Historical Perspectives

Berry Brazelton: Le Magnifique

J. Kevin Nugent, PhD* *The Brazelton Institute, Boston Children’s Hospital and Harvard Medical School, Boston, MA

I was privileged to have worked with Berry Brazelton (Fig) for over 40 years. In 1978, as a new graduate student from Ireland, I first looked over his shoulder in the company of his pediatric fellows, as he used the scale he had just developed— the Neonatal Behavioral Assessment Scale (NBAS)—to examine a less than 1-day- old female newborn in the old Boston Lying-In Hospital. Even as he examined the baby’sreflexes, I was immediately struck by his—what could only be called gentle- ness, even tenderness—in the way he both held and spoke to the baby. He called her by her first name. “You are so alert, Sarah. Your mother must be very proud of you.” Whenhetookaredballoutofhiskitandmoveditslowlyfrom1sidetotheother,the baby began to track the ball and locked on to it, as if she did not want to release it from her gaze. “She can see,” blurted her mother, shaking her head in disbelief. When he begantotalktoherinlilting, melodic phrases, Sarah’s face relaxed and her eyes widened and brightened. They were now interacting with each other—in a give-and- take, back-and-forth cyclical rhythm that had all the hallmarks of true conversation. That babies could see and hear and had a wide repertoire of behavioral endow- ments at birth was a revelation to me, but Berry Brazelton had just demonstrated that this less than 1-day-old baby also had her own well-defined personalized behavioral style and was already shaping and leaving her mark on the world. She and Berry Brazelton left their mark on me and on all the pediatric fellows who were present on that August day, many years ago. In this clinical newborn encounter, we can see 3 principles that can be said to characterize Berry Brazelton’senduringlegacy:firstly, the recognition of newborns as competent and social beings, ready to engage and interact with their environments from the very beginning. Secondly, by integrating parents into the pediatric session he demonstrated the effectiveness of the newborn examination as a teaching tool, on the one hand, and the newborn period as a powerful intervention “touchpoint,” on the other. He maintained that pediatricians, neonatologists, nurses, and allied perinatal health care professionals are in a unique position to make a significant contribution to the lives of parents and children, at this particularly vulnerable time in the parent’s lives. The third principle or stance embraced by Dr Brazelton on that day highlighted the importance of listening to parents and the need for clinicians to be able to translate and communicate with parents in a way that is nonjudgmental, culturally sensitive, and jargon-free. Indeed, it was this capacity to translate theory and research into accessible language without diminishing its complexity or soft- pedalling its urgency that made him so popular with parents and made him a household name in North America and beyond. It also made him a powerfully AUTHOR DISCLOSURE Dr Nugent has effective advocate for health care reform and a champion of parents’ rights. fi disclosed no nancial relationships relevant to Berry Brazelton died in March 2018 at age 99. For more than 70 years, he this article. This commentary does not contain — a discussion of an unapproved/investigative advised parents and health care professionals from almost every discipline and use of a commercial product/device. even counseled presidents—about child rearing and child development. He may

Vol. 20 No. 11 NOVEMBER 2019 e615 Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 and young children, even when he was a very young boy. In his 2013 memoir, Learning to Listen: A Life Caring for Chil- dren, he wrote, “I could keep them amused and safe and keep them from crying for up to two hours at a time.” Encouraged by his grandmother (née Berry, a descendant of the Duc de Berry), Berry Brazelton saw pediatrics as a vocation, as a calling to dedicate his life to serving the health needs of children and their families. Like the Duc de Berry—le magnifique de France—the medieval French knight, who dominated much of France in the 14th century, Berry Brazelton also was an explorer—searching, pursuing, questioning, relentlessly looking for novel solutions in new lands. Indeed, he traversed the globe, studying children’s development and examining child-rearing practices, from the highlands of Chiapas in Mexico to Kenya, where he studied Gusii child-rearing practices, to the southern United States, where he worked with Navajo leaders, and on to the Goto Islands where he worked with Japanese colleagues in a longitudinal study of child development. This experience in diverse environments of child development enabled him to explore questions of universality and cultural variation in mothers’ and children’s behavior and in terms of his own practice, made him open to differences in belief and practice wherever he encountered them. Figure. Berry Brazelton (courtesy of Insieme photo by Fulvia Farassino).

