quality assurance activities and
evaluation of the reach and effectiveness of approaches,
such as the NBO, on improving high-risk infant and
caregiver outcomes.
We acknowledge the study’s limitations. First, despite
aggressive recruitment efforts, the overall sample size for
the study was relatively small. This highlights a challenge
with implementing and testing interventions in “real-
world community-based settings.” The challenges include
the ebbs and flows of high-risk infant EI referrals, the
need to maintain openings on provider caseloads based
upon randomization procedures, and provider turnover.
Yet, despite these logistical difficulties, we recruited a
sample that was adequately powered to detect significant
(and clinically meaningful) group differences, using the
conservative standard error for p-value of .05. In addition,
we were able to implement a randomization protocol,
train providers to intervention fidelity, ensure that infants
received approximately the same number of home visits
within and across treatment arms, include additional out-
come data collection with a researcher who was “blind” to
study group, and implement robust statistical procedures,
despite the small sample size. Moreover, our results
suggest the NBO as an infant mental health intervention
implemented through EI programming has promising
beneficial effects on infant neurodevelopmental function
MCMANUS et al.
and maternal well-being. If interventions such as the NBO
were “scaled up” statewide, there would likely be multi-
plier effects. A second limitation is that we did not include
a measure of parent–infant interaction or baseline (i.e., EI
entry postnatal depressive symptoms). Although the study
protocol included a measure of parent-infant interaction
assessed through a video-taped encounter, many parents
were not comfortable with being filmed. As a result, only
about 45% participated in the videotaped parent–infant
interaction. We did, however, include a measure of social
competence through two social emotional outcomes
that, especially among young infants, are relational items
and could serve as a proxy for parent–child interaction.
Indeed, collecting parent–infant interaction in real world
community-based settings is a challenge. Future research
should explore avenues for assessing parent–infant
interaction through modalities and approaches that are
acceptable to parents. Finally, we only followed infants
and families for 6-months, which limits our ability to
draw conclusions about later development and school
readiness. Future research should consider following
children until EI exit or through preschool to determine
long-term neurodevelopmental effects of infant mental
health interventions such as the NBO delivered in the
newborn period.
4.1 Strengths
Despite these limitations, this pilot study has a number of
strengths. Study infants were randomized to their treat-
ment arms and received similar intervention dosage and
follow-up, which highlights the rigor of this pilot study.
Additionally, it is the first study to evaluate the effect of
an infant mental health intervention, the NBO, in an EI
setting. Additionally, a number of outcome measures were
collected to capture a full battery of infant neurodevelop-
mental function. To this end, state-mandated EI outcome
measures were integrated to reduce provider and parent
burden and to increase the feasibility and generalizabil-
ity of our results. The infants were followed for 6-months
post-EI entry, which extends previous research suggest-
ing that the NBO is associated with improved parental
perceptions of their ability to read their baby’s cues and
respond contingently (McManus & Nugent, 2014) as well
as improved EI provider confidence in working with fam-
ilies of high-risk newborns (McManus & Nugent, 2011).
In the current pilot study, we showed that an EI–NBO
model of care has a great deal of promise to be sustain-
able and to transform and improve how EI care is deliv-
ered to families of high-risk infants while adding to the
evidence-based that infant mental health interventions
delivered in the newborn period has positive neurodevel-
11
opmental effects that extend to at least 6-months post-EI
entry.
5 IMPLICATIONS/CONCLUSION
Conducting outcomes research in EI is challenging due to
the diversity of infants served by EI. In addition, it is dif-
ficult to randomize infants to EI in order to obtain causal
inferences about EI. In this pilot study, we used a multi-
site pragmatic trial design and robust methods to demon-
strate the effectiveness of the NBO. This research built
upon previous work (McManus & Nugent, 2011, 2014) sug-
gesting a positive influence of the NBO on parent’s ability
to read their baby’s cues and respond contingently and on
EI providers’ confidence in working with high-risk fami-
lies. Thus, the results of this pilot study have contributed to
the evidence for making relationship-based care the stan-
dard of care in EI settings.
Developmental, relationship-based care is associated
with improved infant quality of life and maternal well-
being (Als et al., 1994, 2004, 2012; Kalland et al., 2016;
McKelvey et al., 2015; McManus & Nugent, 2011; Nelson
et al., 2019; Nugent et al., 2014). The results presented
here show that NBO has a strong potential to promote
maternal well-being and foster caregiver–infant bonding
by reducing maternal depressive symptoms, improving
early cognitive and social–emotional function for infants
with developmental disabilities and delays, thus creating
a sustainable model of EI service delivery that supports
parents of high-risk infants. Future research should focus
on continuing to follow these families to evaluate the
longer-term effects of the NBO–EI model of care, which
may have important implications for toddlers and school
readiness.
