The protocol helps children overcome phobias related to their food allergies

06 November 2021

5 minutes to read

Source / Disclosures


Dahlsgaard KK. The phobia of anaphylaxis and its impact on daily life: Identification, management and intervention. Presented at: ACAAI Annual Scientific Meeting; from November 4 to 8, 2021; New Orleans (hybrid reunion).

Disclosures: The authors do not report any relevant financial disclosures.

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Allergies do more than trigger physical reactions. They can also have a psychological impact, including crippling fears of life-threatening reactions such as anaphylaxis.

Psychologist Katherine K. Dahlsgaard, PhD, addressed these questions at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting at its conference titled “Anaphylaxis Phobia and its Impact on Daily Life: Identification, Management and Intervention”.

Dahlsgaard and nurse practitioner Megan Lewis, CRNP, are the co-founders of the Food Allergy Bravery (FAB) Clinic at Children’s Hospital of Philadelphia. During sessions at the FAB Clinic, children are safely exposed to allergens via ‘bravery challenges’, allowing them to overcome their fears.

Healio spoke with Dahlsgaard and Lewis to learn more about these anxieties and how to overcome them.

Healio: What is the Difference Between Routine Caution and a Real Phobia when it comes to anaphylaxis?

Katherine K. Dahlsgaard

Dahlsgaard and Lewis: A little anxiety is normal and healthy for children with food allergies, as anxiety in small doses reminds them to be careful when encountering new foods. The vast majority of children with food allergies do well and lead fairly happy and healthy lives. In contrast, the mark of excessive anxiety is identified by a child’s behavior. When a child engages in chronic and medically unnecessary avoidance of foods and social situations that involve food as the primary coping strategy to relieve anxiety, they are at risk of developing an anxiety disorder, namely the specific phobia of anaphylaxis.

Healio: How can this phobia interfere with maintenance and treatment?

Megan lewis

Dahlsgaard and Lewis: The phobia of anaphylaxis can interfere with many facets of life. It can impact socialization, family events, school, and certainly even medical care. Patients and families with this problem are often reluctant to consider dietary diagnostic tests to confirm if they are truly allergic. They may request additional testing, which can lead to unnecessary avoidance, and develop fears of allergic reactions as a result of tests such as skin tests. In terms of the general treatment of allergy, we focus on the fact that patients should avoid consuming food or exposing it to a mucous membrane. Many patients believe in the myths surrounding their food allergy – about the risk of occasional contact with allergens, the airborne risk when not cooked, and disbelief about specific peanut oils and their safety. .

Healio: How can this phobia affect the quality of life?

Dahlsgaard and Lewis: When children with food allergies (or their parents) chronically avoid situations in which the risk of accidental ingestion of allergens is very low, such as being in the same dining room with children who eat the foods they want to eat. they are allergic, all family members may feel temporary relief which inadvertently leads to increased anxiety. Even when avoidance becomes excessive and interferes with daily functioning, it may appear “functional” if the child does not experience an anaphylactic reaction. Risk assessment is becoming more and more flawed, and the family vigilance required to maintain this level of avoidance encourages an anxious concern for worst-case scenarios.

In our clinical practices, we see children who will not try new (and utterly delicious!) Foods, even when an ingredient check confirms they do not contain their allergen, or who will not eat out. or who won’t. t attend parties or sleepovers, even when caregivers have taken prescribed precautions to ensure their safety. These children then miss many joys of childhood, and it is so unnecessary!

Healio: Do these phobias persist into adulthood?

Dahlsgaard and Lewis: This is often the case, and excessive fears of cross-contamination will cling to a child as they develop into their teens and when they leave home as an older teenager. . The main developmental achievement of adolescence is identity formation, and their fearful habit of limiting themselves can really compromise that. In our therapeutic practices, we have encountered adolescents who do not go on a school trip overnight or on vacation too far from home. The joy of traveling and seeing other places and other people that teenagers really love is taken away from them by their fear. We see teens who put themselves at risk for an eating disorder because they are unnecessarily restrictive about what they eat. I see children who are terrified of going to college. They have such a compromised view of their own ability to navigate the world, just at a time when they deserve to feel hopeful and confident. It’s very sad.

Healio: How do bravery challenges help alleviate these anxieties?

Dahlsgaard and Lewis: The technical term for bravery challenge is exposure. Exposure seems like a horrible thing, as people equate it with ingesting the allergen. But in psychology, especially in the treatment of evidence-based anxiety, exposure is a very good thing because it refers to gradual exposure to things or safe situations that a person nonetheless avoids because of. anxiety. Think about children with a phobia of dogs. They need systematic, supervised, and safe exposure to dogs to learn for themselves that dogs are not dangerous.

We use strategic and gradual exposures to things or situations that are safe enough that a child completely avoids or experiences with dread. These proximity exposures include the odor challenge, where we smell allergens. During the grocery store challenge, the child and parents go to a grocery store and choose a food that they have avoided eating that is safe. In the tactile challenge, children touch their allergen and then wash their hands. They learn to be confident that they are a proficient hand washer and that hand washing absolutely works to remove protein from their hands.

Healio: Have you codified these protocols?

Dahlsgaard and Lewis: When we started the FAB clinic, there was a lack of effective evidence-based measures and treatments for these children. Previously, when allergists tried to assess anxiety in children with food allergy, they used generic measures of anxiety that never mentioned the food allergy. The results were at times contradictory and confusing, possibly because there was no measure of anxiety specific to the disease.

Our goal was to improve evidence-based assessment and treatment. We then designed the first specific anxiety measure for food allergies, the Food Allergy Anxiety Scale, or SOFAA, and validated it. It is available free of charge to any physician or clinician online at

Healio: Do you have any plans to promote these strategies?

Dahlsgaard and Lewis: We are about to publish a document on the results of the treatment in which we performed this treatment in groups. We put children with food allergies and excessive anxiety and their parents into groups. We then did these bravery challenges together in session and sent them home for their homework and asked these families to come back the next week and do more. These families have had incredible success. We used standardized measures for the results and saw reductions in symptoms. We are going to manualize this treatment, and our hope is to be able to train other practitioners across the country.

Exposure is the active ingredient in treating anxiety disorders, but research shows that only 10-30% of community therapists use exposure, and most of them worry that exposure is too frightening for them. child, exposure will ruin their relationship with the child or that is a nasty thing to do. None of these things are true. We have excellent evidence from several randomized controlled trials that children can tolerate and benefit from exposures just as much as adults.

It is very difficult for parents to access good exposure treatment providers for any anxiety disorder, and providers who perform exposures involving food allergies are even rarer. Even the most seasoned exposure therapists are very concerned about exposures around food allergies. This is because therapists are people too. That’s why we want to go and train people in food allergy centers across the country because the exhibition works so well with these families, and it works so well with our patients.

Healio: In addition to the challenges of bravery, is there anything else this doctors can to do to mitigate the effects of these phobias and improve care?

Dahlsgaard and Lewis: Any clinician practicing general allergy practices, including physicians, advanced practice providers, and nurses, should dedicate time to diagnostic and follow-up visits for food allergy education. Spending a few extra minutes debunking myths and reducing fears surrounding the allergen can really have a big impact. Clinicians should also consider using screening measures to assess and referral for anxiety surrounding food allergy, as many may not feel comfortable bringing up their concerns or daily difficulties during their annual visit. .

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