Hi, I'm Dr. Mary Barbara, autism mom and
board certified behavior analyst. Today's
short video blog is going to answer the
question" how do you teach a child with
autism to take medication?" As you
probably know I'm a behavior analyst and
a mom to two adult sons, one with autism.
Some of you may not know that I've also
been a registered nurse for over three
decades and feel that my nursing
background has been extremely helpful in
working within the autism field. Because
of my background and experience, I feel
qualified to answer questions about
medication administration and the unique
issues parents and staff members often
face when working with children and
clients with autism. When Lucas was a
baby, we could put liquid medicines such
as infant ibuprofen directly into his
mouth but as Lucas got older the volumes
of liquid ibuprofen for instance
required for his larger size
became a lot more difficult. Also many
medications weren't available in liquids.
Shortly after Lucas's diagnosis at the
age of three, what we would do is we
would crush up the vitamins and
supplements and any prescription
medications, dump them into applesauce
and spoon feed one spoonful of the
concoction, followed usually by an edible
reinforcement. Then another spoonful of
the crushed up vitamins and supplements
and applesauce, followed by another
edible reinforcement. And at times, the
concoction was okay, but many times it
was nasty and Lucas became resistant and
exhibited problem behaviors some time
around
medication administration. I asked
another BCBA to watch me give Lucas's
vitamins and medicines when he was
around five years of age and as I was
looking for ideas on how to have Lucas
take his medicines without problem
behaviors. She basically told me that
crushing the pills made the concotions
smell, and probably taste, really
bad and that the only way to make it
better with the teach Lucas to swallow
pills.
Some parents mix everything into juice,
which I couldn't do because Lucas never
liked juice and it was impossible to
disguise the taste in just water.
I also saw over the years as a BCBA that
giving medications in juice was not the
answer either since it may take the
child a long time to finish that cup
thus affecting the time of the dose plus
the meds usually settled at the bottom
of the cup and many times especially if
the meds weren't juice the parent really
couldn't be sure of how much of the
medication the child actually ingested.
Trying to disguise medicine,
put in food or drinks, is not a great
solution especially because many of our
kids are very picky eaters so this makes
the problem even worse and crushing
pills in food and drinks is not a good
long-term solution since there are some
medicines such as omega-3s that are
really nasty tasting and gross and there
are some meds that are in time capsules
that can't be crushed. So over the years
I've attended a few lectures on pill
swallowing and learned how to teach this
skill using systematic desensitization
procedures and stimulus fading of more
difficult demands or in this case using
stimulus fading involved gradually
making the pill size larger as well as
using the ABA principles of modeling and
of course reinforcement. Coupled with my
nursing background, I have been
successful with teaching kids with
autism to swallow pills, including Lucas.
I got Lucas to start swallowing
pills when he was on prednisone for 21
days to treat a flare-up of his
autoimmune disorder. Lucas was 14 at the
time this medication was prescribed, and
in hindsight, I should have
taught Lucas to swallow pills a lot sooner.
When the doctor prescribed prednisone, he
said that the prednisone pill was
particularly bitter tasting. The doctor
warned me that if I crushed it up it
would be just disgusting, and he was
afraid that Lukas would not take it.
Because I told the doctor I was giving Lucas
other things crushed in
applesauce he advised me to just dunk
the small little prednisone pill, it was
really little, into applesauce without
Lucas seeing me do it at first and then
just give him the applesauce with the
pill already hidden in it and actually
the prednisone pill was so little that
it just slid right down without Lucas
even noticing. Since Lucas was used to
taking applesauce, we started to
systematically increase the size of the
pills that we dumped in applesauce. Also,
we started showing him that we were
dunking pills and that it was actually
medicine time, not hiding pills. And we
always followed each bite and each
administration with reinforcements. Now
Lucas can take large capsules, but he
only still takes them an applesauce. But
if your child is okay with swallowing a
gulp of water from an open cup, that's
where I'd start. Then, I would
systematically, like the lectures I've
seen, start with very small pieces of
things, like a piece of rice or the
smallest little bean you can find, or
something like an orzo pasta. Some people
recommend starting with a tic-tac or
other candy but that's probably not a
good idea because it has a taste to it
and you don't want the child chewing on
candy or experiencing any taste. That's
why using beans, rice, or pasta and then
systematically increasing the size of it
with strong reinforcement is the way to
go. For some kids, you can model directly
like "watch mom take a big gulp of water" and
we both have cups, I take a big gulp, the
child takes a big gulp. Then have the
child imitate "watch mom put for a piece
rice on my tongue," gulp water. The child
might be able to imitate put the piece
of rice on, gulp of water, for
reinforcement. If the direct modeling
doesn't work, you can also consider video
modeling, where you record the same
action that you want the child to
imitate. Sometimes watching it on a
screen is helpful to some kids. If like
Lucas you're more eager to try the
applesauce method, get the applesauce dunk something small like the orzo pasta
or the piece of rice and give the spoon
of apple sauce to your child and
reinforce. And after each successful step
or larger item is successful,
systematically then start showing your
child that you are dunking the medicine
and that you're giving him medicine. Once
they have three trials, for example
they're able to swallow the rice, then I
would go up to a very small orzo pasta,
three trials and then to a small bean. Of
course, you've got to give the child
major reinforcement for each of these
steps. Once your child can swallow pills
then it might be time to have the child,
teen, or adult to learn to be independent
with taking medicine from pre poured
containers and or responding to timers
or visual schedules to take the correct
medicine at the prescribed time. Many of
our kids require lifetime supervision in
terms of medication administration, but
many children can learn to be much more
independent with medicines. These are
some proven ABA strategies to try to
improve your child or client's acceptance
of medication. If your child has any
serious medical issues, swallowing
difficulties, or problem behavior
surrounding medication administration, he
or she will need a thorough assessment
and individualized programming to treat
these issues. I hope you found this
overview helpful and I'll
next week.