Royal College of Psychiatrists and Paediatric Mental Health Association guidance on MUS – https://www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms

Perplexing presentations (PP) – term is used to describe the presence of alerting signs when the actual state of the child’s physical or mental health is not yet clear and there is no perceived risk of immediate serious harm to the child’s physical health or life.

Cf Factitious or Induced Illness (FII, prev Munchausen by Proxy) –

• Mostly associated with the mother
• extreme end of spectrum of abnormal parenting behaviours, from ‘mild’ erroneous belief or overanxiety at one end, through manipulative fabrication to ‘severe’ imminently dangerous induction of illness at the other end.
• Danger that effect on the child underestimated.
• Even milder abnormal parental behaviours creates difficult relationships between family and health professionals

Features of FII

• Unwitnessed, or at least, not independently observed
• Poor response to treatment
• Unexplained impairment esp school but also social
• New symptoms, and multiple opinions sought; yet frequent WNB
• Changes of school/clinician, complaints and demands.  Home schooled often – which also makes it harder to get independent observations

But these features are only to raise suspicion, not diagnostic! RCPCH has guidance.

Is there a risk of harm? If in doubt, discuss early with safeguarding team, rather than trying to decide alone on whether to involve  social services.

Offer a “current consensus opinion” together with at least one other professional, and ideally input from education/nursery! Continue to monitor until things improving.  No right to access parental health records however –would need explicit consent.

Chronology needs to include basis of previous diagnoses, and justification

Admission for observation – some special issues:

• What should nursing staff be looking for?
• Is 24/7 supervision required or possible? Can they leave the ward?
• Where do you keep notes?

Second opinions – for specific issues, and ONLY TO HELP YOU manage the child. And necessary to provide background of concerns.

Discussing with family –

• Bringing father, and child’s own views, into the picture helpful.  Child often defers to mother in these cases [presumably as their views are ignored]
• reassure the parents that there is no current health concern, but emphasise that the team can/will still support and manage any condition the child has

Truancy and going missing as risk factors for sexual exploitation. Experience of conflict, threat and violence – so dealing with these as protective, along with access to safe, stable accommodation, increasing awareness of rights

Acutely – toxicology, parental responsibility, local sexual assault referral centre (SARC – but don’t wait on them), specialist police (good if hesitant). emergency contraception, post-exposure prophylaxis (PEP) incl hepatitis B vaccination.  Advice from the sexual offences examiner (SOE) or forensic medical examiner (FME).  Document if unable to get consent.

Forensics – urine samples, toilet tissue used during the admission, clothing at the time of presentation, underwear and any sanitary wear. Option for self referral for forensic exam (13+yrs) where police are not required.

General paediatrician may be required to get involved with sexual offences examiner, with view to paediatric history, consent issues, referring to social services and/or psychological support

Police protection (which can involve transport to secure location) does not confer right to consent to treatment – needs emergency protection order.

Up to 18 in some respects – Children’s act 1989 defines child as under 18.