ADBB scale : an overview
withdrawal in infancy
It has been well documented that infants, from just a few hours old,
demonstrate the ability to socially interact with adults. From a few
months old infants’ social behaviour can be observed in a variety
of ways, including vocalising, eye contact with the observer, imitating
physical gestures, showing a range of facial expressions, and responding
to the adult. Using facial expressions and vocalisations as indicators
of feeling states, most infants show three emotions by two months
of age (interest, contentment and distress), and eight emotions by
seven months (joy, contentment, anger, disgust, surprise, interest,
distress and sadness).
Smiling in response to a person’s voice and face
occurs by eight weeks old, while anxiety towards strangers
is generally considered to be evident by around nine months
Such anxiety when held by a stranger will usually produce
active behaviour, such as vocal protestations and squirming,
in an attempt to get closer to the infant’s parent.
Withdrawn social behaviour from just two months old, indicated by
a lack of either positive (e.g., smiling, eye contact) or negative
(e.g., vocal protestations) behaviours is more akin to a state of
learned helplessness, and should alert the clinician to the possibility
that the infant is not displaying age-appropriate emotional/social
This would suggest that there is some carry-over effect - that the
infant, exposed to prolonged periods of interacting with an unresponsive
caregiver, has become ‘depressed’ and continues to exhibit
withdrawn behaviour even when someone else interacts in a positive
way with him (for the sake of clarity the infant will be referred
to as a male).
Such low infant sociability can be due to many
factors, including both organic and non-organic disorders
(Guedeney & Fermanian, 2001). In 70% of infants with
nonorganic failure to thrive, where there has been considerable
emotional or social understimulation, Powell and Low (1983)
found that such infants had poor eye contact, diminished
vocalization and a lack of response to an adult. Tronick
and Weinberg (1997) have reviewed how maternal depression,
which can result in either an intrusive or withdrawn parenting
style, can also affect the social behaviour of the infant.
Such infants have less eye contact and more self-comforting
behaviours (self-stimulating gestures).
This connection between depressed mood in the caretaker
(usually the mother) and either withdrawn behaviour in the
infant, or impaired mother-infant interaction, has been
found in a number of studies.
Of note is that such withdrawn infant behaviour has been
found to be associated with decreased frontal EEG activity,
which is present when the infant is interacting with his
mother and also when interacting with other adults (Dawson
et al., 1999).
The diagnostic classificatory system for infants and toddlers, DC:
0-3 (Zero to Three, 1994), has recognized the importance of impaired
affect in infants by including a category of ‘Depression in
Infancy and Early Childhood’.
Field (1995) states that "Infants who interact with
depressed mothers (particularly chronically depressed mothers)
are at risk for later social interaction problems"
It is important to note, however, that depression in the
postpartum period does not necessarily mean the mother-infant
interaction will be impaired, nor should one presume that
all impaired interactions will necessarily lead to withdrawn
Undoubtedly there will be buffers to such effects, such as the role
of fathers and other caregivers and possibly the temperament of the
Given these caveats, there is an increasing realisation that assessing
an infant’s social behaviour is important.
While diminished social behaviour in the infant may not necessarily
be an indicator of pathology, it should alert the clinician to undertake
further assessment of both the infant and the environment.
In some cases it may reveal that the mother is experiencing psychosocial
difficulties (such as postnatal depression or bonding difficulties)
which she may have been reluctant to disclose.
Assessment of the infant’s social
Matthey et al (in press) state :
"While measurement of the infant’s
temperament may have some overlap with his social behaviour,
it is important to realise that these two constructs are
Temperament refers to the infant’s degree and style
of responsiveness to varying internal and external stimuli
(e.g., noise, heat, as well as social stimuli), whereas
social behaviour in infancy refers to degree and style of
responsiveness just to social stimuli.
Thus while an infant may, within temperament measures, be
considered ‘shy’ or ‘slow to warm up to
others’, he will still be responsive to the adult.
A socially withdrawn infant however will lack many of the
features of responsiveness to others." (in press).
Most studies that have investigated infant social behaviour have been
done within an experimental setting directing the mother to interact
with her child.
These experimental settings have sometimes required special apparatus
(e.g., Murray’s use of an infant chair and mirror placed on
a table) while the mother and child are videotaped.
Trained assessors then rate these videotaped interactions, with part
of the rating giving an indication of the social behaviour of the
infant towards the mother.
A different approach has been taken by Rosenn, Loeb and Jura (1980),
who describe an assessment measure that can be used within a clinical
setting, investigating the social behaviour of the infant to a relative
stranger - the examiner (e.g., child health nurse or paediatrician).
They used a semi-structured social interaction, consisting of the
examiner approaching the infant, showing him a toy, picking the infant
up, holding him, and putting him down again.
The infant’s overall social behaviour during this interaction
is then rated on a 7-point scale, from 1 (extremely negative - screaming,
flailing, self-stimulation) to 7 (extremely positive - laughing, cooing,
In their paper they discuss the inter-rater reliability of this measure
across samples of failure-to-thrive and control infants.
