Building Bravery: Tackling Allergy Anxiety with Dr. Katherine Dahlsgaard

In this week's chat about choices, psychologist/researcher Dr. Katharine Dahlsgaard and your host Dr. Whitehouse explore what we can do about the emotional side of food allergies, exploring when everyday anxiety crosses the line into specific phobia and how to address it. Dr. Dahlsgaard walks us through her research demonstrating that exposure therapy, including the proximity challenges, like smelling or being close to an allergen, to help recalibrate fear responses.

We discuss balancing safety with bravery through the healing lens of being “safe enough,” address the overlap of food allergies with Avoidant Restrictive Food Intake Disorder (ARFID), and unpack the essential life skill of functioning even while anxious.

-Dr. Katherine Dahlsgaard | Psychologist | CBT Therapist
-Instagram: @braveisbetter
-Scale of Food Allergy Anxiety (SOFAA) | Children's Hospital of Philadelphia
-Want to help your patients with food allergy anxiety? Do proximity challenges!
-Cognitive-behavioral intervention for anxiety associated with food allergy in a clinical sample of children: Feasibility, acceptability, and proof-of-concept in children - ScienceDirect
-Episode 4 with Kelly Chambers, discussing her experiences as a Food Allergy Bravery parent: https://www.buzzsprout.com/2371319/episodes/15580765 

Special thanks to Kyle Dine for permission to use his song The Doghouse for the podcast theme!
www.kyledine.com

Find Dr. Whitehouse:
-thefoodallergypsychologist.com
-Instagram: @thefoodallergypsychologist
-Facebook: Dr. Amanda Whitehouse, Food Allergy Anxiety Psychologist
-welcome@dramandawhitehouse.com

Transcript

Katherine Dahlsgaard, PhD: 0:00

every time they get anxious, they try and avoid feeling anxiety. And that is no way to live. It is an existential threat to your child if they get to that point, because part of human life is feeling anxious in response to challenges. Your kid is gonna have to ask someone. To marry him, your kid is gonna have to apply for her first mortgage, and they're gonna be anxious and they need to have the confidence that they have built up in childhood with you as the parent that they can be anxious and function anyway. Not perfectly, not happily, but function.

Amanda Whitehouse, PhD (2): 0:39

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence..

Amanda Whitehouse, Phd: 1:00

this summer we are talking about choices and where we have some action and control over our experiences, we may not be able to control whether or not we experience any anxiety about managing our allergies, but we can take steps to mitigate that. That is why I'm so excited for you to meet today's guest, Dr. Katherine Dahlsgaard.. She's a clinical psychologist and a researcher who's been shaping the landscape of food allergy anxiety with her work. You may know of her from her work at Children's Hospital of Philadelphia where she created the Bravery program. You might know about her developing the SOFAA scales to measure food allergy anxiety, and most recently, she co-authored a paper on using proximity challenges, like smelling or being close to your allergen as a deliberate anxiety reducing tool in clinical settings. So I asked Dr. Dahlsgaard to join us so that we could explore not only what she discovered, but how these ideas can feel different, safer, and braver for families managing food allergies. Trust me, you'll want to meet her. thank you so much for joining me here on Don't Feed The Fear, Dr. Dahlsgaard. I am so excited to talk to someone on the podcast for the first time in the same field as me, another psychologist Thank you so much for taking the time to join me. It feels very special to have you here.

Katherine Dahlsgaard, PhD: 2:13

Amanda, I'm delighted.

Amanda Whitehouse, Phd: 2:15

Tell us how you got into this unique combination that we both find ourselves in, of being psychologists, working with the mental health side of food allergies.

