Introducing the Neonatal Behavioral

Assessment Scale (NBAS) and NBO

- therapeutic interventions to help understand babies
and support parents

Joanna Hawthorne, Ph.D.

Psychologist
Director, Brazelton Centre in Great Britain
and Associate, Centre for Family Research,
University of Cambridge
Betty Hutchon
Consultant Neurodevelopmental Therapist
University College London Hospital
Lecturer Institute of Child Health UCL
Trainer and Co-Founder Brazelton Centre in Great Britain
 Historical background
• In 1950’s the newborn baby was thought of as a
‘blank slate’ – a reflexive organism
• Three decades of research have shown that
from birth, babies have many capabilities:
• The competent infant – uses all 5 senses
• The organized infant – system of behaviours
• The social infant - the infant as actively engaged
in transforming her own environment from the
beginning
• The individual infant - has own unique set of
dispositions and sensibilities
 What are newborns doing?
• Imitation and understanding other’s minds
(Meltzoff)
• Making meaning of the world (Trevarthen)
• Learning from relationships about emotional
states – their own and others
• Learning about familiar people around them
• Learning to self-regulate
 Newborn brain development
• Very rapid development; babies learn
fast.
• Early experiences affect the
development and structure of the brain.
• The actual development of brain
function is influenced by the
environment and interactions
 The Competent Newborn
• Competent in all five modalities (taste, smell, touch, hear, see)
• Can visually track (Dannemiller and Friedland, 1991; LaPlante et al.
1996, Meltzoff and Moore, 1999)
• Can hear and locate sounds (Muir and Field, 1979; Moon and Fifer,
2000)
• Can habituate (Hood et al, 1996; Slater et al. 1984)
• Can recognize mother’s voice and smell (deCasper and Spence,
1991; Schaal, 1998; Spence and Freeman, 1996)
• Can discriminate mother’s face from stranger (Pascalis et al. 1995)
• Can recognize emotional expressions (Field, 1984)
• Look significantly more at a face with direct gaze than at a face with
averted gaze (Faroni et al (2001).

Nugent, 2006
 www.brazelton-institute.com

The “discovery of the newborn:”

The newborn can see!
• In 1963, Robert
Fantz
demonstrated
that newborn
infants could not
only see but also
have clear-cut
visual
preferences
 www.brazelton-institute.com

1963 – Michael Wertheimer:

Infants can hear at 10 minutes after
birth
• Wertheimer
showed that
newborns could
orient towards a
sound as early as
10 minutes of age.
• We have learned
more about the
other senses, too –
smell, touch, taste
etc..
Social sensitivity of infant brain

Critical windows

Visual cortex (complete by 2 yrs)

Auditory map (complete by 1 yr)
Language acquisition (by 6 yrs)

Emotional brain (by 18 mos)

Fonagy, 1998

Zeedyk, 2007
• The first ‘higher’ brain capacities to
develop are social and they develop in
response to social experience.
• Rather then holding up flashcards to a
baby it would be more appropriate to his
stage of development to hold him and
enjoy him.
 Social sensitivity of infant brain
Trauma
• Infant brain acutely affected by trauma
Stress & trauma for an infant:
– Not getting a response from others
– Not being able to predict response
– Lengthy wait to be fed, changed
– Lack of stimuli (boredom)
– Too much stimulation (overwhelmed)

“Children’s brains reflect the world they live in:

if their world is one of trauma, fear & chaos,
then that’s the environment their brain develops to cope with”

