Abstract
Background:
Food allergy (FA)-related bullying is common, yet little is known about risk factors for FA-related bullying or the relationship between FA-related bullying and psychosocial wellbeing. This study aimed to (1) identify sociodemographic and clinical factors associated with risk of FA-related bullying in children with FA, and (2) evaluate the psychosocial functioning of children and parents reporting FA-related bullying.
Methods:
This was a cross-sectional survey study of children ages 5–17 years with immunoglobulin E (IgE)-mediated FA and their parents, recruited from Boston Children’s Hospital (BCH) and through social media outlets. Children and parents with versus without history of FA-related bullying were compared on sociodemographic and clinical characteristics and FA-related psychosocial outcomes using validated instruments.
Results:
In this cohort of 295 child-parent dyads, median child age was 8.0 years, 53.2% of children were male, and parent respondents were primarily mothers (96.6%). Reported lifetime prevalence of FA-related bullying was 36.6%. FA-related bullying was associated with certain child characteristics, including coming from a household at risk of food insecurity (FI) (12.0% of bullied children v. 2.2% of not bullied children were from food insecure households, p<0.001), having coexisting atopic and mental health conditions—particularly anxiety (30.6% of bullied children v. 8.6% of not bullied children carried an anxiety disorder diagnosis, p<0.001)—and having a history of more severe FA reactions. FA-related bullying was associated with elevated concerns in child and parental FA-related psychosocial functioning domains.
Conclusion:
Pediatricians and allergists should screen for FA-related bullying and offer families appropriate guidance around managing FA-related bullying.
Keywords: Food allergy, bullying, psychosocial well-being, teasing
Introduction
IgE-mediated FA affects up to 8% of children in the United States (US) and there is growing recognition of its psychosocial impact.1–3 Studies to date on the psychosocial impact of pediatric FA have largely focused on anxiety and quality of life (QOL).2 Having IgE-mediated FA is associated with increased anxiety and decreased QOL in children and their parents, compared with the general population.4,5 A less studied but commonly reported aspect of psychosocial functioning in pediatric FA is bullying.
Per the US Centers for Disease Control and Prevention, “Bullying is any unwanted aggressive behavior(s)...that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated”.6 Children with FA are more likely to experience bullying compared with children without FA.7 In cross-sectional survey studies of children with FA and their caregivers, the reported lifetime prevalence of being bullied, teased, or harassed due to FA is 19%−52%.7–15 FA-related bullying occurs most often in school and can manifest as social exclusion, being the target of rumors, or verbal or physical harassment—including being forced to touch or ingest food allergens.8–10,16 Children who are forced to ingest food allergens are at risk of life-threatening anaphylaxis, and bullying in general is associated with long-lasting adverse psychological, physical, and socioeconomic outcomes.17 Notably, a significant number of allergists, schoolteachers, and parents of children with FA are unaware of the occurrence or prevalence of FA-related bullying.10,11,16,18,19
For pediatricians and allergists, it is important to screen for FA-related bullying and offer appropriate education and guidance for families. It is particularly relevant to identify children at increased risk of FA-related bullying, so that clinicians and school administrations can develop targeted strategies to reduce their risk. Yet, little is known about factors associated with risk of FA-related bullying. This cross-sectional study of children with IgE-mediated FA aimed to (1) identify sociodemographic and clinical factors that are associated with risk of FA-related bullying and (2) evaluate the psychosocial functioning of children and parents who report FA-related bullying.
Methods
Participants, Recruitment, and Inclusion Criteria
This study was part of a larger project—approved by BCH’s Institutional Review Board—evaluating the psychosocial impact of school FA policies. Between 4/2021–11/2022, child-parent dyads were recruited from BCH and social media outlets to complete self-administered electronic surveys online via REDCap.20 Links to the study were posted on Facebook and shared via Twitter and through FA advocacy and support groups. Inclusion criteria were children ages 5–17 years with IgE-mediated FA diagnosed by a physician or other health practitioner, whose parent lived in the same household and was able to provide informed consent for participation in the study. Participants did not receive financial compensation.
