First – Then Board
What is it?
A First-Then Board is a visual display of something preferred that will happen after completing something that is not as preferred. During blood draws, a First-Then board can help motivate your child to take part in an activity that is not enjoyable by clarifying a preferred activity that will occur after it is over.
How do I teach it and use it?
- Decide what task you want your child to complete first (what goes in the "First" box) and the preferred item or activity (what goes in the "Then" box) that your child can have as soon as the "First" task is done. See rewards section for tips on choosing a preferred item or activity. Put a visual on the board for each "First" and "Then" activity. The board can refer to the general overall procedure ("First go to the doctor, Then playground").
- The board can also refer to specific steps during the process that can each be paired with reinforcement. For example, "First sit in waiting room, Then candy." Next, change the board to "First take temperature, Then sticker" and so forth through the blood draw.
- Show the board to your child with a very brief statement ("First sit in waiting room, Then candy") before starting the "First" task. If needed, refer to the board while your child is doing the task ("One more minute, Then candy").
- As soon as the "First" task is over, refer back to the board ("All done with the doctor, now the playground!") and immediately provide access to the "Then" activity.
- It may be helpful to visually show when the "First" task over, such as marking it out or placing a check mark over it.
What if challenging behaviors occur?
If challenging behaviors occur, continue to focus on the task and praise the parts of the procedure your child is completing. Instead of shifting attention to the challenging behavior, provide brief statements or a visual that tell your child what you would like for them to do (e.g., hold your arm out). Then, provide access to the "Then" task when the procedure is complete. This is because the focus of the First-Then board is on completing the "First" task, not on addressing challenging behaviors that happen during it.
If you think challenging behaviors may occur, introduce your child to the First-Then board before the visit and practice them during daily activities he or she enjoys. This way, your child will already understand the meaning of this tool and will trust its use when it is brought out during blood draws and medical procedures.
If challenging behaviors become more difficult to manage, it may be appropriate to consider behavioral consultation with a professional to address these behaviors directly.
