Just A Spoonful of… Just A Spoonful of… Helps the Medicine go Helps the Medicine go

Down!Down!Rosalie Favreau CCLS Certified Child Life SpecialistRosalie Favreau CCLS Certified Child Life Specialist

Dawn Kidder CCLS Certified Child Life SpecialistDawn Kidder CCLS Certified Child Life Specialist

Child Life DepartmentChild Life DepartmentChildren’s HospitalChildren’s Hospital

Health Sciences Centre Health Sciences Centre WinnipegWinnipeg

Just a spoonful of sugar may help the Just a spoonful of sugar may help the medicine go down for some children, but when medicine go down for some children, but when it comes to the child who simply states, “ I can’t it comes to the child who simply states, “ I can’t swallow pills!”, swallow pills!”, You Need a PlanYou Need a Plan!!

Presentation OverviewPresentation Overview

Planning for Success: Assessment, Plan, Planning for Success: Assessment, Plan, Intervention, EvaluationIntervention, Evaluation

Common Barriers to Pill SwallowingCommon Barriers to Pill Swallowing Traditional Behaviour ModificationTraditional Behaviour Modification Review Two Evidenced Based Practices Review Two Evidenced Based Practices

to Successful Pill Swallowingto Successful Pill Swallowing Teaching Video (6 mins)Teaching Video (6 mins) DemonstrationDemonstration References and DiscussionReferences and Discussion

Encouraging Mastery with Pill Encouraging Mastery with Pill SwallowingSwallowing

GOAL:GOAL: To teach a child to swallow pills. In order To teach a child to swallow pills. In order to achieve this goal, the clinician must have a to achieve this goal, the clinician must have a strategy based on an individual strategy based on an individual assessmentassessment, a , a concrete concrete planplan, an , an interventionintervention and be able to and be able to evaluateevaluate the outcome. the outcome.

TB Medications

Assessment:Assessment:

Understand the Understand the common barrierscommon barriers to pill to pill swallowing including: physical issues, fear of swallowing including: physical issues, fear of choking, bad taste, size, loss of control and choking, bad taste, size, loss of control and power (compliance), pill placement, taking too power (compliance), pill placement, taking too much water.much water.

Individually Individually assess the patient and the assess the patient and the patient’s familypatient’s family including: age, development, including: age, development, previous experience with illness and previous experience with illness and hospitalization, relationship with their health care hospitalization, relationship with their health care team, team, understanding of their illness and understanding of their illness and treatmenttreatment, side effects of treatment , personal , side effects of treatment , personal barriers, and family dynamics.barriers, and family dynamics.

Understanding illness and Understanding illness and treatmenttreatment

Rehearse using a personalized muslin doll, patient puppet, photographs, supportive dialogue and/or written information.

PlanPlan:: Choose from evidence based practices or Choose from evidence based practices or

modify a program that you as a clinician are modify a program that you as a clinician are comfortable with. comfortable with.

Use your clinical skills: adopt a playful and Use your clinical skills: adopt a playful and supportive attitude that will encourage the supportive attitude that will encourage the child’s sense of comfort, choice, and control.child’s sense of comfort, choice, and control.

Practice family centered care. Involve and Practice family centered care. Involve and guide the parent/caregiver who will be guide the parent/caregiver who will be supporting their child in “doing their supporting their child in “doing their homework”. Practice is the key to success.homework”. Practice is the key to success.

Intervention:Intervention: Implementation of your chosen programImplementation of your chosen program Ongoing assessment of how’s it’s working Ongoing assessment of how’s it’s working

and problem solving when necessaryand problem solving when necessary

Evaluation:Evaluation:

Is your program working?

Do you need to modify your approach?

Ultimately the goal is achieving MASTERY with pill swallowing within a determined time frame.

Most traditional approaches to pill swallowing Most traditional approaches to pill swallowing rely on Behaviour Modificationrely on Behaviour Modification

BARRIERSBARRIERS STRATEGIESSTRATEGIES LEARNINGLEARNING

TasteTaste Crushing or Crushing or cuttingcutting

Growing Growing autonomyautonomy

SizeSize Alternative Alternative administrationadministration

Learning by Learning by doingdoing

FeelingsFeelings Taking with Taking with foodfood

Repetition/Repetition/

perseverance perseverance

Bodily Bodily discomfortdiscomfort

Taking with or Taking with or without waterwithout water

ControlControl

Avoidance Avoidance

The ABC’S of Behaviour The ABC’S of Behaviour ModificationModification

Problems are defined as behaviours that are Problems are defined as behaviours that are measureablemeasureable. Allows for accurate charting and . Allows for accurate charting and documentation.documentation.

