We found that 31.5% of children who suffer from FA in a specialty clinic in New York report that they were bullied or harassed related to the FA, which frequently involves threats with food, and 45.4% report bullying or harassment due to any reason. It is difficult to compare our results to those that were reported in other studies of bullying, both because of the variable methods that are used to measure bullying as well as because of the unique characteristics of our sample. The rate reported in a study that used a similar measure to ours in school-age children in Norway was 31.8%.9
Population studies using different methodologies revealed bullying rates of ~17% to 35%,7,9–11,14
which should be compared with our reported rate of 45.4% of bullying for any reason. Although we acknowledge the limitation inherent in comparing between different methodologies or demographics, our findings suggest that food-allergic children who were seen in our clinic were bullied or harassed more frequently, as compared with the general population.
This finding, although alarming, is not surprising, given that children with FA have a vulnerability that can be easily exploited (ie, by a threat to throw the offending food item at the child), in addition to any additional vulnerability that they may have. The prevalence of bullying in children with special health care needs in the United States was reported to be 42.9%,26
which is consistent with our finding. We further found a clear association between reports of bullying, increased distress, and lower QoL, both for children and for their parents, and this association was independent of the severity of the allergy. Bullying related to FA was associated with as much decline in QoL and distress as any other type of bullying in our sample (it is a significant threat).
We found that repeated bullying is associated with lesser QoL and more distress in the victim as compared with less persistent bullying, but less frequent incidents were still associated with reduced QoL and distress as compared with no bullying at all. Since even infrequent bullying was associated with lower QoL, we believe that one should not wait for incidents to repeat to address them, a point that is increasingly recognized by the US legislature.12,13
In our sample, when children were bullied, their parents reported more distress and lower QoL. Interestingly, when the child was bullied but the parents did not know about it, the parents’ distress level was lower and their QoL was better as compared with parents who did know. This suggests that knowledge that their child is harassed, not the harassment itself, is the important determinant of parental QoL. Conversely, we found that children’s QoL is better, and their anxiety less pronounced, when their parents knew about the bullying. This result lends empirical support to the recommendation that to reduce the impact of bullying one should “Help the child identify bullying as well as how and to whom to report it.”27
The κ statistic indicated a weak agreement between parents’ and children’s reports about bullying for reasons other than FA, and a better (moderate) agreement regarding FA-related bullying. But even a moderate agreement is not reassuring: in victims of FA-related bullying, parents were still unaware of child-reported bullying ~50% of the time in our sample.
Several limitations of our survey must be acknowledged. First, although self-reported information about bullying is commonly used,10
self-reports may introduce bias. Our study elicited self-reported bullying by parents and their children, but we were not able to ask for independent verification from teachers or other students. Second, although we tried to separately look at bullying for any reason and bullying related to FA, there is a risk that some respondents, especially young children, may not have been able to distinguish between the 2. Our “incomplete” rates (reported in the tables), although low, may be related to this complexity. Third, although this is a representative sample of our FA referral clinic, the respondents’ demographic mix is not representative of the general US population, and they may overall represent a more severe phenotype of FA. For example, the finding that Hispanic patients were more likely to report bullying in our survey suggests a relationship between ethnicity and bullying, but a broader ethnic representation is required to verify whether such an association in fact exists. Fourth, we do not have a control group of children who are not food-allergic but demographically similar to ours; therefore, comparisons that we present between our results to those observed with children without FA may be incomplete in that those other studies might have enrolled children whose baseline demographic characteristics are different from our cohort.
Notwithstanding those limitations, we found that bullying related to FA was common in our sample and is associated with decreased QoL and increased distress in both parents and the targeted children. We also found that much of this bullying remains unknown to parents, but that when parents do know, children report a better QoL and less anxiety. We found that bullying is a significant problem in children with FA who were seen in our clinic. Our clinic population is skewed toward more affluent white families, who would be expected to be less vulnerable to bullying.28,29
It is, therefore, likely that our findings, alarming as they may already be, may still underestimate the true rate of bullying experienced by food allergic children. There is a need to increase the likelihood that children disclose bullying; clinicians might consider asking a screening question about bullying during encounters with children with FA.