Version June 2024
INTRODUCTION — Some increased level of anxiety in children with food allergy and their parents/caregivers is an expected and appropriate response for many of those living with this impactful disease. The natural heightened level of anxiety can be addressed through reassurance and education about the allergy and about the appropriate versus inappropriate levels of emotional distress living with the disease normally entails. However, some children (or their parents/caregivers) have excessive anxiety that requires specific mental health treatments [1].
This topic reviews the prevalence of anxiety and anxiety disorders in children with food allergy and their parents/caregivers, the type of anxiety that is experienced, when anxiety is problematic, how practitioners can identify such problems early on, and what treatments are available. A number of separate topics review the presentation, diagnosis, and treatment of anxiety in children and adults:
●(See "Overview of fears and phobias in children and adolescents".)
●(See "Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course" and "Anxiety disorders in children and adolescents: Assessment and diagnosis".)
●(See "Pharmacotherapy for anxiety disorders in children and adolescents" and "Psychotherapy for anxiety disorders in children and adolescents".)
●(See "Generalized anxiety disorder in adults: Management" and "Generalized anxiety disorder in adults: Cognitive-behavioral therapy and other psychotherapies".)
●(See "Social anxiety disorder in adults: Epidemiology, clinical features, assessment, and diagnosis".)
●(See "Social anxiety disorder in adults: Treatment overview" and "Pharmacotherapy for social anxiety disorder in adults" and "Social anxiety disorder in adults: Psychotherapy".)
●(See "Specific phobia in adults: Epidemiology, clinical manifestations, course, and diagnosis".)
●(See "Specific phobia in adults: Treatment overview" and "Specific phobia in adults: Cognitive-behavioral therapy".)
●(See "Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions" and "Complementary and alternative treatments for anxiety symptoms and disorders: Herbs and medications".)
TERMINOLOGY AND OVERVIEW — Anxiety is defined as "apprehensive uneasiness or nervousness usually over an impending or anticipated ill: a state of being anxious" [2]. Anxiety disorders, which are not the same as the lay notion of anxiety, include conditions that cause excessive worry and result in clinically significant distress or impairment in functioning [3]. A key difference between anxiety and anxiety disorders is that anxiety is an acceptable and appropriate response, whereas an anxiety disorder by definition is excessive and must lead to severe distress or impairment. (See "Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course" and "Overview of fears and phobias in children and adolescents".)
In the setting of food allergy, anxiety is prevalent, and both the patient and parents/caregivers are expected to report a higher level of anxiety compared with population norms [4,5]. However, such anxiety does not necessarily rise to the level of a disorder [6]. Anxiety is a developmentally appropriate coping mechanism so long as it does not reach a threshold beyond which it becomes dysfunctional (eg, prevents the child from attending school or from socializing). Mild anxiety about food allergy is likely to lead to meticulous avoidance of dangerous foods, which in turn protects the patient.
PREVALENCE — The exact prevalence of anxiety symptoms or anxiety disorders in children with food allergy and their caregivers/families is difficult to determine because of substantial differences in how anxiety is defined and measured [6]. Psychological distress, a catchphrase that sometimes is used interchangeably with anxiety, in fact includes anxiety, depression, social isolation, and stress. Distress is seen in both children and adolescents with food allergy, although findings are variable with regard to whether distress is more prevalent among children with food allergies compared with normative samples [7].
The level of anxiety symptoms experienced by patients with food allergy, and even more so by their parents/caregivers, is probably higher than the level of anxiety that is reported by the general population. Food allergy differs from other chronic diseases in that affected persons are in generally good health, but their health may be episodically compromised by acute food-triggered allergic reactions that may be severe or life threatening.
Study results can be affected by lack of distinction among anxiety, distress, and anxiety disorders [6] and by using different methods and patient populations (eg, parents/caregivers, children at different developmental stages, or both) to assess distress or changes in quality of life (QoL) that result from food allergy [8-10]; tools (eg, validated, nonvalidated/modified, or qualitative) [11-14]; and controls (eg, children with other chronic disease, normative scores for the larger population) [11-17]. (See "Food allergy: Impact on health-related quality of life".)
Comparison of adult and child perspectives on food allergy may reveal specific factors that contribute to child distress from food allergy, including parent/caregiver anxiety, negative patient approach to food allergy, and history of anaphylaxis. In one study, scores for anxiety, depression, and social stress symptoms in children with food allergies were comparable with average normative child distress scores. Greater distress was found only in children who perceived the allergy as "bad" or as making them different from others and in younger children of mothers with greater anxiety [7]. In another study [18], the subgroup of children with food allergy who had a perceived experience of anaphylaxis described greater anxiety about their condition and rated their parents as more overprotective compared with children with food allergy without a perceived experience of anaphylaxis [10]. However, an experience of anaphylaxis may result in reduced distress if individuals are able to manage and master the allergic reaction.
