By Elizabeth McQuaid, PhD, ABPP, and Barbara Jandasek, PhD
The rate of food allergies has increased dramatically over the past decade, and recent estimates indicate that as many as 8% of children are affected. This increase in prevalence and awareness has resulted in numerous changes for eating patterns and rules at schools. Across the nation, states’ educational agencies have been reviewing which broad-based policies will be the most effective to keep children with food allergies safe in schools, and schools have been developing and implementing procedures to manage food allergies in classrooms and cafeterias, and on playgrounds and field trips. Parents must communicate effectively with schools to maintain a safe environment and a plan for how to manage reactions.
A consequence of this increased focus on food allergy, however, also means greater peer awareness of food allergies.Children may find close peers a source of support for their condition, however emerging research indicates that children with food allergies may also encounter teasing and bullying due to their food allergies.In this article, we provide a brief overview of pediatric food allergies, issues in food allergy management relevant to school-aged children, and emerging evidence regarding teasing and bullying of children with food allergies. We then review strategies and resources parents can use to provide support to children about teasing and bullying specific to food allergies.
Food allergies occur when the immune system has a response to specific foods; this type of reaction is distinct from food intolerances, such as lactose intolerance. Food allergies usually begin in infancy and toddlerhood when children are exposed to a larger variety of foods. Reactions can produce symptoms across multiple organ systems including skin (hives), the respiratory tract (breathing difficulties) and the gastrointestinal system (vomiting, diarrhea). Some reactions can result in food-induced anaphylaxis, which is a rapid, life-threatening condition that must be treated immediately with self-injectable epinephrine.
To date there is no cure for food allergies. Although some food allergies that begin in early childhood may resolve, such as allergies to milk and egg, others, such as allergies to peanut, may continue through adolescence and adulthood. Food allergies must be managed through careful avoidance of specific foods and prompt treatment of symptoms if ingestion of those foods occurs. Taking care of food allergies may place a substantial burden upon affected families and children.
Many parents of children with food allergies experience distress, worry, and anxiety associated with their child’s condition, and acknowledge that the food allergy affects family activities, such as attending social events, like birthday parties, and going out to eat (Sicherer et al., 2001). The impact of food allergy reaches beyond families to children’s peers and school environments. Managing food allergies effectively in the school setting presents unique challenges for families and for school personnel. Given the risk of exposure to allergenic foods in school settings, many schools have developed broad-based policies that have implications for all children. For example, schools often designate specific “nut-free” tables in the school cafeterias. Some schools place restrictions on foods in the classroom, like designating certain classrooms within a school as “peanut-free” or mandating that classroom celebrations do not involve food to minimize risk.
School-age children typically assume higher levels of independence in managing their own food intake. For children with food allergies, this means possessing a basic understanding of food allergies and being aware of their own trigger foods. Also, behavioral skills in food avoidance and reading food labels to identify safe foods become critically important. Additionally, in the case of an accidental exposure or ingestion, children must be able to take action by identifying symptoms of a food allergy reaction, alerting an adult, and accessing appropriate medications (e.g., antihistamines and/or self-injectable epinephrine). Preliminary findings from our research indicate children find managing their food allergy away from parents stressful, and, at times, may make decisions that could put them at risk for an allergic reaction.
Children with food allergies cannot “fly under the radar;” their food allergy is usually apparent to others. For example, peers in the classroom and cafeteria are often made aware of who has food allergies by the different food choices children with food allergies have to make or by designated lunchtime seating arrangements. Thus, an additional aspect of coping with food allergies is managing the reactions and questions of peers. While many peers may be supportive and are likely to have some awareness of food allergy, challenging situations can occur. Children may encounter negative reactions from peers during attempts to avoid food, such as refusing food offered to them by friends that may contain an allergen, and may be subject to teasing and bullying specific to their condition.
“Bullying” has been defined as a specific type of aggression that is intended to harm, occurs repeatedly, and takes place in a context in which there is an imbalance of power (Lieberman et al., 2010). Many recent legal definitions are consistent with this framework, emphasizing that the harm is intentional, and directed toward someone with a specific characteristic or vulnerability (Shemesh et al., 2013). Bullying can represent a variety of actions, and includes written, verbal, electronic and physical gestures (RIDE policy). Given the increased prevalence of food allergies and higher levels of awareness of which children are affected through the implementation of special accommodations, children with food allergies may be at risk for negative peer interactions and bullying.
