Food Refusal

Food refusal is commonly found in the pediatric population.

Food refusal refers to behaviors that interfere with proper nutritional, caloric and/or hydrational needs. These behaviors include (but are not limited to) throwing food or utensils, holding food in the mouth, hitting the spoon when fed, spitting out food, kicking at mealtimes, crying and vomiting. (Some children without reflux or prior medical history can use a finger or other means to gag and vomit food.)

Causes of Food Refusal

Most times it is difficult to pinpoint the cause of a particular case of food refusal.

Medical Conditions

Food refusal may be caused by a prior medical condition that has in the past or in the present caused discomfort during eating. This makes the act of eating uncomfortable to a child or the experience of discomfort in the past has been paired with eating in general.

Tube Dependence

Tube dependence can be a major cause of food refusal. For various reasons, some children are unsafe to eat orally, while at other times children are at an unsafe weight when a feeding tube is placed.

Attention Maintained

Sometimes children are easily reinforced by attention to their eating behaviors. If a child is being coddled subsequent to the child shaking a head after food is presented, it will be more likely that during the next meal that the presentation of food will result in head shaking.

Food Refusal Treatment

Behavior analysis is the most effective approach to food refusal. The goal of using behavior analysis is to identify problematic behaviors during mealtimes and then to "teach" an appropriate set of behaviors that will yield a proper mealtime experience.

Types of Food Refusal Related Conditions

  1. Texture - Child accepts only certain textures
  2. Complete Food Refusal - Child will not accept any food
  3. Food Selectivity - Child only accepts a limited number of foods
  4. Low Volume Acceptance - Child refuses to eat after a certain volume of food is consumed


Mealtime Behaviors

Every child exhibits a different set of behaviors during treatment.

Mealtime Behaviors

The extent to which behaviors are engrained and exhibited also differ from child to child. This makes the number of distributions nearly infinite. The probability of two children (even identical twins) exhibiting the same distribution of behaviors is miniscule.

Children also respond differently to the various forms of treatments currently used, which adds another degree to the complexity of dealing with food refusal.


Studies have shown that 25% of the pediatric population exhibits moderate to severe food refusal.

Severity of food refusal

Not every child in the 25th percentile that exhibit "moderate" food refusal needs to seek treatment. Other may only need a few treatment sessions.

The criteria used for determining whether to proceed with treatment usually is to what degree a child's health is being affected or what extent the food refusal is causing health to be affected.

A Behavioral Feeding Therapy Case Study on Randomizing Meals to Facilitate Intake

Michael was a 4-year-old child diagnosed with autism. He had an unremarkable medical history. Prior to coming to the Los Altos Feeding Clinic he would only consume bottles of formula. He would drink 6-8 bottles per day of concentrated formula. He would not drink from other containers nor would he drink other liquids. He also did not consume any solids.

He was seen for four weeks in total. Treatment was three times per day, five days per week.
The first week consisted of introducing solids to him. Purees were used for two reasons. First, he had never chewed on a solid, which could make sessions dangerous because poorly chewed solids can be a choking hazard. Second, more trials can occur per session because time is not wasted on chewing. Four foods, chicken, green beans, macaroni and cheese, and applesauce, were randomized throughout the meals and week.

Introducing solids consisted of presenting a bite, while simultaneously verbally prompting him to take a bite. Initially the bite was presented to the top lip until there was a mouth opening, and then the bite was deposited in the mouth. The bite would not be deposited in cases of gagging, coughing or vomiting, but were put in during all other openings. Each meal had a time cap of twenty-five minutes, and volume of ten ounces of food. The session would end when either the time cap had elapsed or the volume was consumed, whichever occurred first.

Child Eating Week 1

The chart above shows how the time between presentation of food and the bite being taken decreased. During the first session bites were taken an average of ten seconds after food presentation. By session three, bites were taken on average after three seconds, and by session five they were stable at about one second.

Week two of treatment involved the introduction of new foods. Bites were presented with the same protocol as in week one. Four novel foods were presented in each session. Volumes of each food were held constant at three ounces each, including all food groups in the meal. Randomizing foods in this way, instead of focusing on one or just a few foods helped to generalize eating across all foods, as can be seen in the next graph.

Child Eating Week 2

There was a general trend in latencies dropping over time. By the tenth session of week two, latencies were stable at or near one second. This graph shows that eating was conditioned to occur at short latencies across all foods.

Generalizing meals to other settings serves the function of not only strengthening eating behaviors, but also ensuring that eating would take place across all settings (no matter the food), including the child's own home environment. Week three consisted of randomizing nine settings across the fifteen meals throughout the week. All other variables were held constant, including randomizing the same foods used in week two. Settings included the park, playroom, different treatment rooms, hotel room, and hotel lobby.

Child Eating Week 3

There was an initial spike of refusal, which was followed by a sharp downward trend. By session 35 latencies were at or near one second.

Week four consisted of training primary caregiver to feed with random foods and random settings. This would ensure that feedings across settings and foods would only take place in the context of the therapist, but also ensure that feedings take place with the primary caregiver.

Child Eating Week 4

There was a downward trend after session 47. Most meals thereafter were at one or two seconds, except for a spike in latency for sessions 52-53. Primary caregiver reported that eating continues at low latencies across foods and settings. This was reported four months subsequent to completion of treatment.

Data was collected by videotaping all sessions. Two data collectors independently took data while viewing video footage at separate times. Inter-observer reliability was measured at 86%.



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