IMPACT OF ANXIETY
Factors affecting impact — To be able to identify patients whose anxiety is excessive, one must look not just at the level of reported symptoms but also their impact. Parent/caregiver anxiety levels, patient perceptions of food allergy, and coping mechanisms all can affect the anxiety and adaptive behaviors of children with food allergy. Excessive anxiety decreases quality of life (QoL) [12] and is associated with comorbid mental health conditions and dysfunctional behaviors.
Quality of life — In the aggregate, data suggest that children with food allergy and their parents/caregivers have a lower QoL compared with the general population. The fear of anaphylaxis as well as the consistent vigilance necessary to prevent accidental allergen exposures can place significant strain on children with food allergies and those caring for them.
Studies that compared the impact of food allergy on anxiety scores or QoL as reported by the patients themselves (mostly adolescents) collectively suggest that the emotional effects seen in patients with food allergy are not easily comparable with those encountered in other disease processes [11]. The clinical manifestations of food allergy are largely episodic in that the disorder is generally not apparent unless or until an allergic reaction occurs. This distinctive characteristic of food allergy may contribute to features of increased anxiety (about the development of acute reactions) but may also result in a lesser impact on socialization compared with less episodic chronic illnesses such as diabetes. Studies comparing children with food allergy to each other rather than to children without food allergy have suggested additional factors affecting food allergy-related distress and QoL, including epinephrine prescription, history of anaphylaxis, and perception of competence in managing personal health [16].
Several studies suggest that there is a greater impact on QoL for parents than for children with food allergy themselves, at least in the younger age groups. A study of more than 1000 parents of children with food allergy in the United States found overall QoL for caregivers to be variable, although caregivers consistently expressed concern about social limitations resulting from their child's food allergy [8]. In another US survey of 253 families of children with food allergy, parents scored significantly lower (worse) on general health perception, emotional impact, and limitation on family activities compared with established norms [12].
Comorbid mental health problems — Anxiety disorders are highly comorbid with other mental health disorders in the general population [19] and in children with food allergy and their parents/caregivers [20]. Depression is the best-studied emotional problem associated with anxiety in this population, and practitioners should be aware of this connection.
Avoidance coping — Avoidance coping is a dysfunctional response to anxiety in which persons who are anxious about a situation or an event try to stop thinking about it and avoid reminders of it [21]. Avoidance of stressful reminders is a known component of posttraumatic stress reactions [22] and is particularly relevant to medically ill patients [21]. It is a dysfunctional pattern that may lead to poor outcomes and is a risk factor that clinicians can identify and help mitigate [23].
For persons with food allergy, this may mean avoiding doctors' appointments or thoughts and actions related to carrying an epinephrine autoinjector. Failure to carry an autoinjector is prevalent amongst adolescents [24] and is perhaps the most dangerous outcome of avoidance coping. Intervention strategies to decrease avoidance coping related to carrying and using an epinephrine autoinjector are under investigation [23].
Avoidance coping may also impact the choice of foods deemed safe to eat. Avoidance of safe foods is noted when children experience an anaphylactic reaction and they and/or their parents/caregivers "overcorrect" by avoiding foods that are safe or not necessarily dangerous. This can cause serious and unwarranted dietary restriction. Avoidance coping is a potential mechanism in patients who continue to avoid of safe foods more than three to six months following anaphylaxis.
DIAGNOSTIC CONSIDERATIONS — The first thing that a practitioner needs to consider when confronted with a seemingly anxious child or parent/caregiver of a child with food allergy is whether the anxiety is appropriate or excessive. There are three possible scenarios:
●An anxiety disorder (a mental health disorder with specific criteria) is present.
●The anxiety is excessive but does not meet specific criteria for a disorder.
●The level of anxiety is appropriate.
Anxiety disorders such as generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder have specific diagnostic criteria, delineated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [3]. The manifestations and diagnosis of these disorders are discussed in greater detail separately. (See "Anxiety disorders in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, and course" and "Anxiety disorders in children and adolescents: Assessment and diagnosis" and "Obsessive-compulsive disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
As a general rule, the clinical evaluation should focus on the presence of symptoms and their impact (see 'Impact of anxiety' above):
●Symptoms that do not cause significant dysfunction (eg, do not cause avoidance coping, impact quality of life [QoL], or result in social isolation of the child) should not be considered a diagnosable condition. While practitioners should continue to monitor such symptoms and may offer advice about ameliorating them, they should not present them as a disorder or even attempt to eliminate them, as elimination of mild anxiety may lead to more risky behaviors.
●Anxiety that results in dysfunction (such as avoidance coping) should be addressed clinically by allergy specialists, primary care clinicians, nurses, or mental health professionals as appropriate, even if the symptoms do not neatly fit into any of the disorders recognized by DSM-5. (See 'Screening and monitoring' below and 'Management' below.)
