« I just had a fight with my girlfriend and then I didn’t feel like eating anymore, » confides Margot, 9. 5 hours a day is the time the parents of Françoise, 11, spend getting their daughter to eat. On a daily basis, they are faced with a range of oppositional behaviors: « bargaining, passive refusal, active opposition, threats, crying, screaming, physical violence ». So much so that they feel they are mistreating their child[i]. Over the past fifteen years, institutions and specialists in eating disorders have witnessed a rejuvenation of anorexia. Nowadays, this pathology can occur in so-called prepubescent children, aged between 6 and 12. The incidence of anorexia in children is on the rise, as much in France as in the United States, the United Kingdom and Canada. « 30 years ago, we saw an average of one case of childhood anorexia per year. It was THE case of the year. Today, we have an inpatient unit dedicated to them, and of the 10 beds we offer, all are occupied by children aged 8, 9 and 10. So this is no longer an exceptional case, » says Marie-France Le Heuzey, psychiatrist at the Eating Disorders Unit of the Child and Adolescent Psychopathology Department at Robert Debré University Hospital.

Symptoms similar to teenage anorexia

Anorexia is less well defined, diagnosed and managed in children than in adolescents. While childhood anorexia may have appeared as an original condition over the last ten years or so, the symptomatology is particularly classic, comparable to that of adolescent anorexia, and includes: 1) refusal to eat, 2) weight loss (or lack of weight gain during the growth period) and 3) a marked preoccupation with weight or body shape, a criterion not always present in the profile of these children. The definition of childhood anorexia is intended to be more summary and flexible than that of adolescent anorexia, in order to take into account any variations in symptomatology due to this age group. As noted by Solange Cook-Darzens, PhD in psychology, family therapist and former co-director of the Eating Disorders Unit in the Child and Adolescent Psychopathology Department at Robert Debré University Hospital, in her book « Approches familiales des troubles du comportement alimentaire de l’enfant et de l’adolescent » (Erès, 2014), only the « central core » of anorexia symptomatology has been retained. « Girls measure the circumference of their hips and think they’re far too fat, even though they’re all skinny… We currently have a child on our ward who refuses to lie down because she’s afraid she’ll get even fatter if she lies down, » says Marie-France Le Heuzey.

However, anorexic children have a particularity of their own: water restriction, which can lead to dehydration. As children are much less expert than their adolescent elders on the calorie content of different foods, they avoid any sensation of « heaviness » or « filling ».  » So they may continue to eat starchy foods or cakes, but worry that drinking water will make them fatter, » notes Solange Cook-Darzens. What’s more, because of their emotional and cognitive immaturity, anorexic children have more difficulty verbalizing their emotions. « The cognitive dimension (preoccupation with weight and shape) is not always expressed, or even present in these children’s minds, which doesn’t stop these little girls from selecting their food as if they were preoccupied. It’s important to emphasize this particularity, because it’s how many GPs and pediatricians ‘miss’ the diagnosis of anorexia nervosa in children, and how these children come to us late, in an emergency, » insists Solange Cook-Darzens. These fears « tend to be expressed in terms of more vague somatic complaints, such as abdominal pain, fear of vomiting, difficulty swallowing, dizziness, etc. ».

Another peculiarity of childhood anorexia is the proportion of boys. « This is generally 3 boys out of 10 children. In adolescence, it’s one boy for every 10, » explains Solange Cook-Darzens.  » Of our 10 beds, we currently have 2 boys, » adds Marie-France Le Heuzey. Lastly, prepubertal anorexia is characterized by weight loss that is generally more abrupt than in adolescents, as well as more marked rigidity and perfectionism.