Survey Instruments and Variables
The following surveys captured characteristics of study participants. First, a demographic survey for the parent, indicating for both child and parent their age, gender, race, ethnicity, and comorbid atopic and mental health conditions diagnosed by a healthcare provider; the child’s FA reaction history; and household characteristics. Household FI status was measured using the validated Hunger Vital Sign® 2-question screener.21 Second, a proxy survey administered to the parent, reporting on their child’s lifetime FA-related bullying. Third, a self-report survey administered to children ages ≥8 years, reporting lifetime FA-related bullying. Both bullying surveys were modified from the EMPOWER Program Survey of Children with FA, developed by Shemesh et al.11 While the EMPOWER Program Survey was not independently validated, it was constructed following other accepted and validated bullying instruments.22,23 Parents were asked: “Has your child ever been bullied, teased, or harassed about their FA?”. Children were asked: “Were you ever bullied, teased, or harassed about your FA?”. The child survey also queried specific FA-related victimization behaviors, as it is known from previous research that a multi-item inventory increases disclosure of FA-related bullying.10
Fourth, participants completed validated instruments to assess FA-related psychosocial wellbeing. For parents, this included: FA QOL-Parental Burden (FAQL-PB);24 FA Independent Measure-Parent Form (FAIM-PF),25,26 Screen for Adult Anxiety Related Disorders (SCAARED);27 Worry About FA 2.0 (WAFA2);28 and FA Self-Efficacy Scale for Parents (FASE-P).29 For children ages ≥8 years, this included: FA QOL Questionnaire (FAQLQ);30,31 FA Independent Measure-Child Form (FAIM-CF);25 Screen for Child Anxiety Related Disorders (SCARED);32 and Worry About FA (WAFA2).28 Parent-proxy surveys included the FAQLQ-Parent Form for parents of children ≤12 years33 and the SCARED-Parent Version for parents of children ages ≥8 years.34
FA-related QOL measures.
The FAQL-PB assesses parental burden associated with having a child with FA.24 Items are rated on a 7-point Likert scale. A mean score is calculated. Higher scores indicate worse QOL. The FAIM-PF and FAIM-CF assess parental and child perceptions, respectively, of expectation of adverse FA outcomes.25,26 Items are rated on a 7-point Likert scale. Higher scores indicate greater perceived FA severity, which has been shown in other studies to be a key determinant of FA psychosocial burden.25,26 The FAQLQ assesses child (age 8–12 years)30 and teenager (ages 13–17 years)31 FA-related QOL. The FAQLQ-PF assesses parental perception of their child’s FA-related QOL.33 Items are rated on a 7-point Likert scale. Higher scores indicate worse FA-related QOL.
Anxiety measures.
The SCAARED is designed to screen adults for anxiety disorders.27 Items are rated on a 3-point Likert scale. A total score is summed; ≥23 may indicate the presence of an anxiety disorder in adults. The SCARED32 and SCARED-Parent Version34 are designed to screen children for anxiety disorders and assess parental perception of their child’s anxiety symptoms, respectively. Items are rated on a 3-point Likert scale. A total score is summed; ≥25 may indicate the presence of an anxiety disorder in children. The WAFA2 Parent-Report assesses parental anxiety associated with having a child with FA.28 The WAFA2 Child (ages 8–12 years) and Teen (13–17 years) forms assess child/teen anxiety associated with having a FA.28 Items are rated on a 5-point Likert scale. Higher mean scores indicate greater FA-specific anxiety.
FA self-efficacy measures.
The FASE-P assesses parental confidence in their ability to manage their child’s FA.29 Each item is rated 0–100 and a mean score is calculated. Higher scores indicate greater FA self-efficacy.
Statistical Analysis
Bullying status was assessed by parent or child report of the child ever being bullied due to FA (Figure 1). If either the child or the parent answered “yes” to this question, the child was classified as bullied, otherwise as not bullied. We used a simple kappa coefficient to estimate the level of agreement between children and parents reporting FA-related bullying.
Figure 1. Study eligibility consort diagram.
Consort diagram of study participation status eligibility. Primary and current study inclusion criteria, exclusion criteria, outcomes of interest, and key comparison groups for the current study are indicated.
Children with versus without history of FA-related bullying were compared on demographics, parent and household characteristics, parent-reported healthcare provider diagnosis of comorbid atopic and mental health conditions, history of FA reactions, and validated instruments assessing psychosocial wellbeing. We used chi-square tests for categorical variables or Fisher’s exact test depending on sample size. Mann-Whitney U tests were utilized for non-normally distributed continuous variables and t-tests for normally distributed continuous variables.
A multivariable logistic regression was estimated with FA-related bullying as the outcome. Independent variables included child age, asthma, atopic dermatitis (AD), anxiety diagnosis, years since FA diagnosis, ever having had a FA reaction at school/daycare, ever having gone to the emergency room for a FA reaction, ever having been hospitalized overnight for a FA reaction, and number of FA reactions treated with epinephrine. Predictors were chosen based on clinical importance. To evaluate for the possibility of selection bias, non-responders to the survey question of whether the child had ever been bullied due to FA were compared with responders on demographic and FA variables. The threshold for statistical significance was p<0.05, 2-sided. Statistical analyses were performed using SAS version 9.4 software (SAS Institute, Cary, NC).
