This is part 2 in a two-part series. If you missed part 1, you can read it here.

Part 2: What is Behavior Based Feeding Therapy? (And why we advocate against it)

11/20/2021 by Caroline Braun, M.S., CCC-SLP

It is the Therapist Neurodiversity Collective’s position that behavior-based feeding interventions are unethical and disrespectful to children of all neurotypes. 

Behavioral approaches to feeding intervention attempt to increase children’s variety and volume of food intake while also claiming to eliminate or diminish challenging mealtime behaviors. Behavioral approaches to feeding do not develop intrinsic motivation for eating, honor children’s mealtime cues, or teach children to honor and interpret vital biological cues such as hunger and satiety. 

Instead, behavioral interventions for feeding rely upon the use of external rewards to “get” children to eat while also frequently incorporating the use of highly aversive procedures such as force-feeding and restraint to ensure compliance. 

Who provides behavioral-based feeding therapy?

Behavior-based feeding interventions are often conducted by Registered Behavior Technicians (RBTs) and Board Certified Behavior Analysts (BCBAs). RBTs and BCBAs are woefully and dangerously underqualified to address feeding challenges. 

RBTs often provide the bulk of behavioral feeding interventions and receive only 40 hours of broad training, frequently delivered online with inconsistent supervision, to qualify for their credential.

BCBAs undergo graduate coursework in Applied Behavior Analysis (ABA).

As part of their standard training, neither RBTs nor BCBAs receive instruction in typical feeding development or training in how to identify, assess, or treat the structural and physiological factors that often cause children to develop feeding disorders. In contrast, this information is embedded within Master’s level coursework for occupational therapists (OTs) and speech-language pathologists (SLPs). OTs and SLPs receive extensive graduate education in anatomy, physiology, swallowing, and respiration. 

To learn more about the poorly regulated RBT credential, see here. To compare a BCBA’s training to the specialized training of an SLP, see here. 

Unfortunately, many SLPs and OTs also deliver behavior-based feeding interventions, so you’ll have to do your research and interview potential providers to ensure that your child receives neurodiversity-affirming care. 

You will know that a therapist is using behavior-based feeding interventions if they: 

• Tell you that your child is manipulating you with their behavior

• Reward your child for eating food or interacting with food through praise, access to a preferred food, or access to a preferred toy/activity/ person

• Tell you that feeding therapy involves “breaking” your child

• Re-present food that your child has spit out or vomited and demand they consume it

• Try to restrain your child in a chair and do not allow them to leave the chair

• Put a spoon in your child’s face and refuse to move it until your child eats, regardless of their protests (i.e. non-removal of the spoon procedure)

• Physically restrain your child while forcing their jaw open to force food into their mouth (i.e. physical guidance procedure)

• Tell you that behavior based feeding therapy is the only evidenced based approach for addressing feeding disorders

While not every behavior-based feeding program will include all of these elements, they are all informed by the same principle: 

That it’s okay to violate a child’s bodily autonomy to get them to eat. 

And that’s why behavior-based feeding interventions are inherently at odds with a neurodiversity-affirming paradigm.

Let’s discuss each aspect of behavioral feeding in-depth:

An ABA provider will tell you that“Your child is manipulating you with their behavior.”

This is fundamentally false. Your child is not manipulating you. They did not wake up one day and decide to make life harder for themself and your family by refusing to eat. There is a very good reason why a child doesn’t eat, but it often requires a highly trained and qualified team to figure it out.

Although interdisciplinary care for feeding disorders is best practice, behavioral-based feeding programs, particularly those taking place in-home or in ABA centers, often do not collaborate with other professionals to rule out underlying reasons for challenging mealtime behaviors. This is problematic because ethical providers of feeding therapy do not practice in isolation. 

In a systematic review of behavioral feeding studies, researchers found that many published studies were violating best practice guidelines (Tereshko et. al., 2021). They found that, prior to initiating behavioral feeding therapy:

• Only 62% of studies reported that a medical assessment was completed 
• Only 24% noted that an oral motor assessment was completed
• Only 10% identified that nutritional assessment was completed

And remember – these studies took place under more rigorous conditions than many community programs since they were conducted by researchers actively seeking to control for a variety of variables. We have no data on how well feeding clinics housed in ABA centers are abiding by best practice guidelines. 

In my clinical experience, I have worked with children, some of whom have been subjected to physical restraint and force-feeding at major ABA clinics in my state (who have the audacity to advertise that they offer “trauma-informed” continuing education to other ABA providers, no less) without appropriate medical clearance, oral motor assessment, or collaboration with nutrition or other therapy professionals.

