A wrinkle in time: Kerry Woolfall at DFTB19

Cite this article as:
Team DFTB. A wrinkle in time: Kerry Woolfall at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21185

Kerry Woolfall is a social scientist and senior lecturer at the University of Liverpool. This talk, our second from the PERUKI track, she talks about doing research without prior parent and patient consent.  Following legislative changes in 2008 it is now possible (in the UK at least) to enter a child into a trial of potentially life-saving treatment then seek consent after the fact. But how would parents react to this? How would clinicians? What would happen if a child died during the trial, as may understandably occur if we are looking at potentially life-saving interventions?

This talk is not just about a researchers point of view but also details Kerry’s experience from the other side of the clipboard as a NICU parent.

The research embodies a core principle of engagement.

 

You can read some of the research here.

 

Woolfall K, Young B, Frith L, Appleton R, Iyer A, Messahel S, Hickey H, Gamble C. Doing challenging research studies in a patient-centred way: a qualitative study to inform a randomised controlled trial in the paediatric emergency care setting. BMJ open. 2014 May 1;4(5):e005045.

Woolfall K, Frith L, Gamble C, Gilbert R, Mok Q, Young B. How parents and practitioners experience research without prior consent (deferred consent) for emergency research involving children with life threatening conditions: a mixed method study. BMJ open. 2015 Sep 1;5(9):e008522.

 

You can follow Kerry on Twitter here.

 

 

#DoodleMed below by @char_durand

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

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Vicarious Trauma : It’s ok to not be ok

Cite this article as:
Jasmine Antoine. Vicarious Trauma : It’s ok to not be ok, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19256

One afternoon my team broke the news to three different families that their children had a non survivable condition. That same week I was involved with a patient transitioning to a palliative pathway focused on comfort. I returned home to utter the words, “She is so sweet, I hope she dies soon.

For many of us, days like these, occur commonly.

Being a doctor is a privilege, an honour, a calling. Our jobs are stressful, diagnostically challenging, involve managing team members, and effectively communicating and engaging with different families whom have different needs. We are reliant on our knowledge and skills. What sets our job apart from other high stress environments is that any given day can involve death and dying. We see distressing conditions. Our day includes the uncommon, the unlucky and the unfortunate events of life. To the public these events occur few and far between, but for us it may be a daily occurrence -a relentless barrage of traumatic events, poor outcomes and sad stories.

The intensive care environment is difficult to navigate. The rates of burnout, mental health issues and self medication are high amongst our peers. 70% of junior doctors feel burnt out following a neonatal rotation. Strikingly, their (our) rates of suicide are twice that of the general population. Most of us have heard the words compassion fatigue. Some of us may even be familiar with vicarious trauma – the negative experience of working directly with traumatised populations. Compassion fatigue and vicarious trauma are on a spectrum. We initially may feel overwhelmed by our interaction but this can develop into symptoms of post traumatic stress.

At DFTB18, I spoke about some of the things we can do to reduce this happening to us, and the events above reinforced that message;

  • Seek the support of those around you.
  • Reflect with your supervisor.
  • Get together with your team to debrief.
  • Seek professional psychological support.
  • Foster a culture in your workplace that is supportive and open, whilst also taking time for yourself.
  • Make a regular appointment to see you GP.

And remember, it’s ok not to be ok

For more on this topic of the difficulties of dealing with death and burn out hit up DFTB at:

Burning out by Mark Garcia

A short story about death by Andy Tagg

Selected References

Boss RD, Geller G, Donohue PK. Conflicts in Learning to Care for Critically Ill Newborns: “It makes me question my own morals”, Bioethical Inquiry. 2015;12:437-448

Hauser N, Natalucci G, Ulrich H, Sabine K, Fauchere JC. Work related burden on physicians and nurses working in neonatal intensive care units: a survey, Journal of Neonatology and Clinical Pediatrics. 2015;2:2:0013.

Nimmo A, Huggard, P. A systematic review of the measurement of compassion fatigue, vicarious trauma and secondary traumatic stress in physicians. Australian Journal of Disaster and Trauma Studies. 2013;1:37-44.

Stress, burnout and vicarious trauma: looking after yourself. RACGP Webinar Series.

The illusion of patient choice

Cite this article as:
Amit Bali. The illusion of patient choice, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19010

“Pick a card…any card”, as the saying goes.

I remember being the recipient of this common trick when a medical student, at a friend’s for dinner where a magician was a fellow guest. The scientist in me wanted to know how it was done, so I prepared to follow my card studiously. I chose carefully and deliberately, feinting to pick one card from the fan offered to me, before choosing – in my eyes – a less obvious card. However, after returning the card to the deck, the magician threw his arms up with a flourish, the pack hitting th eceiling with a thud, causing cards to scatter across the room. Amazingly, my chosen card was stuck to the ceiling, fixed in place by a drawing pin.

