• Helen has a lot of things stacked against her. She is the first-born child to a mother diagnosed with mild mental retardation. A product of the foster care system, her mother lacks any outside family support and is left to struggle with her low IQ and income on her own. Following an abusive relationship, her mother is separated from her husband and has a restraining order against him.
• Jessie is a young teen parent who quit high school. Unable to tolerate any crying, she never lets go of her infant. Prematurely born at 26 weeks gestation, Sam endured a three-month period of invasive procedures in a special care nursery and is now at home on an apnea monitor.
• David's older brother was seen by Cape Ann Early Intervention Program (CAEIP) for sensory integration dysfunction and behavior difficulties. Prior to this her involvement with CAEI, David's mother utilized a submission/punishment approach with her older son that bordered on abuse.

These are some of the infants and families referred to CAEIP, whose mission is to provide family-driven services to enhance a child's overall growth and development. These are also the families that have benefited from Early Intervention (EI) staff who have incorporated the use of the Neonatal Behavioral Observation Scale (NBO) in their work with families within the first few months of life.

Although the typical age for referral to EI is after the child's first birthday, the program receives referrals of many newborns and infants in the first few months of life. These referrals include children that are born with early-diagnosed conditions such as Down Syndrome, babies that are born premature or drug exposed, as well as those whose family circumstances present significant environmental challenges. All of these conditions present risks in development as well as bonding for the child.

In Massachusetts, the Department of Public Health requires all EI programs to evaluate children for eligibility into the EI service system through the developmental score on the Michigan Early Intervention Profile. The Michigan - similar to other assessment tools such as the Hawaii Early Learning Profile, Battelle Developmental Inventory, the Bailey, and the Mullen - has a limited number of pass/fail skill observations, resulting in a numeric score to determine if the child has a developmental delay. Items that are observed include response to sound, visual regard and tracking, vocalizations, reflexive and adaptive movements, head control, and nutritive sucking ability. Reports generated from these tests generally point out areas of weakness, ignoring the individual strengths and capabilities of a child. The skills that are often paramount to the parent and their bonding experience with the baby, such as the baby's tolerance to touch, irritability, consolability, and ability to interact, are neglected.

The Brazelton Institute extended an opportunity for several clinicians at Cape Ann Early Intervention, Healthy Foundations, and Family Support Early Intervention Programs (all programs of the North Shore Arc) to develop specialized skills for assessing individualized infant strengths and vulnerabilities by becoming trained in administering the Neonatal Behavioral Observation Scale (NBO). NBO-certified therapists learned to interpret the infant's basic ability to sustain control of their Autonomic Nervous System (ANS), control of breathing and temperature, and the extent of ability to control tremors and startle reactions. Without sufficient control at this level, the infant's energy is consumed by efforts for ANS stability. Therapists were also trained in assessing the motor system, including the infant's activity level, muscle tone, visual tracking, and movements. State regulation including the levels of alertness, stress, and readiness to become engaged to interact socially within the environment were also identified. Rather than the traditional pass/fail system of scoring, observations are recorded on a grading system accounting for quality of observations.

Following the training, our program entered a research study with the Brazelton Institute to evaluate the effectiveness of using the NBO in early intervention settings. Babies that were referred between the ages of 0-3 months (adjusted age) were randomly assigned to either a clinician trained in administering the NBO or to a "control" group of service providers that provided standard EI services. Following the first month of intervention, both parents and clinicians completed questionnaires. The Parent Questionnaire addressed understanding of their baby, parental confidence, relationship with their EI service provider, and effectiveness of the EI service. The Clinician Questionnaire provided insight into their comfort and confidence assessing infant development and their confidence in providing guidance to families.

During the NBO administration, parents are actively involved and recognized as collaborators. The assessment is fully explained and questions and concerns are elicited. Each step is narrated by the clinician, thereby teaching the parent to understand each infant behavior. Parents are provided with a wealth of information about their child's strengths and needs. Indicators of stress behaviors are demonstrated as well as "in the moment" training on how the parent can support their baby. They are taught how to position and support the infant's attempts to self regulate as well as modify the environment. The process supports the infant and family in succeeding and promotes competence, which is key in the bonding experience. Parents learn how to read their babies cues and understand their child as an individual, promoting improved ability to nurture and care for their baby. The observations and discussion with the parents around the NBO naturally lead to the development of IFSP goals and individualized developmental intervention that parents can implement in their day-to-day care of their child.

The clinicians that administered the NBO felt that this tool allowed the ability to engage parents in a non-threatening manner. For example, the parents just coming home from the hospital with a premature baby on an apnea monitor have been through several months of life-threatening situations and are not sure if they want EI to come in to their home following such traumatic events. Being acutely aware of their baby's vulnerabilities and fragility, they are often filled with insecurities about caring for their child. They may not be as aware of their child's unique strengths and how to build on them. Participation in the NBO provides the parents with a deeper understanding of their infant's behaviors and how they can support their child.

Clinicians also felt that the NBO also allowed an opportunity for parents to discuss topics that may not have otherwise been addressed. Issues that could threaten feelings of competence as parents, such as irritability, excessive crying, arching away from the parent's touch, and difficulty consoling are comfortably discussed in a non-threatening atmosphere. Parents learn to be able to understand their child's individual temperament, read their babyÕs cues, and know how they can provide support. At-risk infants are often more irritable and harder to console, have feeding difficulties, inability in sustaining sleep, and may arch away from their parents' attempts to comfort. These behaviors are extremely detrimental to the parent's self-esteem and in turn to the parent/child relationship. For example, the teen parent, as well as the parent with mild mental retardation mentioned at the beginning of this article, already suffered from isolation, low self-esteem and worries about her ability to parent, even prior to delivering her "at-risk" infant. She also had very limited knowledge about babies and unrealistic expectations. Similarly, the parent of the child with sensory integration difficulties may not have used the submission/punishment approach of parenting with her firstborn (who from day one she reported was "fussy") if she had been taught early about what her child was communicating and how to support him.

The NBO perfectly complements early intervention programs. Its resources for assessing and developing the IFSP in the first few months of life are invaluable. By incorporating the NBO, clinicians and parents are able to observe and interpret individualized infant behaviors and develop supportive strategies to promote competence, develop bonding, and establish an environment where babies like Helen, David, and Sam can grow, develop, and thrive.

For references and further information please contact: mlevine@nsarc.org