Katherine Dahlsgaard, PhD: 2:26

It is a long answer. I will try to make it short. I have been a specialist in treating pediatric anxiety disorders for 20 years. It is my passion and I started at Children's Hospital of Philadelphia. I was the founder and director of their anxiety clinic for kids with anxiety disorders, children and adolescents, and I ran that for a bit over 10 years. And we treated all of the anxiety disorders that kids present with, so things like OCD and all kinds of phobias and separation, anxiety disorder, and selective mutism and PTSD and as the director. I was given appropriately what were considered very difficult cases, and I started to see just a few in my clinic, these kids who had bonafide IgE mediated food allergies, but they had too much anxiety about them and they were engaged in a ton of medically unnecessary avoidance. So in food allergy, we wanna have medically necessary avoidance of ingesting the allergen. But these were kids who were terrorized by being in the presence of their allergen or just by the thought of being in the presence of their allergen. And not only that, but unusual, uh, unusual to my cases. Their parents were terrorized too. So let me explain what I mean. In the case of the dog phobia, the kid is terrified of dogs over predicts. If they see a dog, the dog's gonna bite them and over predicts the catastrophic consequence. Not only is the dog gonna bite me, it's gonna rip my throat out, I'm gonna, I'm gonna die. It's gonna be terrible. But their parents know my kid is way over predicting negative outcomes. She's way too afraid of dogs. In the case of food allergy anxiety, or what I came to call specific phobia of anaphylaxis, the parents were just as terrified as the kids, and my heart went out to these families in a very profound way. And also it turns out that these were not difficult cases to treat like any phobia. They were straightforward to treat. We have a great treatment for phobias, and these kids and their families got better quickly with a very common and strategic treatment. So that's how I got into it.

Amanda Whitehouse, Phd: 5:20

So everyone's going to wanna know immediately. Then. I think I'm familiar because of your work and my work, but tell people what is the very specific and effective treatment that we use for specific phobias.

Katherine Dahlsgaard, PhD: 5:32

It is called exposure therapy, and it is a type of cognitive behavioral therapy, so exposure therapy. For your listeners who haven't heard about it or maybe think they might know what it is, exposure therapy. Is the effective evidence-based scientifically backed treatment for pretty much all anxiety disorders, and the evidence is especially strong for phobias and exposure is gradual strategic exposure to the safe enough thing that is avoided unnecessarily. So to take the instance of, again, dog phobia, the kid will be avoiding dogs. If I go over to my cousin's house, I, I get my mom to tell their parent that the dog has to go in the basement. But even so, even though the dog is in the basement, every time it barks, I get really scared. Because my brain is over predicting the dog's gonna get out. It's gonna come right to me and it's going to bite me. And so you have kids who have been avoiding play dates with friends that have dogs, avoiding going to holidays with families that have dogs, or family members that have dogs. And you would think that all this avoidance would make it so that they're not anxious, but instead they're anxious all the time. And that is because unnecessary avoidance. Means you're collecting bad data. So I haven't been around a dog for three years. Yeah, I see all my friends petting the neighborhood dogs and loving dogs, but I haven't been around dogs for three years and I haven't been bitten that entire time. Therefore, the avoidance is working and I better keep doing it, and that means I better be vigilant every time I see a dog so I can avoid it.

Amanda Whitehouse, Phd: 7:34

Right, and now that's the only coping skill I have for managing this anxiety is avoid everything at all costs. Right.

Katherine Dahlsgaard, PhD: 7:40

Yes, and it is the only coping skill, but it isn't a coping skill

Amanda Whitehouse, Phd: 7:45

Right.

Katherine Dahlsgaard, PhD: 7:46

because what the child is not learning is the relative safety of dogs. They're also not getting a chance to be, um, they're also not getting a chance. To develop the crucial life skill of functioning while they are anxious. So, so many of my anxious kids, when they come to me, they're not just anxious about the doc, about temporary separations from their parents, about getting up in front of other kids at school and giving, um, a, a, a public, uh, speech. They've gotten to the point where every time they get anxious, they try and avoid feeling anxiety. And that is no way to live. It is an existential threat to your child if they get to that point, because part of human life is feeling anxious in response to challenges. Your kid is gonna have to ask someone. To marry him, your kid is gonna have to apply for her first mortgage, and they're gonna be anxious and they need to have the confidence that they have built up in childhood with you as the parent that they can be anxious and function anyway. Not perfectly, not happily, but function.

Amanda Whitehouse, Phd: 9:05

I talk about with my clients, how there's this bell curve or a normal curve showing that a little bit of anxiety motivates us and enhances our performance, right? And so framing that as it's actually a good and a productive thing in certain circumstances at a moderate or appropriate level.

