One More Bite: Why Behavioral Therapy is Sending the Wrong Message

April 24, 2019

Posted in: Early Intervention, Feeding, Feeding Tube Weaning

There is a dirty secret in the world of feeding therapy.  Most therapists don’t even know that there are decades of studies that highlight well-documented risks associated with one of the most common feeding therapy approaches. That’s right, even in the USA in 2019, the majority of our vulnerable eaters go to feeding therapy that puts their relationship with food and health at risk. What is this therapy approach we are speaking of? … behavioral therapy.

Before we get into the nitty-gritty, let’s take a minute to explain just what this therapy is. Behavioral feeding therapy is any feeding intervention that offers external reinforcement for tasting, touching, or eating a food.  External reinforcement can range from actual rewards such as a toy or a treat, to screen time, to praise, kisses, and breaks.  What makes the reinforcement external is that it is adult-directed, meaning that the child did what they did for the adult or for the prize because they were asked to versus doing it for internal motivations.  In this therapy, children are often asked to override the strong messages their bodies and minds are telling them about food, and instead perform to please.   

The alternative to external reinforcement is internal drive.  What are the natural internal drives when it comes to children and eating?  Hunger, comfort, taste, curiosity, and togetherness.  So when all is going as it should, children should accept or initiate the next bite (or first bite) of a food because they are either hungry, seeking comfort in the food and the sensations that come with it, or because they enjoy eating as a way to be together with their family and friends.  Research (and even mainstream media!) shows us that when children are taught to relate to food in a way that ignores or overrides their internal drives, it is correlated with a higher risk of feeding challenges and health conditions later in life.   

It can be difficult or seemingly impossible for kids with medical challenges, anxiety or a rocky, fearful history with food to respond to the natural internal cues that drive eating.  That is why many parents put their trust in well-meaning, but misguided feeding therapists and engage in therapies that unknowingly put their kids at risk for feeding problems and challenges later in life.  Here is a breakdown of the main reasons to stay away from behavioral strategies when trying to help your kid become an eater or improve their eating: 

  • In most cases, your child’s “behavior” around food wasn’t what caused the feeding challenges your child is experiencing, therefore, addressing behaviors is likely addressing the symptom rather than the problem.  
  • “Teaching children to respect and protect their bodies should be everyone’s job. No matter what size you are. Always.,” as our clinical coordinator, Heidi Moreland, aptly points out.  So don’t engage in therapies that hand over control of what happens to your child’s body when they are showing fear and reluctance.  
  • There are no longitudinal studies that suggest such behavioral therapies work in the long-term, despite their short-term benefits.   
  • There are longitudinal studies that suggest adult control, like the methods used in behavioral feeding therapies, can cause harm to health, eating skills, and habits around food .   

Heidi has also reflected that “our most vulnerable eaters are subject to the most harmful techniques”.  When we step back, it makes sense that if you teach a child that they will be rewarded for doing things that they are afraid of instead of first learning to be unafraid, there are going to be lasting implications psychologically and medically. Additionally, if your child is being held still and/or forced or coerced to eat foods they don’t feel comfortable with it can be traumatizing to their relationship with food, but also to their relationship with the person doing the feeding (Black and Aboud). There is overwhelming evidence that trauma in early childhood has a profoundly negative affect on the developing brain. (Shonkoff) Here is a summary of some of the documented health risks that are correlated with approaches to feeding kids that inhibit self-regulation and that focus on external reinforcement versus internal drive:  

  • Poor attachment 
  • Increased risk of diabetes 
  • Increased risk of weight gain challenges 
  • Increased risk of eating disorders
  • Increased risk of substance abuse

This information leaves a lot of parents surprised and wondering what to do instead.  Here is a list of tips that we hope you find helpful when considering therapy decisions: 

  • Never let your child who is feeding averse or afraid of food have their hands held down while they are fed something they don’t really truly want. 
  • Never let your child be tricked or coerced into eating something that they do not want or feel safe around. 
  • Never let your child be fed by a therapist in a room where you aren’t present and able to support them.  
  • Search for therapists who identify as working from a “responsive feeding” framework. Responsive feeding is evidence-based and helps children build skills and mastery while also learning about and responding to their bodies’ internal drives.  This is accomplished in a way that builds trust and connection between the child and the person feeding them.   
  • When faced with difficult decisions about feeding ask yourself “Is this thing I am considering doing with food/feeding going to help my child learn to understand and trust food and eating more or less?”.  If the answer is more… full steam ahead.  If the answer is less, don’t do it.   


Birch, Leann L., and Jennifer O. Fisher. “Development of eating behaviors among children and adolescents.” Pediatrics 101.Supplement 2 (1998): 539-549 

Black, Maureen M., and Frances E. Aboud. “Responsive feeding is embedded in a theoretical framework of responsive parenting.” The Journal of Nutrition 141.3 (2011): 490-494 

Galloway, Amy T., et al. “‘Finish your soup’: counterproductive effects of pressuring children to eat on intake and affect.” Appetite 46.3 (2006): 318-323 

Moreland, H (2018 ASHA National Convention) Facilitation of Self-Regulation & Parent Empowerment in a Hunger-Based Tube-Weaning Program [Oral Presentation with Powerpoint] 

National Institute of Health: National Institute on Drug Abuse, Principles of Substance Abuse Prevention on Early Childhood (March 2016) 

Savage, Jennifer S., Jennifer Orlet Fisher, and Leann L. Birch. “Parental influence on eating behavior: conception to adolescence.” The Journal of Law, Medicine & Ethics 35.1 (2007): 22-34 

Scaglioni, S., Salvioni, M. & Galimberti, C. (2008). Influence of parental … British Journal of Nutrition, 99, 22-25 

Slaughter, C., & Bryant, A. H. (2004). Hungry for love: The feeding relationship in the psychological development of young children. Permanente Journal, 8, 23–29