fi not have been the rst pediatrician to realize that newborn THE NEWBORN EXAMINATION babies were more competent than had been acknowledged, but he played a central, if not the central, role in changing Brazelton went to Columbia University Medical School and conventional perceptions of the newborn among health care afterwards completed his medical residency at the Mas- professionals and parents alike around the world. Even sachusetts General Hospital in Boston and then, as if on among scientists, the dominant view for much of the 20th script, chose pediatric training at Boston Children’s Hos- century was that the newborn infant was essentially a “blank pital. But when he first began to work in the newborn slate” at birth, endowed with so-called primitive motor nursery, he was struck not just by the limitations of the reflexes, which required no cortical involvement and thus, existing pediatric examination in capturing the full richness was only capable of spontaneous reflexive behavior in of the baby’s behavioral repertoire but also by the negative or response to stimulation. Brazelton’s innovative work with deficit-based thrust of these scales. Up to then, the newborn newborns opened the door to a whole generation of clinicians, was assumed to be merely operating at a brainstem level. researchers, and parents and made it possible for them to The newborn assessment tools used by most pediatricians discover and personalize the human newborn. Indeed, he at that time reflected these assumptions, so that even was one of the earliest figures in medicine to build a bridge themoresophisticatedneonatal scales, such as those by between the sometimes-arcane world of clinical practice and Andre-Thomas and Saint-Anne Dargassies (1960) and the general public. The appeal of his work was that complex Amiel-Tison (1968), in France, focused exclusively on ideas were expressed with brilliant simplicity—he had the the assessment of the so-called “primitive reflexes” and rare gifts of a great teacher and communicator. “postural reactions” to identify various disorders. To redress this, Brazelton began his quest to develop a “GOOD WITH BABIES” more comprehensive assessment tool, one that could do justice to the baby’s capacities and more importantly, from “Berry is good with babies,” his grandmother remarked. his point of view, a newborn scale that could capture the She encouraged him to become a pediatrician because she individuality of each baby. This spurred him on to seek out recognized his precocious capacity to “connect” with babies and then join Jerome Bruner—arguably one of the great