Results
Study Population
1,169 child-parent dyads completed the electronic surveys and 541 met inclusion criteria for this study (Figure 1). 295 child-parent dyads responded to the survey question of whether the child had ever been bullied due to FA. Parent responders were primarily mothers (96.6%); the majority of parents were White (88.7%), non-Hispanic (96.9%), and highly educated (59.2% held graduate degrees). 80.1% (n=218) reported an annual household income ≥$100,000, and 5.8% (n=17) reported that their household had experienced FI in the last 12 months (Table 1). Median child age was 8.0 years (IQR 7.0, 12.0) and 53.2% of child respondents were male. Children were predominantly White (82.5%), non-Hispanic (95.5%), and the majority attended public schools (71.4%). 27 states were represented, with most participants (89.4%) from the Northeastern US.
Table 1.
Factors associated with child ever bullied due to food allergies (n=295 parent-child dyads)
| Overall cohort (n=295) |
Child bullied due to food allergy (n=108) |
Child not bullied due to food allergy (n=187) |
p-value | |
|---|---|---|---|---|
| Parent characteristics | ||||
| Parent IgE-mediated food allergy, n (%) n=295 | 33 (11.2) | 18 (16.7) | 15 (8.0) | 0.02 |
| Parent mental health conditions, n (%) n=295 | ||||
| Anxiety disorder | 87 (29.5) | 33 (30.6) | 54 (28.9) | 0.76 |
| Depression or other mood disorder | 51 (17.3) | 21 (19.4) | 30 (16.0) | 0.46 |
| PTSD | 17 (5.8) | 8 (7.4) | 9 (4.8) | 0.36 |
| Household characteristics | ||||
| Annual household income, n (%) n=272 | ||||
| <$50,000 | 18 (6.6) | 5 (5.1) | 13 (7.5) | 0.26 |
| $50,000–$74,999 | 15 (5.5) | 9 (9.2) | 6 (3.5) | |
| $75,000–$99,999 | 21 (7.7) | 8 (8.2) | 13 (7.5) | |
| $100,000–$149,999 | 44 (16.2) | 18 (18.4) | 26 (14.9) | |
| $150,000–$199,999 | 59 (21.7) | 23 (23.5) | 36 (20.7) | |
| ≥$200,000 | 115 (42.3) | 35 (35.7) | 80 (46.0) | |
| Household at risk of food insecurity, n (%) n=294 | 17 (5.8) | 13 (12.0) | 4 (2.2) | <0.001 |
| Child characteristics | ||||
| Age (years), median (IQR) n=295 | 8.0 [7.0, 12.0] | 10.5 [8.0, 13.0] | 8.0 [6.0, 11.0] | <0.001 |
| Gender, n (%) n=293 | ||||
| Male | 156 (53.2) | 62 (57.9) | 94 (50.5) | 0.18 |
| Female | 136 (46.4) | 44 (41.1) | 92 (49.5) | |
| Other | 1 (0.3) | 1 (0.9) | 0 (0.0) | |
| Medical conditions, n (%) n=295 | ||||
| Allergic rhinoconjunctivitis | 192 (65.1) | 73 (67.6) | 119 (63.6) | 0.49 |
| Asthma | 143 (48.5) | 63 (58.3) | 80 (42.8) | 0.01 |
| Atopic dermatitis | 165 (55.9) | 69 (63.9) | 96 (51.3) | 0.04 |
| Celiac disease | 7 (2.4) | 4 (3.7) | 3 (1.6) | 0.26 |
| Eosinophilic gastrointestinal disease | 24 (8.1) | 7 (6.5) | 17 (9.1) | 0.43 |
| Food protein-induced enterocolitis syndrome | 8 (2.7) | 7 (6.5) | 1 (0.5) | 0.004 |
| Lactose intolerance | 12 (4.1) | 7 (6.5) | 5 (2.7) | 0.13 |
| Mental health conditions, n (%) n=295 | ||||
| Anxiety disorder | 49 (16.6) | 33 (30.6) | 16 (8.6) | <0.001 |
| Depression or other mood disorder | 10 (3.4) | 8 (7.4) | 2 (1.1) | 0.006 |
| PTSD | 7 (2.4) | 7 (6.5) | 0 (0.0) | <0.001 |
| Type of school child attends, n (%) n=290 | ||||
| Public | 207 (71.4) | 80 (74.1) | 127 (69.8) | 0.43 |
| Private | 68 (23.4) | 21 (19.4) | 47 (25.8) | |
| Charter | 8 (2.8) | 3 (2.8) | 5 (2.8) | |
| Other | 7 (2.4) | 4 (3.7) | 3 (1.7) | |
| During the current school year, on average, how many days per week child eats a school/daycare provided meal, n (%) n=293 | ||||
| Never | 156 (53.2) | 65 (60.2) | 91 (49.2) | 0.053 |
| Rarely (1 day per week) | 42 (14.3) | 11 (10.2) | 31 (16.8) | |
| Sometimes (2–3 days per week) | 24 (8.2) | 12 (11.1) | 12 (6.5) | |
