Sitting together in a booth at Ponzio’s Diner in Cherry Hill, Amy Leis and her daughter, Zoe Hocking, looked over the menu.
Hocking, who is 11 and in the sixth grade, decided on a bagel with cream cheese and lox.
“And can you make sure there’s no nuts in the bagel, please?” she asked the waitress.
“She’s allergic,” Leis added.
“No, we just have plain, we just have plain,” the waitress reassured them.
Hocking is used to asking about the ingredients in her meals. She’s lived her entire life allergic to a range of foods, including eggs, dairy, nuts, seafood, shellfish, wheat and soy.
It’s a collection of allergens that has landed her in the hospital multiple times, beginning when she was 5 months old and had an anaphylactic reaction, when swelling in the throat makes it difficult to breathe.
“Just imagine, the entire world looks like a minefield,” Leis said. “I would have to say for sure, my anxiety – incredibly, incredibly high her entire life.”
Up until recently, Hocking shared in that anxiety, so much so that she eventually developed an anxiety disorder related to her food allergies. She would decline invitations to sleepovers, avoid eating cake at birthday parties, and would often sit alone at lunch in school, away from what other kids might be eating.
She had panic attacks over the possibility of suffering an allergic reaction.
“I was afraid that I was going to eat something, like my friend would eat Nutella and I would accidentally touch it, and then eat something and I would die,” Hocking said.
An estimated 5.6 million children in the United States have food allergies, many of them allergic to more than one food substance. Previous research suggests these kids are more likely to suffer from anxiety issues.
It’s in part what led psychologists and pediatric specialists at Children’s Hospital of Philadelphia to open the Food Allergy Bravery clinic in 2018. Now, researchers at the clinic have published a new study that shows how targeted, short-term exposure therapy can help significantly reduce food-related anxieties in kids.
“Families with food allergies often don’t know where the line is between healthy caution and unhealthy, medically unnecessary avoidance,” said Dr. Katherine Dahlsgaard, a psychologist and co-founder of the FAB clinic who now works in private practice.
The CHOP team created a treatment manual around exposure therapy, a type of cognitive behavioral therapy. Like the name suggests, it’s a supervised way of gradually exposing people to things they fear so that they can learn to overcome that fear or anxiety.
There’s already an established body of evidence on effective uses of exposure therapy, but Dahlsgaard said there was a lack of research on how well the therapy could work to reduce moderate and severe anxiety disorders in children with food allergies.
At the FAB clinic, kids and their parents attended group therapy sessions where they learned how to be near their food allergens – through touch and smell – without suffering harm. Kids did not ingest their allergens.
For Hocking, who has a nut allergy, it involved sticking her hand in a peanut butter jar, washing her hands off, and then safely eating something right after.
Patients would also participate in bravery challenges, where they would try new exposure scenarios. Leis and Hocking, along with other families, made a trip to Starbucks for the first time to order drinks. Before therapy, they had been too fearful of possible cross-contamination with nut milks and products.
“We all got pink drinks” – it contained strawberries – “and we were so happy,” Hocking said.
“It was momentous for all of us,” Leis said. “This is a kid who, when she was little, I used to have to spend hours food shopping, because I would call every single food manufacturer and say, ‘okay, what are your manufacturing processes, do you make it on the same equipment?’”
CHOP researchers at the FAB clinic said all patients in their small pilot study reported significantly lower levels of anxiety after at least six group therapy sessions and practice at home.
The study results were published Sept. 23 in the Annals of Allergy, Asthma and Immunology.
“We love that it worked,” Dahlsgaard said. “You don’t have to suffer this way and it doesn’t take forever, right. Your kid does not have to be in therapy for two years. It can be targeted and they can get better fast.”
Megan Lewis, a pediatric nurse practitioner and co-founder of the clinic, said the therapy course also helped ease anxiety in parents.
“These exposure therapies are exposures to the parents,” she said. “The most remarkable thing families will say is, ‘I’m so much more confident about managing this and handling this.’”
That’s certainly been true for Leis and Hocking. They said something as simple as going out to a diner and ordering food with minimal worries seemed impossible before.
“It was like I got my daughter back,” Leis said. “I got to see her blossom as this person and become confident again. And we learned as a family how much risk we can tolerate and how to take calculated risks.”
Today, every child with a diagnosed food allergy who is seen at CHOP is referred to the FAB clinic for anxiety screenings. Researchers hope to test their treatment manual on a larger scale, and make it available to community health providers and mental health practitioners.
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