An Alternative to Escape Extinction in Feeding Therapy

The feeding-specific alternative to escape extinction is a shaping-based ABA protocol built around a red/yellow/green choice board, a synthesized reinforcement contingency, and an opt-out space the child can use at any time. The lineage runs from Dr. Wayne Fisher and Dr. Kathleen Piazza's foundational feeding work at Kennedy Krieger and Marcus, through Dr. Greg Hanley's lab at Western New England in 2016, to Dr. Holly Gover's published cases. The host of Feeding Face Off learned non-removal of the spoon at Kennedy Krieger, ran it with fidelity in the hospital, and watched it fall apart the first time he tried it in a community clinic without a Rifton chair, two blockers, and a data taker behind the glass. That experience is why this alternative exists. Dr. Gover put it plainly in the same talk: "If the child is food selective, I would never use escape extinction. I'm saying that now." Her qualifier matters too. For a stable kid living on a G-tube with cleared swallowing and no other route to nutrition, the question is still open and probably belongs in a hospital feeding unit, not in your clinic.

What escape extinction is in feeding therapy#

Escape extinction in feeding usually shows up as non-removal of the spoon. After a functional analysis (often an ISCA) identifies escape as the function of mealtime refusal, the spoon stays at the child's lips until they accept the bite. Other forms include physical guidance, jaw prompts, and re-presentation of expelled food. The child cannot get out of the bite by pushing it away, crying, or hitting, so the refusal behaviors stop being reinforced and acceptance climbs.

It works. The graphs from KKI, Marcus, the Munroe-Meyer Institute, the University of Nebraska, and Miami have shown zero percent acceptance jumping to one hundred percent and holding there for sessions on end. That is real data. It is also data that was collected with a Rifton chair, often two blockers, a snack cart on one side, an iPad on the other, and a research assistant taking data through a one-way mirror.

When applied behavior analysis (ABA), the science of behavior used to teach skills and reduce challenging behavior, gets exported from the hospital to a home or a school, those resources disappear. That is the problem this alternative was built to solve.

Why a lot of practitioners want an alternative#

Most BCBAs (Board Certified Behavior Analysts, the master's-level clinicians who design ABA programs) do not work in a hospital. They work in homes, schools, and small community clinics. They have one technician, maybe two. They have a kitchen table, not a Rifton chair. Their families want to keep mealtimes calm enough that the older sibling does not refuse to come to dinner.

Non-removal of the spoon in that context turns into chasing, blocking, and tears. The host of Feeding Face Off lived this exact transition.

"I had me who knew how to do non removal of the spoon with a bunch of fidelity in the hospital setting. But I found it falling apart in the clinical setting. And that's when I started shaping because I was like, what else am I supposed to do?" From the talk — Dr. Holly Gover

There is also the question of who carries the protocol home. A parent cannot reasonably run non-removal of the spoon at the kitchen table next week. They can run shaping, differential reinforcement, and an opt-out corner. So the alternative is partly about the procedure and partly about who can actually use it after the BCBA leaves.

Where the shaping model came from (Hanley lab, 2016)#

Dr. Holly Gover entered Dr. Greg Hanley's doctoral program at Western New England in 2015 to 2016. Hanley's early mentors had been Dr. Wayne Fisher and Dr. Kathleen Piazza, both giants of the escape extinction feeding literature. He had spent years in that world. He came back to it with a different question.

"Greg in a meeting one day was like, hey, I think I really want to get back into the feeding game. He had his mentors early on were Dr. Wayne Fisher and Dr. Kathleen Piazza. And so he spent time in the feeding world running cases on different papers. And he's, I want to, let's give it a go. Like applying some of the values we were figuring out at the time to an intervention for food selectivity." From the talk — Dr. Holly Gover

The "values" were the same ones that had produced the Practical Functional Assessment and Skill-Based Treatment work. Assent. Choice. Letting the child opt out. Reducing distress as a clinical goal in itself, not a nice-to-have. Gover took the lead. The first kids the lab worked with were carefully chosen. They had language. They could understand instructions. They were food selective, not in total food refusal. They were not relying on a G-tube. The point was not to test the protocol against the hardest cases. The point was to find out whether you could get acceptance to climb without escape extinction at all.

How the protocol works without escape extinction#

The procedure is short to describe.

Start with a caregiver interview. Run a brief preference assessment with preferred and non-preferred foods. Run an ISCA (a synthesized functional analysis that identifies the reinforcers maintaining mealtime refusal). Then build a shaping hierarchy from looking at the food up through chewing and swallowing it.

Present each step as one trial. The child has a choice board in front of them with red, yellow, and green options. Green means doing the target step. Yellow means a partial step. Red means doing nothing with the food and moving on. Each color is tied to a different level of the synthesized reinforcement contingency. Green gets everything (full play access, preferred attention, an edible from the snack bar on the way back to the play area). Yellow gets a subset (often just attention at the table). Red gets nothing, and the next trial starts.

