Looking for studies or articles on the psychological impact of FA on children

Posted on: Sun, 08/01/2004 - 1:55pm
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I am seeking information on the psychological impact of food allergies on children, especially in regards to school. I know Lisa Cipriano Collin's book discusses the stress for parents, but can't remember if it talks about how it affects kids. Any feedback would be appreciated...

Thanks!
Lori

Posted on: Mon, 08/02/2004 - 12:59am
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Joined: 10/07/2003 - 09:00

Did a search in PsychInfo (where most social science articles are listed) and only came up with this, more of a call for needed research then actual impacts. Good luck.
Peanut allergy in children: Psychological issues and clinical considerations.
Subject(s): FOOD allergy in children; CHILD psychology
Author(s): Masia, Carrie L.; Mullen, Kimberly B.; Scotti, Joseph R.
Source: Education & Treatment of Children, Nov98, Vol. 21 Issue 4, p514, 18p
Abstract: Examines potential psychological problems and treatment of peanut allergy in children in the United States. Allergic response to peanut products; Psychological effects of peanut allergy on children and their family; Role of physicians in adjustment to peanut allergy; Behavioral strategies to alleviate anxiety; Treatment of psychological problems due to peanut allergy.
AN: 1835926
ISSN: 0748-8491
Database: Academic Search Premier
PEANUT ALLERGY IN CHILDREN: PSYCHOLOGICAL ISSUES AND CLINICAL CONSIDERATIONS
Contents
* * *
Psychological Issues Associated with Peanut Allergy
Behavioral Interventions
Conclusion
References
Psychopathology Related to Peanut Allergy
Family Adjustment
Peer Relations
School Issues
Adherence to Medical Regimen
Physician Communication
Anxiety Reduction Procedures: Exposure-Based Interventions
Parent Education and Training
Peer Intervention
School Intervention
Psycho-educational Interventions
Physician Training
Abstract
Peanut allergy in children has become a national concern. An allergic reaction to peanuts might include rashes, hives, difficulty breathing, runny nose, gastro-intestinal distress, vomiting, recurrent ear infections, hearing loss, and--in a smaller percentage of children--life-threatening anaphylactic shock. The reported number of children with peanut allergies is growing and has doubled in the last 10 years. In fact, some schools in Massachusetts and New York have eliminated all peanut products from classrooms. Successful management of peanut allergy requires numerous lifestyle changes and may have adverse effects on the psychological well-being of children and their families (e.g., anxiety, difficulties with peers, family disruption). The many issues facing children with peanut allergy were first brought to our attention by a 7-year-old boy, Billy, who came for treatment as a result of psychological complications secondary to peanut allergy. Despite the severity and prevalence of peanut allergy in children, this problem has been neglected in the psychological literature. To facilitate more attention to this area, this paper describes the potential psychological issues related to peanut allergy in children, and discusses how psychologists might help to alleviate these problems.
* * *
Peanut allergy in children is becoming a national concern. It is estimated that between 1 and 3 % of American children exhibit peanut allergy (Ewan, 1996; Sedgwick, 1996), and the number of children affected by this allergy is apparently increasing (Raloff, 1996). For example, 55 out of 60 patients seen at an allergy clinic experienced onset of their allergic symptoms before age 7 years. Peanut allergens accounted for all diagnosed allergies in the first year of life, and 82% of allergies by age 3 (Ewan).
The allergic response upon exposure to peanut products may be the onset of rashes, hives, difficulty breathing, runny nose, gastro-intestinal distress, vomiting, recurrent ear infections, hearing loss, and--in a smaller percentage of children--life-threatening anaphylactic shock (Godbey, 1997). Further, these allergic symptoms may occur as a result of ingesting a minimal amount of products with peanut content, and, in some cases, by simply touching or smelling peanut products (Hunter, 1996). Approximately 100 Americans die from food allergies each year, with the peanut allergen being the most often associated culprit (Ewan, 1996; Sedgwick, 1996).
Due to the potential severity of this life-long allergy, and the frequency with which children are exposed to peanut products (e.g., peanut butter and jelly sandwiches, peanuts at classroom parties, peanut-butter cookies, popular peanut-based candies), there may be significant psychological ramifications for families who have a child with this allergy. The many issues facing children with peanut allergy were first brought to our attention by a 7-year-old boy, "Billy," who came for treatment as a result of psychological complications secondary to a severe peanut allergy. When looking for published information on this topic, we were unable to find literature on the psychological issues associated with this type of allergy. The lack of psychological attention to this problem was particularly surprising given that the prevalence and seriousness of peanut allergy in children has led to the elimination of all peanut products from some classrooms in Massachusetts and New York (Sedgwick, 1996). Therefore, this paper will: (a) describe the possible adverse effects that peanut allergy may have on the psychological well-being of children and their families, and (b) discuss the ways in which psychologists may help to alleviate the problems of children with peanut allergy. As empirical literature on the psychological ramifications of peanut allergy has yet to be published, some of the discussion will be adapted from psychological research on children with asthma, as food-induced allergic and asthmatic responses are alike in that they both entail a (potentially lethal) behavioral reaction upon exposure to an allergen. A case description of our client, Billy, will also be used to illustrate various points.
Psychological Issues Associated with Peanut Allergy
Psychopathology Related to Peanut Allergy
Numerous psychological symptoms can be associated with serious allergy. Internalizing disorders (e.g., anxiety and depression) may be one type of problem observed. Behaviors exhibited by our client, Billy, for example, warranted a diagnosis of obsessive-compulsive disorder (OCD). Billy reported frequent thoughts of being contaminated by peanuts, and was washing his hands and asking his mother for reassurance about safety from exposure to peanuts multiple times per day. He refused to eat any food in closed jars that were positioned near a can of peanuts (even a sealed can), refused to eat food that his mother had prepared if she had consumed peanuts earlier in the day, stopped eating lunch at school, and avoided school personnel--reportedly in case they had been in contact with peanut products. Billy also exhibited enuresis and significant separation anxiety.
