Neonatal Behavioral Assessment Scale
Descriptive Information
Title, Edition, Dates of Publication and Revision*
The Neonatal Behavioral Assessment Scale 3rd edition, 1995
The most recent revision is: The Neonatal Behavioral Assessment Scale, 4th Edition, November 2011;
Authors: T Berry Brazelton, J Kevin Nugent
Source:
Publisher: Mac Keith Press
526/529 High Holborn House, 52-54 high Holborn, London WC1V 6RL
Costs:
NBAS course and certification is $2,500
Neonatal Behavioral Assessment Scale Manual, 4th Edition: $49.00
NBAS Testing Kit: $45.00
NBAS Instructional video: $57.00
NBAS DVD: $29.99
Using the NBAS with infants and Families DVD: $29.99
Using the NBAS with infants and their families booklet: $20.00
Purpose: To create a behavioral image of the infant including autonomic regulation, state regulation, motor organization, habituation, and attention/social interaction. This scale is usually used in research, but can be adapted to the clinic as well.
Type of Test: Evaluative
Target Population and Ages: Newborns and Infants 0-2months
Time Requirements: 20-30 min
Test Administration
Administration: Done by an NBAS trained examiner; there are 28 behavioral items and 18 reflex/neurological items. Each item should be tested in the indicated infant state (1-6) for that specific item. Items are grouped into “packages” which are tested in a particular order for convenience: Habituation, Motor-Oral, Truncal, Vestibular, and Social-Interactive.
Scoring: The infant’s best (not average) response is documented. Neurological items are scored on a 4 point scale and behavioral items are scored on a 9 point scale. Points are given based on response to stimuli/reflex and scales are individualized based on item being tested.
Type of information, resulting from testing: Item-by-item comparison of scores
Environment for Testing: midway between feedings in a quiet, dimly lit room with a temperature 72-80 degrees Fahrenheit.
Equipment and Materials Needed: NBAS Testing Kit
Examiner Qualifications: NBAS trained; NBAS trained examiners should agree on scoring 90% of the time following training.
Psychometric Characteristics: Unable to find published studies to report values of the following characteristics. The following information is based on opinion.
Level of Measurement: Ordinal
Reliability: Inter-rater reliability is achieved through the NBAS training. The goal of inter-rater reliability is 90% as stated by www.brazelton-institute.com
Validity: Appears to have good face and content validity, although no studies have been established to determine the extent of the validity.
Responsiveness: Internal, measuring the change in infant behavior over time.
Standardization/normative data:
There are no true standard scores or MCIDs available for the NBAS; however, the original cohort which utilized the NBAS has been used for comparison in some studies. The original cohort information can be found at the following reference:
Tronick, EZ, Wise, S, Als, H, Adamson L, Scanlon J, Brazelton, TB. (1976) ‘Regional obstetric anesthesia and newborn behavior: effect over the first ten days of life.’ Pediatrics, 58, 94-100.
Evidence of Reliability:
Lester, 1984 and Brazelton et al. 1987 found low to moderate test-retest reliability. However, it has been questioned if reliability is an appropriate judgment for this test due to the rapidly changing state of a newborn. This may create the appearance of an unreliable test, whereas in reality, the infant has merely changed in behavioral profile due to growth and development. Further research is needed to evaluate the reliability of the NBAS.
References:
Lester, B.M. (1984) ‘Data analysis and prediction.’ In: Brazelton, T.B. Neonatal Behavioral Assessmen Scale, 2nd Edn. London: Spastics International Medical Publications. Pp. 85-96.
Brazelton, T.B. Nugent, J.K., Lester B.M.(1987) ‘The Neonatal Behavioral Assessment Scale.’ In: Osofsky, J. (Ed.) The Handbook of Infant Development. New York: Wiley, pp. 780-817.
Evidence of Validity: Validity is suggested to be dependent on repeated NBAS assessments on a particular infant. There is no evidence to suggest the validity of the NBAS.
Discriminative: No discriminative studies found.
Predictive:
Multiple studies have shown that when combining the NBAS with another measure it can be predictive of later development. Correlations have been found between the NBAS and temperament, mother-child interaction, post partum depression, infant mental development, maternal self-esteem, and prenatal alcohol exposure. More specific information can be found at the reference noted below. The following is summary of studies cited in that reference.
