Katie Taylor, CCLS, Child Life on Call

Positive reinforcement is one of the most effective behavior modification techniques.¹

That means saying positive phrases like “You’re staying so still!” to discourage a child from moving is the way to encourage a child’s behavior to change.

It also means the ever popular, “Don’t move!” can be ineffective and unproductive.

So, for children who are sick or hospitalized, Child Life Specialists know that positive reinforcement is the way for compliance and better outcomes during procedures. Positive reinforcement leads to a higher motivation for children to actually take medications and promote eating and drinking which can lead to a faster discharge.

Next time you find yourself teaching or coaching other staff about how to support children in the hospital, keep positive reinforcement at the top of your list. You can tell them with confidence that positive reinforcement, especially when it’s specific, helps with compliance and is the most effective way to make their job easier.

How can we motivate children to promote positive behavior? One of my favorite tools to use is a tangible tracking system that identifies the behavior we want to see.

Let’s take the example of a three-year-old girl who will NOT take her medicine. Parents and staff have tried sneaking it into food, giving choices, and holding her down and squirting it in her mouth. She tells them how she feels about that by spitting the medicine back in their face. Yikes.

The first thing I see here is a child who hasn’t been honestly told what the expectations are and then given boundaries around them. This medicine is not a choice for her, but we do need her compliance to take it. The second thing I see is a child who is craving some control. The last thing I see is a lack of positive reinforcement - the thing we know changes behavior.

If this were my patient, the first thing I would do is have a separate moment with the staff and with the caregiver to find out the ultimate goals for this child and this medicine. How many times a day? How much medicine? What is the impact?

Next, I’d sit down with the patient and engage in role reversal medical play to gather an assessment about her experience with medicine. When we play, what is she expressing? What are some of her motivators? What are her expectations? I would then take that information and the other things I’ve gathered from her and create a sticker chart, because she is three.

I’d ask her to help me decorate a pre-made sticker chart (like the ones above) or I’d encourage her to express herself with her own colors/markers/paints on a paper and turn it into a chart. Letting her choose the stickers, colors and characters we use to generate excitement with this intervention is a key component to its success.

After that, we need her to know what positive reinforcement feels like. Using a cup or syringe, I’d ask her to choose water or juice, put in the cup, and ask her to take the exact same amount as the medication. Count that as successful and let her put a sticker on the chart. Do it again. Do it again. Consider giving her one more opportunity to be successful with juice or water and let her know that the next sip will have to be medicine.

• If she puts the medicine in the cup - that’s a win. Reinforce that positive behavior.
• If she puts the cup up to her lips - that’s a win. Reinforce that positive behavior.
• If she takes the tiniest sip - that’s a win. Reinforce that positive behavior.
• If she takes the whole thing - unlikely at first - but that’s a definite win. Reinforce that positive behavior.

Eventually, though maybe not overnight, we are taking baby steps to promote control, offer autonomy and dignity, and reinforce positive behavior.

The stickers I like to use come directly from SmileMakers. I like the scented sticker options, the mini dot stickers that fit easily on a chart, and the endless options to find the stickers that appeal to a wide audience.

A chart template that I find to be effective is a sticker chart that leads to a prize box. Get 3 stickers? Choose a prize! My favorite prize box items are the Premium Treasure Chest, the Good Clean Fun Treasure Chest, and the Value Toy Treasure Chest.

Find available sticker/behavior chart templates here.

1. The Center for Advanced Study of Teaching and Learning (CASTL). Strategies for Promoting Positive Behaviors.