Interestingly, children with asthma have also been found to exhibit high levels of generalized and specific anxiety (Bussing, Burket, & Kelleher, 1996; Butz & Alexander, 1993; Kinsman, Luparello, O'Banion, & Spector, 1973; Richards, 1994; Staudenmayer, 1982). Anxiety in asthmatic children has been associated with reports of impaired sleep, nervousness, dizziness, exacerbation of asthma episodes (i.e., increases in hyperventilation), increased emergency room visits, and experiencing "panic" at the beginning of an asthma attack (Butz & Alexander; Forero, Bauman, Young, Booth, & Nutbeam, 1996; Richards; Staudenmayer). Similarly, our client, Billy, experienced early morning awakening, reported that he experienced anaphylactic shock- like behaviors from simply the sight of peanuts, and, as reported by his pediatrician, was experiencing a "disturbing number of emergency situations" in which he had to receive injections of epinephrine.
Allergic reactions to peanut exposure can be traumatic. Many individuals with peanut allergies have had several serious or "near death" experiences. For example, one 10-year-old girl was diagnosed as peanut-sensitive at age 2, after ingestion of peanuts was followed by soreness of the tongue, numbness of the mouth, irritation of the throat, and projectile vomiting (Yunginger, Gauerke, Jones, Dahlberg, & Ackerman, 1983). Dr. Ackerman, Professor of Biochemistry at the University of Illinois at Chicago, described a 24-year-old woman who "had a sufficient number of near death hospital emergency room experiences such that she no longer trusts the guarantees made by restaurants or waiters that a particular dish does not contain peanuts. She carries epinephrine, antihistamines, and a bronchodilator, since avoidance of peanut products, even for an experienced allergic adult, can be difficult" (S. Ackerman, personal communication, July 30, 1996). This example illustrates how conditioned fear may develop in response to stimuli associated with the traumatic experience (e.g., peanut advertisements), possibly leading to intrusive thoughts, worry, increased anxiety when detecting allergic symptoms, and sensitivity to physiological arousal (e.g., avoidance of exercise). These responses have also been noted frequently in asthmatic children (Dahl, Gutafsson, & Melin, 1990). A further possibility is that the children may become fearful of needles or be unable to inject themselves, which might then lead to an ineffective response in emergency situations (e.g., failure to administer epinephrine in response to shortness of breath and approaching anaphylactic shock).
An additional problem that appears to be common in asthmatic children is depression. In a study by Forero et al. (1996), a community-based sample of 4550 asthmatic adolescents reported significant feelings of loneliness, unhappiness, and depression. Similarly, Creer and Kostes (1990) have reported low self-esteem and depression in children with asthma. Thus, depression-related behavior may also be a problem for children with severe peanut allergy.
Another area of concern is overt behavioral excesses. Allergies and asthma have been found to be risk factors for behavioral problems (Gortmaker, Walker, Weitzman, & Sobol, 1990). Sometimes excess behaviors may be the result of parental reluctance to set appropriate behavioral restrictions with a child viewed as "ill." In the case of asthma attacks, which are sometimes triggered by emotional arousal (Tal & Miklich, 1976), parents may fear upsetting the child or feel guilty about the child's distress, and thus be ineffective at ignoring temper tantrums, delivering consequences, and refusing requests made by the child. In Billy's case, for example, a behavioral program was implemented to target his enuresis. After a few weeks of failed attempts at this program, Billy's mother stated that she "didn't want to push him." In addition, Billy's targeted allergic behavior (e.g., excessive avoidance of peanuts) was partially being reinforced, and thus maintained by his environment. For example, Billy's mother carried a pager, and on one occasion Billy paged his mother to come to school after he saw peanuts being eaten in his classroom. Billy's mother arrived, took him to lunch at a nearby restaurant, and he remained out of school the rest of the day. With scenarios such as this, children's allergy and asthma-related behaviors may be either positively reinforced (e.g., getting their way, receiving privileges or attention) or negatively reinforced by escaping from aversive situations (e.g., chores, school).
Family Adjustment
Adapting to life with any food allergy may involve considerable adjustment for both the child and the family. First, parents and their children need to learn new behaviors in order to create a safe environment (e.g., checking the ingredients of all products consumed in the home, teaching the child to avoid peanut products, carrying First Aid equipment, and learning resuscitation and to administer injections). Parents may sometimes view these behaviors as inconvenient or stressful. Billy's mother, for example, reported feeling resentful that she and her husband could no longer enjoy peanuts in their home. She also seemed to have difficulty accepting the severity of Billy's peanut allergy. That is, Billy's mother overtly ridiculed him when he refused to kiss her after she had eaten peanuts and when he declined dinner if she had eaten peanuts prior to cooking. Although Billy's behavior may sound extreme, according to his pediatrician, minute amounts of peanut particles on his mother's mouth or hands could be sufficient to induce an allergic response. Billy's mother also reported being embarrassed to call and ask an airline to remove peanuts from a flight on which Billy was a passenger. These behaviors are particularly important to note as failure of the parents to recognize the potential seriousness of allergic responses, and encourage child compliance, have been implicated in the increased morbidity and mortality among children with asthma (Friday & Fireman, 1988; Gergen & Weiss, 1990; Weiss & Wagener, 1990).
