Guest post written by Marsha Dunn Klein, OTR/L,MEd, FAOTA

Goals for children who have pediatric feeding disorders in some settings commonly include some variants of these:

Marsha will consume (# of bites) of a particular food.

OR

Marsha will consume (# of bites or quantity) of food, without refusal behaviors…

OR

Marsha will decrease her refusal percentage when presented with new foods…

There are some assumptions here. Let us consider these.

That the adults get to decide what and how much a child eats……….   NO!

That the eating is a one-way activity and the child has no say in the matter. ……….. NO!

That when adults present food, the child MUST eat it ……….. NO!

That the child is not allowed to say “no”… FOR ANY REASON ………  NO!

On a recent trip to China, I noted that there were scorpions on sale in the market.  Imagine someone is making eating goals for YOU about scorpions such as:

YOU will consume 6 scorpions….

OR

YOU will consume 6 scorpions (fed to you by someone else) with NO refusal behavior…

OR

YOU will decrease your refusal percentage of scorpions when presented by someone else…

To start with, I live in Arizona and scorpions are quite common. We are taught to keep away from them so if I were presented with scorpions, in my opinion, the RIGHT response would be to say “NO”.  But, humor aside, let’s look further.

The child who says “NO” to these scorpions in the above paradigm would be labeled as “refusing” or described as exhibiting “food refusal” or having a “behavior problem”.   Requiring a child to eat a food that she is saying “NO” to is contrary to some very solid principles of feeding children.

1. I believe feeding is a partnership. Ellyn Satter’s Division of Responsibility tells us: Adults are in charge of the what, and when and when of meals and children are in charge of whether they eat at all and how much. Inherent in Satter’s work is the partnership between parent and child in eating. Feeding is NOT a partnership when the adult is insisting.  (Satter, Child of Mine, 2000)
2. I believe we want to support children to become internally motivated to eat, to eat because they want to at their pace and with supports needed for their success. Leanne Birch tells us children were more internally motivated to listen to appetite when allowed to eat with not pressure or external demands. (Birch LL, McPhee L, Shoba BC, Steinberg L, Krehbiel R. ‘Clean up your plate’: Effects of child feeding practices on the conditioning of meal size. Learn Motiv  1987; 18: 301–317).
3. In Get Permission speak, adults offer and children “give permission” to accept that offer, or not. Implicit in the word OFFER is choice. It is not a demand. When children do not eat the food offered, it is the adult’s responsibility to try to understand why and grade the ask as needed for child success.  Sometimes children are just not hungry. Sometimes they do not like THAT food.  Sometimes they do not feel well. Sometimes it is to hard or unsafe to chew.  Sometimes the look, smell, or texture, or flavor is just not right! (Klein, MD.  2019. Anxious Eaters, Anxious Mealtimes: Practical and Compassionate Strategies for Mealtime Peace).
4. I believe our goals and interactions with children and families should be responsive. Responsive feeding is supported by both the World Health Organization and the American Academy of Pediatrics as best practice.   Responsive feeding experts tell us “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 celebrates and promotes internal motivation for eating.” (Rowell, et al, 2020) We know non-responsive feeding is dominated by a lack of reciprocity between caregiver and child. Choice is important! (Rowell,. K., Wong,G., Cormack,J.,Moreland, H,.  (2020)Responsive Feeding Therapy: Values and Practice, https://www.responsivefeedingtherapy.com/rft-values-and-principles)
5. I believe experiences matter. Nicklaus tells us experiences remain the driver in preference learning.  (Nicklaus, S. 2015) So we must be aware  of the positive or negative experiences we are creating. (Nicklaus, S., (2015) The role of food experiences during early childhood in food pleasure learning. Appetite Vol 104 3-9.)
6. I believe we can help parents think about feeding their little ones with these principles. Even the toddler advice in the grocery store aisle tells parents to feed at the baby’s pace and STOP when he shuts his mouth , turns away or arches that he has had enough.

So, Instead of describing the child as REFUSING and then pushing into that worry,  could we consider this reaction from the child as her RESPONSE, her communication, rather than a “behavior that does not comply with the adult presentation.”

Can we note the child’s response and try to understand what the child might be communicating to us? Maybe the child is not hungry? Maybe the child feels worried about the scorpion because he is not able to chew it? Maybe she is worried about the smell, or the texture, or the sound of it crunching in her ear.  Maybe she tried a scorpion in the past and it made her vomit.  Maybe she actually wanted to try it but wanted to go slower and try it at her own pace and mix it with mashed potatoes.