Anorexia nervosa has been reported beginning at age four (4). Childhood anorexia should fulfill criteria for adolescent- or adult-onset anorexia nervosa, except that in children, due to a diminished amount of body fat, a 25 percent weight loss is not necessary. In female childhood cases, primary amenorrhea occurs.

The incidence of prepubertal anorexia nervosa is three percent in a series of 600 consecutive patients of all ages evaluated for anorexia nervosa at the Mayo Clinic (5). Females comprise 73 percent of all reported children with anorexia nervosa (4). However, in one subgroup of anorectics (see below), 50 percent were males (6).

Developmental antecedents of childhood anorexia have not been systematically research (7). Delaney and Silber (8) evaluated approximately 30 cases and noted lack of stage-specific negativism at age two, anxious clinging behavior upon commencement of school, and difficulty maintaining peer relations, leading to a degree of social isolation.

In infants ages nine to 29 months, Chatoor and Egan (9) described a developmental disturbance which they consider to be both a separation disorder and a form of infantile anorexia. These infants were noted to have a diminished growth rate and food refusal. Feeding became a battleground for maternal-infant autonomy struggles. The infants resisted feeding as a manifestation of their independence from an overwhelmingly strong maternal figure. The child's fight for independence through anorexic behavior is sharply contrated to the listless marasmic pattern that characterizes the withdrawn underfeeding in anaclitic depression (10).

Latency-age children, at the Piagetian stage of concrete thinking, conceptualize food and water together as one entity, resulting in global ingestive restriction. This may lead to rapid weight loss and serious dehydration. In addition, prepubertal children, especially girls, have less body fat than their adolescent counterparts and become more quickly emaciated (11). In Irwin's series, over two-thirds of the children with anorexia were hospitalized within six months of the onset of the anorexia. Gislason (4) noted one death in 33 children with prepubertal anorexia nervosa.

Sargent (6) described three subgroups of prepubertal anorectics. The first group, similar to one described by Pugliese et al. (12) severely restricted their food intake, resulting in short stature. They had fears of becoming obese, and by their deficient weight gain they maintained both a physical and psychological immaturity. The second group consisted primarily of prepubertal females, ages ten to twelve, who were psychologically pseudo-precocious, engaging in overt behavior more characteristic of that of a pubescent 14-year-old. However, they were described as being "lost little girls" underneath this facade. Their parents discouraged age-appropriate behavior and strongly encouraged their pseudo-adolescent behavior. This female subgroup is closet to the pubertal-onset anorexia nervosa. The third subgroup consisted of an equal number of male and female anorectics who were more psychologically impaired, having major ego deficits with the occasional prescence of psychotic episodes (13).

Gislason (4) noted premorbid personality characteristics of dependency, timidity, schizoid traits, with features of depression. Significant disturbances of ego development, prepsychotic personality traits, and psychotic episodes have been reported (4). However, these studies were completed prior to the more precise DSM III diagnostic criteria. Moreover, premorbid eating disturbances, including a history of being a finicky eater, have been noted (11).

Family patterns in childhood anorexia nervosa have not been systematically studied. Family structural characteristics found in adolescent anorexia nervosa, consisting of rigidity, lack of conflict resolution, and triangulation, appear to be present in the families of children with the disorder (11). In childhood anorexia, Sargent (6) noted increased divorce among families, as contrasted to adolescent anorexia where the family divorce rate is approximately equal to the general population.

The clinical manifestation of childhood anorexia nervosa should fulfill most DSM III criteria. However, since prepubertal children, especially girls, have less body fat than their adolescent counterparts, a 15 percent reduction in body weight should be sufficient for diagnosis (11,14). These children, while recognizing that they are thin, deny feeling fat. It is unclear if there is a body image distortion equivalent to that of older anorectics. Furthermore, no systematic comparative studies in children have been undertaken. The child may be more concerned with separation-individuation issues than fears of sexuality (11,15). They frequently demonstrate alexithymia, the inability to translate one's feelings into words (16).

