The SOS (Sequential Oral Sensory) Approach to Feeding in Food Aversion

The Sequential Oral Sensory Approach to Feeding (The SOS Approach) is a transdisciplinary program designed to assess and address the reasons why a child is struggling to eat. Assessment occurs across seven different areas of human function involved in the process of learning to eat: organs, muscles, sensory, learning, development, nutrition, and environment. The SOS Approach uses a whole child perspective, integrating sensory, motor, oral-motor, behavioral/learning, medical, and nutritional factors for both assessment and intervention, resulting in strategies to comprehensively evaluate and manage children with feeding/growth problems. Success is determined by intrinsically motivated and sustained interest in trying new foods, enjoyment in and appropriate skills for eating and drinking a wide range of age-appropriate foods and fluids;  consumption of sufficient calories for optimal growth along a child’s own percentile line on a growth curve, and  improved family understanding and functioning during mealtimes for the development of healthy relationships with food and each other. The Sequential Oral Sensory (SOS) approach is a developmental feeding therapy that allows the child to interact with the food in a playful, non-stressful way. It helps increase the child’s comfort level by exploring different properties of foods, including the color, shape, texture, smell, taste and consistency.

SOS Approach to Feeding is a transdisciplinary program for assessing and treating children with feeding difficulties and weight/growth problems of all ages, with a special focus on children from 12 months to 5 years old. It integrates posture, sensory, motor, behavioral/learning, medical and nutritional factors to comprehensively evaluate and manage children with feeding/growth problems.

Food Aversion

An aversion is the avoidance of a thing or situation because it is associated with an unpleasant, stressful or painful stimulus. A feeding aversion refers to a situation where a baby – who is physically capable of feeding or eating – exhibits partial or full food refusal. Babies can develop an aversion to breastfeeding, bottle-feeding and/or solid foods. A feeding aversion is one of the most complex, confusing and stressful baby-care problems a parent could face.

An aversion involves a conditioned response. Initially the baby’s fussy or distressed behavior occurs in direct response to the stimulus (the thing or situation causing the feeding experience to be unpleasant, stressful or painful). However, following repeated exposure the baby learns to associate the act of feeding or eating with the stimulus and may then start to fuss or refuse to feed or eat prior to the stimulus occurring. This can make it challenging for parents and health professionals to accurately identify the stimulus.

Failure to identify and eliminate the stimulus means the baby’s conditioned response (aversive behavior in regards to feeding or eating) may continue to be reinforced, and thus the baby’s fussy feeding behavior or food refusal can continue for weeks, months or years.

Clinical manifestation A baby might exhibit one or more of the following behavior:

  • Skip feedings or meals without distress; or appear hungry but refuse to eat.
  • Fuss or cry when a bib is placed around her neck; when placed into a feeding position; or when the bottle is presented.
  • Clamp her mouth shut and turn her head away from the breast, bottle, spoon or food.
  • Take a few sips or a small portion of the milk or food offered, and pull away or arch back and begin to cry. (Please note: Babies back arch to distance themselves. Back arching does not provide evidence of acid reflux.)
  • Feed only while drowsy or asleep.
  • Consume less milk or food than expected.
  • Display poor growth and may be diagnosed as ‘failure to thrive’

The type and intensity of behavior varies between babies. At one end of the spectrum, a baby might simply refuse to eat a particular food owing to a bad experience while eating that food. At the other end, the baby might display complete food refusal and require a feeding tube to ensure she receives sufficient nutrients for healthy growth.

