Are children and adolescents with food allergies at increased risk for psychopathology?

Highlights

• Concurrently, food allergies were associated with some psychopathology symptoms.

• Over time, food allergies predicted increases in generalized anxiety/depressive symptoms.

• Food allergies were not linked with psychiatric diagnoses.

• Select increases in psychopathology symptoms are likely adaptive in the context of food allergies.

Abstract

Objective

Living with food allergy is a unique and potentially life-threatening stressor that requires constant vigilance to food-related stimuli, but little is known about whether adolescents with food allergies are at increased risk for psychopathology—concurrently and over time.

Methods

Data came from the prospective-longitudinal Great Smoky Mountains Study. Adolescents (N = 1420) were recruited from the community, and interviewed up to six times between ages 10 and 16 for the purpose of the present analyses. At each assessment, adolescents and one parent were interviewed using the Child and Adolescent Psychiatric Assessment, resulting in N = 5165 pairs of interviews.

Results

Cross-sectionally, food allergies were associated with more symptoms of separation and generalized anxiety, disorder, attention deficit and hyperactivity disorder, and anorexia nervosa. Longitudinally, adolescents with food allergy experienced increases in symptoms of generalized anxiety disorder and depression from one assessment to the next. Food allergies were not, however, associated with a higher likelihood of meeting diagnostic criteria for a psychiatric disorder.

Conclusion

The unique constellation of adolescents' increased symptoms of psychopathology in the context of food allergy likely reflects an adaptive increase in vigilance rather than cohesive syndromes of psychopathology. Support and guidance from health care providers is needed to help adolescents with food allergies and their caregivers achieve an optimal balance between necessary vigilance and hypervigilance and unnecessary restriction.

Introduction

Food allergies are increasingly prevalent and pose a significant public health burden [1], [2]. Prevalence estimates range from 2 to 8% [3], and vary within that range depending on the food allergen(s) assessed, the methodology used, and the region and historical period studied [4], [5]. A recent National Health and Nutrition Examination Survey (NHANES) study, using specific serum IgE levels as an indicator, estimated the prevalence of clinical food allergies to four common allergens (peanut, milk, egg, shrimp) at about 2.5% in the US population, with higher rates in 1–5 year-olds (4.2%) and 6–19 year-olds (3.8%) than among older age groups [6].

Living with food allergies constitutes a unique stressor: Daily meals and snacks can trigger a rapidly-progressing, life-threatening allergic reaction. This stressor is both chronic and acute: For years, youth face the daily threat of accidental allergen ingestion compounded by acute stress during allergy-related health crises [7]. Strict allergen avoidance is the best known strategy to manage food allergies [8]. Consequently, successful management requires careful attention to external food-related cues, such as being offered food, and internal, somatic cues associated with food-induced allergic reactions, including skin, gastrointestinal, respiratory, and cardiovascular symptoms. Despite the significant number of US families affected by stressors experienced in the course of this chronic illness, and the constant vigilance to food-related stimuli that is required, relatively little research has focused on the psychological sequelae of living with food allergies. Indeed, a recent meta-analysis of 340 studies that tested associations between chronic physical illness and depressive symptoms in children and adolescents did not include data on food allergies [9].

One extant line of research has examined how quality of life is impacted by food allergies, with a recent review [7] indicating that youth with food allergies reported lower health-related quality of life, more physical symptoms, and higher scores on select anxiety inventories [10], [11], [12], [13]. Specific fears reported included separation anxiety, fear of adverse events, and anxiety about eating [14], [15]. The majority of this work, however, was based on relatively small samples that were recruited in specialty clinics and hospitals, thus limiting the generalizability of the findings. To our knowledge, only one study has examined linkages between food allergies and a range of psychiatric diagnoses in a larger-scale community-based study [16]. Using the Canadian Community Health Study with participants aged 15 and older, it found that self-reported food allergies were associated with an increased 12-month prevalence of several mood and anxiety disorders (major depression, panic disorder/agoraphobia, bipolar disorder). This study was cross-sectional, however, and, while informative, did not address the longitudinal impact of food allergy on psychopathology.

The present study examined cross-sectional and longitudinal associations between food allergy and psychopathology symptoms and diagnoses and extended extant research in several ways. First, we used a community-based epidemiological sample of adolescents. Adolescents in this study were recruited from the community; thus generalizability of findings will not be limited to care-seeking clinic-based samples. Second, we expanded the range of psychiatric symptoms and diagnoses examined to include disruptive and eating disorders. The extension to eating disorders is important considering the constant food-related vigilance required in the context of food allergies. The extension to disruptive disorders is important, because this group of disorders tends to be comorbid with internalizing disorders [17], and also often precedes later internalizing disorders [18]. Third, in order to better understand whether—given the unique stressor that they encounter—adolescents with food allergies present a specific pattern of psychopathology symptoms, we conducted a symptom-by-symptom analysis. Fourth, we tested whether associations between food allergies and psychopathology differed by sex. Sex differences have been suggested by other work on atopy/allergy, but are only rarely tested in work on food allergy [19]. Finally, in order to rule out alternative explanations, we adjusted for the presence of other atopic conditions and medication use when testing associations between food allergies and psychopathology. We focused on ages 10 to 16, an age-range at which responsibility for the management of food allergies is increasingly transferred from caregivers to their children, and toward the end of which risk for serious anaphylactic reactions peaks [20].