Introduction:

Dr. Yvette Blanchard with a newborn

The Newborn Behavioral Observation (NBO) is an individualized infant-focused, family-centered observational system designed for use by practitioners to elicit and describe the infant's competencies and individuality. While the observed behaviors during the NBO can be used by clinicians to offer anticipatory guidance to parents about their child's behavior, its primary purposes are to strengthen the relationship between the parent and child and promote a supportive relationship between clinician and family (Nugent, Keefer, O'Brien, Johnson & Blanchard, 2007).

Before using the NBO in clinical practice, professionals must be trained and certified in its administration. For that reason, the Brazelton Institute offers training seminars throughout the U.S. and Canada. These training seminars, designed for a maximum of 20-30 practitioners, focus on the theoretical foundations and clinical principles necessary to use the NBO system in clinical practice. Participants are introduced to current neurobehavioral development research in the context of early parent-child relationships. Then, using film and live demonstrations, they learn observational strategies to identify newborn behaviors (e.g. feeding, sleeping, crying) and ways to share these unique observations with families. Clinical guidelines on relationship-building and anticipatory guidance on different aspects of development (e.g. feeding, sleeping, crying) are discussed and demonstrated in a way that is developmentally appropriate and culturally sensitive. The participants in those seminars represent various clinical backgrounds (e.g. occupational, physical, speech therapists, special education teachers, psychologists, social workers, nurses, physicians)

At each seminar, participants are asked to complete a pre- and post-training questionnaire to evaluate the quality of the session and to provide feedback about what they learned. Using these questionnaires, we conducted an evaluation of the NBO training program to examine the quality of the program and ascertain the degree to which it met its objectives. We asked:

1. Did participants in the NBO training perceive a change in their level of confidence about their clinical skill regarding early infant development, caregiving, communication with families, and anticipatory guidance?
2. What did participants learn in the NBO training that will help them strengthen their relationship with families?

Quantitative Results
Table 1 presents descriptive data for each of the 14 items on the pre-post-training questionnaire collected at the five training sessions.

Table 1. Number of responses, Mean score (M), Standard Deviation (sd), and t-score for each item on the pre-post training questionnaire

t-tests showed the NBO significantly increased providers' confidence across all dimensions. Overall, participants felt more confident in their ability to communicate with families around their infants' development and provide information that was empowering and supportive to parents. Did Yvette not respond to our questions re. this section? It suggests the specific questions are not very important. To my mind, these are at least as important as the qualitative data, if not more important, given the consistency of the p values, but it's probably too late for a change now.

Qualitative Results:
Participants' responses on the post-training questionnaire to the item, What did you learn in today's training that will help you strengthen your relationship with parents? were categorized into four main themes:

1. Communication with Parents
2. Use of Infant Behaviors
3. Parents as Experts
4. Relationship-building

1. Communication with parents
   The most common theme to emerge from participant responses was related to aspects of communication with parents. Providers specifically reported that they learned,

   "How to speak in a way that validates and empowers the parent"
   "How to relate, how to ask questions..."
   "How to deliver information that is very important and be flexible about including parents in the NBO."

   They reported that they learned specific strategies like

   "a statement can be reframed to be a question"
   "using the NBO opens dialogue with families, creates opportunities to validate and provide anticipatory guidance in a more natural way"
   "to help parents articulate their infant's abilities and strengths."

   Other participants commented on how the NBO emphasized the importance of "active listening" with an "emphasis on the positive" during the joint observation of infant behaviors.

2. Use of Infant Behaviors
   The second theme to emerge described how the NBO offered clinicians an opportunity to use infant behaviors to guide, support and offer anticipatory guidance to parents. Participants reported a deeper understanding of how to use infant behaviors to individualize their approach with infants and parents. Participants responded that they

   "learned how to use the baby as a catalyst in the relationship [with families]"
   " learned how to use the observations for anticipatory guidance and the importance of scaffolding for the infant"
   " learned to teach families to understand their baby's behaviors, rather than what we expect from babies in general.

   Other comments included the importance of "listening and watching" and letting "the baby be the guide" as well as a "continued focus on the positive". Providers also felt the NBO empowered parents.

3. Parents as Experts
   After training, providers acknowledged the value of seeing parents as experts in terms of understanding their children. Participants identified strategies like

   "pausing, taking more cues from the parent and baby"
   "letting the parent hold the child during the evaluation"

   as ways to translate this concept into practice.

   Other participants commented that they would "continue to think about really using the parents as the experts" and "learn how to really make parents feel like their own child's expert."

4. Relationship-building
   The importance of establishing a partnership with families was mentioned repeatedly. Participants suggested that

   "observing rather than talking can be used as a strategy to promote the parent-child relationship"
   "dynamic, non-judgmental observation is validating and promotes the clinician-parent relationship"
   "inclusion, parent as expert, and listening are important tools to strengthen relationships."

   One participant felt the "NBO is a collaboration or partnership with the parent."
   Another reported, "I learned to help parents see their infant's strengths-this will help create a partnership/trust with parents in order for them to feel comfortable sharing concerns they may have for their baby."

   Responses generated from the post-training item, What did you learn in today's training that will help you strengthen the parent-infant relationship? were categorized into two themes:
   1. Parents as leaders
   2. Relationship-building strategies
   

   Responses describe how the NBO encourages reflective practice on how to strengthen the parent-child relationship.

   • Parents as Leaders
     Participants reported that "validating a parent's observations" and "letting the parent make the observation" is an important piece of their work. After training, participants felt like they could promote parent-infant relationships by "observing rather than talking". More specifically, individuals wrote they learned "to be quiet and state by observations instead of teach"; "observe, listen, and be patient in order to support the parent and give them reinforcement" (as opposed to telling the parent what to do or what should happen).

   • Relationship-building strategies
     When asked what participants learned that would help them strengthen the parent-infant relationship, they responded, "a focus on the positive aspects of the relationship"; "observation of infant strengths", and "praise". Specific feedback included,

     "verbalizing all of the baby's strengths during the NBO session and also verbalizing strengths of parents and how they interact with their child" "describing all of the positive aspects of the relationship already present"; "praise and generosity"; strength-based visits, making for proud and involved parents."

     Participants felt that looking for opportunities to reinforce parent confidence and celebrate infant behavior was effective in building successful relationships.

Discussion:
Most professionals who take the NBO training are experienced clinicians or service providers who seek training to refine their understanding of newborn functioning and their approach with families. Results from the questionnaires suggest that the NBO is effective at increasing participants' level of confidence in their ability to offer parents child development information and guidance around caregiving. Whether the reported increase in confidence lead to increased provider competence in clinical settings remain to be demonstrated but, nevertheless, the results indicate that the NBO training is effective in giving participants new information on infant development, on communication strategies and on relationship-building with families.

The qualitative data suggest that providers feel the NBO is an effective tool for communicating with families and sharing observations about a child's behavior, in the interest of establishing successful relationships with families. The NBO prompts a behavioral shift in professionals, moving them from just understanding that parents are experts to a clinical approach that is collaborative and inclusive of families' perspectives and skills. Data suggest that participants value a collaborative relationship with families. They appear ready to let go of their role as "teachers" and instead learn to guide and support the parent, as equal partners. As one participant stated,

"We have so many families from low SES backgrounds who are looked down upon by staff and sometimes become unsure of their own parenting ability. I now know a way to help them regain that confidence and to help them bond with their baby."