Why Forcing Kids to Eat Can Backfire: Rethinking Feeding Therapy

Feeding challenges in children, especially those with autism, are far more complex than “just getting them to eat.” In this episode of Acorns to Oaks, Kristine and Sarah explore the science, psychology, and real-world experiences behind food aversion, selective eating, and feeding therapy.

They unpack why outdated methods like force-feeding and “just make them eat it” can actually cause long-term harm, including trauma and disordered eating patterns. Instead, they advocate for a more compassionate, interdisciplinary approach that considers sensory input, autonomy, family dynamics, and developmental stages.

From early warning signs in infancy to the emotional toll on parents, this conversation highlights why feeding is one of the most misunderstood challenges in child development—and what we can do better. 

Transcript

SPEAKER_01 0:07

Welcome to Acorns to Oaks. I'm Christine Dixon. I am a board-certified behavior analyst, and with me is the phenomenal Sarah Moreau. Sarah, tell us about all the letters after your name.

SPEAKER_00 0:22

Oh, well, thank you for the opportunity to discuss them. I am a PhD student in my third year at UCLA, focusing on uh feeding challenges in children with autism. I'm also a board-certified behavior analyst like the wonderful Christine. And I'm a new grad family nurse practitioner, hoping to work in primary care down the line.

SPEAKER_01 0:43

Outstanding.

SPEAKER_00 0:45

Thank you.

SPEAKER_01 0:45

Yes. And uh today we're here to talk about our love affair of ABA, uh, but on a really uh interesting topic that we're both very passionate about, which is food expansion.

SPEAKER_00 0:58

Absolutely. There's so much to say about feeding and eating. Um, throughout our work together, we have a specific approach that we use, which has been very successful for many of our clients. Uh, there are many approaches out there, um, not all ideal for the home setting, and often really benefit from an interdisciplinary approach. Um, thinking about feeding in general, uh, so much development is attached to feeding. So beyond just the nutritional intake, growth, development of brain, if children aren't eating, they're not building the muscles they need for speech, they're not building the fine motor that they'll need to hold a pencil in the future. So there are so many connections to uh feeding and eating in those early years of life that we see throughout development in other areas besides just health and nutrition. There's work also that shows that in infancy, children that struggle with breastfeeding, bottle feeding often end up with an autism diagnosis down the line. So there's even a push to look at that as an extreme early intervention in terms of identifying these kids early. Because right now in primary care, that's something we don't do very well. When uh children come to the primary care clinic, uh, the provider will ask, How are they eating? And the parent will say, Great, okay, terrible. And the primary care person will mostly just say, okay, great, or hey, do better with that. And then that's the end of the conversation. So it ends up being a problem that is not caught early, and by the time that it is caught and addressed, it has become a much bigger issue than it needed to be. So that's my hope in my doctoral work is that I'm uh learning from parents' experience in the home, which we know a lot about, um, but also understanding through qualitative thematic analysis their experience with their primary care provider to improve um early uh identification and hopefully improve intervention.

SPEAKER_01 3:06

Absolutely. And healthy relationships with food. You know, as a child, I was of the why why variety, and I definitely drove my parents crazy by not eating um certain foods. Um I had food aversion in terms of if the foods touched on the plate, they were dead to me. Very good. And my parents struggled um with eat it. I they would lose their minds um when I wouldn't eat the food. And they always said, Why won't you eat it? I was like, because it touched the other food. And they were like, here, now it's not touching. And and somehow in my little brain, I was like, it doesn't matter now. It's a no for me. But um, you know, I have come to have such a healthy relationship with food. And I think that approach for children is really, really important. Uh, in ABA uh right now in our phenomenal science, there is really um a lot of feedback. Uh, and I think that feedback is really important to acknowledge uh in the grand scheme of things of what has been done in the past. I think one intervention that I'm particularly not a fan of, I want to get your opinion on it, of course, is escape extinction uh for food expansion. This would be where you would tell the child, nope, you're gonna eat it. And you would take the spoon and continuously put it up to their mouth until they eventually take it. My dad did try something like this with me and a plate of liver. And he was like, and I still don't eat liver to this day. I don't like the smell of it. Um, but he was like, You're gonna sit at this table until you eat this liver. And um, then I fell asleep and he woke me up and he's like, go get in bed. Go get ready for bed. It's late. You and I never ate the old liver, but that is an empirical-based intervention in ABA for food expansion. Have you ever seen that implemented? Or what are your thoughts on that sort of uh crude? Absolutely.

