First – Then Board
What is it?
A First-Then Board is a visual display that motivates patients to engage in medical procedures that are not preferred by clarifying the preferred items/activities that will be available after it is over.
How do I teach it and use it?
Determine what task you want your patient to complete (what goes in the "First" box) and choose the item or activity (what goes in the "Then" box) that he or she can realistically have access to immediately following the "First" task. Depending on the need of the patient, this can be the general overall procedure (e.g. "First go to the doctor, Then playground") or can be broken down to specific tasks during the process that can each be paired with reinforcement (e.g. "First sit in waiting room, then lollipop." After this is completed, changing the board to "First take temperature, then sticker" etc. through the blood draw). See rewards section for tips on choosing effective reinforcers.
Show the board to your patient with a brief verbal instruction, (e.g., "First stand on scale, Then candy") before starting the "First" task. If needed, refer to the board while the child is doing the task (e.g., "One more minute, then candy.").
As soon as the "First" task is over, refer back to the board (e.g., "All done with the doctor, now the playground!") and immediately provide access to the "Then" activity.
What if challenging behaviors occur?
Continue to focus on the task and praise the aspects of the procedure that child is completing. Rather than shifting attention to the challenging 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"). 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 occur during it.
If you anticipate challenging behaviors, encourage your patient’s parents to introduce their child to the First-Then board before the visit and practice them during preferred daily activities.
If challenging behaviors become more difficult to manage, it may be appropriate to recommend behavioral consultation with a professional to address these behaviors directly.