PEDIATRICS Vol. 105 No. 2 February 2000, pp. 336-342

Child and Adolescent Illness Falsification

Judith A. Libow, PhD

From the Department of Psychiatry, Children's Hospital Oakland, Oakland, California.

	ABSTRACT

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Objective.  To review the current state of knowledge on factitious illness in children and adolescents to help clarify the relationship of this phenomenon to a range of somatizing disorders in children and factitious disorder by proxy.

Design.  The literature of the past 30 years was reviewed for cases describing children <18 years old who have intentionally falsified symptoms of illness, without known parental involvement. Cases in which a parent was involved, the child acknowledged a credible motive, the deception was identified after age 18, or which appeared in foreign languages were excluded. Data on age, gender, factitious symptoms, method, duration of deception, and outcome of confrontation, where available, were gathered from case studies.

Results.  Forty-two cases of illness falsification by children were identified, with a mean age of 13.9, and a range from 8 to 18 years. The majority of patients were female (71%), and the gender imbalance was greater for the older children. The most commonly reported falsified or induced conditions were fevers, ketoacidosis, purpura, and infections, and the fabrications ranged from false symptom-reporting to active injections, bruising, and ingestions. The mean duration of the falsifications was almost 16 months before detection. Many of the children admitted to their deceptions when confronted, and some had positive outcomes at follow-up. The descriptions of some of these children as bland, depressed, and fascinated with health care were remarkably similar to adults with factitious disorders.

Conclusions.  Medical conditions fabricated by children may go undetected for a variety of reasons, or diagnosed as somatization. Further study of children who falsify symptoms may in some cases help identify earlier experiences of Munchausen by proxy abuse or covert parental coaching of illness falsification, and provide more effective interventions. Better understanding and identification of these children is likely to help prevent the development of more chronic adult factitious disorders.  Key words:  factitious disorder, Munchausen by proxy, children, adolescents, factitious illness.

There has been increasing recognition in the pediatric literature of the past 20 years that illness falsification by caregivers must be included in the differential diagnosis of children presenting with persistent, unexplained symptoms or laboratory findings.¹ We have expanded our knowledge base on the wide range of methods that can be used to falsify believable illness in children,^2,3 as well as the dynamics and presentations of these seemingly devoted parents⁴ and their young victims.^5,6

However, there is considerably less awareness that pediatric symptoms can also be intentionally falsified by child and adolescent patients, and this unique group has remained virtually invisible. A review of the literature on factitious illness demonstrates that it is not only adults who can successfully simulate medical conditions, and that a number of cases of child or adolescent illness fabrication have been described in both the United States^7-28 and abroad.^29-34 More detailed examination of these cases and their relationship to childhood somatization disorder, conversion disorder, and malingering suggests that greater awareness of this phenomenon could allow for more accurate identification and effective treatment.

Munchausen syndrome was named by Dr Richard Asher³⁵ some 25 years before Munchausen syndrome by proxy was identified by Dr Roy Meadow.³⁶ "Munchausen syndrome" is the familiar descriptive term for the disorder of illness falsified in the patient's own body, although it is technically reserved for those cases in which the factitious production of symptoms is serious and chronic, rather than episodic. The more generic term "factitious disorder" appears in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,³⁷ as the intentional feigning of illness with the motivation "to assume the sick role" and an absence of "external incentives" for the behavior. It is differentiated from the range of other somatoform disorders, those that present with physical complaints that cannot be fully explained by a medical condition or the effects of a substance, by the fact that the condition is consciously and intentionally falsified. Furthermore, factitious disorder is distinct from malingering in that it is motivated by factors more complex and less conscious than material secondary gain. The feigning of illness can involve either the intentionally false reporting of symptoms, such as fevers or bleeding, and/or the induction of physical conditions through active means, such as ingesting medications or infecting one's wounds, and both can draw the physician into unwitting and destructive collaboration in the medical charade.³⁸ Although estimates of its prevalence suggest that factitious illness is not a trivial problem in adult patients^1339-41 and often begins at an early age,^23,42,43 there is no systematic research on this problem in the pediatric population.

