I recently attended a superbly insightful presentation by Dr Sue Wilson, the psychiatrist for our Consultation Liaison team 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.
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:
Munchausen’s by Proxy and fabricated and induced illness is a rare and severe form of child abuse. The behaviours may be considered on a spectrum of induced symptoms.
The focus needs to be on caring for the child, not diagnosing the carer.
Consider fabricated and induced illness whenever you encounter a perplexing presentation – it’s more common than some of the other, very rare, diagnoses we chase.
A key differentiator is the parental response to a proposed medical change of direction.
If you are even considering FII as a differential diagnosis, contact your hospital’s child protection team early – as you would for a consulting service to see an opinion.
The line between volitional and non-volitional processes in the caregiver is hard 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 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 to diagnose 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!
Right then, back to it…
Perplexing presentations
FII are one sub-group within the category of perplexing presentations.
FII should be considered 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.
When should you think about 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, once the presenting problems are resolved, 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 or the 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.
Is there a typical carer archetype?
Ascribe characteristics of parents who fabricate or induce illness in their children with caution – many are also true of so-called normal parents. Additionally, they should not be used to confirm or deny the existence of FII, and ultimately, identifying 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 do know…
- That it is typically carried out by women, specifically mothers (95%)
- They are usually the child’s primary carer.
- They often present initially as “good” carers.
(Yes, the three above points are also true of a very high proportion of carers…)
- They are usually accomplished liars and manipulators.
- They are 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 for creating abnormal illness behaviour in children
Remote or longstanding risk factors
- Loss or separation from a 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
- The parent requests a disability living allowance for the child.
Psychopathology of Fabricators
There is no clear relationship between any mental disorder and abusive behaviour towards children. Most mothers with Borderline Personality Disorder (BPD) or a history of abuse do not abuse their children this way. Such a history may trigger looking 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 who 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)
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.
Why do carers make up an illness?
The motivations of FII are complex and vary from case to case. However, extreme anxiety leading to exaggeration of symptoms and signs to encourage the doctor to rule out or identify any treatable disorder may play a role, 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. Fabricated and induced illness keeps the child close and may invoke a material gain, e.g. carer’s benefit. There may be an underlying hostility to the doctor or the child. In one study, motivation for the induced illness in children was unclear in 2/3 of cases.
What role does intergenerational trauma play?
There appears to be a common theme amongst caregivers that there is a past use of illness behaviours in relationships with other individuals, including health professionals. FII may sometimes 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. Some caregivers report feigning symptoms from early childhood to avoid beatings or prevent contact visits with abusive parents/carers. This makes sense if “playing sick” prevents 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 the 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 separation anxiety and over-protectiveness. 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. 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 repetition of FII. There are usually compromised attachment relationships as a result.
Short-term effects
- Self-image of self as sick or disabled
- School absences
- Miss normal developmental opportunities
- Impact on peer relationships
- The only way to achieve nurture or interaction with parents may be via the sick role.
- Impact of possible collusion in an older child
- Following confirmation, one must consider the child’s developmental stage, level of attachment, the effect of separation from sibs and others.
Long-term effects
- 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
- There is little research on the harm of 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 of 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 team members!
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 and 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. Consider whether this is 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 the parent insists must have a medical cause.
How do we manage a case of fabricated illness?
Pragmatically, you must 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. Better outcomes are associated with:
- Acknowledgement 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 and paediatric trainees improve, with the above in mind?
Clinical skills in consultations are always being sharpened. With experience, clinicians become increasingly aware that parents must 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 the childcare perspective of children’s problems in addition to the medical disease model, as well as identification of behavioural and interactional cues, may assist in recognising 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
Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry. 2005 Oct;187:328-33.
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.)