Katherine Dahlsgaard, PhD: 9:20

Yes, and just like with dogs, and then I'll talk about food allergens as well, we want our children to have an appropriate level of anxiety around dogs. I've never met this dog. I don't run up to it and pet it. I ask the owner, is it okay if I pet your dog? In the case of food allergy, we want our kids to have enough anxiety, right? A good enough amount to keep themselves safe. We want our kids when they go over to a friend's house to be cautious about what they eat, to look at ingredient LA labels to carry their EpiPen everywhere, right? That's the appropriate level of anxiety that we want for our children. What we don't want is too much of a good thing because too much of a good, good thing means I avoid too much. The bad thing doesn't happen that my anxious brain was predicting would happen. So I think the avoidance is working and then I turn around and I'm the only kid who just got to college in my college class who's eating alone in my dorm room, rather than going in the cafeteria and developing friendships. So too much anxiety leads to too much avoidance and too much avoidance leads to a life that is smaller than it needs to be. And a food allergy is a chronic condition for most people, but it doesn't have to be a chronic condition that makes your life small. And it shouldn't be. People with food allergies deserve like the rest of us who do not have food allergies. To live as big a life as possible, an adventurous a life as possible.

Amanda Whitehouse, Phd: 11:12

I love that. So that is the inspiration wanting these kids. And their parents to have as big of a life as possible and as full of a life as possible. Is that where you then moved from Directing this anxiety clinic, then you created a specific food allergy anxiety clinic at the Children's Hospital Philadelphia. Correct.

Katherine Dahlsgaard, PhD: 11:30

Yes, very much. I, I can really say I put my money where my mouth was. I put my money where my heart was. In that I, the director of the anxiety clinic at CHOP Children's Hospital, Philadelphia, went over to the food allergy center and started up the first that I know of or that we know of, specialty Anxiety clinic embedded within a food allergy center. So if you can imagine, um, the Department of Child and Adolescent Psychiatry allowing their director to go over to another department to days a week to start at this clinic, you can bet I really, really, really wanted to start that clinic and start doing the work.

Amanda Whitehouse, Phd: 12:10

And your time is precious, but certainly there must have been an abundance of patients for both, I would suspect.

Katherine Dahlsgaard, PhD: 12:17

Very much so. It was a, it was a great thing to do. I've had a lot of really, really satisfying experiences in my career. I love my job. I love helping anxious kids. I love the treatment, I love everything about it. But starting up, the Food Allergy Bravery Clinic, the FAB Clinic. In the food allergy center at CHOP is one of the jewel, one of the jewels in my crown. It was just great. I loved it.

Amanda Whitehouse, Phd: 12:44

I've heard so many good things. I know a lot of people who have been clients there. I'll link for people listening. I had a guest on the show whose daughter, pulled out of some really restrictive eating and, and concerning weight loss, due to food allergies

Katherine Dahlsgaard, PhD: 12:57

So wait. You've interviewed former patients of the FAB Clinic.

Amanda Whitehouse, Phd: 13:00

Uh, just, just one on the show. Yeah.

Katherine Dahlsgaard, PhD: 13:02

Oh my goodness. Oh, that's so great. Alright.

Amanda Whitehouse, Phd: 13:04

her name was Kelly Chambers. She came on the show and she, she gave a really great episode. So I'll, I'll make sure to link that and just said the best things about their experience there.

Katherine Dahlsgaard, PhD: 13:13

Oh, that's delightful to hear. When I got there, the first thing I did was I looked around and I read all the literature. Any person who's gonna start a specialty treatment clinic, you need to be very cognizant of the literature. And I, to some extent was, but the first thing I did there, actually, the first two things I did there was I sat down and I. Read every piece of literature in the food allergy journals, which are different from the psychiatric journals. So your listeners should know. Oftentimes people who work in psychology don't read medical journals and vice versa. And it's just because we get used to reading studies as they come out in the journals that we're familiar with. So I took a very, very deep dive into that. And then the other thing that I did was I started going to the oral food challenge or office food challenge. Clinic so that I was seeing kids come in and ingesting their allergen and for the most part, not having a reaction, but sometimes having reactions and how that was handled, what that actually looked like. So I got a very intimate look in both the science and the practice of treating kids with food allergies. And the first thing I noticed was that there was no disease specific validated questionnaire to measure food allergy anxiety. Now, for all of your listeners who have just fallen asleep, trust me, this was fascinating and very, very, very exciting. And what's needed if you're going to design a treatment for food allergy anxiety is you need to have a validated measure questionnaire. That is scientifically validated. So it measures what it's supposed to measure. It has good reliability, it has good validity because you need to use it as a pre and post measure, pre-treatment levels of anxiety, post-treatment levels of anxiety, and then if you do a follow-up, follow up levels of anxiety. So the first thing I did was. Developed that and wrote that and got that validated, which is a very long process, and that is called, I love it. Every time I say it, I'm gonna say it. It's called the SOFAA, which is an acronym for scale of food allergy anxiety. So anyone who wants to take a look at the sofa, it is free for use for clinicians and researchers. And it is housed at chop.edu/sofa, SOFAA. So I developed that and it's a child measure and a parent measure. So children report on their own food allergy anxiety and parents report on their perception of their kids food allergy anxiety. So we have cross informant reports. So that was number one. And then number two is I started to work on a treatment, and I really like therapy that is targeted and focused. I like treatments that are leaned down so they don't have a lot of bells and whistles And fortunately, I'm an exposure therapist, and so exposure therapy lends itself beautifully to very brief and targeted treatments. So thank goodness that aspect of my personality fixed by my choice of profession. And I was already, to some extent, doing the treatment that I ultimately developed as the food allergy bravery treatment, the FAB treatment. And that was. You come in, we assess your level of food allergy anxiety, specifically the amount of medically unnecessary avoidance in which you're taking part, because again, it's the avoidance that is driving the anxiety. Not the other way around. The more you avoid unnecessarily, the more anxious you're gonna be. And then we start a treatment that is exposure based and you start getting exposures in session one. Let me stop here.