AC K N OW L E D G M E N T S
Drs. Nugent, McManus, and Blanchard acknowledge
funding from the Noonan Medical Foundation. All authors
wish to acknowledge Patti Fougere and Steve McCourt
from the Massachusetts Department of Public Health. All
authors also wish to acknowledge the Early Intervention
Program directors who participated in this project: April
Haefner, Anne Marsh, Kelly Petravicz, Martha Levine, and
Dawn Gutro. Finally, we are grateful to the Early Interven-
tion providers and parents who participated in this project.
The authors acknowledge their affiliation with the
Brazelton Institute (BI), Department of Newborn
Medicine, at Children’s Hospital Boston. Researchers
at the BI (including the second and senior authors) devel-
oped the intervention under study and the first, second,
and senior authors provided training and certification to
clinicians on the intervention tool under study.
12
ORCID
Beth M. McManus https://orcid.org/0000-0002-2481-
0812
REFERENCES
Als, H., Duffy, F. H., McAnulty, G., Butler, S. C., Lightbody, L., Kosta,
S., . . . ., Warfield, S. K. (2012). NIDCAP improves brain function
and structure in preterm infants with severe intrauterine growth
restriction. Journal of Perinatology, 32(10), 797–803. https://doi.
org/10.1038/jp.2011.201
Als, H., Duffy, F. H., McAnulty, G. B., Rivkin, M. J., Vajapeyam, S.,
Mulkern, R. V., . . . Eichenwald, E. C. (2004). Early experience
alters brain function and structure. Pediatrics, 113(4), 846–857.
Als, H., Lawhon, G., Duffy, F. H., McAnulty, G. B., Gibes-Grossman,
R., & Blickman, J. G. (1994). Individualized developmental care for
the very low-birth-weight preterm infant. Medical and neurofunc-
tional effects. JAMA, 272(11), 853–858.
Bayley, N. (1993). Bayley Scales of Infant Development: Manual. San
Antonio, TX: Psychological Corporation.
Blanchard, Y., & Mouradian, L. (2000). Integrating neurobehavioral
concepts into early intervention eligibility evaluation. Infants and
Young Children, 13(2), 41–50.
Blanchard, Y., & Oberg, G. K. (2015). Physical therapy with newborns
and infants: Applying concepts of phenomenology and synactive
theory to guide interventions. Physiotherapy Theory and Practice,
31(6), 377–381. https://doi.org/10.3109/09593985.2015.1010243
Bliss, S. L. (2007). Test reviews: Battelle Developmental Inventory−
second edition. Itasca, IL: Riverside. Journal of Psychoeducational
Assessment, 25(4), 409–415.
Chapin, L. A., & Altenhofen, S. (2010). Neurocognitive perspectives
in language outcomes of Early Head Start: Language and cognitive
stimulation and maternal depression. Infant Mental Health Jour-
nal, 31(5), 486–498.
Dittz, E. S., Alves, C. R. L., Duarte, E. D., & Magalhães, L. D. C. (2017).
Contribution of the Newborn Behavioral Observations (NBO) for
the maternal care of preterm neonates. Journal of Human Growth
and Development, 27, 262.
Downey, G., & Coyne, J. C. (1990). Children of depressed parents: An
integrative review. Psychological Bulletin, 108(1), 50.
Elbaum, B., Gattamorta, K. A., & Penfield, R. D. (2010). Evaluation
of the Battelle developmental inventory, screening test for use in
states’ child outcomes measurement systems under the Individu-
als with Disabilities Education Act. Journal of Early Intervention,
32(4), 255–273.
Feldman, R. (2009). The development of regulatory functions from
birth to 5 years: Insights from premature infants. Child Devel-
opment, 80(2), 544–561. https://doi.org/10.1111/j.1467-8624.2009.
01278.x
Feldman, R., & Eidelman, A. I. (2009). Biological and environmen-
tal initial conditions shape the trajectories of cognitive and social-
emotional development across the first years of life. Developmen-
tal Science, 12(1), 194–200. https://doi.org/10.1111/j.1467-7687.2008.
00761.x
Fonagy, P. (2002). Affect regulation, Mentalization, and the develop-
ment of the self. New York, NY: Other Press.
Guimarães, M. A. P., Lindgren Alves, C. R., Cardoso, A., Penido, M.
G., & de Castro Magalhães, L. (2017). Clinical application of the
Newborn Behavioral Observations (NBO) System to characterize
MCMANUS et al.
the behavioral pattern of newborns at biological and social risk.
