In This Issue
Pill swallowing and children
By Christine Chambers, PhD
Mark is a 7-year-old boy recently diagnosed with ulcerative colitis by the Gastroenterology Clinic at the local pediatric health centre. The medical team recommends an oral medication, and these can sometimes be very large tablets that need to be taken two to four times per day. The family panics. As the parents try to process the impact of this significant diagnosis on their child's health and future, they become anxious as they realize that Mark has never had to swallow a pill before. The clinic sends the family home with some oral medication and a pill swallowing cup, which is purported to be able to help individuals learn how to swallow pills without stress. The family spends a nerve-wracking evening trying to help Mark learn to swallow pills. They try using the cup but with no luck. They try encouraging him to swallow the pills, but by this time Mark and his parents are agitated and stressed. "Did you swallow it?" "No, it's still on his tongue." "Try again." "Yes you can. It's important." "It's going to help your belly." The pill is dissolving in his mouth. Mark cries and storms off, indicating that he will never be able to swallow pills. The parents wonder how they can ever make this happen. How will the babysitter or grandparents manage? The family places an exasperated call to the Gastronterology Clinic, and a referral to the Pediatric Psychology Service for assistance with pill swallowing is made.
At first glance, difficulties with pill swallowing might seem like a trivial health issue. Indeed, there are only a handful of articles in the literature on pill swallowing. However, many adults and children cannot swallow pills, and it is reasonable to assume that, like needle phobia, these difficulties could lead to some degree of avoidance and/or inappropriate medication use and healthcare utilization. Many parents receive extensive coaching from health professionals and pharmacists in how to hide medication (e.g., in foods) rather than in the best methods for teaching their children how to swallow pills. Only one observational cohort study on children's abilities to swallow pills has been published (Meltzer, Welch, & Ostrom, 2006). They reported that among a sample of 124 children aged six to 11 years, 57 (46 percent) were able to swallow pills already on their own, an additional 46 (37 percent) were able to easily learn on their own with an ordinary cup, and nine (seven percent) using a pill cup. Eleven (nine percent) children were unable to learn how to swallow pills on their own.
The efficacy of psychological interventions for pill swallowing may be one of pediatric psychology's best kept secrets. The first studies examining the effectiveness of behavioral treatments for pill swallowing were published in the 1980's, although additional similar papers have appeared over the years (Beck, Cataldo, Slifer, Pulbrook, & Guhman, 2005; Blount, Dahlquist, Baer, & Wuori, 1984; Cruz-Arrieta, 2008; Funk, Mullins, & Olson, 1984; Ghuman, Cataldo, Beck, & Slifer, 2004; Reitman & Passeri, 2008; Walco, 1986). Sadly, there has been no large-scale, randomized trial to test the efficacy of pill swallowing interventions, but the data from the published case studies and single case designs makes a compelling case. Success rates are in the range of 75-90 percent with excellent maintenance at three months and longer. The papers report success in teaching children with a variety of health issues (e.g., cancer, autism, attention deficit hyperactivity disorder) how to swallow pills.
The psychological intervention used for pill swallowing is based on principles of behavior therapy, primarily shaping, where successive approximations to the desired behavior are rewarded. Children are initially taught to swallow small cake decorations (e.g., chocolate sprinkles) and once this task is mastered, the child is offered larger and larger candies, and then placebo tablets and capsules of varying sizes. The hospital pharmacy and the local candy store are helpful resources for psychologists who need to create a pill swallowing placebo kit. It is important that the psychologist always check with parents first regarding any potential allergies or concerns they might have about the use of different types of placebo pills/candies. Children are provided with praise and reinforcement (e.g., a sticker) for mastery of each step. Treatment can also include behavioral modeling, with the therapist demonstrating and the child trying in a game-like manner, and relaxation strategies (e.g., deep breathing). For children with disruptive or inattentive behaviors, basic behavior management principles (e.g., ignoring, time-out) may need to be integrated into the session.
I'll confess…a referral for pill swallowing is one of my favorites. With the various complex issues we can be confronted with in pediatric psychology, it's a treat to receive a referral for something where the treatment is usually straight forward and sometimes immediately successful. Some children are able to master pill swallowing in one session, but this is not the case for all children. Children with complex behavioral, developmental, and/or medical challenges often require up to 10 sessions. And not all children are able to learn to swallow pills, even with significant support.
I typically have parents leave the room and work only with the child; this removes pressure from the child (and the parent). When the parent is asked to rejoin us at the end of the session, the child is always excited to show off which size pills they can now swallow and parents usually are quite adept at genuinely expressing their enthusiasm and pride. The child beams and smiles, and so do the parents.
After the child has successfully mastered pill swallowing in-session, I have found home practice with placebos to be a critical last step before having the family attempt to have the child swallow the active medication at home. I send families home with a bag of placebo pills that most closely resemble the actual pill, and instruct them to take the medication at the same time and in the same environment that they will need to take their real medication. This home practice helps to increase both the child's and family's confidence in managing the situation on their own.
Pill swallowing cases are great opportunities to involve psychology trainees. It gives trainees a chance to see pure behavioral intervention in action. I often involve the trainee in modeling to the child successful pill swallowing of placebos of different sizes—although I learned early in my career to check with the trainee beforehand to make sure that they know how to swallow pills. Same goes for the parent…children who can't swallow pills often have parents who can't swallow pills.
As with many areas in pediatric psychology, we could do a much better job at selling our success with behavioral interventions for pill swallowing. Many more children and their parents could benefit from our expertise and training in this area.
Beck, M. H., Cataldo, M., Slifer, K. J., Pulbrook, V., & Guhman, J. K. (2005). Teaching children with attention deficit hyperactivity disorder (ADHD) and autistic disorder (AD) how to swallow pills. Clinical Pediatrics, 44, 515-526.
Blount, R. L., Dahlquist, L. M., Baer, R. A., & Wuori, D. (1984). A brief effective method for teaching children to swallow pills. Behavior Therapy, 15, 381-387.
Cruz-Arrieta, E. (2008). Pill-swallowing training: A brief pediatric oncology report. Primary Psychiatry, 15(7), 49-53.
Funk, M. J., Mullins, L. L., & Olson, R. A. (1984). Teaching children to swallow pills: A case study. Children's Health Care, 3(1), 20-23.
Ghuman, J. K., Cataldo, M. D., Beck, M. H., & Slifer, K. J. (2004). Behavioral training for pill-swallowing difficulties in young children with autistic disorder. Journal of Child and Adolescent Psychopharmacology, 14(4), 601-611.
Meltzer, E. O., Welch, M. J., & Ostrom, N. K. (2006). Pill swallowing ability and training in children 6 to 11 years of age. Clinical Pediatrics, 45(8), 725-733.
Reitman, D., & Passeri, C. (2008). Use of stimulus fading and functional assessment to treat pill refusal with an 8-year-old boy diagnosed with ADHD. Clinical Case Studies, 7(3), 224-237.
Walco, G. A. (1986). A behavioral treatment for difficulty in swallowing pills. Journal of Behavior Therapy and Experimental Psychiatry, 17(2), 127-128