Transcript Anxiety-related, misperceived, exaggerated, fabricated or induced
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 T alks Doctor Induces illness interferes with investigations or 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) 1.
History, symptoms or signs
by
Exaggerating 2.
3.
4.
Misconstruing real phenomena on basis of mistaken b elief 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 for does not dispute the need 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
E
ffects on
c
hild’s
p
sychosocial
d
evelopment & 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 & over reliance 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 Discomfort of thinking ill of a mother Discomfort of wrongly suspecting/blaming Doctor powerless - bound by: 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 by mother’s flattery or doubting) (encouraged
Obstacles to appropriate response Fear of complaints, 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 that Lead 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, d ispute 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 non attendance 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
1.
2.
3.
4.
5.
Some questions a.
b.
How common are 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