Amanda Whitehouse, Phd: 17:04

Yeah, I think that's where a lot of parents go. What? Because they're doing exposure, food allergy treatments, right? OIT, where we're developing a tolerance and perhaps ingesting the allergen. And

Katherine Dahlsgaard, PhD: 17:14

Yes.

Amanda Whitehouse, Phd: 17:14

not what you're talking about, good idea to clarify.

Katherine Dahlsgaard, PhD: 17:18

Oh, absolutely. Well, I've been doing this for so long exposure means something very positive in anxiety treatment, in food allergy exposure, typically, the way the lay public thinks about it is my child was exposed to cross contamination and then ingested the allergen. That's not what I'm talking about when I talk about exposure in the context of treatment for excessive food allergy anxiety, or specific phobia of anaphylaxis. Exposure in this case is, Hey, let's have you practice engaging in safe enough casual contact with your allergens and all of the exposures that we do, none of them of course, are gonna involve ingestion. That's not a good exposure, but rather they are going to be s trategic exposures that are common and common to all exposure therapy, regardless of what phobia you're treating, but also they're going to be evidence backed that they are safe. So, for instance, typically in session one, we do the whiff challenge. The whiff challenge. Oh, we love the Wif challenge, and that is if you're allergic to peanuts, let's open up a jar of peanut butter and have you sniff it. And if you're super, super scared, which would make sense because you're sitting in front of me, we're gonna have you sniff it from a ruler's length of away. And if that's too scary, let's start with it being six feet away. Because often this is the first time the kids have been around their allergen. And then we bring it closer and have you sniff, and I'm gonna give you tons of positive feedback. Those are great, loud sniffs, good brave sniffing. And the child is afraid. And the parent is afraid. And that is okay because guess what happens? And what happens is they sniff and they get afraid. But what doesn't happen is an anaphylactic reaction., And that has real world implications because. Your kid is gonna be around someone who is eating her allergen, right? Your kid is gonna be around someone who's eating a peanut butter sandwich, and they're gonna be able to smell that peanut butter sandwich, and we want them to know, not because I told them or you told them, but via direct experiential proof, oh, it's okay that I can smell the peanut butter. That doesn't cause an allergic reaction, but therapy through telling works about as well as parenting through telling. Exposure therapy works so efficiently and so powerfully because the kids learn it on their own. So that would be an example of an exposure. And then, I personally have parents present in every session. I want parents to see what I'm doing with their kid. I want parents to see how I manage when their kid gets very anxious that when their kid gets anxious, the more anxious their kid gets, the more relaxed I get. And the impression I wanna give to the child, not by telling, but by showing is it's okay if you're anxious. Your anxiety doesn't make me anxious. Let's keep going and do some more good sniffs. But also I want parents there because I want parents to have firsthand knowledge that this is safe enough for their child. And as I say to my students, when I train them to do exposures, I say. I really like having parents present in session because an exposure for the child is an exposure for the parent too, and it's, that is triple the case with food allergy. Parents really often don't know what is safe enough. It's hard to get really accurate information about what is safe enough, and they really, really have to trust a psychologist to do these exposures, which I already know are safe enough because I've read all the research papers and I consulted with a ton of food allergists when I was developing this treatment.

