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Factitious disorders 1 Early recognition and management of fabricated or induced illness in children

Christopher Bass, Danya Glaser

Lancet 2014; 383: 1412–21 Fabricated or induced illness (previously known as Munchausen syndrome by proxy) takes place when a caregiver Published Online elicits health care on the child’s behalf in an unjustifi ed way. Although the fi fth edition of the Diagnostic and Statistical March 6, 2014 Manual of Mental Disorders specifi es deception as a perpetrator characteristic, a far wider range is encountered http://dx.doi.org/10.1016/ clinically and is included in this Review. We describe the features of fabricated or induced illness, its eff ect on the child, S0140-6736(13)62183-2 and the psychosocial characteristics of caregivers and their possible motives. Present evidence suggests that See Online/Comment http://dx.doi.org/10.1016/ somatoform and factitious disorders are over-represented in caregivers, with possible intergenerational transmission S0140-6736(13)62640-9 of abnormal illness behaviour from the caregiver to the child. Paediatricians’ early recognition of perplexing See Online/Series presentations preceding fabricated or induced illness and their management might obviate the development of this http://dx.doi.org/10.1016/ disorder. In cases of fully developed fabricated or induced illness, as well as protection, the child will need help to S0140-6736(13)62186-8 return to healthy functioning and understand the fabricated or induced illness experience. Management of the This is the fi rst in a Series of two perpetrator is largely dependent on their capacity to acknowledge the abusive behaviour and collaborate with helping papers about factitious disorders agencies. If separation is necessary, reunifi cation of mother and child is rare, but can be achieved in selected cases. Department of Psychological Medicine, John Radcliff e More collaborative research is needed in this specialty, especially regarding close study of the characteristics of women Hospital, Oxford, UK with somatoform and factitious disorders who involve their children in abnormal illness behaviour. We recommend (C Bass FRCPsych); and Great that general hospitals establish proactive networks including multidisciplinary cooperation between designated staff Ormond Street Hospital for from both paediatric and adult services. Children, London, UK (D Glaser FRCPsych) Introduction Unlike other defi nitions, DSM-5 specifi es identifi ed Correspondence to: Dr Christopher Bass, Department Many changes have taken place in nomenclature since deception by the perpetrator as an essential criterion. of Psychological Medicine, Meadow fi rst described Munchausen syndrome by proxy Although restriction of the defi nition in this way allows John Radcliff e Hospital, Oxford in 1977,1 including renaming to factitious disorder by for clarity, the other defi nitions include a far wider range OX3 9DU, UK proxy,2 paediatric condition falsifi cation,3 fabricated or of motivations and behaviour that represent clinical christopher.bass@ 4 oxfordhealth.nhs.uk induced illness in the UK, and medical child abuse in reality. Justifi cation for use of the wider defi nitions of the USA.5 In 2013, the fi fth edition of the Diagnostic and abnormal illness behaviour by carers in relation to their Statistical Manual of Mental Disorders (DSM-5),6 children is that the harmful eff ects on the child are introduced factitious disorder imposed on another remarkably similar, irrespective of the mother’s actions (previously factitious disorder by proxy; panel 1). and motivations. In this Review we use the term fabricated or induced illness and the terms perpetrator and caregiver are used when appropriate. We suggest Search strategy and selection criteria techniques for earlier recognition, and possibly aversion We included the terms “Münchausen syndrome by proxy” OR of fabricated or induced illness, and discuss strategies for “Factitious disorder* by proxy” OR “fabricated illness by carer*” management of diagnosed fabricated or induced illness. OR “induced illness by carer*” OR “Munchhausen syndrome by proxy” OR “Munchausen syndrome by proxy” OR “Munch?ausen What constitutes fabricated or induced illness? by proxy syndrome” OR “P?diatric Condition Falsifi cation” OR Fabricated or induced illness can involve reported “Fabricated or Induced Illness” OR FII and entered them into concerns about both the physical and mental health of 7 PsychINFO and SCIE databases. We reviewed the reference lists of the child, such as diffi culties in the spectrum. articles identifi ed by the search strategy and included articles Fabricated or induced illness has been located on a judged as relevant. We examined