Journal de Pediatria (Rio J), 94(3), 300—307. Retrieved from www.
jped.com.br
Høifødt, R. S., Nordhal, D., Landsem, I. P., Csifcsak, G., Bohne, A.,
Pfuhl, G., . . . Wang, C. E. A. (2020). Newborn behavioral obser-
vation, maternal stress, depressive symptoms and the mother-
infant relationship: Results from the Northern Babies Longitudi-
nal Study (NorBaby). BMC Psychiatry, 20, 200. https://doi.org/10.
1186/s12888-020-02669-y
Individuals with Disabilities Education Act, Reauthorization. (2004).
Kalland, M., Fagerlund, Å., von Koskull, M., & Pajulo, M. (2016).
Families first: The development of a new mentalization-based
group intervention for first-time parents to promote child devel-
opment and family health. Primary Health Care Research & Devel-
opment, 17(1), 3–17.
Kristensen, I. H., Vinter, M., Nickell, I. K., & Kronborg, H. (2019).
Health visitors’ competencies before and after implementing the
Newborn Behavioral Observations (NBO) system in a community
setting: A cluster randomised study. Public Health Nursing, 00, 1–
7. https://doi.org/10.1111/phn.1265
Landsem, I. P., Handegård, B. H., Ulvund, S. E., Kaaresen, P. I.,
& Rønning, J. A. (2015). Early intervention influences positively
quality of life as reported by prematurely born children at age nine
and their parents; a randomized clinical trial. Health and Quality
of Life Outcomes, 13(1), 25.
Laurent, H. K., & Ablow, J. C. (2012). A cry in the dark: Depressed
mothers show reduced neural activation to their own infant’s cry.
Social Cognitive and Affective Neuroscience, 7(2), 125–134.
Lieberman, A. F. (2018). Reflections on the theoretical contributions
and clinical applications of parental insightfulness. Attachment &
Human Development, 20(3), 333–340.
Lyons-Ruth, K., Wolfe, R., & Lyubchik, A. (2000). Depression and the
parenting of young children: Making the case for early preventive
mental health services. Harvard Review of Psychiatry, 8(3), 148–153.
McKelvey, L., Schiffman, R. F., Brophy-Herb, H. E., Bocknek, E.
L., Fitzgerald, H. E., Reischl, T. M., . . . Cunningham Deluca, M.
(2015). Examining long-term effects of an infant mental health
home-based early head start program on family strengths and
resilience. Infant Mental Health Journal, 36(4), 353–365.
McManus, B. M., & Nugent, J. K. (2011). Feasibility study of early
intervention provider confidence following a neurobehavioural
intervention for high-risk newborns. Journal of Reproductive and
Infant Psychology, 29(4), 395–403.
McManus, B. M., & Nugent, J. K. (2012). A neurobehavioral inter-
vention incorporated into state early intervention programming
improves parent’s social interaction with their high risk newborn.
Journal of Behavioral Health Services and Research, 1–8.
McManus, B. M., & Nugent, J. K. (2014). A neurobehavioral interven-
tion incorporated into a state early intervention program is associ-
ated with higher perceived quality of care among parents of high-
risk newborns. Journal of Behavioral Health Services and Research,
41(3), 381–389. https://doi.org/10.1007/s11414-012-9283-1
McManus, B. M., & Poehlmann, J. (2012). Parent–child interaction,
maternal depressive symptoms and preterm infant cognitive func-
tion. Infant Behavior and Development, 35(3), 489–498.
Mertesacker, B., Bade, U., Haverkock, A., & Pauli-Pott, U. (2004). Pre-
dicting maternal reactivity/sensitivity: The role of infant emotion-
ality, maternal depressiveness/anxiety, and social support. Infant
Mental Health Journal, 25(1), 47–61.
MCMANUS et al.
Murray, L., De Pascalis, L., Bozicevic, L., Hawkins, L., Sclafani, V.,
& Ferrari, P. F. (2016). The functional architecture of mother-
infant communication, and the development of infant social
expressiveness in the first two months. Scientific Reports, 6,
39019.
Murray, L., & Cooper, P. (1997). Effects of postnatal depression on
infant development. Archives of Disease in Childhood, 77, 99–101.
Musser, E. D., Ablow, J. C., & Measelle, J. R. (2012). Predicting
maternal sensitivity: The roles of postnatal depressive symptoms
and parasympathetic dysregulation. Infant Mental Health Journal,
33(4), 350–359.
Nelson, C. A., Zeanah, C. H., & Fox, N. A. (2019). How early experi-
ence shapes human development: The case of psychosocial depri-
vation. Neural Plasticity, 2019, 1676285.
Newborg, J. (2005). Battelle Developmental Inventory−Second Edition.