Amanda Whitehouse, Phd: 21:19

What I think is the biggest challenge of working with phobias and anxiety is that even when our logical brain knows this is safe, this is, very unlikely to harm my child, the anxiety reaction and the fear in the body just takes over. So, aside from exposing and experiencing that okayness, it's really hard to shift.

Katherine Dahlsgaard, PhD: 21:38

Yes, and I think parents of kids with food allergy, they get the double whammy because parents of kids with other anxiety disorders, they know that the dog is safe enough for the kid. They know that a separation. Is safe enough for their kid, meaning a temporary separation to, you know, walk down the hall with me and go get like a snack from the fridge at my old office. But those parents are terrified of their kid being terrified because they're afraid that being afraid is gonna harm their child because their experience is, my child is being harmed by being afraid all the time. And what I say to them is, exposure therapy is so efficient. And so powerful that yes, these exposures will have your child be afraid, but the fear will be productive because they're learning a new skill and they're learning that things that they thought were dangerous were safe. So the anxiety is now productive and therefore temporary versus what's going on with your child, where the anxiety is feeding on itself via the avoidance. So the anxiety currently is unproductive and therefore potentially endless With food allergy parents, they're both terrified. I don't wanna see my kid be any more anxious, so why do we have to do exposures that'll make my kid anxious? And then in the back of their minds, even if I hand them the papers. Even if I hand them the handout that we created that gives them sort of the breakdown of what is safe enough they have in the back of their minds, what if my child has a reaction during this exposure? So food allergy parents are my favorite because they do have to put up with a lot of fear to partake in this treatment, and they get through it as well as their kids do, and both parties respond beautifully to the treatment. Because over and over and over, I thought this was gonna happen. I thought my kid was gonna be anxious and it was gonna rip her apart and maybe she'd have an allergic reaction. And it turned out she did get anxious. She didn't have an allergic reaction. And when we went home and did the whiff challenge for homework every day we did the whiff challenge for homework. She got less and less and less anxious. And then I watched her get a little exhilarated, like, oh my gosh, I really am not like, oh my gosh, I can sniff as much as I want. This is safe. And then Dr. Dahlsgaard, I found that she got bored so that by session two, the kid has come back and I've typically assigned the family. This is session one homework, right? You've met me and I'm, we're gonna get going. I've assigned, okay. Do the whiff challenge with different forms of your child's allergen in different rooms of the house. So it's not just that I'm safe to sniff an open jar of peanut butter on my kitchen counter. Three times, it's that I'm, it's safe for me to sniff an open jar of nuts, an open bag of, peanut m and ms in my bedroom, in the living room, in the garage, in my parents' car. Because what I want is quick generalization and generalization means it's not just that this was safe enough to do because I was with my therapist, because now I'm doing it at home. It's not just that this was safe to do because it was a specific allergen that didn't move. As in the case of peanut butter, it is that it's safe to sniff an allergen that is room temperature in all situations, and that is very important because I want your child to be able to go to a friend's house, to be able to go to a picnic, to be able to go to the school field trip and be able to smell peanut butter because people are eating it around her and be very, very, very confident. Oh my gosh. Yeah. Of course. I've done this many times in many situations, and I get to enjoy that field trip. I get to enjoy that picnic just as much as any kid that doesn't have a food allergy.

Amanda Whitehouse, Phd: 25:42

Beautiful.

Katherine Dahlsgaard, PhD: 25:43

that's what I want.

Amanda Whitehouse, Phd: 25:45

Amazing. So would you talk to us then about when the fear extends beyond the specific allergen or proximity to the allergen and into the concept of eating in general? Right. A lot of food allergy parents are becoming more aware of this eating disorder diagnosis called AFRID, which is restricted eating. So tell us about what your thoughts are on that, what you're seeing, and if your approach to that differs any given the broader, fear that shows up with kids who are dealing with that.