Zeedyk, 2007
• Babyhood can be extremely stressful
without the support of tender, protective
parenting
• It is not necessarily the nature of the
stress that matters but the availability of
others to help manage it, as well as the
inner resources of the person experiencing
it.
• Early care actually shapes the developing
nervous system and determines how
stress is interpreted and responded to in
the future.
• Stress in infancy – such as consistently
being ignored when you cry – is
particularly hazardous in the early months
of life because of high levels of cortisol.
• Human babies are born with the
expectation of having stress managed.
• Positive support for parents may help to
reduce some of the defensive behaviour
that harms their children and continues
vicious cycles of insecurity and inability to
regulate feelings well down the
generations.
• Work done with Romanian orphans has
shown that those who were cut off from
close bonds with an adult by being left in
their cots all day, unable to make
relationships, had a virtual black hole
where their orbitofrontal cortex should be.
(Chugani et al. 2001)
• Good timing is a critical aspect of
parenting
• A poorly handled baby develops a more
reactive stress response and different
biochemical patterns from a well handled
baby.
• Children who are emotionally secure and
well regulated rarely become the antisocial
individuals of the future.
• The key feature of insecure attachment is
a lack of confidence in others’ emotional
availability and support.
• A well resourced and well-regulated infant
becomes a child and adult who can
regulate himself well, whilst a poorly
resourced infant becomes a child who
cannot regulate himself well.
• When parents respond to their baby’s
signals, they are participating in many
important biological processes.
• They are helping the baby’s nervous
systems to mature in such a way as that it
doesn’t get overstressed
• They are helping the bioamine pathways
to be set at a moderate level
• They are contributing to a robust immune
system
• They are helping to build up the prefrontal
cortex and the child’s capacity to hold
information in mind
• To reflect on feelings
• To restrain impulses
• To behave socially in the future!
 Keys to shaping an emotionally
healthy infant brain (0-2 years)
Attunement: match between two people’s
emotional states
Empathy: sensitivity to other people’s
emotional states
Sensitive parenting helps baby to regulate
emotions
Zeedyk, 2007
 The social skills
• Entice adults to pay attention to them by crying; then
responds to soothing

• Engage in mutual gazing

• Respond to social interactions in turn; intiates

interaction

• Show dislikes: turning away, yawning, sneezing, hand

movements. Shows likes: bright, focused look, smiling

• Ability to self-soothe: suck on fingers/hand, look, listen

• Smiles actually help the brain to grow.
• Schore suggests that it is positive looks
which are the most vital stimulus to the
growth of the social, emotionally intelligent
brain
 Questions parents ask:
• Can my baby see?
• What can she see?
• Does my baby recognise my voice?
• What kind of stimulation do babies need?
• How do I know when she is hungry?
• How much will she sleep?
• Is there something wrong if my baby cries a lot?
• What can I expect over the next few weeks?
At birth: a critical period in the
parent-child relationship
• The social infant - in a heightened state of
readiness to interact with his/her caregiver
• Interaction leads to growth of attachment
• Reading the baby’s communication cues
• Using the NBAS to sensitise parents to these
communication cues and thus promote the
bond between parent and infant

JK Nugent, 2006
 What do babies need?
1)An observer who sees their strengths and
helps them with their difficulties
2)Warm, responsive interactions with their
caretakers - taking turns
3) Vocalisations reinforced by response,
initially imitation
4) Structure and routine, with flexibility
(Adapted from Brazelton and Cramer, 1991)
 What do babies need? (cont.)
5) Interesting things to look at and do
6) Establishment of a dialogue with their
caretaker who understands variabilities in
development and the process
7) Play, autonomy and flexibility in their
interactions leading to attachment
8) A parent confident in understanding the
behaviour of their baby
(Adapted from Brazelton and Cramer, 1991)
 Mothering tasks

• To keep her baby alive and protect her baby

• Primary-relatedness: Can she love her baby
and baby love her?
• Needs support from others to validate her
relationship with the baby
• Identity reorganisation

(from Daniel Stern, The Motherhood Constellation, 1995)

 Father’s role
•Support mother
•Provide link between mother and staff
•Get to know baby
•Interventions involving fathers ‘appear
to be significantly more effective’ than
interventions focusing on mothers only.
Bakermans-Kraneburg MJ, Van Ijzendoorn MH & Juffer F
(2003)

•NBAS with fathers at birth improves

caretaking contact at one month old
 Fathers
• Research shows that fathers are more
likely to leave the family within the baby’s
first year than at any other time
• NBAS intervention encourages
involvement of the father
• Supportive work with couples helps them
stay together

Brazelton Centre
 Helping parents read, interpret
and respond to behaviour
• Parent’s ability to read and respond appropriately
to their infant’s needs is the most important
component of parental interactive competence

• Sensitive and contingent maternal interactions

between parents and their infants have been
related to better social and cognitive competence
and the formation of secure attachment in infants.

• But, what are the obstacles?

