FAACT's Roundtable

Ep. 268: The Teen Brain and Food Allergies

• Season 5 • Episode 268

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We all know the teen brain is still growing and changing—and that means it doesn’t always think or act like an adult brain. The teen years are full of discovery, independence, and yes, a bit of risk-taking. But what happens when you add food allergies into the mix? How do brain development and decision-making affect how teens manage their safety and choices?

To help us unpack this fascinating topic, we’re joined by renowned psychologist, Nancy Rotter, PhD, who will share insights into how the teen brain works—and how parents, caregivers, and educators can better support young people navigating life with food allergies.

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Caroline: Welcome to FAACT's Roundtable, a podcast dedicated to navigating life with food allergies across the lifespan. Presented in a welcoming format with interviews and open discussions,

each episode will explore a specific topic, leaving you with the facts to know or use.

Information presented via this podcast is educational and not intended to provide individual medical advice.

Please consult with your personal board certified allergist or healthcare providers for advice specific to your situation.

Hi everyone, I'm Caroline Moassessi and I am your host for the FAACT Roundtable Podcast. I am a food allergy parent and advocate and the founder of the GratefulFoodie Blog.

And I am FAACT's Vice President of Community Relations.

Before we start today's very interesting conversation,

I just want to pause for just a moment to say thank you to DBV Technologies for being a very kind sponsor of FAACT's Roundtable Podcast.

Please note that today's guest was not sponsored by DBV or compensated in any way by the sponsor to participate in this specific podcast.

Caroline: Podcast we all know the teen brain is still growing and changing, and that means it doesn't always think or act like an adult brain. The teen years are full of discovery and independence and yes, a bit of risk taking.

But what happens when you add food allergies into the mix? How do brain development and decision making affect how teens manage their safety and choices?

To help us unpack this fascinating topic, we're joined by renowned psychologist Dr. Nancy Rotter, who will share insights into how the teen brain works and how parents, caregivers and educators can better support young people navigating life with food allergies.

Welcome, Nancy, to FAACT's Roundtable podcast. We're absolutely delighted and thrilled you're here because you are going to bring information that we all desperately need.

Dr. Rotter: Thank you for having me today, Caroline.

Caroline: You are very welcome. Before we dive in, let's help our new listeners get to know you. What is your background? And then how did you find your way into this field?

Dr. Rotter: Thank you for asking. So I have been actually working as a child psychologist for over 35 years,

but I developed an interest in the intersection between mental health and medical illness fairly early in my career after working with children who were coping with a variety of medical conditions, including food allergies.

This led me to take a new path and to work in hospital settings with children with a wide range of medical illnesses, along with their caregivers. And in 2010, I actually had the opportunity to join a newly developing multidisciplinary team at the Food Allergy center at Massachusetts General Hospital,

where I continue to work and I work collaboratively with a team of allergists, nurses, nurse practitioners, and nutritionists,

and my work really focuses on conducting quality improvement projects, but primarily providing psychological treatment to children, teens, families, and their parents or caregivers. Coping with challenges related to food allergies.

Much of my work focuses on anxiety about having food allergies, but also coping with procedures related to food allergies, including oral food challenges coping with food allergy treatment interventions such as oral immunotherapy and needle anxiety related to worries about epinephrine injections, as well as treatment with biological agents such as Xolair.

Caroline: I love that you have the full breadth of our allergy life from diagnosis and food challenges. That's a real challenge for parents and caregivers, dealing with the little ones and then treatments and so forth.

You know, we're telling our families and our children, you can't eat this, it could kill you. And then we're like, but come on, let's go have a little bite now,

right?

So there's a whole lot behind that.

Dr. Rotter: Absolutely.

Caroline: To kick things off, let's talk about the teen brain itself. What makes it unique? And then how does it differ from a child's brain or an adult brain?

Dr. Rotter: That is a really important question.

During adolescence, the the brain is actually in transition.

It is highly plastic, so that means it's malleable and open to shaping by experience.

