Feb. 14, 2000 (Atlanta) -- Qualified doctors can't be fooled by a child -- or can they? The sad and surprising answer, according to an article in the journal Pediatrics, is that children as young as 8 can convince their caregivers that they suffer from chronic illness.
One case -- a 12-year-old girl -- was thought to suffer from a mysterious fever until she was 17, when her doctors finally realized that she was faking thermometer readings. In other cases, children and adolescents inflicted serious harm upon themselves or fooled doctors into prolonged hospital stays and even repeated operations. Cases are rare, but early detection and treatment are crucial to preventing long-term harm to the child. Study author Judith A. Libow, PhD, tells WebMD that untreated children could go on to become adults who repeatedly fake illness -- a diagnosis known as factitious disorder, commonly called Munchausen syndrome.
"Most cases of adult factitious disorder seem to be traced to early adulthood if not adolescence," says Libow, coordinator of psychological services at Children's Hospital in Oakland, Calif. "These kids look like the adult patients in their bland indifference to the number of procedures and hospitalization, their fascination with health care, their denial and flight from psychotherapy. It is logical ... that many of these patients begin early in life and don't get picked up on until much later," she says.
In an interview to provide objective comment, Marc D. Feldman, MD, an expert on factitious disease, agrees with Libow. "If children have experienced the misuse of illness to draw attention, they are more likely to do this as adults," he tells WebMD.
Libow also cites disturbing evidence that some children who make themselves sick may previously have been victims of the form of child abuse known as Munchausen by proxy (MBP), in which a parent inflicts disease symptoms on a child in order to get attention and sympathy. "Many of these children may have been victims of MBP," she says. "Some victims do go on to either collude with the illness falsification by the parent or to go on to develop factitious illnesses."
Louisa J. Lasher, an Atlanta-based expert consultant on MPB maltreatment, confirms Libow's assessment. "I can say that I have dealt with several older children -- Munchausen by proxy victims -- who at the time I saw them were themselves exhibiting symptoms of factitious disorder," she tells WebMD.
Feldman, medical director of the University of Alabama at Birmingham Center for Psychiatric Medicine, suggests that a small minority of MBP victims may grow up to become MBP perpetrators themselves. "We know that parents who engage in [MBP] very commonly have their own previous histories of factious disorder," he says. "They are at a heightened risk of becoming MPB perpetrators. The most powerful finding of MBP perpetrators has been Munchausen syndrome or some other preoccupation with health."
Libow's review of the literature over the past 30 years turns up only 42 descriptions of independent illness falsification by children and adolescents. But several experts contacted by WebMD agree with her that while it seems uncommon for children to repeatedly fake illness, the true extent of the problem is unknown. "I think its partly because physicians don't suspect such things, and may write these cases off -- its almost unacceptable to imagine that a kid is able to do something like this," Libow says. "Its disturbing [for a doctor] to feel like you can't necessarily trust history and symptoms reported by your patients when you rely on that information. ... [Physicians who detect factitious illness] are usually astounded and relieved at the same time because the explanation is so simple when they have been considering complex reasons. They feel a little foolish; on the other hand there are legal reasons to pursue everything they can think of. If they are wrong about suspecting the child there are all kinds of problems, from malpractice suits to being called an unfeeling physician."
The study turns up a number of disturbing facts. Like adult fictitious disorder, most of the pediatric cases are female (71%). The deceptions ranged from thermometer manipulation and sucking on the skin in younger children to active injections, bruising, and ingestions begun in adolescence and continued for years.
Perhaps the most disturbing finding was that half of the cases went undetected for a year or more, and nearly a third remained undetected for at least two years. Of the six cases for which follow-up was reported, two had a negative outcome with continued falsification.
Proving that deception has occurred often requires physician ingenuity. For example, Libow points to a case in which a pediatrician encased a child's arm in a plaster cast to prove that suspicious bleeding under the skin was in fact caused by self-beating. For younger children, a properly conducted interview may elicit a confession.
"Try if at all possible to determine the cause and identify it clearly so that the parent will be willing to accept the reality of what is happening, because some parents will flee with their child and deny this is possible," she advises. "Younger children in particular are often willing to admit the deception if approached in a supportive and direct way, not accusatory but concerned. You might say, 'I've been treating you for the last eight months for these bruises and you've missed a lot of school. And I've finally realized you've been banging your arm. Let's sit down together and see if we can find a way to take care of you where you don't have to be sick all the time.'"
Older children are more likely to deny feigning illness -- even when confronted with physical evidence. Parents, too, may be loath to face the facts. Libow recommends sitting down with the parent in a nonaccusatory manner to let them know that the problem has been diagnosed and to discuss treatment approaches. Because children who present with factitious illness tend to grow up in a family that communicates through illness, she says, outpatient family therapy is indicated where possible.
"I would say some cases have had very positive outcomes, particularly if you are able to do long-term work, one or two years," Libow says. "You help the child develop some insight into the meaning of their deception of the physician and the motivations that may have driven the behavior. You help them develop more appropriate strategies for getting what they need from the families or, if that's not possible, from other resources in their lives. I talk about the experience of being a medical patient and what aspects of that may have been rewarding or preferable to being a healthy functional kid. And I help them understand why they made that choice."
- Researchers report that in rare cases, children suffer from factitious disorder, where they fake illness in order to prolong medical treatment and receive attention.
- Doctors note that children who have this disorder and are untreated may go on to fake illness as adults, a disorder called Munchausen syndrome. The cycle may have started when their parents intentionally injured them to get attention themselves, called Munchausen by proxy.
- It's important to consider a child could be faking an illness. If the real problem is factitious disorder, it can be addressed by both family and physician.