Title: Pediatric%20condition%20falsification%20(PCF)%20 %20Factitious%20disorder%20by%20proxy%20(FDP)%20=%20Munchausen%20syndrome%20by%20proxy%20(MSBP)
1Pediatric condition falsification
(PCF)Factitious disorder by proxy
(FDP)Munchausen syndrome by proxy(MSBP)
- Kenneth W Feldman, MD
- University of Washington School of Medicine
- Childrens Hospital Regional Medical Center
- (Thanks to Mark Mendelow MSW for assistance)
2These cases are albatrosses around your neck
3Patterns of fabrication 1) history
- Cut from whole cloth or exaggeration of real, but
milder disease - Normally we trust parental history
- Symptoms are often of reported episodic events,
usually not observed by the physician (eg
seizures) - Symptoms pull our chains-demand response
- Seizures, apnea, vomiting diarrhea, fever,
bleeding
4Patterns of fabrication 2) signs symptoms
- Concrete, but created findings are offered to
corroborate history - Bleeding-check blood type, nucleated cells, Y
chromosome staining, DNA - Urinary stones-chemistry micro
- Rash
- Fever, abnormal samples-do nurse observed
re-check/collection - CF sputum
5Patterns of fabrication3) induction of
symptomatic illness
- Apnea-observation, covert surveillance
- Vomiting diarrhea-toxicology, oral exam
- Intoxications-seizures, sedation, etc
- Bleeding-lacerations, but more often with IV
lines - Infections/line sepsis-recurrent, poly-microbial,
unusual organisms, bugs that should be killed by
antibiotic patient is receiving
6Patterns of fabrication4) precipitation of
unnecessary medical testing intervention
- Diagnostic tests
- Medications-eg. seizure treatment
- Surgery-Nissen, gastrostomy, ENT surgery
- Whatever treatment you try, will fail or cause
complications - Lots medication allergies Rx intolerances
- Abuse by medical intervention-physician complicity
7Induction of psychiatric/behavioral illness in
child (Pediatr 19898357, Pediatr 2000105336)
- Childs response is age appropriate
- Feeding disturbances
- Poor nutrition/failure to thrive
- Oppositional behavior/ADD- yet compliant with
medical treatment - Symbiosis with mother- home schooling, school
phobia, avoidance-tied to apron strings, - Mothering to death (Arch Dis Child 199980359)
- Complicity with deceptions-child gets secondary
gain - Adult Munchausen, conversion disorder, somatic
illness - Adult PTSD
8Munchausen by internet
- Seek social strokes/support on line
- Often completely factitious (Notre Dame
linebacker) - Misrepresent childs illness
- Seek perks-Wish programs
- Seek
- The doctors are fools
9You might think someone would need to be nuts to
do this
10Caretaker/perpetrator characteristics
- Prior medical knowledge-by training or on the
job experience - Pressure for diagnosis treatment
- Doctor shopping- run when suspected or Dr.
refuses to act - Refusal of access to prior information/records
- Florid personal family medical history
- Inappropriate parent/physician boundaries-beware
of flattery/gifts - Befriending/ alliances with other parents
staff- cruise director for the ward - Splitting of staff
- Hyper-attentive, hyper-present mother
11Caretaker/perpetrator characteristics
- However, the diagnosis is not made by the
caretakers profile!
12Perpetrator psychopathology
- Lack of nurture as child
- Experience with attention gained from ill role as
child - Abuse victimization as child /or adult
- Psychosis frank dissociation infrequent
- Axis II disorders-hysteria, narcissism,
borderline - Mood disorders-depression
- Substance abuse
- Suicidality
- Confrontation may cause attempt to prove
childs illness
13- Lasher and Feldman The hallmark of MBP
maltreatment is deception. - MBP perpetrators are usually accomplished
deceivers and manipulators. - They are typically extremely convincing and are
able to give seemingly plausible reasons for any
inconsistent or odd findings or personal
behaviors. - Schreier the perpetrator gleefully plays
with the MD, controlling his actions and
devaluing him by confusing him. - When angry, may escalate induction of symptoms to
act out her rage.
