Sunday, May 20, 2012

Conditioning Our Food-Allergic Children

Thank you to everyone who supported my last blog post. I did not expect my opinion to be popular and was really touched by the support I received. ("Mom! There really ARE people in the world like me!")

However, as always, there were critics. The main criticism seemed to be: "we NEED horror stories in order to keep our children safe."


What we're talking about is conditioning. We all do it as parents from almost the day our children are born:

Say thank you, darling.
Don't wipe your snot on your hand! Use a tissue!
Quit hitting your brother!

(Well, o.k., some of you probably condition slightly differently than I do.)

Food allergy conditioning takes both positive and negative forms:

1. Avoiding food. No casual sampling at grocery stores. No unknown cake at parties. Smile politely and nibble the parsley at buffets. Get only a soda if your friends go to a restaurant. We teach our children to delay gratification every single day in a world filled to the brim with temptations. The question is: do all children have the same capacity for delaying gratification (i.e., avoiding allergenic foods)?

The video above documents the famous "Stanford Marshmallow Experiment" in which children ranging in age from 4 to 6 are offered a marshmallow. If they can wait until the researcher returns, they're promised TWO marshmallows.

About 70% of children tested do not eat the marshmallow. And  guess what  later in life, their ability to delay gratification correlated with higher SAT scores and general school success.

So what does this mean for us allergy mothers? Children can be conditioned to avoid foods/delay gratification. However, continuous reinforcement is required for many kids. Most will give up the Halloween candy if the promise of the toy they're trading it for is large enough and talked about enough, and if they have developed enough natural ability to wait. But a large percentage simply cannot wait. They are hard-wired to have more trouble. If you have one of these children, you're going to work twice as hard and twice as long at conditioning avoidance as other mothers, and there may be a genetic set-up that simply makes your child more impulsive, no matter what you do.

2. Checking ingredient labels. Read every label, every time. That seems so straightforward! So why do children so often turn that into "read labels when a food looks different"?

My mother, the clinical psychologist, tells me that this is a brain immaturity issue. Grouping objects ("I know all pretzels are safe") is the way they develop a manageable frame of reference for the world. However, that frame of reference is being continually refined. By kindergarten, most kids can group objects using two variables ("pretzels that are safe for me" vs. "pretzels that are not safe for me"). However, the sets and subsets of safe foods and ingredients can be very complex, meaning that children have a difficult time consistently grouping items until well into grade school ("Newman's Organic pretzel rods that are safe for me vs. Frito Lay RoldGold pretzel twists that are not safe for me).

Reading a label also requires a number of skills we don't even think about as adults. We know that ingredients make up foods, and that foods that look the same can have very different ingredients. We need to have the vocabulary and spelling skills to be able to interpret difficult ingredients. We need to understand grammatical rules of punctuation and grouping (e.g., "soy flour" vs. "soybean oil, flour"). We need to hunt for information that appears in different places, without dependable patterns. We need to consider somewhat esoteric factors ("was this chocolate manufactured in Europe where labeling rules are different?"). We may need to understand whether a food is regulated by one agency vs. another (such as the FDA/USDA division in the U.S.). We need to double-check our work.

So, in addition to conditioning our children to read labels, we also need to teach these skills sets, some of which are not fully in place until the teen years.

3. Carrying medication. A teen boy's pathological need to avoid carrying anything that looks even REMOTELY like a purse and a teen girl's pathological need to fashionably fit with her friends makes this one a project for all of childhood. It isn't just about forgetting. It's also about image, which means it needs to be renegotiated as the child's self image changes.

It seems like a good idea to get our children used to wearing their medicine on a belt or clipped pouch at an early age. But, social issues quickly creep in. Teasing about the "bulge", changing for jr. high gym class, fashion...all can make our kids toss our careful conditioning out the window.

We can look for the obvious opportunities to help our kids blend in. A set of medication in the school backpack is easy. A bag on the back of a bike is usually acceptable. An Epi in a coat pocket, or cargo shorts. But conditioning our children to always carry medication usually means conditioning them to carry it in the same way every time. That's where parents of teens run into trouble.

And, conditioning requires reinforcement. In the marshmallow study, kids get the marshmallow. When it comes to carrying medication, there is no marshmallow. Kids have to consistently do something that has no reward, and often has a social consequence from their perspective. It's easy to see why carrying meds becomes a flash point.

Interestingly, the best defense against risky behavior seems somewhat counterintuitive: arguing with your teen. A recent study showed that effective, give-and-take arguing with parents actually helps kids resist peer pressure. In situations where mothers continually reasserted their view and the teen backed down, the teens were later MORE likely to take risks than in situations where mothers listened to their teen's opinion and ceded some autonomy. In other words, teens who agree with their mothers the most are also the ones most likely to ditch their medicine bags once they leave the house.

I don't think there are any easy answers on this one. A bad reaction can help reinforce the need to carry medication, but that's a very dangerous method of training. Perhaps the e-cue epinephrine device (supposedly coming to market in November) will make a difference for our kids.

I suppose the point of this post is to question the practice of using anaphylaxis deaths as a means to reinforce conditioning. If you look at these three areas where conditioning is required, brain development and acquisition of skill sets is also required. No amount of fear is going to help a child learn the complexities of label reading, or learn to group object sets faster. And, as I pointed out in my post about exaggerating food allergies, constantly harping on death, a consequence a child is often developmentally unable to process, can cause a child to become desensitized and overly pessimistic.

We can make our kids feel helpless and hopeless with horror stories. Or, we can give them the training and conditioning they need to effectively manage their allergy, along with a positive outlook and belief that they can manage their allergy.

Isn't it time to limit the ghost stories to the family campfire? Much better to spend the time on label reading, appropriate avoidance and carrying meds so we can ALL safely enjoy the s'mores.

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