| Always or almost always (4–5 days per week) | 71 (24.2) | 20 (18.5) | 51 (27.6) | |
| Child food allergy characteristics | ||||
| How long ago diagnosed with food allergies? (years), median (IQR) n=292 | 7 [5.0, 10.0] | 8.0 [6.0, 12.0] | 6.0 [4.0, 9.0] | <0.001 |
| Food allergy, n (%) n=295 | ||||
| Tree nut | 216 (73.2) | 81 (75.0) | 135 (72.2) | 0.60 |
| Peanut | 207 (70.2) | 79 (73.2) | 128 (68.5) | 0.40 |
| Egg | 91 (30.8) | 38 (35.2) | 53 (28.3) | 0.22 |
| Cow’s milk | 76 (25.8) | 31 (28.7) | 45 (24.1) | 0.38 |
| Sesame | 63 (21.4) | 27 (25.0) | 36 (19.3) | 0.25 |
| Shellfish | 42 (14.2) | 17 (15.7) | 25 (13.4) | 0.57 |
| Wheat | 23 (7.8) | 9 (8.33) | 14 (7.5) | 0.79 |
| Fish | 22 (7.5) | 11 (10.2) | 11 (5.9) | 0.18 |
| Soy | 19 (6.4) | 11 (10.2) | 8 (4.3) | 0.047 |
| Other | 65 (22.0) | 26 (24.1) | 39 (20.9) | 0.52 |
| Multiple food allergies, n (%) n=295 | 220 (74.6) | 86 (79.6) | 133 (71.1) | 0.13 |
| Number of allergens, median (IQR) n=295 | 2.0 [1.0, 4.0] | 3.0 [2.0, 4.0] | 2.0 [1.0, 4.0] | 0.03 |
| Ever experienced allergic reaction to food, n (%) n=295 | 269 (91.2) | 100 (92.6) | 169 (90.4) | 0.52 |
| Ever experienced food allergy reaction at school/daycare, n (%) n=269a | 57 (21.2) | 28 (28.0) | 29 (17.2) | 0.04 |
| Ever gone to the ER for food allergy reaction, n (%) n=269a | 166 (61.7) | 70 (70.0) | 96 (56.8) | 0.03 |
| Ever been hospitalized overnight for food allergy reaction, n (%) n=266a | 38 (14.3) | 20 (20.0) | 18 (10.8) | 0.04 |
| Lifetime food allergy reactions treated with epinephrine, median [IQR] n=295 | 0.0 [0.0, 2.0] | 1.0 [0.0, 2.0] | 0.0 [0.0, 1.0] | 0.01 |
| Ever required >1 dose of epinephrine to treat food allergy reaction, n (%) n=141b | 38 (27.0) | 16 (25.0) | 22 (28.6) | 0.63 |
| Symptoms of worst IgE-mediated food allergy reaction, n (%) n=269a,c | ||||
| Skind | 244 (90.7) | 94 (94.0) | 150 (88.8) | 0.15 |
| Gastrointestinal tracte | 186 (69.1) | 75 (75.0) | 111 (65.7) | 0.11 |
| Respiratory tractf | 202 (75.1) | 83 (83.0) | 119 (70.4) | 0.02 |
| Cardiovascularg | 27 (10.0) | 19 (19.0) | 8 (4.7) | <0.001 |
| Neurologicalh | 46 (17.1) | 23 (23.0) | 23 (13.6) | 0.048 |
| Other | 19 (7.1) | 8 (8.0) | 11 (6.5) | 0.64 |
These questions were asked to the 269 participants who answered “Yes” to “Ever experienced allergic reaction to food”
These questions were asked to the 142 participants who indicated ≥1 lifetime food allergy reaction treated with epinephrine
Can select >1 response
Included any of the following parent-reported symptoms: hives, skin itching, skin redness/flushing, skin swelling, rash
Included any of the following parent-reported symptoms: stomach/belly pain or discomfort, nausea, vomiting, diarrhea, loss of bowel control
Included any of the following parent-reported symptoms: nasal congestion and/or sneezing, runny nose, itchy throat/mouth, throat tightness, hoarse voice, wheezing, coughing, trouble breathing, low oxygen level
Included any of the following parent-reported symptoms: low blood pressure
Included any of the following parent-reported symptoms: decreased activity level, passing out
Child and Parent Reports on FA-Related Bullying
Among the 295 child-parent dyads, 36.6% (n=108) reported that the child had ever experienced FA-related bullying (Table 1). There was moderate agreement between children and parents in the report of FA-related bullying (agreement 73.9%, κ=0.47; 95% CI 0.27, 0.68). The reported locations and perpetrators of FA-related bullying according to parents and children are presented in Figures 2A–B. The reported reasons for, methods of, and consequences of FA-related bullying according to children are presented in Figures 2C–F.
