Just A Spoonful of… Helps the Medicine go Down!

1. Just A Spoonful of… Helps the Medicine go Down! Rosalie Favreau CCLS Certified Child Life Specialist Dawn Kidder CCLS Certified Child Life Specialist Child Life Department Children’s Hospital Health Sciences Centre Winnipeg

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

3. Presentation Overview • Planning for Success: Assessment, Plan, Intervention, Evaluation • Common Barriers to Pill Swallowing • Traditional Behaviour Modification • Review Two Evidenced Based Practices to Successful Pill Swallowing • Teaching Video (6 mins) • Demonstration • References and Discussion

4. Encouraging Mastery with Pill Swallowing GOAL:To teach a child to swallow pills. In order to achieve this goal, the clinician must have a strategy based on an individual assessment, a concrete plan, an intervention and be able to evaluate the outcome. TB Medications

5. Assessment: • Understand the common barriers to pill swallowing including: physical issues, fear of choking, bad taste, size, loss of control and power (compliance), pill placement, taking too much water. • Individually assess the patient and the patient’s family including: age, development, previous experience with illness and hospitalization, relationship with their health care team, understanding of their illness and treatment, side effects of treatment , personal barriers, and family dynamics.

6. Understanding illness and treatment

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

8. Plan: • Choose from evidence based practices or modify a program that you as a clinician are comfortable with. • Use your clinical skills: adopt a playful and supportive attitude that will encourage the child’s sense of comfort, choice, and control. • Practice family centered care. Involve and guide the parent/caregiver who will be supporting their child in “doing their homework”. Practice is the key to success.

9. Intervention: • Implementation of your chosen program • Ongoing assessment of how’s it’s working and problem solving when necessary

10. 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.

11. Most traditional approaches to pill swallowing rely on Behaviour Modification

12. The ABC’S of Behaviour Modification • Problems are defined as behaviours that are measureable. Allows for accurate charting and documentation. • Treatment alters patient’s environment to increase functioning. Program increases a patient’s ability to be normal. • Techniques are based in everyday life. Teaching needs to be concrete and easy to understand. • Techniques are based on principles of learning. Program shows patients that swallowing pills is a learned behaviour. • Demonstration of techniques cause change. The skills need to be shown to the patient to promote learning. Martin and Pear 2007

13. Positive Reinforcement, Shaping and Modeling Definitions • Positive Reinforcementsupporting the desired behaviour. Example: praise after both successful and unsuccessful pill swallows • Shaping reinforcing consecutive, increasingly accurate behaviours. Example: Increasing “pill” size slowly to achieve desired goal • Modelingdemonstrating the desired behaviour or skill. Example: showing the patient correct pill placement for success Martin and Pear 2007

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

15. Evidenced Based Practices

16. Breaking Down the Barriers of Pill Swallowing Through Behaviour Modification“You CAN Do It” Pill Swallowing Program A study was initiated after a large number of cardiac transplant patients were “non-compliant” with their anti-rejection medications. The patients ranged from 4 -18 years old. 16 successful programs have been completed within the Cardiac Department. Hansen, Tulinius, Hansen 2007

17. “You CAN Do It” This program is based on a series of steps. The first being the child’s willingness to participate. They must feel that they are ready to learn how to swallow pills. Next, set up the baseline. How large of a ‘pill’ can the child swallow without any intervention? This involves swallowing ‘pills’ ranging from very small to very large, larger than the child’s actual pill size.

18. “You CAN Do It” SLOW & STEADY… The average number of steps for a successful pill swallowing program is: 13 A slow progression leads to an increase in confidence and lowers the chance of anxiety and frustration

19. “You CAN Do It” Wherever the child starts, they must swallow the ‘pill’ three times to prove ability. Continue to move through the next size up until the patient is unable to successfully swallow. At this point move back to the last successful swallow, repeat, and end the session. Each session must always start and end with a successful swallow. This will reinforce all the hard work that was done by the child and ensure continued practice and eventual mastery.

20. “You CAN Do It” Last step of pill swallowing program in comparison to goal size First step of pill swallowing program in comparison to goal size

21. Successful Pill Swallowing Using Head Posture Variations Four systemic studies at the Alberta Children’s Hospital under the direction of Dr. Bonnie Kaplan, demonstrated that practice with head posture variations was more successful than standard behavioral approaches in treating pill swallowing difficulties. One study stated that, “practice with head posture variations were successful in treating pill swallowing difficulties in all 33 children, 2-17 years old, who practiced for 14 days”. Paediatric Child Health Vol 15 No 5 May/June2010

22. Successful Pill Swallowing in Using Head Posture Variations • This technigue is also referred to as “The Method of Off Centre Swallowing”. It requires 30 minutes to learn followed by 2 weeks of practice, 5 minutes a day, with candy. • There is evidence that different head positions makes it easier to swallow pills.

23. Successful Pill Swallowing Using Head Posture Variations • The traditional psychological principles used to engage the children are reassurance, education and the use of candies • The only ‘active’ component of this intervention is head posture and practice • This technique does not rely on conventional behavioural techniques such as stimulus shaping, positive reinforcement and relaxation

24. Successful Pill Swallowing Using Head Posture Variations Introducing the program: • Determine the child’s willingness and ability to learn and practice • Provide reassurance • Adopt a playful attitude • Using a diagram provide a simple explanation of the esophagus, comparing it to the size of a ‘pill’, and describing it’s flexibility

26. Successful Pill Swallowing Using Head Posture Variations • Teach the ‘ngunk’ noise that their throats make when they swallow with their heads turned off centre. When you turn off centre there is a spasm in the esophagus that opens the throat wider • Most children determine a preference other than centre forward • Teach the ‘duck shake’ that will help position the ‘pill’Teach the head postures (centre, up, down, left and right)

27. Successful Pill Swallowing Using Head Posture Variations • First try with water • Assume correct posture with shoulders back • Place a candy on the back of the tongue • Take a small sip of water • Do the ‘duck shake’ • Assume head position • Swallow and record self assessment in each of the 5 positions • Assign homework – I candy in each position - 5 minutes a day for 14 days • Evaluation/Outcome

28. “Better Than A Spoonful of Sugar” Video

29. References and Discussion Behaviour Modification What It Is and How to Do It Garry Martin and Joseph Pear 2007 Internet Sites: Breaking Down the Barriers of Pill Swallowing Through Behaviour Modification “You CAN do It” Pill Swallowing Program Alison Pummel, Child Life Specialist, The Hospital for Sick Kids, Child Life Council 27th Annual Conference on Professional Issues Better than a Spoonful of Sugar-How to Swallow Pills Bonnie Kaplan, Behavioural Research Psychologist, Alberta Children’s Hospital