Anxiety-related, Anxiety-related, misconstrued, misconstrued,

exaggerated, fabricated or exaggerated, fabricated or induced illness (FII)? induced illness (FII)? Or Or Medically unexplained Medically unexplained

symptoms symptoms OrOrPerplexing Paediatric Perplexing Paediatric

Presentations? Presentations? OrOrMedical Child Abuse?Medical Child Abuse?Danya Glaser Danya Glaser ©©

Great Ormond Street Hospital for ChildrenGreat Ormond Street Hospital for ChildrenInstitute of Child Health - University College Institute of Child Health - University College

LondonLondon

FII or Medical child abuseFII or Medical child abuse**MotherMother DoctorDoctor

TTalksalks

Induces illness Induces illness oror Investigates & treats Investigates & treats interferes with interferes with investigationsinvestigations

ChildChildMay have a genuine illnessMay have a genuine illness

Older children may report and believe in their own Older children may report and believe in their own symptomssymptoms=MUS=MUS

* * Mother involved in 85-90% of casesMother involved in 85-90% of cases

The mother -The mother - whatwhat Erroneously reportsErroneously reports (fabricates) (fabricates) History, symptoms or signs History, symptoms or signs byby

1.1. ExaggeratingExaggerating2.2. Misconstruing real phenomena on Misconstruing real phenomena on

basis of mistaken bbasis of mistaken beliefelief3.3. Reporting actual phenomena which Reporting actual phenomena which

only occur in the mother’s presence – only occur in the mother’s presence – i.e. situation specific and therefore i.e. situation specific and therefore not a disorder located solely in the not a disorder located solely in the childchild

4.4. InventingInventing

but but may or may not intend to deceivemay or may not intend to deceive

The mother -The mother - whatwhat Deceives by using ‘hands’ Deceives by using ‘hands’

to make the child appear ill to make the child appear ill byby

Falsifying or interfering with Falsifying or interfering with investigationsinvestigations

InducingInducing signs or illness in the child signs or illness in the child by by e.g. Poisoning / over medication e.g. Poisoning / over medication

(laxatives, salt), suffocating, starving(laxatives, salt), suffocating, starving

The mother - The mother - whywhy Has an underlying need for child Has an underlying need for child

to be recognised as ill (when not to be recognised as ill (when not ill) or as more ill than the child isill) or as more ill than the child is

Motivations:Motivations: AnxietyAnxiety To confirm (false) beliefTo confirm (false) belief Wish for recognition as heroic / suffering motherWish for recognition as heroic / suffering mother AttentionAttention Deflecting blameDeflecting blame Maintain closeness to childMaintain closeness to child Hostility to doctorHostility to doctor (Hostility to child)(Hostility to child) Financial gain (DLA, litigation)Financial gain (DLA, litigation)

‘‘Munchausen by Proxy’ NOT a mental illnessMunchausen by Proxy’ NOT a mental illness Many mothers have personality disorder & / Many mothers have personality disorder & /

somatisation disordersomatisation disorder

The doctor -The doctor - what whatBased on the mother’s reports

(/actions) Examines & investigates the childExamines & investigates the child Treats the childTreats the child

Supports Supports oror does not dispute the need does not dispute the need for for Poor school attendance Poor school attendance Use of e.g. wheelchairsUse of e.g. wheelchairs Financial & other support for care of sick Financial & other support for care of sick

childchild

The child The child

HarmfulHarmful end results for child are end results for child are the same the same

regardless of nature of regardless of nature of parental motivation or actionparental motivation or action

Therefore Therefore abuse abuse or maltreatmentor maltreatment

Child’ experience of Child’ experience of medical care medical care

Undergoes repeated Undergoes repeated (unnecessary) examinations, (unnecessary) examinations, investigations, procedures & investigations, procedures & treatmentstreatments

Health & life threatened if illness Health & life threatened if illness inductioninduction (5-8% deaths). (5-8% deaths).