papers written in English and continuum of parental health-care seeking for a child, published since 2002, but also included widely referenced and which ranges from extreme neglect (failure to seek 8 highly regarded older publications and books published since medical care for the child) to induced illness. This 1998. We did not include the term . We also did a continuum includes both the more common erroneous PubMed search with the same terms, and a MeSH search. We did verbal reports, which might or might not include an our search between Feb 19, 2013, and Aug 19, 2013. We cite intention to deceive, and the far rarer use of hands by the 9 fi ndings from recent research and evidence from learned bodies caregiver to falsify the child’s medical records, interfere (eg, Royal Colleges in the UK and American Academy of with specimens, or induce illness in the child, all of Pediatrics in the USA) and clinical experience. which are forms of deception (panel 2). This abnormal form of health-care-eliciting behaviour by the caregiver,

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for the child, often co-exists with abnormal relationships with health-care and social-work professionals that can Key messages have an adverse eff ect on the child. • The defi nition of fabricated or induced illness in the fi fth edition of the Diagnostic and For fabricated or induced illness to arise, three parties Statistical Manual of Mental Disorders is clear, but narrow, and excludes the many are actively, if inadvertently, involved: the child, the cases of harm not caused by deception caregiver, and a health professional (usually a doctor; • Early recognition by paediatricians of perplexing presentations with alerting signs, fi gure). Important to note is that the child might have past followed by direct observation of the child, might obviate the full development of or coexisting genuine health problems10 and sometimes, fabricated or induced illness the abnormal illness behaviour might involve adults.11 • The fabricated or induced illness is established by paediatricians and child mental health professionals, not by adult psychiatrists Epidemiology • Many children will have a past or coexisting genuine medical disorder Fabricated or induced illness is not confi ned to English- • The eff ects of fabricated or induced illness on children are serious, wide ranging, and speaking industrialised countries. Feldman and Brown12 similar, irrespective of perpetrator behaviour or motivation identifi ed 59 articles from 24 countries describing at least • Interdisciplinary liaison is essential, with multidisciplinary planning for the child’s 122 cases in nine diff erent languages. Some disorders are protection more likely to be fabricated than others. Seizures are a • Perpetrators of fabricated or induced illness are usually caregiving mothers who have presenting feature in 42% of cases of fabricated or reported high rates of early childhood privation, neglect, and abuse induced illness,13 and are especially vulnerable to • More than 50% of perpetrators have a somatoform or factitious disorder, and more fabrication because they are common and intermittent.4,14 than 75% have a coexisting , particularly cluster B disorders In a childhood asthma clinic, 1% of families had fabricated (ie, sociopathic, borderline, or histrionic) or induced illness, with abnormal parenting behaviour • Detection of factitious disorder in a mother of young children should provoke a search leading to combinations of treatment withholding and for fabricated or induced illness and other forms of maltreatment in her off spring overtreatment.15 One series of child victims described • The perpetrating caregiver needs comprehensive assessment of underlying high rates of asthma, allergy, and sinopulmonary psychopathological abnormalities and capacity to acknowledge responsibility before infections that often led to unnecessary surgery.16 treatment can be considered Defi ning of incidence is dependent on the inclusion • The child and family will need therapeutic intervention to develop a narrative about criteria adopted by a specifi c study. With strict criteria, their experiences and adjust to the child’s more healthy functioning 17 McClure and colleagues reported a combined annual • Reunifi cation is feasible but only in very carefully selected cases for which some incidence of roughly 0·5 per 100 000 children younger acknowledgment of fabricated or induced illness has been made; follow-up is needed than 16 years, and of at least 2·8 per 100 000 children • When reunifi cation is not possible, long-term treatment of the personality younger than 1 year. With broader criteria Watson reported disturbance and any other coexisting (often a somatoform disorder) an