Figure 2. Parent and child reported nature and consequences of FA-related bullying.
Parent and child reported locations (A) and perpetrators (B) of FA-related bullying are indicated. Data from the 108 parent-child dyads who selected that the child had ever been bullied due to FA are shown. Child reported reasons for (C), physical (D) and non-physical acts of (E), and adverse consequences of (F) FA-related bullying are indicated. Data from 31 children who reported FA-related bullying are shown. Participants could select more than one response for bullying locations, perpetrators, scenarios, and consequences of FA-related bullying.
Responders versus Non-Responders
Compared with child-parent dyads who responded to the survey question of whether the child had ever been bullied due to FA (n=295), child-parent dyads who did not respond to this question (n=246) had higher prevalence of parent post-traumatic stress disorder (PTSD) (p=0.04), number of food allergens in the child (p<0.01), and prevalence of child egg allergy (p=0.01). Responders versus non-responders did not differ by parent or child age, anxiety or depression diagnoses; child asthma, AD, or prevalence of other FA beyond egg.
Sociodemographic and Clinical Factors Associated With FA-Related Bullying
Compared with children who had not experienced FA-related bullying, children who had experienced FA-related bullying were more likely to have a parent with IgE-mediated FA (16.7% of bullied v. 8.0% of not bullied children, p=0.02) and come from a household at risk of FI (12.0% of bullied v. 2.2% of not bullied children, p<0.001) (Table 1). Children who had experienced FA-related bullying had a higher prevalence of comorbid atopic and mental health conditions including asthma (58.3% of bullied v. 42.8% of not bullied children, p=0.01), AD (63.9% of bullied v. 51.3% of not bullied children, p=0.04), food protein-induced enterocolitis syndrome (FPIES) (6.5% of bullied v. 0.5% of not bullied children, p=0.004), anxiety (30.6% of bullied v. 8.6% of not bullied children, p<0.001), depression (7.4% of bullied v. 1.1% of not bullied children, p=0.006), and PTSD (6.5% of bullied v. 0% of not bullied children, p<0.001) (Table 1). Of all major food allergens, only having FA to soy (10.2% of bullied v. 4.3% of not bullied children, p=0.047) was associated with FA-related bullying (Table 1). Children who had experienced FA-related bullying had more food allergens than those who had not (median 3.0 bullied v. 2.0 not bullied children, p=0.03) (Table 1). FA-related bullying was associated with ever having experienced a FA reaction at school/daycare (28.0% of bullied v. 17.2% of not bullied children, p=0.04), gone to the emergency room for a FA reaction (70.0% of bullied v. 56.8% of not bullied children, p=0.03), and been hospitalized overnight for a FA reaction (20.0% bullied v. 10.8% not bullied children, p=0.04); an increased lifetime number of FA reactions treated with epinephrine (median 1.0 in bullied v. 0.0 in not bullied children, p=0.01); and history of FA reactions with respiratory (83.0% of bullied v. 70.4% of not bullied children, p=0.02), cardiovascular (19.0% of bullied v. 4.7% of not bullied children, p<0.001), or neurologic symptoms (23.0% of bullied v. 13.6% of not bullied children, p=0.048) (Table 1). In the multivariable logistic regression model (Table 2), only child anxiety disorder was significantly associated with FA-related bullying (odds ratio 3.58; 95% CI 1.71, 7.48).
Table 2.
