Herbert Schreier
Factitious disorder by proxy, previously known as Munchausen by proxy, occurs when a caretaker (usually a mother) directly causes her child to be, or appear to be, ill or impaired and obtains medical interventions. The name for this disorder is derived from the adult condition factitious disorder, which is a self-inflicted or fabricated illness to gain medical attention. In factitious disorder by proxy, a child may be hospitalized unnecessarily or may receive inappropriate procedures and treatments that may have devastating effects on the child.
CLINICAL DEFINITIONS AND PREVALENCE
The American Professional Society on the Abuse of Children (APSAC) proposed “pediatric condition falsification” (PCF) as a diagnostic description for abuse through illness fabrication. Conditions may be exaggerated, fabricated, or induced. Factitious disorder by proxy (FDP) refers to a form of PCF in which a caretaker abuses a child for personal psychological motivations. Although often difficult to discern, the motivation in FDP is important to know, because this form of abuse often has a guarded prognosis and may need different interventions than other forms of child abuse. PCF is child abuse regardless of the motivation. The historical term FDP continues to be used by pediatricians and other child advocacy specialists.1
Approximately 140 new cases of the most serious forms of FDP (eg, suffocation, poisoning) can be expected annually in the United States2,3; less dramatic forms are often undetected.
ETIOLOGY
The self-serving psychological needs in factitious disorder by proxy vary. Some individuals appear to need or thrive on the attention that results from their own perception as the devoted parent of a sick child; others appear to be motivated by the need to covertly control or deceive clinicians or other authority figures. These mothers appear to have the ability to convince others of their essential goodness and caring.4External incentives such as monetary rewards may be present but are not the paramount motivation.
The abuse in FDP frequently involves the physician as an unsuspecting agent in harming the child. Qualities that we value in doctors, such as empathic caring and an interest in and need to solve complicated medical problems, may make some clinicians more susceptible to manipulations. This is often the case when a perpetuator is a colleague or someone with medical knowledge.5
Despite signs and symptoms that are not consistent or that are ambiguous, or despite surgical procedures and medications that do not change the reported symptoms, the pediatrician is so often taken in that they disregard the suspicions of others and prolong the child’s suffering. Death rates in reported cases are between 6% and 9%. When a new case occurs, other siblings who died mysteriously may be discovered.2 In a study with covert video surveillance of 38 women and one father suspected of suffocating their children, 33 were observed abusing their child on camera, and 3 others later admitted abuse. Eventually, 38 out of 39 parents were found to have abused their children. Among the 42 siblings of these children, 12 died previously from suspicious causes, 11 were classified as sudden infant death syndrome, and 4 parents admitted to killing 8 siblings of the index children. An additional 15 were abused.6 The abuse in factitious disorder by proxy persists for an average of 14 to 22 months before a diagnosis is typically established.7,8
CLINICAL PRESENTATIONS
Over 100 clinical presentations of FDP have been described, including failure to thrive, vomiting, acute life-threatening events, over-and undertreated asthma, and dermatologic conditions.4,8 FDP can also present as a psychiatric condition9 and school-related disabilities.10 A description of FDP, written by a nurse who was a victim of FDP as a child, is instructive and informative.11
Table 94-1. Clinical Profiles Suspicious for Factitious Disorder by Proxy
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Child Presentations |
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A child who presents with medical problems that do not respond to treatment or that follow an unusual course. |
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Signs and symptoms of a child’s illness fail to occur in the parent’s absence. |
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Parent Presentations |
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A parent who is medically knowledgeable and/or fascinated with medical details and hospital gossip. |
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A parent who appears unusually calm or even giddy in the face of serious difficulties in the course of her child’s illness and may at the same time be very supportive of the physician. Some parents may become demanding and angry when further investigations and procedures are resisted by staff. |
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Discrepancies in the medical history reported by the parent. |
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A parent who makes self-serving efforts at public acknowledgment. |
Clinical profiles can be useful to suspect FDP in a child who is abused by a parent (Table 94-1). However, the parent profiles overlap substantially with behaviors commonly seen in mothers of truly ill children, anxious mothers, parents who are strong advocates for their genuinely ill children, and difficult parents.4
Table 94-2. Fabrication of Symptoms by a Parent in Situations Other than FDP
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“Masquerade syndrome”: Amplification or falsification of an illness to keep a child with mother at home17 |
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Delusion: A belief that the child is ill as part of a psychotic process in the mother (resolves with treatment of mother’s condition) |
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Help seeker: Trying to obtain help for herself by presenting the baby as in need. Usually harm is minimal to child.13 |
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Doctor-shopping and overly anxious parent: Belief that the child is not being diagnosed or treated appropriately. This is not MBP unless it is with the motivations described above. |
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Hypochondria: Overreacting to normal conditions and exaggerating their seriousness. |
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Obsessive compulsive disorder: Focus on child being sick and obtaining unnecessary treatment. |
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Malingering motivation is secondary gain such as monetary reward. |
DIAGNOSTIC PROCESS
A careful review of all relevant medical records is important in order to uncover factitious disorder by proxy and factitious conditions.12 When Munchausen by proxy is suspected, action should be taken immediately to protect the child and confirm the diagnosis. Separating the parent from the child may be useful but only if carried out with the utmost of rigor and concern for the child and parent. Establishing the diagnosis of condition falsification is the first priority.13 Discovering the motivation for falsification is the next step.
Professionals from other disciplines who have experience with this disorder should be enlisted in the diagnostic process and in assessing a potential underlying motivation of the perpetrator. There are no specific psychological tests to diagnose factitious disorder by proxy.
Issuing a psychological assessment to discern a mother’s mental health condition should only be performed by a professional who is familiar with the disorder. In some cases of factitious disorder by proxy, a mother may appear emotionally healthy on psychological tests. There are other situations of child abuse in which illness fabrication takes place for reasons other than that described in factitious disorder by proxy14 (Table 94-2).
Guides for clinicians who are faced with the challenge of differentiating suffocation from sudden infant death syndrome in an infant15 (Table 94-3) and falsification of bowel symptoms from chronic intestinal pseudo-obstruction in toddlers16 are useful.
MANAGEMENT AND TREATMENT
The most difficult aspect of this disorder is ascertaining if symptoms are falsified. It is in the nature of this process that the clinician closest to the case is often least able to recognize that a child is being abused in this way. It is incumbent on the child’s clinician to protect the child. Consultation with a professional child abuse expert is the first step. Care must be taken to avoid false accusations and to balance the parents’ rights against those of a child, often one who is preverbal.
PROGNOSIS
The prognosis in factitious disorder by proxy is grim. Recidivism rates are high,17 and abuse has often recurred even on supervised visits. Mothers rarely concede their behavior; they often continue their denial and may extend the process of manipulation to social service and the court personnel. Treating someone with great simulating skills is difficult, and it is tough to be confident in honest progress.18
Table 94-3. Suffocation vs. Sudden Infant Death Syndrome—When to Suspect Suffocation
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Multiple episodes of reported apnea |
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A child older than 6 months |
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A sibling with a major illness |
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A sibling who has died |
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Index child or sibling on the child abuse list |
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Blood in the nose and mouth in a child with an ALTE (apparent life threatening event) |
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ALTE only by mother’s report or only happens when she is present |