Part 1: Applied Behavior Analysis (ABA) Professionals & Feeding Intervention
Your child’s ABA therapist wants to develop a feeding plan for him right away. What should you know?
Applied Behavioral Analysis (ABA) began in the 1930’s with BF Skinner, who believed that radical behaviorism was the lens through which we needed to view human motivation. Even though there have been many advancements in our understanding of behavior and motivation, his work continues to be used as the basis for an entire therapeutic and business model. With the advent of neurological imaging technology and the scientific measurement of cognitive processes (DeSouza et al., 2012; Kühn et al., 2014), behaviorism has ceased to be a leading theory of learning. Nevertheless, there has been a surge in the number of ABA clinics and providers around the country, with many integrating ‘feeding plans’ into their therapy sessions with children.
I was recently asked to explain how I view the role of behavioral modification principles in feeding therapy and how the therapy model/approach that I practice and promote is different (see part 2 for my answer). Many feeding therapy programs (inpatient and outpatient) and some therapy providers (Speech-Language Pathologists-SLPs, Board Certified Behavior Analyst-BCBAs, etc) use ABA (Applied Behavioral Analysis) methods to “get” children to eat more or different foods than they are currently comfortable eating. The proponents of these approaches point to research that heavily relies on low-level evidence such as “individual case-control studies, case series, or expert opinion without explicit critical appraisal or based on physiology bench research or “first principles” with small sample sizes” (often one child).
I offer my perspective on behavioral approaches as someone trained in college by a Lovaas-based program to provide discrete trial training (DTT) for children with a diagnosis of Autism Spectrum Disorder (ASD). In addition, after obtaining my master’s degree, I worked in an outpatient hospital setting directly connected to a strongly behavioral inpatient feeding program that sent patients to me for continued services. I had training in ABA, but the graduate program I had been enrolled in, the experiences of my clients, and my clinical intuition led me to dig deeper and to look for alternative approaches that would lead to better outcomes. Too many children were getting worse or exhibiting new behaviors when they received ABA. I have done extensive reading regarding the use of ABA principles in feeding therapy, and have seen firsthand what these behavioral principles can and cannot achieve for a child with feeding challenges.
Skinner’s model was called radical behaviorism. “The key difference between radical behaviorism and previous or alternative views of behavior is that Skinner’s model didn’t include looking at factors that aren’t immediately obvious and observable. What you thought, how you felt, what memories you had… none of those things mattered according to radical behaviorism.” That basic tenet that you are to ignore what goes on inside a child when they are not eating well (structural abnormalities, pain, discomfort, past trauma such as vomiting) is completely misguided, but how else would you view a child if you were never taught about all the other reasons that a child may have difficulty eating?
“A lifetime or punishment and reward without an understanding of the task that is being asked, can create individuals who are compliant and conditioned to obey others, independent of a task. It creates individuals without intrinsic motivation, self-confidence, or self-esteem to successfully engage in any task. A lifetime of having food, candy, toys, and other objects being withheld without an understanding as to why, can create learned helpless, anxiety, and stress. Various punishments such as misting the child in the face with water, taking away desired objects, withholding attention from the child, ignoring the child, or removing the child from the situation, and even electric shock have all been utilized without hesitation or contemplation of the long term psychological consequences.” (Sandoval-Norton & Shkedy, 2019)
Most ABA Professionals are Dangerously Unqualified to Provide Feeding Therapy
Behavioral thinking and the methods employed under this approach often lead to ignoring vast amounts of information crucial to successful, long-term outcomes. It is my experience that many behavioral treatment methods often exacerbate initial challenges by ignoring the child’s communication about that problem. In these therapy approaches, such as escape extinction (where the child is unable to “escape” eating and behaviors such as crying, vomiting, gagging are targets for extinction), and continuous reinforcement (reinforcement such as access to watching a video is delivered after every single target behavior), children are not given the power to say ‘no’ and the adult agenda overwhelms the child’s need for autonomy and self protection, with the trust and relationship with the adult being damaged as well.
