27 August 2021

Munchausens by proxy not a ‘rare engima’

Clinical Paediatric oncology

Fabricated or induced illness in a child – aka Munchausen syndrome by proxy – could be more common than currently perceived, clinicians warn in the first Australian guide designed to identify the syndrome.

The complex condition, first described in 1977, occurs when a child’s caregiver induces or fabricates an illness in the child to elicit medical care.

Unnecessary treatments may then cause the child to become more unwell, potentially resulting in long-term harm or death. Typically, the caregiver instigating the treatment is the child’s mother.

Despite the high potential for harm, forensic paediatrician Dr Joanna Tully told The Medical Republic that doctors can be hesitant to diagnose fabricated or induced illness in a child (FIIC).

“When it used to be called Munchausen by proxy, [FIIC] was thought to be this really rare, bizarre form of form of child abuse that you hardly ever saw,” Dr Tully said.

“I’m not sure that that’s the case – I think it’s a lot more common than we think it is.

“We can identify it earlier and try to put barriers in place to stop the levels of harm that you see when it’s left for years unchecked.”

As deputy director of the Victorian forensic paediatric medical service at the Royal Children’s and Monash Children’s hospitals, Dr Tully’s work involves providing clinical care and assessments in situations where child abuse or neglect is suspected.

After experiencing what they felt was a rise in the number of referrals for suspected cases of FIIC, Dr Tully and colleagues now suspect that the condition can be caught earlier, as laid out in a paper published in the Journal of Paediatrics and Child Health.

“Although perceived to be a rare form of maltreatment, FIIC is almost certainly significantly under-recognised and under-reported,” they wrote.

“The experience of this group is that there has been a notable increase in referrals to the Victorian Forensic Paediatric Medical Service in Melbourne regarding FIIC.

“Greater recognition is a positive step, but condition severity leads us to wonder if these cases are merely the ‘tip of the iceberg’.”

According to Dr Tully, FIIC should be considered as a differential diagnosis, rather than a diagnosis of exclusion, in cases where three key criteria are met.

“If the child appears to be receiving excessive health care, the child appears to be presented as more unwell or impaired than it actually is, and it appears to be the parent that is driving that, then you need to have your alarm bells ringing,” she said.

In the paper, Dr Tully and colleagues write that FIIC may present similarly to other over-medicalisation phenomena such as maternal delusional psychosis, over-anxious parenting or medically unexplained symptoms like somatisation.

How the child or parent responds to different interventions – i.e. reassurance and education – can be used to distinguish these behaviours from FIIC.

One clue which may assist in identifying FIIC in primary care, Dr Tully said, could be that a child is seeing multiple specialists at once.

“The GP may be receiving lots of different letters from lots of different providers,” she said.

“It may be a child who has lots of changes of healthcare provision – they may be seeing one gastroenterologist, and then the next month they’re seeing a different one, and then six months later they’re seeing a different one again.

“The parent may frequently consult with the GP for a range of different things, requesting different tests, requesting different referrals, not being reassured by referrals.

“They will often come back and say, ‘well, I saw the allergist last week, and he said this, that and the other but I really think that we need to see a different one’, or they could actually provide the GP with an untruth.”

Other classic cases of FIIC, according to Dr Tully, are characterised by the child’s father being disengaged from care, collections of symptoms and signs which don’t make sense or are constantly evolving.

Once concerns have been identified, Dr Tully said, the child can be referred to a forensic paediatrics service for further evaluation.

“What that involves is that [forensic paediatricians like myself] are provided with the entire medical record for that particular child, as well as collateral information from Medicare, the NDIS and possibly social media,” she said.

The forensic team then analyse the records for patterns or a mismatch between the child’s reported state of health and their actual state of health.

“If there is a mismatch, we’ve got to figure out why it is there and who is driving it,” Dr Tully said.

“Is it that doctors are simply doing too much? Is the mother just not being reassured that her child is okay?

“And if you do reassure her, does she accept it or is it that she’s actively seeking extra investigations for her child, and fails to be reassured that the child is not as sick, unwell or impaired as she believes it to be?”

However, Dr Tully also acknowledges that caution is required, as the fallout from an incorrect FIIC diagnosis can be catastrophic.

“Identifying FIIC, like all forms of child abuse work, needs to be done very, very carefully,” Dr Tully said.

“There needs to be collaboration between professionals involved in the discussion, and there needs to be, if necessary, the involvement of a forensic paediatrician in analysing the information.”

Journal of Paediatrics and Child Health 2021, online July 26

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