SPEAKER_00 5:14

So that is a very common, kind of older falling out of favor approach. Um I I think the problem with escape extinction is a few things. One is we're teaching that your body is not your own. I can do to your body what I want, right? Yeah. And that is a message I think that in older ABA in our past has been um brought up in a contentious way, which it should be. Autonomy. Absolutely. Yeah. Yeah. And then also I think a difficult part of using escape extinction to expand a diet, even if it does work, is that it can be very traumatic. Um, it doesn't really take into consideration that maybe there's a sensory issue, maybe there's a fear issue, maybe there's a disgust issue in terms of why that child doesn't want to eat that food. Over time, that trauma can take what would be a pediatric feeding disorder and become a avoidant restricted food intake disorder, which is a chronic problem that is lifelong. So while we might seem to be addressing the problem today, we need to really think long-term. What message does this give the child about their body? What message does it give them about what food is safe to eat and what feels good to them? And also considering that there's more to eating than just the consumption of foods.

SPEAKER_01 6:41

What is that? What is the the more to eating? How many different stimuli or sensations are involved in Ah absolutely?

SPEAKER_00 6:48

So this is a very complex issue. So it's colors, it's smells, it's texture, temperature. It's also social, right? Sitting around a table with your family, putting away that toy to sit down and have dinner, um, interacting with your brother, which uh was has always been a challenge for me. Sorry, Jeff. Um, but I think that it's really important to consider that there's so much more to a meal time than just swallowing a piece of food, right? Um and when we work with families, I always want to take that into consideration. What would be the best outcome you see for your entire family at the table or on the couch or sitting on the floor or wherever you happen to eat as a family? I think that's something that we are growing in ABA to understand cultural differences and to understand uh what would best um support that family and their own hopes for themselves. But it back to the sensory components of eating, there are so many. And I often think about foods that I hate. And if someone were to say, um, let me give you an example, the food that I hate is called uh, I think it's referred to as uni, and it is sea urchin. Oh yeah.

SPEAKER_01 8:05

And it's fluffy, right?

SPEAKER_00 8:06

Yeah, but it's it's like a custard, a fish-tasting custard, which to me, ugh. Um if someone offered me $100 to eat it today, would I probably, but I'm not going to eat it tomorrow, right? So I think that's also another thing that we have to consider when we're setting up these contingencies. Um, becoming familiar with something can make it a more preferred or at least tolerated food, but it might not ever be a preferable food. And that's okay too, right? Because I have preferences, you have preferences, and so do all of our clients and families.

SPEAKER_01 8:45

Yeah, it's so important to build the structure of the intervention around autonomy and cultural responsiveness or that framework of what is the goal for this family. In terms of sensation and eating, it's so funny because I can remember being like four years old and smelling coffee and coffee breath and thinking, ugh, you know, this is awful. And um, you know, then, you know, I've come to love coffee. I drink it black, I don't use any cream, and that has really changed 180 degrees for me. So it is important that when children are young, that they have positive ideas about food and healthy relationships with food, even if they don't ingest them or uh want to eat them at that time. Do taste buds change? Like, can you go from being disgusted by something to like a month later be like, this is interesting and I'm gonna eat it?