I made peace with the fact I was always going to choose that card, and applauded in awe.

 

The ‘magician’s choice’

A few years ago, during a lecture, I was introduced to the concept of the‘magician’s choice’ by Daniel Sokol (a medical ethicist and magician). He used it as an innovative analogy to illustrate how, in obtaining consent, the presentation of the different options is nothing like the free choice it is intended to be. Rather, the possibilities are presented, much like a deck of cards, only this time the ‘trick’ is that the clinician– whether consciously or not – weights information, making a certain choice more likely. I was reminded of this concept recently, after reading about a new app due to be rolled out in the English National Health System. This new platform, it is claimed, will enable patients to see waiting times at different emergency departments, the implication being that they will choose to go to the one with the shortest wait. Unsurprisingly, this sparked Twitter debate about whether or not this actually was a useful tool to help patient flow, with strong opinions on either side.

To my surprise, however, the assumption from everyone seemed to be that this app would offer choice. To which my first thought was: ‘choice, what choice?’

 

Patient choice?

For many years, the NHS has offered explicit patient choice for specialist outpatient care, offering a range of different hospitals at the point of referral. In recent years, the system has evolved to display waiting times. Sounds good so far? To an extent, I agree. A transparent system that allows patients, in conjunction with their GP, to book in to an appointment – even obtaining a date and time – is a pretty simple but effective use of technology. My objection is that the offered choice is nothing but an illusion.

The patient is given little idea of the constraints through which their choice is being made. As an example, many of the children I see have a long-term condition (epilepsy). Effective, joined-up care is much more than a quick hospital consultation, achieved through a combination of having a point of contact via their specialist nurse, close liaison with school, tracking of development progress, and surveillance of mental health and wellbeing. This is best achieved through local, networked care, a system which has been carefully developed over many years.When I see a patient outside this framework, the care is not just difficult to deliver – in what is far from a delicious irony, it actually gets delayed. When I have to inform families that ‘I can’t access that information’, ‘they won’t accept that referral from me’, or ‘our nurse doesn’t cover that area’ (all recurring themes from my practice over the last year), I empathise with the fact that they took a decision that they thought would get quicker access to care for their child, only to now discover that delay was just shifted further down the road. There are potential ways around this – not least patient record systems that speak to each other. Yet that sort of change doesn’t happen overnight so, until it does, surely patients deserve better? Until then, this resembles the ‘three cup and ball’ trick. The patient believes they have options, when actually the system is too constrained to offer the truly free choice that is advertised. No matter how much you try to pick the cup with the ball under it, the pieces move and the magician ensures you never can.

Legal and Ethical Quandaries: Ian Summers at DFTB18

Cite this article as:
Team DFTB. Legal and Ethical Quandaries: Ian Summers at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18919

When most of us think of ethics and law our eyes roll and we picture Rumpole of the Bailey and quiet Sunday afternoons in front of the television. But his time Ian Summers came up with something unique. Pushing the boundaries of simulation as an educational medium he introduced us to a series of hypotheticals. Take your time to watch rather than just listen to your iDevice. You’ll learn about ethical practice in paediatrics but if you pause, take a step back, and press play again, you’ll see a masterclass of simulation in action.

 

 

 

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

 

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

 

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I fought the law…

Cite this article as:
David McDonald. I fought the law…, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17508

I recently attended my forty-year post-graduation reunion – I graduated from Sydney University in September 1978. It was a cheerful night and great to see old friends.  I am still recovering from the humiliating ritual of dancing the Village People YMCA number. (I was the cowboy).

There has been a lot of awareness about medico-legal matters among junior doctors since the Bawa-Garba case. I thought I would share a retrospective view on some aspects of my personal experience interacting with the legal profession over a long career. The medico legal area is so complicated that I will not comment upon specifics other than saying that joining a Medical Defence Organisation (MDO) is essential for any practicing doctor. MDOs know stuff that you will never know.

 

Choosing a Medical Defence Organisation

Choosing a MDO that suits your needs is one of the most important decisions you will make during your career. The decision should be considered carefully as not all insurance companies are the same. I recommend a Mutual Defence Organisation (MDO) that is not necessarily a part of a large commercial insurance company.  I have remained with the same company very successfully with all the ups and downs for over forty years.  A good Mutual Defence Organisation has the commitment to care about the doctor’s personal welfare as well as the other legal matters. The good ones have experienced and sympathetic medical advisors, and you will need their emotional support as well as expertise if things get sticky.