incidence of 89 per 100 000 children and adolescents in is needed a 2 year period, but no deaths,18 and Denny and colleagues19 reported an incidence of 2 per 100 000 children with the same criteria as McClure and colleagues, but no deaths. Panel 1: Diagnostic and Statistical Manual, fi fth edition, Child’s median age at diagnosis was 2·7 years. All these criteria for factitious disorder imposed on another, code numbers are likely to be underestimates. In a population- 300.196 (International Classifi cation of -10 code based prospective study from Italy,20 14 (2%) of 751 children F68) (mean age 8·4 years) referred to a paediatric unit were diagnosed with factitious disorder, with fever being the 1 Falsifi cation of physical or psychological signs or symptoms, most common presentation. With stringent criteria, the or induction of injury or , in another; associated with investigators identifi ed fabricated or induced illness in identifi ed deception four of the 751 cases, resulting in a prevalence of 0·53% 2 The individual presents another individual (victim) to others (mothers were the perpetrator in three cases and a as ill, impaired, or injured. The perpetrator, not the victim, grandmother in one). This increased prevalence was likely receives the diagnosis to be the consequence of inclusion of a trained 3 The deceptive behaviour is evident even in the absence of multidisciplinary team who were alert to the possibility of obvious external rewards these diagnoses. Important to recall is that induced 4 The behaviour is not better explained by another mental symptoms are generally more diffi cult to detect than disorder, such as or another psychotic fabrication of symptoms, but once they are detected they disorder might be easier to confi rm or prove.21

Possible explanatory mechanisms and Several reasons explain this need, which are not mutually motivations exclusive (panel 3). A possible overall explanation is that the caregiver has an Evidence has shown intergenerational transmission of underlying need to have the child recognised as being ill abnormal illness behaviour in these caregivers. Of the when they are not, or as more ill than they actually are. medically unexplained symptoms reported by mothers www.thelancet.com Vol 383 April 19, 2014 1413 Series

disorder induced illness, not only in herself but also in her Panel 2: Illness fabrication and induction three children, with exogenous insulin injection. Erroneous reporting (fabrication) of medical history, symptoms, or signs by: Characteristics of perpetrators • In view of the diverse motivations, caregivers have no one • Misconstruing of real events on the basis of mistaken profi le of behaviour, personality, or psychiatric disorder belief about their meaning and no psychiatric diagnosis exists for Munchausen • Reporting of actual events that only happen in the syndrome by proxy. People who fabricate illness in their mother’s presence (ie, situation specifi c events, therefore children are almost always women and 14–30% have not a disorder located solely in the child) professional ties to the health-care profession.26 Sheridan26 • False reporting reported that 76% of the perpetrators were the child’s biological mother and 7% were the father. In the few cases There might or might not be an intention to deceive for which fathers are the main perpetrators, the father is Deception by use of hands likely to have either a factitious disorder or clinically • Falsifi cation of records or charts signifi cant somatoform disorder.27 Grandmothers • Interference with investigations and specimens (eg, putting sometimes support the mothers and someone in loco blood or sugar in the child’s urine) parentis can also fabricate illness in a child. • Interference with lines In general, the non-perpetrating fathers of child victims • Inducing of signs or illness in the child by, for example, of fabricated or induced illness tend to be distant, poisoning or overmedication (eg, laxatives, salt), suff ocating, uninvolved, and emotionally and physically detached starving from the family system.28 Some fathers are truly unaware, some might believe the mother’s contentions, and some might be suspicious and attempt to challenge the mother unsuccessfully.29 Talks Findings from studies of female perpetrators have Mother Doctor shown high rates of reported privation, childhood abuse, and signifi cant loss and bereavement.30 In this study of Induces illness or Investigates 41 children (15 with failure to thrive through active interferes with investigation and treats withdrawal of food or alleged allergies) and 26 victims of Child fabricated or induced illness, six mothers had a factitious Might have a genuine disorder, one had , and 16 had a history illness or disorder of .

