The Newborn as a Person

Enabling Healthy Infant Development Worldwide

J. Kevin Nugent, Bonnie Petrauskas, T. Berry Brazelton

• Publisher: Wiley
• Year: 2008
• ISBN:
  9780470482773
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Advances in the fields of psychology and psychiatry have bolstered the perspective that infants are not the passive recipients of sensory stimulation as it was once thought. Built on T. Berry Brazelton s paradigm-shifting work on the individuality of infants, this book provides relevant information on the necessity for family-centered intervention in the newborn period. Coverage is wide-ranging, authoritative, and practical. This landmark collection includes contributions from T. Berry Brazelton, Tiffany Field, Rachel Keen, and many others. Pediatric professionals will receive practical guidance to support families, immediately beginning in the newborn period.

PART I

LOOKING BACK

CHAPTER 1

The Discovery of the Human Newborn: A Brief History

J. KEVIN NUGENT

It is perhaps difficult for the twenty-first century researcher or clinician to imagine how much our understanding and appreciation of the human newborn has changed since the time the Neonatal Behavioral Assessment Scale (NBAS) was first published in 1973. The dominant view for much of the earlier part of the twentieth century, as Berry Brazelton and many authors in this volume point out, was that infants were generally passive recipients of sensory stimulation, responding to environmental input with innate reflexes. There was scant evidence that learning could be demonstrated in the first few weeks or even months of life. Newborn assessment tools reflected these assumptions, so that the earlier neonatal scales, which emerged from the field of neurology, focused on the assessment of the so-called primitive reflexes and postural reactions.¹, ², ³ Because it was assumed that the newborn infant was indeed a “blank slate,” a reflex organism operating at a brain-stem level, the classic tests of intelligence, such as the Gesell Developmental Schedule, the Cattell Infant Intelligence Scale, and the Griffiths Mental Development Scale, for example, did not include any items designed to assess newborn behavior.

However, a number of advances, especially in the fields of psychology and psychiatry, contributed to a major shift in thinking about newborn behavior and development and, indeed, to the notion that the newborn period might be a critical time in the development of the parent-infant relationship. In the early 1960s, it was assumed that the newborn could see only shadows at birth. And then, Robert Fantz demonstrated that the newborn infant could not only see but also had clear-cut visual preferences.⁴ In terms of auditory capacities, the prevailing assumption among both researchers and clinicians was that newborns’ fluid-filled ears impaired their hearing for the first few days. However, in 1963 a report appeared in Science showing that newborns could orient toward a sound as early as 8 hours after birth.⁵ In the previous year, Murphy and Smyth had demonstrated that infants respond to auditory stimuli even before birth.⁶

The notion that the baby could see, hear, and respond differentially to positive and negative stimuli inspired a new body of scientific research on newborn behavior and development. While innovative thinkers from the emerging field of infant mental health, such as John Bowlby, Donald Winnicott, and Selma Fraiberg, studied the mother’s role in the development of early parent-infant relations, a new generation of researchers, among them Jerome Bruner, Peter Wolff, Jerome Kagan, Robert Emde, Kathryn E. Bernard, and Arnold Sameroff, stimulated by the work of Jean Piaget, began to study learning in infancy in an effort to determine how early and under what conditions infants could learn. In the 1960s and 1970s, a new body of research on newborn capabilities emerged, which provided a rich empirical database for subsequent conceptualizations of newborn and infant development. Researchers such as Lewis Lipsitt, William Kessen, T. G. R. Bower, and Rachel Keen developed innovative research methods to demonstrate that newborns could, indeed, learn from the very beginning. This new body of data, which provided evidence that the newborn infant was competent and complex, contributed significantly to the development of the NBAS. However, it was Berry Brazelton’s clinical experience with parents and his work at the Children’s Hospital in Boston that led to a pivotal concept in the thinking about how to assess newborn and infant development—the concept of individual differences. As Brazelton himself explains it, the challenge he faced was how to describe, identify, and ultimately code these differences in a reliable manner. He had provided evidence for differences in crying patterns in his own research and later presented his ideas on individual differences to a wider audience in his groundbreaking book, Infants and Mothers: Individual Differences in Development.⁷, ⁸ In the preface to that book, Jerome Bruner wrote, “What delights me most is Dr. Brazelton’s unflagging sense of human individuality.” It was Brazelton’s recognition that infants were unique, with their own individual styles of responding, that prompted him to begin the quest for a scale that, on one hand, could do justice to the newborn’s capabilities and, on the other hand, could describe the full range of individual differences in newborn behavior.