Mortality is unintentional & Mortality is unintentional & notnot an an intended outcome of illness inductionintended outcome of illness induction

EEffects onffects on c child’shild’s ppsychosocialsychosocial d development evelopment

& life& life Limited Limited or interrupted school or interrupted school

attendance and attendance and educationeducation

Limited normal daily life activities Limited normal daily life activities

Sick role – use of aids Sick role – use of aids (e.g. wheelchairs)(e.g. wheelchairs)

Socially isolatedSocially isolated

Child’s distorted view of Child’s distorted view of illness and healthillness and health

Anxiety or confusion re Anxiety or confusion re state of state of healthhealth False self view of sick & vulnerableFalse self view of sick & vulnerable

Somatisation – Medically Unexplained Somatisation – Medically Unexplained SymptomsSymptoms

Collusion c. ‘illness’Collusion c. ‘illness’

Silently trapped in falsification of Silently trapped in falsification of illnessillness

Most children found to Most children found to have FII are initially have FII are initially

recognised as Perplexing recognised as Perplexing Presentations (PP)Presentations (PP)But not all Perplexing But not all Perplexing Presentations are FIIPresentations are FII

Alerting signs = for PP & FIIAlerting signs = for PP & FII

Reported symptoms not present Reported symptoms not present & signs not observed by others, & signs not observed by others, or independently of motheror independently of mother

Reported symptoms & signs not Reported symptoms & signs not explained by child’s medical explained by child’s medical condition, if anycondition, if any

Physical examination & results of Physical examination & results of investigations do not explain reported investigations do not explain reported symptoms or signssymptoms or signs

Inexplicably poor response to Inexplicably poor response to medication or proceduresmedication or procedures

Reporting of new symptomsReporting of new symptoms

Repeated presentation to different Repeated presentation to different doctorsdoctors

Parent(s) request more Parent(s) request more investigations, continuation of investigations, continuation of (unwarranted) Rx or new Rx(unwarranted) Rx or new Rx

Impairment of child’s daily life Impairment of child’s daily life beyond any known disorderbeyond any known disorder

If one present, look for others If one present, look for others

Current (mis?)managementCurrent (mis?)management Lack of direct observation of childLack of direct observation of child over-reliance on over-reliance on

parental reportsparental reports more & more investigations & over-more & more investigations & over-

reliance on results reliance on results (MUR) (MUR) Taking eye off child’s Taking eye off child’s functioningfunctioning Treating symptoms and resultsTreating symptoms and results Omitting to look at current harm of this Omitting to look at current harm of this

process to the childprocess to the childWhy?Why?

Obstacles to appropriate Obstacles to appropriate response response Concern re missing treatable disorderConcern re missing treatable disorder

Doctors usually work Doctors usually work withwith parents parents Discomfort: disbelief/suspicion of Discomfort: disbelief/suspicion of

parentparent Discomfort of thinking ill of a motherDiscomfort of thinking ill of a mother Discomfort of wrongly suspecting/blamingDiscomfort of wrongly suspecting/blaming

Doctor powerless - bound by: Doctor powerless - bound by: history given by a parent, signs & results of history given by a parent, signs & results of

investigations could be induced by parentinvestigations could be induced by parent Difficult to say ’I do not understand’ Difficult to say ’I do not understand’

feeling foolish, being wrong feeling foolish, being wrong Rising to diagnosticRising to diagnostic challengechallenge (encouraged (encouraged

by mother’s flattery or doubting)by mother’s flattery or doubting)

Obstacles to appropriate Obstacles to appropriate response response

Fear of- Fear of- complaints, reports to licensing authorities, complaints, reports to licensing authorities, litigationlitigation

Time taken to process suspicionsTime taken to process suspicions Uncertainty about Uncertainty about

when to mention suspicionwhen to mention suspicion what to say to parent(s)what to say to parent(s) what to write in medical filewhat to write in medical file

Losing control over child protection Losing control over child protection processprocess

Need to establish what is & is Need to establish what is & is not not

currently wrong with the childcurrently wrong with the child Coordinate medical viewsCoordinate medical views Compile health chronology, noting who Compile health chronology, noting who

observed/reported and what the outcome observed/reported and what the outcome was was

Obtain full account of child’s daily Obtain full account of child’s daily functioning incl. school, activities, aidsfunctioning incl. school, activities, aids

Elicit parents’ explanations for the child’s Elicit parents’ explanations for the child’s reported difficulties reported difficulties

Observe the child: IP admission or constant Observe the child: IP admission or constant observation at home? (may require support observation at home? (may require support of child protection services)of child protection services)

Carry out further Carry out further definitive warranted definitive warranted investigations to reach differential diagnosesinvestigations to reach differential diagnoses

Talking with the childTalking with the child Child’s beliefs/understanding of their Child’s beliefs/understanding of their

illnessillness

What it is like to be …..What it is like to be …..

