我々はこれまでブラゼルトン新生児行動評価法（NBAS）を未熟児やリスクを有する成熟児の早期発達評価と介入手段として応用してきた。今回は未熟児を対象にNBASの評価結果から発達障害を予測された児の新生児行動上の特性を4つの行動系に分けて整理し，我々の実施している早期療育プログラムについて報告した。また，これまでフォローした児について発達経過を加えた。We have applied the Brazelton\u27s Neonatal Behaviour Assessment Scale (NBAS) for the evaluation of early development stages in both premature infants, and mature risk infants, as well as for the clinical application of early intervention method. This paper reports the neonatal behaviour peculiarities of premature infants forecast by NBAS to have mental-motor delays. This paper also report on our practical application of the early intervention program. Finally, we conclude with the progress made in these infant\u27s developments

Akiyama Tomitaro

Fukuda Masafumi

Goto Yoshiko

Kusano Mineko

Ogi Shohei

Nagasaki University's Academic Output SITE: NAOSITE

A Clinical Application of Brazelton's Neonatal Behavior Assessment Scale. Shohei OG11 , Tomitaro AKIYAMA2, Masafumi FUKUDA3, Yoshiko GoT04 and Mineko KUSAN02 Abstract We have applied the Brazelton's Neonatal Behaviour Assessment Scale (NBAS) for the evaluation of early development stages in both premature infants, and mature risk infants, as well as for the clinical application of early intervention method. This paper reports the neonatal behaviour peculiarities of premature infants forecast by NBAS to have mental-motor delays. This paper also report on our practical application of the early intervention program. Finally, we conclude with the progress made in these infant's developments. Bull. Sch. Allied Med. Sci., Nagasaki Univ. 7 : 11-20, 1993 Key words : Neonatal Behavior Assessment Scale (NBAS), Premature Infants, Early Intervention Program Introduction We have applied the Brazelton's Neonatal Behavior Assessment Scale (NBAS) both to the clinical evaluation of neonatal development and as a method of intervention in both premature and mature risk infants. This is because the fundamental principle of the NBAS, to assess the individual char-acteristics and best performance of each neonatal infants, are useful for the early assessment and intervention of risk infants. This study reports on the differences in the neonatal behavior of premature infants with development difficulties, and a discussion of practical early intervention programs using the NBAS. We conclude this with a report the ongoing progress of these infants' development. 3 4 Dept. of Rehabilitation, Nagasaki University Hospital The School of Allied Medical Sciences, Nagasaki University Dept. of Pediatrics, Nagasaki University Faculity of Education, Nagasaki University - 11 -Shohei OGI Fig. 1 Subject Gestational Age 40v 44v 48v 52v Habituation Orientation lotor State State Range Regulation Autonomic Su pplement Ref lexes Stability Items 7. 69~0. 61 5. 33io. 89 5. 45~0. 60 3. 74io. 56 5. 13~0. 64 6. 27iO. 92 6. 64~0. 99 O. 63to. 90 7. 80~0. 54 6. 80~0. 64 5. 97iO. 98 4. 79il. 07 5. 75~0. 67 4. 59iO. 67 3. 93iO. 56 3. 12tO. 86 5. 17il. 15 3. 65iO. 95 6. 97iO. 76 6. 39il. 12 7. 30il. 06 5. 83iO. 89 O. 73iO. 81 3. 6lil. 40 8. 12iO. 63 7. OliO. 71 6. 79tO. 72 5. 06iO. 97 6. O1~0. 57 4. 80iO. 84 4. 29iO. 73 3. 5ltO. 93 5. 59iO. 92 4. 06~0. 93 7. 84iO. 71 7. O0~0. 77 7. 71~0. 80 5. 84~0. 80 O. 64~0. 72 3. 23~1. 37 6. 82io. 75 5. 3lil. 18 4. 81~0 60 3. 34io 92 3. 89tO. 80 7. 16iO. 90 5. 89io. 86 3. 17iO. 89 Fig. 2 Result of NBAS Examinations. The upper line showed controlled subjects. The second line showed the risk infants. - 12 -Brazelton's Behavior Assessment Scale Sub jects We used the NBAS to evaluate 111 premature infants. We examined our-findings on predictions made of developmemt difficulties in 16 cases of these premature infants and implemented the early intervention program as on the basis of these findings. Delays in mental-motor progress were predicated for 14 of the infants, and disorders in the central nervous system were pre-dicated for 2 infants. While the former were extremely premature and had respiratory disease, the latter did not indicate any significant pediatric problems (Fig. 1). (Another 2 infants were found to have disorders in the CNS, however as these displayed sufficient progress