These children presented with extensive dental decay, significantly delayed oral motor skills, and/or significant GI concerns such as impaction; however, ABA providers continued to forcibly feed these children despite serious medical concerns. 

Unsurprisingly, these feeding interventions failed. 

When ABA informed providers fail to consult other professionals, children’s difficulty eating can be dismissed as “bad” or “manipulative” behaviors to be extinguished when there is something seriously wrong. 

Mischaracterizing and dismissing children’s challenging mealtime behaviors as manipulation reveals a fundamental and dangerous lack of knowledge regarding the anatomy, physiology, and development of feeding and sets up an adversarial feeding relationship between parents and children. 

An ABA provider will tell you to reward your child for eating food through praise, access to a preferred food, or access to a preferred toy/activity/person

There is a large body of research exploring the ways in which rewards used to manipulate someone’s behavior are problematic and even harmful. While a reward may get a child to do something that they didn’t originally want to do, rewards often lose their value quickly. They also interfere with the development of intrinsic motivation (for more, see Alfie Kohn’s work here). 

More importantly, though, rewards teach kids to look outward for motivation and to rely on adult cues rather than their own when completing various tasks. In the case of eating, this means that rewarding children for eating teaches them to eat for the reward and the adult’s approval rather than to eat for intrinsically motivating reasons such as hunger, taste, or pleasure. 

Rewards in behavioral feeding programs may further complicate the development of IntInterfering with a healthy relationship with food by establishing a hierarchy among foods. 

A common practice within many behavioral programs is to reward children with a bite of preferred food after they comply with eating a bite of nonpreferred food. This creates a situation in which the non-preferred food is something that the child has to “get through” in order to access their preferred food. When food is presented in this way, it’s unlikely that the child will ever come to see the non-preferred food as something they enjoy. Rather than listening to their body’s cues of hunger and fullness to determine what and how much to eat, they rely upon the promise of a reward, which is not a sustainable way to develop healthy eating habits. 

Finally, a significant problem with relying on rewards in feeding therapy is that it can then be very difficult to fade the reward. 

In the video below, you will see where the reliance upon external reinforcement can lead families and their children. In this video, you will see a child who has undergone feeding therapy at an intensive, hospital-based feeding program that relies heavily upon ABA methodology. As a reward for taking bites, the child is presented with an iPad to watch for a brief period of time. Procedures like this one are commonly provided as home programs for families once behavioral feeding therapy is complete. 

NOTE: I am not sharing this video to shame the mother or the family who created it. This family was instructed to do this feeding procedure by their feeding team. This child’s mother is doing what professionals have told her to do to take care of her child. Mom is not the problem here: the problem is a financially motivated system that demands compliance from children at the cost of bodily autonomy, human dignity, and healthy parent-child relationships. 

Video – Rewards-Based Feeding at Home

Watching this video, I can see how much this mother loves her son. However, I can also see how reliant both she and her little boy are on the iPad for eating. This mealtime is not about enjoying food, connecting socially, or learning new skills; it is all about getting the food in as quickly and efficiently as possible. It’s also not a sustainable way to approach mealtimes as this child grows and develops. 

An ABA provider will tell you that feeding therapy involves “breaking” your child

Your child is not a horse to be “broken.” Your child is demonstrating challenging mealtime behaviors for a variety of complex reasons that must be addressed. Your child is using their behavior to communicate to you that eating is hard, it’s scary, and it might even be painful. We absolutely do NOT want to silence our children’s natural instincts to protect themselves and their bodies. Ethical therapy providers do not ignore children’s cries for help or their protests to “extinguish” those valuable communicative behaviors. Kids do well when they can. 

Unfortunately, I have seen behavior-based feeding programs “break” children.

When children are “broken” by these programs, it’s devastating. I see symptoms consistent with trauma such as hypervigilance, poor sleep, separation anxiety, weight loss, and reduced appetite. For these children, it can take months for them to become comfortable sitting at the table again without panicking. It can take far longer for them to feel comfortable with food on the table. As you can imagine, this significantly increases the length of time they spend in feeding therapy. 

Behavior-based feeding programs will train parents to use many of their methods at home to maintain “progress” as well, so I have seen parents’ relationships with their children become damaged because they were trained by ABA professionals to use demeaning and harmful practices to force their children to comply and eat. 

An ABA Provider will tell you to re-present food your child has spit out or vomited.

