Overcoming food phobia


Different therapy techniques, including careful exposures, can help children with food allergies overcome crippling anxiety over allergic reactions, according to a new report.

An allergic reaction can be a scary thing—especially when it’s an anaphylactic reaction. The feeling of not being able to breathe can stay with you, and for children, it might even create a phobia in anticipation of another reaction.

A new report1 in the Journal of Allergy and Clinical Immunology explores how therapy can help children overcome these phobias.

Allergies themselves are 1 issue, and children with food allergies have to be cautious and have some degree of anxiety about what they eat and new foods they try. However, when they have experienced an allergic reaction, particularly one that has caused anaphylaxis or required treatment with epinephrine, their reactions can cause excessive fear or anxiety over a repeated experience. In these cases, children with allergies may actually begin to suffer from anxiety attacks over their food allergy fears rather than from actual allergic reaction. The new report details when caution about food allergies becomes extreme, and what clinicians can do about it.

“The key message we have for pediatricians, allergists, and other health professionals is that excessive, prolonged anxiety is not the norm for kids with food allergies,” says Katherine K. Dahlsgaard, PhD, ABPP, lead author of the study and a licensed psychologist who is board-certified in Behavioral and Cognitive Psychology. “However, when it does happen, exposure-based cognitive behavioral therapy is a safe, evidence-based, and highly effective treatment to recommend to their patients and families.”

Dahlsgaard, is also the director of FAB: The Food Allergy Bravery Clinic at the Children’s Hospital of Philadelphia in Pennsylvania, and conducted the study in collaboration with her colleagues at the clinic. She says the FAB Clinic is unique in that it offers cross-disciplinary intervention devoted exclusively to evidence-based assessment of child anxiety disorders that occur in the context of food allergies. It is co-directed by Dahlsgaard, Megan O. Lewis, MSN, and Jonathan M. Spergel, MD, PhD. It’s this type of collaborative and cross-disciplinary therapy that makes the biggest difference, she says.

“All our group sessions with families have both a psychologist and an allergy provider present. We focus on structured, gradual, and repeated ‘Bravery Challenges’ designed to help overly-anxious kids test out whether their fearful predictions about being unsafe in the presence of their allergen are true or untrue,” Dahlsgaard says. “During sessions, we might have the children sit near their allergen or deliberately smell their allergen. All Bravery Challenges are designed to help children learn by doing what is truly safe and we try to make the lessons learned from the Bravery Challenges be directly transferable to their real-world situations.”

For example, Dahlsgaard says they might work with a child in the FAB Clinic to help them realize that smelling peanut butter or cheese doesn’t cause an allergic reaction, and that with repeated practice, they can become more comfortable with smelling these foods and sharing in dining experiences with their friend in a more comfortable and relaxed manner.

“Nothing builds confidence like experience,” Dahlsgaard says.

These phobias come from a valid place, though, she cautions, adding that kids need to know how to be safe in regard to their food allergies—but without being scared.
“Kids with severe food allergies need to be cautious—a little anxious, in other words—to keep themselves safe. In the FAB Clinic, we stress that some anxiety is absolutely adaptive but that we don't want you to have too much of a good thing,” Dahlsgaard says.

Pediatricians can help in 2 ways, she says.

“The first is by identifying excessive anxiety as medically unnecessary avoidance of school and social situations that is persistent and keeps the child's world far smaller than it needs to be for healthy development. The second is to educate and direct such families towards evidence-based treatments,” she says. “Yes, a mental health professional with specialized training in exposure-based interventions is required. Unfortunately, such therapists are hard to find; research has found that even among therapists who self-identify as treating anxiety, only 10% to 30% actually use exposure—the very technique that has the most scientific support.”

Parental involvement is also key for successful therapy. The report notes that parental anxiety can exacerbate a child’s anxiety, and family-based sessions might be particularly helpful in allowing parents to see how therapists model certain behaviors that they can replicate at home.

“All exposures should be assigned for repeated practice at home and in community settings to maintain and generalize gains, as well as build the confidence and skill of safe allergy management among family members,” the report notes.

Dahlsgaard says she hopes the report will help clinicians understand the importance of cognitive behavioral therapy for children with allergies and their parents, and to be able to educate their patients with scientifically backed information.

“Our ultimate goal, of course, is for every child with a food allergy to stay safe while living as big a life as they want to,” she says.


  1. Dahlsgaard K, Lewis M, Spergel J. New issue of food allergy: phobia of anaphylaxis in pediatric patients. JACI. July 22, 2020. Epub ahead of print. doi:10.1016/j.jaci.2020.07.010
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