And during this time, there's increased activity in the reward areas of the brain known as the limbic system, that includes the amygdala, which is where emotions originate.

And this creates increased sensitivity to several things,

rewards,

novelty,

and emotions.

In contrast, the frontal lobes of the brain, and particularly the prefrontal cortex,

which is the area of the brain that provides the inhibitory function and controls things like decision making,

planning, regulation,

and future orientation, is not yet fully developed.

And that actually continues to develop into someone's early or mid-20s.

Thus, the wiring of the teen's brain is such that they are prone to engage in risky behaviors,

even when they have the awareness that this may not be a good idea. For example, teens may get their driver's license,

drive fast,

even though they know that may not be a good choice. And that's just part of how a teen brain works.

Additionally, being with peers increases the reward activation system for teenagers, which can contribute to teens engaging in more risky behaviors when they are with their friends.

Although we know that by the age of 16,

teens have the cognitive capacity of adults, the lag in the development of the prefrontal cortex results in these Risky behaviors. This is completely developmentally typical and is actually expected as a result of brain development.

And finally, and I think most importantly is that because the brain is highly plastic at this stage,

both negative experiences and, and positive experience,

which can include things like supportive environments or skills development,

can have an impact on shaping the brain.

Caroline: Thank you for this really important explanation because I think as parents and caregivers who deal with teens,

that's what's so confusing. Because cognitively you see this really bright student or this really bright youth, and then they make this ridiculously crazy adult choice that doesn't even make sense.

But now this actually makes sense. And this explains why we can have two different flavors, I should say, of a person.

Dr. Rotter: Right. Different parts of the brain develop at different rates. And it does cause this mismatch, in a sense, between impulse control and risky behaviors coupled with really the intellectual cognitive level of an adult.

Caroline: I love this explanation.

So now that we understand a little bit more about how the teen brain works,

how does that development impact the way teens manage their food allergies and make decisions? So now let's focus in on our food allergy world.

Dr. Rotter: Absolutely.

So there's several ways that the teen brain development impacts food allergy management and decision making. You know, as we know,

adolescents is a time for increased independence. It's a time where adolescents are making decisions about so many things,

including food and food choices. And developmentally, teens in this age group are spending more time outside of the home and the family.

They're spending time at school and activities with friends,

maybe they start driving, perhaps they've gotten a job. And so they really are spending much more time away from the family and making independent decisions.

As teens become more independent, they really are much more fully in charge of their food allergy management.

They have the responsibility for eating when they're not at home, at activities, at friends homes, at restaurants.

And that requires the use of self management skills, reading labels, informing restaurant staff, carrying their epinephrine.

And all of these things are really significant when we think about the teen brain. And all of these things are important because as I noted earlier, risk taking is increased.

The reward and emotional parts of the brain, like the amygdala have not yet developed and lag in development behind those parts of the brain, like the prefrontal cortex, that are the stop and think functions and that help with inhibition.

So teens are more likely to act in response to reward and they may be less careful with food allergy management as a result. You know, maybe they're not reading labels as diligently as they should be.

And a third component is considering peers and friends and peer perception,

because teens also are in a stage of their lives where they are more concerned about what peers think,

perhaps, than their family. And then if you add another component that peers may have some social anxiety. All of these things can impact safety behavior. So the issue of risk taking is combined with concerns about what peers think.

And that might interfere with things like feeling comfortable asking at a restaurant or informing the restaurant staff about their food allergies, or not speaking up when they need help.

Another factor that comes up when we're thinking about peers and teenagers and relationships is things like experimentation with alcohol or intimate kissing. And these are times that may also be impacted in a different way for those who have food allergies than teens who do not have food allergies.

Caroline: Hearing this makes me realize how hard it is just to be a teenager. And then when you add in food allergies, that's a whole nother layer.

But I guess what really has me clicking away is coming. Could our children develop better coping skills so maybe by the time they do get to adulthood,

does this help with coping skills?

