I. Abstract
Current medical perspective recognizes that childhood and adolescent health is embedded within a psychosocial, ecological and ethological context (Bronfrenbrenner, 2001). More simply, it is important to recognize that child health and behavior reflects a dynamic system of cultural, educational and social factors (Brazelton & Greenspan, 2000). From this viewpoint, the field of developmental-behavioral pediatrics has emerged: an ecological approach in medicine intended to diagnose, treat and prevent developmental issues resulting from chronic illness, stresses in the environment, or metabolic, neurological or biochemical causes.

In Portugal, there is little formal education or clinical guidance around this approach, hindering the quality of Pediatrics training. It is important for us to think about how to integrate elements of developmental-behavioral pediatrics into the education of residents for the purpose of improving the quality of Pediatric care for children and families.

In this study, we sought to examine whether Pediatric residents can discriminate and make meaning of newborn behaviors, believing that this type of skill is one necessary ingredient for the integration of developmental-behavioral practice in Pediatrics.

Pediatric residents in the Department of Pediatrics at the Hospital de Santa Maria were individually interviewed and asked to view a film containing excerpts of the Newborn Behavioral Assessment Scale (NBAS), a tool designed to examine individual differences in the newborn, across various developmental areas like motor, state, and social-interactive systems (Brazelton & Nugent, 1995). Interview data was collected post viewing the film and analyzed using the á posteriori technique.

Results showed that while residents could observe and describe newborn behavior they were less able to assess and describe differences in newborn behaviors presented during the NBAS, in a way that would enable them to provide appropriate guidance to parents. Such findings suggest that Pediatric residents in the Santa Maria Hospital are ill-equipped to evaluate developmental newborn behaviors; as a result, they are unable to provide quality healthcare to children and families. The medical education system in Portugal needs to integrate new, more developmental-behavioral-focused curriculum, such as the NBAS to address this disparity.

II. Introduction
The concept of "Developmental-Behavioral Pediatrics" emerged in medical literature about 30 years ago. Since then, the approach has been described in a myriad of editorials, articles, and texts (Holt, McDowell, 1998; Roy, 1995; Mullan, Wolf, Ertel, 1989; Oberklaid, 1988) alongside the growing understanding that psychosocial, ecological, ethological and trans-cultural aspects of a family have an impact on child health.

Using the Newborn Behavioral Assessment Scale (NBAS) as a guideline, we define resident competency as the ability to identify and interpret newborn behaviors according to the following dimensions: motor function, autonomic stability, habituation, range and regulation of states and interactive orientation. To date, in Portugal, the medical educational system does not recognize this developmental-behavioral approach to be a compulsory component for training in neonatology and/or child development.

The goal of this study is to examine how Pediatric residents at the Hospital de Santa Maria in Lisbon, Portugal discriminate and make meaning of newborn behaviors during the NBAS. We hope to demonstrate the effectiveness of using videotaped observations of NBAS examinations as a form of resident teaching in meeting these goals or as a way to help them better understand differences in newborn behavior.

III. Method
Residents (n=18) from the Clinical Universitária de Pediatria at the Hospital de Santa Maria were interviewed by a researcher. During the interview, residents were 1) asked for personal information such as name, age, gender, years of residency, and number/age of their children, 2) given a brief explanation of the methodology used to inform the residents of the goals and objectives of the study and description of the study design and 3) allowed to view a 10-minute film containing images of a pediatrician administering the NBAS with two full-term newborns, one typically developing and one infant who was exposed to material substance use during pregnancy. Residents were blind to the health status of the newborns during the study. In both cases, NBAS behaviors included: sensory awareness, stability of states, autonomous regulation, and soothing/consoling strategies.

Prior to viewing the film, residents were told "You will see images of two babies being examined on the NBAS. After you have seen them, I would like you to talk to me about what you have just seen." Then before each newborn was presented, residents were told "This is the first baby" and then, "This is the second baby." Half of the residents viewed the typically developing child first and then the child who had been exposed to drugs in-utero. The other residents viewed the film in the reverse order. During the discussion following the film, a researcher asked the following questions:

1. Could you tell me about these two babies that you have just seen?
2. What differences were there between them?
3. Mention three aspects that best differentiate the two babies
4. One of these babies is the child of a drug addict. Which one do you think it is?
5. Would you like to take one of these babies home with you? Why?
6. Do you think that these two babies will have the same future?

Responses were recorded and fully transcribed for á posteriori content analysis. Analysis recorded frequency of: recorded units (RU) and number of subjects (N). The frequency of RU captured the number of times a particular topic was mentioned. The frequency of N summarized the number of residents that referred to a particular topic. Together, RU and N frequencies were then, categorized in an attempt to make sense of responses.

Using a qualitative-content analysis approach, based on verbal responses, resident observations were examined and thematically categorized. Four broad categories were derived based on the recorded units.

• Description of newborn behavior patterns and difference between the two babies
• Characterizing the baby exposed to drugs in-utero
• Reasons for adopting one of the babies
• Predicting the future development of the babies

N frequencies were used as the main factor component to ensure validity of findings, as RU frequencies can be unreliable and subject to individual participant style. N frequencies were not exclusive.

IV. Results
Interview data was collected from 18 residents.

A. Description of Newborn Behavior Patterns and Difference between the Two Babies

Six infant neurobehavioral categories were observed and identified by residents: motor activity, orientation, state regulation, reflexes, appearance, and environment (see Table 1).

Table 1
Description of Newborn Behavior by Residents