Anorexia nervosa has been reported to occur as early as age four [1]. 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 [2]. Females comprise 73 percent of all reported children with anorexia nervosa [1]. However, in one subgroup of anorectics (see below), 50 percent were males [3].

Developmental antecedents of childhood anorexia have not been systematically researched [4]. Delaney and Silber [5] 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 [6] 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 [7]. In Irwin’s series, over two-thirds of the children with anorexia were hospitalized within six months of the onset of the anorexia. Gislason [1] noted one death in 33 children with prepubertal anorexia nervosa.

Sargent [3] described three subgroups of prepubertal anorectics. The first group similar to one described by Pugliese, et al [8] 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 [9].

Gislason [1] 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 [1]. Moreover, premorbid eating disturbances, including a history of being a finicky eater, have been noted [7]. 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 [7]. In childhood anorexia, Sargent [3] 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-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 one’s feelings into words [12].

Irwin [7] 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 [1] or ileitis [13].

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 child’s 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 [1] summarized and reported cases of prepubertal anorexia and noted that 63 percent improved, 21 percent did not improve, and 3 percent died. Russell [14] 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. [15] 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.