It was one explanation of why children attending his unit at the Hospital for Sick Children, Great Ormond Street, had often been delayed for six months before eventually being referred.
'It is clear that very many doctors are not aware of the possibility of eating disorders in young patients,' Dr Bryan Lask, consultant psychiatrist, said at Eating Disorders '93, an international conference organised by the hospital and the British Journal of Hospital Medicine.
Dr Lask said that, in a survey, GPs and paediatricians had been given details of two anorexic children. Most had failed to get the right diagnosis.
He told the meeting that 40 per cent of the children did not get completely better. Often, the lower their weight the more difficult they were to treat.
In some boys treated at the unit, starvation was so advanced that gangrene had set in their toes - caused by bad circulation, Dr Lask said. But anorexia could be difficult to diagnose because the symptoms could appear and disappear, he said. The list includes emaciation, with children 30 per cent below their weight for height, cold feet, hairy backs, infected sores, low blood pressure and a low pulse rate.
In a recent Great Ormond Street study of 88 young patients, the average age was 11.7 years with the youngest child being 7.5, Dr Lask said.
In the majority, there had been no history of eating problems. Most had lost a quarter of their body weight and some had lost half of it. Two boys in this group had gangrene in their toes and the girls - who made up three quarters of the 88 children - showed regression of their uterus and ovaries to an infantile state, he said.
A family that failed to function well as a unit was now seen as an important factor in the disease in children. Dr Lask said that it was essential to offer comprehensive therapies and work with the whole family. Unless the child was seriously depressed, medication had little place in their treatment.
The children least likely to recover were those where there was 'a high level of family dysfunction, parental resistance to treatment and very low weight for height on referral'.
During treatment the children were likely to become aggressive and difficult, which was resented. 'We are attacked by parents for turning their child from someone who was perfect to a disruptive individual. We see this as essential. The children have got to get their feelings out,' he said.
He made a plea for greater awarenss of anorexia in children, for early diagnosis, early referral to specialist units and more units to treat them.
The incidence of anorexia in children was difficult to assess, Dr Lask said in a paper released for the meeting. Estimates from several researchers ranged from 0.1 per cent of 5,700 schoolgirls to 18.35 per cent of girls aged 12 to 18 showing some level of eating disorder. In a study of French children aged 12 to 19, a 0.7 per cent incidence was found.