Letters to the Editor

Bullying and Food Allergy: What Can Allergists Do?

by Ralph E. (Gene) Cash, Ph.D., Nationally Certified School Psychologist, and Past President of the National Association of School Psychologists

The two main characteristics of bullying are its repetitive nature and the implicit imbalance of power between bully and victim. The imbalance of power inherent in bullying refers to the victims’ perceptions that they cannot easily defend themselves or stop the interaction. As a result, victims are left feeling powerless and vulnerable, which often produces devastating psychological consequences. While bullying with regard to food allergies isn't all that different from bullying about other attributes, children with food allergies must bear an additional burden, because they already have the responsibility of taking care of themselves medically.

According to a recent survey published in the October issue of Annals of Allergy, Asthma & Immunology, about 25% of children are bullied, teased, or harassed because of a food allergy. When children under five were excluded from the results, the figure rose to 35 percent, and among students in grades six through 10 it was as high as 50 percent. The survey was completed by 353 teens, adults up to age 25, and parents and caregivers of children with food allergies. Peanut allergy affected 81% of the group, and 84% of the group had multiple food allergies. Fifty-five percent were between the ages of four and 11, and 61% were boys.

“Food allergies affect an estimated 12 million Americans, including 3 million children. These children face daily challenges in managing their food allergies,” said allergist Scott Sicherer, M.D., co-author of the study and a researcher at the Jaffe Food Allergy Institute at The Mount Sinai Medical Center in New York, in a news release. Nearly four percent of children younger than 18 in the United States have food allergies, and that figure jumped 18 percent from 1997 to 2007. Peanut allergies rose from 0.4 percent of kids in 1997 to 1.4 percent in 2008, according to a previous study by Sicherer.

“Recent cases involving bullying and food allergy include a middle school student who found peanut butter cookie crumbs in her lunchbox and a high school student whose forehead was smeared with peanut butter in the cafeteria,” related Christopher Weiss, Ph.D., study co-researcher and vice president for advocacy and government relations of the Food Allergy and Anaphylaxis Network. “Bullying, whether physical or verbal, is abusive behavior that can have a tremendous impact on a child’s emotional well-being. Educators should develop anti-harassment policies related to food allergy. The public needs to understand this behavior is unacceptable.”

Researchers at the Jaffe Food Allergy Institute at The Mount Sinai Medical Center in New York and the Food Allergy and Anaphylaxis Network, which supported the study, also found the following:

  • Among those who reported bullying, 86% reported multiple episodes.
  • Verbal abuse was the most common form of bullying.
  • 82% of these episodes occurred at school, and 80% took place among classmates.
  • 21% reported teachers or school staff as the perpetrators.
  • 79% said the bullying and harassing were solely related to a food allergy, whereas others reported being harassed for having to carry medication for their food allergy.
  • 57% of those bullied reported being touched or harassed by the actual food allergen.
  • Fortunately, none of the children in the study suffered an allergic reaction as a result of bullying or harassing.

Despite the absence of allergic reactions, the impact of bullying in all forms is profound and pervasive, producing emotional distress; underachievement and diminished productivity; potential physical damage or even death because of injuries, anaphylaxis, or suicide; and often somatization of stress. Of 67 children who reported consequences, about 65 percent described being sad, depressed, or embarrassed, the study showed.

Because bullying frequently results in physical problems and/or somatization of psychological difficulties, any physician who cares for children or adolescents, whether in primary care or in a specialty area, may be in an important position to recognize the effects of bullying, sometimes even before parents or guardians become aware of it. Children exposed to domestic violence frequently become bullies and/or victims, so whenever abuse in the home is suspected, bullying should also be considered as a co-occurring phenomenon. Youth who are brought to the doctor for physical injuries of unknown or questionable origin or for whom there are no identifiable physical causes of their complaints may be victims of abuse, either within the home and family or by bullies outside the family purview. Recognizing these warning signs and following up with pointed, but matter-of-fact, questions is a physician responsibility and a critical area of skill development for medical doctors.