	METHODS

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Study Design

Forty-eight cases of illness falsification by children <18 years old were identified in a Medline search of the literature of the past 30 years. This article focuses on the 42 cases of independent illness falsification (Table 1), in which a child or adolescent is identified as the primary agent intentionally deceiving physicians and receiving medical evaluations for physical symptoms they themselves helped create, with a primary motivation of assuming the sick role, and without apparent active parental involvement. For clarity, the terms "illness falsification" and "factitious illness" rather than "factitious disorder" are used to describe this phenomenon, because many of the reports provide insufficient information for precise psychiatric diagnosis. Cases were judged to involve intentional deception by the child based on either direct admission, systematic elimination of all other options by the child's treating physicians, or the discovery of specific methods, equipment, or substances surreptitiously used by these patients to falsify or induce illness. Data regarding age and gender of the child as well as factitious symptoms, method(s) of deception, duration of deception, and outcome of confrontation were identified or extrapolated from the case histories, where possible. Duplicate case reports were excluded.^13,14,20,23

Cases were also excluded from this sample for any of the following reasons:

1. The case was not identified as illness falsification until after age 18.
2. Articles written in languages other than English and Spanish were excluded.
3. The author(s) clearly identified a credible, conscious motivation for the child's falsification to which the child readily admitted. However, cases were not excluded from this review solely because the patients were described as having comorbid emotional or family problems or other presumed psychiatric diagnoses, or simply gained increased attention.
4. The case description included a parent who seemed to have coached the child or was a possible participant in the child's deception (Table 2).

	RESULTS

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Of the 42 patients in Table 2, 30 (71%) are female and 12 (29%) are male, figures remarkably close to the 3:1 ratio noted for adult factitious disorder patients.^39,44 The mean age of the children is 13.9 years, with a range from 8 to 18. The group approximately divides into a group of children aged 14 and younger (n = 20) and aged 15 and older (n = 22), with an increasing number of girls in the older (82%) compared with the younger group (60%). All 13 younger children for whom data are available actually admitted to (or did not deny) their intentional falsifications when confronted, yielding a 100% rate of confession, compared with only 55% confession rate by the older group (6 of 11 adolescents for whom data are provided).

Similar to descriptions of adult factitious disorder patients, children involved in illness falsification are generally described as bland, flat, and indifferent during their extensive medical investigations. Most commonly these patients are also described as depressed, socially isolated, and often obese. In several articles, additional diagnoses given to these children include dysthymia, oppositional disorder, adjustment disorder, anorexia nervosa, passive-dependent personality, and hysterical personality. Many of these children seem to have initiated their career of illness falsification as a result of experience with the medical world either through chronic illness or after a bona fide, if minor, episode of illness. Several articles note that their patients showed an early interest in the medical world, and aspired to careers in medicine or nursing. In one case an adolescent boy worked part-time in a medical office during the course of his illness falsification.

These case reports make no mention of a parental role in instigating or abetting the deceptions. However, a number of articles describe enmeshed parent-child relationships, or significant family psychiatric history. Some of the articles note in passing that the patients' mothers are nurses, or are actively engaged in caring for disabled children.

Characteristics of Illness Falsification

The most commonly reported factitious or induced conditions included fever of unknown origin (n = 13), diabetic ketoacidosis (n = 10), purpura (n = 7), and infections (n = 5). The duration of the falsifications in the 31 cases for which this data are available ranged from several single incidents to a 5-year duration. Not surprisingly, the younger group of children had a shorter average duration of deception (12.8 months) compared with the older group (18.9 months). It should be noted that this data must be considered preliminary given that many of the articles provided inexact or insufficient information.

