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    Sleep Onset Association Type BIC

    Behaviourial Insomnia in Childhood (BIC)
    Sleep Onset Association Type BIC
    What to Look Out For
    Risk Factors
    Where to Seek Treatment
    KK Women's and Children's Hospital
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    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 medications.

    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

    Have a good sleep routine with positive sleep

    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.

    Risk Factors

    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 include:

    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 some children.

    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 taxing.

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