Anxiety-related, misconstrued,
exaggerated, fabricated or
induced illness (FII)? Or
Medically unexplained
symptoms Or
Perplexing Paediatric
Presentations? Or
Medical Child Abuse?
Danya Glaser ©
Great Ormond Street Hospital for Children
Institute of Child Health - University College
London
FII or Medical child abuse
*Mother
Talks
Induces illness or
interferes with
investigations
Doctor
Investigates & treats
Child
May have a genuine illness
Older children may report and believe in their own symptoms
=MUS
*
Mother involved in 85-90% of cases
The mother - what

Erroneously reports (fabricates)
History, symptoms or signs by
1.
2.
3.
4.
Exaggerating
Misconstruing real phenomena on basis
of mistaken belief
Reporting actual phenomena which only
occur in the mother’s presence – i.e.
situation specific and therefore not a
disorder located solely in the child
Inventing
but may or may not intend to deceive
The mother - what
Deceives by using ‘hands’ to
make the child appear ill by



Falsifying or interfering with
investigations
Inducing signs or illness in the child by

e.g. Poisoning / over medication (laxatives,
salt), suffocating, starving
The mother - why


Has an underlying need for child to
be recognised as ill (when not ill) or
as more ill than the child is
Motivations:











Anxiety
To confirm (false) belief
Wish for recognition as heroic / suffering mother
Attention
Deflecting blame
Maintain closeness to child
Hostility to doctor
(Hostility to child)
Financial gain (DLA, litigation)
‘Munchausen by Proxy’ NOT a mental illness
Many mothers have personality disorder & /
somatisation disorder
The doctor - what
Based on the mother’s reports (/actions)
Examines & investigates the child
 Treats the child


Supports or does not dispute the need
for
Poor school attendance
 Use of e.g. wheelchairs
 Financial & other support for care of sick
child

The child
Harmful end results for child are
the same
regardless of nature of
parental motivation or action
Therefore abuse or maltreatment
Child’ experience of medical
care
 Undergoes
repeated
(unnecessary) examinations,
investigations, procedures &
treatments


Health & life threatened if illness
induction (5-8% deaths).
Mortality is unintentional & not an
intended outcome of illness induction
Effects on child’s psychosocial
development & life

Limited or interrupted school
attendance and education

Limited normal daily life activities

Sick role – use of aids


(e.g. wheelchairs)
Socially isolated
Child’s distorted view of illness
and health



Anxiety or confusion re state of health
False self view of sick & vulnerable
Somatisation – Medically Unexplained
Symptoms

Collusion c. ‘illness’

Silently trapped in falsification of illness
Most children found to have
FII are initially recognised as
Perplexing Presentations (PP)
But not all Perplexing
Presentations are FII
Alerting signs = for PP & FII





Reported symptoms not present &
signs not observed by others, or
independently of mother
Reported symptoms & signs not explained
by child’s medical condition, if any
Physical examination & results of
investigations do not explain reported
symptoms or signs
Inexplicably poor response to medication
or procedures
Reporting of new symptoms



Repeated presentation to different
doctors
Parent(s) request more investigations,
continuation of (unwarranted) Rx or
new Rx
Impairment of child’s daily life
beyond any known disorder
If one present, look for others
Current (mis?)management
Lack of direct observation of child
 over-reliance on

parental reports
 more & more investigations & overreliance on results  (MUR)

Taking eye off child’s functioning
 Treating symptoms and results
 Omitting to look at current harm of
this process to the child

Why?
Obstacles to appropriate response



Concern re missing treatable disorder
Doctors usually work with parents
Discomfort: disbelief/suspicion of parent



Doctor powerless - bound by:


Discomfort of thinking ill of a mother
Discomfort of wrongly suspecting/blaming
history given by a parent, signs & results of
investigations could be induced by parent
Difficult to say ’I do not understand’
feeling foolish, being wrong

Rising to diagnostic challenge (encouraged
by mother’s flattery or doubting)
Obstacles to appropriate response



Fear ofcomplaints, reports to licensing
authorities, litigation
Time taken to process suspicions
Uncertainty about




when to mention suspicion
what to say to parent(s)
what to write in medical file
Losing control over child protection
process
Need to establish what is & is not
currently wrong with the child






Coordinate medical views
Compile health chronology, noting who
observed/reported and what the outcome was
Obtain full account of child’s daily
functioning incl. school, activities, aids
Elicit parents’ explanations for the child’s
reported difficulties
Observe the child: IP admission or constant
observation at home? (may require support of
child protection services)
Carry out further definitive warranted
investigations to reach differential diagnoses
Talking with the child

Child’s beliefs/understanding of their
illness

What it is like to be …..