Itasca, IL: Riverside.
Nugent, J. K., Bartlett, J. D., & Valim, C. (2014). Effects of
an infant-focused relationship-based hospital and home visit-
ing intervention on reducing symptoms of postpartum mater-
nal depression: A pilot study. Infants & Young Children, 27(4),
292–304.
Nugent, J. K., Blanchard, Y., & Stewart, J. S. (2008). Supporting
parents of premature infants: An infant-focused family-centered
approach. In D. Brodsky & M. A. Ouellette (Eds.), Primary care of
the premature infant (pp. 255–267). New York, NY: Elsevier.
Nugent, J. K., Keefer, C. H., Minear, S., Johnson, L. C., & Blanchard,
Y. (2007). Understanding newborn behavior and early relationships:
The Newborn Behavioral Observations (NBO) system handbook.
Baltimore, MD: Paul H Brookes Publishing.
Parsons, C., Young, K., Murray, L., Stein, A., & Kringelbach,
M. L. (2010). The functional neuroanatomy of the evolv-
ing parent–infant relationship. Progress in Neurobiology, 91(3),
220–241.
Poehlmann, J., Schwichtenberg, A. J., Bolt, D. M., Hane, A., Burn-
son, C., & Winters, J. (2011). Infant physiological regulation and
maternal risks as predictors of dyadic interaction trajectories in
families with a preterm infant. Developmental Psychology, 47(1),
91–105. https://doi.org/10.1037/a0020719
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale
for research in the general population. Applied Psychological Mea-
surement, 1(3), 385–401.
Rinaman, L., Levitt, P., & Card, J. P. (2000). Progressive postna-
tal assembly of limbic–autonomic circuits revealed by central
transneuronal transport of Pseudorabies virus. Journal of Neuro-
science, 20(7), 2731–2741.
Schore, A. N. (2001). Effects of a secure attachment relationship
on right brain development, affect regulation, and infant mental
health. Infant Mental Health Journal, 22(1-2), 7–66.
View publication stats
13
Shah, T. (2018). The Effects of the NBO on breastfeeding mothers with
high levels of perinatal maternal anxiety. Paper presented at the
16th World Congress of the World Association for Infant Mental
Health, Rome.
Shonkoff, J. P. (2010). Building a new biodevelopmental framework
to guide the future of early childhood policy. Child Development,
81(1), 357–367.
Simkin-Tran, K., Harman, B., & Nicolson, S. (2020). Mentalisation
amongst maternal and child health nurses using the Newborn
Behavioural Observations with infant-mother dyads: A qualitative
study. Journal of Pediatric Nursing, 50, e21–e27. https://doi.org/10.
1016/j.pedn.2020.01.018
Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A.
(2005). Maternal reflective functioning, attachment, and the trans-
mission gap: A preliminary study. Attachment & Human Develop-
ment, 7(3), 283–298.
Suchman, N., Pajulo, M., Kalland, M., De Coste, C., & Mayes, L. C.
(2011). At-risk mothers of infants and toddlers. In A. W. Bateman &
P. Fonagy (Eds.), Handbook of Mentalizing in Mental Health Prac-
tice (pp. 309–346). Washington, DC: American Psychiatric Pub-
lishing.
Thoyre, S., Park, J., Pados, B., & Hubbard, C. (2013). Developing a co-
regulated, cue-based feeding practice: The critical role of assess-
ment and reflection. Journal of Neonatal Nursing, 19(4), 139–148.
https://doi.org/10.1016/j.jnn.2013.01.002
Thoyre, S. M., Hubbard, C., Park, J., Pridham, K., & McKech-
nie, A. (2016). Implementing co-regulated feeding with moth-
ers of preterm infants. MCN: American Journal of Mater-
nal Child Nursing, 41(4), 204–211. https://doi.org/10.1097/nmc.
0000000000000245
Tronick, E. (2007). The neurobehavioral and social-emotional devel-
opment of infants and children. London, UK: Norton.
Van Doesum, K. T., Hosman, C. M., & Riksen-Walraven, J. M.
(2005). A model-based intervention for depressed mothers and
their infants. Infant Mental Health Journal, 26(2), 157–176.
Weber, A. M., & Harrison, T. M. (2014). Maternal behavior and infant
physiology during feeding in premature and term infants over the
first year of life. Research in Nursing and Health, 37(6), 478–489.
https://doi.org/10.1002/nur.21618
How to cite this article: McManus BM,
Blanchard Y, Murphy NJ, Nugent JK. The effects of
the newborn behavioral observations (NBO). Infant
Ment Health J. 2020;1–13.
https://doi.org/10.1002/imhj.21882