Figure: The inter-relationship between mother, doctor, and child Somatoform and factitious disorders Somatoform and factitious disorders are over-represented Panel 3: Explanatory mechanisms and motivations among perpetrators: in a study of 47 mothers, 30 of 31 • Extreme anxiety leading to exaggeration of symptoms and whom were active inducers, Bools and colleagues noted signs to encourage the doctor to rule out or identify any that the most probable diagnosis for 34 (72%) participants treatable disorder was a somatoform disorder (of whom 25 [74%] had a • To confi rm (false) beliefs about a child’s ill health factitious disorder with physical symptoms). Similar fi ndings were reported in a more recent study of (eg, , food allergy7,22,23), including beliefs held by caregivers with Asperger’s syndrome and 28 mothers (all with evidence of fabrication or induction 24 rarely with a delusional disorder) of illness in children), in which somatoform disorders • Wish for attention were reported in 57% of participants and factitious • Defl ection of blame for child’s (usually behavioural) disorders in 64%, with co-occurrence of these disorders diffi culties in 39% of participants. A third of these patients were in • Maintain closeness to child receipt of disability benefi ts. Detailed examination of • Material gain both primary care and extensive medical and social-work records might uncover episodes of illness deception and ,32 often coexisting with somatoform with somatoform disorders, a high proportion is presentations. pseudoneurological (fainting and pseudoseizures), The distinction between a somatoform and factitious gastroenterological (abdominal pain and nausea), and disorder is mainly based on volitional choice and the obstetric or gynaecological.24 Caregivers with pseudo- known consequences that might follow its exercise in neurological disorders might state that their off spring has specifi c situations.33 With a somatoform disorder the adult similar distressing symptoms, such as syncope and does not consciously or deliberately fabricate symptoms, seizures.24 In a report,25 a mother with adult factitious whereas with factitious disorders the caregiver consciously

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chooses this behaviour, or is at least consciously aware of adult somatisation, and, in some women, transmission the deception and possible gains involved. of abnormal illness behaviour to their off spring.46 These fi ndings are important for two reasons: (1) mothers with somatoform disorders have children with Eff ect on the child more health problems and higher rates of medical At the rare, severe end with illness induction, several consultations than those of well mothers or organically accounts have been reported by victims of this abuse,47 ill mothers;34,35 (2) that some of these mothers include and a bestselling book by Gregory48 describes the their children in abnormal illness behaviour suggests physical, behavioural, and emotional consequences. In a their capacity to care for them appropriately is impaired. review of 451 cases of fabricated or induced illness from As a consequence the children of mothers with rigidly 154 articles from medical and psychological journals,26 held or abnormal health beliefs can become medicalised time elapsed from onset to diagnosis averaged and in turn the victims of abnormal illness behaviour by 21·8 months. Most of the 6% of children who died had proxy. At present it is not known what characteristics of illness induced. and 7% were judged to have suff ered mothers with somatoform or factitious disorders might long-term or permanent injury. 25% of victims’ known determine that they will involve their children in siblings were dead, and 61% of siblings had illnesses abnormal care-eliciting behaviours. Only by assessment similar to those of the victim or which raised suspicions of cohorts of childbearing women with somatoform of fabricated or induced illness. disorders will this question be answered.36 Aside from mortality, which is associated with illness induction, the child has the same forms of harm, Personality disorder irrespective of the nature of the mother’s behaviour. The Very few studies have been done of personality in female harm to the child can be grouped within three domains perpetrators. In a systematic study of personality in (panel 4).49 19 mothers with fabricated or induced illness (two-thirds Many children also have comorbid emotional and with evidence of deception), high rates of personality behavioural problems not directly related to the illness disorder were identifi ed in 17 (89%) mothers, with fabrication or induction, but probably related to parent– antisocial, histrionic, borderline, avoidant, and child interactions.50 narcissistic categories being most frequently identifi ed.29 Some mothers had more than one personality disorder. Eff ects in adolescence In a German study, three of four mothers had a In adolescence the complexity of the situation increases. personality disorder, with paranoid personality diagnosed Some children who independently falsify illness might in two mothers.37 Borderline personality disorder in have had a previous experience of victimisation or particular is associated with marked diffi culties in encouragement of illness falsifi cation by a caregiver,51 mother–infant interaction.38 and so-called symptom coaching has been described.52