The therapeutic relationship between a child and therapist is one that is built upon mutual respect. Presenting rejected food and/or vomit for a child to eat is a violation of human dignity. Full stop. 

In ABA terminology, the re-presentation of rejected food and vomit is a form of “escape extinction.” Escape extinction procedures are those in which an adult does not let a child’s behavior result in escape or avoidance of a task. Within feeding therapy, escape extinction procedures prevent children from using their behavior, like running from the table or throwing food, to escape or avoid eating. 

This is really unfortunate because behavior IS communication, and it is often a form of self-advocacy. Escape extinction procedures, regardless of what they are targeting for extinction, often seek to extinguish the self-advocacy attempts of children with significant communication needs. 

What’s even more unfortunate is that the ABA literature considers escape extinction to be a vital part of successful behavioral feeding programs (Piazza, etl. al., 2003). 

An ABA provider will tell you to try to restrain your child in a chair and do not let them leave the chair.

Placing a child in a chair that they cannot escape and denying their pleas to leave is often another form of escape extinction ABA providers use. It is also a form of restraint. 

Mechanical restraint refers to the use of equipment or devices (such as straps on feeding chairs) that restrain children and prevent them from moving or escaping. 

Notably, a mechanical device that serves as a postural support aid for one child can become a mechanical restraint for another. The difference lies in the purpose of the device and whether or not the provider has the child’s consent to use it. Many children with feeding needs require the use of adaptive seating and other devices to achieve upright positioning for safe and less effortful eating. These devices are used with the child’s consent and comfort in mind. 

In contrast, mechanical restraint is a coercive tool used by many behavior-based feeding providers as a form of escape extinction to prevent the child from leaving and force them to stay in place and continue engaging in an aversive task. Mechanical restraint is applied without a child’s consent and can be highly distressing. 

Aids to provide postural support are therapeutic.
Devices intended to restrain a child to force compliance are never therapeutic.

The use of physical and mechanical restraints are ubiquitous within behavior-based approaches to feeding therapy. 

In a 2018 systematic review of the behavioral feeding literature, a team of researchers found that over half of all study designs used restraint or other restrictive procedures, such as requiring the child to stay in a certain area until a task was complete. At least 30% of study designs using restrictive procedures clearly reported use of restraint, but many studies failed to provide adequate details of their study protocols, meaning that as many as 55% of designs evaluated may have relied upon the use of mechanical or physical restraint, or both (Ledford, et. al., 2018). 

We just don’t know how prevalent restraint is in the literature because researchers don’t clearly specify their procedures. 

This is one of the critical methodological flaws within what ABA providers consider the highly evidenced-based literature supporting the use of escape extinction procedures: vital aspects of escape extinction procedures are not disclosed.

And because the details of these procedures aren’t disclosed, these studies are difficult to replicate with fidelity, which blows a huge hole in the claim that these methods are supported by high-quality research. 

An ABA provider will tell you to put a spoon in your child’s face and refuse to move it until your child eats, regardless of their protests (i.e. non-removal of the spoon procedure).

Another popular and deeply disrespectful escape extinction technique that may be used in behavior-based feeding therapy is called non-removal of the spoon. Non-removal of the spoon occurs when the provider presents a child, who is typically mechanically restrained, with a spoon at the level of their mouth, directs them to “take a bite,” and does not remove the spoon from the child’s face, despite the child’s pleas and protests. 

Some providers only put the spoon in the child’s mouth when they open it willingly to accept the bite, but many force the spoon into the mouth while the child’s mouth is open as they scream, cry, and protest. Since the body is not prepared for food in the latter case, non-removal of the spoon carries a risk of aspiration (material entering the lungs) and choking. This is one reason why many behavior-based programs use purees in the initial stages of feeding therapy – it is easier to force puree into the mouth of a protesting and terrified child and there is less risk they will choke in the process. 

In theory, non-removal of the spoon seems pretty straightforward. The provider just waits while holding the spoon in the child’s face until they open their mouth. 

However, as you can imagine, children subjected to these types of forceful interventions often fight it, and they fight hard. 

In the following video, you see what non-removal of the spoon can become. In the video, an occupational therapist is using non-removal of the spoon to force-feed an autistic child a highly aversive texture while he is mechanically restrained. You can hear the child’s mother narrate the video, and she openly describes the technique as “force.” She also reports that her child will gag when presented with the dry, crumbly texture used in the session.

