By David Tuller, DrPH
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The journal Child Abuse & Neglect recently published a paper called “Characteristics of 86 families and 142 children diagnosed with Pediatric Condition Falsification in the Netherlands.” The study analyzed files from the country’s Child Abuse Counseling and Reporting Center (CACRC), to which anyone can refer a suspected case. According to the paper, the aim was “to gain more insight into common factors in these families, making it easier and earlier for professionals to recognize PCF.”
But there’s something a bit odd about the article. The study was approved by an ethics committee in 2014. The files examined were “collected [by CACRC] over a five-year period (January 2008–December 2013).” This statement reveals two problematic issues.
First, these data are really, really old. I assume that investigatory processes and strategies, as well as understandings of child abuse, have changed in the dozen years since the last case examined. The authors, as far as I could tell, did not offer any explanation for this very, very long lag in producing and publishing their analysis. Without some sort of explanation, it is hard to understand how the findings should be interpreted. How can we have confidence that these data, and the analysis based on them, are currently relevant?
(The lead and corresponding author, pediatrician and child abuse specialist Patries Worm, has been featured extensively in news reports about a woman who was found to have harmed her daughter with poisoned breast milk and was convicted last year of attempted murder. Perhaps this terrible case prompted the publication of the recent article, although that still does not explain the unusual delay. It is important to note, of course, that this guilty verdict does not in any way mean that many or even most such accusations are true.)
Second, the indicated dates–January, 2008, through December, 2013—cover a six-year period, not a “five-year period” as claimed. (Do I need to itemize this for clarity? Six years: 2008, 2009, 2010, 2011, 2012, 2013.) The authors’ apparent inability to count correctly and fix this obvious mathematical error raises concerns about their competence and attention to detail.
Pediatric Condition Falsification (PCF) is another term for what has often been called Munchausen Syndrome By Proxy (MSBP), and more recently Factitious or Induced Illness (FII) and Factitious Disorder Imposed on Another (FDIA). Although these latter names do not require that the individual suffering harm is a minor, most identified or purported cases that fall into these categories involve a parent and child.
These cases are devastating; for most people, it is hard, if not almost impossible, to understand how parents could intentionally harm their children. According to the Cleveland Clinic, which refers to the syndrome as FDIA, “isn’t common,” although reliable data on prevalence are scarce or non-existent.
However, given the frequency with which parents of children with ME/CFS, Long COVID and related complex disorders have been accused of intentionally harming their kids, the construct–whatever it is called—is clearly susceptible to serious abuse. Parents can get slapped with these accusations when they resist medical advice they consider unhelpful or harmful—such as when they refuse to let their child be subjected to graded exercise therapy (GET) and/or cognitive behavior therapy (CBT) if they have ME/CFS.
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Professor Esther Crawley’s malign and harmful views
The case of 27-year-old Maeve Boothby O’Neill, who essentially died from malnutrition four years ago after her ME/CFS made it impossible for her to ingest food, is telling in this regard. At the inquest into the circumstances of her death, which was held in Exeter, England, in the summer of 2024, evidence indicated that, even in the weeks before she passed away, health authorities were continuing to investigate whether her mother, Sarah Boothby, was responsible for her devastating decline.
I obviously have zero interest in defending parents who abuse their kids in any way. At the same time, it is hard to imagine a worse nightmare than being the parent of a seriously ill child and having authorities claim it’s all your own doing. But that’s what seems to happen with some frequency when it comes to these complex illnesses. In the UK, much of the impetus behind efforts challenging parents’ decision-making was attributed in the past to the views and behind-the-scenes actions of Bristol University’s ethically and methodologically challenged pediatrician and grant magnet, Professor Esther Crawley. (Professor Crawley, a GET/CBT fanatic, has since retired from the university and from medicine, for reasons that remain unexplained. But her malign and harmful views appear to linger on.)
It goes without saying that suspected cases of abuse must be investigated. The problem occurs when these cases are investigated based on purported warning signs or “red flags” that clearly parallel the experiences of families with a child suffering from ME/CFS, Long COVID, and related diseases. Given the widespread lack of understanding of these conditions, it is easy to see why authorities reflexively point the finger at parents when their kids’ medical issues resist easy biomedical explanations.
