Sleep Onset Association Type BIC
Behaviourial Insomnia in Childhood (BIC)
Insomnia, which is the inability to initiate
and/or maintain sleep, may not only
affect children, but also their parents
and the whole household.
There are many possible causes
of insomnia in children, including
behavioural insomnia of childhood (which is discussed below), delayed
sleep phase disorder (common in
adolescents due to a ‘shift in their body
clock’ at puberty), medical conditions
(causing pain, itching or coughing in
the night), psychological conditions
(e.g. anxiety, depression, stress) and
This section will discuss behavioural
insomnia of childhood, which can
be further classified into sleep-onset
association type, limit-setting type,
or combined. If you suspect that
your child has insomnia, consult a
doctor who may refer your child to a
paediatric sleep specialist.
Sleep Onset Association Type BIC
A child with sleep-onset association
BIC relies on a specific stimulation
(object or setting) for the initiation of
sleep at bedtime, or to fall back to sleep
following an awakening in the night.
Associations that are highly demanding
or disruptive to the caregivers are
considered negative sleep onset
associations (e.g. prolonged rocking,
night feedings inappropriate for age).
How common is it?
This is common, and estimated to affect
between 25 to 50 percent of infants at
the age of 6 to 12 months of age, and 15
to 20 percent of toddlers.
What to Look Out For
The child with sleep-onset associations
often presents with frequent night
awakenings as he/she is unable to
self-soothe back to sleep after a
spontaneous night awakening. The child
may continue to cry and stay awake for
prolonged periods until the caregiver
intervenes to provide the association
required for him/her to fall back to sleep.
Factors that may increase the
likelihood of night awakenings include
breastfeeding, co-sleeping, colic,
acute illness, changes in the sleep
environment, a difficult temperament,
parental anxiety, and when the child
has just achieved a certain motor or
cognitive developmental milestones (e.g.
pulling to stand, separation anxiety).
Management of sleep-onset association
type BIC includes establishing a good
sleep routine, and the use of positive
sleep associations: e.g. a comforting
object (stuffed toy or used mother’s shirt)
that the child can bring to bed with him/
her each night.
There is no ‘best’ method to help a
child fall asleep independently, but the
key is to be ‘consistent and persistent’
every night, especially if more than one
caregiver is involved. Often, once the
child is able to fall asleep independently
at bedtime, he/she is more likely to
be able to self-soothe to sleep during
spontaneous night awakenings.
Some methods that have been used
1. Extinction – Putting the child to bed
at a fixed time and ignoring his/her
cries until a specific ‘wake’ time. This
method is not recommended for
infants below the age of 6 months,
and may be emotionally draining.
Parents should be prepared for a
‘post-extinction burst’ (a period of
worsening before improvement) in
2. Graduated extinction – This is a
‘gentler’ method, where you can
respond to your child briefly each
time he/she calls (after being put
to bed), but only after progressively
longer periods of time e.g. 5 minutes,
then 10 minutes, and then 15 minutes
until he/she falls asleep. This method
is likely to take longer to work, but is
less emotionally taxing.
3. Fading of adult intervention –
Establish a bedtime routine before
sleep, and gradually increase the
physical distance between you and
your child while he/she is falling
asleep (sit by the crib or bed, and
move the chair slightly further away
each night, until out of sight of the
child). This method is also likely to
take longer but is less emotionally