Dr. Rotter: That is a really good question. And so there's several ways that parents and caregivers can support teens with food allergies during this time. Keeping in mind that positive experiences can impact the developing brain and collaborating with teens and supporting their problem solving skills.

Skills are really key to address. What you just mentioned and is something I think about all the time, is that it's really important for parents and caregivers to start early by building their child's food allergy self management skills, by building their confidence, their independence long before they reach the teen years.

Teaching, modeling, supporting age based allergy self management strategies throughout childhood and the prediction preteen years really creates the strong foundation so that these things really become in many ways kind of like muscle memory that is really key.

So starting before,

long before your child is a teenager is really an important piece, you know, and that might mean even when they're very little, modeling, label reading, oh, let's see if this food is safe for you.

We're going to read the ingredients even before the child is able to read so that they are learning that this is just part of the process.

Demonstrating to children how you inform staff at restaurants or using chef's cards,

carrying their epinephrine device and knowing how to use it.

These things that have a strong foundation can really help with the teen by the time they get to the teenage years.

And I think continuing that is really important. Once they're teens.

I see a lot of kind of preteens who are in the middle school kind of,

and they are spending more time outside of the home. And there are ways that parents and caregivers can really scaffold their experiences. I'll give you an example. I have recently worked with a teen who really wanted to go out to eat.

We have early release days in my neck of the woods here in the kind of greater Boston area.

Sometimes it's once a month.

And the middle schoolers really like to go into the town, if their school is near a town, and kind of walk around and to stores and get something to eat.

And so one of the preteens I worked with recently wanted to be able to do this. And so his mother figured out what were some of the kind of restaurants or places that he might be able to eat given his food allergies.

And after figuring that out, they actually practiced going to these places. First, she modeled the skill informing the staff about the child's food allergies. And the second time they went, he was in charge of that.

The third time, after he felt comfortable, the parent backed off.

There was a friend there with him. And eventually there was a parent sitting kind of at a table away from where the child and the friend were sitting to practice that and rehearse it.

So he would feel confident and comfortable in using these skills when he was with his friends after school.

A second thing I think is really important is educating teens about their developing brains.

You know, knowledge is power, as we say,

and it really sets the stage for normalizing that they're going to make mistakes. And I'll talk more about that later. But that is such an important piece.

Encouraging things like what we call coping ahead, which is mentally preparing for stressful situations,

and another term which we call reverse planning, which is looking at a situation that you want to be in and then backing up and figuring out what you need to do to be able to be in that situation.

These kinds of things support development and enhancement of positive skill development during this period when the brain is plastic. These are good things to be doing.

So things like reviewing the use of emergency medication or the epinephrine device. You know, I find a lot of times teens have never needed epinephrine, but now they're going out on their own.

And so they really need refreshers,

how they use it,

even problem solving about how to carry their emergency medication. Some of the smaller devices, like the AVI Q or the new nasal epinephrine Nephi are small and can fit in pockets pretty easily.

But sometimes those devices aren't available to people based on what their insurance covers. And so figuring out how someone can carry these devices comfortably,

I've had a lot of kind of young men agree to carry what they call cinch bags, which is like a little teeny, lightweight, kind of almost sporty bag that they're willing to carry with them.

But that can be a challenge.

Practicing strategies to remember the epinephrine device is also really important. I actually learned from someone I worked with a really good strategy that they used, which is they used Apple Airtags.

They put the Apple airtags on the epinephrine device because teens always have their phones with them. So if they leave the house without their device, they get some notification or a sound to remind them.

And I thought that was a really smart intervention that I have recommended to other people based on what I've heard from a family I worked with.

In terms of coping ahead,

a way to do that is to run through examples,

things like let's imagine that your friends decide to change plans and instead of going to a pizza restaurant where they had gluten free pizza that you could eat,

they're going to a restaurant that doesn't have that. What options do you have? What do you want to do? And sort of thinking through it, you know, letting the teenager kind of lead and kind of think through it with you.