 The Special case of Preterm
and LBW infants
• Some babies are more difficult to read
• Preterm and low birthweight infants tend to
be less responsive, are more fretful, smile
less and give less readable communication
signals than full-terms infants (e.g. Melnyk et
al. 2002, Spiker et al.,1993).
• Parents of at-risk infants experience even
more stress in meeting the infant's daily
needs and are at greater risk for postpartum
depression
 Background of NBAS
Developed by Dr T Berry Brazelton (1973)
•interactive and systematic way of observing infant
behaviour
Model used
•positive model of child development and parenting, not
deficit model of paediatrics and child psychiatry
Features of NBAS – observes:
•infant’s contribution to the parent-infant system, infant’s
competencies and difficulties, individual differences
The newborn period- a new view of the newborn baby
the contribution of T. Berry Brazelton (Nugent, 2006)

• The competent infant

• The organized infant
• The social infant -
the infant as actively
engaged in
transforming her
own environment
from the beginning
• The infant as an
individual with her
own unique set of
dispositions and
sensibilities
JK Nugent, 2006
 Neonatal Behavioural
Assessment Scale (1973)
• Systematic observation and neurobehavioural
interactive assessment producing a profile of
infant behaviour (birth - 2 months old)
• shows infant’s reactions to stimulation, reflexes
and social interaction
• habituation, state-regulation, self-quieting
 Uses of Brazelton Scale
• Pre-term babies (over 35 weeks ga,
medically stable)
• Down’s syndrome, congenital
malformations, birth trauma, HIE, IUGR
• Maternal anxiety, fear, previous babies
with problems
• Postnatally depressed mothers
• Teen mothers
Key concepts of the NBAS
•Interactive
•Not pass/fail
•To bring out the baby’s “best
performance” – show the baby’s
strengths
•Collaborate with parents
Newborn Developmental Agenda

Social Interactive System

State System

Motor System

Autonomic
System
 Habituation items
Sleep (1,2,3)

Alert (4) Awake

Social-Interactive
What is
baby’s
(3,4,5) Reflexes and
Items
State?
Motor Items

Crying (6)

Consoling Manoeuvres
 NBAS is a useful tool to look at
issues around:
• Sleeping – provides information about the
baby’s ability to cope with disturbances during
sleep, and get themselves back to sleep
• Crying – provides information about the baby’s
ability to comfort themselves
• Feeding – provides information about the baby’s
sucking ability and ability to stay in an alert state
for feeding.
Self-regulation and facilitation

• Recognise infant’s efforts at self-

regulation
• Offer examiner-facilitation based on
infant’s own efforts at self-regulation

(Blanchard, 2003)
 Behavioural States
(Brazelton and Nugent, 1995)

Deep sleep (State 1) Alert (State 4)

Light sleep (State 2) Alert and active (State 5)

Drowsy (State 3) Crying (State 6)

STATE REGULATION

- transitions between states

- robust states
- full range of states

part of self regulatory mechanism

 Stress/time out signals
• Looking away, shutting eyes, spitting up,
hiccuping, yawning, sneezing, holding
hands up defensively, finger splaying,
clenching fists, arching back, squirming,
staring with no facial expression, frown,
grimace, skin colour changes, sucking,
changing position, changing state
Recognizing signs of stress
Shutdown
• Inappropriate
stimulation
causes a baby to
go back to sleep
or at least
disengage

Nugent, 2006
How do I feel?
 Reflexes and Motor Items

• Used to stimulate a sleepy baby

• Parents see these as skills
• Shows how strong the baby is
• Screening tool for major problems
• Can help to organise the baby
 Habituation
• Watch how disturbing stimulation affects
the baby’s sleep states
• Use light, rattle, bell, foot probe
• Can baby settle after he/she is disturbed?
• Strategies he/she uses to settle back to
sleep
 Crying
• When baby cries, stand back for a few
seconds to watch if he/she uses any
strategies to help calm – e.g.
Hand to mouth, hands together across
chest, sucking, changing position, looking
at something.
• If baby needs help to calm, proceed with
consoling manoeuvres
 Consoling manouevres
• Look at baby
• Look at and talk to baby
• Look at, talk and put hand on belly
• Look at, talk, hold arms across chest
• Look at, talk, pick up and hold calmly
• Look at, talk, hold and rock calmly
• Look at, talk, swaddle with hands to mouth, rock calmly
• Look at, talk, swaddle, rock calmly, give finger to suck or
pacifier

