The speech therapist would say, "If you don't kiss the raisin, Mommy has to leave. You don't want Mommy to leave, do you?" I would ALWAYS end up leaving because there wasn't a chance in hell she was going to kiss that raisin. She would SCREAM my name again and again, hysterical, hard-to-breathe screams and cries. I felt like I might as well have been leaving the room while someone stabbed her. I always felt it was wrong -- and we don't do that therapy anymore." -- Carol, mother of 4-year-old Emma, with severe selective (picky) eating
As a childhood feeding expert, I have been dismayed recently with the increasing number of parents seeking me out after their children "fail" feeding therapy. With more children diagnosed on the autism spectrum and up to 80 percent of children with special needs struggling with feeding, far more children are entering feeding therapies than even a decade ago.
After reading Carol's words on my Facebook feed, I had an "A-ha" moment. Instead of desensitization through behavioral modification or exposure therapy aimed at increasing the amount and variety consumed, what children like Emma endure, often for months on end, is actually very effective aversion therapy.
Here is a definition from minddisorders.com: "Aversion therapy is a form of behavior therapy in which an aversive (causing a strong feeling of dislike or disgust) stimulus is paired with an undesirable behavior in order to reduce or eliminate that behavior."
For Emma, the "strong feeling of dislike" was the primal terror of abandonment -- and the undesirable behavior repeatedly associated with it? Eating.
For children like Emma, eating becomes automatically associated with heightened stress, fear and arousal, often worsening the initial feeding challenge. The neural pathways are reinforced so that eating = fear. The child eats fewer and fewer foods in smaller quantities, requiring more and more effort (and therapy), until typically 18-24 months later, the child "fails" and is left eating five or so foods, with a relationship to food defined by anxiety and avoidance. As one mother warned, "Bad therapy is worse than no therapy."
And Emma is not alone. Consider a couple of my other cases: the little girl who, within weeks of beginning food "exposure" therapy with a psychologist, would vomit simply pulling into the parking lot, or the boy who cries, gags and vomits every night for two years through the prescribed therapy task of eating two bites of non-preferred foods before being allowed to eat a safe food.
As a doctor, I take my oath to "first do no harm" seriously. And what I am increasingly seeing, as feeding therapy becomes almost a mainstream, first-line strategy for addressing everything from typical picky eating to serious feeding disorders, are children harmed by the very therapies parents turn to for help.
Reviewing the histories of the feeding therapy "failures" I've worked with, in every case there was coercion to varying degrees -- from extreme, where the child was restrained, vomiting and sobbing during therapy, to simply arguing and fighting over therapy tasks like having to eat those "non-preferred" bites, or having to kiss foods. (Some sensitive children even find positive reinforcement, like earning video game time for trying a new food, lessens appetite and worsens selective eating. As one dad explained, "Rewards work for everything but food.") As I talk with colleagues in the eating disorder world, I tell them to get ready. A wave of children who have been part of a grand experiment is coming their way.
All parents need support, but especially those whose children present with feeding challenges. Ellyn Satter's Division of Responsibility in feeding has been around for 40 years, and the research to support this tuned in or "responsive" style of feeding grows by the year. There are amazing speech and occupational therapists helping children overcome oral-motor and sensory processing roadblocks. The key is low stress, no pressure exposures paired with pleasant family mealtimes and structure.
Doctors and therapists must be better educated about the complex nature of feeding challenges. Parents must be empowered to know when a therapy is helping or not and how to support their child's eating where it matters most -- in the home.
Parents tell me that what they were told to do went against their instincts and felt wrong. It is unconscionable that desperate parents are unknowingly bringing their children to experts who do more harm than good. These aversion therapies are failing the children, not the other way around. We can do better.
See the Feeding Doctor's resource page for a list of questions to ask your feeding therapist.
For more on feeding therapies and rehabilitating a difficult feeding relationship at home, see Love Me, Feed Me.