Fabricated or Induced Illness By Carers: Solving the Conundrum
Image credit: The Lancet
This Monday’s debate comes from John Wong, fourth year medical student at King’s College, who writes about Fabricated or Induced Illness by Carers and how to recognize it.
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The patient feigns symptoms repeatedly for no obvious reason and may even inflict self-harm to produce symptoms or signs.
Fabricated or Induced Illness by Carers (often referred to as FII) is a spectrum of disorder rather than a single entity. The media refer to the condition as Munchausen Syndrome by Proxy. In the USA, it can be referred to as factitious disorder by proxy and paediatric condition falsification.
The International Classification of Diseases – 10th Edition (ICD-10) classifies Fabricated or Induced Illness in adults as a Disorder of Personality and Behaviour. The patient feigns symptoms repeatedly for no obvious reason and may even inflict self-harm to produce symptoms or signs. FII in children is a form of child abuse and should be taken seriously to safeguard and promote the child’s welfare.
Fortunately, FII seems to be rare. The best epidemiological studies to date show that health professionals are likely to encounter at least one case of FII during their careers, with paediatricians seeing many more.
FII spectrum can span from less extreme behaviours such as a genuine belief that the child is ill because of misinformation. At the severe spectrum, the behaviour of carers can include: deliberately inducing symptoms by administrating drugs; intentional suffocation; interfering with treatments by overdosing; not administering medication; tampering with medical equipment; claiming that the child has symptoms that are not verifiable unless observed directly; exaggerating symptoms; and falsifying test results and observational charts.
The crux to solving this complex conundrum begins with a good history, examination, investigations; followed by a list of differential diagnosis; treatment and follow-up. However, a doctor may try to pursue a medical diagnosis and this can lead onto invasive investigations and missing the underlying problem.
When concerns exist about FII, professionals need to keep an open mind at all times to ensure that they have not missed a vital piece of information. They must work with other professionals, with particular input from paediatricians, and be prepared to refer to the relevant bodies, such as the police or local children’s social care services.
In the UK, the Royal College of Paediatrics and Child Health and the Department of Health recommend the use of covert video surveillance (CVS) if concerns about the child abuse cannot be resolved in any other way. Stringent protocols exist for such surveillance: being police-led and instigated with permission of the trust’s Chief Executive. CVS usage is controversial; several ethical and moral considerations must be considered. This include: the breach of trust between parent and paediatrician and unnecessary harm to the child.
Solving this conundrum will require the efforts of all those working with children. Lack of awareness of the signs of child maltreatment and processes for reporting to child-protection agencies, and a perception that reporting might do more harm than good, are among the reasons for not reporting. These must be resolved to ensure the safety of children.
Reference
(1) ICD-10 Available at: http://apps.who.int/classifications/apps/icd/icd10online/?gf60.htm+f681
(2) Fabricated or induced illness by carers: a complex conundrum : The Lancet Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60177-8/fulltext?_eventId=login.
(3) Safeguarding Children in whom illness is fabricated or induced. Department for Children, Schools and Families. Available at: http://www.dcsf.gov.uk/consultations/index.cfm?action=consultationDetails&consultationId=1667&external=no&menu=1
(4) SHABDE N, CRAFT AW. Covert video surveillance: an important investigative tool or a breach of trust? Archives of Disease in Childhood 1999 October 1;81(4):291-294.
(5) Gilbert R, Kemp A, Thoburn J, Sidebotham P, Radford L, Glaser D, et al. Recognising and responding to child maltreatment. Lancet 2009 Jan 10;373(9658):167-180.