e616 NeoReviews Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 minds of the 20th century—at the Center for Cognitive demonstrated that as early as 18 hours after birth, not only Studies at Harvard University, in an effort to integrate can babies see but they prefer to look at complex rather than developmental theory and neurological principles into his simple patterns. He also went on to show that babies pre- clinical understanding of newborn behavior and develop- ferred to look at a human face than at any other pattern ment. Observing babies and toddlers in this unique labo- (Fantz, 1961). It was also believed that babies could not hear ratory setting confirmed his growing conviction that every because their ears were filled with fluid at birth, but in the child was different and that each child needed a different same year, Michael Wertheimer’s research showed that kind of care and support, all of which challenged the before they were 10 minutes old, neonates were able to “ ” “ fi ” maturational milestone or one-size- ts-all approach to turn in the direction of an auditory stimulus (Wertheimer, child development which informed pediatric guidance at 1961). that time. Then, Peter Wolff, based on a study of 22 infants who were observed in their homes for 30 hours each week during “COURTEOUS TO BABIES” the first months after birth, showed that newborns had distinctly organized behavioral states—deep sleep, light Given his interest in individual differences in children, not sleep, quiet alert, active alert, and crying states. He went ’ fi surprisingly, perhaps, Brazelton s rst research study on to examine how state transitions and changes can influ- focused on infant crying. The study included a sample of ence developmental transformations in the infant’s social- 80 mothers of healthy full-term newborn infants, whom he emotional behavior and development (Wolff, 1959). These asked to keep daily records of their infants’ fussing for the data provided the evidence Brazelton needed to show that first 12 weeks of age. He reported that while there was an the newborn infant was, indeed, competent and complexly average of 2½ hours daily crying in the first 7 weeks, there organized. was a wide range in individual differences in the amount and rate of crying behavior across this period (Brazelton, 1962). Not long after, he presented his ideas on individual THE DEVELOPMENT OF THE NBAS differences to a wider audience in his groundbreaking book, Stimulated by this body of research, the first iteration of the Infants and Mothers: Differences in Development, the first NBAS appeared, known as the Cambridge Behavioral and sentence of which reads, “Normal babies are not all alike.” Neurological Scales, which Brazelton developed along with In this best-selling book, he presented a contrast between psychologist Daniel Freedman from the University of Chi- the development of the very active, the moderately active, cago and which he now used to test the applicability of the and the quiet baby, which led Bruner to remark in the concept of individual differences (Brazelton & Freedman, preface that, “Dr Brazelton has an unflagging sense of 1971). One of the first studies with this scale provided evi- human individuality..he invites us to be courteous to dence for clearcut behavioral differences between Chinese- the infants, who are our children and he helps us achieve American neonates and American babies of Northern this courtesy by sketching the range of individual expres- European origin (Freedman and Freedman, 1969). In the sion that infancy can take.” same year, Brazelton went to Mexico to test out the new scale in a study of the behavior of Zinacanteco Indians in the A NEW RESEARCH TRADITION highlands of Chiapas. The behavior of the Zinacanteco Fortunately for Brazelton, in addition to Jerome Bruner, a neonates was strikingly different from white infants in new generation of researchers at this time, stimulated by the North America, according to Brazelton, and he and his work of Jean Piaget and Erik Erikson, and including Colwyn colleagues reported that they had a more uniform quiet Trevarthen, Jerome Kagan, Daniel Stem, Ken Kaye, Lewis activity level, allowing for long periods of responsiveness to Lipsitt, Arnold Sameroff, Heidelise Als, Ed Tronick, Barry auditory and visual signals, and the caregiving practices of Lester, and others, had begun to develop novel ways to study the Zinacanteco mothers seemed to reinforce this quiet learning in infancy in an effort to determine how early and sustained alertness (Brazelton et al, 1969). This cross- under what conditions infants could learn. This new body of cultural experience, coupled with his own systematic obser- research provided Brazelton with a rich empirical database vations of infant cry patterns, prompted him to continue his for subsequent conceptualizations of newborn and infant quest for an assessment scale that could describe the full development. Although it had been assumed that the new- range of individual and cultural differences in newborn born could see only shadows at birth, Robert Fantz behavior.