Trigger warning for mechanical restraint, emotional distress, and ABA-induced trauma

Video – OT Using Non-removal of the Spoon

This video is really hard for me to watch. I’ve watched videos of my own clients subjected to these procedures (parents are often encouraged to film these kinds of sessions so they can use the same techniques at home) and have read the notes and feeding protocols from the BCBAs and RBTs involved in their feeding interventions. 

This is what happens when we force compliance at all costs rather than getting to the root of why a child is having trouble eating.  And this is the ugly truth about behavioral feeding therapies that clinics and providers don’t want you to see. 

Instead, the ABA industry, which is largely owned by private equity firms and raking in billions of dollars a year, would much rather show you carefully edited promotional material like this. 

I suppose showing kids screaming, crying, and gagging would clash with the colorful decor and cheerful music. It would also reveal that their “good, play-based” ABA is not good or playful at all. 

As you may have noticed in the video of the OT, non-removal of the spoon doesn’t always work in getting kids to give up and take a bite. For many kids, non-removal of the spoon isn’t enough to “break” them. As a result, providers may escalate to procedures involving physical restraint.

An ABA provider will tell you to physically restrain your child while forcing their jaw open to force food into their mouth (i.e. physical guidance procedure).

As mentioned before, many ABA-based feeding programs rely upon escape extinction procedures. This means that kids can’t have an opportunity to escape the task of eating. To ensure that kids can’t escape the task, physical force can be used. 

Physical guidance is a procedure in which the adult feeding the child escalates non-removal of the spoon to add pressure to the jaw to open the child’s mouth so they will accept the spoon. Notably, though, there is inconsistency in the literature regarding what constitutes a physical guidance procedure. The details of this procedure are actually so inconsistent in the ABA literature that a team of researchers recently sought to examine what defines a physical guidance procedure and found that it refers to four different techniques (Rubio et. al., 2021). 

In the previous video of the OT, it appeared that she was attempting this technique when she was placing her hand under the child’s jaw and putting her fingers on the sides of his face. However, as you saw, that wasn’t enough to stop the child from physically resisting and escaping the task. Because of the child’s desperate attempts to get away from her, she couldn’t get a secure enough grip on his jaw to pry it open. 

This is why a second person, sometimes called a “blocker,” is added to the protocol. This person sits or stands behind the child and restrains them from behind while the adult in front forces the child’s jaw open to accept the spoon. 

Unfortunately, extensive online searches have failed to produce an image of this procedure and the ABA literature is inconsistent in defining what actually constitutes a physical guidance procedure. As a result, we have created this image to demonstrate what physical guidance looks like. This image is based on my clinical experiences watching videos of my clients subjected to this procedure, reading their BCBAs’ feeding protocols, and discussing therapy techniques with their BCBAs. 

In clinical practice, physical guidance procedures often require the use of “blockers,” a second adult who restrains the child from behind, as the “feeder” forces the child’s jaw open with pressure at the temporomandibular joint. This is all done without the child’s consent and often while the child actively protests the procedure.

But it doesn’t always look this tidy. 

The following is a video of what physical restraint in behavior-based feeding therapy can look like.

Trigger warning for child restraint, emotional distress, and ABA-induced trauma

Video – Physical Guidance Procedure

That was probably really uncomfortable for you to watch, but this is the reality of behavior-based feeding. This is what happens when providers demand compliance at the cost of human dignity. 

Some ABA providers of feeding therapy may tell you that this video is not what evidence-based physical guidance looks like. However, that is categorically false. 

That’s because no one knows what the “evidence-based” physical guidance procedures in literature actually look like because researchers consistently fail to disclose vital aspects of techniques including uses of mechanical restraint, positioning of adults, and discussion of what techniques are used when a child overpowers the adults and actually does escape the restraint. 

Additionally, this traumatizing event took place at the University of Nebraska Medical Center’s Munroe-Meyer Institute Feeding clinic, a nationally renowned feeding clinic affiliated with researchers who are highly involved in producing literature supporting the use of ABA-based feeding interventions like physical guidance. 

Traumatizing and abusive procedures like this are the result of “cutting edge research” produced by supporters of ABA. 

We know that restraint has a devastating effect on children’s emotional and psychological well-being. We know that fear and stress actively suppress our appetites and the desire to eat. So why would we intentionally subject children to stressful events like restraint and then expect them to want to eat? 

This is where the evidence base supporting behavioral feeding therapy begins to fall apart. Like much of the literature within applied behavioral analysis, researchers supporting the use of behavioral-based feeding interventions, particularly escape extinction methods, have failed to incorporate modern neuroscience research into their practice. 