The American Medical Association (AMA) has recommended that “physicians should enhance their awareness of the social and mental health consequences of bullying, be vigilant for signs of bullying in young patients, screen for psychiatric symptoms in at-risk patients, counsel affected patients and their families, and advocate for programs to treat perpetrators and victims of bullying” (http://www.jaredstory.com/ama_bullying.html). The AMA issued two policy resolutions, Bullying Behavior Among Youth (D-60.993, 2001) and Bullying Behaviors Among Children and Adolescents (H-60.943, 2003), that underscore the seriousness of bullying and recommend actions to be taken by AMA, physicians, parents and caretakers, and coalitions interested in addressing bullying (http://search0.ama-assn.org/search/pfonline/?chkALL=ALL&query=bullying).

In addition, the American Academy of Family Physicians has published recommendations for bullying screening and intervention for those in primary care. The American Academy of Pediatrics urges doctors to tell parents to talk to their children about bullying, to teach children how to resolve conflicts, and to promote respectful relationships. It also suggests that doctors volunteer to talk about the topics at schools, churches, and youth organizations. The Wisconsin Medical Society last year published specific recommendations for bullying prevention for physicians which include strategies for identifying the problem; counseling children, parents, and school personnel on methods of prevention and intervention; screening for, treating, and/or referring to a mental health professional when symptoms of mental illness are present; and advocating for violence prevention in schools and communities.

Allergists have a special responsibility in light of the recent data regarding bullying and food allergies to suspect and to identify the effects of bullying in their child and adolescent patients who are allergic to foods. The warning signs are similar to other forms of bullying. A child may appear sad, upset, withdrawn, or anxious and/or have trouble sleeping. He or she may also refuse or express reluctance to go to school, although some of them may be quite hesitant to admit that bullying is the reason. Parents should be particularly questioned about changes in their children's eating habits, such as coming home with an untouched lunchbox, for example, or about reasons for unexplained weight loss or other dramatic changes in behavior.

Three screening instruments which can assist physicians in following up on any suspicions or risk factors are the Bully Victimization Scale (BVS), the Bully Victimization Distress Scale (BVDS), and the School Violence Anxiety Scale (SVAS). The BVS and BVDS are appropriate for children in grades 3 through 12, and the SVAS is appropriate for grades 5 through 12. Each takes about 5-10 minutes to complete and can be administered and scored by a nurse or technician under the supervision of a physician. All three are published by Pearson Assessments, and a complete kit with 30 forms for each scale costs $203. These 3 scales lend themselves to screening for those who engage in bullying as well as those who are victims. In addition, a large-scale, 2009 European study suggests that Kidscreen-52 shows promise as a cross-cultural screening tool for identifying children ages 8-18 who are victims of bullying and harassment. As a matter of full disclosure, I have no fiduciary interest in any of these scales and no relationship with the publishers.

Early identification of potential bullies and victims is critical for intervening effectively to stop the cycle of bullying and to prevent harmful or even fatal outcomes. Once a patient has been identified as being at risk for bullying or victimization, he or she should be referred to a mental health professional experienced in dealing with such problems. When the bullying involves food allergies, effective collaboration among the allergist, the mental health professional, the family, and the patient’s school is necessary for effective intervention. The allergist can provide essential information about the degree of medical risk for the patient; what steps must be taken to guard against anaphylaxis; what medication(s), if any, must be available during school hours and who must keep them; what to do in case of emergencies; and what level of environmental control is required. In addition, school personnel and students need training in the risks associated with allergies, particularly food allergies, as well as asthma. Who better to provide such training than the allergist or his/her nurse practitioner?

Perhaps the most important step allergists can take to combat bullying is to promote prevention. Speak with your patients and their families proactively about bullying risks. Work with schools and public policy makers to ensure that each school has a bullying prevention plan in place and that each of your patients has a go-to person in the school to whom any incidents of bullying should be reported. Volunteer to train families, students, and school personnel in the risks and consequences of bullying. Help to change the culture of violence, whether overt or covert, in your community. By so doing, you will enhance your own practice, and you will help to make the world worthy of its children.

Jeffrey Miller MD, FACAAI
Mission: Allergy, Inc.
Hawleyville, CT

Kathleen R. May MD,
Editor-in-Chief, acaai.org

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