Part 2: The Case For a Responsive Approach to Feeding Therapy
(Missed Part 1: Applied Behavior Analysis (ABA) Professionals & Feeding Intervention? Find it HERE.)
Drawbacks of Behavioral Methods in Feeding Therapy
Practitioners who use behavioral modification methods in their therapy sessions do so because they believe them to be useful tools for achieving their agenda of getting a child to eat. I have worked with therapists who use them, have been directly referred patients from inpatient behavioral feeding programs, and have seen many behavioral protocols that parents have been asked to follow within these programs/therapies. My core belief system rejects the idea that it is my job to “get” a child to eat, and therefore it is not necessary for me to use any tool that may cause anxiety in child I am treating, which is often the case when these methods are used.
I have heard ABA clinicians use the term “break the child” in reference to the point in therapy where a child ultimately gives up and begins complying with “taking bites” in therapy; this smacks of dehumanization and is cruel, in my opinion. Another explanation for “giving in” could be found in trauma theory. Research is needed to examine if giving in and eating is actually a trauma response. “When the dorsal vagal nerve shuts down the body, it can move us into immobility or dissociation”…that comes after “fight or flight”, where a child is trying to avoid eating whatever the adult is presenting. A child who ‘zones out’ after fighting tooth and nail to avoid something they perceive to be dangerous is not ‘complying’. They are potentially “dissociated” in the freeze, emergency state. That is NOT where we want children to be and not where they will learn to do their best with eating.
There are many reasons why I believe that the focus on behavior is not the best thing for the child. Here are a few:
- Behavior is communication. A child with problematic behavior is communicating that there is a problem. It’s our job to listen and pay close attention to determine what the problem is and help the child solve that problem—then they can focus on developing skills. Our job is NOT to extinguish that behavior (which includes crying, gagging, vomiting, and refusing) without getting to the root of the issue.
- Behavioral protocols attempt to simplify what is a complex process. Given what we know about how children learn to eat, the complexity of the developmental process, and the often traumatic experiences around food (hospitalization, pain, vomiting, force-feeding), why would we try to simplify eating into an isolated behavior?
- Developmental stress experiences make a huge difference in the way your brain develops and functions. Ignoring a child’s stress signals, activating their sympathetic nervous system, causes changes in the DNA and brain. Dr. Bruce Perry calls this process a “sensitizing pattern” of a child’s neural networks. Children who are coerced into eating food that they cannot safely or comfortably eat will undoubtedly be stressed, which changes their reactions the next time they are eating.
A Gentler Way: Responsive Feeding Therapy
So how is what I do different from the behaviorally-focused therapy that many hospitals and clinics utilize? I have determined that, for me, the difference between “using behavioral principles” and what I do in my work is the responsive piece. Modeling a skill may be considered a “behavior principle” but what I do after I model something is where I veer away from an Antecedent-Behavior-Consequence mindset. I don’t believe that it’s my job to provide a consequence during feeding therapy. The child does not learn the complex task of eating well through my direct interference or application of punishment or reinforcement. I absolutely try to determine the antecedent for a behavior, but so do all good diagnosticians— it isn’t strictly an ABA skill.
I believe that development through discovery is the way to build trust— trust in me, trust in their caregiver, trust in food, and trust in their own body. Most of my patients are medically complex, have experienced much developmental trauma, and I feel it is my job to give them back their bodily autonomy as much as I can. Anything that would take away that autonomy is off limits.
What I do in my work is facilitation- I’m focused on what the child’s agenda is instead of mine. Their response to any presentation (modeling a skill, a food placed on the table, an offer of touch to the face) informs what I do next. There is no consequence if the child refuses or chooses to do something different. They dictate the pace and the path that we take. I always get their permission, they are not made to do anything they don’t want to do, and I’m there to give support if they have trouble doing something they want to do. If they show any signs of stress, I back off, move to something less difficult, and give them time to feel safe and comfortable again.
Facilitation is different than encouragement. Gentle facilitation is focused on helping a child do what they already want to do. Encouragement is trying to get a child to do what I want them to do, and can easily lead to pressure- and the research is clear that pressure results in LESS eating, LESS enjoyment, and LESS progress.
Do I model new ways to interact with a food? Absolutely. What I don’t do, however, is set up a situation where the child HAS to do what I modeled or feels like there’s an expectation that they do it or there will be consequences. It is always their choice, they have the power of no, and I’m constantly reading their signals to determine my next step.
Facilitation creates an atmosphere of autonomy, and that is my first goal. And the long-term outcomes are worth it.
( See Part 1: Applied Behavior Analysis (ABA) Professionals & Feeding Intervention HERE)
For more on the growing responsive therapy movement, check out our May 14th and 15th, 2020 Responsive Feeding Therapy Conference in Dallas, Texas.