Earlier this month, experts reviewed what allergists should consider when conducting in-office proximity challenges for patients facing food allergy anxiety.1,2
The report addressed frequently asked questions, such as what attitude should I convey to my patients regarding proximity challenges? Or: how do I assign proximity challenge homework?
Katherine Dahlsgaard, PhD
Credit: X
HCPLive spoke with the authors of the review, psychologist Katherine K. Dahlsgaard, PhD, ABPP, from Brave is Better LLC – Therapy and Consulting in Philadelphia, and Megan O. Lewis, MSN, RN, CPNP-PC, from Children’s Hospital of Philadelphia, regarding food allergy anxiety management.
Megan Lewis, MSN
Credit: CHOP
HCPLive: What are the most common manifestations of food allergy anxiety among pediatric and adult patients?
Lewis: What Dr. Dahlsgaard and I see a lot of is suffering in silence. People start to do things because it proves itself useful, like not keeping the allergens in the house, or not going out to eat. When they don’t have a reaction, it reinforces that. What we see is people engaging in a lot of unnecessary avoidance…not going to that birthday party because they’re not sure of what they would eat. We see a decreased quality of life and this chronic worry for families because food is everywhere.
Dahlsgaard: The thing that maintains an anxiety disorder, any anxiety disorder… is unnecessary avoidance. In the case of food allergy, what we mean is medically unnecessary avoidance.
We want kids to engage in medically necessary avoidance…Please carry your EPIPen with you everywhere. That’s a good amount of anxiety. The excessive anxiety is maintained by the medically unnecessary avoidance…I won’t have casual contact with my allergens. They’re not in my house. I eat at a separate lunch table…but meanwhile, the vast majority of kids with food allergies…sit at the regular lunch table, and they don’t have allergic reactions either, and that is because casual contact is safe enough for kids.
HCPLive: You describe proximity challenges as comparable to CBT exposure tasks. How would you summarize the core principles of exposure therapy as they apply here?
Dahlsgaard: For all anxiety disorders, the evidence-based treatment is…exposure-based…cognitive behavioral therapy.
Most parents and kids, when they hear the word exposure, think, “Wait. Exposure means I’ve been exposed to eating my allergen, and that’s dangerous.”
What we mean when we talk about exposure is: We’re going to expose you strategically to safe enough casual contact…so you get direct experiential proof that sniffing your allergen…is safe enough.
You do that repeatedly, you will find out, “Oh, I do these things…I can keep myself safe. And so, the next time I’m at a picnic or on the school field trip [and] someone next to me is eating a peanut butter sandwich…I don’t have to worry that I’m going to have an allergic reaction because I’ve practiced…over and over and over the exposure to sniffing my allergen. So, I can enjoy the picnic.”
HCPLive: What distinguishes a well-designed proximity challenge from an unstructured or unhelpful encounter with an allergen?
Dahlsgaard: A good one is designed to provide a disconfirming experience. It should be strategic, should have a goal in mind, and should have real world application.
It’s touching your allergen, then…washing your hands for 20 to 30 seconds with soap and water and then going around. You can touch anything…You can even touch food that you’re now eating because you have removed the protein from your hand, so it is now safe.
We do that because kids believe that if they touch their allergen, it will soak in through their skin and cause an allergic reaction. And maybe their parents’ kind of sort of believe that, too.
Bad proximity challenges [are] not repeated. We do them multiple times in our sessions, and we do them with parents’ present…We assign it for homework so that they can repeat it with different forms of their allergen, not just touching peanut butter, but touching peanuts and… peanut M&M’s…in different rooms of their house as well as outside in the world.
HCPLive: In the review, you noted that proximity challenges aren’t always decreasing anxiety in the moment. Could you elaborate on how clinicians should instead frame success?
Dahlsgaard: With children, we might rate loud sniffs: “Good job sniffing.” Or: “I can see that you’re anxious. That means this exposure is working.” “Beautiful job touching your allergens.”
A misconception…is that exposures shouldn’t make the kid anxious. What we say is, your kid is already anxious all the time…but their anxiety is unproductive and therefore potentially endless. Whereas with exposure, it’s going to be productive anxiety. Your kids [are] going to be temporarily more anxious, but it is in the service of finding out [the] truth, and that is, I can’t have an allergic reaction from sniffing a room.
HCPLive: What kind of training or preparation do you recommend for allergists or primary care providers who want to integrate proximity challenges into their practice, but don’t have a background in psychology?
Lewis: We received funding at the Children’s Hospital of Philadelphia to build a clinic to help address anxiety around food allergies, and through a really wonderful partnership with Dr Dahlsgaard and myself and Dr. Spergel, we were able to launch the Food Allergy Bravery Clinic.
One of the missions was to help identify patients who have unnecessary avoidance. We developed a screening measure called the SOFAA, the screening of food allergy anxiety. There’s a parent form and a child form, and it’s publicly available. Anyone can download it and use it in their practice to identify patients.
HCPLive: How would you handle a parent who is highly anxious and may unintentionally reinforce their child’s avoidance?
Dahlsgaard: We designed [the] treatment to have parents present in every session…because we want parents to get the same disconfirming experiences that their kids are doing…that will… result in a in a lessening of anxiety for them, and not just a lessening of anxiety, but also increased confidence that they, the parent, are competent to parent a child with food allergy anxiety and confidence in their child’s ability to navigate a world where their allergens are all over the place.
Lewis: We often start off our session talking about that, like that must have been terrifying to see your child need 3 doses of epinephrine, or to be in the emergency room, or to call 911…It can be a varying degree of experiences for families that can feel terrifying, but living with that fear for the whole family is not helpful.
Dahlsgaard: One of the things that did not make it into our paper…was parents who had written feedback about having gone through the treatment with their child and…how life transforming it was for not only their child, but the whole family.
HCPLive: Do you recommend proximity challenges for patients with a history of severe anaphylaxis?
Dahlsgaard: Without question, yes. Anaphylactic reactions…are absolutely scary, but you can also learn from them.
Lewis: We still remind them of important safety behaviors like carrying your epinephrine. We don’t want to take away their adaptive anxiety that’s keeping them safe by reading labels and carrying epinephrine. We still encourage all those safe behaviors, but also things that are safe enough to do.
References
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Dahlsgaard KK, Lewis MO. Want to help your patients with food allergy anxiety? Do proximity challenges! Ann Allergy Asthma Immunol. 2025 Mar 13:S1081-1206(25)00099-7. doi: 10.1016/j.anai.2025.02.020. Epub ahead of print. PMID: 40088945.
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Derman C. How To Go About Proximity Challenges for Food Allergy Anxiety in the Clinic. HCPLive. May 7, 2025. https://www.hcplive.com/view/how-to-go-about-proximity-challenges-for-food-allergy-anxiety-in-the-clinic. Accessed May 29, 2025.
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