A public hospital has its own insurance to cover claims for financial compensation made by patients against it. Legally, the employer hospital is liable for its employees, so the cover extends to resident staff. But such staff may be the subject of other, personal, types of legal situations such as HCCC complaints and coronial inquiries and whatever help the hospital may provide is discretionary. You cannot assume that the hospital will provide representation for you personally. A colleague of mine had assistance denied only a short time before an inquest where his management was a focus of attention. An MDO will provide assistance in these other legal situations.

 

How do you manage if you hear that you are being involved in a legal matter?

 This is one of the most stressful things that can occur for a doctor so be prepared in advance. Step 1 is to find a good experienced mentor that suits your personal style as early as possible in your career and before bad stuff has happened. There are differences between a supervisor and a mentor. A supervisor is appointed by the hospital administration, whereas you can choose your own mentor. Accordingly, a mentor is a better fit for your personality and aspirations. Sensible mentors recognise that being asked to mentor a junior colleague is a compliment in the Hippocratic tradition, and don’t mind helping when approached. You don’t have to propose formally.

If you do hear that you are being involved or sued, contact your MDO immediately. You will need emotional support from understanding contacts like your mentor or peer colleagues. This support may come from your partner; however non-medical partners may not understand the paradigm completely. It is difficult when you “put yourself out there” doing what you hope is the very best for your patients, usually because have a great deal of internal self-drive, and then have the whole thing turn into a mess. Also, you may reasonably wish to quarantine work stuff and home stuff, especially if you have a young family.

Friends and colleagues that have been sued often say it is the reassurance and support of their colleagues who remind them that “you really are a good doctor” that is most helpful. In addition to your mentor and colleagues, consider professional support from your organisations Employee Assistance Program. Most of all, do not personalise it excessively nor let it affect your sense of self or enjoyment of your profession. Many people that have been through the difficult journey find that they emerge with a greater sense of destiny and fulfilment and greater skill and knowledge.  It takes some effort and luck to get to that point.

If you do have to attend court get specific orientation and support from your MDO. Be prepared – you may be permitted to carry your notes into the witness stand and read from them, for example. Know what type of proceedings that you are giving evidence -is it Criminal or civil? At all times, with or without a lawyer’s help, you must tell the truth about the facts and not be evasive (e.g. if you did tell a superior about something), even if the truth may not help others.

 

How is medical conduct adjudicated?

The Bawa-Garba case showed that doctor’s performance is judged “on the facts of that specific case”. That principle was a factor in why the Bawa-Garba case judgement appeared so unreasonably harsh. Despite the sadness of the whole affair, the court took the view based on the bare facts of the case that the management of the patient was well below reasonable professional standards. Mitigation for prolonged shift length/personal situation was not a consideration.

It means that if you are in a situation where you believe that workplace practices impair your ability to practice safely, consider raising a paper trail or at least initiate a discussion that objectively states your concerns with your supervisor. Situations could include excessive clinical workload or roster lengths, systematically poor communication, unavailable supervision, or being directed to provide care or undertake a procedure that is outside your level of expertise.

 

Workplace matters

Workplace matters are another area that MDOs can be very worthwhile. There is the potential for an enormous range of conflicts or difficulties. I was once threatened with substantial legal action for defamation by another clinician following a complaint I made to a teaching hospital about the medical care that was provided to one of my patients. It was a difficult time. I was able to deter the threatened defamation action with the assistance of my MDO. My painful teaching lesson was that “You can express an opinion and relate facts about what happened but don’t be malicious, and tell the truth”.

Your MDO can assist with workplace disputes such as bullying and harassment from staff or patients, or if you are accused of that. There are processes in place for this and many other workplace scenarios of which you may not be aware. An example could be if you feel the need to withdraw from providing medical care to a patient if they are harassing you. That needs a number of carefully calibrated steps including making satisfactory to the patient alternative arrangements for care.

Medical insurance does not substitute for a professional organisation such as ASMOF or the AMA and all doctors should belong to one of these.

 

Root cause analyses

NSW Health does have a process for misadventure called Root Cause Analysis (RCA), and most Public Health Organisations have similar processes. They are supposed to look at systems rather than individuals. They have legal privilege and confidential recommendations, although the information can leak out. RCAs can be a useful means of improving patient care. Even if it is difficult I advise honest engagement with this process. RCAs are humbling and stressful. If there is senior medical staff engagement and diligent exploration of the facts, clinically useful outcomes are possible.