●Several proposed mental health disorders may capture the unique constellation of distress related to fear of a life-threatening event that may be more specifically experienced by persons with food allergy (as opposed to other patients with anxiety). It is not clear that persons with food allergy should have specific considerations when diagnosing a disorder; yet, some authors emphasize posttraumatic stress and phobia as likely comorbidities in patients who present with severe anxiety [25-27].
SCREENING AND MONITORING — There is no evidence that screening for anxiety in children results in any clinical benefits [1]. In addition, training allergists to identify anxiety in their patients using a one-hour educational workshop did not improve their ability to recognize anxiety symptoms [28].
We do monitor quality of life (QoL) via questionnaires or directed questions since minimizing the impact of food allergy on daily living is a therapeutic goal and monitoring QoL can assess the degree to which a clinician has been able to promote achievement of that goal.
We also directly question about avoidance coping and bullying in clinical practice since it is possible to address dysfunctional coping and eliminate exposure to bullying if those are known to be present [25]. (See 'Impact of anxiety' above and "Food allergy: Impact on health-related quality of life".)
Some authors have developed specific scales that purport to assess anxiety in the setting of food allergy [29-31]. One study found that nonspecific but validated anxiety scales do not completely correlate with "food-allergy anxiety" noted on a nonvalidated visual analog scale [32]. However, confirmation of the utility of food allergy-specific scales requires head-to-head comparison of various approaches. No studies have ever evaluated the performance of a food-anxiety-specific mental health assessment scale against a full psychiatric diagnostic evaluation. In addition, one rigorous such examination found that generic mental health scales perform well in children with chronic illness [33]. It is similarly not clear that there is a need to modify the diagnostic criteria for anxiety disorders for this particular population, and it is not clear that those scales offer a clinically important advantage over the use of (age-appropriate) validated scales for anxiety. Until rigorous controlled trials demonstrate clinical benefit, we do not use such scales in practice.
Impact of the coronavirus pandemic — One survey study showed poor QoL and heightened anxiety reported by mothers of children with food allergy [34]. However, there was little difference in scores on the anxiety and QoL measures between the index mothers and controls (mothers of children who did not have food allergy). In addition, day-to-day food allergy management was felt to be better during the pandemic by the same respondents. A study of the anxiety level of the children themselves demonstrated a heightened level of anxiety during the pandemic [35], which is typical of almost any population investigated during the pandemic. This study also observed a reduction in bullying, most likely related to remote schooling and decreased interactions in social settings.
MANAGEMENT
Referral to a mental health professional — Consultation with a mental health professional is generally warranted if an anxiety disorder is suspected or diagnosed. Anxiety disorders are highly treatable and, therefore, should be treated if they are present. There are many treatment options [36,37], including psychotherapy (eg, cognitive-behavioral therapy [CBT]) and medication (eg, anxiolytic medications or selective serotonin uptake inhibitors). (See "Psychotherapy for anxiety disorders in children and adolescents" and "Pharmacotherapy for anxiety disorders in children and adolescents" and "Generalized anxiety disorder in adults: Management".)
Most anxious children with food allergy and their parents/caregivers, however, will not turn out to have a specific disorder [6]. Simply noting a high level of anxiety does not in and of itself justify an intervention. Whether or not to refer such patients is a clinical decision that can be made after assessing the following parameters: how dysfunctional is the anxiety, are mental health professionals who are able to address such anxiety available, and will a referral send the wrong message to the patient (or parent/caregiver) by "labeling" the issue as a mental health problem rather than a coping strategy that needs to be adjusted. There is a risk of overtreatment or mistreatment by pharmacologic means (eg, overprescription of anxiolytics) [38], and, therefore, mislabeling anxiety symptoms as a disorder may have untoward implications.
If the practitioner decides not to refer, monitoring of the anxiety and its consequences are warranted. Other techniques that may be applied by pediatricians and allergists are reviewed below. (See 'Facilitating self-management' below.)
Whether the mental health treatment of anxiety related to food allergy (for patients whose symptom levels are high enough to merit a referral) should be any different from the treatment of any anxiety disorder is an unresolved question. There is some indication from a case series that a "modified" CBT schedule may be of some help [39]. However, in the absence of blinded, randomized, controlled trials, it is not clear whether modifications to standard CBT techniques are necessary in order to deliver successful mental health interventions in this population. Therapists should be aware of topics related to food allergy management, which can be done through self-education or through a liaison with an allergy specialist or food allergy treatment team or center.