Katherine Dahlsgaard, PhD: 26:16

Well, certainly. So in the case of ARFID, ARFID is an acronym that stands for Avoidant Restrictive Food Intake Disorder. And the way for people to understand it is that ARFID is the eating disorder where food is restricted. For any reason that is not due to concerns about body size or shape, that would be food is restricted in the case of anorexia. So in ARFID, it's excessive restriction of food, and there are three broad subtypes of ARFID. The first one is the picky eating subtype, where food's a restricted due to the sensory qualities of the food, the smell, the taste, the texture. The second is the subtype. Number two is The apparent lack of interest or enjoyment in food. That's the way it's written in the DSM. I prefer the, a relative lack of interest or enjoyment in food. And these are the sort of low appetite kids who just kind of need to be reminded to eat. They often also are, low weight kits. They weigh lower than they should not, because again, they're deliberately restricting, but just their, their brain isn't giving them strong hunger cues and so they don't take in enough calories. And then the third subtype is the type that you're talking about. And that is, food is restricted due to excessive concerns about the negative consequences of eating. And this is where an eating disorder and anxiety disorder often overlap. And I treat all three kinds of arfid all day long. And, when I was director of the anxiety clinic, chop. I treated a lot of choking phobia, vomit phobia, and then ultimately food allergy phobia or specific phobia of anaphylaxis. I keep using the term specific phobia anaphylaxis, and I'm guessing that your listeners are saying what everyone should have a specific phobia of anaphylaxis. No. Um, yes. No. So there is such a thing as specific phobia of choking. Right. Everyone should have a fear of choking. The issue is what makes for a phobia is it's an excessive fear of choking, and it is m aintained via all kinds of unnecessary avoidance. So when I treat specific phobia of choking, people over chew their food. They chew and chew and chew, and chew and chew until it's a plum in their mouth. They'll restrict eating solids, only eating liquids. They'll semi restrict solids, et cetera. So when we do exposures for specific phobia of choking the exposure is not to choking, right? That would make no sense. The exposure is to good, fast swallows and racing up the exposure hierarchy to eating, you know, the kind of easy soft foods to the tippy top of the hierarchy, which is always popcorn and steak without question. So that is why specific phobia of anaphylaxis. Of course we wanna be afraid of anaphylaxis, but we don't wanna have that fear rule our lives. So for all of you who are like, I don't think that's a good name, I am gonna stick to that name for what we're talking about specifically of anaphylaxis. So I see kids with specific phobia of anaphylaxis, and if they are not, underweight or weight compromised. I treat it as a straightforward phobia case and the food allergy bravery treatment. The FAB treatment is designed for that presentation, meaning it's a more straightforward phobia case. The kid is normal, weight is not weight compromised, and that treatment is six sessions plus a booster. And the second thing I did after starting the food allergy center is I developed this treatment and then I published the results of this six session with a very small little sample. 10 patients. And we got great results, which is, we got not just significant reductions in the SOFAA, but the effect sizes were also large. And they weren't only large pre and post for the sofa, meaning anxiety came down, but they were also large. On another measure, one I did not write, which is called the F-A-Q-L-Q, which is the Food Allergy Quality of Life questionnaire. We got significant increases and the effect sizes were quite large, meaning that the kids got less anxious and their disease specific quality of life also improved. And we did that with both inpatient, meaning patients coming into the office and COVID hit. And so we finished out treating some of those kids via telehealth. Now that I'm in private practice, I treat only via telehealth and many of my patients come from. Around the country, right? And people often say. Well wait, is it, is it a bad idea to see kids with specific phobia of anaphylaxis over telehealth, over video? And the answer is absolutely not. It can be hard to find a specialist. So my patients who live in other states. It's good for them. But the other is, is that the exposures from day one are taking place in ecologically valid settings, meaning in their homes from day one For kids who present with both specific phobia of anaphylaxis and ARFID subtype three, typically those kids, they have a more severe presentation and they are often weight suppressed, and that means that just over time they haven't gained weight as they normally should. And so they maybe if they were a kid who the universe meant them to be at the 50th percentile, they've now kind of drifted down to the 30th percentile or 25th percentile. Often those kids are also picky eaters, so they have a history of picky eating and they have food allergies, and now they have specific phobia of anaphylaxis, and now they're also weight suppressed. So those kids are a bit more complicated, but I treat them all the time. I would say 50% of the kids that I treat for specific phobia of anaphylaxis or excessive food allergy anxiety also have ARFID I, and in that case, typically I wanna get the kid back up to a therapeutic weight. So initially the treatment is gonna focus on getting them to eat a bit more and gain some weight.