The deceptions of the children were discovered either because they were so blatant as to be quite obvious after brief assessment, or because the hospital staff began searching the patient's belongings or organized controlled nursing observations after exhausting all other plausible explanations. Some of the methods of detection by treating physicians were quite ingenious, as in the use of a plaster cast to prove that leg bruises were self-inflicted, or devising bets or predictions that engaged a child in demonstrating control over his symptoms. In a few instances it seems that a deception was discovered only by chance, as when hypodermic needles were discovered in a child's bedsheets.

The deceptions of the younger children tended to be more simple and concrete, such as sucking on drinking glasses to cause rashes, warming thermometers with heating pads, or putting blood from superficial wounds into urine specimens. With the exception of the diabetics, younger children tended to engage in more blatant deceptions than the older children, more readily acknowledged the deceptions when confronted, and were more likely to have a positive outcome, with cessation of deception, when follow-up data were available.

By contrast, the level of medical sophistication in older children or those with chronic diseases allowed for more convincing and harmful deceptions. Sheehy¹² described a diabetic boy who underwent a subtotal pancreatectomy and liver and lymph node biopsies before he admitted to repeatedly inducing diabetic ketoacidosis through deliberate insulin manipulation. The literature also describes a variety of very effective medical deceptions by children without chronic diseases such as the feigning of chronic fever²¹ by a 15 year old which was worked up repeatedly with radiographs, ultrasounds, GI contrast studies, CT scans, and a bone marrow aspiration. Gilarski and Graham¹⁶ described a 14-year-old girl whose ingrown toenail progressed to erythema, edema, exfoliation, ulceration, and eventually necrosis, until hospital staff found a bottle of hydrofluroic acid in her garment bag and the child admitted her active involvement. Adolescents have deliberately ingested steroids to cause factitious Cushing syndrome,¹⁸ injected air to cause subcutaneous facial emphysema,³³ introduced egg and other foreign matter into their bladders to induce proteinuria³¹ and feculent urine,²⁰ and used tourniquets to cause swelling and wrist pain.³⁰ The older children who confessed to their fabrications only did so when confronted with concrete evidence, and at least 45% stubbornly maintained their denial even when confronted. As in the literature on adult factitious disorder, many of the families fled the institution and the children were lost to follow-up, or the parents angrily rejected recommendations for psychotherapeutic treatment.

	DISCUSSION

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Obstacles in Recognition

Given that factitious illness is not uncommon in adults and is known to often begin earlier in life, it is somewhat surprising that this review yielded only 42 cases describing independent illness falsification by children or adolescents. As in factitious disorder by proxy, we have no way of knowing how many illnesses fabricated by children have entirely escaped suspicion by physicians, or have been suspected but never confronted or published because of a lack of positive evidence. Some adolescent cases are not being captured in the pediatric literature because of long delays in identification, and are eventually published as adult cases.

We know that for the physician, even suspecting a devoted parent of deliberate illness falsification is very difficult.⁴ Believing a child or young adolescent capable of deliberately deceiving the doctor into unnecessary medical intervention may pose a serious psychologic obstacle for the pediatrician as well as a highly uncomfortable conclusion to offer the parent. The fact that the present study identified an average duration of almost a year and a half of fruitless medical investigation before confirmation of the deceptions makes it obvious that physicians are not immune to the manipulations of even preadolescents, sometimes for long periods.

In the case of milder fabrications, some, or perhaps many factitious illnesses may begin with false symptom-reporting (eg, fever, headaches, pain, nausea). In the absence of a child's active self-harm to create symptoms, the pediatrician may be unwilling to challenge the child when unable to verify the intent to deceive. As parents essentially control their child's access to medical care, it further complicates the physician's ability to determine the degree to which it is the child or the parent who is pursuing the child's sick role, or how much physician attention the child is seeking independently of the parent. The parent's presence in the examining room may also hamper candid history-taking to assess the child's intentions. Furthermore, the fact that any illness, whether bona fide or falsified, will necessarily result in secondary gain (school absence, parental attention) makes the accurate assessment of a child's primary motives that much more challenging.