Psychoeducation — Education of the patient with food allergy and their parents/caregivers should include information about the food allergy itself and its management [40,41] but should also emphasize the natural evolution of anxiety across the lifespan in persons with food allergy. As children with food allergy grow up, they become more aware of the potential life-threatening nature of their allergy and thus may become more anxious almost "overnight," without any specific inciting event. This is an underappreciated and inconsistently studied phenomenon, but specific educational efforts directed at exploring these fears and discussions about anxiety, its consequences, and its natural evolution as the child grows older, particularly during early adolescence, may help preempt concerns and facilitate honest discussion with the parents/caregivers about the child's feelings. Parent/caregiver and child educational materials are available online and may be used to facilitate such discussions with patients and parents following an experience of an anaphylactic reaction.
Facilitating self-management — As with any other chronic disease process, transition to self-care in adolescence and young adulthood is a period of increased risk for those with food allergies [24,42]. Efforts to improve self-management skills may help in patients who have not appropriately acquired such skills due to anxiety, apprehension, or other barriers.
As an example, a teenager may decide to stop carrying an epinephrine autoinjector since it is a stressful reminder of the allergy, especially if injecting oneself with a needle is perceived as stressful. Practitioners can address this problem by having a frank discussion of avoidance and its potential consequences, by using an "exposure" paradigm in which the patient is asked to demonstrate self-injection in the clinic with an empty syringe [23], or by engaging in a safe but stressful activity in the clinic (eg, go through a food challenge, if indicated) [43]. This technique is based upon the exposure component of CBT for anxiety disorders. These exposure paradigms may initially increase anxiety but can subsequently decrease anxiety and improve quality of life (QoL) [23,44]. (See "Psychotherapy for anxiety disorders in children and adolescents", section on 'Exposure'.)
Similarly, patients, especially during adolescence, may be overly concerned about casual exposure (eg, touching an allergen), even when such exposure is not expected to trigger a reaction [24,45]. Detailed education about the differences between a casual exposure (for example, touching) and actual ingestion may reduce anxiety.
The parents/caregivers — Parent/caregiver supervision and support are essential for good child outcomes. Thus, parents/caregivers are part of any attempt to improve a child's anxiety. Parents/caregivers may be involved in interventions that target the child or may themselves be the target of interventions if their own anxiety becomes dysfunctional. Treatment of anxiety in the parent/caregiver is indicated whenever such anxiety is deemed to be sufficiently distressing or dysfunctional [46].
PROGNOSIS — Although it is not definitively known whether food allergy-related anxiety improves over time in children and their parents/caregivers, anxiety in children and adolescents with food allergy and their parents/caregivers should improve over time with appropriate care in most cases.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Food allergy" and "Society guideline links: Anxiety and trauma-related disorders in children" and "Society guideline links: Anxiety and anxiety disorders in adults".)
SUMMARY AND RECOMMENDATIONS
●Anxiety symptoms versus anxiety disorder – Anxiety in children with food allergy and their parents/caregivers is an acceptable and appropriate response. In contrast, an anxiety disorder by definition is excessive and must lead to severe distress or impairment. (See 'Terminology and overview' above.)
●Prevalence – Although the exact prevalence of anxiety symptoms or anxiety disorders in children with food allergy and their parents/caregivers is uncertain, children with food allergy and their parents report more anxiety symptoms than the general population. (See 'Prevalence' above.)
●Impact – Anxiety can have a positive influence if it is mild and leads to an appropriate focus on safety or a negative one if it is excessive and leads to substantial distress and dysfunction. Excessive anxiety decreases quality of life (QoL) and is associated with comorbid mental health conditions and dysfunctional behaviors. Avoidance coping is a dysfunctional response to anxiety in which persons who are anxious about a situation or an event try to stop thinking about it and avoid reminders of it. (See 'Impact of anxiety' above.)
●Diagnostic considerations – The first thing to determine when confronted with a seemingly anxious child or parent/caregiver of a child with food allergy is whether the anxiety is appropriate or excessive. Anxiety disorders such as generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder have specific diagnostic criteria. Anxiety disorders should only be considered in children whose anxiety is dysfunctional (eg, prevents the child from attending school or socializing). (See 'Diagnostic considerations' above.)
●Monitoring – There is no evidence that screening for anxiety in children with food allergy results in any clinical benefits, but monitoring of QoL via questionnaires or directed questions, as well as direct questioning about avoidance coping, may be helpful. (See 'Screening and monitoring' above.)
●Management – Consultation with a mental health professional is usually warranted if an anxiety disorder is suspected or diagnosed. Treatment options for anxiety disorders include cognitive-behavioral therapy (CBT) and pharmacotherapy. Anxiety that does not meet criteria for a disorder may still benefit from interventions to ameliorate anxiety, including "exposure"-based treatments. (See 'Management' above.)
●Prognosis – If adequately monitored and treated, it is reasonable to expect resolution or amelioration of anxiety symptoms in most cases. (See 'Prognosis' above.)
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