Amanda Whitehouse, Phd: 32:40

So what do you think, is stopping more clinics from popping up around the country? There are some of us therapists working individually, what do you think needs to happen or what will open the door to more of this

Katherine Dahlsgaard, PhD: 32:52

I think there's two things. So the first is that. It is very hard to find an exposure therapist generally, particularly a pediatric exposure therapist. I think exposure therapy still has a reputation among the lay public of being an exotic therapy. It is not, it is the stodgiest, most conservative, most evidence backed therapy that there is. It's been around, you know, 70 years, so it's quite stodgy, but. It is the lucky student who gets a lot of training and exposure when they're in a graduate program. It can be hard to access. So the first is sort of my fantasy, and that is that there's a lot better and more pervasive treatment in this incredibly evidence backed technique. And then the second is one of the things that I'm working on now, and that is. Can people who are other than therapists deliver exposure therapy competently, particularly in the case of food allergy. So I love seeing patients outpatient. I love my telehealth practice, et cetera, but it can be a burden to find a therapist and go to therapy. Wouldn't it be nice if you could go and get this powerful treatment at your food allergist? And not all food allergy centers have a dedicated psychologist. And even if they do, often that psychologist is not trained in exposure. One of the big surprises for me when I, moved over to the food allergy center and I read the literature, is that the word exposure was in none. Zero of the, food allergy, articles written by psychologists. So these were psychologists writing about food allergy anxiety. Typically an exposure was never mentioned. Interestingly, it was the allergists who had mentioned exposure, but without knowing what they were doing. So the, the, the granddaddy paper of them all, or the grandmommy paper of them all really was written in 2016 by UR and roa, and I have forgotten the third author, I'm sorry, but it's called the Transforming Power of Proximity Challenges. And these were allergists, um, an allergist, a physician and a nurse practitioner. And they were the original people who said, well, when kids are anxious, let's have them sniff their allergen during a regular food allergy visit. Let's have them touch their allergen during a regular food allergy visit. And so exposure had been there, but the people who were doing it didn't know. Anyway, so I think that a great way of accessing this would be that we have this treatment be given within food allergy centers, and it can be delivered by a psychologist or a therapist like licensed, um, clinical social worker, or by a nurse practitioner. And so the data that I'm looking at now is from a, a quality. Um, improvement study that the nurse practitioner, the wonderful Megan Lewis at chop, I trained her to do the treatment. We did it together, and now I'm in private practice. She's still at CHOP and she now does the treatment. And I am analyzing the data from 130 patients that she has treated 130 and. Um, preliminary results look very, very good. So that would be my hope that a treatment like the fab treatment or treatment like it efficient, focused, short, effective gets into food allergy centers.

Amanda Whitehouse, Phd: 36:52

That would be amazing. You said not very many allergist office have mental health practitioner on staff, but I would argue that almost none of them do. I, I know of very few. Practices that that operate that way. And it's difficult to understand why, because it just goes so hand in hand so nicely, the way you're describing.

Katherine Dahlsgaard, PhD: 37:09

Yes. You know, I, I was thinking about academic medical centers, right? That's where I've cut my teeth and. You know Penn, university of Minnesota, NYU, and then CHOP. So I'm used to in, you know, GI centers or food allergy centers. There is a pediatric psychologist, but you raise a really good career opportunity for psychologists and therapists, and that is what if I embed myself in a food allergy office? Not full-time. Wouldn't have to be, but it could be. Right. So part-time, because you will get these patients and you will be able to help them. There's this, Megan and I just wrote a paper. It was a review paper for Annals of, uh, allergy, asthma, and Immunology, and it was just published 2025. And it was a review of using exposure in the context of food allergy and. Megan wrote much of the discussion I just thought it was so beautiful and she said, for people who do this treatment, it will be an incredibly satisfying part of your career. So Megan. Who had never done exposure therapy. Why would she? She's a, decorated nurse practitioner now is saying, and will say to me, this is one of the most satisfying aspects of my career. I love doing it. So I think those of you therapists who are listening. Get ready to be very, very happy.

Amanda Whitehouse, Phd: 38:41

Wonderful. What better outcome? We can't make the allergies go away, but to make that anxiety go away and to help people live their lives more fully, like you said earlier in the conversation, what could be more rewarding

Katherine Dahlsgaard, PhD: 38:51

I think the thing I'd like to talk about is the parents. So parents come to me with their child and they are often. And they acknowledge this sheepishly to me, I think I'm more anxious than my child is. And first off, parents, there's no reason to be sheepish. No one is gonna make fun of you for having anxiety. Your kid has a potentially lethal medical condition.