Somatization and Diagnostic Dilemmas

For these and other reasons, unexplainable, extensively evaluated pediatric problems which may represent the beginning of illness falsification may instead be diagnosed as somatization, considered a fairly common way for youngsters to manifest emotional and familial distress.⁴⁵ The literature on somatization in children is considerably more extensive than the factitious illness literature, documenting that complaints of medically unexplained aches and pains, headaches, fatigue, nausea, dizziness, and other childhood symptoms are quite common.^4345-47

Most authors and reviewers concur that the term "somatization" tends to be used over-inclusively and imprecisely by physicians. It is used to describe physical symptoms for which medical evaluation reveals no discernible physical pathology or mechanism, or the complaints or impairment exceed what would be expected from the medical findings alone.⁴⁸ Clearly this broad definition is inclusive enough to incorporate child and adolescent factitious symptoms, as well as malingering, conversion disorder, and even psychogenic pain, as issues of patient intentionality and motivation are absent from this pragmatic definition. To further complicate matters, malingering, conversion disorders, and factitious disorders present with several striking similarities including beginning in late adolescence or early adulthood, a relatively chronic course, relatively poor response to therapeutic approaches, and a similar pattern of comorbid personality disorders.⁴⁹

Utility of the Construct

There is general agreement that in some cases, children classified as somatizers may intentionally exaggerate^47,50 or deliberately falsify symptoms.⁵¹ Yet some authors believe that the complexities of identifying patient intentionality and motivation make it impractical to attempt to differentiate young illness falsifiers from somatizers⁴⁹; others suggest that the distinction is more of a "moral judgment about the origin of symptoms" than a useful distinction.⁵² Yet increased awareness of the problem of intentional illness falsification offers an opportunity to better identify these patients at a young age and intervene preventively. This review lends support to the suggestion that without early intervention, children who intentionally falsify illness may well be headed toward more chronic factitious disorder in adulthood, with the potential of serious self-harm including unnecessary surgeries and permanent disability. As a group, they bear a striking similarity to adult patients in such factors as female gender imbalance, histories of early medical fascination, bland affect, denial of deception, and flight from psychotherapeutic treatment. We know that the mean age of onset of adult factitious disorder is most commonly in the patient's early twenties⁴² and perhaps up to half the cases may begin in adolescence.⁴³ One study of adult factitious disorder²³ found that all their patients who self-induced infections had started this behavior in adolescence, although many were not identified until years later.

Reports of illness falsification cases that began in adolescence but were not identified until years later demonstrate that these deceptions can go undetected for years, resulting in serious and permanent damage. One article described a 22-year-old woman with a history beginning at age 15 of self-induced leg abscesses via use of fecal material, resulting in an amputation.⁵³ Another described a 28-year-old woman with a history of extensive treatment for factitious abdominal and gynecologic complaints starting at age 17.⁵⁴ Another described the 5-year history, beginning at age l5, of a young woman who endured 13 surgical procedures and 23 hospitalizations as a result of self-induced joint inflammation.⁵⁵

In addition to its preventive value, differentiating children who intentionally falsify illness from somatizing children may also allow for more effective psychotherapeutic intervention, particularly with younger children and those with less extensive medical histories. Although additional research is needed, it seems likely that identification of children who fabricate illness will allow a more rapid and direct challenge of these children's symptoms in psychotherapy than is generally possible or effective with somatizing children. This might enable a more rapid resolution of the misuse of their bodies and of medical resources, and focus more direct attention on the unconscious needs being expressed through medical attention-seeking.

Parental Coaching, Collusion, and Factitious Disorder by Proxy

The cause of illness falsification in children is likely complex and multidetermined and there may well be different subtypes of children who develop this problem through different pathways. Early experience with illness and physicians and general emotional neglect are likely to play pivotal roles, just as elements of our health care system itself may help reinforce or maintain these destructive behaviors for some young patients.