Brazelton and Nugent, 1995

• Babies temperament differ – some are
more demanding.
• Less reactive and
• Highly reactive baby (15%) – more
sensitive sensory system, cries more,
more timid and fearful, easily
overwhelmed by stimuli.
• Need more than average amount of
calming and soothing
CASE STUDY
• DOB 20.04.
• 30 Gestation (EDD 20.06.)
• Birth Weight 1.106kg
• Apgar: 6 at 1 minutes, 8 at 5 minutes
• Intubated and ventilated
• Chronic lung disease
• GOR
• Behavioural and feeding problems
• Failure to thrive
• Very Irritable
• Cried frequently for long periods and difficult to
console
• Slept poorly and mostly light sleep and for short
periods of time
• Problems sustaining relaxed tone and posture
• Difficult to feed
• Parents distressed by her behaviour
• Medical and nursing staff pessimistic about
outcome
• 26.06. Day 67
• Still irritable – Bottle and tube feeding
• 07.07.
• Very irritable and unsettled
• 10.07. Day 81
• ? Feeding slowly improving
• Still very irritable and unsettled
• 16.07.
Irritable poor feeding
Increasingly irritable and difficult to
manage with persistent crying
• 17.07.
Assessed by OT using Brazelton
Neonatal Behavioural Assessment Scale
Aged 43 weeks
Results of assessment presented a profile of
• A sensitive and poorly organized infant.
• Reacted to every presentation of habituation
items.
• Squirming
• Fidgeting
• Increased respiratory effort
• Waking and crying
• Little or no self- regulatory behaviours
Interpretation of Results of NBAS -
Hypersensitive to
• Noise
• Light (unable to block out or habituate to this
type of stimuli)
• This affected her ability to get into deep sleep
• This in turn made her very irritable
• Once upset unable to calm herself due to lack of
self-regulatory behaviours
Main goals for Aysha as results of NBAS
were:
• Constant reading of behavioural cues
• Support efforts to self-regulate
• Modulation of the environment
• Reduction of stimulation
• Help parents and staff understand the
reasons for her over-reactive behaviours
• Slower, gentler handling
• Swaddling
• Undisturbed sleep
• Protection from light and noise
• Move to side room/quiet
• Dimmed lighting
• No talking near her cot
• Happier, calmer baby
• Less irritable
• Slept better
• Fed better
• Parents and staff much happier too
• People began to respond to Aysha
differently and more positive interactions
20.07.
• Doing well, taking bottles
• Much more settled, gaining weight
21.07.
• Well, gaining weight
• Seems much less irritable
25.07.
• Bottle feeding, gaining weight, less irritable
28.07.
• Stable
• Responsive – fixed and follows
• Smiled today
• Gained 100g
05.08.
• Handles well
• Feeding well
• No problems
• Self-regulatory skills have important
implications for how well children negotiate
many other tasks of early childhood.
• Identifying and intervening with children
who need extra help in developing these
skills is important.
• This can be a promising entry point for
early interventions aimed at getting new
parents and infants off to a good start.
What do we know about the baby
after the NBAS?
• The NBAS tells us how the baby manages the tasks and
handling
• Is the baby easily overstimulated?
• Does the baby have any self-soothing strategies?
• Does the baby manage to protect his sleep?
• How does the baby manage state changes?
• How does the baby manage crying?
• Is the baby available for social interaction?

Hawthorne, 2008
 NBAS used as a supportive intervention (3
times in first month)
• shows parents amazing abilities of their infant
• validates parent’s observations + share
concerns
• provides therapeutic alliance with professional
• demonstrates infant’s stress signals and abilities
to self-quiet
• provides observation of parent-infant interaction
• helps parents come to terms with baby they
have
 Studies using Brazelton Scale -
(over 700)
• Mothers felt more confident and were more
responsive
• mothers spent more time playing and talking
with their infants
• fathers more involved in their baby’s care at
one month
• premature babies had higher cognitive scores
• low-birthweight babies had higher
developmental scores at 4 years
 Training in the NBAS
•Pre- and post-training questionnaire
•2 day course with Trainers
•Self-training phase: practice on 20-25
babies
•Refresher day (optional)
•Certification day – assess one or two
babies to achieve a 90% reliability
•NBAS certificate (renewed every 3 years
for those in research)
 Brazelton Institute
www.brazelton-institute.com

Introduction to NBO
(Newborn Behavior Observation)
Betty Hutchon, Consultant Occupational Therapist
Royal Free and University College Hospital London

Constance H. Keefer, M.D

Boston Children’s Hospital
 What is the NBO*?
A structured,
neurobehavioral,
relationship-based,
Observation System of
Newborn Behavior for parents

