family life. Michael and I don't really talk
or think about anything else."
Michelle has been in and out of a private clinic since March this year. Doctors have told Denise that she must make sure her daughter has 2,000 calories a day - but it can take Michelle four hours to finish a bowl of cereal.
"By the time she's managed to eat something, she will have missed another meal and the schedule is all messed up," says Denise. "Sometimes I have to go out because I could thump her. She can be a right little bitch; she knows what she's doing to me. Other days, though, she sits at the table and cries. It breaks my heart to see her so mixed-up."
Think of an anorexic, and most people think of a teenager terrified of putting on weight and deliberately starving herself in the pursuit of thinness. But Michelle Collins is only six. Her favourite TV programme is Scooby Doo.
There are increasing numbers of little girls like her. Recent research at Swansea University found that over a quarter of the five- to seven- year-olds they assessed wanted to be thinner, and one in six were dieting - even though a third of them were already underweight.
Experts are alarmed at the growing numbers of children starving themselves, often with serious long-term consequences for their health. Everyone is asking the same question. Why?
"I don't know where Michelle got this idea of not eating from," says her distraught 41-year-old mother. "People like to blame the parents but I can't see where we've gone wrong. I've never dieted in my life. Michelle knows more about calories than I do."
Denise says her daughter was always strong-natured, having tantrums if she didn't get her way, but otherwise was a very happy, affectionate little girl. Then, at three, she started refusing food and losing weight.
Doctors said it was a phase she was going through and prescribed diet supplements. But at five, Michelle was wearing knickers for a 112-year- old and her spine and ribs were sticking out more than ever. "We called her Little Bot and Tin Ribs. That made her laugh, but maybe that was wrong," says her mother.
At home Michelle started saying she was still full from school lunch. She would only have crisps or half a slice of bread. She seemed to have so much energy - getting up at 6.30am and spending hours in the garden with her skipping rope - that her parents didn't worry. Then a dinner lady dropped the bombshell that Michelle wasn't eating school dinners either.
Packed lunches came back scarcely touched, and mealtimes became a battle between mother and daughter, often ending in tears. Michael, a 52-year- old engineer, increasingly retreated into himself or lost his temper. Michelle still picked at her food and became increasingly argumentative and morose.
The family doctor said it was time to look into the situation more deeply. He recommended a psychiatrist who, to Denise's astonishment, referred Michelle to a private clinic for children with anorexia and bulimia. She is their youngest ever patient.
Michelle is now almost the right weight for her height and age, but it is a power struggle for Denise to keep her daughter's weight stable. Michelle knows she will have to go back to the clinic if she loses weight. All the family can do is take one day at a time.
"When Michelle had hardly eaten all weekend, I started packing her Daffy Duck pyjamas and 101 Dalmatians dog into her overnight bag," remembers Denise. "She actually got on her knees and promised to do anything if I didn't send her back. But the next day there was always another excuse for not eating - a tooth coming through, tummy ache or sore lips. So I had to take her in. That day I completely broke down. I felt such a failure as a mother. Michelle is always asking if I still love her. I say 'We both love you very much. That's why we want you to eat so you don't have to go back into hospital.'
"I've found myself walking round town with tears pouring down my face. I just don't understand it. Michelle has a lovely home and we spoil her rotten. Her older sister, Louise, is perfectly normal - but then we always treated her more as a grown-up. Michelle was our little baby. Perhaps that has made a difference."
While parents like the Collins wonder where they went wrong, doctors believe hereditary biological factors may play a part. Dr Bryan Lask, who runs the eating disorders clinic at Great Ormond Street Children's Hospital, London, believes this to be the case. "We're convinced people who have eating disorders are genetically predisposed to do so," he says.
Doctors at the Maudsley Hospital in south-east London have studied sets of twins where one has anorexia nervosa. With non-identical twins, there was only a five per cent chance that the other sister would develop it too. But with identical twins, who have exactly the same genetic make- up, this rose to 56 per cent.
"This doesn't mean a child who has the gene will necessarily become anorexic, but she will have a genetic vulnerability, just as someone might have a disposition towards high blood pressure," says Dr Lask. "It may be that a gene for anorexia nervosa will eventually be identified. But the causes are complex. There are multiple factors all coming together."
