How have the steps of implementation science been used to develop The Possums Sleep Programs?
Baby and toddler sleep is highly contextual, impacted by and interacting with multiple elements of environmental experience
From 2011, the 'Neuroprotective Developmental Care Model of Infant Sleep' (NDC-MIS), which is the theoretical model underlying The Possums Sleep Program, uniquely located infant sleep in the context of responsive infant care, breastfeeding, feeds, cry-fuss problems, infant health, and parent mood and well-being. The profoundly contextual nature of parent-infant sleep and also of breastfeeding is foundational to the broader NDC model, detailed in about 30 research publications.
The NDC-MIS and its education or clinical translations, into
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The Possums Sleep Film and Workbook (2015-2016)
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The Possums Baby and Toddler Sleep Program (2020)
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Sleep Baby & You (2020)
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And now The Possums Baby and Toddler Sleep Program (2024),
comprise the sleep domain of Neuroprotective Developmental Care (NDC or ‘the Possums programs’). The NDC-MIS and its education or clinical translation as The Possums Sleep Program is also detailed in the educational materials of the
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NDC Masterclasses (Unsettled infant behaviour and perinatal mental health)
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NDC Accreditation Pathway, delivered by The NDC Institute here.
Each NDC domain offers a paradigm shift within that domain. I developed these frameworks, with the assistance of my collaborators, by applying the theoretical lenses of
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Complexity science (more here)
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Evolutionary biology
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Contextual behavioural science
to extensive interdisciplinary research literature. Because the NDC theoretical frameworks and clinical translations have been developed over time, I apply the name NDC retrospectively to some of the early theoretical and clinical research publications. The frameworks have then been translated through the lens of
- Holistic generalist clinical practice and iterative parent and health professional feedback, into education and clinical programs.
The NDC project aims to conform with best practice in development of complex new community-based healthcare interventions by drawing on the principles of implementation science (Wensing 2019), which I detail in eight steps below.
#1. Questions and concerns about parent-infant sleep arose out of personal and clinical experience, inviting research
I had questions and concerns which arose out of my experiences
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As a mother of two children (1990, 1992)
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As a GP or generalist medical practitioner with a special interest in indigenous health (1987-1989), more here and here
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As a breastfeeding medicine physician (qualification as International Board Certified Lactation Consultant 1994-2004; 2012 ongoing).
#2. The multi-disciplinary research literature relevant to these questions and concerns was formally searched, analysed and synthesised, including analysis of existing frameworks and approaches for helping families facing infant sleep problems
I began publishing systematic and meta-narrative reviews of the literature across multiple relevant disciplines. I knew that sleep could not be effectively addressed without considering context, that is, the domains of breastfeeding and feeds; the baby's health, including gut, gut microbiome, and medical conditions; perinatal mental health; and infant sensory motor needs.
Prior development of contextual theoretical foundations of Neuroprotective Developmental Care Model of Infant Sleep (NDC-MIS) in four publications detailed in Box 1 including
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Stakeholder engagement in development of theoretical frame
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Systematic review of existing infant sleep research, theoretical models, and clinical/educational translations.3-6
I identifed existing infant sleep models. Two prior existing infant sleep models were identified, the dominant behavioural model, and the ecological model, which Dr Whittingham and I referred to as an ‘alternative paradigm: normalizing night-waking’ in our 2014 publication.
#3. Key informant interviews were conducted
I gathered qualitiative data from 24 health professionals across 11 disciplines in Australia and the United Kingdom, all of whom were senior in the delivery of care for unsettled infants and their families, as clinicans or researchers. This project was funded by the RACGP's Chris Silagy Research Scholarship. The results were published in 2012.
#4. The contextual factors which impact on family-infant sleep were also identified, analysed, and published in the research literature, including the inappropriate medicalisation of unsettled infant behaviour
I located The Possums Sleep Program in the context of multiple other domains theoretically.**
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Two theoretical publications which develop a complexity science/evolutionary biology model of unsettled infant behaviour
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‘The unsettled baby: how complexity science helps’ (2011) details a new model of unsettled infant behaviour which re-interprets and synthesises extensive research across multiple disciplines through the lenses of complexity science and evolutionary biology. This article frames infant sleep and unsettled behaviour in the context of interaction with the domains of breastfeeding/feeds, parent well-being, infant medical conditions, and socioculturally-located parent-infant behaviours (e.g. ‘sleep training’ or ‘first wave behavioural’ approaches). The article proposes that unsettled infant behaviour arises when complex sociocultural contexts fail to align with the infant’s biological expectations, which have evolved out of the human’s environment of evolutionary adaptedness
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‘A neurobiological model for cry-fuss behaviours in the first three to four months of life’ (2013) continues to develop a new model which re-interprets and synthesises research across multiple disciplines concerning unsettled infant behaviour (also conceptualised as regulatory problems, or as sleep, feed, or cry-fuss problems), through the lenses of complexity science and evolutionary biology. Infant sleep is framed as one domain which interacts with the four other domains of breastfeeding/feeds, environmental enrichment (referred to as sensory nourishment), parental mental health, and infant health, giving rise to the clinical/educational translation of the NDC or Possums five domain approach to unsettled infant behaviour
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A 2013 systematic review of the research to identify existing infant sleep models, their clinical/educational translations, and evaluations. 43 articles were identified and analysed, 19 of these in detail as key studies
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A review of the research literature which demonstrates the potential benefits of integrating applied functional contextualism (popularly known as Acceptance and Commitment Therapy) for parent mental health and well-being into the Possums programs, including the Possums Sleep Program.
