What is the NBO? 

The Newborn Behavioral Observations (NBO) system is a relationship-based tool that offers individualized information to parents about their baby’s communication strategies and overall development, with a view to strengthening the parent-infant relationship. The NBO describes the infant’s capacities in such a way that the parents can begin to see their baby as a person and learn to understand and respond to their baby in a way that meets the baby’s unique developmental needs. It consists of 18 neurobehavioral observations and is designed for use from birth through the third month of life. The development of the NBO was inspired by the work of T. Berry Brazelton and over 40 years of experience working with the Neonatal Behavioral Assessment Scale (NBAS), which he developed, so that it is based on an appreciation of the richness and complexity of the newborn’s behavioral repertoire and the agency of the baby in shaping parent-infant interactions (Brazelton, 1973; Brazelton & Nugent, 1995, 2011; Nugent & Brazelton, 1989, 2000). In the NBO approach, the baby’s behavior is seen as the “port of entry” into the parent-infant system (Stern, 1995).  While the focus of the NBO is frankly on the baby’s behavior and on the baby’s communication cues as a window into the baby’s mental state, the NBO is not an assessment but is designed to enhance parent-infant interaction and promote the parent-infant relationship.  

The NBO is useful in a range of clinical and cultural settings and with families facing diverse challenges. It can easily be integrated into a range of clinical practices and is used in hospital, clinic, or home visit settings by pediatric professionals such as nurses, doctors, psychologists, social workers, midwives, physical and occupational therapists, doulas, communication specialists, child life specialists, lactation specialists, home visitors, and other early intervention professionals.

A strength-based approach

The NBO system was developed as an interactive relationship-building tool to strengthen the relationship between infants and parents beginning in the newborn period , so that the NBO is above all, strength-based and is primarily guided by the princi­ple that the quality of early experiences drives brain development and functional outcomes.   

The first months of life and the AMOR Framework

The newborn period and the first months of life make up a significant stage in the development of the parent–infant relationship and in infants’ behavioral adaptation to their new environment. Because it is a major transition stage in the lives of both infants and their parents, it presents clinicians with a unique opportunity to affect change at what can be called a critical transition stage in the development of the parent–infant relationship and, indeed, in the development of the family itself. It can be used to support parents at a time when the very bases for parental functioning are being established. The theoretical framework of the NBO can be summarized by the acronym AMOR, which may be applied, in turn, to all NBO participants – the infant, the parent, and the practitioner. The Infant AMOR describes the developmental agenda of the baby, while the new parents’ regulatory challenges are addressed by the Parent AMOR. Finally, the practitioner’s own mental states and shared consciousness with both the baby and the parents are also critical to effective implementation of the NBO. The Practitioner AMOR mnemonic attempts to capture these principles.

The Infant AMOR

Over the first few months of life, newborns face a series of hierarchically organized tasks in self-regulation that are in some ways similar to stages. From this developmental perspective, the newborn infant is seen to confront a series of tasks or challenges as they attempt to adapt to their new extrauterine world, both the world of objects and the world of people. These tasks are summarized by the acronym AMOR, for Autonomic, Motor, Organization of State, and Responsiveness.

  • A – Autonomic/physiological stability: involves the stabilization of breathing, temperature regulation, reducing tremors and startles, etc.
  • M – Motor regulation: focuses on development of good motor control and feeding skills; ability to maintain a controlled activity level
  • O – Organization of State: describes the ability to cope with stress; to be able to regulate state and develop predictable sleep-wake patterns
  • R – Responsiveness: captures the development of a growing awareness of the environment and the capacity to process visual and social information and engage in social interaction

The Parent AMOR

Every parent is in a state of potential disequilibrium and reorganization through the transition to parenthood with the attendant possibility of crisis and opportunity for development. The Parent AMOR acronym is intended as an aide memoire for key psychic regulatory processes in parents that promote reciprocity in the relationship. These challenges are: Affect regulation, Mentalizing, Openness, and Responsiveness.

  • A – Affect regulation: firstly there is the need to re-settle heightened emotions, such as anxiety, sadness, anger.
  • M – Mentalise: then the parent needs to understand the baby’s mental state and be able to scaffold the baby’s mental state.
  • O – Openness: or being curious about “the real baby” enables the parent to become more aware of the baby’s as an individual person, whereby the parent is “in the present moment”, with more awareness, acceptance and availability to being surprised. The parent is thereby psychologically poised for
  • R – Responsiveness: to communication from the baby.

The Practitioner AMOR

Parallel AMOR processes are at work for the NBO Practitioner, as well. Practitioners who work with parents and their infants must have both human sympathy and shared consciousness with both the baby and the parents to use the NBO appropriately. Whether the NBO takes place in a bustling hospital ward or a busy apartment, the NBO Practitioner creates a psychologically safe holding environment for the parents, a space that is respectful and non-judgmental and where the outside world – for now at least – is set aside, as practitioner, parents, siblings, grandparents, family, and friends gather around and “meet” the baby. There are three partners in this elegant dance: the baby, the parent, and the practitioners themselves. Practitioners must be aware of what they are bringing in their hearts to this dance and are ready to respond to whatever parents or baby reveal about themselves as the NBO session unfolds. The Practitioner AMOR captures some of the practitioner’s own regulatory tasks and support strategies.

