Inappropriate sleep onset associations are one of the most important causes of night awakenings in infants, young children, and (rarely) older children. This is a disorder which will respond to behavioral management (or sleep training). For more information, here’s my comprehensive review of sleep training methods. The first step to successfully sleep training your child is correctly identifying that your child has a behavioral problem. If your child has a disorder such as asthma or obstructive sleep apnea which is interrupting their sleep, any attempt at sleep training is likely doomed to fail. Behavioral insomnia of childhood is divided into two types: sleep onset association subtype, and limit setting subtype. Toddler night wakings are frequently due to sleep onset association disorder. Frequently children may have characteristics of both. In this post I’m going to talk about inappropriate sleep onset associations.
Let me paint a picture for you. It’s been a long evening in the Smith household. Jimmy is 14 months old. Every night, since he was an infant, his parents have rocked him to sleep every night and then put him in his crib, at around 8 PM. His parents put him to sleep, sit down to watch some television and try to relax, but they are dreading the night ahead. Just when they get into bed, around 11 PM, they hear Jimmy crying out. They rush into his room frantically to try to rub his back so he falls asleep more quickly. These awakenings occur for the rest of the night every hour to an hour and a half. When he gets up for the day at 5:30 AM, Jimmy is quite irritable, and his parents are exhausted. They don’t have the luxury of taking two naps today. Jimmy’s problem is that he has developed inappropriate sleep onset associations, one of the subtypes of behavioral insomnia of childhood.
Inappropriate Sleep Onset Associations Cause Frequent Awakenings
The typical child with inappropriate sleep onset associations is between 6 and 36 months but may be older. This child needs his parent present to fall asleep and wakes up very frequently during the night. Parents view the awakenings as the problem, but they are a symptom of the primary issue: the child has not learned to fall asleep by himself. To understand why this is the case, I’ve created a few illustrations.
First, let’s look at a night of normal sleep, on a graph called a hypnogram, which represents the various stages of sleep that a child goes through at night. Notice that the child falls asleep into very deep sleep at the beginning of the night, then has more REM or dream sleep as the night goes on. (REM is highlighted in red.)
Note that the child briefly awakens after bouts of REM sleep. However, this child is used to falling asleep on his own. Thus, he does not signal to his parents.
Compare this with a child who needs her parents present to fall asleep. She may be held and rocked until she falls asleep. She may need his back rubbed or to nurse to fall asleep. She may even fall asleep with a pacifier in her mouth which falls out during the night. In Jimmy’s example, his parents rock him to sleep.
This child has not yet learned to fall asleep by himself. Thus, every time he has a normal awakening, he will call out to her parents and need them present to fall back to sleep. If your child falls asleep under a set of circumstances that are not present during the night (being held, having his back rubbed, nursing, even having a pacifier in her mouth) he or she will need the same set of circumstances multiple times during the night. So if he falls asleep in your arms, you are likely going to have to get up multiple times during the night. Dr. Ferber used a great analogy in his classic book (affiliate link). Most of us fall asleep with a pillow and blanket. If we woke up and our pillow and blanket were missing when we woke up at night, we would get up and go looking for them. We would likely worry about were they had gone.
The key to fixing this problem is helping your child to fall asleep on their own. For more advice, please see my post on various sleep training methods.