Amanda Whitehouse, Phd: 39:18

Right, and they've been traumatized usually by witnessing that life-threatening reaction. That's often how things are diagnosed, unfortunately. So

Katherine Dahlsgaard, PhD: 39:26

Yes.

Amanda Whitehouse, Phd: 39:26

real trauma.

Katherine Dahlsgaard, PhD: 39:28

Yes, definitely. So I would like to address the bravery of the parents that I see and say, good for you for pursuing treatment for your child, recognizing that it was also going to be treatment for you. And yes, as a parent you are allowed To seek treatment on your own if you have excessive anxiety and your kid does not. So I have seen parents where they come to me and I assess their kid and I say, okay, I don't think your kid actually needs treatment, but I think you do. Will you allow me to treat your anxiety? You will respond as beautifully to an exposure protocol as your kid would, but you need it. They do not. But I also have parents who have come to me, particularly of toddlers, who say, yep, I'm afraid to give my toddler. I already know she's allergic to peanuts and I'm afraid to give her any other new food. I know that I am potentially, you know, limiting her life by, by doing this, I feel terrible. I'm anxious all the time. Can I have treatment? And the answer is yes. You will respond just as well. To an exposure based protocol as your kid would. The, radio station when the treatment paper first came out to one with just the, the 10 kids, the local, public radio station in Philadelphia did a story on us and they interviewed some of the parents. So some of the parents agreed to be interviewed and. There was a mom who I think on the interview was crying and saying, this has changed my kid's life, but it's also changed our life. And there is no greater gift to a psychologist than a parent who is sobbing in happiness.

Amanda Whitehouse, Phd: 41:21

Yeah. Thank you so much for that work that you're doing, because I know it's reaching so many and now extending beyond with the research and the tools that you're sharing. The whole food allergy community is excited about it and appreciates it. I think it's so important.

Katherine Dahlsgaard, PhD: 41:33

Thank you very much. It is. It is my pleasure. Part of what's great about food allergies is that your kid does get some education in being brave. And I wanna be clear about what I mean. So being brave is not going through life and doing hard things because you don't feel fear. It is being afraid and getting the job done anyway. And as much as I do not want any child to suffer unnecessarily, I do not want any child to be burdened by any Chronicle medical condition. But the reality is, is that some children are, and so my kids with food allergies, they are getting an early education in, well, I gotta keep myself safe and this is how I'm gonna do it, and this is how I'm going to function well at the level of my peers. I think the greatest gift that we can give our children, particularly if we have kids whose brain tilt a little hot, as I call it, meaning tilt, a little anxious, is multiple, as many as possible as pervasive as possible examples and practice at functioning while anxious. Yep. I know you're anxious and you gotta go to school and I'm your mom and I care about you and I'm not fighting you. I'm fighting anxiety. I'm on your side against anxiety. Yep. You gotta go to school. Nope. I'm not gonna ask for an accommodation to get you out of doing public talks at school. Because I want you to learn you can function while you're anxious. The more kids have that experience, the stronger they are and the more confident you as a parent are going to be about their ability to navigate life when they're no longer living with you.

Amanda Whitehouse, Phd: 43:29

Beautifully said. Thank you so much for sharing that and everything that you shared

Katherine Dahlsgaard, PhD: 43:33

Oh, my pleasure. I, I, I just love your work as well, so thank you so much.

43:39

Talking with Dr. Dahlsgaard has been a good reminder that food allergy anxiety isn't just a feeling, it's measurable, it's addressable, and it's even transformable with empathy and expertise. So if you are ready to turn deeper awareness into meaningful action, here are three steps that you can take to carry forward today's insights. If you want to dive deeper, you can read her recent article and learn more about the proximity challenges that she told you about today. You can check out the SOFAA scale, S-O-F-A-A. The link will be in the notes. You can download the parent or the child version from the Children's Hospital of Philadelphia and notice what it reveals to you about the anxiety that you're managing and. Number three, I just want you to think about this word bravery. I want you to think about your own bravery cues. About how you can tie that word brave into the actions that you're already taking to manage your anxiety, Weaving that word and that concept and the physical feeling of bravery into everything you're doing can bring an extra power and shift so thank you so much for joining me for this courageous exploration with Dr. Dahlsgaard. And as always, I ask that if you like what you're hearing, please subscribe to the podcast, share with another family who might benefit from listening. And if you really wanna help me out and spread the word, you can leave a review wherever it is that you listen to your podcasts. the content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse Thanks for joining me. And until we chat again, remember don't feed the fear.