The Newborn as a Person
Enabling Healthy Infant Development Worldwide
By J. Kevin Nugent
John Wiley & Sons
Copyright © 2009
J. Kevin Nugent
All right reserved.
ISBN: 978-0-470-38645-3
Chapter One
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. 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.
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. In the previous year,
Murphy and Smyth had demonstrated that infants respond to
auditory stimuli even before birth.
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. 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. 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. 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.
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. This research was followed by a study by
Freedman and Freedman that provided evidence for clear-cut differences
between Caucasian and Chinese neonates. 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."
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). 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.
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, 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. 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. 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), 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.
Ida Cardone and Linda Gilkerson used the concepts of the NBAS
to develop the Family Administered Neonatal Activities (FANA).
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.
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 the newborn period.
She defines these crucial interactions as micromoments of change
in the mother-infant relationship, moments when the relationship
is transformed and moves to a higher level. She goes on to describe
how she promotes these moments of meeting between parent and
infant and how the infant can become an "interlocutor" in this
process. In a series of clinical reflections taken from her practice,
Dr. Bruschweiler-Stern demonstrates how this approach can be
used with a wide range of families and how fathers can be engaged
in these relationship-building encounters.
(Continues...)
Excerpted from The Newborn as a Person
by J. Kevin Nugent
Copyright © 2009 by J. Kevin Nugent.
Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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