At around the same time, Peter Wolff’s seminal work on “newborn behavioral states” led to a greater appreciation of the human newborn as a responsive organism, capable of organized behavior.⁹ Indeed, the idea of “state” was acknowledged as a critical matrix on which to assess all reactions, sensory as well as motor, in the newborn.³, ¹⁰ The first behaviorally based scales for the assessment of the newborn appeared at this time. The Graham Scale and the Graham-Rosenblith Scale were the first to attempt to outline behavioral differences among neonates as they responded to different stimuli.¹¹, ¹²

Shortly after this research was published, the first iteration of the NBAS appeared—the Cambridge Scales—which Brazelton developed along with psychologist Daniel Freedman from the University of Chicago and which he now used to test out the applicability of the concept of individual differences in different settings. Intrigued by the question of how children achieve competence, Brazelton and his colleague, John Robey, went to southern Mexico, where they used the new scale with the Zinacanteco Indians, in the highlands of Chiapas. There Brazelton’s ideas on neonatal differences were confirmed. The two colleagues discovered that compared to their Caucasian counterparts, these infants could “pay attention to auditory and visual signals for 30 minutes without a break,” and their motor behavior was characterized by smooth fluid movements.¹³ This research was followed by a study by Freedman and Freedman that provided evidence for clear-cut differences between Caucasian and Chinese neonates.¹⁴ Working with Jerome Bruner at the Center for Cognitive Studies at Harvard University and with Mary Louise Scholl from the Department of Neurology at Massachusetts General Hospital, Brazelton began to integrate developmental theory and neurological principles into his clinical understanding of newborn behavior and development. Finally, in 1973, the first edition of the NBAS was published by Spastics International Medical Publications. In the preface of that monograph, Ronald MacKeith and Martin Bax were perceptive when they wrote that they were “happy to predict that people will be using and working with the NBAS for many years to come.”¹⁰

Since then, the NBAS has become the gold standard of newborn assessments. It has been used in many studies to examine the effects of a wide range of pre- and perinatal variables on newborn behavior. By the time I joined Brazelton and coauthored the NBAS, numerous studies had demonstrated that the scale was sensitive to variables, such as the effects of intrauterine growth restriction; the prenatal ingestion of cocaine, alcohol, caffeine, and tobacco; the exposure to environmental polychlorinated biphenyls (PCBs); the effects of different modes of delivery; or the effects of prematurity. The NBAS also stimulated the development of a number of assessment scales for use with different populations and in different settings, a testament to its theoretical richness and its generativity. Heidelise Als, Barry Lester, Berry Brazelton, and Ed Tronick, for example, used the concepts of the NBAS to develop the Assessment of Preterm Infants’ Behavior (APIB).¹⁵ Barry Lester and Ed Tronick also used the NBAS as the basis for the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS), which was designed for the neurobehavioral assessment of drug-exposed and other high-risk infants, especially preterm infants.¹⁶

While the NBAS has been used in hundreds of research studies as an outcome measure and continues to be used as a means of assessing pre- and perinatal influences on newborn behavior, we began to realize, in the 1980s, that the NBAS was a powerful teaching tool and could be used as a form of intervention. A series of studies, summarized by Nugent and Brazelton,¹⁷, ¹⁸, ¹⁹ showed that demonstrating the newborn infant’s behavioral capacities to parents can serve as a mechanism for helping parents learn about their new infant, thereby strengthening the relationship between parent and child and supporting family adjustment. Specifically, a number of studies consistently have reported positive effects of exposure to the NBAS on variables such as maternal confidence and self-esteem, paternal attitudes toward and involvement in caregiving, parent-infant interaction, and developmental outcome.

Just as the NBAS was adapted to assess different at-risk populations, as in the case of the APIB and the NNNS, it has also been adapted or modified to render it more effective as a teaching tool for parents. A number of approaches based on the NBAS were developed for use in clinical environments as a form of parent education or intervention. The first of these modifications was by Tiffany Field and her colleagues who developed the Mother’s Assessment of the Behavior of the Infant.²⁰ The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) training process, developed by Heidelise Als, has profoundly changed the way in which neonatal intensive care unit (NICU) staff, particularly nurses, are trained in the observation and care of the premature infant.²¹ By incorporating behavioral items and concepts from the NBAS into the routine physical pediatric examination, Constance Keefer developed the Combined Physical Exam and Behavioral Exam (PEBE),²² while João Carlos Gomes-Pedro and his colleagues, in their efforts to sensitize parents to the behavior of their newborns, effectively tested a shortened version of the NBAS for use as the newborn pediatric discharge examination.²³ Ida Cardone and Linda Gilkerson used the concepts of the NBAS to develop the Family Administered Neonatal Activities (FANA).²⁴ Finally, the recently developed Newborn Behavioral Observations (NBO) system also comes from this tradition and was developed by myself, Constance Keefer, Susan Minear, Lise Johnson, and Yvette Blanchard, as a relationship-building instrument, to sensitize parents to the capacities and individuality of the newborn infant and to foster the relationship between parent and child and between clinician and parent.²⁵

This brief description of the origins of research on newborn and infant development and of the transforming influence of the NBAS on clinical and research endeavors sets the stage for the wide range of reports that appear in this volume.