Overt or covert seduction or sexual abuse may be found in the histories of some patients, although Bruch (17), Blinder (18), and Piazza (19) question this hypothesis. Sloan and Leichner (20) reported childhood sexual abuse in a number of adult patients with bulimia nervosa. Oppenheimer et al. (21) reported that two-thirds of 78 eating disorder patients spoke of distressing sexual experiences as a child, including sexual abuse. However, the significance of a history of sexual abuse for the occurrence of anorexia nervosa remains unclear.

Many children with anorexia nervosa manifested signs of depression. These feelings may be the result of helplessness and ineffectiveness internally perceived and mirrored from family attitudinal reactions. Studies reported prior to DSM III did not utilize structured interviews such as Kiddie SADS. In child anorectics, no formalized studies specifying biochemical, diagnostic, or family criteria for major depressive disorders have been reported. While anorexia nervosa has been considered a variant of affective disorder (22,23), the relationship between childhood anorexia nervosa and affective disorder must still be clarified.

Anorexia nervosa has been associated with Tourette's Syndrome (stereotyped movement disorder) (24,25,26) with Turner's Syndrome, a chromosome disorder with XO genotype and gonadal dysgenesis (27), and with mental retardation (28).

Piazza (19) reported anorexia nervosa in association with childhood ulcerative colitis and ileitis. The patient manifested typical bowel symptoms with diminished appetite, and only upon careful questioning was the diagnosis of anorexia nervosa determined. One child had anorexia nervosa and abdominal complaints which initially masked colitis.

The etiology of childhood anorexia is uncertain. Irwin (11) feels dynamics in childhood anorexia nervosa are similar to the dynamics of adolescent onset and include identity disturbance, failure of separation/individuation with fears of growing up, maladaptive attempts to be in control, and failure of parents to resolve marital or family conflicts. An alternative pattern may include a child who is sensitive to family food preoccupation and identifies with a family member who has an eating disturbance.

Precipitating events associated with the onset of childhood anorexia nervosa include: 1) the birth of a sibling; 2) dereavement over the death of a parent or relative; 3) a disappointment in object relations; 4) family discord; 5) viral illness; 6) peer criticism about being fat; 7) the fear of becoming obses; 8) the onset of breast development; 9) sexual abuse; 10) sustained fear of choking while eating; 11) anticipated fear of parental loss related to an ill or depressed parent; and 12) the onset of a psychophysiologic disorder such as ulcerative colitis (4).

In the treatment of the childhood anorectic, the therapist should work closely with a pediatrician to rule out medical and psychological conditions producing anorexia. A physical examination and laboratory studies are mandatory to monitor starvation effects which include: 1) hypotension; 2) syncope; 3) bradycardia; 4) hypothermia; 5) dry skin; 6) lanugo hair; 7) diminished triceps skin-fold thickness; 8) hypoglycemia; 9) hair loss; 10) sensitivity to noise; 11) leukopenia; 12) fatigue; 13) cardiac arrhythmia; 14) electrolyte disturbance; 15) hypothalamic dysfunction; 16) diminished thermoregulation; 17) hypercortisolism; 18) vasopressor regulation; 19) gastric ulcer; and 20) initial motoric hyperactivity. Starvation can cause psychological and cognitive disturbances including food preoccupation, poor concentration, social isolation, depression, and labile moods (29).

Children, especially those restricting both fluids and food, may need immediate hospitalization. A children's inpatient psychiatric unit can be effective in resolving both physiologic and psychological problems (15,30). The dietician must determine the appropriate caloric intake for the child. Calories and nutrients not ingested due to food refusal must be supplemented by liquid intensive formula per mouth, or by tube feeding if necessary. Parenteral hyperalimentation is rarely necessary for childhood anorexia.

