Responsive Feeding Therapy:
Values and Practice

Lead authors: Katja Rowell MD, Grace Wong MSc, RD, CEDRD-S, Jo Cormack, MA MBACP, Heidi Moreland, MS, CCC-SLP, BCS-S, CLC

Early contributors: Jenny McGlothlin, MS, CCC-SLP, CLC, Jennifer Berry, MS, OT/L

Reviewers: Erin VandenLangenberg Ph.D., MPH, Jennifer Berry, MS, OT/L

White paper released 8/16/2020

Acknowledgment:

The responsive feeding therapy framework draws from the wisdom, knowledge and expertise of many teachers and mentors from different fields.  

Introduction

This white paper offers a philosophical and clinical framework for Responsive Feeding Therapy (RFT). It is applicable to practitioners working in pediatric feeding as well as with food avoidance in adolescence and adulthood, from multiple fields, primarily speech-language pathologists, dietitians, psychologists and therapists, occupational therapists, primary care providers, and community nurses.

The RFT approach and respective values build on a body of research from the field of pediatric feeding and related areas of study. This includes, but is not limited to, responsive parenting, humanistic psychology, attachment theory and interpersonal neurobiology, theories of development, Self-determination Theory (SDT), and trauma physiology. 

In addition to helping clinicians understand and implement RFT, this framework provides a foundation for researchers to contribute to the empirical evidence base and improve clinical utility.

While separated for the sake of clarity, the values listed in the RFT framework are interrelated. For example, skill acquisition must be grounded in the context of attuned relationships and individual autonomy. 

 

Definition

Responsive Feeding Therapy (RFT) is an overarching approach to feeding and eating interventions applicable to multiple disciplines and across the lifespan. RFT facilitates the (re)discovery of internal cues, curiosity, and motivation, while building skills and confidence. It is flexible, prioritizes the feeding relationship, and respects and develops autonomy.  

 

RFT Values

Autonomy, Relationship, Internal Motivation, Individualized Care, Competence

 

Autonomy  pertains to agency and respect for personal space and bodily integrity, enabling a person to be in control of their own actions 

 

Relationship refers to warm and attuned interpersonal connections

 

Internal motivation describes a desire to act that is self-driven rather than brought about by external forces

 

Individualized care refers to personalized interventions with a focus on the whole person, in the context of their families, communities and cultures

 

Competence means the individual’s perceived (as opposed to objectively assessed) sense of having sufficient skills to manage a situation

Autonomy

What we believe:

  • The child’s bodily integrity (“my space, my body”) must be respected

  • Strategies to ‘get’ children to engage with a food or therapy task (such as physical restraints, opening a child’s mouth with mandibular pressure or rubber-coated spoon, holding lips or jaw closed, or non-removal of the spoon) undermine autonomy

  • The child’s agency (“I decide”) must be prioritized

  • Crying, gagging, or vomiting are not ‘behaviors to extinguish’, they are responses to past or current negative experiences with food or eating (including, but not limited to, developmental and/or medical challenges, and compromised autonomy)

  • Therapeutic goals are guided by the child’s current presentation, skills, and readiness

 

What we do:

  • Uphold a child’s right to say “no” 

  • Attend and respond to verbal and non-verbal communication 

  • Neither recommend nor implement negative consequences (such as taking away screen time or withdrawing affection) if a child decides not to eat, interact with a food or, engage in a therapeutic task

  • Provide developmentally appropriate support designed to cultivate and foster autonomy

  • Consider each child’s temperament, abilities and sensory profile so they can discover ways to interact with food that are comfortable and positive

Relationship

What we believe:

  • Parents are not to blame for feeding challenges

  • Parents are doing the best they can 

  • The feeding relationship between parent and child is central to long-term well-being and psychological healing

  • High levels of anxiety and conflict around feeding impact the parent-child relationship beyond mealtimes

  • Positive and sustainable changes will only take place when a child feels a sense of well-being and emotional security

  • Healing from trauma happens within trusting relationships

  • Healthy attachment and trusting relationships should not be sacrificed for short-term feeding goals (such as counting bites or calories)

  • Trusting relationships between child and practitioner, and parent and practitioner, facilitate healing

 

What we do:

  • Listen to, acknowledge, and address parental worries about weight, growth, intake and nutrition as well as psychosocial pressures, such as judgment from peers

  • Help parents identify and replace maladaptive feeding practices with responsive practices including:

    • Modeling positive eating experiences 

    • Establishing an appropriate structure and environment for eating 

    • Encouraging communal eating, and addressing obstacles to family meals

    • Responding to children with emotional warmth

    • Ensuring children are exposed to a variety of foods - even if they are not ready to eat them yet - alongside accepted foods 

  • Emphasize the importance of positive, attuned relationships with parents, caregivers, and clinicians

  • Hold space for parents to process difficult feelings experienced in the feeding relationship 

  • Offer resources and psychoeducation to build resilience and anxiety management skills in both parents and children