 

Expert certificates and reports

There are some differences between an “Expert Certificate” and an “Expert Report”. An Expert Certificate is prepared for the court by doctors involved in a case, such as for the Coroner. Any grade of doctor can be approached. Senior doctors are much more likely to be approached to write expert reports, which may seek review of a case that they did not personally manage. In both areas, sticking carefully to the facts of the case is crucial, and not being tempted to step outside your area of expertise or to conjecture. A skilful barrister can make even the most caring doctor look pretty stupid in the witness stand. In both circumstances look at them as an objective means of assisting the court, and not representing or supporting any individual. Don’t run the risk of appearing biased (or excessively sympathetic to a colleague).

 

If you are asked to provide a mandated expert certificate I would advise that is done with the assistance of your MDO. Expert reports are generally a request rather than a directive. Although agreeing to write an expert report is “doing the right thing”, it exposes the doctor to what may not be a nice experience. You need to ask what it will involve for you e.g. being subpoenaed to court, maybe having to attend joint conferences with other experts. Enquire about fees and a timeline for “when you will be paid”. I personally accept those expert report requests with my eyes wide open, and agree to cooperate if the matter is of sufficient merit, the request is put reasonably and originates from a reputable source (such as a MDO).

 

Dealing with legal profession is stressful but it is also a crucial part of our professional responsibility. An important lesson from the Bawa-Garba case is that it is essential for any doctor of any grade to be a member of a good Medical Defence Organisation. Ask your senior colleagues about their experience. Choose your MDO carefully – you could be married to them for life.

Paediatric Research Priorities

Cite this article as:
Andrew Tagg. Paediatric Research Priorities, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.16058

In order to help us all keep up to date the DFTB team and friends scour a great many journals to fill the monthly edition of Bubble Wrap. Given the large volume of research already out there that has not made it from the journal to the bedside, the major research agencies have been trying to determine what we really want to know.

Norman Swan: Breaking boundaries in medicine at DFTB17

Cite this article as:
Team DFTB. Norman Swan: Breaking boundaries in medicine at DFTB17, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.15288

This talk was recorded late on the second day of DFTB17 in Brisbane.

Norman Swan is a multi-award winning broadcaster and producer. He has one three Walkey awards for national journalism and in 1989 he was given the Michael Daly award, Australia’s highest prize for science journalism. In this amazing talk he takes us through his formative years as a junior doctor, on to his role in exposing the scientific fraud of Dr William McBride, and beyond.

The Quagmire

Cite this article as:
Natalie Thurtle. The Quagmire, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.13504

Our community is made up of health care folks that do hard things, go the extra mile, work on themselves and their knowledge so that patients get better outcomes. We’re not good all the time. We make mistakes, forget stuff, get grumpy or emotional, slide into tribal behaviour. But we’re working on it. So when someone comes along and shines a light on what’s happening outside our normal frame of practice, shows us patients that can’t get care, who are needlessly dying or suffering, it makes us uncomfortable. We want to do something.

Sometimes I get asked to be the person that turns on that torch, the person that makes everyone else uncomfortable, most recently at the excellent DFTB17. I try to do this with balance, to show another context, but also not to make people feel helpless or shocked. Sometimes I get it right, sometimes not. Without fail though, at least one person always asks me afterwards a variation of ‘What can I do?

A gentle nudge…

Cite this article as:
Tessa Davis. A gentle nudge…, Don't Forget the Bubbles, 2017. Available at:
https://doi.org/10.31440/DFTB.11516

Children have a right to receive healthcare regardless of the decisions made by their parents. This week, the RACP released a further statement citing refusal to treat patients for non-vaccination as ‘unethical coercion’. Whilst the majority of paediatricians are clear on the benefits of vaccinations, parents can choose not to vaccinate their children. Under the No Jab No Pay policy, this choice can lose them their right to Child Care Rebate. However, it should not lose them their right to receive healthcare. A poll by the Royal Children’s Hospital in Melbourne found that 17% of children who were not fully vaccinated had been refused healthcare by a provider. But what does ‘refused’ actually mean? And does the RACP’s statement leave us confused rather than providing clarity?

 

What was the poll?

The Australian Child Health Poll team at RCH is led by Dr Andrea Rhodes. It runs a quarterly poll on contemporary child health issues by conducting national surveys across Australia. The latest poll, released earlier this week, looked at vaccination perspectives of Australia families.

Data was collected from 1945 parents (with 3492 children). They were asked questions relating to the vaccination status of their children and attitudes to vaccinations.

 

What were the key findings on refusal of care?

  • 95% of the children were fully up to date with their vaccinations
  • 30% of parents had some concerns about vaccination
  • 9% of parents did not agree that “…it was important to vaccinate their child to protect the community (herd immunity)”
  • Of those not up-to-date, 17% had been refused healthcare (29 children)

 

Why are children not up-to-date with their vaccinations?

