From an early age, children with life-threatening food allergies are taught to proceed with caution: check labels, ask about ingredients, don't eat something at a friend's house if you don't know what is in it. In some cases, however, necessary caution evolves into unnecessary avoidance – not only of foods but also of social situations where food might be served. This sort of disordered eating and avoidance is driven by anxiety, which if left unaddressed can significantly derail a child's quality of life and social development.
Now, a new study in the Annals of Allergy, Asthma & Immunology shows that a first-of-its-kind program at Children's Hospital of Philadelphia (CHOP) can help children with food allergy-related anxiety reduce their fears and improve their quality of life. The Food Allergy Bravery (FAB) program at CHOP provides cognitive behavioral therapy (CBT) in five to eight sessions to children who have severe anxiety related to their food allergies.
"For children with food allergies, a little anxiety is helpful in staying vigilant, but too much anxiety can prevent them from participating in safe – and fun – activities that are important for their development and quality of life," said Megan O. Lewis, MSN, CRNP, co-director of the Food Allergy Bravery Clinic at Children's Hospital of Philadelphia and co-author of the study. "This study shows that our Food Allergy Bravery program is a successful treatment for helping children with food allergy anxiety overcome their fears and improve their day-to-day life."
The FAB Clinic was launched in 2018 as a collaborative project to address food allergy anxiety. Clinic leaders developed a new screening tool to measure food allergy-related anxiety and a treatment manual for patients to address that anxiety and related fear of anaphylaxis. Today, all patients seen with food allergies at CHOP are screened for anxiety and referred to the FAB Clinic as needed.
Over the course of five to eight sessions, patients in the program receive individualized, cognitive behavioral treatment that includes repeated "brave practices" to encourage the child to take small steps towards facing allergen-related fears and building confidence around food and social situations. Each session typically lasts 30 to 45 minutes and can be led by an allergy practitioner or mental health provider. In each session, patients perform a variety of bravery challenges that involve tasks like sniffing an allergen, touching an allergen (followed by hand washing), or eating a needlessly feared allergen-free food, followed by homework that involves performing these tasks at home. The exposures happen gradually, getting patients comfortable with being progressively closer to their allergen without having an allergic reaction.
The study, led by psychologist and former co-director of the FAB Clinic Katherine K. Dahlsgaard, PhD, evaluated the effectiveness of the FAB program by following 10 patients referred by their allergists specifically for evaluation and treatment of food allergy-related anxiety. Although the FAB Clinic is available to children and adolescents of all ages, children included in the study were between the ages of 8 and 12. All patients in the study had confirmed IgE-mediated food allergies that were well-controlled, as well as excessive anxiety and medically unnecessary and impairing anxious avoidance related specifically to their food allergy.
Although current sessions in the FAB Clinic are done virtually and individually, the paper analyzed pre-pandemic participants who had enrolled in a group format, in which children and their caregivers attended six 90-minute sessions together.
The study found that after six sessions in the FAB program, patients showed significant reductions on two standardized scales of anxiety: one that measures food allergy-specific anxiety (SOFAA), which was created at CHOP; and one that measures general anxiety (SCARED). Improvements were seen on both child-rated and parent-rated forms. Caregivers also filled out satisfaction surveys at the end of treatment, and the results showed that 100% of caregivers found the FAB program to be "Very Helpful" or "Extremely Helpful" for both their children and themselves. The children and parents also reported an improvement in quality of life.
"A huge part of the FAB program is education, for both patients and families – informing them of what practices are 'safe enough,'" Lewis said. "Not only has this helped our patients participate in more social events, but it has also made them more comfortable engaging in important experiences related to allergy treatment, such as food allergy testing, food challenges, and oral immunotherapy, which they were unable to do prior to enrolling in the FAB program."