Multivariable regression predicting food allergy-related bullying (n=292)
| Variable | Adjusted Odds Ratio (95% CI) |
|---|---|
| Child age (years) | 1.05 (0.94, 1.18) |
| Child asthma | 1.28 (0.73, 2.23) |
| Child atopic dermatitis | 1.55 (0.90, 2.66) |
| Child anxiety disorder | 3.58 (1.71, 7.48) |
| Years since food allergy diagnosis | 1.04 (0.92, 1.16) |
| Ever experienced food allergy reaction at school/daycare | 1.30 (0.65, 2.60) |
| Ever gone to the ER for food allergy reaction | 1.31 (0.72, 2.41) |
| Ever been hospitalized overnight for food allergy reaction | 2.17 (0.93, 5.09) |
| Lifetime number of food allergy reactions treated with epinephrine | 0.87 (0.72, 1.05) |
Psychosocial Impact of FA-Related Bullying
FA-related bullying was associated with worse psychosocial functioning in both children and parents in all constructs assessed (Table 3). Child-parent dyads who reported FA-related bullying had lower FA-related QOL compared with child-parent dyads in which the child had not experienced FA-related bullying, as measured in the FAQL-PB (mean 2.9 in parents of bullied v. 1.8 in parents of not bullied children, p<0.001), FAIM-PF (mean 4.2 in parents of bullied v. 3.4 in parents of not bullied children, p<0.001), FAIM-CF (mean 4.1 in bullied v. 3.5 in not bullied children, p=0.01), FAQLQ-PF (mean 3.3 in bullied v. 1.8 in not bullied children ages 4–6, p<0.001; mean 3.6 in bullied v. 2.1 in not bullied children ages 7–12, p<0.001), and FAQLQ-TF (mean 5.3 in bullied v. 4.2 in not bullied teenagers, p=0.02) surveys (Table 3). In child-parent dyads who reported FA-related bullying, both children and parents also had higher rates of screening positive for potential presence of an anxiety disorder as measured in the SCAARED (38.9% in parents of bullied v. 24.7% in parents of not bullied children, p=0.01) and SCARED-P (37.8% in bullied v. 15.6% in not bullied children, p<0.001) surveys, as well as higher rates of FA-specific worry as measured in the WAFA2-P (mean 36.6 in parents of bullied v. 21.0 in parents of not bullied children, p<0.001; mean 34.4 in parents of bullied v. 21.4 in parents of not bullied teenagers, p=0.008) and WAFA2-T (mean 30.1 in bullied v. 11.1 in not bullied teenagers, p=0.01) surveys (Table 3). Parents whose child had experienced FA-related bullying reported lower FA-related self-efficacy compared with parents whose child had not experienced FA-related bullying, as measured in the FASE-P survey (mean 78.4 in parents of bullied v. 85.8 in parents of not bullied children, p<0.001) (Table 3).
Table 3.
Parent and child psychosocial well-being by food allergy-related bullying status (n=295 parent-child dyads)
| Psychosocial well-being measure | Score among families who report bullying due to food allergy (n=108) | Score among families who do not report bullying due to food allergy (n=187) | Test statistic (df), where applicable | p-value | ||
|---|---|---|---|---|---|---|
| Number of respondents | Mean (SD), except where noted | Number of respondents | Mean (SD), except where noted | |||
| Parent measures | ||||||
| FAQL-PBa,b | 107 | 2.9 (1.5) | 184 | 1.8 (1.4) | z = 5.97 | <0.001 |
| FAIM-PFa,b | 107 | 4.2 (1.0) | 187 | 3.4 (1.0) | z = 6.20 | <0.001 |
| WAFA2-Pc | ||||||
| WAFA2-P-Child | 67 | 36.6 (21.5) | 107 | 21.0 (19.6) | z = 5.09 | <0.001 |
| WAFA-P-Teen | 27 | 34.4 (24.6) | 28 | 21.4 (21.9) | z = 2.65 | 0.008 |
| FASE-Pa,d | 105 | 78.4 (12.7) | 184 | 85.8 (12.2) | z = −5.32 | <0.001 |
| Elevated SCAARED, n (%)e | 108 | 42 (38.9) | 186 | 46 (24.7) | χ2(2) = 6.53 | 0.01 |
| Child measures | ||||||
| FAQLQb,f | ||||||
| FAQLQ-PF (ages 4–6) | 12 | 3.3 (1.2) | 57 | 1.8 (1.4) | z = 3.21 | 0.001 |
| FAQLQ-PF (ages 7–12) | 60 | 3.6 (1.5) | 92 | 2.1 (1.4) | z = 5.22 | <0.001 |
| FAQLQ-CF | 26 | 4.6 (1.7) | 26 | 4.2 (1.7) | t = −0.94 (50) | 0.35 |
| FAQLQ-TF | 18 | 5.3 (1.3) | 18 | 4.2 (1.3) | t = −2.46 (34) | 0.02 |
| FAIM-CFa,b | 42 | 4.1 (1.3) | 41 | 3.5 (1.0) | t = −2.65 (81) | 0.01 |
| WAFA2c | ||||||
| WAFA2-C | 24 | 27.0 (23.3) | 23 | 17.8 (22.9) | z = −1.48 | 0.14 |
| WAFA2-T | 17 | 30.1 (26.7) | 17 | 11.1 (13.9) | z = −2.59 | 0.01 |
| Elevated SCARED, n (%)g | ||||||
| SCARED-P | 82 | 31 (37.8) | 96 | 15 (15.6) | χ2(2) = 11.35 | <0.001 |
| SCARED-C | 44 | 14 (31.8) | 41 | 6 (14.6) | χ2(2) = 3.48 | 0.06 |
Abbreviations: DF, degrees of freedom; FAIM, Food Allergy Independent Measure; FAQL-PB, Food Allergy Quality of Life-Parental Burden; FAQLQ, Food Allergy Quality of Life; FASE-P, Food Allergy Self-Efficacy Scale for Parents; SCAARED, Screen for Adult Anxiety Related Disorders; SCARED, Screen for Child Anxiety Related Disorders; SD, standard deviation; WAFA2, Worry About Food Allergy 2.0
