Children's Hospital Boston The Brazelton InstituteHarvard Medical School


 Understanding the Baby's Language

While babies may not speak their first word for a year, they are born ready to communicate with a rich vocabulary of body movements, cries and visual responses: all part of the complex language of infant behavior.

The Neonatal Behavioral Assessment Scale
(NBAS) was developed in 1973 by Dr. T. Berry Brazelton and his colleagues. The scale represents a guide that helps parents, health care providers and researchers understand the newborn's language. "The Scale gives us the chance to see what the baby's behavior will tell us," says Dr. Brazelton, professor emeritus, Harvard Medical School. "It gives us a window into what it will take to nurture the baby."

The Scale, looks at a wide range of behaviors and is suitable for examining newborns and infants up to two months old. By the end of the assessment, the examiner has a behavioral "portrait" of the infant, describing the baby's strengths, adaptive responses and possible vulnerabilities. The examiner shares this portrait with parents to develop appropriate caregiving strategies aimed at enhancing the earliest relationship between babies and parents.

Scale reveals infant's individuality
 When the Scale was published in the early 1970s, people were just beginning to appreciate the infant's full breadth of capabilities, and the only tests available were designed to detect abnormalities. The Scale was designed to go beyond available assessments by revealing the infant's strengths and range of individuality, while still providing a health screen.

The NBAS is based on several key assumptions. First, infants, even ones that seem vulnerable, are highly capable when they are born. "A newborn already has nine months of experience when she is born," Dr. Brazelton notes. "She is capable of controlling her behavior in order to respond to her new environment."

Second, babies "communicate" through their behavior, which, although it may not always seem like it, is a rational language. Not only do infants respond to cues around them, like their parents' faces, but they also take steps to control their environment, such as crying to get a response from their caregivers.

Third, infants are social organisms, individuals with their own unique qualities, ready to shape as well as be shaped by the caregiving environment.

Assessing the baby's capabilities
In an effort to reveal everything the infant has to say, the Scale was built to 28 behavioral and 18 reflex items. The exam does not yield a single score but instead assesses the baby's capabilities across different developmental areas and describes how the baby integrates these areas as she deals with her new environment.

 When infants are born they face four developmental tasks vital to their growth. The Scale examines how well the infant manages these interrelated tasks and sees if the baby may need extra caregiving support in some areas.

The most basic challenge facing newborns is to regulate their breathing, their temperature and the rest of their autonomic system, which needs to be functioning properly before infants can concentrate on other developmental areas. High-risk infants may spend most of their energy trying to maintain their autonomic systems, so they cannot focus on other areas of growth. Sights and sounds may overtax them, so looking at their mother's face may disturb their breathing or noise may set off tremors, startles or color changes, signals that are assessed by the Scale.

Next, infants strive to control their motor system. Inhibiting random movements and controlling activity levels lets the newborn focus her energy on other developmental tasks vital to growth. If the baby is having difficulty in this area, caregivers can help her by providing as much tactile support as necessary to help her settle down, such as holding or swaddling her. The Scale assesses the quality of the baby's tone, activity level and reflexes.

Once the baby can manage motor behavior, she will be ready to tackle the next sphere in her developmental agenda: "state" regulation. State is a key developmental concept that describes levels of consciousness, which range from quiet sleep to full cry. The infant's ability to control her states enables her to process and respond to information from her caregiving environment. The NBAS examiner looks at how an infant controls her states, and at the transition from one state to another.

 For example, the exam reveals how an infant responds to light, sound and touch during the sleep state. The examiner briefly shines a light in a sleeping baby's eyes. Generally, the child blinks and squirms in irritation. When we repeat the process several times, the infant usually tunes out the stimulation and remains asleep. The baby's ability to ignore the stimulation allows her to conserve energy and to develop. If a baby has trouble blocking out stimulation during the exam, parents will know that they need to support their child, perhaps by being quiet or keeping her from bright light.

Finally, when an infant's autonomic, motor and state systems are in equilibrium, she is ready to interact socially, the ultimate developmental task. The Scale shows how babies are ready to be engaged in their new world from the first moments of life. In this portion of the assessment, the examiner looks to see how a baby follows a red ball, a face and a voice. It is a powerful experience for parents to see their new child respond to their voices or study their faces.

Best performance
NBAS examiners are trained to get the best performance from the child by doing everything possible to support the infant in "succeeding." For example, one part of the exam looks at an infant's ability to self-console when she is upset. Some infants console themselves easily, while others have a more difficult time. If the infant cannot console herself, the examiner takes measured steps to help her. Not only do we learn how much support the infant may need at home, but also how far along the child is at completing her developmental agenda.

 By the end of the exam, the examiner has developed a vibrant portrait of the newborn, which can be used to tailor caregiving to the baby's specific physical needs and behavioral style. Does the baby like to be handled? Is the baby receptive to social interaction? Does the baby easily calm herself? "One of the important things about the Scale is that it parallels what parents are looking for," Dr. Brazelton says. "It puts health care providers on the same wavelength as parents."

Brazelton, T.B., & Nugent, J.K. (2011). The Neonatal Behavioral Assessment Scale. Mac Keith Press, Cambridge.

Nugent, J. K. Petruaskas, B., Brazelton, T. B. (2009). The Infant as a Person: enabling healthy infant development worldwide. Hoboken, NJ.: John Wiley & Sons, Inc.

The NBAS requires training to be able to administer it effectively and reliably. For more information, please see the Training Program section.

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