Both neurotypical and neurodivergent children and adults may experience feeding difficulties or a feeding disorder. Some challenges associated with feeding include “picky” eating, limited caloric intake, limited variety of foods, reduced or delayed oral motor skills, sensory processing concerns, anxiety about food, and more. Caregivers of individuals with feeding disorders may find themselves concerned about their loved one’s health and frustrated when their attempts to increase volume or variety of food at mealtimes are not successful.
Feeding disorders are complex and may be the result of medical conditions, nutritional deficiencies, feeding skill challenges, or psychosocial concerns. Many feeding disorders are the result of a combination of these four factors. As a result, best practice guidelines across disciplines indicate treatment from a multidisciplinary team. The treatment team may include GI specialists, allergists, dietitians, occupational therapists, speech-language pathologists, and mental health professionals.
Decades of interdisciplinary research indicate that feeding challenges are common among infants and children regardless of neurotype. Studies reveal that between 20-50% of typically developing children experience feeding difficulties during childhood, while the prevalence of feeding challenges is significantly increased among children with developmental disabilities, rising to 70-89% (Benjasuwantep et. al., 2013).
In fact, eating differences or challenges may be one of the first signs that a child may be neurodivergent. As a result, neurodivergent children often receive feeding therapy services. Unfortunately, many of those services are informed by Applied Behavior Analysis (ABA), and the methods used in these therapies are highly disrespectful and potentially traumatic.
ABA-Based Feeding is Disrespectful and Potentially Harmful
Unfortunately, many private clinics and hospitals offer feeding interventions that are informed by Applied Behavior Analysis (ABA). ABA research and practice supports the use of rewards and punishments in feeding therapy as well as the use of highly aversive and potentially traumatic techniques such as mechanical restraint, physical restraint, and forcible feeding. ABA-based feeding therapy may include:
- Rewards (such as praise, token economies, access to preferred foods, access to preferred toys/activities, etc)
- Punishments (such as timeout, reprimands, or exposure to aversive stimuli like loud noises or restraint)
- Mechanical restraint (i.e. seating equipment children cannot escape)
- Physical restraint and forcible feeding
- Planned ignoring
- Withholding food or drinks to induce compliance
Therapist Neurodiversity Collective does not recommend ANY ABA-derived or compliance-based techniques in feeding therapy.
ABA-Informed Feeding Therapies are Dehumanizing to Children
ABA-informed feeding therapies rely upon the use of consequences, both rewards, and punishments, to get children to eat. When praise, access to preferred foods, or iPad time don’t coerce children into eating, ABA providers often employ highly aversive and invasive techniques like strapping children into chairs and physically restraining them to force them to eat.
And many professionals and parents have no idea that children will be subjected to these techniques until they are already enrolled in an intensive behavioral feeding program.
Who is your feeding therapist?
Most ABA providers are fundamentally and often dangerously unqualified to provide feeding therapy. In fact, many ABA-based feeding programs, both in private clinics and hospitals, employ entry-level employees, known as registered behavior technicians (RBTs), to provide the majority of feeding treatment. The RBT credential requires only a high school diploma and 40 hours of online training. Board Certified Behavior Analysts (BCBAs) often write behavioral feeding treatment plans, yet graduate training for BCBAs does not require training in the areas of feeding and swallowing.
In contrast, Occupational Therapists (OTs) and Speech-Language Pathologists (SLPs) often receive extensive graduate education and supervised training in the assessment and treatment of feeding disorders. Required graduate coursework for American-Speech-Language-Hearing Association (ASHA) certified SLPs includes typical feeding development, feeding/swallowing disorders, assessment and treatment of feeding/swallowing disorders, and anatomy and physiology of the structures and organs involved in eating, swallowing, and breathing.
Responsive Feeding Therapy
All ethical and neurodivergent-affirming feeding techniques must be informed by a responsive feeding framework. Responsive parents and feeding therapists support children by developing a warm, trusting relationship as well as an environment that facilitates positive emotional responses to mealtimes (Black & Aboud, 2011). At the same time, they support the child’s autonomy by allowing the child to determine how they will interact with the food that adults provide them. All of this is done in accordance with Self-Determination Theory, which provides a philosophical underpinning for responsive feeding therapy (Cormack, J., Rowell, K., & Postăvaru, G., 2020).
Responsive feeding therapy prioritizes personal autonomy, the feeding relationship, internal motivation, individualized care, and the child’s sense of competence (Rowell, K.,et. al., 2020).)
To learn more about each of these values, please see Responsive Feeding Therapy: Values and Practice (Rowell, K., et. al., 2020). Each of these five values must be included in treatment to be considered responsive feeding therapy.
NOTE: Any provider, regardless of discipline, who claims to provide responsive feeding but also uses rewards, punishments, restraint, pressure, or “gentle”/”play-based” ABA is not practicing responsive feeding.
Like all other aspects of the Neurodiversity Movement, the term “responsive feeding” has been commodified by some professionals to promote feeding interventions that continue to include the use of ABA-derived and/or compliance-based techniques.
ABA-based, compliance-based feeding is not, and never will be, responsive or respectful.
For further reading
The Nuance Between a Responsive &. Behavioral Approach to Feeding Therapy: Applied Behavior Analysis (ABA) Professionals & Feeding InterventionThe nuance between a responsive &. behavioral approach to feeding therapy: Part 1. Helping Your Child with Extreme Picky Eating. (2019, September 12). Retrieved January 6, 2022, from https://www.extremepickyeating.com/the-nuance-of-a-responsive-vs-behavioral-approach-to-feeding-therapy-part-1/
The Nuance Between a Responsive &. Behavioral Approach to Feeding Therapy: The Case For a Responsive Approach to Feeding Therapy
The nuance between a responsive & behavioral approach to feeding therapy: Part 2. Helping Your Child with Extreme Picky Eating. (2019, September 12). Retrieved January 6, 2022, from https://www.extremepickyeating.com/the-nuance-of-a-responsive-vs-behavioral-approach-to-feeding-therapy-part-2-2/
When Feeding Therapy Becomes Aversion Therapy
Katja Rowell, M. D. (2013, May 26). When feeding therapy becomes aversion therapy. HuffPost. Retrieved January 6, 2022, from https://www.huffpost.com/entry/when-feeding-therapy-becomes-aversion-therapy_b_2951294
Black, M. M., & Aboud, F. E. (2011). Responsive feeding is embedded in a theoretical framework of responsive parenting. The Journal of Nutrition, 141(3), 490-494.
Cormack,J., Rowell, K., & Postăvaru, G. (2020). Self-determination theory as a theoretical framework for a responsive approach to child feeding. Journal of Nutrition Education and Behavior, 52 (6), 646 – 651.
Rowell, K., Wong, G., Cormack, J., & Moreland, H. (2020). Responsive feeding therapy: Values and practice. Responsive Feeding Therapy. https://www.responsivefeedingtherapy.com/rft-values-and-principles