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.
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:
- MBP/FII is a rare and severe form of child abuse. The behaviours may be considered on a spectrum of induced symptoms.
- Focus needs to be on caring for the child, not diagnosing the carer.
- Consider FII whenever you come across 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, 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.
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.
[toggle title=”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. [/toggle]
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. [/toggle]
[toggle title=”Risk factors of mothers for creating Abnormal Illness Behaviour in children”]
Remote or longstanding risks include;
- Loss or separation from parent
- 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 [/toggle]
[toggle title=”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. [/toggle]
[toggle title=”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. [/toggle]
[toggle title=”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. [/toggle]
[toggle title=”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.[/toggle]
[toggle title=” 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.[/toggle]
[toggle title=”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
[toggle title=”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.[/toggle]
[toggle title=”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.[/toggle]
[toggle title=”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 [/toggle]
[toggle title=”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.
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.)
Adshead G, Bluglass K. Attachment representations in mothers with abnormal illness behaviour by proxy. Br J Psychiatry. 2005 Oct;187:328-33.