Intensive ABA Services Q&A: Swallowing Pills - The Lovaas Institute

Meeting Point: Latest From Lovaas

Fall 2010

Meeting Point: Latest From Lovaas

Q&A: Swallowing Pills

With contributions from Shawn Condon, Amanda Huish, Stefanie Knaus, Noreen Laberinto, Jennifer LaMarca, Mariko Okano, and Jennifer Willis

Initial Question

I am working with a 6-year-old student who has been receiving ABA services for almost 3 years. "Andrew" is able to speak in single-word responses, is learning beginning abstract concepts such as colors, and is learning some beginning interactive play skills. In order to assist Andrew with his receptive and expressive language skills, sign language and visual prompts are frequently used. I am looking for suggestions to successfully teach this child to swallow a pill. He takes anywhere from 5-15 vitamins per day and the family is no longer able to administer the vitamins "secretly" in his juice.

Response One

We taught a child to swallow supplements and vitamins systematically. We began by teaching the child to swallow all of the liquid on a spoon in one swallow, beginning with a small amount of liquid and increasing the amount up to a full teaspoon. We began with juice, then water, and then a variety of liquids. Once the child had learned to swallow a variety of liquids, we began adding things to the spoon. We started with juice plus a powdered form of the vitamin. Then we gradually reduced the amount of juice on the spoon while simultaneously increasing the size of the solid item the child was required to swallow. The team often followed the response with a spoon full of the child's favorite juice.

Response Two

I taught swallowing vitamins and pills to an older client through imitation and by initially using very small ice chips and gradually increasing the size. We crushed a bunch of ice and started with very small pieces that would nearly melt as soon as they were placed on the tongue. Through imitation, we taught the student to place the ice chip on his tongue, take a drink of water, and swallow. Once we increased the size of the ice chips, it was a smooth transition to replace the ice chips with actual pills.

Response Three

I have taught swallowing a pill using a Tic Tac, since it is a similar shape and size to other pills and small enough that it is fairly easy to swallow. Initially, we placed the Tic Tac on the child's tongue and taught tolerance with holding the Tic Tac there for increasing lengths of time without spitting it out. Then we used imitation to teach swallowing the Tic Tac. We had to probe with and without liquid to determine with which method the child would be most successful. This particular child was more successful when required to drink the liquid at the same time as swallowing the Tic Tac, and he did not exhibit any gagging reflexes when teaching this skill. You may also want to teach tolerance with drinking juice so that he is still taking his vitamins. Is he not drinking the juice because of the flavor? Does he ever have juice that does not contain vitamins? If he intermittently receives juice without vitamins, this may be enough reinforcement for him to always drink his juice. This skill could be taught using systematic desensitization as with any food tolerance program.

Response Four

I have worked with Occupational Therapists who have had success having the child swallow pills using empty gelcaps you can buy at nutrition/health food stores (I think these gelcaps are traditionally used by people who make their own "vitamins?"). I do not know the exact procedure used, but this material with the other ideas proposed sounds like a plan!

Response Five

Here are some techniques or "gadgets" that may assist the child with swallowing pills.

  1. "Pill cup" - It is a cup with a little pocket in it that floats the pill down as the child is taking a drink. A quick internet search using the words "pill cup" will provide a variety of options, though I do not have personal experience with a specific one.
  2. Use of a straw - If the child is able to hold the pill on his tongue, have him first place the pill on his tongue. Then, using a straw, have him suck down big gulps of the drink (a highly preferred drink may be used to facilitate success). This is like trying to swallow a pill with a big mouthful of water or other drink.

Response Six

Most of my clients take chewable vitamins, however, maybe you could try one of the following methods:

  1. Put the vitamins in desirable solid foods (e.g., mashed potatoes, ice cream, etc.)
  2. Along the same lines, teach him to eat anything/everything from a specific bowl. This bowl would not have to be used for all meals, however, teach him that whenever this bowl is presented, he is required to eat all of its contents and can receive a highly desired reinforcer (e.g., TV, video, slide) for doing so. Once instructional control is gained with preferred foods (e.g., cookies, candy, French fries), require him to eat the mashed potatoes or ice cream containing the vitamins. Begin with smaller portions and increase systematically.
  3. If you had to teach him to actually swallow without chewing, you may want to teach him to discriminate between foods that you're supposed to chew and those that you're supposed to swallow. Instructors could model an exaggerated chewing motion when eating solid, everyday foods (without the necessity of water/juice). When teaching him to swallow pills, it may help to begin with similar sized/shaped foods such as Skittles or M&M's; he may overgeneralize the swallowing response. However, if you could model the non-verbal imitation chain of placing the vitamin on his tongue, taking a drink, and throwing his head back and swallowing, there would be a clear discrimination between chewing and swallowing.

If the third approach is attempted, there may need to be some systematic desensitization/tolerance taught. Could you bring swallowing under instructional control by teaching it as a receptive instruction/non-verbal imitation skill and/or reinforcing it when it occurs naturally (when eating)? I have taught a non-verbal client who drools to swallow on command by running a finger from his chin down his neck; this was faded to modeling that action on the instructor. In addition, tolerance to seeing/holding/placing the vitamin in his mouth may need to be taught systematically.

Do you have other ideas of skills to incorporate in teaching to swallow? Share them with us here

The names of all children in this newsletter have been changed in respect for family confidentiality.

Big Bear Wants In! Put stuffed animals down the back of the child's shirt, up the pants leg, in the sleeves.

The Big Spin! Pick the child up by the armpits for a big spin (don't fall over!).

Pump Me Up! Say, "It's time to pump me up!" Mimic two-handed bicycle pump while inflating your cheeks. Now you can't talk, but hold the child's hands and have them POP your mouth. You can also mime inflating your entire body by slowly lifting up onto your toes, and expanding your arms and stomach (in rhythm with the child's pumping action).

Train Ride! Line up the chairs, one behind the other and go for a train ride. Who's the engineer? Who's in the caboose?

Go Swimming! Manipulate the child's arms and legs so they are "swimming" or doing a "cheer."

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