Those who typically provide ABA services lack even the most basic knowledge regarding the multitude of reasons why children don’t eat enough or don’t eat a variety of food. Most day-to-day ABA sessions are not done by a licensed BCBA but by an RBT (Registered Behavior Technician which requires only a high school diploma and forty hours of training in behavioral principles and techniques but NO training in feeding development or disorders), who is not licensed, minimally trained, and is totally unqualified to determine why a child is not eating. Competent and ethical feeding therapy requires education and experience with anatomy and physiology, phases of swallowing and ability to recognize and respond appropriately to children who are in trouble/experiencing potentially dangerous difficulties that need further testing, oral motor/sensory knowledge, and understanding of how feeding dynamics works.
The complete lack of crucial curriculum-based education around anatomy and physiology and feeding development/disorders should disqualify most Behavior Analyst professionals from working with children around feeding and swallowing. There is a similar discussion in the field of psychology about the role of ABA for children with Autism. “To apply only behaviorist principles, to vulnerable children without voices, completely disregarding newer, better researched or more holistic interventions, especially at the extreme that ABA promotes, is frankly irresponsible, damaging, and goes against the code of ethics.” (Sandoval-Norton & Shkedy, 2019)
If one doesn’t have the knowledge and education to determine if feeding behaviors are developmentally appropriate or adaptive, or may be due to an undiagnosed medical issue (which is not uncommon) how can one provide ethical treatment? Feeding therapy is largely diagnostic therapy, as children are constantly changing and developing. Behavioral modification focuses on isolated behaviors and not on the WHY (or antecedent, in behavioral language) behind a child not eating. In my opinion, one can’t figure out what the antecedent to a behavior is if one doesn’t have the knowledge to figure it out. It precludes them from making ethical and appropriate decisions when it comes to a child’s care in feeding therapy.
Scope of Practice
In my opinion, rooted in almost 20 years of working with children with feeding disorders, BCBAs should only be involved in feeding as ancillary professionals who might help a family with structuring their home environment to support what the feeding specialist asks for help with. Any decisions around IF they should present a child with food, what foods to present, or how to present them to a child are out of their scope of practice. These decisions should be based in understanding the oral motor skills needed to manipulate different foods, that particular child’s skills and medical history, the way that the sensory system contributes to safe swallowing, the science of food consistency and texture, and the dynamic feeding relationship between a caregiver and a child and a child’s trust in their own body. These decisions fall squarely in the scope of the SLP (and many OTs) due to our curriculum-based education, practical training, focus on continuing education in these areas, and established code of ethics dictating our role in feeding/swallowing.
Feeding is low-hanging fruit for ABA clinics, and ABA is estimated to be a $17 billion cash cow, annually. When a child is at an ABA clinic or the ABA provider is in a child’s home for 20-40 hours a week, they will be around for meals. (I’m not going to go into why this schedule is ridiculous for a child- that’s a whole other discussion.) Having a “feeding plan” allows the ABA clinic to bill for services when the child is eating regular meals. With little to no training on actual feeding development or knowledge of the research literature around feeding, their ‘therapy’ often consists of withholding preferred foods in an effort to force children to eat other foods, seemingly chosen arbitrarily based on the whims and judgments of the provider. Or, they show the child a video on an iPad, turning it off if the child refuses a bite, which often leads to more ‘behaviors’ than they started with. When a child zones out watching a video, they are engaging in dissociated eating which can lead to poor oral manipulation of foods, gagging, and negative associations with meals. Through the years, I’ve had countless parents tell me during our feeding therapy sessions that their BCBA wanted to add a ‘feeding plan’ for their child, even though they are already being treated by me, a director of a University feeding clinic and author of books on feeding. The audacity of ABA providers wanting to take feeding over, even though my patients’ parents never ask for help, is an overriding theme in my two decades of practice.