SOS (Sequential Oral Sensory)

  • The SOS (Sequential Oral Sensory) Approach to Feeding program is an effective way to address problematic feeding behaviors in a variety of settings and populations. Parents and caregivers of children who will not eat are faced with a difficult and often puzzling challenge. Because the interplay between weight gain and a child’s experience of food can be complicated, there is rarely an easy solution when a feeding problem arises. The SOS Approach uses a transdisciplinary team approach which assess the “whole child”: organ systems, muscles, development sensory, oral-motor, learning/behavior, cognition, nutrition and environment. The SOS Approach focuses on increasing a child’s comfort level by exploring and learning about the different properties of food and allows a child to interact with food in a playful, non-stressful way, beginning with the ability to tolerate the food in the room and in front of him/her; then moving on to touching, kissing, and eventually tasting and eating foods.
  • The SOS Approach to Feeding is a developmental feeding therapy that allows a child to interact with and learn about foods in a playful, non-stressful way. It helps increase a child’s comfort level by exploring different properties of the foods, including the color, shape, texture, smell and taste. The child is encouraged to progress up a series of steps to eating using “play with purpose” activities. Parent education and involvement are an essential part of this feeding program.
  • The SOS Approach to Feeding program can be used in individual sessions as well as with small groups of three to four children.
  • The SOS approach follows a systematic hierarchy to feeding, from tolerating foods in the room, interacting with foods, smelling, touching, tasting and eventually eating the food. Parent education and involvement are an essential part of the SOS approach.
  • Parents may observe sessions with TV monitors or be directly involved in the sessions. Therapeutic meals are initiated as a home program with recommendations from the therapist. Behavioral techniques are utilized as needed to increase the child’s follow-through with the SOS protocol.
  • The SOS approach can be used in individual sessions as well as with small groups of three to four children. Feeding groups are held as a continuation of the protocol in addition to or upon completion of one-on-one sessions.
  • Food aversions are far more common, far more diverse both within and across cultures, and far stronger than is often realized. Examination of the characteristics and origins of food aversions can help to illustrate the many contributions of genes and environment to behavior. Further, an understanding of food aversions can be useful in understanding, as well as treating, many eating and drinking disorders.

[P1000257_resize.JPG]Food aversions have been classified into four types:

  1. foods that are rejected because they are dangerous
  2. inappropriate
  3. disgusting
  4. distasteful

The consider foods to be dangerous, and therefore do not eat these foods, if eating them has previously resulted in physical harm, or if eating these foods is reputed to cause physical harm. However, a dangerous food, such as poisonous mushrooms, would be eaten by someone if there were some medication to prevent any illness from occurring.

Inappropriate foods are items that we consider not to be food. An example of an inappropriate food would be Kentucky bluegrass. Although deer and other herbivores might eat this grass, we would consider it inappropriate for humans to do so. Similarly, there may be an item, such as a particular kind of berry, that is considered to be a food by one culture but not by another.

SOS (Sequential Oral Sensory)

  • The SOS (Sequential Oral Sensory) feeding program is an effective way to address problematic feeding behaviors in a variety of settings and populations. It focuses on increasing a child’s comfort level by exploring and learning about the different properties of food, such as texture, taste, smell, and consistency. The SOS approach allows a child to interact with food in a playful, non-stressful way.
  • The SOS Approach is a trans-disciplinary feeding program that assesses and treats the whole child. Because feeding is the most complex of human physical tasks, it is critical that all the possible problem areas be examined when working with children who won’t eat. The SOS approach follows a hierarchy of feeding, beginning with the ability to tolerate food in the room, in front of him/her, touching, kissing, and eventually tasting and eating foods.
  • [P1000260_resize.JPG]
  • There are several reasons why someone might treat an item as an inappropriate food. One involves the taste of the item. From birth, humans find certain tastes, notably the taste of bitter, to be aversive, and therefore may not consider items with those tastes to be appropriate foods. For example, many wild plants taste extremely bitter. Given that poisonous plants are often bitter, scientists believe that humans who avoided bitter tastes were more likely to survive and therefore humans evolved to have an innate aversion to bitter tastes. Direct experience with an item may also contribute to its classification as an inappropriate food; attempts to chew some wild plants can be fruitless. Finally, someone may consider an item to be an inappropriate food because of information passed on by someone else. For example, caregivers may tell children that grass is not food.