after being transferred to anothersite, they have been omitted from this report.) Result of the NBAS examinations The score of each NBAS cluster (by Lester, 1982) is seen in Fig. 2. In comparison with controlled subjects who developed normally, at risk infants showed a low score for a long period. It was shown that in such cases,neo-natal behavior was very fragile, and progressive adaptation to the environ-ment did not come about successfully. Results of the NBAS examinations showed that at risk infants displayed neonatal behavioural differences according to the following classifications (Fig. 3); ~) Physiological System : Eleven cases of the subjects with predicted delays displayed RDS, outof witch six cases showed chronic respiratory disorders,BPD,Wilson Mikity Syndrome. In these at risk infants stress behavior was observed in the physiological system. During rest, paradoxical or irregular breathing was observed. Crying capacity was weak,breathing was gasped and exerted and cyanosis was detected. The ability to maintain a constant physiological standard was poor, impairing the organization of other neonatal behavioral systems. @ State Control System : Sleep and waking rhythms were prone to change, and problems such as the presence of only brief woken states during the day were also noticed. Sleeping ability was slight and easily disturbed by numerous distractions. Waking episodes were a very brief with brief periods of alert response and displays of drowsiness frequent, - 13 -Shohei　OGI　　　　These　infants　were　easily　irritated　by　extemal　stimulation　and　wereproneto　sudden　crying．　Their　self．quieting　ability　was　poor　so　they　lapsed　intopanic　easily．③MotorSystem　　　　In　these　at　risk　infants　abnormal　posture　occured　frequently　due　to　pro－blems　in　the　central　nervous　system　an（l　from　the　long　period　of　intubation．Asymmetrical　posture，shoulder　retraction　and　opisthotonic　posture　were1．Physiological　Syste臨：　　　　　　　。　paradoxica1，　irregular，　forced　　　　　　　●　gasPing，　9runting，　stridof　　　　　　　・skincolorchangestocyanosis　　　　　　　・　可eak　cryi　ng　capas　i　ty　　　　　　　・　tre皿oring，　startling　　　　　　　・ya胃ning　　　　　　　・etcrespiration2．State　Cootrol　Syste■＝　　　　　　　●　unstable　sleep－a冒ake　r血yth■　　　　　　　●　1ight　sleep，　excess　responce　to　stiロulation　in　s　leeping　　　　　　　・　short　a冒ake　state，　short　period　of　alertness　　　　　　　●　panicked，　冒orried，　dro冒sy　alertness　　　　　　　●　rapid　state　change　to　crying　　　　　　　・irritability，prolongedcfying（fussystate）　　　　　　　●　unconsolabi　l　ity，　poor　self－quiet　ing　act　ivi　ty　　　　　　　・etc3．聾otorsysteg：　　　　　　　●　abnor粗al　muscle　tonus　（hypotonus，　hypertonus）　　　　　　　●　abnor魅al　posture　（flaccid，　opistLtonic，　high－gird　posture）　　　　　　　・　abnor皿al　response　to　priロitive　reflexes　　　　　　　　　　　　　　　’　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　（hypo一，　hyper一，　asy皿皿etrica1）　　　　　　　●　overshooting，　jerky　皿ove皿ent　　　　　　　・poorpostualrightingreaction　　　　　　　●　POOr　unti－graVitiC　aCtiVity　　　　　　　・etc4．Interactioo　syste■：　　　　　　　●　OVer－SenSitiVe　reSpOnSe　　　　　　　．　inattention　　　　　　　．　rovin9，　avertin9，　staring　eye　皿ove田ent　　　　　　　●　panicke（1。　blankly　glassy　exPression　　　　　　　。　stiffen，　passively　cuddling　　　　　　　・　weak　sucking　capasity　　　　　　　・etcFig．3　Characteristics　of　Neonatal　Behavior　at　Risk　infants　using　NBAS一14一Brazelton's Behavior Assessment Scale observed, as well as underdeveloped anti-gravitational activity in head, body and limbs. Furthermore, Iimbs movements were uncoordinated, it showed overshooting and/or jerky movement. The infants withsymptomsofampaired CNS showed abnormal response in primitive reflex items, predominantly so in the total movement patterns of lower limbs. ~ Interaction System : The stress shown in the physiological control and state regulatory system made the obstruction of the social interaction process likely. An excessively agitated facial expression and staring eyes, change of state to crying or drawsyness, the excessive uncoordinated movement of limbs and total exten-sion of body, all demonstrated signs of stress. Early Intervention Programs Next,we express on our practical early intervention programs for at risk infants who shows the above pecularities of newborn behavior. The premature infants