Helping kids who have difficulty swallowing pills

A significant part of my work as a cognitive-behavioral therapist specializing in anxiety and related disorders is providing families with recommendations for good resources. "Good resources," in these cases, are usually books and websites that offer general, up-to-date information on the disorder for which I am treating the child, as well as sound suggestions for at-home interventions (i.e., parent manuals).  Of course, I provide such psychoeducation in session, but I like parents to be able to hear the information more than once, from more than one source, and for it to be accessible to them outside of the therapy hour.

What I do not want is for families to garner information or recommendations for treatments from "unsafe" sources – that is, sources that provide information that is not scientifically supported or has been directly contradicted by science.  In fact, I explicitly warn families about this, because there is so much misinformation on the web.

During initial sessions, when giving my families handouts printed with what I think are the best and safest sources of information on their child's disorder and treatment for that disorder, I typically say: "Please DO NOT put the name of your child's diagnosis into Google search and hit 'return.' You will receive millions of hits, many of them from untrustworthy sources having something to sell, and you will feel even more overwhelmed than you already do.  Instead, start with these I am recommending – you can always read more later."

The number of my child and teen (!) patients who "can't swallow pills" is always surprising to me.  It shouldn't be: Though good prevalence data have yet to be published, difficulty with pill swallowing is thought to be relatively common among the young, and drug companies graciously try to accommodate this by offering liquid versions of common medications.

Parents also go to heroic lengths to get their children to just swallow the pills by a variety of means such as begging, bribing, whining, nagging, yelling-then-apologizing, hiding, disguising, mashing, dissolving, or smoothie-making.

Kids, understandably, don't like this and they generally end up: still hating the pills, now hating the foods you tried to disguise them in, and – so what else is new – hating you.*

The bad news: Just like all kids need to learn to tolerate injections and shots, kids need to learn to comfortably swallow pills. Both abilities are crucial to a long and healthy life.  Moreover, there are additional reasons to help kids develop the skill than mere convenience: liquid and chewable medications are much less available (and typically much more costly), dosing with liquids can be less accurate, and the VAST MAJORITY of medications do not come in a liquid/chewable form at all – which can really be a problem in an emergency situation when your child, on top of everything else, suddenly refuses to swallow a pill that will stop the pain or halt the infection.

The very, very good news:  In what published studies there are, the vast majority of children with pill swallowing difficulties can be taught to swallow pills like a champ via a safe-and-sound, relaxed-but-effective behavioral procedure known as "shaping."  It hardly takes forever, too: The most common number of treatment sessions required (at least in published studies and in my clinical experience) is one (1!), though 2 or 3 is fine, too.

Even better news: before parents stampede off to a pro to help their child learn to swallow pills, there are excellent resources out there that instruct parents how to teach the program to their kids themselves (empowering!).  The following are my favorites:

1. Short and sweet: The NYU Child Study Center (Full disclosure: My post doctoral fellowship was there.) has a nice website with lots of published tips for parents. There is a section describing a clear, step-by-step procedure for gradually introducing your child to swallow larger and larger items (ahem, candy) using sound behavioral techniques.  I typically follow this one almost to the letter in my own sessions with children – and it generally works: Pill Swallowing Made Easy.

2. Longer and sweet: Researchers at the University of Calgary developed an inspired protocol for training children to comfortably swallow pills using a series of practices employing different head placements for swallowing tilted back, tilted forward, and turned 45 degrees to the side (based on the evidence that head posture can result in small increases in esophageal diameter and delay the upper esophageal sphincter closure during swallowing).

Training and practice in the various head placements takes place for about 10 minutes a night over 14 consecutive days until children are consistently swallowing using the head posture they have learned is most comfortable to them.  The results of their published study were impressive, 33 of 41 children were successful. The authors very generously put up the entire set of training videos, plus the daily recording sheet, free on the web! (This is a rare treat in my field). I suggest parents watch all training videos by themselves first before introducing their children to them. Better Than A Spoonful of Sugar: How To Swallow Pills.

*Don't worry – they don't really hate you; they are just angry and frustrated, much like you.

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