14Getting at motivation
15Parents of chronically ill children often become
difficult
- Behaviors of survival value for child parent
- can become dysfunctional frustrate providers.
- They may be similar to MSBP behaviors.
- (Krener. AJDC 1988142945)
- Social support may vary in chronic childhood
illness - (Patterson. Devel Behav Med 199718383).
- Overprotection may result
- (Thomasgard Devel Behav Med 199516244).
16What happens when a parent has a chronically ill
child?
- Depression/anxiety
- Lack of empathy
- Marital problems/social stressors, few outside
supports - Attention
- Admiration from family
- Admiration from community
- Gifts
- Publicity
- Lack of challenge from medical system
- They develop feelings of competence learn
medical vocabulary from managing complex
treatment regimens. - Admiration from others for that competence
- The equilibrium in the marital system may become
upset as mothers attention shifts away from the
husband onto the child - Defend child from medical misadventures.
17What happens when a parent has an ill child?
- They often receive much support and sympathy from
friends and family - They may develop a close relationship with their
pediatrician. They develop a new support system
in the milieu of the hospital - Staff
- Other parents
18Transference
- A warm, caring physician offers an intensely
tempting, but ambivalently regarded ideal
transference object - The physician shares the mothers emotional
space, values her opinion and admires her
(counter-transference) - This may be the first time the mom has ever
experienced this in a relationship
19The Context Predisposing Factors
- A history of emotional abandonment as a child
- History of childhood illness
- Familial MBP or Factitious disorder
- They are not simply overwhelmed needing help
- They do not look like parents who overtly abuse
their children - Often fascinated with medical field
- Fathers who perpetrate are often more overtly
disturbed than the mothers who perpetrate
20Common Features
- Pathological lying
- Need for an audience
- Causing repeated serious harm to the infant
- A compulsive need to repeat the behavior
- Can focus on one, several or serial children
(youngest) - Displaying excitement or some other unusual
affect that is not appropriate for the situation,
e.g. at a time when the childs life may be in
danger
21Psychodynamic Formulation
- Schreier the mother is engaged in a masquerade
of of mothering that springs from roots that were
quietly traumatic and that include a profound
absence of recognition
22Psychodynamic Formulation
- The mother uses the child to forge a relationship
with the physician in which lying is the primary
mode of interaction - The mother becomes a perfect parent in a
perverse, fantasized relationship with a
symbolically powerful physician who represents
the idealized parent for the mother
1Schreier, The Perversion of Mothering
Munchausen Syndrome by Proxy
23Perpetrator psychopathology
- Behavior speaks more strongly than MMPI
- No specific psychiatric profile or test
- Psychiatry can explain why help understand
treatment needs prognosis, but cant deny
proved fabrication - Schrier-female perversion, with child as fetish
object-simulating the good mother - Learned means of obtaining nurture
- Anger/revenge at authority figures for lack of
nurture - Attention seeking occurs in multiple
forums-medical, veterinary, fires, school, legal,
press
24Partner issues
- Absent or unavailable dad
- Substance abuse
- Abusive relationship
- Head in the sand-can pay amazing medical costs,
without recognizing child ill - Collaborate with or facilitate abuse
- Childs illness defends/distracts from marriage
dysfunction - Suicidality
25Nomenclature-it guides thinking
- MSBP-memorable/evocative-but we dont know if
were talking about victim or perpetrator - British Working Group-Fabrication or induction
of illness in a child - Irish guidelines-Induced illness (MSBP)-lacks
false history - DSM IV-TR- 300.51 Factitious disorder with
physical symptoms-only talks about perpetrator - Rosenberg (CAN 200327421)- intent not part of
definition - APSAP- Pediatric condition falsification
- AAP Medical child abuse/child abuse in the
medical setting - 14 labels only accounted for 51 of article titles
26APSAC guidelines(Child Maltreatment. 20027105)
- Define harm/abuse to child- Pediatric Condition
Falsification (PCF). - Define caretaker motivation to fabricate-
- Factitious Disorder by Proxy (FDP).
