Fabricated illness: working within the family system to find a pathway to health

A matter of balance. Positioning of parents' selves through negotiations of symptoms' meaning at a pain clinic for children/young people

This paper traces how the meaning of symptoms and the positioning of selves are entangled and discursively constructed in therapeutic conversations between parents and therapists at a pain clinic for children and young people (age 8 to 18) with recurrent or chronic pain or other somatic symptoms with no established biophysical pathology. Based on data material from an ethnographic fieldwork it is examined how the selves of respectively children/young people and their parents are discursively positioned in conversational encounters and the role positioning of selves play in the context of establishing and negotiating the symptoms' meaning. The bearer of medically unexplained symptoms is oftentimes subjected to moral assessments. In this paper it will be shown that parents, in the institutional setting of the pain clinic, enter the negotiation of moral assessments assigned to their children, and that these moral assessments not only concern the sufferers' selves but also the selves of the parents. The overall argument is that dialogues between parents and therapists concerning the meaning and source of their children's symptoms are simultaneously negotiations in which not only the sufferers'  but also their parents' moral positions are at stake.

Overmedicalization in Children with Medical Complexity

Children with medical complexity (CMC) are a unique pediatric patient population with increased exposure and interactions with the health care system and reliance on family caregivers. These attributes place CMC at high risk of overmedicalization (OM). This article reviews the risk factors for OM in CMC and presents an algorithm that primary providers can use to recognize and address this issue. Involvement of a broad multidisciplinary team, including child advocacy when needed, is recommended. The article also focuses on challenges and additional considerations that arise when medical child abuse as the cause of OM is suspected in this population. [Pediatr Ann. 2020;49(11):e478-e485.].

Families' and healthcare professionals' perceptions of healthcare services for children and young people with medically unexplained symptoms: a narrative review of the literature

Children and young people frequently report physical complaints that have no observable physical pathology known as medically unexplained symptoms (MUS). Research suggests that MUS are associated with substantial physical and psychological impairments and may have a negative impact on children's and young people's functional status and well-being in the long term. Due to the potentially complex needs of this group, children and young people with MUS may require timely access to suitable health and social care services to effectively manage symptoms and achieve their academic, social and personal potential. Families and professionals can offer important insights into the availability and appropriateness of current community and specialist health and social care services. This review is the first critical evaluation and synthesis of research that has examined families' and healthcare professionals' (HCP) perceptions of healthcare services for children and young people with MUS. A systematic search of electronic databases and manual searches of key journals and reference lists identified 17 papers from 15 studies for inclusion in the review. The review highlights the paucity of rigorously conducted research on this topic. Studies have been narrowly focused on the views of a homogeneous group of mothers and young people attending single centres. There has been some attempt to examine doctors' views, but the perceptions of children, fathers and health and social care professionals are absent or under-represented, and multi-site and longitudinal studies are lacking. Thematic analysis of the results from the included studies suggests that knowledge, communication, health beliefs and healthcare settings are factors that influence families' and HCPs' perceptions of services. Families report dissatisfaction with some HCPs' approach to managing MUS. The findings suggest that children and young people with MUS are at risk of receiving suboptimal care and support because there is insufficient research to inform high-quality, evidence-based practice.

Early recognition and management of fabricated or induced illness in children

Fabricated or induced illness (previously known as Munchausen syndrome by proxy) takes place when a caregiver elicits health care on the child's behalf in an unjustified way. Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders specifies deception as a perpetrator characteristic, a far wider range is encountered clinically and is included in this Review. We describe the features of fabricated or induced illness, its effect on the child, and the psychosocial characteristics of caregivers and their possible motives. Present evidence suggests that somatoform and factitious disorders are over-represented in caregivers, with possible intergenerational transmission of abnormal illness behaviour from the caregiver to the child. Paediatricians' early recognition of perplexing presentations preceding fabricated or induced illness and their management might obviate the development of this disorder. In cases of fully developed fabricated or induced illness, as well as protection, the child will need help to return to healthy functioning and understand the fabricated or induced illness experience. Management of the perpetrator is largely dependent on their capacity to acknowledge the abusive behaviour and collaborate with helping agencies. If separation is necessary, reunification of mother and child is rare, but can be achieved in selected cases. More collaborative research is needed in this specialty, especially regarding close study of the characteristics of women with somatoform and factitious disorders who involve their children in abnormal illness behaviour. We recommend that general hospitals establish proactive networks including multidisciplinary cooperation between designated staff from both paediatric and adult mental health services.