Also see: Bulimia in Children
Anorexia nervosa has been reported to
occur as early as age four . 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 . Females comprise 73 percent of all reported
children with anorexia nervosa . However, in one
subgroup of anorectics (see below), 50 percent were
Developmental antecedents of childhood
anorexia have not been systematically researched .
Delaney and Silber  evaluated approximately 30 patients
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
twenty-six months, Chatoor and Egan  described a
developmental eating disturbance which they consider
to be both a separation disorder and a form of infantile
anorexia. 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 . In Irwins
series, over two-thirds of the children with anorexia
were hospitalized within six months of the onset of
the anorexia. Gislason  noted one death in 33 children
with prepubertal anorexia nervosa.
Sargent  described three subgroups
of prepubertal anorectics. The first group similar to
one described by Pugliese, et al  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. Their parents discouraged
age-appropriate behavior and strongly encouraged their
pseudo-adolescent behavior. This female subgroup is
most similar to pubertal-onset anorexia nervosa. The
third group consisted of an equal number of male and
female anorectics who were more psychologically impaired,
having major ego deficits with the occasional presence
of psychotic episodes .
Gislason  noted premorbid personality
characteristics of dependency, timidity, and schizoid
traits, with features of depression. Significant disturbances
of ego development, prepsychotic personality traits,
and psychotic episodes have been reported . Moreover,
premorbid eating disturbances, including a history of
being a finicky eater, have been noted . 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 . In childhood
anorexia, Sargent  noted increased divorce among
families, as contrasted to adolescent anorexia where
the family divorce rate is approximately equal to the
The clinical manifestation of childhood
anorexia nervosa should fulfill most DSM III-R 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 [7, 10]. It is unclear if there is a body
image distortion equivalent to that of older anorectics.
The child may be more concerned with separation-individuation
issues than fears of sexuality [7, 11]. They frequently
demonstrate alexithymia, the inability to translate
ones feelings into words .
Irwin  feels psychodynamics in childhood
anorexia nervosa are similar to those 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. Precipitating events associated
with the onset of childhood anorexia nervosa include:
the birth of a sibling, bereavement over the death of
a parent or relative, a disappointment in object relations,
family discord, viral illness, peer criticism about
being fat, the fear of becoming obese, the onset of
breast development, sexual abuse, sustained fear of
choking while eating, anticipated fear of parental loss
related to an ill or depressed parent, and the coincident
onset of a psychophysiologic disorder such as ulcerative
colitis  or ileitis .
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 the childs physical condition.
The prognosis in childhood anorexia is unclear. Sargent
feels that his group II females have less individual
and family psychopathology, and have the most favorable
outcome as contrasted to group III, where both individual
and parental psychopathology are more severe. The group
I prognosis is intermediate between groups II and III.
Gislason  summarized and reported cases of prepubertal
anorexia and noted that 63 percent improved, 21 percent
did not improve, and 3 percent died. Russell  found
prolonged delay of puberty (a later menarche) and possible
permanent interference with growth in stature and breast
development in children with prepubertal anorexia nervosa.
In contrast, Pfeiffer, et al.  noted relatively
minimal growth retardation on follow-up of treatment.
He stresses the importance of identifying childhood
anorexia nervosa and returning the children to an optimum
weight to safeguard their puberty.