  • A – Affect Regulation: Practitioners must be aware of their own affective state at this time, how mindful they are of their own inner feelings about themselves, as well as their feelings about the baby and the baby’s family. 
  • M – Mentalization: Carefully observing, and thinking about the baby and parents, practitioners can begin to mentalize and think about how the baby and parents themselves are feeling and thinking.
  • O – Openness: Respecting the parent’s social and cultural values enables a sense of active openness, of being available to the baby and parent as they are, which can serve as a protective factor against a cycle of mistrust or interactional mismatch.
  • R – Responsiveness: Practitioner AMOR provides the scaffold for Parent AMOR regulatory functioning, so the parents become increasingly responsive to their baby, and infant AMOR regulatory capacities develop such that the baby is able to be in a quiet alert state and socially responsive for greater periods.

Whether the NBO takes place in a bustling hospital ward or a busy apartment, the NBO Practitioner creates a psychologically safe holding environment for the parents, a space that is respectful and non-judgmental and where the outside world ­- for now at least – is set aside, as practitioner, parents, siblings, grandparents, family, and friends are invited to gather around and “meet” the baby. The baby remains at center-stage throughout the NBO. The practitioner, by eliciting the baby’s behaviors, is the choreographer, who not only draws out the baby’s capacities through sensitive handling but also draws in the parents as the baby’s primary caregivers, as part of the baby’s on-stage supportive cast. Although the NBO is designed to capture the “baby’s story”, clinicians provide parents with the relational space so that they feel free in sharing “the family story”. The scene is now set for the emergence of reciprocity in the parent-infant relationship through increasingly visible moments of affective attunement, synchrony, and mutually rewarding interaction or co-regulation between infant and parent.

Research

Although the NBO is still in its infancy as a clinical intervention approach, a number of randomized control studies have demonstrated its effectiveness as a form of support. Infants receiving the NBO infant mental health intervention had greater gains in cognitive and adaptive functions at 6 months (McManus et al. 2020). In a number of studies, the NBO was associated with enhanced mother–infant engagement (McManus and Nugent, 2012; Nicolson et al. 2020; Nugent et al. 2017) and was effective in helping parents be more responsive to their infant’s communication cues (Kristensen et al. 2020; Høifødt et al., 2020). An Icelandic study of pregnant women with current emotional distress and/or a history of anxiety and depression reported that early home visits – combining NBO with standard care – enhanced maternal confidence and the mother’s understanding of their infant (Valla et al. 2025). Studies have also shown that mothers who participated in the NBO sessions demonstrated a reduction in postpartum depressive symptomatology and reduced anxiety symptoms (HuiPing et al, 2018; McManus et al. 2020; Nicolson et al. 2022; Nugent et al. 2014). A study in Norway demonstrated that the NBO conducted in home visits is a feasible and acceptable intervention for both parents and healthcare workers within the well‐baby clinic services (Greve, Braarud, Skotheim, Slinning, 2018). NBO practitioners demonstrated higher perceived confidence in working with low- and high-risk newborns and their families in a State Early Intervention program setting in the United States (McManus and Nugent, 2011). Congdon, Nugent, McManus, Coccia & Bush (2020) provided evidence for the reliability and validity of the NBO by demonstrating sub-scale associations with infant salivary cortisol reactivity and maternal report of infant temperament.

In a series of non-randomized controlled studies the NBO has been associated with enhanced mother–infant engagement, a greater understanding of the baby’s communication cues, increased levels of confidence among parents, positive parental perceptions of their interactions with their high-risk infants, increased levels of father involvement, and higher perceived confidence and enhanced practitioner mentalization among service providers in working with low- and high-risk newborns and their families (Alvarez-Gomez, 2014; Appleton, Nickell & Nicolau, 2016; Cheetham & Hanssen, 2014; Connorton et al. 2022; Hawthorne & Nicolau, 2017; Holland & Watkins, 2015; Kashiwibara, 2012; Nugent & Alhaffer, 2006; Parveen et al., 2022; Saito, 2012; Sanders & Buckner, 2006; Savage-McGlynn & Hawthorne, 2014; Schilling, Nicolson and Ridgway, 2017; Shah, 2018; Simkin-Tran et al. 2020; Windarti and Suryawan, 2021; Zhang et al. 2021). Finally, a number of studies using the NBO as a form of relationship-support are now in progress in different countries – China, Hong Kong, Japan, Brazil, Ireland, South Africa, the UK and the United States.

NBO system items

  1. Habituation to light (sleep state)
  2. Habituation to sound (sleep state)
  3. Muscle tone in legs and arms
  4. Rooting
  5. Sucking
  6. Hand grasp
  7. Shoulder and neck tone
  8. Crawling response
  9. Visual tracking (red ball)
  10. Visual response to face
  11. Visual response to face and voice
  12. Orientation to sound (rattle)
  13. Orientation to voice
  14. Crying
  15. Soothability
  16. State regulation
  17. Response to stress- color change, startles, tremors
  18. Activity level