Over the last week or so, I have examined 3 children, all referred, with a tentative diagnosis of malingering. The medical dictionary defines malingering as “the act of intentionally feigning or exaggerating physical or psychological symptoms for personal gain.” When adults do this, it is usually an attempt to obtain a status of visually disabled in order to collect monetary benefits. With children, it is more likely because they want a pair of glasses. Perhaps a sibling or a best friend has recently gotten a pair of incredibly chic eyeglasses and a heavy dose of positive feedback! This is not an uncommon scenario in a busy pediatric service, and I have a bunch of different techniques to “trick” my young patients into reading the littlest letters without any lenses. Here is how it worked out for me with these 3 patients.
JB is a 9 year old boy, brought in by his foster mother. He has had a traumatic childhood and is being treated for a bipolar disorder. He is in a special education program but still struggling academically. He was referred by another doctor who suspected malingering but JB kept insisting he could not see any letters of any size at any distance. But when I questioned him and his mother, he did not behave like a child with such reduced vision. He watches TV, plays video games and runs around during recess without getting hurt. Objective measurements made it very clear that he does not require any lenses, and there was no obvious pathology that might account for his vision loss. After multiple “malingering busting” tricks, JB finally read the 20/20 line without any lenses. I believe that JB’s “malingering” is much more than an exaggeration of his symptoms for personal gain. This is a desperate cry for help, from a young boy with some serious problems. It took so much time to determine that he does not have any ocular pathology or a need for a distance correction, that I was unable to assess him for the presence of a learning related vision problem. I discussed this with his mother, and we both agreed that JB needs further evaluation. She accepted a referral to the Vision Therapy Service.
DD is an 8 year old girl. She was very quick to point out to me that she is, in fact, almost 9 years old. She was referred by her school because her teacher felt that she was faking a vision problem so she would not have to complete her schoolwork….. she’s lazy! DD had a pair of glasses and all our measurements indicated that making her glasses a little stronger should have done the trick, but she consistently stopped reading the letters at the 20/80 line. Now, it was a busy evening, I had several patients still waiting to be seen, this was taking too long and I was getting cranky. I reached all the way to the bottom of my bag of “malingering busting” tricks but she was stuck at 20/80. I kept insisting that she could read smaller letters and she kept stopping at 20/80. I finally looked at her retinas with my ophthalmoscope and felt like a fool. Indeed 2 weeks later she was diagnosed with a retinal dystrophy that is causing her poor vision. Her vision will probably get worse, it certainly isn’t going to get better. DD has an appointment with my colleagues in our Low Vision Service. It is time to help her make the most of her remaining vision and prepare her to function with progressive vision loss. I also began the process of obtaining appropriate services and accommodations from her school.
BT is a 10 year old girl referred by the school after failing a vision screening. She was also seen by another optometrist who couldn’t figure it out. Once again, she does not behave like a child with reduced vision, but she could only read the biggest letters on the chart. After trying several lens combinations, and getting minimal improvements, I finally told her that I ran out of lenses. If this last set of lenses didn’t improve her vision, then she wasn’t going to be getting any glasses. Bingo. She read the 20/20 line with a combination of lenses that added up to zero power. Finally, a malingering malingerer. Mom was not surprised. She agreed to purchase an inexpensive pair of sunglasses for BT.
What’s the lesson here? If your child is complaining about poor vision, or the school suspects a vision problem, please make sure your child has a comprehensive vision examination. If something doesn’t seem right, get a 2nd opinion. Yes, sometimes they really are “exaggerating.” But sometimes its evidence of a much more serious problem that needs serious intervention.