On the other hand, parents may experience significant amounts of worry and stress related to their child's physical and emotional well-being and adjustment. This might especially be true with peanut allergy, given the popularity and availability of this food product. In addition, peanut products are sometimes found in foods in which they would not be expected, or are not included in the list of ingredients in foods that would be supposed safe. For example, a 15-year-old with peanut allergy died after eating a piece of coffee cake that unknown to her contained peanut products (Sedgwick, 1996). Foods such as plain chocolate, that would be expected to be safe, can be dangerous because at the factory it is sometimes touched by machinery that has also had contact with peanut products. Products containing peanuts have also been de-flavored and re-flavored to resemble walnuts, pecans, or almonds, and used as a cheap substitute in many bakery goods, candies, and even certain ice creams (S. Ackerman, personal communication, July 30, 1996; Yunginger, Squillace, Jones, & Helm, 1989).
Worries surrounding child safety may negatively impact both the emotional well-being of parents and their quality of parenting. In a study of asthmatic families (Schulz, Dye, Jolicoeur, Cafferty, & Watson, 1994), parents reported that interference with daily activities and the emotional impact (e.g., worry, fear, concern) were the two greatest areas of personal stress. In addition, parents of asthmatic children have reported higher levels of anxiety than parents of healthy children (Brook, Weitzman, & Wigal, 1991). Parents of asthmatic children have reported being frustrated, drained, terrified, "on pins and needles," unable to sleep, and physically and emotionally drained (Schulz et al.). In addition, parents may restrict social outlets, and experience self-doubt concerning their parenting abilities (Schulz et al.). Safety concerns may also result in an overprotective parenting style (e.g., restricting the child's activities) (Davis & Wasserman, 1992; Richards, 1994). This is particularly problematic as overprotective parenting has been shown to be associated with the development of social difficulties with peers (Masia & Morris, 1998).
Peer Relations
Children with peanut allergy may be at risk for peer relationship difficulties. Several school lunches and party food may contain peanut products; thus, children with peanut allergies can sometimes be excluded from group activities. Billy, for example, had an allergic reaction in his classroom where peanuts were being mixed for a party, and his mother was called to come to the school. After the incident, the parents of the children in Billy's class were notified not to send peanut products for classroom activities. In addition, when students ate peanut butter sandwiches for lunch, Billy chose to eat at another lunch table. These types of events can stigmatize children with peanut allergy, thus leading to isolation from peers. There are also incidents of peanut butter sandwiches being thrown at children with peanut allergy (Sedgwick, 1996).
The literature on the effect of asthma on peer relations is inconsistent. Although some researchers have found childhood asthma to be related to feelings of loneliness and social isolation (Creer & Kostes, 1990; Forero et al., 1996), others have found that children with asthma did not differ from healthy peers on measures of social performance and social skills (Nassau & Drotar, 1995). However, mothers of asthmatic children report being worried regarding how asthma affects or inhibits the participation of their child in peer group activities (Schulz et al., 1994). The impact of peanut allergy on peer relations must be attended to as positive peer relations are related to the quality of later emotional and social adjustment (Cowen, Pederson, Babigian, Izzo, & Trost, 1973; Parker & Asher, 1987).
School Issues
Dealing with a child's allergy in the schools may be problematic and stressful for parents, children, and school personnel. As mentioned previously, peanut products are popular in schools, which makes the school environment a potentially dangerous situation. Analogous to asthma, teachers, administrators, and other nonmedical personnel (e.g., secretaries) are often responsible for managing attacks at school (Eisenberg, Moe, & Stillger, 1993). This type of care is worrisome as many of these individuals do not know what to do if a child has a severe attack (Bevis & Taylor, 1990). In fact, parents reported that teachers who were not informed about medicines or how asthma affects sleep and school performance, isolated asthmatic children from their classmates, made their children run during a wheezing attack, and believed that asthma was not a problem (Schulz et al., 1994). Considering this lack of knowledge by school personnel regarding asthma--which is surprising given that asthma is the leading cause of school absence (Murphy, 1995)-- it is probable that school personnel know even less about the management of peanut allergy. In fact, many schools are unaware of this problem, and unprepared for the severity and speed of the allergic attacks (Sedgwick, 1996).
Adherence to Medical Regimen
Failure to adhere to medical regimens has been repeatedly documented (Becker & Maiman, 1975), and is related to higher morbidity and mortality rates in children with asthma (Friday & Fireman, 1988; Gergen & Weiss, 1990). Nonadherence to medical regimens ranges from 17 to 90% in children and adolescents with asthma (Baum & Creer, 1986; Chryssanthopoulos, Laufer, & Torphy, 1983). In the case of severe peanut allergy, medical recommendations may consist of avoiding contact with all products that contain peanuts, carrying injections of epinephrine (adrenalin), and being able to administer the injections in emergency situations. Individuals with peanut allergies tend to take many risks (S. Ackerman, personal communication, July 30, 1996).
Non-adherence with the recommendations may occur for several reasons. First, the avoidance of all peanut products may be a difficult dietary restriction for children who enjoy peanut products. In addition, as mentioned earlier, it is difficult to avoid peanut products due to their prevalence in the environment. Some of the necessary behaviors (e.g., asking parents not to send peanut products to school, leaving lunch areas where children are eating peanuts, asking if school lunches contain peanut products) may cause social discomfort and embarrassment for allergic children and their parents. Parents and children may also have phobias of needles or feel uncomfortable administering injections. Disruption in family interaction, which can occur due to the stress caused by severe peanut allergy, may also lead to poor control of an illness (Lemanek, 1990). As is found in asthma management (e.g., Rubin, Bauman, & Lauby, 1989), knowledge concerning peanut allergy (e.g., an allergic attack may be triggered by the smell of peanuts) and the associated management behaviors (e.g., the procedure for giving an injection) may be related to whether or not children and families are adherent. Finally, the quality of communication between the physician and patient may be linked to adherence (Deaton, 1985; Schraa & Dirks, 1982).
