TERIA, much more than a childhood mania for certain foods

There are children who have many eating habits and reject bananas, peppers, broccoli or fish. It seems that they will continue like this all their lives, but they get over it over time without their food preferences affecting their health. This is not the case of children suffering from TERIA (Avoidant/Restrictive Food Intake Disorder): for different reasons, they restrict the number of foods they consume so much that they cause serious nutritional deficiencies and their social, emotional, school and family life. Are affected.

“We had a patient who only ate bread, onion rings and French fries,” explained Dr. Mariela de los Santos, a pediatrician and part of the Gastroenterology and Nutrition team, and psychologist Eduard Serrano, from the Sant Joan de Déu Hospital. the Eating Disorders Unit. They describe the TERIA, or also known as ARIFD for its acronym in English, “as a selection or restriction of food that has the repercussion of a nutritional deficit or a significant loss or gain of weight, psychosocial interferences such as problems at home or not being able to attend activities common as going on excursions or camps”.

Some patients are diagnosed with malnutrition that requires admission. “TERIA is taking to the extreme not wanting to eat specific things and, sometimes, in a certain place. They are not capricious children or bad eaters because, unlike them, those who suffer from TERIA do not adapt and if they are not given what they have chosen to eat, they will not eat”, explains De los Santos. “Their hunger signal is altered to such an extent that they stop eating. Some don’t even drink water. And others, of those few foods that they eat, eliminate some because they get tired of them”.

Dr. Belén Unzeta Conde, coordinator and psychiatrist of the Eating Disorders Unit of the Santa Cristina University Hospital, agrees with the above. “Eating problems during childhood have been described over time by various authors. The diagnosis of TERIA was included in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, in 2013, as a new diagnosis within Eating and Eating Disorders (TAI) to describe a group of patients who have avoidant eating behaviors. or restrictive that are not motivated by a change in body image or a desire to lose weight.

In fact, the TERIA diagnosis is not compatible with anorexia. “They are exclusive,” says De los Santos. “The fear suffered by patients is not of gaining weight nor do they have a distortion of their personal image, although TERIA can coexist with other mental health problems.” Sara Bujalance, director of the Association Against Anorexia and Bulimia, a psychologist specializing in EDs and part of the PIATCA Program, clarifies that TERIA is not manifested by a lack of access to appropriate food either, but that we will always see how the patient’s health it has gotten worse. For this reason, early diagnosis is key, as it determines to what extent there will be physical health consequences and, in turn, food restriction may not yet be as high.

TERIA manifests itself in the prepubertal stage, around 9 years of age, but it may have started earlier and is not exclusive to childhood, although it is when it is diagnosed the most. There are three profiles:

1. The inappetent, those who have never been big eaters and for this reason have always been underweight. It is believed that the origin may be caused by a dysfunction in appetite hormones, the amygdala or the taste cortex.

2. The sensory or selective, which occurs in children who reject certain textures, colors, flavors or shapes, or who only eat a specific brand of food. The hypothesis is that this profile is due to the hyperactivation of brain areas and is common in children on the autism spectrum. “These first two groups -Unzeta points out- generally appear during the first years of life, having a chronic presentation, and whose selectivity becomes evident when introducing more whole foods”.

3. The anxious or aversive, where the anxiety generated by the fear of suffering from food, be it choking, vomiting or a stomach ache, is greater than hunger and children stop eating what they perceive as a danger potential. It is theorized that this is a possible reaction to having choked or witnessed choking, as well as having suffered from anaphylactic shock or gastroenteritis. Any other traumatic event unrelated to food may also have occurred, according to Unzeta: “the death of a family member, the start of treatment with any medication, a hospitalization or medical procedure.” This variant is the one seen in adults: they have suffered a traumatic episode that has led to TERIA and they may have other pathologies such as anxiety or obsessive-compulsive disorders, as well as avoidance behaviors that involve eating food in a social context.

“In general, they have an anxious temperament and hypersensitivity to bodily sensations, so when faced with a traumatic feeding experience, their fear increases rapidly. This leads them to overestimate the probability that this event will be repeated over time with the same or different foods and, because of this, they begin to limit their intake of what caused the trauma and then expand it to similar foods. In severe cases they limit all solid intake, and consume only liquid or soft foods. To avoid these foods, they also do not expose themselves to situations where they can taste them, thus eliminating negative predictions about the danger and safety of food. The aversive or post-traumatic presentation can present throughout the life cycle and occur in combination or independently”, describes Unzeta, who points out the psychiatric comorbidity of TERIA with mood, anxiety and obsessive disorders, post-traumatic stress disorders, autism spectrum disorders and attention deficit hyperactivity disorder. “Most of the patients are very young, mostly men, and have been sick longer than in other eating disorders. TERIA has a prevalence of 14%–23% in patients diagnosed with eating disorders”.

The data are similar to those presented by Dr. Manuel Durán Cutilla, psychiatrist and care coordinator of the ED Clinic of the Institute of Psychiatry and Mental Health of the Gregorio Marañón General University Hospital, and part of the PIATCA Program: “Since it is a relatively recent diagnosis there are no long-term follow-up studies. Some studies prior to 2013 in which patients with clinical characteristics similar to TERIA were studied reflected a prevalence of around 19 to 26.7% in our clinics and 3% in the general population. The first studies after the inclusion of the new diagnosis place the prevalence between 5-14% in a sample of children and adolescents receiving treatment in a North American hospital and 23% in another sample of patients in a day hospital. In the adult population, the prevalence figures would be around 9.3%”.

Suspecting that someone close to you may have TERIA, you should go to the corresponding primary care doctor or pediatrician, who will examine symptoms such as dysphagia, abdominal pain, reflux, nausea, anxiety and slow eating. Lack of interest in eating from early childhood, weight loss or malnutrition, verbalization of lack of appetite or gastrointestinal disturbances, eating little, fear of vomiting, choking or swallowing, rejection of food, avoidance of socializing because of food or family conflicts related to eating are other indicative signs of TERIA. “The usual thing in childhood is that you have an aversion to one or more foods: it is part of development and you should not pathologize it. For this reason, the one who will determine if TERIA exists will be a mental health team”, affirms Bujalance.

Is the TERIA the fault of the times in which we live? Serrano argues that no: “these children have always been there, but they were called by other names and there was no consistent diagnosis like now, which encompasses everything to be able to systematize it. TERIA can be a daily conflict at home that perpetuates the problem. The relationship with food is both physiological and social. If it becomes an ordeal for you and your environment insists in inappropriate ways, it ends up conditioning you and stops being a potentially pleasant stimulus to become a problem. That is why it is very important to talk to the families and make them blameless: the child has not stopped eating because he has not been educated well, but there are other causes”.

Bujalance says that the diagnosis of TERIA brings some relief to families because they can finally understand what is happening to their child and, at the same time, it helps to sort out the atmosphere of worry and tension that worsens meal times. “Treatment must be started to understand what is worrying the child, what is behind his disorder” and for this, says Cutillas, it will be essential to determine which subtype of TERIA is affecting the patient. Cognitive therapy may be proposed to restructure those thoughts that exaggerate fears, as well as exposure to food and its gradual incorporation.

In cases where there are nutritional deficits, the patient must take supplements to regain health. In addition, the experts consulted affirm that it is vital to be able to work with families and some units create support groups for parents. Depending on the patient, speech therapy focused on swallowing may also be recommended. “There is treatment for all profiles and those affected end up expanding their food repertoire, although we never know what their ceiling will be,” concludes Serrano.