  • Work with childcare providers, schools and the wider support network to implement  responsive feeding principles consistently in all of the child’s natural environments 

  • Support relationship-building and responsive parenting 

Internal motivation

What we believe:

  • Children do well with eating when they can

  • Humans eat for many reasons including fuelling their bodies, comfort, pleasure, novelty, and enjoying culture and community 

  • Positive mealtimes, however limited the diet, are central to improving the child’s relationship with food

  • Almost all children have an innate capacity to regulate energy intake, which continues into adulthood if nurtured (including those with avoidant/restrictive food intake disorder (ARFID), autism spectrum disorders (ASD), medically complex situations, and children fed by a feeding tube)

  • Eating may not be a pleasurable experience for everyone, but mealtimes can become neutral or positive, nurturing social interactions

  • A focus on skill development beyond the child’s pace and stage can result in dysregulation and hinder progress

  • A child’s anxiety hinders internal motivation, internal cues of hunger, a sense of relatedness, and feeling safe

  • Parental anxiety, misperceptions, and misinformation often contribute to maladaptive feeding, which thwarts the child's ability to recognize and respond to intrinsic drives

  • Strategies that rely on external motivation, such as rewards, persuasion, or inducing fear of negative health consequences, may ‘work’ in the short term, but can override the child’s ability to listen to their body, limiting long-term, sustainable change

  • Long-term, sustainable change is underpinned by intrinsic motivation and internal drives including hunger, the seeking of pleasure and new experiences, curiosity, and a striving for competence 

 

What we do:

  • Nurture appetite through structured eating, supporting the experiencing of hunger and satiety

  • Address parental worries, including nutrition, growth and appetite; reassure and provide anticipatory guidance and education on responsive feeding

  • Address mealtime stress and conflicts and create positive eating experiences so parents and children can come to the table as calm and relaxed as possible

  • Determine what is getting in the way of the child’s eating and positive relationship with food, rather than “how do I get the child to eat?”

  • Provide input regarding development and developmentally appropriate skills, strategies and expectations, such as serving sizes, schedule, or length of mealtimes

Individualized care 

What we believe:

  • Child feeding difficulties need a holistic approach, encompassing child factors, parent factors, the family system, socio-economic and cultural influences

  • Every child is an individual with a unique history and differing needs

  • Humans come in a range of sizes and weights, impacted by many factors

  • ‘Healthy’ foods vary depending on each child’s context 

  • Pace and nature of progress differ from one child to the next

  • While sensory, oral-motor or graded exposures may be helpful in some cases, goals and progress should be guided by the child and not externally imposed by adults 

 

What we do:

  • Seek first to understand why a child is struggling or refusing to eat

  • Consider, rule out, treat, and refer as appropriate for medical, sensory-motor, social and emotional underlying challenges

  • Consider trauma, whether environmental, medical, developmental, or due to prior experience of feeding and/or therapies

  • Avoid (re)traumatizing children in the therapeutic setting

  • Allow each child’s internal motivations and goals (including hunger, curiosity, and desire for social connection) to guide therapeutic interventions that support child-directed eating

  • View and talk about foods in neutral terms

  • Consider societal inequities which may impact interventions, including food insecurity

  • Seek to understand individuals’ social, historical and cultural contexts, and practice with cultural humility 

Competence

What we believe:

  • A positive relationship with food and the skills to eat are attainable goals for most children, even those with severe challenges

  • The acquisition and development of skills, including feeding and other motor skills, is a process of discovery optimally experienced through meaningful activities in a natural context

  • Children gain skills in a safe and meaningful environment, to the best of their abilities (including those with developmental and/or motor disabilities)

  • Even children who have never eaten by mouth may not need skill interventions (including non-nutritive chewing or oral-motor exercise)

  • Interventions should consider the child’s capabilities and development and mirror typical development when possible

  • Progress is not simply measured in bites taken or number of accepted foods

  • Early progress such as comfort, decreased anxiety, and curiosity builds a foundation that leads to increased variety 

  • Parents’ competence as feeding partners increases as they see early progress and success

  • Long-term healing may take place over an extended period, at a pace that is comfortable to the child  

  • Nutritional well-being is a long-term outcome of responsive feeding relationships and a positive relationship with food

 

What we do:

  • Help the child build skills and confidence at their own pace 

  • Work with children at their clinically-relevant developmental stage, regardless of age

  • Facilitate changes within the child’s ‘zone of proximal development’ ensuring that therapeutic expectations are both sufficiently challenging and attainable

  • Support natural opportunities (such as shared meals or food preparation) to have positive experiences with food and allow the child to gain skills at their level of comfort and interest

  • Introduce skill-building interventions with caution after optimizing the feeding environment, considering the impact on autonomy and level of comfort with food 

  • Maintain mealtimes as ‘safe zones’ where any skill development strategies or clinical interventions are guided by the child’s comfort and enjoyment 

