Behavioural insomnia and circadian rhythm disorders — formative SAQs

SAQ 1 — The toddler who wakes all night (20 marks, ~15 minutes)

A 15-month-old girl wakes three or four times every night and can only be resettled by being picked up and rocked, which she was rocked to sleep at bedtime. Her parents are exhausted. She is thriving, does not snore, and sleeps well once she is finally asleep. ^[1]

Questions

1. Give the most likely diagnosis and subtype, and the features that support it. (5 marks) ^[1]
2. Explain the mechanism that produces the repeated night wakings. (5 marks) ^[1]
3. State the first-line treatment and name two specific behavioural techniques you would use. (6 marks) ^{[1] [2]}
4. State the evidence that behavioural treatment works and what you would tell the parents to expect. (4 marks) ^[3]

Model answer (must-hit)

1. The most likely diagnosis is behavioural insomnia of childhood, sleep-onset association type. It is supported by the requirement to be rocked to fall asleep, the repeated night wakings that need the same rocking to resettle, normal sleep once asleep, normal growth, and the absence of snoring or other organic features. ^[1]
2. Every child has brief arousals throughout normal sleep. This child has learned that sleep begins only while being rocked, so at each normal arousal she cannot bridge back to sleep without that same condition being recreated, and she signals for a parent instead. The wakings are therefore a conditioned association, not a new problem each night. ^[1]
3. The first-line treatment is behavioural, not medication. I would use graduated extinction (controlled comforting, checking at gradually lengthening intervals so she learns to self-settle) and bedtime fading with a consistent, soothing bedtime routine, teaching her to fall asleep independently at the start of the night so she can resettle unaided later. ^{[1] [2]}
4. Mindell and colleagues' review, the American Academy of Sleep Medicine practice parameter and Meltzer and Mindell's meta-analysis show behavioural interventions are effective and durable for bedtime problems and night wakings, with benefit to the child and to parental wellbeing. I would warn parents that a brief increase in protest is common before improvement and that consistency is the key to success. ^[3]