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.