No abstract

SYNOPSISInterviews were conducted with parents of 100 children taken to a ‘School attendance committee’, because of persistent failture to attend School. Clinical assessmen t of the attendance problem was carried out so that children were categorized as ‘School refusers’ (N = 24), ‘truants’ (N =53), ‘both refusers and truants’ (N =9), or as ‘neither’ (N =14). Any ICD-9 psychiatirc disorder was separately identified. Cluster analysis of information collected in a standard way indicated that there was a group of children with the features of ‘School refusal’ who often had genralized neurotic disorders as well and who were mostly girls, another group with the feature of ‘truancy’ all of whom had conduct disorders who were mainly boys, and a third cluster of childrsen who were usually ‘truants’ but less often psychiatrically disturbed. The study provided evidence for the existence of School refusal with and without generalized neurotic disturbance in a non-clinical population.

Fifty six children who had been victims of fabricated illnesses and 82 of their 103 siblings were studied. In addition to the index fabrication, 64% of index children had had other illnesses fabricated by their mothers. Twenty nine per cent of the index children had a history of failure to thrive and 29% a history of non-accidental injury, inappropriate medication, or neglect. Seventy three per cent of the index children had been affected by at least one of these additional problems.Eleven per cent of the siblings had died in early childhood, the cause of death not being identified. Thirty nine per cent of siblings themselves had had illnesses fabricated by their mothers, and 17% had been affected by either failure to thrive, non-accidental injury, inappropriate medication, or neglect. First in 1977, and then subsequently, one of the authors (SRM) used the term Munchausen syndrome by proxy to describe cases in which a parent, invariably the mother, fabricated illness in her child or children and presented the problem to doctors.' 2 Since that time, the number of reported cases has increased steadily, so that in 1987 a review considered 117 cases.3 In that meta-analysis Rosenberg reported associated problems for the index child, including physical abuse in 1% and failure to thrive in 14%. Unusual deaths of siblings, and probable fabricated illnesses in other siblings, were mentioned but could not be assessed accurately because of the limitations of meta-analysis.4 Our experience is that this 'co-morbidity' of index children and siblings may be considerably more prevalent. We believe that the best way to assess this is by the systematic study of the original case records of a series of affected children and their siblings.

Fifty four children were studied 1-14 (mean 5.6) years after fabrications of illness had been identified. Thirty of the 54 children were living in families with their biological mothers and 24 were with other family members or in substitute families. Further fabrications were identified for 10 children who had been living with their mothers and there were 'other concerns' for a fiurther eight children.Thirteen children residing with mother and 14 not residing with mother at follow up had a range of disorders including conduct and emotional disorders, and problems related to school, including difficulties in attention and concentration and non-attendance. Overall, 20 children (490/0 of those successfully followed up) had outcomes that were considered to be unacceptable.

Child and adolescent psychiatry is a growing speciality. Significant increases in workload, the reasons for which have been described elsewhere (Black, 1989), have led to an expansion in consultant posts across the UK. Recently the Joint Planning and Advisory Committee (JPAC) reviewed senior registrar numbers and recommended an increase in the establishment by 38 whole-time equivalents in England and Wales, a rise of 38%, to meet the expected shortfall. How existing senior registrars, as well as this large number of new recruits, are trained is clearly a matter of some importance.