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Fabricated or Induced IllnessFabricated or Induced Illnessin Childrenin Children

Dr Paul Davis

Consultant Paediatrician

“Caught in the Crossfire”Leicester

11th March 2008

Areas to be coveredAreas to be covered

λ What is FII and how do you diagnose it?

λ Epidemiology and main features

λ What to do when you suspect FII

λ Outcomes

FII or FII or MSbPMSbP: What: What’’s thes thedifference?difference?

λ Q: Who ‘Suffers From’ MSbP?

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FII or FII or MSbPMSbP??

λ A: Nobody! FII and MSbP aresynonyms for a form of abuse. The childis the victim and the abuser is theperpetrator.

Problems with FIIProblems with FII

λ No universally agreed definitionλ Confusion over ‘MSbP’ labelλ Difficulty of obtaining hard evidenceλ Involvement of campaigners,politicians and media

λ High profile ‘baby deaths’ cases andthe ‘prosecutors fallacy’

λ Difficulty in obtaining secondopinions

λ Evidential difficulties in court

FII: Public MisinformationFII: Public Misinformationλ “ t her e ar e bi g quest i onmar ks about i t [ MSBP] f orexampl e i t ’ s not r eal l y adi sease l i ke mal ar i a i s adi sease or l epr osy i s adi sease or whoopi ng cough,i t ’ s a l abel and i t ’ s apsychol ogi cal l abel , i t ’ s aki nd of pr ofi l e t hi ng r at hert han a bug, and i t causesconcer n because i t pr esumesgui l t and admi t s nodef ence. ”John Sweeney, BBC 5 Live, 13th January 2004

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Inappropriate Comments byInappropriate Comments byPoliticiansPoliticians

Mr George Osborne (Tatton) (Con.):“ I am neither a doctor nor a lawyer, but alltoo often our legal and medicalestablishment gets swept along by new-fangled theories and fads…Munchausensyndrome by proxy is the latest in a longline of theories that has now beendiscredited.”

Commons, Hansard 24 Feb 2004

FII: Debate around definitionFII: Debate around definition“ (FII) can include the old termsMSbP or MbPS whether applied tocarer, child or scenario, and includesdelusion, excessive anxiety,masquerade, hysteria, doctorshopping, doctor addicts, motheringto death, seekers of personal help orattention or financial gain, and thosewho fail to give needed treatmentas well as those who treatunnecessarily.” (RCPCH 2002)

When to consider FII?When to consider FII?

λ The common factor is that a child ispresented for medical attention withsymptoms or signs of illness when infact the child does not have a diseasewhich explains their symptoms

λ This creates a risk of iatrogenic harm

λ In some but not all cases the carer maybe directly harming the child

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The The ‘‘spectrumspectrum’’ of FII concerns of FII concerns

λ Anxious/misinformed carersλ ‘Parent child interactions causingimpairment’

λ ‘True’ FII (deliberate act of deceptioncausing harm)

λ Deluded or mentally ill carersλ ‘False Positive’ diagnosesλ Benefit seekers (DLA)λ Children who fabricate

Fabricated or Induced IllnessFabricated or Induced Illnessin Childrenin Children

λ Fabrication

λ Fabrication with Falsification

λ Illness Induction

FII: Possible clues to abuseFII: Possible clues to abuse

λ Symptoms only begin in the presence of one carerλ Lack of objective corroborating featuresλ ‘Illness’ does not ‘fit’ for a natural illness (known or

unknown) but does fit for abuseλ Inconsistent histories from different observersλ Treatments ineffective or poorly toleratedλ Symptoms subside when child closely supervisedλ Unusual parental behaviour/illnessesλ Unusual family history of illness/deaths etc.λ Reports from third parties

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FII: Other Common FeaturesFII: Other Common Features

λ Very frequent ‘demand led’ medical presentationsλ Escalation of symptoms over timeλ Parental pressure to investigate or treatλ Transfer or substitution of symptomsλ Seeking multiple opinions, ‘sacking’ doctorsλ Carer may ‘fit in’, be calm, or very well informedλ (or) may be obstructive, manipulative or hostileλ Parental ‘Abnormal Illness Behaviour’ (often from

adolescence), or mental health problems

FII FII ‘‘TemplateTemplate’’ (1) (1)1. Reported symptoms and signs found on examination are not

explained by any medical condition from which the child may besuffering.

2. Physical examination and results of medical investigations do notexplain reported symptoms and signs.

3. There is an inexplicably poor response to prescribed medicationand other treatment.

4. New symptoms are reported on resolution of previous ones.5. Reported symptoms and found signs are not seen to begin in the

absence of the carer.6 The child’s normal, daily life activities are being curtailed beyond

that which might be expected for any medical disorder fromwhich the child is known to suffer.