Physician Communication
The quality of physician communication may be associated with whether or not a healthy adjustment to peanut allergy occurs. According to Billy's mother, when Billy received a skin test for an allergy to peanuts, his arm exhibited considerable swelling. In fact, the pediatrician reported that she had never observed this type of reaction before, and even called in medical residents to observe Billy's reaction. This event was reportedly quite traumatic for Billy, as multiple doctors gathered around him to watch how a drop of peanut substance caused severe irritation of his arm. When the pediatrician subsequently told Billy that "he had a severe peanut allergy and could die," Billy's mother became angered by this type of communication with her son. She reportedly believes that this incident was the reason that Billy developed psychological symptoms related to his peanut allergy. Additionally, the pediatrician had not convinced Billy's mother of the severity of Billy's peanut allergy, and Billy's mother exhibited an oppositional attitude (e.g., continued to keep peanuts in her home) towards the pediatrician's suggestions. Thus, it appeared that physician behaviors at the allergy clinic had dramatically--and negatively--influenced the level of adherence to medical recommendations.
This observed behavior is similar to findings in the asthma literature. Increased adherence has been associated with satisfaction of medical services, perception of physicians as being interested and approachable, and close supervision during outpatient visits (Smith, Seale, Ley, Shaw, & Bracs, 1986; Spector, 1985). Conversely, nonadherence has been related to insufficient and incorrect information regarding the nature of asthma and treatment management, uncertainty about the efficacy of treatment, concern about side-effects of medication, unclear instructions presented in technical terms, and failure to rephrase or repeat instructions (Deaton, 1985; Schraa & Dirks, 1982). In letters sent to the National Allergy and Asthma Network, parents reported being frustrated by physicians due to the following reasons: (a) the physician provided them with conflicting information, (b) the physician did not share their concerns about their child's health, (c) the physician viewed mothers as "overreactive," and (d) the physician did not initiate treatment "because the child was not blue" and did not give them assistance for daily management of asthma (Schulz et al., 1994). As noted by Davis and Wasserman (1992), psycho-educational components of care are often lacking and may only be implemented when a medical crisis occurs.
Finally, many practitioners focus primarily on medication-based treatment and give minimal attention to psychological factors (Davis & Wasserman, 1992). This lack of consideration to psychological issues (e.g., family dynamics, behavior modification, anxiety) is disconcerting as these variables may influence the course of chronic illness in children, and chronic illness may affect the later behavioral adjustment of children (Davis & Wasserman). Physicians often are not informed about how negative psychological outcomes occur or how to prevent adverse effects of illness (Davis & Wasserman).
In summary, there are many potential psychological issues facing both children with severe peanut allergy and their families. Psychologists may be able to implement several interventions aimed at preventing and alleviating the distress associated with this chronic problem. The next section will discuss the potential role for psychologists in helping children with peanut allergy.
Behavioral Interventions
Anxiety Reduction Procedures: Exposure-Based Interventions
Behavioral strategies that are typically used to alleviate anxiety (e.g., self-management, relaxation training, contingency management, and discrimination training) may be helpful in reducing anxiety symptoms accompanying peanut allergy, as these techniques have been shown to be effective in controlling and reducing anxiety-related asthmatic symptoms (e.g., Creer, 1991; Dahl et al., 1990). For example, asthmatic children frequently misidentify an anxiety-related behavior (e.g., hyperventilation) as a representative symptom of an allergic response (Creer), which can then result in unnecessary and undesirable behaviors (e.g., calling mother to school, injection of adrenalin). In addition, some children with asthma experience panic (e.g., becoming fearful and agitated) during allergic reactions. Such anxiety may exacerbate the reaction and lead to requests for increasing amounts of medication (Creer). Conversely, becoming anxious during an allergic reaction may also prevent the performance of the necessary medical procedures to control the response. Thus, relaxation and coping procedures, such as progressive muscle relaxation, abdominal breathing exercises, and distraction, may reduce anxiety symptoms during allergic response to peanuts. This decrease in anxiety may allow children to discriminate signals of an allergic reaction from other anxiety symptoms, remain calm during the reaction, and perform the necessary medical behaviors more efficiently.
As noted above, allergic reactions can be traumatic, and thus conditioned fear or anxiety may develop to stimuli related to an allergic response (e.g., physiological arousal, sight of peanut). This conditioning can lead to allergic reactions that are triggered by conditioned stimuli and result in unnecessary avoidance and restrictions (e.g., social interaction with persons in contact with peanuts in the case of Billy). In addition, children and their parents may develop a specific phobia of needles, or of receiving an injection, thus inhibiting them from executing proper medical care in emergency situations. In these instances, exposure-based interventions might be effective in eliminating anxious behaviors.
One type of exposure-based intervention, systematic desensitization, may be utilized by constructing hierarchies of the situations in which children feel anxious. The child is then taught to relax prior to being exposed, in hierarchical fashion, to the stimuli that elicit fear reactions (e.g., pictures of peanuts, needles). This technique has been shown to be effective at reducing the panic experienced by asthmatic children during attacks (Creer, 1991), and may represent a promising intervention for children with peanut allergy.