Crucially, the child also has an opt-out space in the room. A beanbag, a few toys, some books. Not their absolute favorites, but a real chill zone. They can go there anytime they want, for as long as they want. They come back when they are ready. The opt-out was added after the lab's first kid stood up and tried to leave the room, and the team realized "you can't leave" was a sentence they did not want in their protocol.

"There is an element of extinction related to positive reinforcers, but there's still no escape extinction because they can choose to do whatever they want with the food, whether it's red, yellow, or green." From the talk — Dr. Holly Gover

That sentence is the whole technical answer to "but how is this not extinction?" Positive reinforcement is on a schedule. Escape is always available. The two things are different.

A few procedural details from the cases. Liam (the first published participant) cruised through the hierarchy until swallowing, where the contingency broke down. The team went back one step, gave him more chewing exposure, and then he ate everything in the last meal. Allie hit a wall at swallowing and needed a smaller bite size and a step where she chewed one tiny noodle twenty times. Luke was a "light touch" kid whose refusal turned out to be about control more than sensory experience; the second he had real choice, he ate burritos.

Multiple foods get targeted at once. If one food consistently does not track the contingency while the others do, that is a preference signal. Drop the food. Do not force it to the finish line.

Sessions are short. Three to four trial blocks. Around thirty trials a day. Three days a week. Liam and Allie both finished in three to four months.

When escape extinction may still be the right call#

The talk is honest about the boundary. Escape extinction is not "wrong." It is just a heavier procedure that needs more support to run safely and humanely. There is one population where the question genuinely remains open.

A child with a G-tube who is medically stable, cleared by an SLP (speech-language pathologist) for safe swallowing, and not eating any food at all is a different clinical problem than a kid who eats chicken nuggets and applesauce but no vegetables. The shaping protocol was developed and tested on food-selective kids. It was not developed on full food refusal.

Gover is clear that if she got that referral today, she would refer it out. Not because shaping definitely will not work, but because that profile needs interdisciplinary expertise (SLP, OT, nutrition, often a feeding psychologist) and probably a hospital-like setting. Time pressure also matters. Four months of shaping is reasonable when a kid is eating something. It is harder to justify when the only intake is a feeding pump.

So the practical rule is closer to this. If the child is food selective and medically cleared, use this protocol. If the child is in total food refusal or on a G-tube, refer to a feeding clinic and let the team there decide whether shaping, escape extinction, or some combination is the right path.

What the evidence base looks like today#

The first published participants from the Hanley lab are in the literature. The protocol has been replicated in a university clinic, in a school-day Early Intervention clinic, in classrooms with preteens, and now in some home settings with parent implementers. The shaping-based approach is younger than the escape extinction literature and the long-term renewal data (what happens when context changes after treatment) is still being collected. That is also true of every behavioral feeding approach right now, including non-removal of the spoon. Renewal mitigation is the open question in the whole field.

What is clear from the cases is that you can get acceptance to climb to clinically meaningful levels without escape extinction, without restraint, without tears that read as trauma, in a clinic room with one therapist, in three to four months, in a kid who can opt out at any moment. That is enough to make this the first-line option for food-selective referrals in most community settings.

Frequently asked questions#

Is shaping less effective than escape extinction? On a per-session basis, escape extinction usually produces faster jumps in acceptance once the extinction burst settles. Shaping takes longer in calendar time, often three to four months for the published cases. Total acceptance at the end of treatment is comparable for food-selective kids. The trade is speed for distress and resource load. Most community clinicians and most families will accept the slower timeline to avoid the chair, the blockers, and the tears.

Can you use this approach with a child who has a G-tube? Probably not as a first move, and probably not as a solo BCBA. A stable G-tube refuser with cleared swallowing is a real open question that the protocol was not built or tested on. The honest answer is to refer to a hospital feeding program or an interdisciplinary clinic. If you do not have access to one and you decide to try shaping, get medical clearance, work with an SLP for swallow safety, and set explicit checkpoints for when you will stop and refer.

What if the family already started escape extinction and wants to switch? You can. Stop non-removal of the spoon, build the choice board, run an ISCA, and start shaping at a step the child can already do. Expect the first week to look weird. Kids who were on non-removal of the spoon are sometimes braced for the spoon to stay at their lips. Once they figure out they can pick red and walk away, that bracing usually drops within a few sessions and you can move up the hierarchy from there.

Watch the full session and see the actual case data#

Dr. Holly Gover walks through the Liam, Allie, and Luke graphs trial by trial, shows the cultural adaptation work in Nicaragua and with a South Indian family, explains the modifications for kids with less language, and goes deeper on when to refer. The full talk is one hour, free, and BACB-eligible.

Watch the full CEU on openceu.com

Then pick the next food-selective referral on your caseload and try the choice board on session one.