The role of attachment Fabricated or induced illness has been suggested to Panel 4: Eff ect of fabricated or induced illness on the child represent an abnormality in the attachment system Physical health 39 between mother and child. Because attachment theory • The child has repeated (and, in retrospect, unnecessary) provides an account of both care eliciting and caregiving investigations, procedures, treatments, and periods of as behavioural systems operating between parents and hospital admission 40 children, this theory might be useful for understanding • Illness induction is associated with additional serious harm, dynamics within fabricated or induced illness. and 6% mortality26 Attachment insecurity is over-represented in maltreating parents compared with non-clinical samples, including Daily life and functioning in those with fabricated or induced illness.41,42 An • Low or interrupted school attendance and education attachment perspective might also be relevant because of • Few normal activities such as sport the association between attachment security and both • Assuming of a sick role with aids (eg, wheelchairs) illness behaviour and medically unexplained symptoms • Social isolation in adults. Patients with fearful and insecure attachment Psychological health report substantially more physical symptoms than do • The child is troubled by a distorted view of their health and 43 secure patients, and patients with chronic widespread might become anxious and preoccupied about their state pain are more likely to have insecure attachment than are of health and vulnerability; be confused about their state of 44 those who are free from pain. The early attachment health because they might not feel ill, but be repeatedly experiences of these mothers are likely to aff ect both examined, investigated, and treated; collude with the 45 parenting capacity and personality development. These illness presentation or be silently trapped in falsifi cation of fi ndings suggest an important association between illness; or develop a factitious or somatoform disorder abnormal forms of attachment, childhood adversity, www.thelancet.com Vol 383 April 19, 2014 1415 Series

they had attention defi cit hyperactivity disorder.59 Notably, Panel 5: Alerting features that should prompt health-care two of the fi ve mothers in this series had a factitious workers, social workers, teachers, and families to suspect disorder, and four (44%) of the children had a coexisting 56 fabricated or induced illness fabricated medical disorder. The mother’s actions might The child’s history, physical, or psychological presentation be inferred, false reporting sometimes witnessed, shows discrepancy with fi ndings of examinations, assessments, physical actions rarely observed, and her actions (verbal or investigations, and one or more of the following occurrences: and physical) occasionally admitted to by the mother.52 • Reported symptoms and signs are only observed, Guidelines for school and other personnel confronted or appear in the presence of, the parent or carer with repeated requests for unwarranted special • An inexplicably poor response to prescribed drugs or educational services have been published.60 other treatment Fabricated or induced illness can present in obstetric • New symptoms are repeatedly reported settings, and mothers who are responsible for fabricated • Biologically unlikely history of events or induced illness in their children have been described • Despite a defi nitive clinical opinion being reached, various with factitious disorder in pregnancy.61 Characteristic opinions from both primary and secondary care are sought fabricated presentations include antepartum haemor- and disputed by the parent or carer, and the child rhage, feigned premature labour, and induced post- continues to be presented for investigation and treatment partum bleeding leading to anaemia. Self-induced labour with a range of signs and symptoms has been described leading to death of a child.62 These • The child’s normal daily activities, (eg, school attendance) fi ndings suggest that a fi nding of fabricated or induced are few, or the child is using aids to daily living (eg, illness in a previous child should suggest to the wheelchairs) beyond expected need from any medical obstetrician an increased risk of obstetric factitious disorder that the child has disorder in a pregnant woman. Furthermore, the • Expression of concern by relatives or other professionals presence of factitious symptoms during pregnancy should alert the paediatrician to the possibility of The child might have a recognised past or concurrent physical fabricated or induced illness.63 Increased rates of or psychological disorder pseudocyesis () have been reported in female perpetrators.24 Cases have been reported of victims of fabricated or induced illness corroborating and participating in the Medical contribution perpetrator’s deception,53 or continuing to be the victims Unlike the usual medical response to ill health or a sick of fabricated illness by their parents decades after the child, for fabricated or induced illness there seems to be initial abuse.54 In a remarkable case an adolescent male an over-reliance on parental reports even when they do victim, after separation from the perpetrator, continued not accord with others’ direct observations of the child. to endorse symptoms of chronic medical illnesses for This over-reliance often leads to over investigation and which there were no causes.55 Of particular interest is inappropriate treatment of the child’s reported that adolescents with factitious disorders have strikingly symptoms and incidental abnormal fi ndings from similar clinical and demographic characteristics to the investigations, neglecting the harm to the child’s present adult perpetrators of fabricated or induced illness.24 In a functioning. Moreover, doctors