24% had delayed some vaccinations due to to minor illnesses, and there were misconceptions about when to delay.  36% thought that vaccines should be delayed in child with a runny nose but no temperature, and 47% thought they should be delayed if the child was on antibiotics. 22% thought vaccines should be postponed due to a local reaction from a previous vaccination.

18% had a preference against vaccinations, and perhaps worryingly 10% thought that vaccinations were linked to autism and a further 30% felt unsure about the link.

22% had delayed because of barriers to education and access. Half of these struggled to attend for vaccination and the other half had questions about vaccinations that they were unable to get answered. This emphasises the importance of our role. This sizeable group needs our input as paediatricians – to offer information, be open to discussion and assist with making vaccinations accessible.

 

What can we take from this?

This is the first poll in Australia providing information about refusal to provide healthcare.

Our role as paediatricians is to provide healthcare for each child regardless of their circumstances and certainly regardless of any actions of their parents. This poll makes it clear that there is a sizeable group of parents with uncertainty about vaccination who are interested in engaging and accessing services. We would be doing them a disservice by refusing to treat their children. And even where parents have made a specific decision not to vaccinate, we still have a duty to provide healthcare for their children. It is only by keeping the channels open that we can support, educate, and engage.

The RACP has released a clear statement on this which reinforces their Immunisation Position statement.

It is inappropriate to refuse to treat unvaccinated children, firstly because it represents unethical coercion and secondly because the children will be further disadvantaged.

Yes, we know that vaccinations are beneficial. And yes, we want to increase vaccination rates and ensure our patients are vaccinated. However, by denying unvaccinated children healthcare we are disadvantaging them even further. The RACP goes as far as to call this ‘unethical coercion’. We need to provide healthcare and not use it as bargaining chip.

However, the concept of refusal may not be clear cut. This poll did not collect data on the circumstances of refusal so we do not know which provider has refused treatment or how that refusal has occurred. It is possible that parents perceive that healthcare professionals are not happy to treat them and classify this as outright refusal.

Research in the US has shown that providers worry that unvaccinated children will pose a risk to young babies in their waiting rooms, or that the unvaccinated child themselves is at risk of catching a serious infection. These are reasonable concerns and therefore steps may need to be taken to minimise these risks. If unvaccinated children need to sit separately, could this constitute refusal in the eyes of parents? If the parents have to engage in an awkward 10 minutes of discussion with the paediatrician about the benefits of vaccination, could this constitute refusal in the eyes of the parents?

So the answer is not as clear cut as the RACP’s statement makes it seem. Of course we should not refuse to treat a child because their parents didn’t vaccinate them. But it is also our role to encourage vaccinations and to engage in discussion about the benefits of vaccination. This engagement may make vaccine-refusers feel uncomfortable and affect their perception of our willingness to provide healthcare. This is not the same as refusal to treat.

 

Munchausen by Proxy : Fabricated & Induced Illness

Cite this article as:
Henry Goldstein. Munchausen by Proxy : Fabricated & Induced Illness, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.9772

I recently attended a superbly insightful presentation by Dr Sue Wilson, the psychiatrist for our Consultation Liaison team here at Queensland Children’s Hospital. Some years ago, I was involved with a case of FII / Munchausen’s syndrome by Proxy, and – as is often the case – the case continues to resonate and evoke strong feelings. She has kindly offered her source material for this post.

Theoretical conceptualizations

Fabrication and Induction of Illness (FII) tends to be conceptualized as a rare/severe form of child abuse. The term Munchausen’s syndrome by proxy is used less in clinical practice, as it places an emphasis on the abuser rather than the victim. We’ll mostly use FII hereafter in this post, although there’s a short explainer about Munchausen himself later on.

An alternative view is that fabricated illness occurs along a broad spectrum that ranges from exaggerated reporting of symptoms by very anxious parents to the actual production of symptoms, with varying degrees of risk. This broader definition includes a far wider range of motivations and behaviours that represent clinical reality.

Here’s a 5 point summary:

  1. MBP/FII is a rare and severe form of child abuse. The behaviours may be considered on a spectrum of induced symptoms.
  2. Focus needs to be on caring for the child, not diagnosing the carer.
  3. Consider FII whenever you come across a perplexing presentation – it’s more common than some of the other, very rare, diagnoses we chase.
  4. A key differentiator is the parental response to a proposed medical change of direction.
  5. If you are even considering FII as a differential diagnosis, make early contact with your hospital’s child protection team – as you would for a consulting service to see an opinion.

Important to remember


The line between volitional and non-volitional processes in the caregiver is difficult to identify. To be clear, volitional means the cognitive process whereby a person decides on and commits to a particular course of action. The harmful effects on the child are very similar, irrespective of the parent’s actions and motivations.