One of the important directions for further exploration is suggested by the related cases cited in Table 2. They demonstrate that parents can train even young children to fabricate symptoms, as in the case of a mother who trained her 4-year-old son to feign seizures and shaking^26. Parents can also play an important supporting role in a child's manipulations.^27,28,34 Although the present review focused on children who falsify illness without known parental involvement, the cases point up some disturbing similarities to children exposed to Munchausen by proxy abuse in that some of the parents are health care professionals, many seem to join with the child in denying the deception, and many of these families flee from psychiatric referrals. It remains for future research to address the question of whether a significant percentage of children who falsify illness have passively experienced Munchausen by proxy abuse earlier in life, later learning to collude with the parent's falsifications⁵⁰ and eventually initiate their own fabrications, as opposed to developing this behavior independently.

	RECOMMENDATIONS

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It is recommended that pediatricians include illness falsification by the child patient in the differential diagnosis of a persistent and unexplained medical condition, along with somatization, malingering, and Munchausen by proxy abuse. Signs suggestive of falsification include a child who appears blandly indifferent, unconcerned, or flat in affect in response to unpleasant procedures and hospitalizations, or who demonstrates an unusual level of sophistication or interest in the medical world. Conditions that always begin when the child is alone or unobserved (eg, hematemesis only seen after the child emerges alone from the bathroom, or bruises that always appear when the child is unobserved) should arouse suspicion, as should lesions and rashes that only occur on accessible parts of the body.

A detailed examination of the child's early medical history indicating frequent, unexplained medical problems may provide clues to the possibility of the patient's earlier experiences of intentional illness exaggeration or falsification by a caregiver. The parent's affect and degree of concern and cooperation should be carefully observed when presented with the physician's suspicions or evidence of deception, because this may yield clues to possible coaching or collusion. Young children may even be willing to reveal specifics of parental coaching or collaboration if directly questioned.

Methods similar to those recommended for physicians investigating the possibility of caregiver falsification can also be helpful in verifying a factitious condition initiated by the child, such as close observation in the hospital, tox screens for a variety of household products as well as known family medications, or room searches for substances and equipment. The physician will need considerable creativity to even imagine the range of methods that a child might use to create the symptoms in question, and may require even greater creativity to test these hypotheses.

If conscious fabrication by the child is strongly suspected or verified, nonthreatening but direct discussions with the patient can sometimes yield a confession; less sophisticated children may be willing to reveal their clever ruse when engaged in a game to see if they can control the symptom in question. In the case of older adolescents, it is more likely that only tangible evidence (ie, syringes, witnessed self-bruising) will result in admission of conscious self-harm. A thorough psychosocial history, and psychologic assessment of the child and family system will help clarify whether the child is malingering for tangible gain (such as hospitalization to escape from an intolerable home situation, or increased visitation from a divorced parent) or is instead motivated by less conscious factors.

	CONCLUSION

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A review of the literature on factitious illness in young people indicates that children and adolescents can intentionally falsify illness, although younger children tend to use more obvious, easily identified falsifications and more readily acknowledge their deceptions. These cases may escape diagnosis because of the difficulties for physicians in suspecting deception by children, and the complexities of accurately assessing intent and motivation. An unknown number of somatizing children may, in fact, be involved in more conscious deception than has heretofore been recognized, and there may be an element of previous or ongoing parental coaching or collaboration. Although limited, follow-up data on children who admit to their deceptions suggests there may be less risk of repetition, particularly when the fabrications are confronted at an early stage.

Given the risk of these patients developing a chronic pattern of illness falsification and the potential for early intervention, it is proposed that there is value in differentiating this specific population of children from those with other forms of persistent, undiagnosed medical complaints.

	FOOTNOTES

Received for publication Jan 19, 1999; accepted Apr 29, 1999.

Reprint requests to (J.A.L.) Department of Psychiatry, Children's Hospital Oakland, 747 52nd St, Oakland, CA 94609. E-mail: jlibow{at}mail.cho.org

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