In the case of Billy, another exposure technique, direct therapeutic exposure with response prevention, was employed to reduce obsessive and compulsive behaviors related to his peanut allergy. In Billy's case, and perhaps with other children who have peanut allergy, the treatment paradigm had to be somewhat modified as this was not a simple case of OCD or specific phobia of peanuts. That is, some of Billy's avoidant behaviors were necessary (e.g., refusing to kiss his mother after she had eaten peanuts), while others were excessive (e.g., repeated washing of hands). Billy's pediatrician voiced concern that we would eliminate Billy's anxiety to peanut-relevant stimuli, placing him in increased danger of ingesting a peanut substance. Thus, we collaborated with Billy, his mother, and his pediatrician to develop a list of reasonable (e.g., asking adults once whether food items contained peanut products; avoiding direct contact with peanuts) and unreasonable (e.g., avoiding items that have had contact with air-sealed peanut products; avoiding a room where peanuts are being eaten) precautionary behaviors. These behaviors were discussed with Billy and his mother and the reasonable precautions were implemented as "house rules" to follow (e.g., mother could kiss or touch Billy after eating peanuts only after brushing her teeth and washing her hands. with soap and water; Billy would eat the food his mother cooked if she washed her hands after consuming peanuts; Billy would only ask his mother once whether a food item contained peanuts). In addition, modeling, role-playing, corrective feedback, and homework assignments were used to teach Billy to read food labels, and to ask strangers whether peanut products were included in certain foods (e.g., asking a waiter).
To address Billy's unreasonable, phobic behaviors (e.g., not eating a closed package of a safe food when it is near an air-tight, closed jar of peanuts; excessive hand washing), an in-session exposure paradigm was utilized. During several therapy sessions, Billy was taught to rate his fear and anxiety using the Subjective Units of Distress Scale (SUDS). He was then systematically exposed to unreasonable fear-evoking stimuli, such as a sealed jar of peanuts paired with a preferred food item. In one session, for example, Billy was asked to rate his fear/anxiety every minute, concurrent with being asked to consume a preferred food item that had been in contact with a sealed jar of peanuts. Escape from the scene was prevented (having obtained prior consent from Billy and his mother), and exposure was continued until Billy reported a significant reduction in his SUDS ratings.
A strategy that might be used for the child with peanut allergy who develops an avoidance of physiological arousal is exposure to internal cues of arousal, similar to the procedure used in the program developed for panic disorder, Mastery of Your Anxiety and Panic II (Barlow & Craske, 1994). With this technique, the child with peanut allergy would be exposed, in session, to physiological cues similar to those that occur during a fear response. For example, the child might be asked to self-induce hyperventilation or increase heart rate, and be asked to maintain this state until extinction of fear to these internal stimuli occurs.
Finally, it is important to assess for symptoms of posttraumatic stress disorder (PTSD) in children with peanut allergy because being informed of having a life-threatening allergy or experiencing an anaphylactic shock may be traumatic events for children. If PTSD symptoms are present, imaginal exposure might be useful for reducing intrusive thoughts and excessive avoidance of stimuli associated with these traumatic events. This procedure, however, should not be performed to eliminate reasonable checking behaviors that will keep children with peanut allergy safe.
Parent Education and Training
There are several ways in which psychologists can aid parents in coping with severe peanut allergy in their children. First, the response of parents to being informed of this allergy should be assessed. It is important for the practitioner to recognize the occurrence of different types of reactions and advise parents of their significance. Depending on their reaction, parents may need assistance in developing a realistic view of the seriousness of this allergy for their child. For example, Billy's mother was reluctant to acknowledge the severity of Billy's peanut allergy (e.g., continued to eat peanuts in their home) and treatment required reframing her view of Billy's condition. On the other hand, some parents may benefit from help with avoiding parental overprotection (e.g., prohibiting a child from eating with other children in the lunch room). As with parents of children with asthma, unnecessary limitations and restrictions may need to be eliminated (Richards, 1994).
Parents may also need assistance in adjusting to and performing necessary behavioral changes to keep their child safe. For example, Billy's mother reported being embarrassed to call the airline and request that they eliminate peanuts from their flight. She also had difficulty eliminating peanuts from the household. Thus, Billy's mother was provided with support for these behaviors and alternative plans for adapting to these changes (e.g., keeping peanuts in a separate cabinet from all other products at home; washing hands after eating or handling peanuts). Parents also may have difficulty administering injections to their children. In these cases, parents might practice giving injections in session to props (e.g., dolls), or their anxiety may be reduced via systematic desensitization. In addition to other first aid equipment, parents of food-allergic children should be advised to stock injections of epinephrine and administer these promptly to prevent anaphylactic shock (Hunter, 1996).
Another important area for psychologists is to assist parents with effective implementation of contingency management procedures. That is, parents might benefit from assistance in setting appropriate behavioral limits, recognizing and limiting reinforcement of allergic-related behavior (e.g., leaving the child at school after assessing that everything is normal), and providing reinforcement for appropriate or healthy behavior. In addition, reinforcement can be used for adherence to the medical regimen (e.g., avoidance of peanut products, asking if peanut products are in school lunch, timely injection of epinephrin). In the case of Billy, therapy sessions involved a significant amount of discussion with Billy's mother of setting behavioral limits. For example, we worked with Billy's mother to help her learn not to reinforce Billy's excessive amounts of recruiting reassurance that food items were safe. Interviews with Billy and his mother had indicated that Billy's reassurance-recruiting behaviors were being maintained by a considerable amount of social attention. Thus, we worked with Billy's mother to implement a "one checking-question" policy, whereby she only responded to the initial question about food safety, and ignored all other identical questions. In addition, Billy was taught alternative methods to recruit his mother's attention (e.g., "Mom, can we talk?"), and Billy's mother was encouraged to reinforce these replacement behaviors (see Scotti, Mullen, & Hawkins, 1998).