What child most worried about

What child would like to be different
What to say &
what to write in notes

Diagnosis unclear





Need for further observations
Need for staff to collect all specimens
Need for staff to observe child closely
Preface all notes by who reported
Separate observations from their
interpretations
MUS

If, following full medical review




No rare condition, no new syndrome, no active
interference &, beyond known condition,
symptoms remain unexplained = MUS*
Distinguish between child/young person’s
complaints & parents’ presentation of the child’s
difficulties
Establish who carries the primary ‘ownership’ of
the symptoms
Are the parents fully supportive of the CBT
approach towards restoration of function rather
than continuing medical investigations and a
search for an underlying medical cause?
Changing tack


Obtain agreement of all professionals involved
thatLead paediatrician & colleague meet with
parents & explain that







Unable to give diagnosis or define problem because
does not know (avoiding descriptive ‘diagnoses’ e.g.
Chromic pain syndrome)
Has some explanation for reported symptoms & signs
Reported symptoms & signs not life threatening
There is no medical treatment
Further investigations & repeated presentations to
doctors more harmful than NFA
Child & family need to be helped to function
alongside symptoms
Child will not come to harm as a result
Rehabilitation
 Doctor
initiates rehabilitation
programme
 May
reduce/stop some medication
 Active multidisciplinary/multiagency
rehabilitation incl.
 Re-establish
full school attendance
 Graded physical mobilisation
 (Enteral) oral feeding
 Psychological
work
Psychological work with the family
Explore implications of change for the
parents  understanding of how illness
beliefs arose
 Explore what changes will be in parents’
and child’s (if old enough) daily life if child
was functioning optimally
 Help child & family to construct a narrative
explanation for improvement in the child
 Help child to adjust to a better state of
health by using coping strategies for
symptoms
 Help parents to ‘fill the gap’ created in
their life by having well (or better) child

Timing & importance of
understanding mother
AFTER establishing child’s state of
health
 Understanding of mother’s difficulties
neither necessary nor sufficient for
diagnosis of FII
 Referral to adult psychiatrist for

Understanding mother’s motivation
 Prognosis
 Indication of treatment to effect change

The ‘test’ for FII
Illness induction
 Clear deception by the mother
 Parents disagree, dispute independent

/clinical observations




Request more investigations
Seek further medical opinion (when >1 already
obtained)
Decline rehabilitation plan & child not functioning
e.g. Not attending school fully
Rehabilitation not proceeding (not lack of resources)
 Refer to child protection services (CPS)
because child’s functioning is being
avoidably impaired by parents
Why not refer to CPS for FII
earlier?




Although CPS responsible for child
protection, they are dependent on medical
evidence
Doctors likely to have been involved in
unnecessary investigations, doubtful
diagnoses, treatments, school nonattendance
Need for establishing current definitive
medical position
Possibility of rehabilitation without CP
Threshold for child protection
intervention
Ill treatment actually causing or
likely to cause harm
or
Impairment of child’s health &
functioning
attributable to care given or not
given.
In FII




Threshold/case currently based on proof
of mother fabricating or inducing illness in
the child (Ill Treatment)
(Erroneous) resorting to mother’s mental
ill-health diagnosis for evidence
Threshold should, in first instance, be
Impairment – not Ill-treatment
Evidence should be that child is currently
being avoidably harmed because of
parents’ position/views re rehabilitation
Is child’s medical chronology
useful?

Chronology may show a now familiar
pattern of


previous episodes of reported ill-health of the
child with negative findings
previous involvement of medical profession in
investigating and treating
But

It is not reliable proof of FII
Some questions
1.
How common are
a.
b.
2.
3.
4.
5.
FII – less common
Perplexing presentations requiring
rehabilitation – more common
How early is it possible to recognise
Perplexing Presentations?
Should child protection services be
involved in all Perplexing Presentations?
Is there a risk of precipitating illness
induction?
How long should the child continue to be
regarded as at risk after improvement –
will it recur?
Conclusions





Perplexing presentations, while may ‘become’
FII, are commoner and do not include ‘blaming’
the parents
Effects on children same regardless of mother’s
motivations
When something does not add up, independent
observations
Need to reach early firm medical conclusion &
present this to parents
Key = Are there concerns re child’s current
functioning which cannot be resolved due to
parents’ position?
Hippocrates
(Aphorisms 1)
said
Life is short, and Art long; the crisis
fleeting; experience perilous, and
decision difficult. The physician must
not only be prepared to do what is
right himself, but also to make the
patient, the attendants and externals
cooperate.
Key References
RCPCH (2009) Fabricated or Induced
Illness by Carers (FII): A Practical
Guide for Paediatricians
 Nice Guidance (2009) When to
Suspect Child Maltreatment
 Medical Child Abuse (2008) Thomas
A. Roesler & Carole Jenny
 Safeguarding children in whom illness
is fabricated or induced (2008) DCSF

d.glaser@ucl.ac.uk