UK: Royal College of Paediatrics and Child Health: Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children, 2021

Background
Since the publication of the Royal College of Paediatrics and Child Health (RCPCH) guidance on Fabricated or Induced Illness by Carers (FII) in 2009, there have been significant developments in the field. The RCPCH Child Protection Companion 2013 extended the definition of FII in 2013 by introducing the term Perplexing Presentations with new suggestions for management.

This new guidance provides procedures for safeguarding children who present with perplexing presentations and FII and offers practical advice for paediatricians on when and how to recognise it, how to assess risk and how to manage these types of presentations in order to obtain better outcomes for children.

This guidance presents the current view and supersedes previous RCPCH guidance on this subject.

https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fii/

 

"Medically Unexplained Symptoms (MUS)

In Medically Unexplained Symptoms (MUS), a child’s symptoms, of which the child complains and which are presumed to be genuinely experienced, are not fully explained by any known pathology. The symptoms are likely based on underlying factors in the child (usually of a psychosocial nature) and this is acknowledged by both clinicians and parents. MUS can also be described as ‘functional disorders’ and are abnormal bodily sensations which cause pain and disability by affecting the normal functioning of the body. The health professionals and parents work collaboratively to achieve evidence-based therapeutic work in the best interests of the child or young person. In 2018, the Royal College of Psychiatrists and the Paediatric Mental Health Association (PMHA) developed a guide to assessing and managing medically unexplained symptoms (MUS) in children and young people[14] and a recent editorial is very helpful[15]. Experienced clinicians report that, on occasion, MUS may also include PP or FII."

Ref 14 is to the document discussed here, UK: Document: MEDICALLY UNEXPLAINED SYMPTOMS (MUS) IN CHILDREN AND YOUNG PEOPLE, 2018

Ref 15, the "very helpful" editorial, I have just created a thread for here, Editorial: Mind the gap: integrating physical and mental healthcare for children with functional symptoms 2019 Heyman

 

The villagers are sick.
She dances with satan.
Burn the witch.

 

Parents can and do abuse their children in strange and unusual ways. Still society hasn’t found good ways to support children who have certainly and demonstrably been abused by their relatives and caregivers. Children taken away from their parents are very often abused further in the state system.

Simultaneously children have been removed from their homes by the state in massive numbers over the centuries. As a means of control and suppression of the population based upon discrimination. By race by disability status by economic class. The medical profession has always played an active role in these matters.

The medical profession has always discriminated against their patients based upon their racial, disability and sex categorisation. Allocating medical treatment disproportionately to some and not so much for others.

Some of what the medical profession did to people based upon their categories of personhood is too disturbing to mention here.

But what occurs to me is being told about the “ refrigerator mother” who in her coldness gave the child Autism. The “smothering mother” who in her (over) protectiveness causes her child to struggle to breathe. To have Asthma attacks.

It was but five minutes ago that patients were not told about their Cancer status least they lose hope and this reduces their resistance to the Cancer shortening the time they have left.

But more than all this I think about when children should be seen and not heard. Certainly not heard asking for help from adults.

Has there ever been a child with a long term pain condition and no immediately obvious cause that hasn’t been told to think about something else and go out play by an adult?

Drs aren’t any different from other adults in this respect. But they are able to construct a narrative around the interior mental condition of a person, a child and their caregivers that once written is inescapable. With potentially catastrophic outcomes for those they label. Maybe a block on future access to medical care. Maybe a block on a future as a family.

So I think the medical profession needs to reassess its policies around such a serious safety issue.

In my opinion if a child is in physical pain it’s safer to assume a physical cause than not to, in most cases. That the child needs medical attention.

It’s not safe to assume that a mother has caused a child’s pain based upon a child’s symptoms. Especially if these are very common.

 

You can tell that she deserved it by being all wet after being dunked in water. QED.

