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Christopher Bass, Consultant in Liaison Psychiatry, John Radcliffe Hospital, Oxford, UK,
Catia Acosta, Specialty Trainee in General Adult Psychiatry, Charing Cross Rotation, West London Mental Health Trust, London, UK,
Gwen Adshead, Forensic Psychiatrist and Consultant Forensic Psychotherapist, Broadmoor Hospital, Crowthorne, UK,
Gerry Byrne, Clinical Lead, Family Assessment and Safeguarding Service & Infant–Parent Perinatal Service, Oxford Health NHS Foundation Trust, UK
In the fabrication or induction of illness in children, an adult – characteristically a parent and usually the mother – presents a child to healthcare professionals as ill when in fact the symptoms of the illness are falsified, fabricated or actively induced by the adult. There have been many changes in nomenclature since Meadow first described this manifestation of disturbed parenting and caregiving as ‘Munchausen syndrome by proxy’ (Meadow, 1977). Other terms have since been introduced, including ‘factitious disorder by proxy’ (DSM-IV: American Psychiatric Association, 1994), ‘factitious disorder imposed by another’ (DSM-5: American Psychiatric Association, 2013), ‘paediatric condition falsification’ (Ayoub et al, 2002) and, in the UK, ‘factitious or induced illness’ (Department of Health, 2002). The term ‘medical child abuse’ has also been used in the USA (Roesler & Jenny, 2009), to reflect the role of the doctor in ordering interventions and procedures that are invasive and unnecessary, which (inadvertently) maintain the abuse. In this chapter, we will use the term ‘fabricated or induced illness by carers’ (FII), which has also been adopted by the Royal College of Paediatricians in the UK (Royal College of Paediatrics and Child Health, 2009). In practice, however, the majority of perpetrators (85%) are parents.
All of these definitions have limitations because they attempt to describe a spectrum of abnormal illness behaviour involving a perpetrator and how this behaviour affects a child. Abnormal healthcare seeking behaviour in the perpetrator can range from hypervigilant preoccupation with a child's symptoms at one end of the spectrum through to intentional induction of illness or poisoning of the child at the other. However conceptualised, FII is a form of child abuse that involves an abnormal form of care-eliciting behaviour in the caregiver, usually manifested as an abnormal relationship with healthcare professionals that has an adverse effect on the child.
The incidence of FII is unknown, but the behaviour is widely believed to be underreported. In 1996, the combined annual incidence of identified FII, non-accidental poisoning and non-accidental suffocation in the UK and Ireland among children 5–16 years of age was 0.5 per 100 000; among those 1–4 years old it was 1.2 per 100 000; among those 0–11 months old it was 2.8 per 100 000; 8 deaths were recorded (McClure et al, 1996).
Previous studies have shown that 17 to 60% of psychiatric trainees have been physically or verbally assaulted. To measure the frequency of assaults and the trainees' reactions, we conducted a retrospective self-reported survey of attendees at MRCPsych teaching courses in south London and at an annual meeting of psychiatric trainees.
Overall, 64% of the questionnaires distributed were returned completed. Of the trainees who responded, 41% had been physically assaulted at least once and 89% had been verbally assaulted. As a result of the assault, 34% of trainees were subsequently more risk aware and 11% were now hesitant to assess patients with a history of violence. There was no association between the level of training or attendance at a breakaway training course and having been subject to physical assault.
Our study showed unacceptable levels of physical and verbal assault on psychiatric trainees and an important effect of those incidents on clinical practice.
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