might also support or recent retrospective study of adolescents with factitious not question the child’s low or non-attendance at school, disorder (mean age 16 years), three-quarters were confi rm the use of aids that the child might not actually female, half had witnessed severe somatic illness within need, and support seeking of fi nancial and welfare their immediate family, a third had personally had severe payments for the care of the child. Several possible or chronic illness, half had been adopted or fostered, explanations exist for this medical response, which 42% had histories of self-harm, and 42% history of become obstacles to a more adaptive or appropriate physical or sexual abuse.56 approach (panel 6).58,65 Conversely and rarely, paediatricians might conclude a Presentation and recognition decision of possible fabricated or induced illness too Many children who are subjected to fabricated or induced early, and not pursue suffi cient investigations. The illness also have, or have had, a genuine medical (physical balance between overinvestigation and underin vesti- or psychological) disorder or disability.57 Fabricated or gation is potentially diffi cult to make. induced illness should be recognised and identifi ed early in the process by several alerting features in the child’s Earlier recognition and management of presentation,58 usually to doctors (panel 5). Other potential fabricated or induced illness professionals including, in particular, teachers, might With the exception of some cases of illness induction, a notice some of these features. For example, fabricated substantial delay almost invariably takes place before an educational diffi culties were described in nine children explicit mention of fabricated or induced illness by a from fi ve families whose mothers were insistent that doctor. During this period, alerting features of fabricated

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or induced illness are repeatedly encountered, meaning doctors face perplexing presentations.66 However, not all Panel 6: Possible explanations for the medical response to signs alerting to fabricated perplexing presentations are, or need to be treated as, or induced illness fabricated or induced illness. • Concern about missing a treatable disorder in the child To shorten the process, reduce harm to the child, and • Usual practice of working with parents possibly avoid the development of fabricated or induced • Diffi culty of withstanding pressure from the mother to continue to investigate and illness, the doctor should establish as quickly as possible treat the child what is or not wrong with the child as soon as they feel • Discomfort of disbelieving or suspecting a parent, especially if this might prove to be perplexed, after undertaking the usually expected unjustifi ed examination and investigations. To achieve early • Doctors’ dependence on the history of the child’s problems given by the parent or parents 66 identifi cation, several steps are needed. At this early • Diffi culty of saying explicitly that doctor is mystifi ed about child’s presentation stage, the responsibility lies with paediatric services, • Doctors with interests in particular diseases might want to rise to the diagnostic although information might also be needed from other challenge agencies. The appendix provides a full account of this • Doctors working in private practice are likely to work in isolation with little alternative approach. communication with other professionals • Increasing medical subspecialisation, with poor communication between specialists, Child protection process risks having no identifi ed clinician with overall responsibility for the child64 Child protection procedures to manage probable cases • Doctors might want to avoid complaints against them and therefore continue to of fabricated or induced illness have been well follow the parents’ requests described9,64,66–69 and entail joint responsibility of • Doctors might be uncertain when to mention suspicion, what to say to parents, and children’s social care services and the police. Any what to write in the medical fi le possible evidence of physical actions by the mother • Pursuing concerns about the possibility of fabricated or induced illness is very time requires preservation for the police of all relevant consuming specimens and materials that might have been tampered • Some doctors are reluctant to initiate a child protection process within which they will with. An aspect of concern during investigations of have little control and about whose benefi ts they might have doubts fabricated or induced illness is the theoretical possibility that if the mother becomes aware of suspicions before the child is removed from her care, she might cause The use of standardised measures can be helpful in some See Online for appendix serious harm to the child by illness induction to prove cases. These measures, which include the relationship her contention that the child is unwell. scales questionnaire72 and the parental bonding Recognition of fabricated or induced illness in a child instrument,73,74 can provide an indication of attachment usually results in care proceedings to establish whether security of the parent. The adult attachment interview is a the abusing parent should continue to care for the child. well-validated method for the measurement of attachment Other siblings are also at risk.13,26,30 Therefore, in most organisation in adults, but needs training for administration cases children will, in the fi rst instance, be placed in the and rating.75 The dynamic maturational model has been care of the non-abusing