INTERNATIONAL PERSPECTIVES ON RESEARCH, EARLY INTERVENTION, AND TRAINING

The chapters that follow represent many disciplines from many countries and examine the effects of different perinatal and cultural influences on behavior and the relationship between newborn behavior and later outcome. These studies also attest to the shift in emphasis toward intervention that begins ever earlier in the child’s life. These reports embrace an approach to children and families that eschews the classic deficit-seeking medical model and is committed instead to interventions that are both family-centered and relationship-based.

One of the questions that continues to challenge theorists, researchers, public policymakers, and educational planners is whether there is a relationship between newborn behavior and later development, especially in the case of high-risk infants. Karin Stjernqvist from the University of Lund in Sweden examines the relationship between newborn behavior and later developmental outcomes in her longitudinal study, “Predicting Development for Extremely Low Birthweight Infants” (Chapter 2) In this chapter, she reports a positive correlation between the newborn orientation capacities at term, Developmental Quotient (DQ) at 4 years of age, and IQ at 10 years, despite the fact that in the neonatal period, instability in physical, physiological, and behavioral systems is pronounced, and neonatal assessments are thought to be less predictive.

The sensitivity of the NBAS as an outcome measure has been demonstrated in numerous studies conducted by Tiffany Field and her colleagues at the University of Miami. Field, one of the pioneers in infancy research, in particular, in the role of touch, describes a series of studies in different settings, in which she and her colleagues examined the effects of infant massage on newborn behavior. She reports the effects of a recent meta-analysis of data from 19 of these studies, which revealed that 72% of the massaged infants were positively affected. Most of them experienced greater weight gain and better performance on the NBAS. In addition, she points out that the use of the NBAS seems to be an important demonstration to the parents of how their infants’ behavior can improve following massage therapy. This, in turn, seems to encourage parents to continue massage therapy at home.

At the Universitat Autònoma de Barcelona, Carme Costas-Moragas has established an impressive research tradition by conducting numerous research studies on the effects of a wide range of perinatal factors on developmental outcome. Chapter 4 provides a review of this body of research, describing studies on the effects of acute fetal distress, gestational and pregestational diabetes, cesarean section, intrauterine exposure to lead, neonatal hyperbilirubinemia, low birthweight, and prematurity.

At the invitation of Dr. Tomitaro Akiyama from the Department of Rehabilitative Medicine at the University of Nagasaki, Berry Brazelton and I began a collaborative longitudinal study of Japanese infants in the Goto Islands in 1985. Dr. Akiyama’s research goal was to identify the origins of cerebral palsy as early as possible in a child’s life. In Chapter 5, along with his colleague, Shohei Ohgi, he describes their research on the early assessment of infants at risk for developmental disorders, such as cerebral palsy and mental retardation. In a series of longitudinal studies, Shohei Ohgi and the Nagasaki research group have provided consistent evidence for the capacity of the NBAS to identify neonates who are at high risk for later developmental disabilities, including cerebral palsy.

In Korea, Yeonghee Shin and Byunghi Park designed a study to provide normative data on Korean newborn behavior. In Chapter 6 they describe the cultural context of the transition to parenthood in Korean society and discuss their study of a sample of Korean newborns, explaining what their research reveals about the universals of newborn behavior, and the behavioral characteristics that are specific to the Korean cultural setting.

In her research and clinical practice in Geneva, pediatrician and psychiatrist Nadia Bruschweiler-Stern discusses the significance of what she refers to as “moments of meeting” in promoting mother-infant attachment, beginning in th...

Table of contents

• Title Page
• Copyright Page
• Dedication
• Acknowledgements
• Contributors
• Preface
• PART I - LOOKING BACK
• PART II CONTEMPORARY RESEARCH AND PRACTICE: INTERNATIONAL PERSPECTIVES - ...
• PART II CONTEMPORARY RESEARCH AND PRACTICE: INTERNATIONAL PERSPECTIVES - Early ...
• PART II CONTEMPORARY RESEARCH AND PRACTICE: INTERNATIONAL PERSPECTIVES - New ...
• PART III - LOOKING TOWARD THE FUTURE
• Author Index
• Subject Index