Great Ormond Street doctors are also researching blood flow in the brains of children with anorexia nervosa. Using a new brain imaging technique on 16 of their patients, they have discovered that 14 had restricted blood flow in the temporal lobe on one side of the brain.
"This is the area serving the function of memory and spatial awareness," Dr Lask explains. "Youngsters with anorexia misperceive their own size. They genuinely think they are fat. We are hoping that this will ultimately prove to be a breakthrough in our understanding of the causes of anorexia nervosa."
It is already well established that Western culture - with virtually all our positive role models being thin - is a major influence on young girls. What is new is the discovery that these images are making children as young as six want to diet. Deanne Jade of the National Centre for Eating Disorders agrees: "The images begin with Barbie dolls and continue with teen magazines which are now read by children as young as 10." Dr Dee Dawson, who runs Rhodes Farm Clinic where Michelle is a patient, says: "Everywhere you look, the message is that to be popular and successful, you must be a size 10. No wonder children as young as six have a startling awareness of body image and a sophisticated knowledge of dieting.
"Schoolkids used to have chips and spotted dick. Now schools are encouraging children as young as seven to have a low-fat diet. Combine this with a child or mother who is already obsessed about her weight, or other difficulties at home, and you may have a problem."
Dr Andrew Hill, a senior lecturer at Leeds Medical School, is researching the development of dieting and weight control in pre-teen girls. He says: "As soon as a five-year-old learns to read, she learns the difference between thin and fat. And, in a world where thin is beautiful, children are aware of the same cultural fashions as adults from an extraordinarily early age."
The nine-year-olds he studied were already stereotyping overweight people as unfit, unpopular and less successful at school. Though the boys wanted to grow bigger, the girls wanted to weigh 11 per cent less than they did.
"Everywhere in the media, heavier body shapes are under-represented," he says. "Then we're inundated with information about controlling our food intake, and children can't discriminate between healthy eating and dieting.
"In past research, we found that girls who were dieting tended to have low self-esteem or mums who were also on diets. You have to ask yourself what makes a child so unhappy that she thinks she has to starve herself to be liked? Parents can have an enormous role in not passing on their own insecurities about body image."
Childhood dieting can have disastrous long-term consequences, as Jacqueline Blissett, a researcher at Swansea University, explains. "If children are worried about their weight at six, then it's not unlikely that, as they grow up, dieting will become their normative eating pattern. And children who diet are predisposed towards the development of an eating disorder."
Ironically, it is ambitious, perfectionist children who have low self- esteem who are most prone to anorexia. "The children I see are almost invariably conscientious high achievers who work hard and appear to be model children," says Dr Lask. Opinions vary as to how much damage parents can cause. Suzanne Bryant from the Eating Disorders Association says: "The children ringing our helpline usually have some sort of family problem - abuse, family breakdown, death of a relative, or sibling rivalry." Dr Lask says there is little evidence that families are a major contributing factor.
All are agreed, however, that once these children are in treatment, getting them to put on weight is the easy bit. "It's what happens months, years after they are discharged that counts," says Dr Lask. He says 65 per cent of his patients do well, 25 per cent stay out of hospital but are still preoccupied with body image, and 10 per cent remain chronically ill. A third will relapse within the first three years. The ones who recover are almost always those whose parents are totally involved in the treatment.
At Rhodes Farm Clinic, where Michelle Collins is being treated, anorexic children will not be offered a place unless the family - the parents at the very least - come to therapy. Dr Dee Dawson explains why: "If you send a girl back to a family home where everything is the same, there are going to be difficulties again."
"No two cases are the same," Dr Dawson adds. "The only common factor in these families is that the parents have lost control of their child, who has chosen food rather than playing truant or stealing as a way of showing her unhappiness. We need to help these children understand that starving isn't the way to deal with their problems. But these children have obsessive personalities - and wills of iron."
! For information write to Dr Bryan Lask, Department of Psychological Medicine, Great Ormond Street Children's Hospital, Great Ormond Street, London WC1N 3JH, or to the Eating Disorders Association, Sackville Place, 44 Magdalen Street, Norwich, Norfolk NR3 1JU.Reuse content