Do they want to suggest maybe we could go to another restaurant? Do they want to come up with a plan to look at the menu at that restaurant and see what they might be able to eat there?

But helping them problem solve and thinking ahead is really helpful.

And then I had mentioned reverse planning. So it's looking at what's the goal and then backing up and figuring out what you need to get to that goal. So one example might be, let's say a teenager wants to go camping with their friends and they're going to go and spend one night in a tent.

So we have to kind of think about,

okay, so how are you going to reach that goal? You need to think about what food you're going to bring. You need to think about your friends understanding and knowing about your food allergies and about if there were to be an emergency, you know, how close is the nearest hospital,

thinking through all the details of that to really imagine how can this be successful and then sort of backing up to, okay, so what do I need to be able to make sure I'm, you know, I can go and be safe and have a good time.

So third,

the role of friends.

As I mentioned, and as we all know, friends,

peers are central to a teen's life.

And given where brain development is for teenagers, friends are very rewarding, often for teens. So we want to keep that in mind.

We also know it's protective for teens to have friends who know about their allergies, who are accepting, who are understanding, who can provide emotional support, but also can be helpful if there is an emergency situation.

As I was referencing before with the example of going camping.

A recent paper published by one of my colleagues, Melissa Engel, and her colleagues raises a really important piece too, and that's the construct of social anxiety impacting food allergy management.

We know that a lot of children and teenagers are fearful of having a reaction which is really scary.

Many are fearful of needing epinephrine. Many are fearful, particularly when there was just only the needle option, fearful of needles. But when we think about other types of things that teenagers can be anxious about,

it's normal for teenagers to have some social anxiety.

And so that could lead to avoiding social situations or fear of telling friends about their food allergies,

or even embarrassment about eating a different food or speaking up in a restaurant to self advocate.

So really thinking through those things and helping teenagers role play and rehearse so that they are prepared for dealing with challenging situations.

Additionally helping teenagers to kind of develop initiation skills, which is easier for some than for others. And this is more general, kind of beyond food allergy specific, but relates to food allergies because that can really promote self advocacy as well.

So being the one to set up social plans or direct activities can really help to put a teenager with food allergies in a situation that feels safe and comfortable. For example, if a teenager getting together with friends and said, hey, let's, you know, let's go to the park and do pick up basketball.

And they do it in the middle of the day. And so the get together is really round and 10,

rather than going out for a meal or for something to eat, or someone said, hey, why don't you come over and we'll, you know, give each other manicures.

That initiation and kind of getting ahead of things can really be helpful so that there's a situation that would be comfortable for the teen and they wouldn't have to worry as much about how do I handle situations where there may be lots of unsafe food.

It helps them to get ahead of the situation so they can be in a place that they're doing something fun. With their friends and they're not having to worry about eating or about managing a place where there's a lot of unsafe food.

Fourth,

providing teams with data about allergy related challenges so that they can be informed about safe practices and risks. And this is sometimes things that, well, parents are a little hesitant to talk about.

I'm talking about experimentations with drugs that and alcohol and intimate kissing. So that can be kind of difficult for parents and caregivers to talk with teens about. And I really, really encourage parents and caregivers to partner with their teens.

Allergy professional to help figure out how to best talk with teens about this,

I will tell you. One of the nurses I work with who has been in allergy nursing for a very long time uses the length of time someone is there for a food challenge to be able to really talk with teens about these things.

She refers to it as teen boot camp.

And she, you know, asks the teen if they'd like to talk about it alone or with the parent in the room and then spend some time talking with them about this, which I think is a really nice thing.

So it's really important for teens to know the research, the data on the risks of intimate kissing because studies suggest that waiting several hours after the partner is has eaten a meal that contains allergens and eating another meal that doesn't contain allergens reduces the detectable salivary allergen and is more effective than things like a partner brushing their teeth before kissing.

It's really helpful and again, hard for many parents to have these conversations with their teens. But it's also really hard for teens to talk to somebody they might be kissing because that might be a spontaneous activity.