parent (if separated), grand- used to code assessments of attachment in both adults and parents (only if they accept the presence of fabricated or children and adolescents.76,77 The structured clinical induced illness), or the local authority. Criminal interview for DSM-IV-TR axis II personality disorders78 is a prosecution of the parent can be pursued by the police if diagnostic technique; the standard assessment of deemed to be in the public interest, but is not a main or personality79 is a screening technique, and document- necessary part of child protection. derived assessment80 can provide useful information. This assessment will lead to an understanding of the Assessment of the caregiver and the role of the caregiver’s mental health, including possible autism psychiatrist spectrum disorder, for which there is a screening After the paediatric assessment and investigation has instrument.81 Some parents with this disorder might established the existence of fabricated or induced illness present with beliefs about their child’s health that are and the child’s state of health and ill health, or after a diffi cult to corroborate (panel 3). Predisposing and legal fact-fi nding hearing has taken place,70 and maintaining factors for the fabrication or induction of sometimes in the process of management of perplexing illness in the child should also be sought. Most presentations, an adult psychiatrist might be asked to importantly, the assessment will also show the degree assess the caregiver (panel 7). and quality of acknowledgment of abuse by the caregiver, Establishment of whether the caregiver can their partner and wider family, and their willingness and acknowledge the concerns of others and accept some individual capacities to engage in a programme of risk responsibility for harming the child is important. Such management and treatment. Some risk factors have been establishment will have a major eff ect on management identifi ed that should alert the clinician to the potential recommendations and outcome and willingness to risk a caregiver might pose by involving a child in engage with professionals in the long term.71 abnormal illness behaviour.24 www.thelancet.com Vol 383 April 19, 2014 1417 Series

need a truthful narrative to explain the caregiver’s Panel 7: Assessment of caregiver and the role of the actions,82–84 and, when applicable, the reasons for psychiatrist separation from her. They will also need sensitive support • Assessment of the caregiver follows paediatric for the possible loss of a primary caregiving relationship ascertainment of the presence of fabricated or induced with their parent. Older children might feel guilty and illness complicit, and some children have great diffi culty in • The purpose is to provide an opinion on the mental state accepting the fact of illness fabrication by their parent. and personality of the caregiver, elucidate underlying reasons for their behaviour, suggest therapeutic steps, and Therapeutic needs of the family identify capacity to change This section is written from the perspective of a • Preparation is essential before any interview of the heterosexual nuclear family, because this pattern is the caregiver in the form of detailed scrutiny of all medical, most common. The father needs individual help to social work, and police records process the new awareness of his family, in particular the • Important to establish whether the caregiver can abuse of his child or children, and any possible feelings of acknowledge the concerns of others and accept some guilt for his previous absence of awareness, or of his responsibility for harming the child support of the mother. He will need additional support if • Use of standardised measures can be helpful he assumes the role of the main caregiver, particularly if he had been excluded from involvement in his child’s day- to-day physical and emotional care.85,86 Panel 8: Characteristics of perpetrators that present obstacles Siblings will often have been relatively neglected whilst to psychotherapy the caregiver focused attention on the “sick” child. They might feel excluded and angry, especially if their mother • Confrontational and demanding leaves the family. The remaining family together need • Low impulse control help in the formation of a diff erent family with a now • Denial of past actions and their consequences and well child. An important aspect of this work is the pathological lying—eg, “I used to lie because it made me construction of a narrative of their experiences. Work feel happy and got me friends”; “is it possible that I put with the child and family would appropriately be done by the drugs into Jack’s bottle without knowing that I did it?” child and adolescent mental health services. Pragmatic • Somatisation—eg, attribution of bodily sensations to a interventions encouraging engagement of the family, serious physical cause such as chest tightness and feelings of problem solving, and formulation sharing (with use of so-called air hunger caused by anxiety or hyperventilation assessments of attachment) have been described in the are attributed to heart attack; this characteristic is often treatment of complex presentations involving allied to diffi culty accepting reassurance when informed that exaggerated or fabricated symptoms in children.82,87–89 tests and investigations are normal • Feelings of emptiness and diffi culty in regarding emotional Therapeutic needs of the perpetrating caregiver experiences as real, leading to the creation of drama and Perpetrating caregivers will need therapy to address the excitement to compensate for feelings of emptiness