What is the best approach to address sleep association issues in a 2-year-old child who wakes up at midnight and requires parental presence to fall back asleep?

Graduated Extinction at Bedtime

You should recommend graduated extinction at bedtime for this 2-year-old with sleep association disorder who requires parental presence to fall asleep. 1, 2

Why Behavioral Intervention is First-Line

This child has a classic sleep-onset association problem—she has learned to require her mother's presence to fall asleep both at bedtime and during normal nighttime arousals. 1 The key clinical features are:

• Normal sleep duration (9 hours total, age-appropriate) 1
• Quick return to sleep (5 minutes) when the problematic association (mother lying with her) is provided 1
• No daytime impairment or developmental concerns 3
• No red flags for primary sleep disorders (normal physical exam, appropriate development) 3

Behavioral interventions should always be attempted before pharmacological options in typically developing children with behavioral insomnia. 1, 2 Starting with medication when behavioral interventions have strong evidence and avoid medication side effects is a critical pitfall to avoid. 1

Graduated Extinction: The Evidence

Graduated extinction is rated as an individually effective therapy for treating bedtime problems and night wakings in young children (Guideline-level recommendation). 2 This approach involves:

• Systematically increasing intervals before parental response to nighttime crying 2, 4
• Allowing the child to learn self-soothing without complete parental absence 2, 5
• Higher parental compliance compared to unmodified extinction (complete ignoring), which 30-40% of parents find behaviorally or ideologically difficult 5

The intervention produces reliable and significant clinical improvement in sleep parameters, with benefits typically seen within 2-4 weeks. 1, 2

Why Not the Other Options

Reassurance alone is inappropriate because this 6-month duration of sleep disruption with clear sleep-onset association problems requires active intervention, not watchful waiting. 3, 2 Assuming all infant sleep disruption is normal developmental variation is a critical diagnostic error. 3

Cognitive behavioral therapy for insomnia (CBT-I) is designed for older children and adolescents who can engage in cognitive restructuring—it is not developmentally appropriate for a 2-year-old. 1, 6

Evening melatonin is not indicated for this child because:

• She falls asleep easily at bedtime (within 20 minutes) 1
• She has no sleep-onset delay problem 7
• Melatonin primarily addresses sleep latency issues, not sleep-onset associations 7, 1
• The evidence for melatonin improving night wakings is weak—studies show it does not significantly reduce night wakings or parasomnias 7
• Starting with medication when behavioral interventions are indicated is a critical error 1

Implementation Strategy

The graduated extinction protocol should include:

• Parent education about sleep-onset associations and the rationale for intervention 1, 2
• Consistent bedtime routine maintained at current 8 PM bedtime 1, 2
• Gradual withdrawal of parental presence at sleep onset (e.g., sitting progressively farther from bed over nights) 2, 4
• Scheduled check-ins at increasing intervals if child cries at night (e.g., 3,5,10 minutes) 2, 4
• Sleep diary to track progress objectively 1, 6

Follow-Up and Monitoring

• Schedule follow-up within 2-4 weeks after initiating the intervention 1
• Expect improvements within 4 weeks—if no benefit is seen, reassess the diagnosis and consider alternative approaches 1
• Monitor for treatment adherence—inadequate parent education and support is a common cause of behavioral intervention failure 1, 2

When to Escalate

Refer to a sleep specialist if: 1

• No improvement after 4 weeks of properly implemented behavioral intervention 1
• Emergence of concerning symptoms suggesting primary sleep disorders 1, 3
• Severe daytime impairment develops 1