The focus must be on the outcomes or the impact on the child’s health and development and not initially on attempts to diagnose the parent or carer.

Detailed descriptions of the impact of the carer’s behaviour on the child are more useful than diagnostic labels which may distract from the central issue of harm to the child. Recognition of the carer’s difficulties is neither necessary nor sufficient for the diagnosis of FII.

So, who was Munchausen?

Munchausen refers to a satirical character based loosely on Hieronymus Karl Friedrich von Münchhausen, a German nobleman born in 1720. He gained notoriety in German aristocratic society after returning from a number of foreign wars with literally unbelievable stories. An author, so inspired by the Baron’s tales, expanded them into satire and farce and published them widely, much to the rage of Munchausen himself. This last point, to me, serves to reinforce the point above about volition versus non-volitional processes – I’m sure the original Baron von Munchausen did not intend to leave this kind of legacy! The satirical Munchausen features in a number of books and movies, most recently in a 2012 TV movie.

munchausen

Right then, back to it…

Perplexing presentations vs FII

FII are one sub-group within the category of perplexing presentations – FII should be considered as a differential diagnosis when some of the other indicators are present. Think to yourself, “What doesn’t make sense about this child’s presentation? ” What differentiates perplexing presentations from FII is the parental response to a proposed medical change of direction – from investigation to rehabilitation. That is, some parents persist in seeking medical opinions and investigations and decline or do not participate in the rehab process. They find difficulty in enabling their child to function and cope better.

Indicators which should alert professionals to the possibility of FII


Several indicators can give clues to an FII presentation. These include a carer reporting symptoms and signs which are not explained by any known medical condition, physical examination and investigations that do not explain reported symptoms and signs, inexplicably poor response to medication or other treatment, or intolerance of treatment or acute symptoms that are exclusively observed by/in the presence of the carer.

Additionally, on resolution of the presenting problems, the carer may report new symptoms or symptoms in different children.

The child’s daily life and activities may be limited beyond what is expected due to any disorder from which the child is known to suffer e.g, poor or no school attendance; use of seemingly unnecessary special aids.

Occasionally there is objective evidence of fabrication – history from different observers in conflict or being biologically implausible; test results (toxicology or blood typing); covert video surveillance (this is a minefield and we heavily caution against this course of action, even if you loved The Sixth Sense!!).
Sometimes a carer expressing concern that they are under suspicion of FII or relatives raising concerns about FII may be an indicator, as is a carer seeking multiple opinions inappropriately.

Characteristics


Characteristics of parents who fabricate or induce illness in their children should be applied with caution – many of them are also true of many parents. Additionally, they should not be used to confirm or deny the existence of FII and ultimately the identification of characteristics consistent with parents or carers fabricating or inducing illness in children may add to suspicions during the investigation process but do not constitute a profile. Nonetheless, we know;

  • Typically carried out by women, specifically mothers (95%)
  • Usually the child’s primary carer
  • Often present initially as “good” carers

(Yes, the three above points are also true of a very, very high proportion of carers…)

  • Usually accomplished liars and manipulators
  • Usually the only ones consistently present or associated with the onset of the child’s symptoms (when the carers are absent, symptoms or illnesses are not reported or may begin to improve)
  • They may have a history of self-induced symptoms/illness exaggeration, falsification or induction
  • They may have mental health evaluations indicating they are “normal” – psychiatric disturbance may be well-concealed from the observer
  • They may have no prior involvement with child protection services
  • They may appear to be overanxious, overprotective, mistaken or deluded
  • They may have a background in the health profession (14-30%) or an unusual degree of knowledge about health
  • They may seek publicity or attention from a variety of people

These parents or carers do not necessarily stop their behaviour towards the child when under suspicion or caught, but change tactics by:

  • Changing health professionals.
  • Denying all or part of what they have done, even in the face of overwhelming evidence.
  • Accusing their accusers, and shifting blame onto those who are aware of their behaviour. 

Risk factors of mothers for creating Abnormal Illness Behaviour in children

Remote or longstanding risks include;

  • Loss or separation from parent
  • Abuse/neglect
  • Foster care
  • History of lying in adolescence
  • History of self-harm

Recent or acute risks include;

  • Current somatoform disorder
  • Current factitious disorder
  • In receipt of disability living allowance
  • Child missing school
  • Frequent visits to doctors (symptoms unexplained)
  • Frequent moves of house and GP
  • Parent requests disability living allowance for child

Psychopathology of Fabricators

There is no clear relationship between any mental disorder and abusive behaviour towards children.  Many mothers with Borderline Personality Disorder (BPD) or history of abuse do not abuse their children in this way. Such a history may be a trigger to look more closely but doesn’t constitute proof; it’s important to remember that FII is a behaviour to be identified, not a medical or psychiatric diagnosis.

