Choosing Reinforcers for Children with ASD
How to Use Rewards with Children with ASD
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Because of the difficulties people with ASD have with communication and social interactions, typical ways of using reinforcement may not be as effective. For example, a child with ASD may not go along with a procedure for some of the social reasons another child might comply (e.g., be embarrassed if they did not do it or do it because everyone else is doing it).
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Since many people with ASD have strong feelings about what they like and do not like, typical rewards that are used for children without ASD may not be as motivating. For example, very loud praise or clapping may not be reinforcing to an individual who is oversensitive to sound; candy or other edible reinforcers may not be reinforcing to a picky eater; or other generic rewards such as stickers, may not be reinforcing to the individual if it does not hold meaning for them.
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It is important to use specific rewards when asking your patient with ASD to participate in blood draws, and encouraging families before the visit to practice strategies, such as relaxation, that will help. Doing this will help your patient with ASD associate these procedures with something that is enjoyable. This may make the process less stressful and communicate to your patient that his or her hard work will be rewarded.
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The first step in choosing reinforcers is to think "outside the box" and identify things that are specifically motivating to your patient. They may relate to your patient's sensory or restricted interests. Ask the parent for ideas.
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If you find it difficult to identify possible reinforcers, it may be helpful to observe the patient when several items/activities are available to help determine which ones are preferred and the how long your patient interacts with these items/activities after he or she chooses them.
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It may be helpful to identify 3 to 5 reinforcers to use since some may not be available the day of the procedure and/or multiple reinforcers may be needed during the different components of the procedure (e.g., providing one reinforcer for sitting in the waiting room, providing another for getting vitals taken, providing a for completing the blood draw).
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Certain packages of using reinforcement have enough of an evidence base to be categorized as "an established treatment" for children with ASD. For more information about evidence-based treatments, go to the National Standards Project at www.nationalautismcenter.org.
If I know my patient's sensory interests, what are some examples of items to consider for reinforcers?
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Visual: portable television/DVD player, portable video games, light-up items, mirrors, bubbles, items that spin/twirl, pouring water or squeezing water from a sponge to watch it drip, slinky
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Auditory: music/headphones, sound-producing toys
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Vestibular: swinging, rocking, jumping on trampoline, tickling, trip to playground
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Tactile: massager, feathers, playdough, lotion, ice pack, heating pad, shaving cream, water/sand table
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Edible/Oral: candy, salty snacks, drinks, teething toy
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Activity: playing board game, elevator ride, or a planned activity with the parent to occur after the visit.
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Social: praise, pat on the back, hug, smile, high five, special one-on-one time with a caregiver where the child gets to choose the activity
Tips for Using Rewards Effectively
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Make them Immediate.
Give reinforcement as soon as you can. If this is not possible, provide some type of visual (link to visual supports section) way to let your patient know that the reward has been earned and is coming soon (e.g., a picture of the activity, a token).
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Keep them Varied and Novel.
Choose a reward that your child does not always have available and is novel enough to be motivating during something like a blood draw. For example, do not use toys that your patient is allowed to play freely with at home as a reward. The reward you choose also should not have been available immediately before the procedure. For example, candy or an edible treat would not be the best choice if your patient just had candy or had just eaten a large meal.
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Have Several Options.
If your child is undergoing several medical procedures, have a few different rewards so that your patient remains motivated throughout the entire visit. It is important to remember that something that is reinforcing in certain situations with your patient may not be reinforcing for every situation.
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Be Clear.
When giving your child the reward, make eye contact and speak enthusiastically. Be clear about what the reward is and exactly what your child did to earn it (e.g., sat still, walked in without help).
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Always Follow Through.
It is very important to provide the reward promised to your child when the task is completed. If you are offering something and you are not sure if it can realistically be provided, do not offer it. Offering these will make the use of rewards less effective because your patient may stop believing that they will be given.
What if challenging behaviors occur?
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Continue to focus on the task and praise the aspects of the procedure the child is completing. Rather than shifting attention to the unwanted behavior, provide brief statements or a visual that tell the child what you would like for them to do (e.g., "Hold your arm out").
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If you anticipate challenging behaviors, encourage the parent to introduce the strategies outlined on this website prior to the visit and to practice them during preferred daily activities.
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If challenging behaviors become more difficult to manage, it may be appropriate to recommend behavioral consultation with a professional to address these behaviors directly.
