Teaching Children to Identify and Avoid Food Allergens using Behavioral Skills Training

Quiroz, M. J., Schnell-Peskin, L. K., Kisamore, A. N., Watkins, J. D., & Vladescu, J. C. (2023). Teaching children to identify and avoid food allergens using behavioral skills training. Journal of Applied Behavior Analysis, 56(3), 565–574. https://doi.org/10.1002/jaba.999

Reviewed by: Melisa Dennis, PsyM, and Robert H. LaRue, PhD, BCBA-D, Graduate School of Applied and Professional Psychology, Rutgers University

Why research this topic?

Teaching Children with autism to Identify and Avoid Food Allergens

Photographed by Pixabay (pexels.com)

Severe food allergies represent a significant concern for adults and children across the United States. In fact, about 8% of school-aged children in the United States have food allergies (Gupta et al., 2011). Children with severe food allergies are primarily dependent on their caregivers for their safety needs (Burks et al., 2012). This presents a significant challenge for caregivers as it is nearly impossible for parents to monitor their children continuously. A longitudinal study following children with severe food allergies indicated that 58% of children had accidentally ingested the allergenic food after a 5-year follow-up and 75% had done so at a 10-year follow-up (Vander Leek et al., 2000). Severe food allergies can be especially concerning for caregivers as they rely on school administrators, teachers, and food management staff when they are in educational settings (Dupuis et al., 2020). These concerns extend to community settings as well where peers and other parents may need to be aware of these allergies and ensure the safety of children with food allergies. As concerning as these issues are, the literature regarding the avoidance of food allergens remains underdeveloped.

There have been several studies showing that it is possible to teach children safety skills and protect them from potentially dangerous situations using behavioral skills training (BST). BST includes four primary components, including, instructions, modeling, rehearsal, and performance feedback. These training steps are repeated until the person being trained is able to demonstrate the skill independently (Miltenberger, 2008). BST has been used to teach children other safety responses related to firearms, abduction lures, and suspicious packages. The purpose of the current investigation was to use similar procedures (BST) in naturalistic environments (i.e., in-situ training; IST) to teach neurotypical children to identify food allergens by reading food labels and engaging in an appropriate safety response.

What did the researchers do?

Three elementary-aged children aged between seven- and nine-years-old participated in the study. All three children were neurotypical and had severe food allergies. All three were allergic to peanuts and two of the three children were severely allergic to tree nuts. All intervention procedures were conducted in the participants’ elementary school. All three participants could follow simple three-step directions sequentially and recognize written allergens on a food package label. The experimenters first tested each child’s performance before any training to determine if they were able to engage in the safety responses before intervention. They did this by exposing the participant to the food and food packaging while engaging with leisure materials (e.g., completing a word puzzle). None of the participants were able to reliably demonstrate the safety responses before training.

The food packaging and labels used for the study were created by the experimenter in partnership with a company specializing in food packaging. The food packages were created and not purchased from the store. Creating original food labels ensured that the participants did not have prior exposure and consequences with the labels that could have coincidentally taught them how to respond in the presence of the items. The food labels were individualized to each child’s specific allergy (i.e., packaging with peanuts listed as an ingredient). It should be noted that the food packages and food items used in the study were never in contact with actual food allergens to maintain each child’s safety. The labels on the food packages used were presented in one of three formats: a.) after a “contains” statement on the label (i.e., “contains [allergens],” b.) within the ingredients section, c.) after a “produced” or “manufactured” statement (e.g., “manufactured in a facility that also processes [allergen].”

A three-point scale was used to measure how the participants responded in the presence of a food item that had allergens listed. The three safety responses included a) looking at the food label, b) telling an adult, and c) not consuming the food if an allergen is listed on the label. Safety responses were scored as completely correct when all three steps were carried out by a participant in any order. Safety responses were scored as partially correct if only one or two safety responses were demonstrated. A participant would receive a score of zero if the participant did not engage in any of the safety steps.

The authors then implemented BST (i.e., instructions, modeling, rehearsing, and feedback) to teach the children the three safety responses. After training, the experimenters evaluated the effectiveness of BST by placing the children in the same baseline condition (i.e., in the presence of the food/food container). The experimenters also incorporated generalization sessions to assess whether the participants could engage in correct responding across new people, different food containers (novel training material), and in other locations.