A final note about parent education is worth mentioning. Although peanut allergy is thought to be related to genetic factors, it is also suspected that a contributing factor is exposure to peanuts before full development of the immune system occurs--at approximately age 3 (Godbey, 1997; Raloff, 1996; Sedgwick, 1996). Thus, parents may be able to prevent the occurrence of peanut allergy by simply eliminating peanut products in their child's diet before age 3 years (Godbey). Additionally, concerned parents with young children might be encouraged to have their children tested for susceptibility to the peanut allergen. With such preventative measures available to families, psychologists might make an important contribution by disseminating such information about risk factors and diagnostic screening to parents expecting babies.
Peer Intervention
As discussed earlier, it is possible that children with peanut allergy will have difficulty with peer relations and experience significant social isolation. Social skills training may be one intervention useful in teaching these children more effective skills for achieving successful social interactions. In addition, these children might develop significant anxiety in social situations due to the stigma associated with peanut allergy (e.g., being teased at school) and the aversive nature of social events. In these instances, cognitive-behavioral interventions shown to be effective for treating social anxiety in children (e.g., exposure, cognitive restructuring) may be indicated (see Albano & Morris, 1998; Kendall & Treadwell, 1996; Silverman & Kurtines, 1996).
Finally, peer-mediated interventions have been used for problems related to social isolation. Socially withdrawn children, for instance, are paired for "play intervention" sessions with same-gender outgoing and socially-skilled peers in the home or school setting. This approach has been empirically supported with early elementary-aged children (Albano & Morris, 1998; Morris, Messer, & Gross, 1995), and may prove useful with children with allergy-related social withdrawal and anxiety.
School Intervention
Schools can play a large role in dealing with a child's peanut allergy as this is the environment where a child spends most of his or her day. Psychologists can help to educate school personnel about the many facets involved in managing severe peanut allergy. Additionally, parents can be assisted with handling school problems that may arise.
Schools must be aware of the health risk of having peanut products in the classroom. Some schools, such as the Breck School in Minneapolis, have required that peanut butter and jelly sandwiches be eaten at separate tables (Sedgwick, 1996). Both the Bradstreet Early Childhood Center in North Andover, MA and the Trinity School in New York have eliminated all forms of peanuts from the classrooms (Sedgwick). Young children at day care and at preschool cannot protect themselves, and thus personnel must be made aware of these issues.
School personnel should be advised of a child's medical problem and be provided with specific recommendations. For example, a note might be sent to all parents at the beginning of the school year requesting them not to send peanut products to school. Medication should be readily available for the child if needed for acute symptoms, and school personnel should learn how to administer injections. School personnel might ensure that the child does not accidentally consume peanut products at school, such as in the school cafeteria. In general, every effort should be made to keep the child in school, and thus situations that could lead to peanut allergen exposure should be minimized. Teachers should be alerted to possible interpersonal problems the allergic child may encounter with classmates. Efforts by school personnel to increase the knowledge of healthy pupils at school concerning allergy may lead to greater tolerance (Nassau & Drotar, 1995). Frequent communication between parents and school is essential (Richards, 1994). Eisenberg et al. (1993) developed an educational program to teach school personnel about asthma, and a similar intervention is needed to ensure the appropriate management of children with peanut allergy.
Psycho-educational Interventions
In addition to providing education to school personnel, psycho-educational programs for children with peanut allergy and their parents may also be beneficial. Psycho-educational interventions for children with asthma and their parents have been shown to be helpful in the management of asthma (Brook, Mendelberg, & Heim, 1993; Persaud et al., 1996). That is, these programs have been associated with increased adherence to the medical regimen, reductions in anxiety and symptoms of illness, decreased number of attacks, decreased emergency room visits and hospitalization, and improved school attendance (see Davis & Wasserman, 1992). It is likely that these programs would also be helpful for children with peanut allergy.
The components of psycho-educational interventions used for asthma seem likely to be applicable for peanut allergy. Modified from psycho-educational programs for asthma (Creer, 1991), an educational intervention for peanut allergy might include all or some of the following components: general information regarding peanut allergy; learning to recognize an attack or discrimination skills; learning to manage an attack or self-management skills; teaching effective communication skills between children, parents, physicians, and school personnel; teaching lifestyle behavior change; and teaching parental contingency management. Creer provides a detailed description of these methods as they apply to the asthmatic child; however, they will be briefly reviewed here to illustrate their potential application to the child with a peanut allergy.
The first step in assisting families in learning how to cope with peanut allergy should involve the provision of general information given to the parents and child about the nature of peanut allergy and its management. Families should be provided with factual information that explains the importance of following both medical and behavioral recommendations. In addition, the negative side-effects of adrenalin, the typical medical management strategy, can be discussed.