So it's really important to be thinking about this, but also to make sure that you have epinephrine with you, that you have your treatment in case there is an accident due to risk.

So the research on alcohol use in particular is mostly on adults and not on adolescents. But it suggests that alcohol may be what's considered a CO factor in allergic reactions.

So it's one factor that impacts or increases reactions.

There are other CO factors as we know, which can be risk taking, eating out, having an illness, or exercising. So it's always important to consider CO factors. But adolescents may be new to experimentation with alcohol, so it's really important they know about its risk.

Certainly alcohol can impair decision making, it reduces inhibition and might increase risk taking. So being aware of that's really important.

There's some suggestion that it may also be a biological cofactor that alcohol may increase gut permeability and histamine release so that it would lower the threshold for a reaction and that would mean that it might make it more likely for a smaller exposure to become significant.

Again, it's so important for teens to know about this and to know about the overlapping factors. All of those things are very important.

And again, if it's something that feels hard to talk about,

really engaging your allergy professional or your allergy team to help with this.

And then finally, I just want to say that it's so important to expect and normalize mistake making.

It is really important to have these conversations to keep the lines of communication open.

So many times anxious and well meaning caregivers tell teens, just simply don't do that thing, don't drink.

And unfortunately, that tends to shut down communication, meaning that if they do decide to do it, then they don't talk about it.

So instead really providing the information and getting teens to think about it and also giving them messages such as, look, if you're in a situation where you feel like, you know, you're at risk or you've made a mistake,

having a backup plan or safety plan is really important. A lot of families I know have a code like it could be an emoji or it could be a phrase that signals to the parents that the teen texts to the parents that they need help and they need to be picked up.

It could be, you know, I've, I've had, you know, teens have codes like, I have a headache, I need to come home now. And the parent can pick up the teenage and often giving them some space and asking details, allowing them to share with you.

But hopefully the lines of communication have been left open so they can talk with you about what happened or if they made a mistake.

Normalizing risk is also important.

Everyone engages in risk every day of their life. You get in a car,

that's risky. We manage risk in a car. We wear seatbelts, presumably, we drive safely,

we change our behavior depending on the weather, we drive more safely in the snow. Or maybe we decide not to drive in the snow.

But I think we need to think about risk for food allergies generally in the same way. But there's that, that next level when we're talking about teens and risk and then, you know, when possible,

always great to focus on prevention, you know,

having knowledge, knowing about risks, doing all these things that we've been talking about.

But also important is having your backup plan, is having your epinephrine with you.

Caroline: Nancy, these are powerhouse suggestions. I'm so happy you brought up the alcohol and kissing because that is so awkward and so difficult and something that most of us have never dealt with.

That was incredible.

And I love the term reverse planning. I am going to use this. My kids are 22 and 27 and we're just going to use this for the rest of our lives now because that is such a brilliant strategy that also encompasses a lot of the other strategies.

So this is just incredible pragmatic information.

Dr. Rotter: I really appreciate it.

Caroline: I know our listeners appreciate it. So before we say goodbye today, is there anything else you would like listeners to hear from you?

Dr. Rotter: I guess the only thing that I would add is if you as a caregiver or parent or your teen is struggling coping with food allergies related to anxiety or to some of these issues that are pretty specific to the teen brain,

don't hesitate to ask your child's allergist, your child's pediatrician,

for mental health referrals to get some additional support.

Caroline: Well, thank you very much. We really appreciate you taking time out of your busy life and busy day to spend with us to empower us with this incredible strategies and information that will help us help our families and all the teens in our life with food allergies.

So thank you so much.

Dr. Rotter: So much. It's my pleasure, always a pleasure to talk with you, Caroline, and to be on the podcast. So thanks for having me.

Caroline: Thank you. You're welcome.

Caroline: Once again, I would like to say thank you to DBV Technologies for being a very kind and generous sponsor of FAACT's Roundtable Podcast. Please note that today's guest was not sponsored by DBV Technologies or compensated in any way by the sponsor to participate in this sponsor specific podcast.

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