A Clinician's Guide to Helping Children Cope and Cooperate with Medical Care: An Applied Behavioral Approach

CHAPTER 10. Teaching Children to Swallow Pills and Capsules

185 chapter 10 Teaching Children to Swallow Pills and Capsules in this chapter • This chapter discusses oral medication refusal in children and youth, which can be a serious impediment to medical care. • Some of the variables that contribute to medication nonadherence are considered, such as the unpleasant taste of some liquid medications and pills, unpleasant side effects, the size and shape of pills and capsules, the child’s oral motor skills, anxiety about choking, and the level of parental supervision and encouragement . • Training procedures for pill swallowing from the published literature and recent clinical experience are presented. • Stimulus-fading and response-shaping techniques for effectively teaching children to swallow pills and capsules of various sizes are described and explained here. • Supporting behavior analysis research and related studies from the literature are reviewed. 10.1. patient population and target problem(s) For the purposes of this chapter, compliance and cooperation will be used interchangeably to discuss the immediate behavior required for ingesting medication when presented. The term adherence will be used to refer to reliably taking medication over time according to the prescribed dosage and schedule once the child has demonstrated the ability to accept and swallow it when presented. 186 helping children cope with medical care People of all ages can have difficulty with taking medication and adhering to a prescribed medication schedule. This difficulty can occur for a host of reasons that will be discussed throughout this chapter. Adults may have difficulty appreciating the purpose of the medication or the importance of taking medicine at the right time, in the right amount, and either taking the entire course of medication (taking all of the prescribed antibiotics ) or taking medicine for maintenance of wellness (antidepressants for a person with a history of major depression). Many people fail to understand that one cannot necessarily discontinue a medication because symptoms are no longer occurring. People of all ages can have thinking and memory problems that may interfere with medication adherence. This is even more likely in individuals with a history of injury or illness affecting the brain and in those with intellectual and developmental disabilities (IDD). Many children may have difficulty accepting medication of some type, especially during early childhood. Fortunately, many medications routinely prescribed for children are flavored and sweetened to appeal to children (favorites often include bubble gum, grape, cherry, orange, and strawberry). When medication is not already flavored for children, many pharmacies are able to prepare medicine for children by adding flavoring. Some pharmacies carry a brand of special flavoring for liquid medication called FLAVORx (FLAVORx, Inc., 9475 Gerwig Lane, Columbia, MD 21046; 800884 -5771; www.flavorx.com; info2@flavorx.com) that physicians or parents can request, provided that the flavoring contents are compatible with the medication, which is usually not a problem. Another alternative is for parents, with physician and pharmacist approval , to flavor the medication themselves. This can be done with liquid medication or with pills that are crushed and then mixed with a flavoring liquid, syrup, or thickened liquid. Some capsules also can be opened and mixed with flavoring in the same way, but some may involve specially formulated granules that produce a time-release mechanism. One must always check with the prescribing physician and dispensing pharmacist for clearance to open and mix capsules in this way. Inexpensive pill cutters and crushers can be bought at most pharmacies and many supermarkets. For physician-approved self-flavoring, cherry, chocolate, strawberry, and grenadine syrups are readily available at supermarkets. Similarly, depending on the patient’s taste preferences, medications can be mixed in pudding, yogurt, milk, milkshakes, apple sauce, or smoothies of a variety of flavors. One problem with flavoring medication with any of the methods mentioned above is that the unpleasant (sometimes foul) taste of some medica- teaching children to swallow pills and capsules 187 tions cannot be effectively disguised. In these cases the person may develop taste avoidance for both the medication and the flavoring, that is, a favorite flavor or food may become nonpreferred or even nauseating because it has been paired with the nauseating medication. For this reason the reader is cautioned not to mix medication in a patient’s favorite food because under some circumstances the patient may stop eating it or similarly tasting foods, or may start avoiding food altogether. This is an especially difficult problem in medical patients who may have poor appetite as a part of their illness or...