Teaching the child symptom discrimination--the detection of symptoms of asthma (and the ability to discriminate asthmatic responses from other physiological responses) by the patient-- is another important component of the psycho-educational package. By accurately perceiving respiratory changes, patients can initiate treatment and abort attacks while still in the early stages. This skill is important because when symptom discrimination is delayed, exacerbation of an ongoing attack may occur. Skills in discriminating symptoms can be enhanced by teaching patients to self-observe and/or self-monitor both public and private (e.g., physiological) events. That is, patients learn to perform a functional analysis of allergic attacks. Conducting a functional analysis includes attending to the antecedents correlated with the precipitation of asthmatic respiratory change, identification and implementation of the behavior needed to correct the maladaptive respiratory change, and identifying the consequences of their action (e.g., reduction or no reduction in asthmatic responses). Such an analysis helps teach the child to prevent unwanted attacks, and to perform effective actions, thoughts, or behaviors in response to antecedent stimuli, thus leading to more desirable consequences. This increased understanding may also enable children to more effectively educate nurses, parents, and physicians about typical antecedents of attacks.
Self-management behaviors may include participating in imagined rehearsal to develop strategies to manage attacks, practice of relaxation techniques, and problem-solving. Patients must consider a variety of possible solutions to asthmatic reactions and select the most appropriate choice to resolve relevant issues. Parents may be encouraged to provide ample opportunities for rehearsal of management skills and to reinforce independence in self-management. Children may also be taught to recruit reinforcement for themselves following correct implementation of management skills.
Finally, helping to establish and implement behavioral or lifestyle modifications is another important part of psycho-educational programs. Behaviors that might be relevant for the child with peanut allergy include the following: (a) learning reasonable checking to avoid peanut products, (b) developing behavioral plans for different situations during unexpected exposure to peanuts (e.g., peanuts placed on table at friend's party), (c) learning to carry and use first aid equipment, (d) ways to ask others if peanuts are included in food items (e.g., in restaurants), and (e) methods to inform others about the seriousness of the allergy.
Physician Training
Psychologists can enhance the care that is given to children with peanut allergy and their families by helping physicians to improve doctor/patient communication. First, psychologists can train physicians to educate parents and children in the most optimal manner for avoiding maladaptive reactions in families (e.g., excessive fear or stress reactions). In addition, psychologists should encourage physicians to allow for sharing of information, and support in managing the psychosocial impact of illness (Davis & Wasserman, 1992). These interactions might allow for important discussions with parents, such as the identification of products that are potentially harmful to their children (e.g., peanut butter, Reese's Pieces(R), peanut M& M's(R), and all other products with peanut ingredients including things like Chinese food due to the use of peanut oils). Finally, physicians must be trained to pay attention to important aspects of comprehensive care such as asthma knowledge, skill in self-assessment and self-care, obstacles to treatment adherence, frequency of emergency room visits, school days missed, developmental needs of patients and families, and behavioral adjustment (Davis & Wasserman). Treatment for both psychological factors affecting illness and adjustment problems secondary to illness should be made accessible (Davis & Wasserman). The employment of behavioral psychologists in allergy clinics may be one method of ensuring that comprehensive services are made available to patients and that physicians are sensitive to the psychological issues associated with peanut allergy.
Conclusion
In conclusion, peanut allergy in children is becoming a significant health concern, and there are many potential psychological consequences to consider. Psychologists may play an important role by addressing the psychological aspects or issues that confront children with peanut allergy. Psychologists can work with children, parents, school personnel, and pediatricians to facilitate adjustment to the peanut allergy. Relevant issues may include anxiety, life-style changes, compliance to a medical regimen, behavior problems, difficulties with peer relations, and parental reactions. However, empirical research will be necessary to substantiate the potential psychological implications of peanut allergy outlined in this paper, as well as to delineate the most effective methods for working with these children and their families and care-givers.
Author note. Correspondence concerning this article and reprint requests should be addressed to Joseph R. Scotti, Department of Psychology, West Virginia University, Morgantown, WV 26506-6040. This work was supported by the facilities of the Quin Curtis Center for Psychological Services, Research, and Training, in the Department of Psychology at West Virginia University.
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~~~~~~~~
By Carrie L. Masia; Kimberly B. Mullen and Joseph R. Scotti
Copyright of Education & Treatment of Children is the property of ETC and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Source: Education & Treatment of Children, Nov98, Vol. 21 Issue 4, p514, 18p.
Item Number: 1835926
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Posted on: Mon, 08/02/2004 - 1:04am
Chicago's picture
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There are two good articles in the summer "Living Without" magazine.
One is specifically peanut related "Shell Shocked" which is a interview with a young man about his PA and the other is called "Who's the Boss" and it discusses how to teach children the importance of avoiding certain foods w/o creating phobias.
Living Without is a magazine for people with allergies and food sensitivities. I usually buy it a Whole Foods or the health food store. Their web site is [url="http://www.LivingWithout.com"]www.LivingWithout.com[/url]