FII FII ‘‘TemplateTemplate’’ (2) (2)7. Over time the child is repeatedly presented with a

range of signs and symptoms.8. History of unexplained illnesses or deaths or multiple

surgery in parents or siblings of the family.9. Once the perpetrator’s access to the child is restricted,

signs and symptoms fade and eventually disappear10. Exaggerated catastrophes or fabricated bereavements

and other extended family problems are reported.11. Incongruity between the seriousness of the story and

the actions of the parents.12. Erroneous or misleading information provided by

parent.

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FII: Difficult areasFII: Difficult areas

λ Children who collude

λ Manipulation of real illness

λ Unexplained infant deaths

λ ‘Treatment’ of perpetrators

λ Mothers with Munchausen’s Syndrome

λ Covert Surveillance

FII: Literature ReviewFII: Literature Review

λ 451 cases in 154 articles worldwideλ Male and female victims, usually <4 yrsλ Average 21.8 months from onset of

symptoms to diagnosisλ 6% dead, 7.3% long term disabilityλ 25% siblings dead, 61% similar illnessλ 76.5% mother-perpetrators

Sheridan 2003, Child Abuse and Neglect

FII: EpidemiologyFII: Epidemiology

λ BPSU study– 97 FII cases, 44 poisoning and 32 suffocation

cases in 2 years in UK and Ireland– Most poisoning and suffocation was in context

of FII– Mother was suspected perpetrator in 99% of FII

cases– Median age 20 months– No sex difference– Large geographical variations in UK

(McClure, Davis et al 1996)

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FII: EpidemiologyFII: Epidemiology

λ ¾ acute admission, ¼ out-patientsλ ¼ school age (either had LD orcollusive with carer)

λ High morbidity‒ 95% inpatient care‒ ¼ long term symptoms‒ 12% lasting disability

λ Siblings: 10% had died; abuse in41%

BPSU study results: FII casesBPSU study results: FII cases

λ Direct physical harm in >half of casesλ 42/97 involved poisoning or suffocationλ 55/97 children also had a significant

genuine medical illnessλ Eight children had unnecessary surgical

procedures (fundoplication, central linesetc.)

N = 97

FII: Common PresentationsFII: Common Presentations

λ Seizures (25%)

λ Apnoea/ALTE (23%)

λ Drowsy/Coma (14%)

λ GI bleeding (14%)

λ FTT/feeding (11%)

λ Bowel disturbance (9%)

λ Asthma (9%)

λ Vomiting/reflux (8%)λ Haemoptysis (5%)λ Skin lesions (4%)λ Disability (3%)λ Allegations of abuse

(3%)λ Blood in urine (3%)λ Fabricated Overdose

(3%)

BPSU Study, n = 97

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FII: Less common presentationsFII: Less common presentations

λ Child Psychiatric presentations

λ False allegations of abuse

λ Fabricated special educational needs

λ Abuse of unborn infants

FII: Confirming the diagnosisFII: Confirming the diagnosisλ Converting ‘soft’ concerns to hard evidenceλ Meticulous history taking and corroborationλ Check all factual informationλ Carefully selected tests (avoid harm!)λ Toxicology, blood typing etc.λ Seek information from

GP/HV/school/SS/policeλ Surveillance/Physiological recordings/CVSλ Exclusion of parentλ Police search of cubicle/handbag/home etc.

Adapted from Samuels 1992, British Journal of Hospital Medicine

FII: The Paediatrician's Role 1FII: The Paediatrician's Role 1

λ Role of ‘Lead Consultant’

λ Make the diagnosis!

λ Safeguard child from immediate harm

λ Stop unnecessary investigation/treatment

λ Share information (‘Working Together’)

λ Acknowledge uncertainty

λ Communication with other professionals

λ Health Chronology

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FII: The PaediatricianFII: The Paediatrician’’s Role 2s Role 2

λ Monitoring child’s health and development

λ Contribution to ongoing risk assessment anddecision making

λ Ensure carer is offered appropriate healthsupport

λ Communication with NHS Managers

λ Consider your own welfare and look afteryour colleagues!

FII: Role of Other ProfessionalsFII: Role of Other Professionals

λ CAMHS

λ Surgeons

λ Primary Care Teams

λ Adult Psychiatrists

λ Teachers

λ Social Services

λ Police

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Outcomes of FII: BPSU studyOutcomes of FII: BPSU study

– Half of children were subject to legalprotection

– 40% children were living at home

– 70% were at home if not physically harmedby carer

Davis ’98: (n = 96, FU median 24 months)

Outcomes of FII: BPSU studyOutcomes of FII: BPSU study

– No children were subsequently found tohave had genuine disease which had beenincorrectly diagnosed as FII

– 24% still had signs or symptoms due toabuse

– 17% of index children living at homesuffered further abuse

– High rates of sibling abuse

Follow up median 2 years

Outcomes of FIIOutcomes of FIIλ Bools 1993:

– 55% of children remained at home

– One third re-abused

– Better outcomes if child spent period in fostercare before rehabilitation

– Insight by carer, commitment to plan,corroboration of information and goodcommunication between professionals allassociated with better outcomes

(duration of follow up av. 5.6 yrs)

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Thank You!Thank You!