A quick look at this paper indicates just how much overlap there is between these “red flags” and situations involving complex illnesses. In the cases studied, the authors categorized the triggers for the report of medical abuse:
“Doubts about the child’s medical history and the amount of unexplained medical complaints were often reasons for reporting: medical overconsumptions of the child, meaning a strikingly high number of doctor and hospital visits not consistent with the symptoms (63,4 %), discrepancy between the history and observation about functioning by others (54,9 %), somatization (45,8 %), lying about (the seriousness of the) illness by the parent (43,7 %), medical unexplained complaints (39,4 %), social isolation of the child (37,3 %), conflicts between parents and professionals (36,6 %) and magnifying complaints (33,8 %)…
“Another indication of the suspicion of PCF was the involvement of multiple caregivers with the child. 52,1 % of the children had four or more (medical) professionals involved at start of the CACRC investigation and had visited several hospitals at the same time. Various somatic medical specialists were involved in 60 % of cases: pediatricians (57 %), general practitioners (38 %), pediatric neurologists (16,9 %), rehabilitation doctors (11,3 %), metabolic disease pediatricians (9,2 %) and pediatric gastroenterologists (8,5 %).”
Many parents of kids with chronic complex conditions will recognize some or all of these “red flags” as paralleling their own encounters with medical and health care providers in the course of their desperate search for answers and effective treatments, A psychologist or pediatrician might easily be convinced that a parent resisting their advice repeatedly represents PCF. But when that advice is bogus or even potentially harmful—as in recommending graded exercise therapy for children with ME/CFS—smart and informed parents are likely to object.
That makes them appropriately concerned caretakers—not abusive ones.
Tellingly, the PCF paper makes no mention of ME/CFS or Long COVID and the confusion that can emerge around safeguarding when kids suffer from these and related illnesses. The 2021 ME/CFS guidelines from the UK’s National Institute for Health and Care Excellence are very explicit on this point, so it’s worth quoting the document in detail. Here are the key points:
“Recognise that people with ME/CFS, particularly those with severe or very severe ME/CFS, are at risk of their symptoms being confused with signs of abuse or neglect…
“If a person with confirmed or suspected ME/CFS needs a safeguarding assessment, directly involve health and social care professionals who have training and experience in ME/CFS as soon as possible….
“If a person with confirmed or suspected ME/CFS needs to be assessed under the Mental Health Act 1983 or the Mental Capacity Act 2005, directly involve health and social care professionals who have training and experience in ME/CFS as soon as possible…
“Recognise that the following are not necessarily signs of abuse or neglect in children and young people with confirmed or suspected ME/CFS:
- physical symptoms that do not fit a commonly recognised illness pattern
- more than 1 child or family member having ME/CFS
- disagreeing with, declining or withdrawing from any part of their care and support plan, either by them or by their parents or carers on their behalf
- parents or carers acting as advocates and communicating on their behalf
- reduced or non-attendance at school.”
Some of us are old enough to remember the sound of cars backfiring. Most times in most places it would be just that but it could sound so much like a gunshot that it was probably wise to keep that possibility at the back of your mind and quickly assess the risk of that in your particular setting/situation. (Over the years, I heard loads of cars backfiring but once, just once, it did turn out to be a gun being fired.)
I know that doctors get to see terrible instances of child abuse and neglect and that they do always need to be conscious of that possibility. But when it comes to medically unexplained symptoms, which will always be highly prevalent (because people do actually go to their doctors hoping to have the unexplained explained), I’d suggest that most times the cause isn’t likely to be sinister from a neglect/abuse point of view and instead the chances are that it’s a poorly understood medical issue that’s affecting the child. Parents usually know their child best and suspecting the parent/s for no better reason than that the child has harder-to-explain symptoms or that the parents disagree with the doctor over a proposed treatment plan may mean that important or key medical information from them isn’t sought, transferred or taken on board.
Unfortunately, medicine these days appears to be riddled with patient tropes (see – https://bjgplife.com/unlearning-resentment/) and I’d suggest that the realm of medically unexplained symptoms (MUS) is perhaps the worst for that. First there’s the trope that women are far more likely than men to present with medically unexplained symptoms due to their mental health issues being converted to physical symptoms. So women may be 3 or 4 times more likely than men to have their physical symptoms dismissed as mental or behavioural problems and, with high MUS prevalence rates expected overall, that could mean that it’s close to 50:50 whether their GP will believe them about their physical symptoms with an even lower chance of their symptoms being taken seriously in secondary care. But, from my own experience, that seems to have been extended into mothers’ opinions and hunches about their sick children (minor or adult) being deemed unreliable, prone to emotionality/catastrophic thinking, and not to be trusted. The one person who’s most likely to know their child better than anyone else and have their best interests at heart finds themselves sidelined and ignored or, worse than that, accused of making the situation worse in some way or, worse still, held under suspicion of abuse or neglect. How on earth did it get to this point?
