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.V1. on responsivefeedingtherapy.com conference website
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, Intrinsic Motivation, Individualized Care, Competence
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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
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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
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Intrinsic 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 intrinsic 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
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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 intrinsic motivation 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
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Competence Page 6
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 *‘Parent’ refers to care providers (nanny,
progress in emotional, self-regulatory and foster parent, family members) involved in
sensory-motor realms the feeding and care of children
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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.
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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
aniels, L. A. (2019). Feeding practices and parenting: A pathway to child health and family
D
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
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