An interplay of unfavorable factors

If for many decades, mothers – nurturers by definition – were considered (partly if not exclusively) responsible for their daughters’ anorexia in some psychoanalytical minds, the tide has turned. « For my part, I’ve been leaving mothers alone for a long time now! Ironically, Marie-France Le Heuzey. Incidentally, in adolescents more than in children, cases of anorexia can very well be triggered by hurtful comments from the father, such as « you’re too fat ». I remember a GP who specialized in helping obese women lose weight. He gave one of his tapes to his daughter, who ended up losing a lot of weight and becoming anorexic… ». . The onset of anorexia in a child is the result of the interplay of various factors: personal (tendency towards rigidity, idealization of thinness, low self-esteem…), family (moving house, divorce, bereavement…) and social (argument with a girlfriend, over-investment in school…). As Solange Cook-Darzens points out, studies have identified life events likely to precipitate the onset of anorexia in children, such as remarks and mockery from peers, a change of school, a bad summer camp experience, a physical illness, etc.

Contrary to popular belief, childhood anorexia cannot, of course, be reduced to a question of image and societal idealization of thinness.  » If the environment feeds this pathology, it doesn’t initiate it, » reminds Marie-France Le Heuzey. Perfectionism, on the other hand, remains a predominant risk factor: « These are little girls who seem perfect in every way. They may play a musical instrument, do ballet, have lots of extracurricular activities, do well at school, and so on. At the end of the day, they’re also perfectionists when they’re ill, » comments Marie-France Le Heuzey. Finally, research shows that eating disorders in infancy, including anorexia, are a risk factor for developing an eating disorder in adolescence.  » However, not all late-onset anorexics suffered from anorexia as babies… » insists Marie-France Le Heuzey.

Parents, budding co-therapists

Psychological management of children with anorexia is no easy task.  » The child’s motivational and cognitive immaturity inevitably limits the possibilities of a therapeutic alliance, » explains Solange Cook-Darzens. Rarely is the child the typical ‘good patient’ – the one who wants to change, who can verbalize fears and emotions, and link certain psychological conflicts with symptoms.  » It’s with the parents that the therapeutic alliance will have to be built, at least initially, » adds Solange Cook-Darzens. Family therapy is the only therapy that has really proved its effectiveness in the field, as Marie-France Le Heuzey confirms: « Although it’s not the parents’ fault, we can’t treat children without their parents. As I often tell them, if we give priority to family therapy, it’s not to point the finger of blame, but to teach you how to get your child to eat again. In fact, the family therapist in our department sometimes includes siblings in her talks ». Unlike adolescents, children are still very much influenced by their families, due to their dependence and immaturity.  » The place given to family resources and parental authority in the treatment of anorexia is therefore legitimately more important, » emphasizes Solange Cook-Darzens. The author insists that divorced parents are « condemned to get along » and to distinguish, in their child’s interest, their relationship as a couple from their relationship as parents.

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No weight gain: warning sign no. 1

What are the warning signs for parents and professionals? The absence of weight gain, regardless of the child’s age. This is followed by an abnormal height curve, « bearing in mind that dozens of somatic causes need to be eliminated before considering a psychological cause such as anorexia », explains Marie-France Le Heuzey. On a behavioral level, certain clues can alert the family: the child’s eating habits change drastically, he or she begins to excessively sort out drinks and foods previously enjoyed, cuts food into small pieces on the plate and eats only small quantities, tries to escape mealtimes, suddenly becomes addicted to sporting activities, etc. The family’s first point of contact is the family doctor. Are community doctors, the first point of contact for families, well aware of the diagnosis of childhood anorexia ? More and more, » replies Marie-France Le Heuzey. Although prepubertal anorexia is still little-known, doctors always check that their young patients are growing properly. So, if there’s an anomaly, they’ll dig deeper until they’ve made the right diagnosis. I have a fax on my desk from a doctor referring a 10-year-old girl who refuses to put on weight ». .