Martha’s rule (see here – https://www.bbc.com/news/articles/c8e1zw28766o ), to enable families to seek an urgent second opinion for their sick children, was campaigned for and is finally being rolled out this autumn in English NHS hospitals. That’s great, and will hopefully mean that many children’s lives are saved, but I worry that insufficient attention has been paid to the realization that women and mothers aren’t being listened to by NHS doctors. Rather than there being isolated cases of sexism or misogyny, I strongly suspect that medical teaching is at fault here, and I fear that both women and their children will continue to suffer and die unnecessarily until a taught sexist MUS narrative is finally exposed for the harm that it does and is consigned to the medical scrap heap.
I & other family members have had doctors/AHP’s misdiagnose & accuse my parents of over reacting, wasting their time, wasting our money. Later we find we were right and the previous doctors/AHP’s were wrong. Medical records have had errors of varying severity. I don’t know how much it matters in the cases studied above but I understand the risks.
This may be an interesting read https://www.communitycare.co.uk/2025/10/13/why-fabricated-or-induced-illness-needs-to-be-dropped-as-a-child-protection-category/
Thank you to the previous commenter for flagging up that article -https://www.communitycare.co.uk/2025/10/13/why-fabricated-or-induced-illness-needs-to-be-dropped-as-a-child-protection-category/ . Having read it, I can’t help thinking that if the ‘medically unexplained symptoms’ (MUS) construct, with all the sexism, prejudices and tropes that to my mind go with it, was debunked then a lot of the problems of unfair suspicion and action against innocent parents/caregivers might disappear too. The term Munchausen syndrome by proxy (MSbP) may no longer be in use, but I very much doubt that the ‘proxy’ part has been erased from doctors’ minds. I wonder, has MSbP perhaps now been replaced by a kind of MUSbP, that has the potential to impact way more parents/caregivers than MSbP ever did by only requiring there to be evidence of them rejecting medical advice or seeking to prevent treatment they’re genuinely concerned may harm their child rather than there being suspicion/proof of them harming the child on purpose?
With the clinic prevalence of MUS being taught as being even higher in adults (30% to 50% perhaps) than it is in children (I’ve seen 10% to 30% suggested), and with doctors taught that women are 3 or even 4 times more likely to consult with MUS than men, then I imagine the scene is set for parents, especially mothers, of children with harder-to-explain symptoms to be under considerable suspicion from the moment they attend with their child. Perhaps it then only takes for the parent to disagree with the suggested treatment plan for the doctor or medical team to see this as a kind of MUSbP abuse (especially if they believe the bad press that’s been levelled at critics of ME and MUS medical dogma) and retrospectively contemplate that the parent may have fabricated at least some of the reported symptoms, particularly those which make the least sense. A major plank of the MUS model is the idea that patients -predominantly women – might bring iatrogenic harm upon themselves via their false illness beliefs and/or their healthcare demands – arguably not so much deliberately as in Munchausen’s but more subconsciously because of their mental health/behavioural problems. If ‘proxy’ thinking is still alive and kicking, then maybe this MUS iatrogenic harm process is also being viewed as transferable from parent to child. The harm supposedly being inflicted may not be identified as deliberate from the start but rather from the time that the parent or mother takes action to try to prevent the child from being managed in accordance with the psychogenic playbook or presses for investigations or treatment that the doctor views as unnecessary or counterproductive.
In defence of doctors, the doctor likely feels a duty to step in to try to prevent what they fear would be almost inevitable iatrogenic harm to the child from them not being managed correctly and safely under the MUS recommendations. If the MUS model that’s been drummed into them was medically sound, if it was correct and safe, then their actions might be justifiable – them trying their best to protect innocent children. But this is all about suspicion and I can’t help thinking that doctors should, first and foremost, be highly suspicious of a model that teaches that women are several times more likely than men to waste valuable medical resources with their supposed somatization BEFORE those same doctors suspect parents/ caregivers of acting against their child. I suppose that medics are taught from medical school onwards to religiously respect, follow and obey authority, and that authority appears to have taught them that the MUS psychogenic model is unquestionably sound and that women are indeed this dreadful drain on healthcare systems. To my mind, that is downright dangerous.
I’d contend that it’s the MUS model that needs to be challenged and overturned as a matter of urgency. Is psychogenic MUS, (rather than just harder-to-explain symptoms), really rife in primary and secondary care? How sound is the evidence that the unexplained symptoms are due to mental health issues? Are women really several times more likely than men to be somatizing their symptoms? Can doctors be sure that MUS misdiagnosis rates aren’t worrying high? I’d suggest that a great risk to children’s biopsychosocial welfare might come from such a high percentage of caregivers, mothers in particular, being regarded with high levels of suspicion by the medical profession. I may be wrong, but I strongly suspect that debunking the flawed MUS dogma and eradicating the MUS model from medicine would go a long way towards ensuring that loving, caring parents are respected by doctors for all they can contribute towards their child’s care and that the only parents/caregivers who are suspected of child abuse are those who deserve to be.