Candidate for referral, any of the following are present:

  • Ongoing poor weight gain (rate re: percentiles falling) or weight loss
  • Ongoing choking, gagging or coughing during meals
  • Ongoing problems with vomiting
  • More than one incident of nasal reflux
  • History of traumatic choking incident
  • History of eating & breathing coordination problems, with ongoing respiratory issues
  • Inability to transition to baby food purees by 10 months of age
  • Inability to accept any table food solids by 12 months of age
  • Inability to transition from breast/bottle to a cup by 16 months of age
  • Has not weaned off baby foods by 16 months of age
  • Aversion or avoidance of all foods in specific texture or food group
  • Food range of less than 20 foods, especially if foods are being dropped over time with no new foods replacing those lost
  • An infant who cries and/or arches at most meals
  • Family is fighting about food and feeding (i.e. meals are battles)
  • Parent repeatedly reports that the child is difficult for everyone to feed
  • Parental history of an eating disorder, with a child not meeting weight goals

Disgusting foods are those that most of us would not want in our meals or stomachs no matter how the foods were disguised and no matter how small the amount. Some examples of items classified as disgusting foods are urine and feces. Foods can become disgusting because of someone’s having observed others’ reactions to these foods, because of contact of a previously nondisgusting food with something considered disgusting, or because a food looks similar to something disgusting. Thus, because most American children learn from others that insects are disgusting foods, we consider a glass of milk that used to have a cockroach in it to be disgusting, and we find fudge that looks similar to feces to be disgusting. Similarly, cultural beliefs can result in certain foods being considered disgusting. For example, many vegetarians consider meat to be disgusting, and Jews who keep kosher may find meal combinations of meat and dairy products to be disgusting.

Probably the most studied is the fourth and final category: distasteful foods. These are foods that most of us would not mind eating if the taste of the food were covered up by another taste, or if we only found out that we had eaten it after we had finished eating. An example is warm milk. Once again, an innate dislike of certain tastes can contribute to food aversions of this sort. However, many members of the distasteful food category are illness-induced food aversions (also known as taste aversions). Humans and many other species exhibit illnessinduced food aversions when they eat something, become ill, and then do not want to eat that food again. This is an extremely powerful type of learning. Study of the acquisition of illness-induced food aversions has proved extremely important to the development of general learning theory, and has resulted in a number of different applications outside of the laboratory. Therefore, the following sections discuss illness-induced food aversion learning in some detail.

Prior to scientists’ conducting any investigations of taste aversion learning, farmers were aware of this phenomenon, which they called bait shyness. The farmers found that it was difficult to kill rats by putting out poisoned bait. The rats would take only small samples of any new food, in this case the bait, and if they then became ill, they would subsequently avoid the bait.

Laboratory experiments on taste aversion learning began in the 1950s. Researchers noticed that rats eat less after being irradiated. Apparently irradiation makes rats gastrointestinally ill and they associate the illness with food, resulting in a taste aversion to the food.

In 1966 John Garcia and Robert A. Koelling used a taste aversion paradigm to show learning theorists that it is easier to learn some associations than others. In their experiment, rats more easily learned to avoid licking flavored water when that licking was followed by illness than by shock, and they more easily learned to avoid licking water accompanied by clicks and light flashes when that licking was followed by shock than by illness. Garcia and Koelling concluded that it is easier for rats to associate tastes with illness and audiovisual events with shock than vice versa. It was due to results such as these that this type of learning was labeled taste aversion learning.

Odors may also play an important role in food aversions linked to illness, yet the term “taste aversion learning” has persisted. The fact that tastes and odors are more easily associated with illness than with other sorts of events helps us to survive. The presence of a poison is more likely to be indicated by a particular odor or taste than by a particular appearance or sound.

Subsequent experiments found that taste aversion learning has some other special properties that may help animals to survive. For example, taste aversions can be acquired with up to twenty-four hours between consumption of the food and illness. This is advantageous because it may take hours before a poison will result in illness. In addition, in taste aversion learning, the taste actually seems to come to taste bad. This also helps animals to survive because a poison should be avoided no matter under what circumstances it is encountered. Finally, taste aversions are more likely to form to novel foods, and often form after just one pairing of a taste with illness. These characteristics help to ensure that, as much as possible, animals learn quickly to avoid new poisonous foods. Animals appear to have evolved so that they easily acquire long-lasting aversions to cues associated with poisonous foods.