What did the researchers find?

Prior to BST, none of the participants reliably engaged in the three safety steps in the presence of allergenic foods. In fact, all participants ate at least one of the food items when an allergen was listed on the container. It is worth noting again that all of the food items used in the study were safe for particpants to consume. Following BST with in-situ training, all the participants demonstrated the three safety steps in the presence of an allergenic food label. In addition, two participants were able to demonstrate complete safety responses using novel food items (items that were not used during training) in a setting outside of the training context, with a novel school staff member. One of the participants failed to demonstrate the complete safety response during the initial trials of these generalization sessions, and additional feedback was needed. Regarding the nonallergenic foods presented, all participants responded appropriately by reading the food label and refrained from reporting that they were allergic. This differentiated responding indicated that their safety responses occurred because they were able to discriminate the writing on the package (i.e., presence or absence of allergen on the food label).

What are the strengths and limitations?

The current investigation is an important addition to a small group of studies demonstrating that BST and in-situ training are effective for teaching safety responses. It is the first study to demonstrate that it is possible to use these procedures to teach safety responses to neurotypical elementary school children who were at risk for consuming food to which they were allergic. A strength of the current study is that the researchers used performance-based measurements to train and assess individuals to manage their own allergies. An important implication of this performance-based method is that it allows young children with food allergies to remain safe when close supervision is not available.

The authors did note some limitations that could be addressed in future research. First, the allergenic foods used in the current study were presented in a relatively contrived manner (i.e., poured onto a plate). The authors noted that future researchers might consider different presentation formats alongside other non-allergenic foods in more naturalistic formats (e.g., different packaging, presenting the food in a buffet format, having foods handed to them, or eating food alongside other children) to enhance generality. The authors also noted the fact that they used contrived reinforcers, rather than naturally occurring reinforcers could limit the generality of the findings as well. Finally, while the researchers trained across multiple types of food packaging in the study, only one experimenter and one location were used for the training.

What do the results mean?

The results of the current study show that the use of BST in conjunction with IST is efficacious for teaching safety responses to children. More specifically, the results of this study support the use of BST and IST as a treatment package to teach children with severe food allergies how to identify food allergens on food packaging and avoid such allergens. It is important to note that further research would be needed to assess the extent to which these outcomes can be replicated with children on the autism spectrum.

Citation for this article:

Dennis, M., & LaRue, R. H. (2024). Research synopsis: Teaching children to identify and avoid food allergens using behavioral skills training. Science in Autism Treatment, 21(03).

References

Burks, A. W., Tang, M., Sicherer, S., Muraro, A., Eigenmann, P. A., Ebisawa, M., Fiocchi, A., Chiang, W., Beyer, K., Wood, R., Hourihane, J., Jones, S. M., Lack, G., & Sampson, H. A. (2012). Icon: Food allergy. The Journal of Allergy and Clinical Immunology, 129(4), 906–920. https://doi.org/10.1016/j.jaci.2012.02.001

Dupuis, R., Kinsey, E. W., Spergel, J. M., Brown-Whitehorn, T., Graves, A., Samuelson, K., Epstein, C., Mollen, C., & Cannuscio, C. C. (2020). Food allergy management at school. Journal of School Health, 90(5), 395–406. https://doi.org/10.1111/josh.12885

Gupta, R. S., Springston, E. E., Warrier, M. R., Smith, B., Kumar, R., Pongracic, J., & Holl, J. L. (2011). The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics, 128(1), e9–e17. https://doi.org/10.1542/peds.2011-0204

Miltenberger, R. (2008). Teaching safety skills to children: Prevention of firearm injury as an exemplar of best practice in assessment, training, and generalization of safety skills. Behavior Analysis in Practice, 1(1), 30–36. https://doi.org/10.1007/BF03391718

Vander Leek, K. T., Liu, A. H., Stefanski, K., Blacker, B., & Bock, S. A. (2000). The natural history of peanut allergy in young children and its association with serum peanut-specific IgE. The Journal of Pediatrics, 137(6), 749–755. https://doi.org/10.1067/mpd.2000.109376

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