There are a number of associated conditions for those parents/caregivers whom fabricate;

72% somatoform disorders
55% self harmed

21% misused alcohol &/or drugs
89% personality disorder especially Borderline (by interview)
23% personality disorder (by self-rating scale)

Additionally, symptoms of depression and anxiety are common, as well as a high prevalence of somatising and factitious disorder. It’s worth noting that Factitious disorder and FII in children can co-occur; Somatoform disorder in the mother indicates some abnormality of illness behaviour and relationships with health professionals. Detection of factitious disorder in a mother of young children should provoke a search for FII in her offspring.

Fabricators are classically highly persuasive and have a tendency to split between staff (the idealisation of some, whilst devaluing others). FII involves all social classes (not just Barons). There may be a history of significant lying behaviours and deception dating back to childhood. One study notes 1 in 4 abusing carers had a history of being victims of child abuse, whilst another found high rates of deprivation, childhood abuse, significant loss or bereavement in the mothers, however FII is not necessarily associated with young, inexperienced parents or deprivation.

Possible explanatory mechanisms and motivations


The motivations of FII are complex and vary from case to case. However, it can be noted that extreme anxiety leading to exaggeration of symptoms and signs to encourage the doctor to rule out or identify any treatable disorder may play a roles. As can the need to confirm (false) beliefs about the child’s health (e.g, developmental disorder, food allergy) including beliefs held by caregivers with ASD and rarely with a delusional disorder. There may also be a wish for attention or deflection of blame for the child’s (usually behavioural) difficulties. FII also maintains closeness to the child and may invoke a material gain e.g. carer’s benefit. There may be an underlying hostility to doctor or even the child themselves.

In one study motivation for the induced illness in children was unclear in 2/3 of cases.

Intergenerational transmission of abnormal illness behaviours


There appears a common theme amongst caregivers that there is a past use of illness behaviours in relationships with other individuals, including health professionals. FII may at times represent extensions and distortions of childhood patterns of behaviour whose function was to obtain comfort and protection from others, with clinicians now placed in the caregiving role.

This adaptive use of deception develops early in life, and becomes entrenched over time and further distorted by subsequent losses and traumas. From early childhood some caregivers report feigning symptoms in order to avoid beatings or to prevent contact visits with abusive parents/carers. This makes sense if “playing sick” saves you from physical or other abuse.

When parents have been exposed to significant loss and trauma their behaviour is likely to be motivated by trauma-related triggers in situations where they feel threatened or perceive their children to be threatened; it’s worth noting that these ways of thinking and behaving are not always accessible to conscious reflection.

Disturbed attachment

 It may be more useful to see FII as a function of a disturbed mother-child attachment bond, influenced by mother’s own attachment experiences; insecure attachment is associated with higher levels of somatisation. Indeed, a study of attachment models in mothers who fabricated or induced illness found high levels of insecure attachment and unresolved bereavement. This may, in turn, sensitise individuals to see others as more sick than they really are.

Mother-child relationship

Remember, the mother may appear to have a close and caring relationship with the child (may not be so), with presence of separation anxiety and over protectiveness noted.
FII has been described as a “symbiotic bond”, although symbiotic infers mutually beneficial, and in FII it’s pretty hard to see any benefits for the child.  However, illness is the way for this child to maintain a relationship with his/her parent and perhaps preserve the parent’s mental equilibrium.


Consequences

Half of the patients suffer psychological harm including emotional and behavioural problems, school non-attendance and concentration difficulties, whilst a high percentage are affected by other forms of maltreatment or neglect or a repetition of FII. There are usually  compromised attachment relationships as a result.

Short-term effects include;

  • Self-image of self as sick or disabled
  • School absences
  • Miss normal developmental opportunities
  • Impact on peer relationships
  • Only way to achieve nurture or interaction with parent may be via the sick role
  • Impact of possible collusion in older child
  • Following confirmation, must consider child’s developmental stage, level of attachment, effect of separation from sibs and others

Long-term effects include

  • Impairment of overall development
  • Risk of psychological harm
  • Long term implications for child’s mental health including risks of Factitious disorder
  • Long term implications for attachment – effect on trust
  • Relationships and caring mediated through illness
  • Little research on harm from verbal fabrication

Role of mental health

Since no psychiatric diagnosis is pathognomonic of a perpetrator of this type of abuse, psychiatric assessment should not be used to determine whether FII has occurred, however there is a role for mental health after the behaviour has been confirmed, by way of;
  – assessment: parents, family dynamics, parenting skills, child
  – treatment planning: opinions re possibility of family intervention

The Mental Health team may be asked to assess parents who have a history of psychiatric disorder, especially if it seems that parental anxiety or misinterpretation may be contributing to the presentation. The main role for mental health is providing support for the team behind the scenes and taking part in case discussions; this process can be very stressful for all members of the team!