*Understanding Newborn Behavior & Early

Relationships: The Newborn Behavioral
Observations (NBO) System Handbook
(2007). Nugent JK, Keefer CH, Minear S,
Johnson LC, Blanchard Y. Baltimore: Paul H
Brookes Publishing Co.
The NBO: Infant-
focused and
family-centered
… is a relationship-
based, structured,
neurobehavioral
observation which
enables infant
specialists and family
workers to describe
and interpret newborn
Aisha at one month home visit (video)
behavior for parents
•NBO is based on
30 years of
research and
clinical work with
newborns

•Shifts the focus

from assessment to
relationship-
building

•Can be easily
integrated into
everyday clinical
practice
Brazelton Institute
www.brazelton-institute.com

Whence came the NBO?

 The newborn:
The contribution of T Berry Brazelton - the NBAS

• The competent infant

• The organized infant
• The social infant
• The infant as an
individual with her
own unique set of
dispositions and
sensibilities
 Could the NBO be an effective
therapeutic tool
Q. Could we retain the
conceptual richness of
the NBAS and develop a
flexible interactive tool
for use in clinical settings
that was still effective as
a form of intervention
with parents?
 NBO – infant-focused and family-centered

• The NBO gives the

infant a voice – the
infant’s story
(answers the “who am I”
question?)
• The NBO session
gives parents a
voice – the family
story
(“who we are and what our
hopes and expectations are”)
 The Goal of the NBO:
• to sensitize parents to their infant’s
capabilities and individuality
• to strengthen the relationship between
the parents and their infant and
• to promote a positive relationship
between clinician and family

Brazelton Institute
 NBO Observations Item Summary
• Habituation to light and • Visual and auditory
sound Responsiveness: face
and voice, the red ball,
• Muscle tone in legs and
the rattle
arms and activity levels
• Crying and
• Reflexes: rooting, sucking, Consolability
hand grasp, pull to sit and • Self-regulation
crawling
Effects of the NBO:
• Promoted more positive interactions of pediatric residents with
parents (McQuiston et al., 2006).

• Helped nurses promote positive parent-infant interactions (Sanders

and Buckner, 2006).

• Reduced by 80% mothers’ reports of depressive symptomatology

(Nugent et al., 2007).

• Promoted positive parent-infant relationship in parents of infants

with hearing loss (Hartblay, 2010).

• Contributed to parent’s ability to read and respond appropriately to

their infant’s needs and positively influenced parental interactive
competence and professional confidence (McManus and Nugent,
2012).
Brazelton Institute
 Pre-training questionnaire (UK)
• Motivation – increase knowledge, skills, better future
outcomes and benefits for parents and babies, mandatory
in their NHS Trust

‘Greater understanding, supporting parents in recognising

cues and states of behaviour.

To empower parents to understand what their baby is saying

to them.’.

Brazelton Institute
 Practitioners least likely to discuss with
parents

• Habituation,
• visual tracking,
• response to stress and
• hand-grasp.

Brazelton Institute
 Post-training questionnaires (UK)
• Statistically significant increase in practitioners
confidence level in discussing infant behaviours
with parents
• Specifically – those who scored low on pre-t
questionnaires showed a bigger increase in levels
of confidence post training. An independent
samples t-test found that the change in
confidence was significantly greater for those who
had initially reported low levels of recognition

Brazelton Institute
Potential change in practice:
Improvement in communication with parents:

Going at their pace - letting them set it at the start.

Change my language, prepare before sessions.
Hope to be able to communicate calm and confidence in the midst of crying baby
and to be able to relate information about "states".
Tailoring advice depending on observations. More confidence with high risk
babies.

Focus on baby’s strengths and positivity

Increase parents’ knowledge and involvement with baby

Brazelton Institute
Objectives for NBO Training
1. Learn how to identify, describe and interpret newborn
behavior in the context of the NBO

2. Learn how to administer the NBO

3. Develop a deeper understanding of the importance of

relationship-based care in working with parents

4. Learn how to implement the NBO in a way that is

developmentally sound and culturally appropriate.

