What Occupational Therapists Need to Know: Restrictive Eating and Pathological Demand Avoidance Part 4 | Ep. 161

This is the fourth episode in my series on PDA and restrictive eating, and this one is for therapists.

If you are an occupational therapist, a speech language pathologist, or another type of therapist working with a child who isn't responding to gentle, play-based, sensory-based, or exposure-based feeding approaches the way you'd expect, this episode designed to help you.

I share the full arc of my older son Cooper's journey with extremely restrictive eating, from the time he was four and a half years old and eating primarily three processed foods, through five years of occupational therapy, to where he is today. I walk through how we adapted the SOS feeding protocol over time to incorporate autonomy, equality, lower demands, play, and connection to special interests. I also share five specific strategies you can bring into your sessions.

Key Takeaways

• The Sensory Lens Is Not Enough |00:02:04 I share how Cooper's restrictive eating was initially understood through a sensory lens, and how, for about a year and a half, that framing guided his therapy. But the sensory lens alone was not sufficient to explain the patterns I was seeing or to help him expand his eating. What I came to understand was that his survival drive for autonomy was also a major factor, and that the two had to be held together rather than treated separately.

• What Was and Was Not Working |00:11:56 I walk through what was working in the early stages of occupational therapy, specifically the therapist's focus on establishing relationship and rapport before moving to skill acquisition, and the role that dopamine, novelty, and sensory-intense experiences played in Cooper's initial engagement. I also describe what was not working: visual schedules and laminated choice boards, pressure to describe sensory experiences verbally, and structured home-based feeding protocols. For a PDA child, I explain, even chosen structure can become an internal demand.

• Autonomy and Equality as Accommodations |00:16:37 I describe two specific accommodations that became central to how we approached feeding therapy over five years: autonomy and equality. Autonomy meant shifting away from scheduled, structured feeding time and toward strewing, declarative language, and following Cooper's lead. Equality meant deliberately allowing him to win, be above the therapist and me in games, direct the session, and have the last word. I explain how these accommodations address the root cause of nervous system activation rather than managing the surface behavior.

• Lowering Demands in the Session |00:29:35 I describe what it looked like to lower demands in the occupational therapy session itself, meaning doing things for Cooper that he was cognitively or physically capable of doing himself, so that his available capacity could go toward tolerating and engaging with food. I give specific examples and I address the common concern that this approach enables children rather than building independence, and explain why the logic is different for PDA.

• Special Interests as a Turning Point |00:37:06 I describe the turning point in Cooper's feeding therapy, which came when eating became connected to his special interest in football. I explain how this connection made it possible to revisit things he had previously rejected, including the laminated food charts, but this time entirely on his terms. I also offer five specific strategies for therapists at the end of the episode.

Relevant Resources

Topics Covered

• PDA and restrictive eating
• Pathological Demand Avoidance and food refusal
• Occupational therapy for PDA children
• SOS feeding protocol and demand avoidance
• Autonomy-based approach to feeding therapy
• Equality accommodation in occupational therapy
• Lowering demands in therapy sessions
• PDA and sensory processing
• Nervous system disability and eating
• PDA burnout and basic needs
• Strewing as a therapeutic strategy
• Declarative language in feeding therapy
• Monotropic focus and special interests in PDA
• Intrinsic motivation and food expansion
• PDA profile in autism
• Survival drive for autonomy
• Feeding therapy for autistic children
• DIR floor time and PDA
• Persistent drive for autonomy and eating
• Supporting therapists who work with PDA children