Given the early life experiences of caregivers, they tend to draw clinicians into close relationships in which boundaries can become blurred; this may be a red flag as well as an issue that can be explored in staff support meetings. There is also the potential to cause splitting in the team and arouse strong feelings (including around diagnosis and methods of investigation).

This is particularly challenging as medical & nursing staff must balance the need to remain engaged with the family as clinicians, whilst also being involved in observation and complex case discussions about the family; the period of growing suspicion and investigation is often the most difficult.

Areas of uncertainty

 FII is an area that has some intrinsic uncertainty, often as cases evolve over time. It’s important to always come back to impact on the child. Additionally, consider is this just an overanxious parent, perhaps exaggerating symptoms? Is there something medical being missed?  How much medical investigation is enough? For the parent?  For the treating team? Could it be conversion or somatoform disorder in the child rather than FII?


In older children, there is also a potential for coaching and collusion.


Plus, it is possible that a child may actually experience symptoms of a psychological nature (e.g. headache) which parent insists must have a medical cause.

Management

 Pragmatically, it is essential to notify your local child safety/child protection organisation. In some jurisdictions, including Australia, this is mandatory for health practitioners. One key message from Dr Wilson’s presentation was that if you are beginning to suspect FII, then making early contact with your hospital’s child protection team – as you would for a consulting service to see an opinion – can facilitate the diagnosis and subsequent management. Generally speaking, psychological treatment is not indicated for individuals who cannot admit their behaviour.

In some cases, reunification is possible eg specialist unit in UK.  Better outcomes are associated with:

  • Acknowledgment of fabrication
  • Less severe abuse
  • Improvement in parent’s psychological functioning and empathy for the child
  • Improved parent-child relationship and child attachment behaviour
  • Change in the family system
  • Therapeutic alliance with the partner and extended family – safety network

Training for Paediatricians

So, how can Paediatricians & Paediatric trainees improve, with the above in mind? Clinical skills in consultations are always  being sharpened; with experience clinicians, become increasingly aware that parents need to be listened to but not always agreed with. Additionally, the skills of managing the potential conflict in the doctor-patient relationship also develop with time. In FII, there is a shift in emphasis so that the child truly becomes the primary client.

In the case of perplexing presentations, exploration of childcare perspective of children’s problems in addition to medical disease model, as well as identification of behavioural and interactional cues may assist in the recognition of FII.

Be mindful of obstacles which stand in the way of paediatricians recognising FII:
  – discomfort with not believing a parent, on whose history paediatricians rely
  – discomfort with not understanding the child’s presentation
  – concern about missing a treatable condition
  – concern about litigation or complaints.

References:

Jureidini JN, Shafer AT, Donald TG.”Munchausen by proxy syndrome”: not only pathological parenting but also problematic doctoring? Med J Aust. 2003 Feb 3;178(3):130-2.

Proops & Sibert (Eds), Fabricated or Induced Illness by Carers (FII): A Practical Guide for Paediatricians. RCPCH, 2009. (Dr Wilson also referenced the 2002 edition of this publication in her talk.)

Bass C, Glaser D. Early recognition and management of fabricated or induced illness in children. Lancet. 2014 Apr 19;383(9926):1412-21.

Kozlowska K, Foley S, Savage B.Fabricated illness: working within the family system to find a pathway to health. Fam Process. 2012 Dec;51(4):570-87.

Kozlowska K.When the lie is the truth: grounded theory analysis of an online support group for factitious disorder. Psychiatry Res. 2014 Dec 30;220(3):1176-7.

Bass C, Jones D.Psychopathology of perpetrators of fabricated or induced illness in children: case series. Br J Psychiatry. 2011 Aug;199(2):113-8.

Bools CN, Neale BA, Meadow SR.Follow up of victims of fabricated illness (Munchausen syndrome by proxy). Arch Dis Child. 1993 Dec;69(6):625-30.

Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry. 2005 Oct;187:328-33.

Adshead G, Bluglass K. A vicious circle: transgenerational attachment representations in a case of factitious illness by proxy. Attach Hum Dev. 2001 Apr;3(1):77-95.

Fish E, Bromfield L and Higgins D. A new name for Munchausen Syndrome by Proxy: Defining Fabricated or Induced Illness by Carers. Australian Institute of Family Studies. 2005; 23.