Infectious Disease

Novel therapy reduces food allergy anxiety among children

September 30, 2022

5 min read


Dahlsgaard and Lewis report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.


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Key takeaways:

  • Food Allergy Bravery is a brief, novel, manualized intervention based on cognitive behavioral therapy that targets children with anxiety related to food allergy.
  • Interventions involve graded proximity exposures to allergens, coaching strategies, problem solving and relapse prevention.
  • Results showed significant decreases in anxiety and increases in quality of life with results maintained 2 to 4 months after therapy had ended.

Anxiety related to food allergy among children goes beyond being nervous in uncontrolled environments where triggers may be encountered, and current therapies may fall short of addressing the specific needs of these patients.

But a novel intervention resulted in improvements in anxiety scores and quality of life as measured by validated questionnaires with gains maintained at follow-up, according to a study published in Annals of Allergy, Asthma & Immunology.

Source: Adobe Stock

“Food allergy anxiety is too much of a good thing,” Katherine K. Dahlsgaard, PhD, ABPP, a pediatric anxiety specialist in private practice, told Healio, adding that appropriate caution and following established protocols keeps people safe.

Katherine K Dahlsgaard

“But these kids are so afraid of cross-contamination that they are avoiding things where the risk is very, very low. They’re avoiding going to birthday parties. They’re avoiding trying new foods. They’re avoiding eating in the lunchroom. Some kids are so afraid that they don’t even go to school,” she continued.

Patients with clinically impairing anxiety related to food allergy (FAA) experience poorer health-related quality of life (HRQOL), greater condition-specific burdens and poorer allergy management, the researchers said. These patients also may even delay or refuse oral food challenges or immunotherapies, the researchers continued.

Cognitive behavioral therapy typically addresses anxiety via graded exposures to avoided situations, the researchers continued, but these tests are not ideal for patients with FAA, who require specific situations pertaining to their allergens. The Food Allergy Bravery (FAB) protocol aims to address these shortcomings.

“By creating this protocol, we’ve been able to incorporate this really specific treatment into the medical setting, which typically in the past would only have been in a mental health setting,” Megan O. Lewis, MSN, RN, CRNP, pediatric nurse practitioner in food allergy and program manager of the Food Allergy Center at Children’s Hospital of Philadelphia (CHOP), told Healio.

Megan O. Lewis

“So, we’re able to focus just on exposures around food allergies to help increase comfort and socialization around food,” Lewis added.

The study involved 10 children aged 8 to 12 years (mean age, 10.12 years; standard deviation, 1.47; 80% girls) who had been referred by their allergists for evaluation and treatment of FAA.

These children and their parents completed questionnaires including the Scale of Food Allergy Anxiety, Child-Related and Parent-Related (SOFAA-C and SOFAA-P); Screen for Child Anxiety Related Emotional Disorders Child Report and Parent Report (SCARED-Child and SCARED-Parent); Food Allergy Quality of Life Questionnaire Parent Form (FAQLQ-PF); and Treatment Satisfaction Questionnaire. Also, a psychologist used the Clinical Global Impression (CGI) scale to measure progress.

An initial evaluation appointment that lasted between 1 and 2 hours measured the severity of each child’s FAA and suitability for group treatment. FAB then involved between five and eight proximity exposure sessions with each patient and with family members as appropriate.

During these sessions, which ran for 30 to 45 minutes and were conducted by an allergy practitioner or mental health provider, participants experienced graded, evidence-based proximity exposures to their allergens that have been proven not to produce reactions.

“Lots of kids are afraid that if they can smell peanut butter, that means they are going to have an allergic reaction. So, what we do in sessions is we have them smell their allergen,” Dahlsgaard said.

“We have kids practice touching their allergen and washing their hands so they find out that they can’t go into anaphylaxis if they touch their allergen,” she said. “They learn they can be competent hand-washers and that works to remove allergens from their hands.”

In between sessions, patients practice these exposures at home too. Patients also participated in psychoeducational treatments during sessions, in addition to coaching strategies, problem solving and relapse prevention. Plus, patients and parents participated in six 90-minute group sessions and had options for boosters and additional individual sessions as well.

According to the researchers, all the participants completed at least five active treatment sessions, and 70% completed six of them, with 70% further attending five or six of the sessions with both parents and 80% taking part in the optional booster session.

Additionally, all the parents said the treatment was very or extremely helpful for their child and for themselves on the Treatment Satisfaction Questionnaire, and their open-ended responses were extremely positive as well, the researchers said.

“The results were stunning. The families loved the treatment,” Dahlsgaard said.

Based on the CGI, all the children were much or very much improved. Results from the SOFAA questionnaires indicated significant reductions in food allergy anxiety from pretreatment to posttreatment as well, with gains maintained 2 to 4 months after active treatment was over.

General anxieties not specific to food allergy declined significantly from pretreatment to follow-up according to the SCARED questionnaire. Patients further experienced significant increases in FAQLQ-PF scores from pretreatment to posttreatment with gains maintained 2 to 4 months later.

“The anecdotal results are the most important,” Lewis said. “The joyful emails we received after they finished months later are just really heartwarming.”

One of the patients, an adolescent boy, would not eat outside of his home. He also would over-analyze ingredient labels, and he preferred virtual school over attending in person. His family would have to get their own kitchen whenever they traveled as well.

“By lots of hard work through the spring and summer, he is tolerating takeout from restaurants. He is able to smell and touch his allergens. He’s able to sit at the dinner table while his family members are eating his allergens,” Lewis said.

“There are still things to work on. He hasn’t eaten in a restaurant,” Lewis continued. “But I think that he is able to go to school, which is a huge, huge piece for them.”

Another participant was able to have her own birthday party for the first time and sit with other kids as they ate. As a result of the therapy, others were able to begin and pass in-office food challenges and initiate OIT.

“Now they get to eat what they formerly thought they were allergic to, and their life is just bigger and more joyful,” Dahlsgaard said. “This was a life-changing medical intervention.”

Noting that this is the first study of this outpatient psychosocial treatment for FAA diagnosed via clinical interview, the researchers concluded that FAB is feasible and acceptable, although larger, randomized studies are needed to test and inform its efficacy.

Meanwhile, the researchers will continue to assess patients and provide FAB to patients who they believe would benefit from it.

“We’ve seen such good results from this first treatment group, we are now screening anyone who comes into the CHOP allergy clinic with the SOFAA, both the child and parent version, who has a food allergy to make sure people aren’t suffering silently and so we can help as many people as we can,” Lewis said.

“We designed a very lean treatment. We got great results with just six sessions. It’s a very brief and targeted treatment, and we are particularly proud of that,” Dahlsgaard said. “Kids shouldn’t spend their lives in therapy. We should have the shortest and most effective treatment possible, and we think we got that with them.”

Now, the researchers are writing up the manual for FAB treatment. They plan on sharing it and training other clinicians in providing FAB once they are finished.

“Based on the amount of suffering we’re seeing here in Philadelphia, we can only imagine what’s out there in the rest of the world,” Dahlsgaard said. “Our plan is to get it out as quickly and to as many people as possible.”


For more information:

Katherine K. Dahlsgaard, PhD, ABPP, can be reached at Megan O. Lewis, MSN, RN, CRNP, can be reached at


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