Taste aversion learning has been studied in a great many species, including humans. Surveys have found that most college students report having acquired at least one taste aversion. In general these aversions are strong and have persisted a long time. Laboratory experiments have shown that taste aversions are acquired similarly across species.

Research on taste aversion learning can help us to understand, and possibly modify, many food aversions and preferences. For example, taste aversion learning may cause what are termed specific hungers. These are preferences for specific foods containing a nutrient, such as thiamine or sodium, in which an animal’s diet has been deficient. Animals may feel ill when deficient in these nutrients, and thus form taste aversions to their usual foods. New foods, or foods associated with recovery from the illness, are therefore preferred.

In a very different application, taste aversion learning has been used for wildlife management—to prevent coyotes from attacking sheep on ranches in the western part of the United States. Many ranchers choose simply to kill the coyotes. However, coyotes are a valuable part of the ecosystem (for example, by decreasing the rabbit population). Researchers reasoned that, if they could train the coyotes to avoid sheep but not rabbits, this would preserve the ecosystem. They therefore placed lamb bait laced with an illness-inducing drug on the range in areas frequented by coyotes. The coyotes appeared to acquire an aversion to eating or even approaching sheep. In fact, after aversion training, coyotes behave submissively toward sheep, running the other way when a sheep approaches.

Taste aversion learning has also been helpful in understanding the life-threatening anorexia that can accompany cancer. Some cancer treatments, such as radiation and chemotherapy, can cause gastrointestinal illness. When this illness is paired with food consumption, taste aversions can result. Ilene L. Bernstein and Mary M. Webster gave child and adult patients a novel-tasting ice cream prior to their chemotherapy and the patients acquired an aversion to that ice cream. These findings and others have resulted in the development of the “scapegoat technique.” This technique involves giving cancer patients a novel food along with some familiar food just prior to their chemotherapy. The patient forms an aversion to the novel food and not to the familiar, usual food.

Although it might seem that taste aversion learning could be useful in decreasing overeating, it is not employed for this purpose. Taste aversions form to specific foods, and it is too easy for a patient to switch to overeating a different food once an aversion has been acquired to a previously overconsumed food.

In contrast, taste aversion learning has been successfully employed in treating alcohol abuse, although the pairing of alcohol and illness must be done carefully in order for strong taste aversions to develop. In addition, it is necessary for illness to be paired with a variety of alcoholic beverages in order to ensure that an alcoholic does not switch to new alcoholic beverages following aversion training.

There are a great many different types of food aversions in humans and other animals. Some of these aversions help animals to survive, and others can be extremely debilitating. Continuing research will help to maximize the positive effects of these aversions, and minimize their negative effects.

The SOS (Sequential Oral Sensory) Approach to Feeding

Once the child can tolerate BEING at the table with a food (you have successfully played with a food and they can tolerate being near it) then do the following:

  • do not EVER let the child see the package or container that the food came in, always put it in a ziploc bag, or clear container&they will start to associate the container with the food soon, and then will only eat foods out of that exact container.
  • Do not ever force feed
  • Always make it fun and non stressful
  • Provide a lot of deep pressure touch through massage or brushing and calming choices at mealtime
  • Use a white plate, and white napkin to present foods
  • Let the child cover up the food with the napkin if they don’t like it but offer another way to interact with it through play, it is good in this sense to play with your food!!!
  • Give the child a “SAFE FOOD” this is a food that they normally eat and enjoy such as chicken. Introduce a new food that is either the same color or the same texture to that child with the safe food, such as chicken with apple chips close to the same color, other examples: green beans and green snapeas (baked snapeas), or potatoe chips and the same color of dried fruit such as pineapple or banana, or green beans and peas, carrots and sweet potatoes
  • It can be the same color, shape, or texture as the “safe food”. Keep talking about how the two foods are the same all through the session and mealtime. Even making PECS and do a matching game of those that are the same. The idea is the convey that the new food is also safe, because it is the same as the food they normally eat.
  • Save chewy or sweet foods and any drinks for after the meal is eaten only, do not let the child fill up on snacks, juices, milks, or other drinks or snacks in between meals. Make meal time a priority 3 times a day to sit and work on skills. Sweets, drinking, and chewy foods fill the child up quickly, but make them hungry again without giving them the nutrition their brains and bodies need. Then they learn to snack, graze, and drink to get calories instead of eating well balanced meals.