#5. The research was translated into the educational and clinical program called The Possums Sleep Program
I developed an early version of The Possums Sleep Program, which I delivered in the clinic and offered to health professionals in conference and education settings, in the context of the five domains of NDC or the Possums programs
I developed and delivered The Possums Sleep Program in the Brisbane Possums Clinic from February 2011, when the Queensland Centre for Mothers and Babies funded an evaluation of my initial education of health professionals in the Possums 5-domain approach to unsettled infant behaviour.
I iteratively improved and developed this in response to parent feedback in the clinic, and health professional feedback during education courses.
#6. The Possums Sleep Program was published in the international research literature as both a novel contextual model of infant sleep and its translation into education programs
I retrospectively refer to the theoretical model that I was developing up, and which Dr Koa Whittingham worked with me to publish in 2014, as the Neuroprotective Developmental Care Contextual Model of Infant Sleep (NDC CMIS).
This model proposed that infant sleep could only be fully understood and optimised in the context of a multi-domain approach to parent and infant well-being (which comprise the NDC domains of breastfeeding/feeds, sleep, infant sensory motor needs, parent mental and emotional well-being, and infant health including gut health), with the evolutionary norm of breastfeeding foundational.
A synthesis and interpretation of the existing interdisciplinary infant sleep research literature through the theoretical lenses of complexity science, evolutionary biology and contextual behavioural science (NDC-MIS), translated clinically/educationally as The Possums Sleep Program.
#7. The Possums Sleep Program was disseminated using multiple platforms
I put in many hours attempting to disseminate The Possums Sleep Program, through
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An online program which could be purchased from the Possums charity (2013-2023)
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Education of health professionals
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Multiple conference presentations
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Multiple articles about The Possums Sleep Program published in media including online media
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Social media.
#8. Evaluations of The Possums Sleep Program
Four promising evaluations of The Possums Sleep Program and Sleep Baby & You have been conducted, peer-reviewed, and published. The Possums Sleep Program also comprises the sleep domain in four other broader evaluations of NDC, which have been peer-reviewed and published. Two other evaluations are currently being analysed and written up.
Recommended resources
About the development of The Possums Baby and Toddler Sleep Program (from 2011 ongoing)
What is the Neuroprotective Developmental Care Contextual Model of Infant Sleep (NDC-MIS)?
Timeline of development of The Possums Sleep Program
Selected references
Ball H, Taylor CE, Thomas V, Douglas PS, Sleep Baby and You Working Group. Development and evaluation of ‘Sleep, Baby & You’ - an approach to supporting parental well-being and responsive infant caregiving. Plos One. 2020;15(8): e0237240.
Ball H, Douglas PS, Whittingham K, Kulasinghe K, Hill PS. The Possums Infant Sleep Program: parents' perspectives on a novel parent-infant sleep intervention in Australia. Sleep Health. 2018;4(6):519-526.
Closson L, Flykt M, Bringen Z. Evaluation of possums sleep intervention: a pilot feasibility study. Journal of Nursing Education and Practice. 2020;10(2):https://doi.org/10.5430/jnep.v5410n5432p5415.
Crawford E, Waldby L, Crook E. New perspectives on responsive infant care: a qualitative study of the ways in which Neuroprotective Developmental Care (NDC) shapes mother-infant co-occupations. Journal of Occupational Science. 2023:https://doi.org/10.1080/14427591.14422023.12236117.
Crawford E, Whittingham K, Pallett E, Douglas PS, Creedy DK. An evaluation of Neuroprotective Developmental Care (NDC/Possums Programs) in the first 12 months of life. Maternal and Child Health Journal. 2022;26(1):110-123.
Douglas PS. The need to acknowledge similarities between the 2022 D'Souza and Cassels and the 2014 Whittingham and Douglas contextual models of infant sleep. Sleep Health. 2023;9:797-800.
Douglas PS. The Possums Sleep Program: supporting easy, healthy parent-infant sleep. International Journal of Birth and Parent Education. 2018;6(1):13-16.
Douglas P, Hill PS. Behavioural sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J Dev Behav Pediatr. 2013;34:497–507.
Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772.
Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.
Douglas PS, Hill PS, Brodribb W. The unsettled baby: how complexity science helps. Arch Dis Child. 2011;96:793-797.
Douglas P, Mares R, Hill P. Interdisciplinary perspectives on the management of the unsettled baby: key strategies for improved outcomes. Australian Journal of Primary Health. 2012;18:332-338.
Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.
Douglas PS. The need to acknowledge similarities between the 2022 D'Souza and Cassels and the 2014 Whittingham and Douglas contextual models of infant sleep. Sleep Health. 2023;9:797-800.
Moullin JC, Dickson KS, Stadnick NA, Albers B: Ten recommendations for using implementation frameworks in research and practice. Implementation Science Communications 2020, 1(42):https://doi.org/10.1186/s43058-43020-00023-43057.
Ozturk M, Boran P, Ersu R, Peker Y. Possums-based parental education for infant sleep: cued care resulting in sustained breastfeeding. European Journal of Pediatrics. 2021;180:1769-1776.
Whittingham K, Palmer C, Douglas PS, Creedy DK, Sheffield J. Evaluating the 'Possums' health professional training in parent-infant sleep. Infant Mental Health Journal. 2020;41(5):603-613.
Whittingham K, Douglas PS. "Possums": building contextual behavioural science into an innovative evidence-based approach to parenting support in early life. In: Kirkaldy B, editor. Psychotherapy in parenthood and beyond. Turin, Italy: Edizioni Minerva Medica; 2016. p. 43-56.
Whittingham K, Douglas PS. Optimising parent-infant sleep from birth to 6 months: a new paradigm. Infant Mental Health Journal. 2014;35:614-623.
Wensing M, Grol R. Knowledge translation in health: how implementation science could contribute more. BMC Medicine. 2019;17(88):https://doi.org/10.1186/s12916-12019-11322-12919.
