The Possums Sleep Programs were developed from the Neuroprotective Developmental Care Contextual Model of Infant Sleep + evaluations to date

What is the NDC Contextual Model of Infant Sleep?

This article is adapted from Douglas 2022 "D'Souza and Cassels and the 2014 Whittingham and Douglas contextual models of infant sleep."

The development of the Neuroprotective Developmental Care Contextual Model of Infant Sleep has occurred in the context of development of the Neuroprotective Developmental Care or ‘Possums programs’.

• From 2011 ongoing, iterations of Neuroprotective Developmental Care Model of Infant Sleep (NDC-MIS) uniquely located infant sleep in the context of responsive infant care, breastfeeding, feeds, cry-fuss problems, infant health, infant sensory motor development, and parent mood and well-being. The NDC-MIS and its clinical translations into the Possums Sleep Program (2015-2016), the Possums Baby and Toddler Sleep Program (2020), and Sleep Baby and You (2020) comprise the sleep domain of Neuroprotective Developmental Care (NDC or ‘the Possums programs’).1, 2

• 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.

• Each NDC domain offers a paradigm shift within that domain. I and my co-authors developed these frameworks by applying the theoretical lenses of complexity science, evolutionary biology and 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.3-12

Applying implementation science to develop NDC-MIS and The Possums Sleep 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.13 As a result, the NDC-MIS (NDC infant sleep domain) is developed from:

1. My clinical experience as a GP working with mothers and babies, iteratively refined in response to parent feedback, including between 2011-January 2023 in The Possums Clinic Brisbane;

2. Peer-reviewed and published analysis of key informant interviews with 24 health professionals from 11 disciplines in Australia and the United Kingdom (2012);7

3. Two theoretical publications which develop a complexity science/evolutionary biology model of unsettled infant behaviour:

   • ‘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;6

   • ‘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.5, 6

4. 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;14

5. 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 (2014).15

6. 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.11

7. An analytic review of infant development which builds the case that NDC, including NDC-MIS, optimises infant development. The proposed role of the NDC-MIS in optimising infant development is explored through the lens of neurodivergence.12

Evaluations of The Possums Sleep Program and its adaptation Sleep, Baby & You

Five promising preliminary evaluations specifically of the sleep domain (Possums Sleep Program and Sleep Baby and You) have been conducted, in four countries.

1. Evaluation of 164 practitioners upskilled in Sleep Baby and You (UK adaptation of Possums Sleep Program) and 535 parents over 5 locations (UK 2021) showed that SBY promotes responsive care; changes in parent attitude, behaviour and well-being; reduction of negative thinking. Health professionals and parents report ‘Sleep Baby and You’ (UK version of Possums Sleep Program) easy to understand and to use; parents rated it helpful to their own and their baby’s sleep; parents reported less night waking and stress about sleep and more enjoyable days.19

2. Evaluation of 144 health professionals upskilled in The Possums Sleep Program (Australia 2021) showed improvement in sleep knowledge and quality of sleep; in psychological flexibility; and reduced burnout and secondary traumatic stress. Health professionals report improvements in knowledge on infant sleep regulation, the mother–infant relationship and ACT; improvements in own sleep quality; improvements in psychological flexibility; reduction in professional burnout and secondary traumatic stress.21

3. Evaluation of 64 parents who used the Possums Sleep Program (Australia 2018) showed it is highly valued by parents, resulting in reduced stress, less concern about perceived sleep problems and better quality of life.Acceptable to parents and perceived by them to align parent and infant needs, improve their quality of life, and reduce their focus on perceived infant sleep problems.20

4. Evaluation of 24 mothers with infants 0-6 months (Finland 2020) who received a Possums-adapted psychoeducation workshop 4 x 2 hours duration, in a collaboration between Colorado State University and Finnish researchers. “Results showed improvements in the perceived emotional availability in the mother-infant relationship; however, positive effects related to maternal or infant sleep were only on a trend level.”18

5. RCT 183 mothers comparing Possums-based sleep approach and usual care (Turkey 2021) showed sustained breastfeeding and improved breastfeeding rates.22

Evaluations of Neuroprotective Developmental Care or the Possums programs generally

1. NDC/Possums services is efficacious in addressing infant’s crying, the mother’s perceptions of their baby’s sleep problem (Crawford et al Maternal and Child Health Journal 2022)2

2. Highly valued by parents, who report that NDC/Possums programs were ‘life-changing’ and ‘transformative’, significantly improving emotional well-being and mental health. ‘Flexibility across the days’ was identified as the overarching theme regarding mother-infant co-occupations (Crawford et al 2023)1

3. The Possums 5 domain approach halves infant cry durations in first 3 months post-birth and improves Edinburgh postnatal depression scale scores.23

See elsewhere for breastfeeding-related evaluation.

References

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.

1. 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.
2. 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.
3. Douglas P. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry alot in the first few months overlooks feeding problems. J Paediatr Child Health. 2013;49(4):e252-e256.
4. Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011;343:d7772.
5. 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.
6. Douglas PS, Hill PS, Brodribb W. The unsettled baby: how complexity science helps. Arch Dis Child. 2011;96:793-797.
7. 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.
8. Douglas PS. Excessive crying and gastro-oesophageal reflux disease in infants: misalignment of biology and culture. Med Hypotheses. 2005;64:887-898.
9. Douglas PS, Geddes DB. Practice-based interpretation of ultrasound studies leads the way to less pharmaceutical and surgical intervention for breastfeeding babies and more effective clinical support. Midwifery. 2018;58:145–155.
10. Douglas PS, Keogh R. Gestalt breastfeeding: helping mothers and infants optimise positional stability and intra-oral breast tissue volume for effective, pain-free milk transfer. Journal of Human Lactation. 2017;33(3):509–518.
11. 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.
12. Douglas PS. Pre-emptive intervention for Autism Spectrum Disorder: theoretical foundations and clinical translation. Frontiers in Integrative Neuroscience. 2019;13(66):doi.org/10.3389/fnint.2019.00066.
13. Wensing M, Grol R. Knowledge translation in health: how implementation science could contribute more. BMC Medicine. 2019;17(88).
14. 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.
15. Whittingham K, Douglas PS. Optimising parent-infant sleep from birth to 6 months: a new paradigm. Infant Mental Health Journal. 2014;35:614-623.
16. Douglas PS, Perrella SL, Geddes DT. A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series. BMC Pregnancy and Childbirth. 2022;22(1):94. DOI: 10.1186/s12884-12021-04363-12887.
17. Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life ("The Possums Approach"): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013;21:38-45.
18. 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.
19. 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.
20. 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.
21. 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.
22. 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.
23. Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life ("The Possums Approach"): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013;21:38-45.