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Avoiding Trauma in the Therapeutic Setting: Considerations for Pediatric Feeding Therapies

“The 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.”mother of 4-year-old Emma, with severe selective (picky) eating

“We were told we had to make our son eat two bites of non-preferred food before he can have his preferred food. Every night at dinner, he cries and gags. This has been going on for two years, and our therapist tells us it might take years to get better.”father of a six-year-old selective eater in sensory and behavioral feeding therapies

“He would cry and gag and spit up foods he had swallowed. I would watch them scrape it off his chin and put it right back in his mouth. It felt awful, but this was a PhD running the program.”

“The pediatrician from the NICU said to do whatever I had to to get the breast milk in, so I would hold her head and force the bottle. She would arch and cry and cough, but I was terrified she would need a feeding tube.”paraphrased from father of infant diagnosed with reflux (later ruled out) and “oral aversion”. Dad reported that not one health care or feeding professional involved asked how he was feeding or observed a feeding.

Up to 80 percent of children with special needs struggle with eating and an estimated one in ten children experience persistent or ‘extreme’ picky eating. ‘Extreme picky eating’ (EPE) can be used to describe a child who eats so little amount or variety that it impacts growth, nutrition, or social and emotional development. Diagnoses and labels used to describe EPE have included ARFID (avoidant/restrictive food intake disorder), feeding disorder, failure to thrive, problem feeder, selective eating, or sensory challenges. These are complex, multifactorial problems that by their nature involve the feeding relationship between the parent and child, and are often a major source of worry and conflict for families.

There is no agreed on “gold standard” of treatment, and the number of centers and therapists providing feeding therapies has exploded in the last ten to fifteen years, with a range of training and experience. Feeding therapy may be offered in large multidisciplinary group practices, nestled among other special needs programs, or offered in smaller settings, even at school. Children may be referred to occupational, speech or physical therapists. They may also be in behavioral or exposure therapies with psychologists or therapists. With the addition of ARFID eating disorder diagnosis in the DSM-5, eating disorder facilities are increasingly providing care, often to older children with more complex histories, who may have wrestled with poor eating most of their lives. There seem to be as many approaches to treatment as there are providers. With known oral-motor weakness or delay, speech therapists may prescribe strengthening exercises. Occupational therapists often use sensory therapies and desensitization with a combination of behavioral strategies. Some therapists use primarily a behavioral approach with reward or response cost (removing desired items) to motivate children to eat. Some incorporate deliberate use of screens (TV, iPad) to distract children to eat, sometimes for hours a day.

For some time now I have been concerned with the apparent lack of trauma-informed care in many feeding therapies, as described in the scenarios above from my clients and parents at workshops (many seek me out for “feeding therapy failure”.) With the increasingly overwhelming evidence for the negative impact of trauma on the developing brains of children, every effort must be made to avoid traumatizing children in the therapeutic setting. With ‘first do no harm’ as a guiding principle, we must at least consider the physical and psychological risks associated with therapy-related trauma.

Trauma around food and feeding happens (see upcoming MN Trauma Project Blog Post about Food and Feeding Trauma), and aversive experiences like choking are known risk factors for feeding challenges (criteria for Avoidant/Restrictive Food Intake Disorder ARFID DSM-5). Wouldn’t being force-fed, or held down and fed while resisting be considered aversive and even traumatizing? While neglectful, impaired or abusive parents may use forceful feeding practices, it is especially heart breaking to consider that children may be traumatized by the very therapies that worried and nurturing parents turn to for help.

When a worried father resorts to clamping his infant’s head in place and forcing the bottle, or parents are advised to make children eat foods or the child is literally placed in a head-lock and forced into a highchair attached to the table so there is no escape, when children are “zoned out” during feedings while gagging and vomiting, all in the name of therapy—this begs further examination. (This illustrative video is hard to watch, but important to understand what can happen when children are pressured to eat. Note the boy’s affect, body language, signs of arousal and reactions. Note also that the beans are swallowed whole and he is trying to comply.)

I ask you, trauma-informed therapists, when the not uncommon therapeutic strategy of “escape extinction” is described this way, “Treatment fidelity when implementing EE also may be compromised as a result of the child’s size or strength”, does this raise any red flags? Is it not implied that this therapy, which results in side effects described as “including response bursts (i.e., initial increases in problem behavior), extinction-induced aggression, and emotional responding (e.g., crying…)”1 is less effective when the child is large enough or strong enough to fight back? Do we not owe it to children and parents to explore every possible alternative to therapies that rely on a size and strength differential over children?

Rarely is the nutritional scenario so urgent that a thrashing child needs to be held down and forced to eat, even more rarely is the need to do this for days, weeks or months on end.

With feeding therapies like those described above occurring often two to three times a week, and pressured and anxiety-filled feeding at home, are these children in a chronic state of hyperarousal because of therapy? (“Maria responded to her mother’s feeding attempts by whining, crying, arching her back and vomiting… Maria’s mother reported that trying to force Maria to eat was too stressful for her and that she could not continue.” 2) Chronic hyperarousal impacts appetite, growth and self-regulation.

Furthermore, can children be expected to forge a positive relationship with food under these circumstances? What neural pathways and associations are created and reinforced? (Research has described conflicted early feeding as a risk factor for the later development of eating disorders.3) How might these therapies impact the relationship, trust and attachment between the parent and child?

Doctors and therapists must be better educated about the complex nature of feeding challenges, including what should be standard-of-care, basic training in childhood attachment and the physical and emotional fallout from trauma. They must provide care that is sensitive to past trauma and avoids further traumatizing children. With a lack of comprehensive, quality research on feeding therapies, any forceful therapies, those that clearly traumatize children, must be viewed as an absolute last resort.

Parents so often share that what they were told to do went against their instincts and felt wrong. It is unconscionable that desperate parents are unknowingly engaging in therapies that may do more harm than good. These therapies are failing children and families, not the other way around. As one mother warned, "Bad therapy is worse than no therapy."

* There are many skilled speech and occupational therapists helping children overcome oral-motor and sensory processing roadblocks as well as aversions due to past negative experiences. With low stress, no-pressure exposures responsive to the child, paired with pleasant family mealtimes and structure, these therapies avoid traumatizing children. (Marsha Dunn-Klein OT and Suzanne Evans-Morris PhD, SLP are pre-eminent pioneers in the field.) Kerzner’s, “A practical approach to classifying and managing feeding difficulties.” (Pediatrics. 2015) is a good review, that advocates a responsive approach to feeding therapies.

1. Bachmeyer M, Treatment of Selective and Inadequate Food Intake in Children: A Review and Practical Guide. Behav Anal Pract. 2009 Spring; 2(1): 43-50

2. Curtiss H, Positive Behavior Supports and Pediatric Feeding Disorders of Early Childhood: A Case Study. Jnl of Early Childhood and Infant Psychology. 2008 (4) *accessed online 2015

3. Kotler LA, Cohen P, et al. Longitudinal relationships between childhood, adolescent, and adult eating disorders. J Am Acad Child Adolesc Psychiatry. 2001 Dec;40(12):1434-40.

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