Most children's psychiatric inpatient unit use flexible behavioral modification approaches to weight gain. Unlike adolescent or adult behavioral programs, children should be allowed to attend all ward activities regardless of specific weight gain (15). Overactivity on the ward must be monitored and controlled to avoid weight loss. Panikar (31) used a wheelchair to restrain a severely overactive child. The schizoid, withdrawn child can be rewarded with points, tokens, etc., for engaging in verbally expressive social interaction. More intensive involvement of the family in the therapeutic pain may have to await medical stabilization and emerging data concerning developmental history, effects of separation (positive and negative), and family strengths and liabilities.

Play therapy using projective techniques can be useful. While children ages ten through twelve may feel too old for play therapy, they may not be cognitively prepared for verbal therapy. They may also be resistant in therapy; therefore, therapeutic creativity is needed. Panikar (16), noting alexithymia, draws smiling faces and asks the childre to identify various moods. Affective expression can be encouraged, such as in Gardner's "Thinking, Talking, and Feeling Game" (32). Lucas (33) finds art therapy to be particularly effective when compared to play therapy which the anorectic child often resists and obscures.

Feinstein (34) alternating both male and female therapists, recognizes that the child can work through separate conflicts with different therapists.

Sargent (6) modifies treatment according to the three anorexic subgroups described above. In the first group of anorectics, with growth retardation described by Pugliese et al. (12) the social worker and nutritionist meet on a regular basis to improve caloric intake. Pugliese uses a cognitive approach, informing the children that they need to eat to be strong and grow.

In Sargent's (6) second group of precocious females, individual psychotherapy explores the child's underlying separation, identity and sexual conflicts and her need to recognize feelings of ineffectiveness and confusion. The parents must recognize their need to push their daughter into premature adolescence and must work with a dietician to promote normal caloric intake.

In the third group, the therapist must assist the child in recognizing his own sense of worth and must establish a strong therapeutic alliance encouraging normal ego development, interpreting, countering, and ameliorating what may be a chaotic enviornment in the family. The parents, often having severe psychopathology, need to resolve their own conflicts to stabilize the family. With such a family setting, a period of hospital separation may be a beneficial opportunity for clarification, intensive therapeutic focus on the child, and emergency of diagnostically significant elements of family psychopathology masked by the dramatic nature of the child's anorexia.

Chatoor (35), in her treatment of infantile anorexia, uses ten food rules, including restricting a specific meal time to thirty minutes and refraining from emotionally laden comments. The goal is to allow the infant to reexperience hunger in a neutral, time-limited setting. In some cases, the mother may need to work through her own internal conflicts (9).

The prognosis in childhood anorexia is unclear. Sargent feels that the group II females have less individual and family psychopathology, and have the most favorable outcome as contrasted to group III, since both individual and parental psychopathology are severe. The group I prognosis is intermediate between groups II and III. Delaney and Silber (8) noted male anorectics with a poor prognosis and reported that many families have been resistant to follow-up. Gislason (4) summarized and reported cases of prepubertal anorexia and noted that 63 percent improved, 21 percent did not improve, and 3 percent died.

Russell (36) found prolonged delay of puberty (a late menarche) and possible permanent interference with growth in stature and breast development in children with prepubertal anorexia nervosa. In contrast, Pfeiffer, et al (37), noted relatively minimal growth retardation on a several-year followup of treatment. He stresses the importance of identifying childhood anorexia nervosa and returning the children to an optimum weight to safeguard their puberty. A long-term followup is necessary to accurately determine prognosis.

Anorexia nervosa has been reported in prepubertal children, many of whom appear to be more disturbed than adolescents with the same disorder. The precise etiology is uncertain, but life events centering on losses and separation may be onset factors. Due to less body fat and ingestive restriction of both food and water, this disorder may be more ominous in children, necessitating a rapid and vigorous therapy and frequently requiring inpatient treatment. Prognosis is guarded and uncertain. Furthermore, coexistent medical illnesses, colitis, or ileitis require careful physical examination and diagnostic procedures and comprehensive integrated treatment and management.