What child most worried aboutWhat child most worried about

What child would like to be differentWhat child would like to be different

What to say & What to say & what to write in noteswhat to write in notes

Diagnosis unclearDiagnosis unclear Need for further observationsNeed for further observations Need for staff to collect all specimensNeed for staff to collect all specimens Need for staff to observe child closelyNeed for staff to observe child closely

Preface all notes by Preface all notes by whowho reported reported

Separate observations from their Separate observations from their interpretations interpretations

MUSMUS If, following full medical review If, following full medical review

No rare condition, no new syndrome, no active No rare condition, no new syndrome, no active interference &, beyond known condition, interference &, beyond known condition, symptoms remain unexplained = MUS*symptoms remain unexplained = MUS*

Distinguish between child/young person’s Distinguish between child/young person’s complaints & parents’ presentation of the complaints & parents’ presentation of the child’s difficultieschild’s difficulties

Establish who carries the primary Establish who carries the primary ‘ownership’ of the symptoms‘ownership’ of the symptoms

Are the parents fully supportive of the CBT Are the parents fully supportive of the CBT approach towards restoration of function approach towards restoration of function rather than continuing medical rather than continuing medical investigations and a search for an investigations and a search for an underlying medical cause?underlying medical cause?

Changing tackChanging tack Obtain agreement of Obtain agreement of allall professionals involved professionals involved

that-that- Lead paediatrician & colleague meet with Lead paediatrician & colleague meet with parentsparents

& explain that& explain that Unable to give diagnosis or define problem because Unable to give diagnosis or define problem because

does not know (avoiding descriptive ‘diagnoses’ e.g. does not know (avoiding descriptive ‘diagnoses’ e.g. Chromic pain syndrome) Chromic pain syndrome)

Has some explanation for reported symptoms & signsHas some explanation for reported symptoms & signs Reported symptoms & signs not life threateningReported symptoms & signs not life threatening There is no medical treatmentThere is no medical treatment Further investigations & repeated presentations to Further investigations & repeated presentations to

doctors more harmful than NFAdoctors more harmful than NFA Child & family need to be helped to function Child & family need to be helped to function alongside alongside

symptomssymptoms Child will not come to harm as a resultChild will not come to harm as a result

Rehabilitation Rehabilitation Doctor initiates rehabilitation Doctor initiates rehabilitation

programmeprogramme May reduce/stop some medicationMay reduce/stop some medication Active Active

multidisciplinary/multiagency multidisciplinary/multiagency rehabilitation incl.rehabilitation incl.Re-establish full school attendanceRe-establish full school attendanceGraded physical mobilisationGraded physical mobilisation(Enteral) oral feeding(Enteral) oral feeding

Psychological workPsychological work

Psychological work with the Psychological work with the familyfamily Explore implications of change for the Explore implications of change for the

parents parents understanding of how illness understanding of how illness beliefs arosebeliefs arose

Explore what changes will be in parents’ Explore what changes will be in parents’ and child’s (if old enough) daily life if and child’s (if old enough) daily life if child was functioning optimallychild was functioning optimally

Help child & family to construct a Help child & family to construct a narrative explanation for improvement in narrative explanation for improvement in the childthe child

Help child to adjust to a better state of Help child to adjust to a better state of health by using coping strategies for health by using coping strategies for symptoms symptoms

Help parents to ‘fill the gap’ created in Help parents to ‘fill the gap’ created in their life by having well (or better) childtheir life by having well (or better) child

Timing & importance of Timing & importance of understanding motherunderstanding mother

AFTER establishing child’s state of AFTER establishing child’s state of healthhealth

Understanding of mother’s Understanding of mother’s difficulties neither necessary nor difficulties neither necessary nor sufficient for diagnosis of FIIsufficient for diagnosis of FII

Referral to adult psychiatrist forReferral to adult psychiatrist for Understanding mother’s motivationUnderstanding mother’s motivation PrognosisPrognosis Indication of treatment to effect changeIndication of treatment to effect change

The ‘test’ for FIIThe ‘test’ for FII Illness inductionIllness induction Clear deception by the motherClear deception by the mother Parents disagree, dParents disagree, dispute ispute

independent /clinical observationsindependent /clinical observations Request more investigations Request more investigations Seek further medical opinion (when >1 Seek further medical opinion (when >1

already obtained)already obtained) Decline rehabilitation plan & child not Decline rehabilitation plan & child not

functioning e.g. Not attending school fullyfunctioning e.g. Not attending school fully Rehabilitation not proceeding (Rehabilitation not proceeding (not lack of not lack of

resources)resources) Refer to child protection services Refer to child protection services

(CPS) (CPS) because child’s functioning is because child’s functioning is being avoidably impaired by parentsbeing avoidably impaired by parents

Why not refer to CPS for FII Why not refer to CPS for FII earlier?earlier?