  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: APA, 1994.
  • Nakajima, S., H. Ka, and H. Imada. “Summation of Overshadowing and Latent Inhibition in Rats’ Conditioned Taste Aversion: Scapegoat Technique Works for Familiar Meals.” Appetite 33 (1999): 299–307.
  • Rozin, Paul. “The Selection of Foods by Rats, Humans, and Other Animals.” In Advances in the Study of Behavior, edited by J. S. Rosenblatt, R. A. Hinde, E. Shaw, and C. Beer. Vol. 6. New York: Academic Press, 1976. Description of specific hungers.
  • Rozin, P., and April Fallon. “The Psychological Categorization of Foods and Non-Foods: A Preliminary Taxonomy of Food Rejections.” Appetite 1 (1980): 193–201.
  • Seligman, Martin E. P., and Joanne L. Hager, eds. Biological Boundaries of Learning. New York: Appleton-Century-Crofts, 1972. Description of sauce béarnaise phenomenon.
  • Wiens, Arthur N., and Carol E. Menustik. “Treatment Outcome and Patient Characteristics in an Aversion Therapy Program for Alcoholism.” American Psychologist 38 (1983): 1089–1096.
  • Barnett, Samuel Anthony. The Rat: A Study in Behavior. Chicago: Aldine, 1963. Description of bait shyness.
  • Bernstein, Ilene L., and Mary M. Webster. “Learned Food Aversions: A Consequence of Cancer Chemotherapy.” In Cancer, Nutrition, and Eating Behavior. Edited by Thomas G. Burish, Sandra M. Levy, and Beth E. Meyerowitz. Hillsdale, N.J.: Lawrence Erlbaum, 1985.
  • Garcia, John, and Andrew R. Gustavson. “Carl R. Gustavson (1946–1996) Pioneering Wildlife Psychologist.” APS Observer ( January 1997): 34–35. This paper and ones by C. R. Gustavson describe work on training coyotes to avoid sheep.
  • Garcia, John, Donald J. Kimeldorf, and Robert A. Koelling. “Conditioned Aversion to Saccharin Resulting from Exposure to Gamma Radiation.” Science 122 (1955): 157–158.
  • Garcia, John, and Robert A. Koelling. “Relation of Cue to Consequence in Avoidance Learning.” Psychonomic Science 4 (1966): 123–124. Paper showing it is easier to associate tastes than audiovisual stimuli with illness.
  • Gustavson, Carl R. “Comparative and Field Aspects of Learned Food Aversions.” In Learning Mechanisms in Food Selection. Edited by L. M. Barker, M. R. Best, and M. Domjan. Waco, Tex.: Baylor University Press, 1977.
  • Gustavson, Carl R., Linda P. Brett, John Garcia, and Daniel J. Kelly. “A Working Model and Experimental Solutions to the Control of Predatory Behavior.” In Behavior of Captive Wild Animals. Edited by H. Markowitz and V. J. Stevens. Chicago: Nelson-Hall, 1978.
  • Logue, A. W. The Psychology of Eating and Drinking: An Introduction. 2d ed. New York: W. H. Freeman, 1991. General text including information on origins, characteristics, and applications of food aversions.
  • Logue, A. W. “Taste Aversion and the Generality of the Laws of Learning.” Psychological Bulletin 86 (1979): 276–296.
  • Logue, A. W., Iris Ophir, and Kerry E. Strauss. “The Acquisition of Taste Aversions in Humans.” Behavior Research & Therapy 19 (1981): 319–333.

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