Neonatal behavior at 3 months of age has a significant correlation between NBAS orientation and motor categories and an infant being considered “fussy-difficult and unpredictable”. Within an infant’s first 4 months of life, there is also a correlation between poor orientation scores and development of colic.
Post-partum depression of the mother at 6 weeks can be correlated to infant irritability as measured by the NBAS at 10-15 days of life.
Motor development at 8 and 12 months, as measured by the Griffiths Scale, is related to state control as measured by the NBAS measured during the same time frame.
Visual discrimination at 3 months correlates significantly with the NBAS cluster: range of state.
Finally, mental and motor performance on the Bayley Scales of Infant Development can be predicted by the orientation, reflexive behavior, autonomic functioning, and motor performance NBAS scores.
Reference:
Brazelton, B. T., Nugent, K. J., Keefer, C., Wolke, D. and Munck, H. (1995) Neonatal behavioral assessment scale / T. Berry Brazelton, J. Kevin Nugent. 3rd edn. Edited by M. Bax. United Kingdom: Mac Keith Press
Summary Comments
Strengths:
The NBAS has been used in many research studies to monitor the behavioral state of infants in many situations. These situations include infants with nutritional deficits, infants of diabetic mothers, infants of drug addicted mothers, low birth weight infants, and other prenatal and perinatal situations that may cause the infant to be at risk. Item-by-item comparison of scores can be used to monitor an infant as they progress through high risk situations.
Weaknesses:
A major weakness of the NBAS is that there are no normative values and no evidence of reliability or validity of this scale. It is also expensive to obtain the training that allows for more reliably in administration of the NBAS.
Clinical Applications
In the clinic, the NBAS can be used to enhance patient/family centered care by including the caregivers and helping them to learn about their baby’s behavior. This can be a way to objectively depict baby’s behavior and express concerns to the parents as well as discuss the concerns of the parents. This is also a good way to track changes in an infant’s behavior, which may allow for an objective way to determine if further intervention or a referral may be appropriate.
Article Review:
The purpose of this study was to describe the relationship between neonatal behavior and prenatal phthalate exposure; specifically related to gender of the infant. The study population included 404 mother-infant pairs whom the mother sought prenatal care at the “Mount Sinai prenatal clinic and two private practices with singleton pregnancies, and who delivered at Mount Sinai Hospital between May 1998 and July 2001”. A questionnaire including medical history, socioeconomic status, and lifestyle factors was given to the mothers during their third trimester and at 25 and 40 weeks gestation, a urine sample was collected to obtain phthalate levels. Before hospital discharge following delivery, a Brazelton Neonatal Behavioral Assessment Scale was administered by a Brazelton Institute trained examiner (n=311). Results sis not find any significant results; however, they did find strong trends between maternal phthalate concentrations in the third trimester and neonatal behavior. For boys, there was a slight positive relationship between motor performance and low molecular weight phthalates (found in personal care products which are scented). For girls, there was a strong, inverse relationship between orientation (0.37 point decline) and increased high molecular weight phthalate concentrations as well as quality of (0.48 point decline) and increased high molecular weight phthalate concentrations (found in plastics). The article concluded that further research is needed on the effects of phthalates and neurodevelopment as well as childhood behavior and cognitive development. Although there were no race differences in phthalate effect, there did seem to be a gender related component to how phthalates effected the infants.
I found a strength of this article to be the large sample size in which data was collected from. Also, although there were not significant findings, the article explained the findings of each “package” of the Brazelton Neonatal Behavioral Assessment Scale (NBAS). A limitation of this article to be that there was only one Brazelton NBAS completed on each infant. I would have liked to get a broader picture of how the infant developed in the first few months of life or at least multiple assessments for validity of results. I also this a weakness of this article is the lack of normative data available to compare results of the Brazelton NBAS to. Normative values would have added value to the variations in performance noted.
Reference:
Engel SM, Zhu C, Berkowitz GS, et al. Prenatal phthalate exposure and performance on the Neonatal Behavioral Assessment Scale in a multiethnic birth cohort. Neurotoxicology. 2009;30(4):522-8.
One response to “Neonatal Behavioral Assessment Scale”
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With no normative value, no reliability and no validity I would have a heard time selecting this test. I do however, appreciate that the use of it in combination with another assessment tool to give predictive values. The course and certification cost as well as the lack of normative data, reliability, and validity decreases its appeal significantly.