Although CPS responsible for child protection, Although CPS responsible for child protection, they are dependent on medical evidencethey are dependent on medical evidence

Doctors likely to have been involved in Doctors likely to have been involved in unnecessary investigations, doubtful unnecessary investigations, doubtful diagnoses, treatments, school non-diagnoses, treatments, school non-attendance attendance

Need for establishing current definitive Need for establishing current definitive medical position medical position

Possibility of rehabilitation without CPPossibility of rehabilitation without CP

Threshold for child Threshold for child protection interventionprotection intervention

Ill treatment Ill treatment actually causing or actually causing or likely to cause harmlikely to cause harm

ororImpairment Impairment of child’s health & of child’s health &

functioning functioning attributableattributable toto care given or care given or

not given.not given.

In FIIIn FII Threshold/case Threshold/case currentlycurrently based on proof based on proof

of mother fabricating or inducing illness of mother fabricating or inducing illness in the child (Ill Treatment)in the child (Ill Treatment)

(Erroneous) resorting to mother’s mental (Erroneous) resorting to mother’s mental ill-health diagnosis for evidence ill-health diagnosis for evidence

Threshold should, in first instance, beThreshold should, in first instance, beImpairmentImpairment – not – not Ill-treatment Ill-treatment

Evidence should be that child is Evidence should be that child is currentlycurrently being avoidably harmed being avoidably harmed because of parents’ position/views re because of parents’ position/views re rehabilitationrehabilitation

Is child’s medical Is child’s medical chronology useful?chronology useful?

Chronology may show a now familiar Chronology may show a now familiar pattern ofpattern of previous episodes of reported ill-health previous episodes of reported ill-health

of the child with negative findingsof the child with negative findings previous involvement of medical previous involvement of medical

profession in investigating and treatingprofession in investigating and treatingButBut

It is not reliable proof of FIIIt is not reliable proof of FII

Some questionsSome questions1.1. How common areHow common are

a.a. FII – less commonFII – less commonb.b. Perplexing presentations requiring Perplexing presentations requiring

rehabilitation – more commonrehabilitation – more common 2.2. How early is it possible to recognise How early is it possible to recognise

Perplexing Presentations?Perplexing Presentations?3.3. Should child protection services be Should child protection services be

involved in all Perplexing involved in all Perplexing Presentations?Presentations?

4.4. Is there a risk of precipitating illness Is there a risk of precipitating illness induction?induction?

5.5. How long should the child continue How long should the child continue to be regarded as at risk after to be regarded as at risk after improvement – will it recur?improvement – will it recur?

ConclusionsConclusions Perplexing presentations, while may ‘become’ Perplexing presentations, while may ‘become’

FII, are commoner and do not include ‘blaming’ FII, are commoner and do not include ‘blaming’ the parentsthe parents

Effects on children same regardless of mother’s Effects on children same regardless of mother’s motivationsmotivations

When something does not add up, independent When something does not add up, independent observationsobservations

Need to reach early firm medical conclusion & Need to reach early firm medical conclusion & present this to parentspresent this to parents

Key = Are there concerns re child’s Key = Are there concerns re child’s currentcurrent functioning which cannot be resolved due to functioning which cannot be resolved due to parents’ position?parents’ position?

Hippocrates Hippocrates (Aphorisms 1) (Aphorisms 1) saidsaid

Life is short, and Art long; the crisis Life is short, and Art long; the crisis fleeting; experience perilous, and fleeting; experience perilous, and decision difficult. The physician decision difficult. The physician must not only be prepared to do must not only be prepared to do what is right himself, but also to what is right himself, but also to make the patient, the attendants make the patient, the attendants and externals cooperate.and externals cooperate.

Key ReferencesKey References RCPCH (2009) Fabricated or RCPCH (2009) Fabricated or

Induced Illness by Carers (FII): A Induced Illness by Carers (FII): A Practical Guide for PaediatriciansPractical Guide for Paediatricians

Nice Guidance (2009) When to Nice Guidance (2009) When to Suspect Child Maltreatment Suspect Child Maltreatment

Medical Child Abuse (2008) Medical Child Abuse (2008) Thomas A. Roesler & Carole Jenny Thomas A. Roesler & Carole Jenny

Safeguarding children in whom Safeguarding children in whom illness is fabricated or induced illness is fabricated or induced (2008) DCSF(2008) DCSF

d.glaser@ucl.ac.ukd.glaser@ucl.ac.uk