Brazelton Institute
NBO Training

Brazelton Institute
Brazelton Institute
www.brazelton-institute.com

NBO Training sites:

www.brazelton.co.uk
www.brazelton-institute.com
Norway
Australia
 Families in neonatal units

• Parents – grief response at loss of baby they

expected and loss of their pregnancy, lack
confidence, anxiety, stress, much-wanted baby,
unexpected event, loss of control

• Babies – behaviourally challenging, look

different, uncertain outcome

Hawthorne, 2008
 Follow-up of babies in a neonatal unit using
the NBAS (22 babies) (Hawthorne, 2002)
• First visit – introduction, listening to
parent’s concerns
• Second and other visits – discussion of
baby behaviour, signals and cues;
observations
• First NBAS
• Second and third NBAS
• Teaching of staff
Brazelton concepts - 10 points

When watching the baby with the parents, ask them:

What is your baby like – his/her personality?
What does your baby like to do/look at?
How does your baby react to noise and light?
How does your baby react to handling?
What position does your baby like to be in?
How does your baby manage his/her sleep and awake states?
How does your baby comfort him- or herself?
Is your baby cuddly?
Is your baby strong?
How does your baby show you he/she knows you?
Hawthorne, 2002
Brazelton concepts - 10 points

When watching the baby with the parents, ask them:

What is your baby like – his/her personality?
What does your baby like to do/look at?
How does your baby react to noise and light?
How does your baby react to handling?
What position does your baby like to be in?
How does your baby manage his/her sleep and awake states?
How does your baby comfort him- or herself?
Is your baby cuddly?
Is your baby strong?
How does your baby show you he/she knows you?
Hawthorne, 2002
Parent’s comments

“Bonding is difficult in the NICU. Baby does not feel like

your own. The assessment helps to affirm you do know
your baby.”
“Gave us the ability to see him as a “normal” developing
baby and not seem like a medical patient.”
“Sessions helped us relax and enjoy time spent with him
rather than anticipating the worst.”
“Seeing someone respond to her and play with her as if
she was a normal baby.”

Hawthorne, 2002
Parents’ comments (cont.)

“Hadn’t previously realised how much it was possible to

interact with her and therefore played with her much more
following sessions.”
“Amazing to me to see someone being positive about my
baby who was so sick.”
“Before and after the Assessment, I spent almost everyday
with her. Afterwards, I just knew for certain that our
guesses about her behaviour were true.”
Hawthorne, 2002
 Recent developments in the UK
•Department of Health named NBAS named as important intervention
in the newborn period (Child Health Promotion Programme - CHPP,
2008), renamed Healthy Child Programme, 2009
•One Plus One project – Brief Encounters and NBAS training
combined in order to develop innovative training programme for
practitioners to help them support relationships between new parents
and between parents and their infant. (Funded by the Department for Children,
Schools and Families through the Children and Young People’s Fund).
•Project in Wales – Getting to know you: A community project to help
mothers with their newborn babies (Funded by Laura Ashley Foundation)
•Newborn Behavioural Observations Systems Training (NBO)
introduced to UK, 2009
 Summary
• Babies are extraordinary communicators
• We can support parents in understanding
their baby’s language
• Supporting parents very early in the
postnatal period leads to better outcomes
• The NBAS and the NBO are excellent
tools for understanding babies and
supporting parents
 Relationship-based intervention
• There is a growing body of scientific literature,
demonstrating the positive preventative effects of
relationship-based interventions for infants and
their families

• Most successful interventions, whether they are primarily

preventive or therapeutic, are based on facilitating that
relationship and helping both the child and the caregiver
learn to adapt successfully to each other’s individuality

(Als et al. 2004; Meisels and Shonkoff, 1990; Nugent and Brazelton, 2000; Shonkoff
and Phillips, 2000)
JK Nugent, 2006
Helping parents read, interpret and respond
to behavior
• Research shows that parent’s ability to read and respond
appropriately to their infant’s needs is the most important
component of parental interactive competence (Brazelton et
al. 1974; Tronick and Weinberg, 1997).

• There is evidence to show that sensitive and contingent

maternal interactions between mothers and their infants
have been related to better social and cognitive
competence and the formation of secure attachment in
infants (Barnard and Bee, 1984; Egeland and Farber, 1984; Greenberg et al.
1988; Grossmann and Grossmann, 1991;Mertesacker et al. 2004; Pederson et al,
1990; Van den Boom, 1994)

JK Nugent, 2006
 Useful websites
• www.brazelton.co.uk
• www.touchpoints.org
• www.brazelton-institute.com
• www.oneplusone.org.uk
• www.zerotothree.org
• www.talktoyourbaby.org.uk
• www.socialbaby.com