with developmental difficulties had not matured sufficiently in utero. These infants easily contracted infectious or respira-tory distress and had central nervous system disorders. Therefore, the organization of their neonatal behavioral processes obstructed. Further, 10ng-term medical supervision and separation from the mother were all reflected in their developmetal processes. Due to these peculiaruties of behav-ior, progress in adaptation to the environment did not progress well, and the course of learning was delayed as well. A fundamental principle of the early intervention program is to assist development of neonatal behavior system by encouraging mother-infant interaction. Therefore, we attach importance to the daily transactions bet-ween mother and infants (Fig. 4). Program I : Assisting development of mother-infant interaction The infant's early separation from the mother, the fragility of the infant's behavior and the difficults in socialisation of premature riskinfants make it difficult for the mother to deal with the infant. We recommend that early stepsare taken to assist development of a normal and healthy mother-infant relationship. In the intervention method,it is important that the mother appreciates the infants behavior abilities and the infant's signs of stress. Program 2: Assisting the development of sleep-wake rhythm Sleep and wake rhythms should be in accord with the natural cycle of the daysothat a pattern of sleep at night and waking during daytime - 15 -Shohei　OGIisensured。　　　　Sleep　shou1（1be　in　a　dark　room　to　prevent　disturbance　by　su（1d．en　orstrong　light　or　noises．　Stable　sleep　is　an　essential　behavior　pattern　whichhelps　regulate　neonatal　behavior．　　　　Thirty　minutes　to　an　hour　after　mid．day　feeding　can　be　employed　as　atime　for　gentle　play　activities　that　stimulate　senses　of　touch，sight　andhearing　and　so　to　help　controle　regulate　the　waking　state．　Extend．ing　astable　waking　cond．ition　d．uring　the　day　helps　increase　the　infants　interactionabilities．　　　Program31Assisting（1evelopment　of　state　control　　　　Appropriate　forms　of　stimulation　from　the　extemal　environment　arerecommended　in　order　to　improve　neonatal　behavior　system，In　usingappro．priate　treatment　it　is　vital　to　deal　carefully　with　the　infants，without　elicitingany　stress　behaviour，　In　infants　that　easily（iisplay　stress　behavior，signs　of①Assistingthede▼elop6eotofinf聞t皿d瞳otherinteracti㎝　　・apPreciationofinfant’sbehavioralability　　・　apPreciation　of　stress　behavior②Assistin窓thede▼elop■entofa肥』e－s1㏄prhyth■　　●　rhyth皿　adaptatable　a　day　cycle（1ight　and　darkness）　　●　stable　sleep　；　1ife　environ巴ent　care　　・　s　table　awake　：　treat皿ent　in　a罵ake　state③Assistingthede▼elop・eotofstatecontro1　　・staring（visua1）　　．　talking　（audi　tory）　　・touch，皿assage（tactile）　　・s冒inging，rocking（vestiblar）　　●　kand　to　皿outh，　ha1｝d　to　eyes　coordinat　ion　　■　pLysical　exercise　　●　oPPortuni　ty　to　sel　f－quiet　fro皿　crying④Pro■oti㎎口otor　de▼elop■ent（Physical　Exercise）　　．　positioning　in　lying，　holding　　。　facility　of　head，　body　righting　reaction　　・　breathing　assisst　techniques⑤Pro量otingfeedingabilities　　●　皿outh，　tangue，　passive　sti皿ulation　　．　pos　i　t　ioning　in　feedingFig．4　Early　i皿terventional　Program一16一Brazelton's Behavior Assessment Scale stress may be prevented by gentle rocking and holding so that the state of alertness is also promoted. To encourage the sense of touch,begin by using hands gently. To foster the audio-visual sense, eye contact and familiarity with the mother's voice as well as other sounds, will enable gradual progressive steps in recognition. In play between mother and infant, playing with the hands,hand to eye-contact and encouraging hand to mouth behavior is recommended to improve coordination inthese regions. In the crying state, it is important to allow the infant to self-quiet and then to use consoling techniques. Program 4: Promoting motor development (Physical Therapy) Abnormal posture in the neonatal period obstructs the process of acquir-ing normal motor development. An early correction of posture is necessary in order to acquire normal motoric development. In the lying and holding posture,it is important to inhibit abnormal-posture, as