SPEAKER_00 9:48

Uh, they do change. Taste does change quite quickly, actually. I can give you the example of the person that eats a lot of processed foods, right? So they're eating a lot of sodium in all of their meals, and that's what tastes really good to them. And then if you switch over to say eating something that isn't a processed food that doesn't have so much salt, it will taste very bland to that person at first. But if a few weeks go by and they continue eating that food, it won't taste the same. They'll start to uh recognize those flavors and then craze the sodium less. And then if you present them with the processed food, it will taste really salty. So it's a taste uh is a really interesting sense in that it does shift and change over time. Uh, I'm sure anatomically there are changes as well, but in terms of the way that we perceive how things taste and what we like or prefer does tend to change based upon familiarity. I'll give you an example. My best friend um had a colonoscopy and was um given a very strict diet for like four days. Um, very different protocol than I knew of. But uh basically he had to just drink Gatorade for like three days. And he got this blue frost, I think it's blue frost, it's like a white one, and um complained nonstop throughout the whole process of how awful this was, and he just hated it, and he can't, all he wanted was chips. He wanted to go back to his usual food, and then he had the procedure and all of that was done, and he could go back to the food. And a week later, he started craving the Gatorade.

SPEAKER_01 11:20

Interesting.

SPEAKER_00 11:21

And there is some evidence that you know, your your microbiome plays into these cravings a bit. So uh, based on what you've been eating, messages are sent back to your brain of you know what I would like down here is that thing that we've been eating a while back. So taste changes, cravings change, and what feels good in our body, I think changes over time as well. Um in with the elderly population, I've always found this interesting that they may have memories of favorite foods, but if you present it to them, it it just doesn't, it's not the experience that they had before, likely due to um anatomical changes over time that happen with aging. Also, uh hunger and thirst signals when you're an elderly person decrease. The way that we approach these things should really also identify where we are in life and those developmental stages, even up through our elder years.

SPEAKER_01 12:17

Yeah. For children, I, you know, I really did appreciate when Michelle Obama had that big garden because I do think it's fun to be exposed to food in terms of growing food. I know when you were walking up, you were like, you have a lemon on your tree. And it, you know, it's exciting to see those natural foods grow. You know, there's playsets and kitchens. I also think that's really important. A lot of family values and family culture is tied into certain foods, certain dishes during certain times of year. And I think children should play in that model. Um, I don't know if it has an impact on food expansion, but I do think playing with food, pretending to cook is of some value in terms of your knowledge of foods. Some foods really do seem to be uh tied up in emotions, like, you know, there's the birthday cake, right? Um, there's also comfort foods. Uh, how do those develop over time? We've all heard of emotional eating and things like that, but um do you have comfort foods? Oh, absolutely.

SPEAKER_00 13:28

Actually, I I have interesting um associations, which I'm sure most of us do. Uh for example, if I hear the opening theme to Star Wars, I taste my mom's spaghetti. Oh, really? Yeah, she's I had a Rainbow Bright um TV tray. Nice. And that was like a special thing. Getting that out, watching Star Wars, and she's gonna go disassociate. That's not true, but it's kind of a joke. Um, but yeah, I I think that uh those things do develop over time and you paired uh certain feelings, certain uh smells and tastes um together in your mind for the birthday party is a perfect example. And I think that that happens a lot with our clients as well, in terms of what feels safe to me. The chicken nugget is safe for so many of our clients. And I think a lot of that is because it's kind of a bland color. It's you can eat it with your hands. Eat it with your hands, there's like a little crunch to it. There is a crunch, but the flavor isn't overwhelming, right? It's kind of a blander, you know, I know what to expect anytime someone puts that chicken nugget in front of me. And I think that's a lot of it for our clients, is that that's a safe food. And then if you bring up something they have never seen before, but I expect you to eat it, um, we see all kinds of responses to that as well. So even if you have associations with this is safe, this is fun, this is a you know a party atmosphere versus that is new and it's scary, I don't like it, and I'm running away. It's kind of a similar, even on on opposite ends of a spectrum of eating that I think is important to consider when we are we're choosing foods and we're thinking about how we're going to introduce them for our clients.

SPEAKER_01 15:12

Yeah, so true. Comfort foods and the and the stress, you know, the birthday party uh for children that may have developmental disability like autism, uh, the birthday party, the cake, that whole ritual can be absolutely frightening. Um, it cannot be a positive experience.