There is increasing evidence that children with food allergies do experience teasing and bullying. A recent study by Shemesh and colleagues (2013) indicated that almost half (45.4%) of children with food allergies reported having been bullied, and 31.5% reported bullying specific to their food allergy. Parent-reported rates were somewhat lower but still remarkable; approximately a third (36.3%) of parents reported that their child had been a victim of bullying, and 24.7% reported bullying specifically due to the food allergy.
Episodes of bullying relating to food allergy found across studies include verbal taunts, and even threats with allergenic foods (Lieberman et al., 2010; Shemesh et al., 2013). Bullying is not uncommon, typically occurs at school, and includes general taunts, like accusing children of “faking,” as well as more targeted threats, such as throwing food at the child, or even approaching the child in a threatening manner with an allergenic food.
There are a variety of internet resources developed to provide education
and help children cope with these issues. One website,
www.stopbullying.gov/kids/, is a website about bullying and includes
videos and interactive games.
The Food Allergy and Anaphylaxis Network
(FAAN) is a support groups for families affected by food allergies that
sponsors a website containing facts about food allergies, games, and a
question/answer forum (www.fankids.org/).
contains several articles for children on both food allergies and coping
with bullying. With increased awareness on the part of parents, peers,
and school personnel, children with food allergies can feel safe and
comfortable in their school environments.
For children who may already be selfconscious about their eating habits and required food restrictions, experiencing bullying from peers can be highly distressing. In the study by Shemesh and colleagues (2013), reported bullying was associated with decreased quality-of-life and greater reported distress for both children with food allergies and their parents. Parents were aware of the bullying only half (52.1%) of the time; however, when parents did know about the bullying, children reported being less distressed. This suggests that open and ongoing family communication about peer stresses relating to food allergies may serve an important protective function among children with food allergies.
Initiating conversation with children about peer reactions to their food allergy is important, as children may not spontaneously share this information. In ongoing conversations, parents can help children problem-solve potential ways to address a bully. These conversations may also provide valuable opportunities to discuss actions that may not be as effective or could have negative consequences, like tasting an unhealthy food to appease a bully or to “get out of a situation.” Parents can also help children develop and rehearse specific phrases children can use if they encounter unsupportive peers or bullying. This role play can help children feel prepared and confident, and help them to manage these challenging situations more effectively if and when they do occur.
Children can be coached with multiple responses to use depending upon the situation, including calmly and assertively telling a bully to stop, making jokes about their food allergy, or simply changing the subject. Talking about when to get help or when to leave an unsafe situation is also important. Children can also find “safety in numbers.” First, increasing all children’s awareness and accurate knowledge of food allergies can help to address teasing and bullying. Also, parents can help children to identify and form a network of supportive peers and adults. Finally, all children should be encouraged to report any incidents of bullying to school personnel or any adult the child trusts. Schools have well-developed zero tolerance policies to manage bullying.
In Rhode Island, accounts of bullying are encouraged to be reported immediately to any school staff, may be reported by any credible witness, and may be reported anonymously (RIDE Policy Brief).
Elizabeth McQuaid, PhD, ABPP, is a staff psychologist in the child and family psychiatry outpatient department at Rhode Island Hospital, and associate professor (research) in the department of psychiatry and human behavior at Alpert Medical School of Brown University and .
Barbara Jandasek, PhD, is a staff psychologist in the child and family psychiatry outpatient department at Rhode Island Hospital, and assistant professor (research) in the department of psychiatry and human behavior at Alpert Medical School of Brown University and .
Sicherer SH, Noone SA, & Munoz-Furlong A. The impact of childhood food allergy on quality of life. Ann Allergy Asthma Immunol. 2001;87(6):461–464.
Lieberman JA, Weiss C, Furlong TJ, Sicherer M & Sicherer SH. Bullying among pediatric patients with food allergy. Ann Allergy Asthma Immunol. 2010;105(4):282–286.
Shemesh E, Annunziato RA, Ambrose MA, Ravid NL, Mullarkey C, Rubes M, Chuang K, Sicherer M, Sicherer SH. Child and parental reports of bullying in a consecutive sample of children with food allergy. Pediatrics. 2013;131(1):e10–e17.
State of Rhode Island Department of Elementary and Secondary Education. Safe school act: Statewide bullying policy. June 30, 2012. http://sos.ri.gov/documents/archives/regdocs/released/pdf/DOE/6774.pdf. Retrieved online 5/6/13.