Vol. 20 No. 11 NOVEMBER 2019 e617 Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 Brazelton did not reach his rich understanding of the (Lester et al, 1982; Sepkoski et al, 1992); neonatal hyper- capabilities of newborn infants overnight or alone. Many bilirubinemia (deCaceres et al, 1991); maternal ingestion of scholars contributed to his understanding of the newborn toxins such as cocaine, tobacco, alcohol, and caffeine (Mansi infant, while he, in turn, enriched their understanding of et al, 2007; Morrow et al, 2001; Nugent et al, 1991; Tronick, early parent-child relationships with his rare appreciation of 1987); and predicting later atypical development or devel- the sensibilities and vulnerabilities of new parents. With opmental delay and disability (Bedford et al, 2015; Ohgi et al, help from Daniel Freedman, Frances Degan Horowitz, 2002; Shoaff et al, 2018) (See Brazelton & Nugent [2011], for Barbara Koslowski, John Robey, Henry Riciutti, Arnold a detailed review of NBAS studies). In addition, a large Sameroff, and Edward Tronick, Brazelton produced the first number of studies have used the NBAS in different cultural edition of the NBAS, published in 1973. He graciously settings (Nugent et al, 1989, 1991). This body of research invited me to be the coauthor of the NBAS on the sub- reveals a wide range of variability in newborn behavioral sequent editions. differences across cultures and suggests that whereas the However, at that time, the doors of academic publishing basic organizational processes in infancy may be universal, houses in the United States were closed to this new scale, the range and form of these adaptations are shaped by the undoubtedly deterred by its novel unorthodox character,which demands of each individual culture. In this way, cross- included items measuring the infant’svisualandauditory cultural studies using the NBAS have expanded our under- capacities when it was universally assumed that babies could standing of the range of variability in newborn behavior neither see nor hear at birth! This new assessment scale may patterns and the diversity of child-rearing practices and have included classic neurological items such as the Glabella belief systems across settings (Nugent, 1995; Nugent reflex and the Moro response, but it also included items that et al, 2009). measured the infant’s “cuddliness” and “attractiveness,” The NBAS can be said to have played a major role in which were deemed to defy objective measurement. But Berry expanding the understanding of the phenomenology of new- Brazelton did not relent. Finally, he had to cross the Atlantic born behavior among researchers and clinicians alike and where he met Ronald McKeith and Martin Bax at the Spastics has, in turn, stimulated the development of a number of Society Medical Education and Information Unit in London, scales for use with different populations and in different who hailed this new assessment as one that would revolu- settings. Als and colleagues, for example, used the concepts of tionize the field and predicted that it “would be used for many the NBAS to develop the Assessment of Preterm Infants’ years to come.” They agreed to publish the NBAS in 1973, and Behavior, an assessment of the behavior of the preterm infant within a few years, it was hailed as the most comprehensive (Als et al, 1989), while Lester and Tronick used the NBAS as examination of newborn behavior available and was increas- thebasisfortheNeonatalIntensiveCareUnitNetwork ingly used in research studies across the globe. Neurobehavioral Assessment Scale (Lester and Tronick, 2004). Keefer (1995) developed the combined Physical and RESEARCH WITH THE NBAS Behavioral Neonatal Examination, while Cardone and Gilker- son (1995) also used the concepts of the NBAS to develop the Never conceptualized as an objective assessment in the Family Administered Neonatal Activities. classic psychometric or medical diagnostic tradition, with The Newborn Behavioral Observations (NBO) system an emphasis on pass/fail criteria, the NBAS is based on a also comes from this tradition and was developed by Nugent broader appreciation of the complexity of newborn behavior, et al as a relationship-building instrument, designed to including the newborn’s motor and social interactive capac- sensitize parents to the capacities and individuality of the ities. The scale consists of 28 behavioral items, which newborn infant and to foster the relationship between measure the infant’s behavioral capacities, and 16 re- parent and infant and between clinician and family (Nugent flex items, which measure the infant’s neurological status et al, 2007). A series of studies have shown that the NBO (Brazelton, 1973, 1984, Brazelton and Nugent, 1995, 2011). is an effective tool for perinatal professionals to enable Because it is sensitive to even subtle environmental effects, parents to build positive relationships with their newborns the NBAS has demonstrated that newborn behavior and (McManus & Nugent, 2012; Nugent et al, 2014; 2017). development can be affected by many variables including intrauterine growth restriction, low birthweight, and pre- ADVOCATING FOR PARENTS maturity (Costas et al, 1989; Figueras et al, 2011; Lester et al, 1986); environmental polychlorinated biphenyls (Sagiv et al, Although Berry Brazelton’sworkwiththeNBASre- 2006); different modes of delivery and obstetric medication flected a deep appreciation of and respect for the baby

