This section will discuss behavioural insomnia of childhood, which can be further classified into sleep onset association disorder, limit-setting sleep disorder, or combined disorder (combination of both sleep onset association and limit-setting disorder). A child with sleep onset association disorder relies on specific stimulation, objects or settings for initiation of sleep, or to return to sleep, following an awakening. Sleep onset association disorder is estimated to affect 25 per cent to 50 per cent of children at 6 to 12 months of age, and 15 per cent to 20 per cent of toddlers.
The child with sleep onset association disorder often presents with frequent night awakening as he is unable to self-soothe back to sleep after a spontaneous night awakening. Factors that may increase the likelihood of night awakenings include breastfeeding, co-sleeping, colic, acute illness, changes in the sleep environment, difficult temperament, parental anxiety, and when the child has just achieved a certain motor or cognitive developmental milestones (e.g.

Management of sleep onset association disorder includes establishing a good sleep routine which involves positive sleep associations.
They include behavioural insomnia of childhood (which is discussed below), and other causes such as delayed sleep phase disorder (more common in adolescents due to the two-hour phase delay in their circadian rhythm mentioned earlier), medical conditions (e.g. If you suspect that your child has difficult-to-manage behavioural insomnia of childhood, or if your child has other causes for his insomnia, consult your doctor who will be able to help, or refer your child to a paediatric sleep specialist. Although there are no universally acceptable or unacceptable sleep associations, specific associations that are highly demanding, or disruptive to the caregivers are considered negative sleep onset associations (e.g.
The child may get frustrated and cry without caregiver intervention to provide the association required to sleep.

Persistent night awakenings are likely to continue for some time without intervention, although negative sleep associations developed during infancy tend to taper off with age depending on the associations (e.g. Usually once your child is able to fall asleep alone at bedtime, he is likely to learn to self-soothe to sleep during spontaneous night awakenings soon.

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