SPEAKER_00 15:31

Um that's very true. And also for the parent going to a birthday party with their child, will there'll be foods there that their child would want to eat? Do I need to call ahead? Do I need to pack my own lunch? I think parents take on actually quite a lot of the emotional stress of this. Um and I I really wish there were more supports for them. Things that I have heard primary care, you know, say to parents, like this is in your hand, so just feed him more. Well, just give him more vegetables. We'll stop giving him that. You know, like it puts so much blame on that parent that then they they tend to step away from that instead of leaning in to ask for more support. And sometimes when they do ask for more support, there's nothing there, right? So we are really fortunate in that we can be in the home because that's where this problem exists on the day-to-day, and we can provide that support in that way. I think that's really crucial when you're dealing with a feeding problem.

SPEAKER_01 16:30

Yeah. So there's like, you know, very restricted diets. A lot of times we see where they'll only eat certain things. Those choices might not always be a well-balanced diet and not um nutritionally um what they need.

SPEAKER_00 16:47

Absolutely. Yeah. When I came into my PhD program, I first thought, and I'm getting a PhD in nursing, I think that it's really important to have behavior nursing and primary care all working on this issue in a collaborative way, along with registered dietitians and speech and OT people who all see different parts of this problem. When I first came into my program, I was looking at autism and obesity, which is what we often see later in life with our clients. Then I kind of shifted away from that as I started to look at more root causes of where did that come from? And then I looked at microbiome differences in autism versus typically developing children. And all of that led me back to dietary intake. What are we eating? And all of the offshoots of what happens as a result. So we have digestive problems, constipation, diarrhea, nausea, abdominal pain, vomiting, very unpleasant things that is so common uh in the children that we work with. And then beyond that, we have a very stressed parent. And these very stressed parents want nothing more than to nourish their child. Absolutely. And to put out food in front of their child and have them scream and run away or throw or engage in some sort of large behavior aggression, self-injury. It's really traumatizing for the family. And what I see, and I'm sure you have seen clinically, is what happens is the parent will find the foods that the child will eat, and that becomes the diet. That's what we're gonna do because they won't eat anything else. And I'm so tired of fighting. And so over time, those foods tend to be hyper palatable, very high calorie, very processed typically foods. And so then we'll see a swing from we are undernourished to now we are overnourished in terms of calories, not necessarily nutrition. But then we have the problems of obesity, high blood pressure, diabetes, which all occur at higher rates in people with autism. Again, I feel like if we could just catch this early, that maybe it wouldn't snowball into such a bad health outcome for these kids and for their families.

SPEAKER_01 18:56

Yeah. I mean, when you think of the parents, I have such compassion because parental stress and then the response effort of making a nutritious meal is higher than going through the drive-thru. That's much higher, more expensive um approach to food. And so it's like, why am I putting forth all this effort, um, all this money, and uh my child is not eating this food when I can just roll through the drive-thru with a guarantee that they will eat this food? That's absolutely true.

SPEAKER_00 19:32

Yeah. And it also depends too on where we're growing up. You know, is there access to healthy foods? Um, do we know what to do with those healthy foods and how to prepare them? A lot of parents are working more than one job. Um, it's a lot of pressure to pick up your kid, come home, now do this 50s, you know, mom situation where you're making this meal that we used to spend culturally all day on dinner. Um, we don't have that kind of time anymore. There's a lot of additional barriers to making food and eating as a family that, you know, have changed over time. And depending on your family situation, could be a lot harder for some people than for others.

SPEAKER_01 20:16

Yeah. I think my dog heard you say dinner. I think he did. So conditioned to uh that word that I think this is.

SPEAKER_00 20:24

Yeah, I see him. His ears are up. They're like, is it dinner time? Are you hungry? And they're like, it's not dinner time. It's gonna break through the door.

SPEAKER_01 20:34

We love you, Bew. Yes. Yeah.

SPEAKER_00 20:37

Thanks for joining us at Acorns to Oaks. Look forward to speaking to you again. Feel free to reach out if you have any questions or comments, and be sure to hit that subscribe button when you get a chance.