♫ Welcome to the new dark ages ♫

 

The fact that they mix perplexing, which is a property of physicians not being able to figure out the issue rather than something to do with the patients, with fabricated is plain absurd. It truly is the exact same thing as "we don't understand" = WITCH! And no different than saying "insert bigoted trope here" / natural criminal.

 

I’m also thinking for most people it’s distressing to witness an another person in pain and especially a child. The child may lose sleep from the pain and their parent too. So maybe they all go a touch insane. That’s reasonable.

A family might appear to present themselves strangely after all this. Some Dr’s might not be empathetic enough to realise how likely it is that prolonged physical pain will cause psychological distress. Then somehow get the cause and effect switched around.

 

agreed. And Which is of course a problem in the doctor that they are unable to see that (and I do wonder whether like other jobs have psychometric tests or certainly tests for required abilities, empathy is a core one that certain specialisms and certainly jobs within these need to be requiring by testing for and continually checking/training in) .

because this will not be an unusual one-off situation

I do think the service needs to ask itself whether if the doctor is deficient in the skill of empathy and situational analysis they are positioned to be making any judgements at all. Without someone who can add this skill who is respected and protected from being worried about disagreeing.

It’s bad from the angle of anyone who was s hoodwinker too - they’ll hardly be thx ones looking like these people stereotype either.


given where the core of the issues in misdiagnosuses seems to be from I see no reason why direct experience of ME and autism/ASD shouldn’t be prioritised

what happened when there were discoveries in the past of other conditions that explained certain miscarriages of justice eg where things like shaken baby syndrome were thought to be the only possible cause previously?

it does feel like given the implications for things like FII biomedical experts on possible differential diagnoses (particularly where it is likely to be the severe or very severe end it needs to be the few who are familiar with what that looks like not a ‘generic CfS person’) should be independently writing sections on these documents? And perhaps the same with comorbidities sbd situational stressors to factor in (ti explain and be kind and understanding of not ‘to treat’ as if it’s fine to then to deal with others contempt better) ?

 

Spare a thought for the poor doctor who is Perplexed. Gotta find a scapegoat (mother).

 

I think the trouble is most people do tend to think of themselves as empathetic, which may or may not translate into better behaviour or they think empathy has no value. But they can fake having it quite easily.

Empathy is very noticeably in short supply in quite a few areas of medicine and I blame medical training for that, at least as a major contributor. It’s brutal and probably finishes off a good deal of the empathy left after most of it has already been extracted from people via schooling.

There are arguments though that empathy isn’t helpful in many ways. I find some of these very persuasive. But I think it partly comes down to semantics whether or not one would be convinced by this argument. So I am on the fence. But I use empathy to mean an ability to relate to people who are in pain because you can connect to their situation with feeling and that this is one tool that helps you to engage your compassion. The behaviour and attitude of a dr can make all the difference for better or worse. Life and death sometimes.

Also from a practical organisational point of view you couldn’t do worse for patients outcomes, than Drs being allowed to go from “I don’t know why this child is sick?” to “the child is insane!” or “it’s a demonic mother!” with so very little in between. Unjustified and unevidence, literally.

So maybe Drs who couldn’t give a shit about the patient would still care about their own reputation for brilliance or the lack of it, and if wild speculation was no longer considered to represent brilliance, maybe….

But probably only if society’s like the UK invest in staff buildings and equipment sufficient to provide biomedical healthcare to the population will outcomes really improve. Otherwise there’s always gonna be incentives to justify cutting corners. Adding insult to injury.

 

@Ash wrote -

"Also from a practical organisational point of view you couldn’t do worse for patients outcomes, than Drs being allowed to go from “I don’t know why this child is sick?” to “the child is insane!” or “it’s a demonic mother!” with so very little in between. Unjustified and unevidence, literally.

So maybe Drs who couldn’t give a shit about the patient would still care about their own reputation for brilliance or the lack of it, and if wild speculation was no longer considered to represent brilliance, maybe…."