Treatment alters patient’s environment to increase Treatment alters patient’s environment to increase functioningfunctioning. Program increases a patient’s ability to . Program increases a patient’s ability to be normal.be normal.

Techniques are based in Techniques are based in everyday lifeeveryday life. Teaching . Teaching needs to be concrete and easy to understand.needs to be concrete and easy to understand.

Techniques are based on principles of Techniques are based on principles of learninglearning. . Program shows patients that swallowing pills is a Program shows patients that swallowing pills is a learned behaviour.learned behaviour.

DemonstrationDemonstration of techniques cause change. The of techniques cause change. The skills need to be shown to the patient to promote skills need to be shown to the patient to promote learning.learning.

Martin Martin and Pear 2007and Pear 2007

Positive Reinforcement, Shaping Positive Reinforcement, Shaping and Modeling Definitionsand Modeling Definitions

Positive ReinforcementPositive Reinforcement supporting the supporting the desired behaviour. Example: praise after both desired behaviour. Example: praise after both successful and unsuccessful pill swallowssuccessful and unsuccessful pill swallows

Shaping Shaping reinforcing consecutive, increasingly reinforcing consecutive, increasingly accurate behaviours. Example: Increasing “pill” accurate behaviours. Example: Increasing “pill” size slowly to achieve desired goalsize slowly to achieve desired goal

ModelingModeling demonstrating the desired demonstrating the desired behaviour or skill. Example: showing the patient behaviour or skill. Example: showing the patient correct pill placement for success correct pill placement for success

MMartin and Pear artin and Pear 20072007

Positive reinforcement and appropriate incentives: Praise, sticker charts, prizes that appeal to the individual, etc.

Evidenced Based Practices

Breaking Down the Barriers of Pill Breaking Down the Barriers of Pill Swallowing Through Behaviour ModificationSwallowing Through Behaviour Modification “You CAN Do It”“You CAN Do It” Pill Swallowing Program Pill Swallowing Program

A study was initiated after a large number A study was initiated after a large number of cardiac transplant patients were “non-of cardiac transplant patients were “non-compliant” with their anti-rejection compliant” with their anti-rejection medications. The patients ranged from 4 medications. The patients ranged from 4 -18 years old. 16 successful programs -18 years old. 16 successful programs have been completed within the Cardiac have been completed within the Cardiac Department.Department.

Hansen, Tulinius, Hansen 2007Hansen, Tulinius, Hansen 2007

This program is based on a This program is based on a series of series of stepssteps. The first being the child’s . The first being the child’s willingnesswillingness to participate. They must to participate. They must feel that they are feel that they are ready to learnready to learn how to how to swallow pills. Next, set up the swallow pills. Next, set up the baselinebaseline. . How large of a ‘pill’ can the child swallow How large of a ‘pill’ can the child swallow without any intervention? This involves without any intervention? This involves swallowing ‘pills’ ranging from very swallowing ‘pills’ ranging from very small to very large, larger than the child’s small to very large, larger than the child’s actual pill sizeactual pill size..

“You CAN Do It”

““You CAN Do It”You CAN Do It”SLOW & STEADY…The average number of steps for a successfulpill swallowing program is: 13

A slow progression leads to an increase in confidence and lowers the

chance of anxiety and frustration

““You CAN Do It”You CAN Do It” Wherever the child starts, they Wherever the child starts, they must swallow must swallow

the ‘pill’ three timesthe ‘pill’ three times to prove ability. Continue to to prove ability. Continue to move through the next size up until the patient move through the next size up until the patient is is unableunable to successfully swallow. At this point to successfully swallow. At this point move back to the last successful swallow, move back to the last successful swallow, repeat, and end the session. Each session repeat, and end the session. Each session must must alwaysalways start and end with a successful start and end with a successful swallow. This will reinforce all the hard work swallow. This will reinforce all the hard work that was done by the child and ensure that was done by the child and ensure continued practice continued practice andand eventual mastery eventual mastery..

““You CAN Do It”You CAN Do It”

First step of pillswallowing program incomparison to goal size

Last step of pillswallowing program incomparison to goal size

Successful Pill Swallowing Using Successful Pill Swallowing Using Head Posture Variations Head Posture Variations

Four systemic studies at the Alberta Children’s Four systemic studies at the Alberta Children’s Hospital under the direction of Dr. Bonnie Hospital under the direction of Dr. Bonnie Kaplan, demonstrated that practice with head Kaplan, demonstrated that practice with head posture variations was more successful than posture variations was more successful than standard behavioral approaches in treating pill standard behavioral approaches in treating pill swallowing difficulties. One study stated that, swallowing difficulties. One study stated that, “practice with head posture variations were “practice with head posture variations were successful in treating pill swallowing difficulties successful in treating pill swallowing difficulties in all 33 children, 2-17 years old, who practiced in all 33 children, 2-17 years old, who practiced for 14 days”.for 14 days”.