e618 NeoReviews Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 as a unique individual, he maintained an equally ACTIVISM AND ADVOCACY respectful stance toward parents. Almost from the out- Brazelton came to believe that programs and policies that set, Brazelton realized that the pathological, deficit- serve children are most effective when they are informed by based thrust of his medical training left him ill-prepared data and evidence and grounded in deep knowledge of child for meeting the needs of the parents who came to his development and rely on cutting-edge research, indepen- office with concerns about their baby’s behavior, such as dent analyses, actionable recommendations, and clear com- sleep, crying, or toilet-training issues. Moreover, the munications to improve policies and interventions that “mother-blaming” thrust of existing approaches to child serve children and their families. He was an evidence-based guidance ran counter to his natural sympathetic stance optimist, animated by a utopian purpose and frequently toward parents and his awareness of how much energy, appeared before congressional committees, playing a key passion, and wisdom parents bring to the task of parent- role in the enactment of the Family and Medical Leave Act, ing. While he advocated for parents, he helped physicians which guarantees 3 months of maternity leave, and Public and patients understand each other better, broke down the barriers among physicians, patients, and the public at Law 99-457, which extends the rights and protections of the large, and encouraged parents to look within themselves Individuals with Disabilities and Education Act to young for answers to their parenting challenges. He proposed children. He also served on the National Commission on that the newborn period and the first months of age Children. His resolve, combined with his sympathetic sen- presented perinatal professionals with a unique opportu- sibilities, transformed him into an activist pediatrician. He nity to support parents in this quest, by offering them saw health issues not just as individual problems but also as unconditional respect and nonjudgmental support. a consequence of social justice, which involves providing better health and social care services for currently under- served populations with unmet needs. THE TRAINING OF PROFESSIONALS IN CHILD DEVELOPMENT THE DANCE OF IDEAS Hand in hand with his work with newborns and their “ families, Brazelton turned his attention to pediatric The poet Rilke, wrote, Be patient toward all that is unsolved in ” training, where he saw the need to provide training your heart and try to love the questions themselves. Berry designed to increase pediatricians’ awareness of young Brazelton knew that science begins by asking questions children’sbehavior.Hefirmly believed that perinatal and then seeking answers. He fostered curiosity, a sense of professionals were in a uniquely privileged position to wonder, a thirst for knowledge, a need to know more. When, fi support parents at a time when parents often felt as a newly arrived student, I rst entered the meeting room alone and vulnerable. Combining his interests in pri- in the 3-story Victorian building which housed the Child ’ mary care pediatrics and child psychiatry, he set up Development Unit at Boston Children s Hospital, I watched one of the first training programs for pediatricians at him lead a discussion on the genes-environment debate, the Child Development Unit and went on to play a surrounded by 10 or so of his fellows. I half-sat on the chair pivotal role in the establishment of Behavioral and feeling unworthy to be in this august academic setting. Developmental Pediatrics as a pediatric subspecialty. But, despite the give-and-take first name–laden informal- He believed that pediatricians needed to be schooled ity and the palpable camaraderie, the discussion was impas- in developmental and infant mental health theories and sioned and opinionated. Clearly, this was no conventional in a more strength-based, family-centered approach to lecture and was unlike anything I had ever experienced, so pediatric care. that when Dr Brazelton turned to me and asked me on In an oral history interview at the American Academy which side I was in the genes-versus-environment debate, I of Pediatrics, he said that pediatricians should be able surprised myself by offering an opinion. But the answer was to offer parents help and resources to deal with behav- not important. It was the fact that he had honored me by ioral issues and concluded that “We’re very good at asking that struck me so powerfully on that day and that identifying everything that’swrongwithanybody, Berry Brazelton assumed I had something to contribute. In but we don’t have any idea about what’s going on in that stunning revelatory moment, I knew that that this was them or what’s right about them” (https://www.aap.org/ a place where one could learn. en-us/about-the-aap/Gartner-Pediatric-History-Center/ Brazelton mastered the art of asking good questions. DocLib/Brazelton.pdf). Adopting the Socratic method, he simply posed the kinds of

