Health Topics

Sleep-Onset Association Disorder

Sleep-onset association disorder occurs when your child associates or closely connects his ability to fall asleep with "something in the environment" (such as being held by his parent; being rocked to sleep; nursing, drinking, or eating at bedtime; watching television or even sleeping in a parent's or sibling's bed). When this "something in the environment" is absent, your child cannot fall asleep. All of us wake up briefly a number of times each night, but we are usually not aware that we wake up because we fall back asleep very quickly. For children with sleep-onset association disorder, when they awake during the night, they are not able to fall back asleep if their "something in the environment" is not present. If your child is only able to nap or fall asleep at night in the car (or in one bed but not another), he likely has a sleep-onset association problem.

Nighttime Eating / Drinking Disorder

Nighttime eating / drinking disorder is more common among infants and toddlers and involves "excessive" nighttime feeding (often nursing or bottle-feeding) that is required for the child to fall asleep or return to sleep. For infants, feeding during the night is a normal part of development. However, by the age of 5 or 6 months, most children are not drinking more than 8 ounces of fluid during the night (or nursing more than once or twice).

Limit-Setting Sleep Disorder

Limit-setting sleep disorder is more common for children who are fully ambulatory (i.e., able to walk / run) and have developed receptive and expressive language skills (typically after age 2). Limit-setting problems are characterized by a child refusing or stalling bedtime (e.g., "I need to go to the bathroom, get a drink of water, one more hug, tell you something really really important, etc.) and making it hard for the parent to leave the child's room without them getting up out of bed. Attempts to have the child return to bed may result in behavioral outbursts (e.g., crying; screaming; destruction of property or aggression).

1. A consistent sleep routine is helpful for treating and / or preventing the most common childhood sleep disorders. Routines that integrate relaxing pre-sleep activities and an environment free of over stimulating or distracting activities are best for your child.
2. Spending time with your child before bed each night is a critical part of the bedtime ritual. Do not substitute television or videos for personal time with your child each night. Positive parent-child interactions before bed help your child to calm and feel comfortable with the transition to bed.
3. For children with a sleep-onset association problem, a bedtime routine that promotes the child's ability to fall asleep by herself is important.  Teach your child to fall asleep independently at all sleep intervals (including naps).
1. Set up an environment (sleep associations) at bedtime that does not require a response from you (e.g., play music, put on a nightlight, provide comfort items).
2. Avoid having your child fall asleep in your arms or while you are rocking her. Place her in her bed before she falls asleep.
3. For the young child (that is still napping) it may be easiest to start the relearning process at night.
4. Your child is expected to cry at first during this process.
5. You are not abandoning your child by intentionally ignoring her mild distress for set periods of time. When you allow her to experience increasingly longer periods by herself followed by brief encouragement and reassurance, she can learn to fall asleep without your presence.
6. Place your awake or drowsy child in his bed after you have completed a calming and quiet bedtime routine.
7. Say goodnight and leave the room. You may keep the door open to allow some dim light into the room or use a nightlight.
8. If your child begins to cry and is still crying after a few minutes, return to the room and provide brief reassurance with words or light physical touch (placing hand on back or belly). Do not pick up your child, turn on the lights, or respond to requests (e.g., another bedtime story). Do not stay in the room longer than one or two minutes. Repeat this process, extending the time that you give your child to fall asleep independently (e.g., 2 minutes; then 5 minutes; then 10 minutes; then 15 minutes). Increase the time that you are out of the room in increments of five minutes to help your child gradually become more comfortable being alone in her bed.
9. On subsequent nights increase the intervals of time that you allow your child to self-sooth. For example on the second night start at 5 minutes and on the third night start at 10 minutes.
10. The first few nights are going to be the most difficult for you and your child as you learn this new routine. The time that you spend away from your child when he is upset can be very difficult for you. However, it is important to keep in mind that you are teaching him to learn a very important developmental skill (falling asleep independently).
4. If you are able to use this approach consistently on consecutive nights, you are likely to see results in 5 to 10 days.
5. If your child becomes sick or there is some other event that interferes with this process, you will likely have to start the process again.
6. If you feel you have been consistent with this approach for a two-week period and you are not seeing results, you should consider having your child evaluated for another underlying sleep disorder.
7. For a child with nighttime feeding problems it is important to gradually wean your child from this habit by reducing access to food / drink. This can be accomplished by reducing the frequency of nighttime feedings (i.e., increase the interval of time between feedings). It may help to set defined time intervals to offer your child her bottle (e.g., every two hours) and slowly increase the interval periodically until you are no longer offering the bottle at night. If your child wakes up and signals hunger before the time you have set for access to food / drink, provide brief reassurance and give her an opportunity to fall back asleep without access to food (see above for guidelines on helping your child to self-soothe and fall asleep independently).
8. For a child with limit-setting problems at bedtime it is important to have a consistent bedtime routine as well as very clearly defined behavioral limits for bedtime. Parents should focus on having a relaxing pre-sleep ritual each night, however, the transition to bed may require a more "matter of fact" approach. A firm and consistent response to your child's delay at bedtime will prevent you from inadvertently reinforcing your child's "delay behaviors." Limit-setting during the day and night are important. It may be helpful to establish a behavioral reinforcement system that provides behavioral incentives for your child's cooperation with bedtime and staying in bed through the night.