Paediatric Child Health Vol 15 No 5 May/June2010Paediatric Child Health Vol 15 No 5 May/June2010

Successful Pill Swallowing in Successful Pill Swallowing in Using Head Posture VariationsUsing Head Posture Variations

This technigue is also referred to as “The This technigue is also referred to as “The Method of Off Centre Swallowing”. It Method of Off Centre Swallowing”. It requires 30 minutes to learn followed by 2 requires 30 minutes to learn followed by 2 weeks of practice, 5 minutes a day, with weeks of practice, 5 minutes a day, with candy. candy.

There is evidence that different head There is evidence that different head positions makes it easier to swallow pills.positions makes it easier to swallow pills.

Successful Pill Swallowing Using Successful Pill Swallowing Using Head Posture Variations Head Posture Variations

The The traditional psychological principlestraditional psychological principles used to engage the children are used to engage the children are reassurance, education and the use of reassurance, education and the use of candiescandies

The only ‘active’ component of this The only ‘active’ component of this intervention is intervention is head posture and practicehead posture and practice

This technique This technique does notdoes not rely on rely on conventional behavioural techniques such conventional behavioural techniques such as stimulus shaping, positive as stimulus shaping, positive reinforcement and relaxationreinforcement and relaxation

Successful Pill Swallowing Using Successful Pill Swallowing Using Head Posture Variations Head Posture Variations

Introducing the programIntroducing the program::

Determine the child’s willingness and Determine the child’s willingness and ability to learn and practiceability to learn and practice

Provide reassuranceProvide reassurance Adopt a playful attitudeAdopt a playful attitude Using a diagram provide a simple Using a diagram provide a simple

explanation of the esophagus, comparing explanation of the esophagus, comparing it to the size of a ‘pill’, and describing it’s it to the size of a ‘pill’, and describing it’s flexibilityflexibility

Successful Pill Swallowing Using Successful Pill Swallowing Using Head Posture Variations Head Posture Variations

Teach the ‘ngunk’ noise that their throats make Teach the ‘ngunk’ noise that their throats make when they swallow with their heads turned off when they swallow with their heads turned off centre. When you turn off centre there is a centre. When you turn off centre there is a spasm in the esophagus that opens the throat spasm in the esophagus that opens the throat widerwider

Most children determine a preference other than Most children determine a preference other than centre forwardcentre forward

Teach the ‘duck shake’ that will help position the Teach the ‘duck shake’ that will help position the ‘pill’Teach the head postures (centre, up, down, ‘pill’Teach the head postures (centre, up, down, left and right)left and right)

Successful Pill Swallowing Using Successful Pill Swallowing Using Head Posture Variations Head Posture Variations

First try with waterFirst try with water Assume correct posture with shoulders backAssume correct posture with shoulders back Place a candy on the back of the tonguePlace a candy on the back of the tongue Take a Take a smallsmall sip of water sip of water Do the ‘duck shake’Do the ‘duck shake’ Assume head positionAssume head position Swallow and record self assessment in each of Swallow and record self assessment in each of

the 5 positionsthe 5 positions Assign homework – I candy in each position - 5 Assign homework – I candy in each position - 5

minutes a day for 14 daysminutes a day for 14 days Evaluation/OutcomeEvaluation/Outcome

““Better Than A Spoonful of Sugar”Better Than A Spoonful of Sugar”VideoVideo

References and DiscussionReferences and Discussion

Behaviour Modification What It Is and How to Do ItBehaviour Modification What It Is and How to Do It Garry Martin and Joseph Pear 2007Garry Martin and Joseph Pear 2007

Internet Sites:Internet Sites:Breaking Down the Barriers of Pill Swallowing Breaking Down the Barriers of Pill Swallowing

Through Behaviour Modification “You CAN do It” Pill Through Behaviour Modification “You CAN do It” Pill Swallowing Program Swallowing Program Alison Pummel, Child Life Alison Pummel, Child Life Specialist, The Hospital for Sick Kids, Child Life Specialist, The Hospital for Sick Kids, Child Life Council 27Council 27thth Annual Conference on Professional Annual Conference on Professional IssuesIssues

Better than a Spoonful of Sugar-How to Swallow PillsBetter than a Spoonful of Sugar-How to Swallow Pills Bonnie Kaplan, Behavioural Research Psychologist, Bonnie Kaplan, Behavioural Research Psychologist, Alberta Children’s HospitalAlberta Children’s Hospital