by, for harm they have caused, its eff ect on the child, and example, fi re setting, calling out ambulances, or making possibly the eff ect of the loss of that relationship. Therapy hoax telephone calls should address feelings of guilt, shame, and sometimes associated suicidal feelings. When feelings of guilt and shame are wholly absent, the perpetrator’s capacity to Further steps after ascertainment of fabricated mentalise the eff ect of harm on the child should be or induced illness questioned and explored. As for all psychological Whether the child might at a future time return to the treatments, successful treatment needs both engagement care of the perpetrating parent is dependent on two main and commitment. Personality pathology is treatable,90,91 issues. First, overall parenting capacity should be but many perpetrators report having experienced assessed in relation to the child in question and other extreme neglect and abuse, and have little capacity for children in the family on the basis of possible other self-refl ection, making meaningful engagement in diffi culties in the parent–child relationship, not related to psychological therapy diffi cult, especially if they continue fabricated or induced illness.38 The second issue is the to display deceptive behaviour. Furthermore, individuals caregiver’s response to treatment off ered. who use denial and cannot admit their behaviours present almost insurmountable obstacles to psychological Therapeutic needs of the child treatment. The initial focus of therapy should include the Children whose health and daily life and functioning, individual’s acknowledgment of the harm they have including education and peer relationships, have been caused to any child in their care. Panel 8 shows some of adversely aff ected by fabricated or induced illness, will the psychological characteristics that present obstacles to need active rehabilitation. The child and siblings will psychological treatment.

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Very few specialist services can provide treatment for expert witnesses are needed. There is scope for both perpetrator and child in cases of this nature.92 The interdisciplinary collaboration between Royal Colleges of parent will often be rejected by regular psychological Psychiatrists and Paediatrics and Child Health. treatment services as being too disturbed, yet they are More collaborative research is needed in this often not disturbed enough to reach criteria for the specialty,102 which has so far been scarce. Many questions intervention of forensic services. Most parents will need remain,1 such as what distinguishes perplexing treatment for somatoform, mood, or personality disorders, presentations that do not develop into fabricated or usually of the emotionally unstable, borderline type. induced illness from those that do, and what is the Ample evidence exists to show that personality pathology relative prevalence of the two;2 could an international responds to treatment regimens that address aff ect and database be established;3 what is the prevalence of this arousal regulation, such as dialectical behaviour therapy disorder in educational settings;4 why do some mothers and mentalisation-based therapy.93 Although many patients with chronic somatoform disorders involve their report reductions in symptom severity, improvement in children in this behaviour and not others5; and how does social and vocational function is more diffi cult to achieve.94 the internet contribute to this disorder?103,104 A case exists for the establishment of more proactive Prognosis networks to support professionals in the early Prognosis is dependent on a multitude of complex identifi cation of parents and children before harm to the factors, but in general, a better outcome for reunifi cation child takes place. For example, recommendations state of carer and child is associated with acknowledgment by that regular hospital-based multidisciplinary meetings the carer of the illness fabrication or induction, be established to discuss cases and share information willingness to work and cooperate with helping agencies, between disciplines. These meetings should involve a the capacity of the treating team to work with a psychiatric designated child protection doctor for the hospital, formulation, and the presence of specifi c stressors at the hospital paediatricians, the local community time of the abuse.95,96 paediatrician, nurses and social workers, and an adult Very few studies have been done of reunifi cation of consultation liaison psychiatrist with experience of these families. Reunifi cation is dependent on clear evidence of presentations.105 Involvement of hospital legal teams the caregiver’s positive response to treatment, within might also be needed. timescales appropriate for the child’s developmental Contributors stage and managed within a child protection framework.97 CB and DG conceptualised the Review, CB did the literature search and This fi nding was shown in a small follow-up study of wrote the fi rst draft. DG wrote the section on perplexing presentations and assessment, and contributed to later refi nements and additions to 17 children from 16 families (12 with induction of illness, the fi nal draft. Both authors contributed fi gures and approved the fi nal four with fabrication, and one with tampering of submitted version. 98 samples). Reunifi cation requires careful consideration, Confl icts of interest as in 20% of cases the abuse recurs if the child remains We declare that we have no confl icts of interest. 99 with the parent/abuser. 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