Yes. Many children will “break” and start to eat if two adults hold them down and repeatedly force a spoon into their mouth. For the sake of self-preservation, kids subjected to these methods may eventually learn that their physiological sensations and communication won’t be honored and they will give up. However, although they may have finally eaten the food, they’ve learn nothing about its sensory properties, how to manage it with a utensil, or how to develop the oral motor skills to break it down.

That’s because behavioral feeding interventions aren’t teaching programs; behavior-based feeding interventions are compliance training. 

An ABA provider will tell you that behavior-based feeding therapy is the only evidence-based approach for addressing feeding disorders.

This is what I believe is the biggest myth perpetuated about feeding by ABA professionals involved in feeding intervention. Behavior-based feeding therapy is NOT the only evidence-based approach to feeding intervention, despite how much they would like you to believe that it is. 

Feeding Matters, the leading research, education, and advocacy organization for pediatric feeding disorders clearly states: 

“There is no identified longitudinal, evidence-based best practices for intervention. This is due to the lack of longitudinal information available in the current research, and the heterogeneous nature of the population of children with pediatric feeding disorders.”

– Feeding Matters

Despite the fact that the leading international organization for pediatric feeding disorders does not recognize any treatment method as the “gold standard” treatment for feeding disorders due to a paucity of high-quality research, ABA clinics and providers often fraudulently state that ABA is the only evidence-based intervention for treating pediatric feeding disorders. Spreading this kind of blatant disinformation helps their bottom line while harming countless children and families in the process. 

Furthermore, the evidence base supporting the use of ABA tactics, such as escape extinction, in feeding is fundamentally flawed. A brief summary of flaws in this body of literature include:

• Failure to disclose conflicts of interest which may bias the researchers

• Failure to adhere to best practice guidelines in the treatment of pediatric feeding disorders (such as utilizing a team-based approach), resulting in failure to control for confounding variables such as medical and oral motor/sensory needs impacting feeding

• Failure to measure longitudinal outcomes

• Failure to measure and report adverse outcomes
  
  

When it comes to feeding intervention, there are far more ethical and respectful approaches than the behavior-based techniques touted by ABA providers. 

An ever-growing interdisciplinary body of literature supports the use of Responsive Feeding Therapy, which prioritizes child autonomy, intrinsic motivation for eating, and the parent-child feeding relationship. 

Resources for Respectful Feeding Therapy:

https://therapistndc.org/therapy/feeding-therapy/

For additional reading regarding the differences between behavioral and affirming feeding interventions, we highly recommend reading Jenny McGlothlin’s work. Jenny is a CCC-SLP, lactation consultant, and responsive feeding specialist:

The Nuance Between a Responsive and Behavioral Approach to Feeding Therapy

References:

Piazza, C. C., Patel, M. R., Gulotta, C. S., Sevin, B. M., & Layer, S. A. (2003). On the relative contributions of positive reinforcement and escape extinction in the treatment of food refusal. Journal of applied behavior analysis, 36(3), 309-324. https://doi.org/10.1901/jaba.2003.36-309

Ledford, J., Whiteside, E., & Severini, K. (2018). A systematic review of interventions for feeding-related behaviors for individuals with autism spectrum disorders. Research in Autism Spectrum Disorders. 52. 69-80. 10.1016/j.rasd.2018.04.008.

Rubio, E. K., McMahon, M. X. H., & Volkert, V. M. (2021) A systematic review of physical guidance procedures as an open-mouth prompt to increase acceptance for children with pediatric feeding disorders. Journal of Applied Behavior Analysis, 54 (1),144-167. doi: 10.1002/jaba.782. 

Tereshko, L., Leaf, J.B., Weiss, M.J., Rich, A. and Pistorino, M. (2021), A systematic literature review of antecedent and reinforcement-based behavioral feeding interventions without the implementation of escape extinction. Behavioral Interventions, 36: 496-513. https://doi.org/10.1002/bin.1769

About the author: Caroline Braun, M.S., CCC-SLP, is an Autistic speech-language pathologist practicing near Baltimore, Maryland. Through her private practice, she provides neurodiversity affirming language and feeding both virtually and in the home environment. Caroline is an aspiring researcher with a particular interest in responsive feeding therapy and affirming parent-mediated interventions. You can find Caroline at: https://www.carolinebraunslp.com/

About the illustrator: Andrew Moore is an illustrator, designer, and educator in the Baltimore/Washington area whose work focuses on sustainability and social responsiveness.

www.andrewmooredesign.com
acmooredesign@gmail.com
815.520.4173

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