well as a development of anti-gravitic activities is attended. Physical Therapy will promote behavioral development, if the stress that accompanies physiology can gradually be alleviated. The approach put into practice is the facilitation of the head and body's righting reaction, and anti-gravitic activities. When an infant has asevere respiratory disease, enforce chest physical therapy. The postural drainage and thoracic mobilization which assists the infant's breathing movement will improve respirational efficiency, and regu-late neonatal behavior. Program 5: Promoting feeding abilities Disorders of feeding in a premature infant originate frorn respiratory distress. However, one group of infants may have a neurogical disorder and over-sensitivity in their oral regions. In this type of infants, fingers should be used to practice stimulation of the internal-external oral region. Attention should also be paid to the posture during feeding. Development Progress In one year's treatment up to the present, 11 cases out of the 16 at risk infants viewed in the Fig. 5 indicated a developmental level of 12 months on the Bayley Scales. In 9 infants with predicted difficulties in mental-motor development, both MDI and PDI scores showed comparatively smooth prog-ress. However it did not develop to a standard value yet. In 2 cerebral palsy - 17 -Shohei OGI infants, with 80.5 average points MDI scores indicated comparatively smooth progress. However in 61.0 average points PDI scores reflected delayed acqui-sition of walking. This Fig. 6 shows progress of the former cases' motor development. In comparison with the standard values, smooth progress in development lagged by two or three months later. In cerebral palsy infants the progress from sitting and sanding, to acquiring walking, tended to be markedly slow. Conclusion The above has been a report of the effects of intervention based on the NBAS on the early development of at risk infants, and our application of the early intervention program. The NBAS was extremely useful for the assess-ment and intervention planning of development difficulties, as well as assist-ing at theirdevelopment. We strongly recommend a clinical application of NBAS for at risk infants. ID I PDI Control Subjects Risk Infants 102. 4~ 7. 7 80. ItlO. 6 97. 9i 8. 2 77. 3~ 9. 7 Fig. 5 Development level of 12 months (Corrected Age) on the Bayley Scales. ua I k i ng hold IJa t k i n8 oreep i n8 s i tt i ng rol , I ng head control e h-- ~c>--e H~( l)~--H e r- --1C e : control (~): RISK InT. , HDH H--O-H e (Corr . Age) 2 4 o 12 14 16 lO lO Fig. 6 Motor Development Progress - 18 -Brazelton's Behavior Assessment Scale Ref erence 1. Akiyama T, et al:Neonatal behavior of healthy matured infants and devel-opment through 5 year old.Bull Sch Allied Med Sci Nagasaki Univ, 4: 19-27. 1990. 2. Akiyama T, et al: Neonatal behavioral assessment of SFD infants and 10ngitudinal study of their development-During the first postnatal year-. Bull Sch Allied Med Sciences Nagasaki Univ, 5: 41 -50. 1991. 3. Brazelton T. B.: Neonatal behavioral assessment scale. Clinics in Devel-opmental Medicine No. 88, Blackwell Scientific Publication Ltd. , London, I -104, 1984. 4. Joy Donigor Osofsky (Edited): Handbook of Infants Development. Second Edition. A Wiley-Interscience Publication, New York, 1987, 788-817. 5. Ogi S, et al: Early Assessment and Intervention for Premature Infants with respiratory distress.Bull Sch A1lied Med Sci Nagasaki Univ, 6: 25-30. 1992. 6. Ezure K, et al: Physiotherapy for the premature and mature newborn infants. Rigakuryohogaku, 14: 357-364, 1987. - 19 -Shohei　OGIブラゼルトン新生児行動評価の臨床活用　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　ヨ大城　昌平　　穐山富太郎　　福田　雅文　　　　　4後藤ヨシ子 　　　　　2草野美根子1234長崎大学医学部付属病院理学療法部長崎大学医療技術短期大学部長崎大学小児科長崎大学教育学部要旨我々はこれまでブラゼルトン新生児行動評価法（NBAS）を未熟児やリスクを有する成熟児の早期発達評価と介入手段として応用してきた。今回は未熟児を対象にNBASの評価結果から発達障害を予測された児の新生児行動上の特性を4っの行動系に分けて整理し，我々の実施している早期療育プログラムにっいて報告した。また，これまでフォローした児にっいて発達経過を加えた。　　　　　　　　　　　　　　　　　　　　　長崎大医療技短大紀7：11－20，1993一20一

ブラゼルトン新生児行動評価の臨床活用

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ブラゼルトン新生児行動評価の臨床活用

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