Vol. 20 No. 11 NOVEMBER 2019 e619 Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 questions that led the conversant to further question his or In: Fitzgerald HE, Lester BM, Yogman MW, eds. Theory and her own beliefs. He knew that a good open-ended question Research in Behavioral Pediatrics. New York: Plenum Press; 1982:35–63 can excite, disturb, or comfort, and eventually yield an Amiel-Tison C. Neurological evaluation of the maturity of newborn unexpected bounty of understanding and critical awareness. infants. Arch Dis Child. 1968;43(227):89–93 His ease in asking questions and his humility in learning Andre-Thomas C, Dargassies S. The Neurological Examination of the from others is a mark of his greatness. This was the reason he Infant. London, England: Spastic Society Medical Education and had a reserve of apparently intuitive supernatural gifts, which Information Unit; 1960 allowed his mind to roam and, on occasion, enigmatically Bedford R, Pickles A, Sharp H, Wright N, Hill J. Reduced face reveal some of its secrets hidden from ordinary mortal view. preference in infancy: a developmental precursor to callous- unemotional traits? Biol Psychiatry. 2015;78(2):144–150 We were often dazzled by his instant understanding of the Brazelton TB. Crying in infancy. Pediatrics. 1962;29(4):579–588 deeper dynamics of every case and by his imaginative inter- Brazelton TB. Infants and Mothers: Differences in Development. New York: ventions, but his genius lay in his curiosity and his ability to Dell Publishing; 1969 “ ’ ask questions. He was never afraid to say, Idont understand. Brazelton TB. Neonatal Behavioral Assessment Scale (Clinics in What do you mean?” This humility led to the dance of ideas. Developmental Medicine No. 50). Philadelphia, PA: Lippincott; 1973. Brazelton TB. Neonatal Behavioral Assessment Scale. 2nd ed. London, England: Blackwell Scientific; 1984 RESOLVE, HUMILITY, AND HOPE Brazelton TB. Touchpoints: Your Child’s Emotional and Behavioral Development. Reading, MA: Addison-Wesley; 1992 While Berry Brazelton will be remembered by many of our Brazelton TB. The Neonatal Behavioral Assessment Scale (NBAS). In: generation for his warm fixed photogenic carpe diem smile, Nugent JK, Petrauskas B, Brazelton TB, eds. The Newborn as Person: suggesting an easygoing fun-loving disposition, beneath Enabling Healthy Infant Development Worldwide. Hoboken, NJ: John this smile was a leonine resolve and determination; indeed Wiley & Sons; 2009:278–286 it may well have been that steely mindset that led to the Brazelton TB, Freedman DG. Manual to accompany the Cambridge sheer range and breadth of his achievements across a Behavioral and Neurological Scales. 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If one might nd a hidden emotional spine to all 1969;44(2):274–290 his work, it is that policies that support families are critical, Brazelton TB, Sparrow J. Touchpoints: Birth to Three. Cambridge, MA: Da as the strength and quality of the relationship between Capo Lifelong Books; 2006 caregivers and their children are fundamental to the effec- Cardone IA, Gilkerson L. Family Administered Neonatal Activities: A tive development of children’s brain functions and capacity. first step in the integration of parental perceptions and newborn – While the backdrop to Berry Brazelton’s monumental behavior. Infant Ment Health J. 1990;11:127 131 achievements in the field seems to have been a rare com- Costas C, Botet F, Ortolà ME. Behavior of the small-for-date newborn, according to the Brazelton Scale. An Esp Pediatr. bination of energy, charisma, warmth, persistence, deter- 1989;1:37–40 mination and zest, more than all else, it included an ease in deCáceres ML, Costas C, Botet F, Niveles RS. Assessment of newborn asking questions and humility in learning from others—a behavior and serum bilirubin levels. An Esp Pediatr. true humility that is the mark of greatness. 1991;37:466–468 I will end this tribute with a quote from the great Nobel Fantz RL. The origin of form perception. Sci Am. 1961;204:66–72 Prize–winning Irish poet, William Butler Yeats: Figueras F, Cruz-Martinez R, Sanz-Cortes M, et al. Neurobehavioral outcomes in preterm, growth-restricted infants with and without Think where man’s glory most begins and ends prenatal advanced signs of brain-sparing. Ultrasound Obstet And say my glory was I had such friends. Gynecol. 2011;38(3):288–294 Freedman DG, Freedman NC. Behavioural differences between Chinese-American and European-American newborns. Nature. Suggested Readings 1969;224(5225):1227 Als H, Lester BM, Tronick E, Brazelton TB. Towards a systematic Keefer CH. The combined physical and behavioral neonatal assessment of preterm infants’ behavioral development. examination: a parent-centered approach to pediatric care.

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Vol. 20 No. 11 NOVEMBER 2019 e621 Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 Historical Perspectives: Berry Brazelton: Le Magnifique J. Kevin Nugent NeoReviews 2019;20;e615 DOI: 10.1542/neo.20-11-e615

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Downloaded from http://neoreviews.aappublications.org/ by 162054 on November 1, 2019 Historical Perspectives: Berry Brazelton: Le Magnifique J. Kevin Nugent NeoReviews 2019;20;e615 DOI: 10.1542/neo.20-11-e615

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