Matthey et al (in press) state :
"One advantage of assessing an infant’s
social behaviour with a comparative stranger, rather than
with his parent, is that it does not put the parent under
any perceived pressure.
Within a clinical setting, such as a hospital or early childhood
clinic, to ask a parent to ‘play with her infant’
and for the clinician to assess the resultant infant social
behaviour would undoubtedly make parents feel anxious, and
possibly unwilling to visit such centres if they felt their
competence was being assessed.
A scale that therefore neither requires special apparatus,
nor a special sequence of prescribed interactions, and which
does not require the parent’s active interaction with
the infant, could be considered by clinicians interested
in assessing the infant’s social behaviour as being
more desirable." (in press).
Such a scale is the Alarme Distress Bébé Scale (ADBB),
by Guedeney and Fermanian (2001), constructed to assess infant social
behaviour during routine physical examinations given by a range of
The ADBB Scale
This French scale consists of eight items related to the
infant’s social behaviour, and is used during the clinician’s
routine physical examination of the infant.
It requires the clinician to engage the infant in social behaviour
- by talking to him, touching him, and smiling to him, which are
practices normally undertaken during such examinations.
The eight items, each rated from zero to four (with low scores being
optimal social behaviour), are: facial expression; eye contact;
general level of activity; self-stimulation gestures; vocalizations;
briskness of response to stimulation; relationship to the observer,
and attractiveness to the observer.
The clinician keeps in mind the eight items while he/she is conducting
the routine physical assessment, and then spends approximately two-three
minutes completing the scale.
Matthey, Guedeney, Starakis and Barnett (in press) state :
"Recently high scores on the ADBB (indicative
of withdrawn behaviour) have been show to be associated
with less optimal interactive behaviours by both the mother
and her infant in a Finnish study on 127 two-month-old
infants (Puura, 2004) and in an Israeli study on 97 seven
to eighteen-month-old infants (Dollberg, 2004).
The original paper (Guedeney & Fermanian, 2001) shows
the ADBB scale to have good psychometric properties on
a sample of sixty infants in France, aged between 2-24
Good inter-rater reliability was found between raters
using it during live (as opposed to viewing the videotape)
assessments and an expert’s rating.
Inter-rater reliability, as well as acceptable test-re-test
reliability (rs = 0.91, one month interval), have also
been demonstrated in a Brazilian study (Lopes, 2004).
A total ADBB cut-off score of 4/5 was found to be optimal
in detecting those infants considered to have unusually
low social behaviour.
This optimum cut-off score has recently been replicated
in both a Finnish study (Puura, 2004) and a Brazilian
study (Lopes, 2004).
Thus a score of 1 on only five of the eight items is sufficient
to indicate possible sub-optimal social behaviour."(in
Matthey et al (in press) state that :
Dr. Stephen Matthey: South West Sydney Area
Health Service: Infant, Child & Adolescent Mental Health Service,
George St. Health Centre, 157-161 George Street (2nd Floor), Liverpool,
NSW 2170 AUSTRALIA.
"The original paper (Guedeney &
Fermanian, 2001) shows the ADBB scale to have good psychometric
properties on a sample of sixty infants in France, aged
between 2-24 months.... Factor analysis, using the criterion
of factor loadings of 0.5 or more, identified two factors
accounting for 63.6% of the variance - an interpersonal
factor (five items: eye contact, level of activity, self-stimulating
gestures, relationship, attractivity) and a non-interpersonal
factor (3 items: facial expression, vocalization, response
to stimulation), with one complex item (response to stimulation)
loading greater than 0.5 on both factors (but with the
authors deciding to put it under the non-interpersonal
The authors of the scale recommend that further studies
investigate this factor structure. This has been done
in a Brazilian study on 90 infants aged between 0 and
2 years (Assumpcao, Kuczynski, Da Silva Rego, & Castanho
de Almeida Rocca, 2002). This study found four factors
accounting for 63.5% of the variance. While the authors
specified the factor loading criterion of 0.5, examination
of the data reveals that all non-included items had loadings
of less than 0.3, which is the usual criterion used in
factor analysis (Child, 1990). Factor 1 consisted of facial
expression and level of activity; factor 2 of eye contact
and response to stimulation; factor 3 of self-stimulating
gestures and the relationship to the observer; and factor
4 of vocalisations. There were no items loading on more
than one factor.” (in press).
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Available translations of adbb scale
Translations credits :
Italian : Dra Vania Valoriani,Firenza
Catalan and Castillan : Dr Jorge Tizon, Barcelona
Dutch : Pr Peter De Chateau, Nijmegen
German : M. Moralès-Huet & Claudia Klier, Wien
Hebrew : Ruth Feldman & Miri Keren, Bar-Ilan university
Portugal : Barbara Figereido, Porto
Brazil : Franciso Baptista Assumçào, Sao Paulo.
Dra Simone Facuri- Lopez, Belo -Horizonte.