Only those who responded to every item or are missing only 1 item for this measure were included in the calculation
A higher score indicates worse food allergy-related quality of life
A higher score indicates greater food allergy-related anxiety
A lower score indicates worse food allergy-related self-efficacy
A score of 23 or greater may indicate the presence of an anxiety disorder (cut-off for binary variable)
Only those who responded to every item for this measure were included in the calculation
A score of 25 or greater may indicate the presence of an anxiety disorder (cut-off for binary variable)
Bolded values indicate statistically significant differences between groups
Discussion
To our knowledge, this is the first study identifying specific risk factors for FA-related bullying. In this cohort of 295 children with IgE-mediated FA, the reported lifetime prevalence of FA-related bullying was 36.6%, which is in line with published data.7–15 In comparison, the estimated prevalence of general bullying victimization among US children ages 6–17 years is 22.7% based on data analyzed from the 2016 National Survey of Children’s Health, though this questionnaire was only administered to parents/caregivers.35 Similar to prior studies, we found that FA-related bullying usually occurred in the school setting, was most commonly perpetrated by classmates, and often involved overtly physical acts.8–10,16 While one prior study found significant disagreement between child and parent report of FA-related bullying,10 we found moderate agreement between children and their parents in the reported lifetime prevalence of FA-related bullying. This may have been influenced by our study design, as surveys were administered online and completed first by parents, with children given the option to respond to surveys immediately after parents completed their sections.
We report the novel finding that children who had experienced FA-related bullying were more likely to have coexisting atopic (asthma, AD, FPIES) and mental health conditions (anxiety, depression, PTSD) than those who had not experienced FA-related bullying. There is known to be high prevalence of bullying in children with asthma and AD.36–43 FA, asthma, and AD are all relatively “visible” chronic health conditions and future studies should examine the interplay between these atopic conditions and the mechanisms through which their association with bullying is mediated.
While prior studies have not found an association between history of severe FA reactions or number of food allergens and FA-related bullying,7,11 in our bivariate analyses several markers of FA severity (e.g. going to the emergency room or being hospitalized overnight for a FA reaction, increased lifetime number of FA reactions treated with epinephrine) were associated with FA-related bullying, and children who had experienced FA-related bullying had a greater number of food allergens than those who had not. Additionally, children who had experienced FA-related bullying were more likely to have ever had a FA reaction at school/daycare than children who had not experienced FA-related bullying. Taken together, these novel findings suggest that children with a history of more severe or public FA reactions may be at higher risk of FA-related bullying, perhaps due to greater visibility of the reactions to peers and/or anxiety generated by these reactions. A recent study of parents of children with FA found that children with more severe FA were more likely to experience emotional, social, and psychological harms from bullying, suggesting that this subgroup of children with FA is especially vulnerable.44 However, that study examined the effects of general bullying victimization rather than FA-related bullying, so their results may not be directly relevant to our findings. When discussing patients’ FA reactions in clinic, physicians should enquire about the impact of these reactions on patients’ daily lives, including peer dynamics at school.
Interestingly, specific symptoms of FA reactions were associated with FA-related bullying: respiratory tract, cardiovascular, and neurological symptoms. Symptoms involving these organ systems indicate greater severity of anaphylaxis,45 which could be consistent with our above findings of an association between FA reaction severity and FA-related bullying. It is also noteworthy that many of these symptoms are subjective and overlap with symptoms of anxiety and panic, which are also common in people with FA and may mimic or compound symptoms during allergic reactions.46 Children with FA, their families, and healthcare providers would benefit from allergy-specific, evidence-based information and management skills aimed at helping them discern and effectively manage anxiety.