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Key figures

In France, no epidemiological study of childhood anorexia has yet been carried out, although clinicians note that the number of children with anorexia is increasing, although it remains lower than the number of adolescents with anorexia. Childhood anorexia, which is mostly observed from the age of 8 or 9, rarely before, occurs in a wide variety of socio-cultural environments. According to a British study published in 2011, around a hundred children aged 5 to 7 had been hospitalized in the previous three years for severe anorexia. The study also revealed that 600 of the 2,000 children aged 5 to 15 hospitalized in 35 public institutions for anorexia were under 13. Various studies have highlighted the fact that girls as young as 4/5 years old can be preoccupied with the shape of their bodies and fear gaining weight. [ii]. And 10 to 24% of girls aged 7 to 13 are trying to lose weight by playing regular sports or cutting down on food. All risk factors that could contribute to the onset of anorexia.

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Anorexia in babies

Anorexia in babies and adolescents is much better understood and identified than in children and pre-adolescents. First of all, it’s important to remember that all babies are likely to experience periods of dietary turbulence, hampered by intestinal pain or other transient organic causes.

The work of Irène Chatoor, Professor of Psychiatry and Pediatrics at George Washington University and a specialist in eating disorders in young children, has made it possible to distinguish attachment eating disorder from true infant anorexia.

Attachment disorder, which occurs early in a baby’s life, is thought to be the result of an attachment disorder between mother and child. These babies, whose mothers suffer from a mental pathology (depression, drug addiction, for example), end up malnourished and withered. « The repercussions are both nutritional and psycho-affective. This very serious disorder requires hospital care, » emphasizes Marie-France Le Heuzey. Infantile anorexia, on the other hand, occurs later, around the child’s 6th month of age, particularly at the time of food diversification and the switch to the spoon: the child turns his head when his parent presents him with the bottle or spoon, refuses to open his mouth, and spits. Mealtime thus becomes a time of forced distraction and strategies to get the child to eat, marked by high levels of anxiety on the part of the parents. However, « the child shows good psychomotor development and remains very lively. In fact, we don’t talk about infantile anorexia if this behavior has no real impact on the child’s nutrition and weight curve, » points out Marie-France Le Heuzey. According to Irène Chatoor, this avoidance of food is not due to a mental pathology in the mother, but rather to an « encounter » between a baby with a difficult temperament and a mother going through her own difficulties. The mother has difficulty adjusting to her child. As a result, this temporary feeding problem can crystallize and take on a pathological character.

The anorexic baby is to be distinguished from the « small eater », or the child who excessively « selects » his or her food. In fact, many older anorexics were small eaters when they were younger.  » Selective eating behaviours are often associated with a diversification problem between the ages of 1 and 3, » explains Solange Cook-Darzens. « Incidentally, research suggests that parents should present the same food 8 to 11 times to optimize the chances that the child will want to try it. Most young children are afraid of what they don’t know. What’s more, parents need to eat enough of everything if they want their child to do the same. Let’s not forget that parents are still children’s role models! » insists Marie-France Le Heuzey.

Suggested reading :

Cook-Darzens S. (2014). TCA of the child and preadolescent (pp. 259-277). In Cook-Darzens, Approches familiales des troubles du comportement alimentaire de l’enfant et de l’adolescent. Érès, Toulouse.

Marie-France Le Heuzey (2003). « L’enfant anorexique. Comprendre et agir ». Odile Jacob.

Safrano-Adenet (2014). Prepubertal anorexia nervosa and families: genetic and environmental approaches. An observational study with a cohort of 17 female patients and their parents. Human health and pathology. Thèse pour l’obtention du diplôme d’état de Docteur en Médecine, Université de Bordeaux.

[i] Clinical cases taken from chapter 13 « Abords spécifiques des TCA de l’enfant et du préadolescent » in « Approches familiales des troubles du comportement alimentaire de l’enfant et de l’adolescent » by Solange Cook-Darzens (Erès, 2014).

[ii] Le Heuzey MF. Socio-cultural determinants (pp.115-120). In Mouren MC, Doyen C, Le Heuzey MF, Cook-Darzens S, (eds): Troubles du comportement alimentaire de l’enfant : Du nourrisson au pré-adolescent. Issy-les-Moulineaux : Elsevier Masson ; 2011b.