  • Discuss therapy goals and the sequence of progress, for example, eating out at a restaurant may require many smaller, interim goals 

  • Draw parents’ attention to early, foundational progress in emotional, self-regulatory and sensory-motor realms

 

 

*‘Parent’ refers to care providers (nanny, foster parent, family members) involved in the feeding and care of children

 

RFT across the lifespan

An important goal of this white paper is to bring a lifespan perspective to the treatment of food avoidance, including ARFID (as opposed to eating disorders characterized by concerns about body size and weight such as anorexia nervosa). The RFT framework draws from knowledge and clinical experience across pediatric feeding, adolescent and adult eating disorders, and psychology. While the RFT values and therapeutic principles are heavily informed by best practices in pediatric feeding, these fundamental values and principles are also important in guiding treatment for adolescents and adults. A keen appreciation of the early lived experiences that shaped the individual’s relationship with food and their body is essential for optimal treatment.

 

Below is a brief discussion of the application of RFT to adolescents and adults:


 

RFT in adolescence

When working with this age group, clinicians must understand and consider development and issues specific to adolescence, such as hormonal changes, growth during puberty, and increased social pressures. Additionally, adolescents and parents are navigating the balance between family involvement and independence, often reflected in the feeding relationship. RFT addresses the parent-child feeding relationship, and the adolescent’s growing independence.

 

RFT in adulthood  

RFT prioritizes a trusting therapeutic relationship and emphasizes helping the client understand and accept their current relationship with food as part of the process of change. Client autonomy is central, and treatment plans are devised collaboratively. Each case is unique and clinicians take time to understand the antecedents of eating challenges (such as childhood experiences, sensory profiles or aversive experiences) coupled with the client’s current family system and lifestyle. 

 

Selected Relevant Publications

 

Birch, L. L., & Deysher, M. (1985). Conditioned and unconditioned caloric compensation: evidence for self-regulation of food intake in young children. Learning and motivation, 16(3), 341-355.

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., Postavaru, G.I. (2020). Self-Determination Theory as a Theoretical Framework for Responsive Approach to Child Feeding. Journal of Nutrition Education and Behavior, 52(6), 646-651. https://doi.org/10.1016/j.jneb.2020.02.005

Daniels, L. A. (2019). Feeding practices and parenting: A pathway to child health and family happiness. Annals of Nutrition and Metabolism, 74(2), 29-42. https://doi.org/10.1159/000499145

 

Davies, W., Satter, E., Berlin, K. S., Sato, A. F., Silverman, A. H., Fischer, E. A., ... & Rudolph, C. D. (2006). Reconceptualizing feeding and feeding disorders in interpersonal context: the case for a relational disorder. Journal of Family Psychology, 20(3), 409.

Galloway, A. T., Fiorito, L. M., Francis, L. A., & Birch, L. L. (2006). ‘Finish your soup’: counterproductive effects of pressuring children to eat on intake and affect. Appetite, 46(3), 318-323.

 

Jaffe, A. C. (2011). Failure to thrive: current clinical concepts. Pediatr Rev, 32(3), 100-107. https://doi.org/10.1542/pir.32-3-100

Kerzner, B., Milano, K., MacLean, W. C., Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2), 344-353. https://doi.org/10.1542/peds.2014-1630

Leung, A. K., Marchand, V., Sauve, R. S., Canadian Paediatric Society, & Nutrition and Gastroenterology Committee. (2012).

 

The ‘picky eater’: The toddler or preschooler who does not eat. Paediatrics & child health, 17(8), 455-457. https://doi.org/10.1093/pch/17.8.455

Satter, E.  (1986). The feeding relationship. Journal of the American Dietetic Association, 86(3), 352-356.

Segal, I., Tirosh, A., Sinai, T., Alony, S., Levi, A., Korenfeld, L., Zangen, T. Mizrachi, A., Boaz, M. & Levine, A. (2014). Role reversal method for treatment of food refusal associated with infantile feeding disorders. Journal of pediatric gastroenterology and nutrition, 58(6), 739-742. https://doi.org/10.1097/MPG.0000000000000309

Slaughter, C. W., & Bryant, A. H. (2004). Hungry for love: the feeding relationship in the psychological development of young children. The Permanente Journal, 8(1), 23.

Walton, K., Kuczynski, L., Haycraft, E., Breen, A., & Haines, J. (2017). Time to re-think picky eating?: a relational approach to understanding picky eating. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 62. https://doi.org/10.1186/s12966-017-0520-0

"Responsive Feeding Therapy (RFT) is an overarching approach to feeding and eating interventions applicable to multiple disciplines and across the lifespan. RFT facilitates the (re)discovery of internal cues, curiosity, and motivation, while building skills and confidence.

It is flexible, prioritizes the feeding relationship, and respects and develops autonomy."

RFT Values

Autonomy, Relationship, Internal Motivation, Individualized Care, Competence

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