Noting that children who reported ever having been bullied due to FA were older, had been diagnosed with their FA for longer, and had a higher number of lifetime FA reactions treated with epinephrine compared with children who had not experienced bulling, we hypothesized that child age could be a confounding factor in some of the associations that were found with FA-related bullying. In our multivariable regression analysis including child age, child comorbid health conditions, and markers of FA reaction severity, only an anxiety diagnosis was significantly associated with FA-related bullying. Our study also showed that FA-related bullying is associated with lower FA-related QOL, higher rates of screening positive for the potential presence of an anxiety disorder, and higher rates of FA-specific anxiety in both children and their parents, along with lower parental FA-related self-efficacy. This expands on prior literature showing an association between FA-related bullying and increased anxiety and decreased QOL in children and their parents.11,12 As our study was cross-sectional, the directionality of associations cannot be determined, though many children in our study who had experienced FA-related bullying reported that it had led them to feel anxious or depressed (Figure 2F). It is well-established that there is a bidirectional relationship between internalizing symptoms and peer victimization, where children who are anxious or depressed are more likely to be bullied and bullied children are more likely to experience anxiety or depression.47 We hypothesize that child anxiety may be both a key outcome of and risk factor for FA-related bullying, mediating the association between atopic comorbidities, mental health comorbidities, FA reaction severity, and FA-related bullying. Future prospective cohort studies can evaluate whether the bidirectional relationship between internalizing symptoms and peer victimization holds true for FA-related bullying as well.
Limitations
As our study was cross-sectional, we could not establish causality between sociodemographic or clinical characteristics and FA-related bullying, or between FA-related bullying and psychosocial wellbeing. Surveys were distributed via social media and participation rate is not known as data were not available on the potential participants reached by this survey. Parent responders were primarily mothers, so findings may not be generalizable to other caregivers. It relied on self-report of a healthcare provider diagnosis of FA and other medical and mental health conditions, history of FA reactions, and FA-related bullying, but recall bias should have been similar between case and control groups. Our cohort was majority White, non-Hispanic, higher-income, and from the Northeastern US, which limited power to perform analyses stratified by race, ethnicity, socioeconomic status, or geographic location. Future studies should focus on recruiting participants from more diverse backgrounds, to be more representative of the US population affected by FA and to gain a fuller understanding of how sociodemographic factors may mediate risk of FA-related bullying. It is notable that in this cohort, FA-related bullying was associated with households at risk of FI, consistent with another recent study,48 though the number of households at risk of FI in our study was small.
Conclusion
FA-related bullying is common and associated with certain child characteristics, including coming from a household at risk of FI, having coexisting atopic and mental health conditions—particularly anxiety diagnoses—and having a history of more severe FA reactions. Future prospective cohort studies can help delineate how certain sociodemographic and clinical factors may predispose children with IgE-mediated FA to FA-related bullying, and how FA-related bullying impacts FA-related psychosocial wellbeing. Our findings underline that it is important for allergists and pediatricians to screen at-risk children for FA-related bullying, as it is associated with elevated concerns in other child and parental FA-related psychosocial functioning domains. Children who experience FA-related bullying and their parents would benefit from referral to psychological support services with expertise in the mental health challenges associated with FA. The association we found between FA-related bullying and lower parental FA-related self-efficacy highlights that such psychological support services should ideally be family-centered and include practical guidance to increase parents’ confidence in managing their child’s FA. Ultimately, future research should seek to inform anti-bullying legislation and school policies that address the root causes of bullying to help prevent FA-related bullying and reduce its impact on children and their caregivers.
Key message:
Our study provides critical insights into risk factors for food allergy-related bullying and the relationship between bullying victimization and psychosocial wellbeing. Food allergy-related bullying was associated with having a history of more severe food allergy reactions, coexisting atopic and mental health conditions—particularly anxiety diagnoses, and elevated concerns in other child and parental food allergy-related psychosocial functioning domains. This work is important as it highlights the need for pediatricians and allergists to screen for food allergy-related bullying during clinic visits and offer families appropriate education, guidance, and support around management of food allergy-related bullying.
Funding/Support:
This research is supported by K23 AI143962 (Bartnikas) and K24 AI106822 (Phipatanakul).
Footnotes
Conflict of Interest Disclosures: SHS reports royalty payments from UpToDate and from Johns Hopkins University Press; grants to his institution from the National Institute of Allergy and Infectious Diseases, from Food Allergy Research and Education, and from Pfizer, Inc.; and personal fees from the American Academy of Allergy, Asthma and Immunology as Deputy Editor of the Journal of Allergy and Clinical Immunology: In Practice, outside of the submitted work. All other authors have no conflicts to declare.
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