Posted on: Mon, 08/02/2004 - 1:22am
Nick's picture
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I can't speak for the effect on children, as I have none - and have never actually spoken to any children who suffer any allergies. I do know a couple with intolerances : and they cope just fine.
I *can* vouch that when *I* developed PA / TNA / sesame allergy as an adult (of, ahem .... 40 years+), it had a pretty darned profound effect on me!! It made me "down", scared - even "paranoid" ... and it took some time for those feelings to diminish.

Posted on: Mon, 08/09/2004 - 9:15am
packrat's picture
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I wanted to do my master's thesis on this very topic but it was not approved. email me and I will forward you my references:
[email]georgie.ferguson@umontana.edu[/email]

Posted on: Mon, 08/09/2004 - 4:02pm
Driving Me Nutty's picture
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Quote:Originally posted by Chicago:
[b]There are two good articles in the summer "Living Without" magazine.
[url="http://www.LivingWithout.com"]www.LivingWithout.com[/url] [/b]
Chicago, thanks for posting as I never heard about this magazine. I liked one of their on line featured articles also.

Posted on: Mon, 08/16/2004 - 11:00pm
Lovey's picture
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A very comprehensive article.
It's a pleasure to see more thoughtful and independent research, than what has mostly been available.

Posted on: Tue, 08/17/2004 - 12:49pm
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Quote:Originally posted by Schnook:
[i]Did a search in PsychInfo (where most social science articles are listed) and only came up with this, more of a call for needed research then actual impacts. Good luck.
Peanut allergy in children: Psychological issues and clinical considerations.
Subject(s): FOOD allergy in children; CHILD psychology
Author(s): Masia, Carrie L.; Mullen, Kimberly B.; Scotti, Joseph R.
Source: Education & Treatment of Children, Nov98, Vol. 21 Issue 4, p514, 18p
Abstract: Examines potential psychological problems and treatment of peanut allergy in children in the United States. Allergic response to peanut products; Psychological effects of peanut allergy on children and their family; Role of physicians in adjustment to peanut allergy; Behavioral strategies to alleviate anxiety; Treatment of psychological problems due to peanut allergy.
AN: 1835926
ISSN: 0748-8491
Database: Academic Search Premier
PEANUT ALLERGY IN CHILDREN: PSYCHOLOGICAL ISSUES AND CLINICAL CONSIDERATIONS
"Adapting to life with any food allergy may involve considerable adjustment for both the child and the family. First, parents and their children need to learn new behaviors in order to create a safe environment (e.g., checking the ingredients of all products consumed in the home, teaching the child to avoid peanut products, carrying First Aid equipment, and learning resuscitation and to administer injections). Parents may sometimes view these behaviors as inconvenient or stressful. Billy's mother, for example, reported feeling resentful that she and her husband could no longer enjoy peanuts in their home. She also seemed to have difficulty accepting the severity of Billy's peanut allergy. That is, Billy's mother overtly ridiculed him when he refused to kiss her after she had eaten peanuts and when he declined dinner if she had eaten peanuts prior to cooking. Although Billy's behavior may sound extreme, according to his pediatrician, minute amounts of peanut particles on his mother's mouth or hands could be sufficient to induce an allergic response. Billy's mother also reported being embarrassed to call and ask an airline to remove peanuts from a flight on which Billy was a passenger. [b]These behaviors are particularly important to note as failure of the parents to recognize the potential seriousness of allergic responses, and encourage child compliance, have been implicated in the increased morbidity and mortality among children with asthma (Friday & Fireman, 1988; Gergen & Weiss, 1990; Weiss & Wagener, 1990).............[/b]"
[/i]

Posted on: Tue, 08/17/2004 - 12:54pm
MommaBear's picture
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Joined: 09/23/2002 - 09:00

linking.
[url="http://uumor.pair.com/nutalle2/peanutallergy/Forum3/HTML/000206.html"]http://uumor.pair.com/nutalle2/peanutallergy/Forum3/HTML/000206.html[/url]

Posted on: Tue, 08/17/2004 - 12:56pm
MommaBear's picture
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linking something else too.....
[url="http://uumor.pair.com/nutalle2/peanutallergy/Forum1/HTML/005283.html"]http://uumor.pair.com/nutalle2/peanutallergy/Forum1/HTML/005283.html[/url]

Posted on: Tue, 08/17/2004 - 7:27pm
williamsmummy's picture
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Joined: 03/26/2002 - 09:00

the anaphylaxis campaign UK published a study on children with diabetes and peanut allergy.
it was a small study, but the peanut allergic children where the only ones to worry about the safety of their food and dying. the diabetes children were more concerned with portion size!
please click on there web site , and also try the 'latest news ' section'
sarah

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