- Differential of caretaker motivation (Child MalTx
20027160) - Anxiety/vulnerable child
- Help seeker
- Delusions
- Malingering
- Allegations in divorce/custody
- FDP can involve sex abuse claims
27Other associated motivations for FDP
- Escape from adverse environment
- Develop complicated social support network
- Thrill of the chase-outwit authority figures
seek revenge for lack of nurture - Intellectual interest in medicine
- Secondary gain (eg. malingering) can co-exist,
but not be the primary motivation
28Epidemiology
- British Pediatric consultants2.8/100K lt 1 yo,
0.5/100K lt16 yo - (McClure. Arch Dis Child 19967557).
- New Zealand Pediatric survey-2.0/100K lt 16 yo
- (J Paediatr Child Health 200137240).
- Atlanta 23 cases diagnosed by videotape in 4
years _at_ 165 bed tertiary care hospital (5.75/yr) - (Hall. Pediatr 20001051305).
29Outcome is poor
- General Review (Rosenberg. CAN. 198711547)
- 10/117 (8.5) die
- 20 deaths after confrontation
- 10 sibs died-of suspicious causes
- Abuse continues under observation
- General Review (Sheridan CAN. 200327431)
- 6 die, 7.3 long term injury
- 25 had dead sibs 61 sibs with similar
problems - Bools (Arch Dis Child 19926277) 29 of index
children had FTT 29 physical abuse, 39 of
sibs illness falsification, 11 mortality
30Outcome Induced apnea
- Overlap of PCF with routine physical abuse- cant
stand crying vs seeking attention - Meadow (J Pediatr. 1990117351)
- 9/27 die
- 1/27impaired
- Only 2 survivors returned to mom in two years
- 18/33 prior sibs die, 13 history apnea, seizures
or cyanosis - Rosen (Pediatr. 198371285)
- Out of normal SIDS age range (1-12 months),
repetitive spells/begin with mom-child observed
later, compromised
31Case evaluation
- Usually no smoking gun
- Doctors legal system dont believe
- Toxicology, sample evaluation
- Covert surveillance
- Collect all records on child, mom sibs-time
line - Check collateral contacts-eg. day care
- Insurance records as source of care information
- CPS access to records (WAC 26.44.056.10)
- Compare caretaker reported vs actual diagnoses
- Consult widely-seek proof of your Good faith
in numbers (WAC 26.44.060)
32Should you do covert video-surveilance?
- It can prove illness induction (Southall. Pediatr
1997100735). - It can also can disprove false history (Hall.
2000). - Is it ethical?
- Are you monitoring child or caretaker?
- Consent for diagnosis treatment? Private vs
state facility. - Are you putting the child at risk?
- If enough to monitor, you can get court trial
separation (Flannery. U Mich J Law Reform
199832105) - Who monitors? Crawford v Wash issue?
338 month old girl with seizures apnea
- Febrile seizures _at_ 3 months
- Afebrile Sz at 9 months, EEG MRI nl, Rx
phenobarb. - Sz continued, with apnea Sz
- Nurse at outside hospital questioned seeing mom
covering childs nose mouth, at onset of a
spell. - Admitted for video EEG, then ward room
observation with covert video-no events, till
discharge plans discussed - Mom caught suffocating child-trying to get Drs
to pay attention to childs problems - Guilty plea, child no events out of her care.
34Making your legal case
- Were often in a jam
- Tendency to not
- believe possible
- Get ducks in a row
- Moms look good
- The injury to the child
- is what counts
- Maternal motivation/psych
- only for Rx/prognosis
35Protect child from further abuse by your staff
- Notify all involved medical providers.
- Try to limit care to through a primary care
gatekeeper - Consider flagging record Concern for illness
falsification, undertake diagnosis and treatment
based on objective signs and symptoms.
36Intervention
- Feldman Lasher MBP case plans must contain
elements activities specific to MBP
maltreatment - A court finding of facts that confirms MBP is
essential to establishing an appropriate case
plan that can be legally justified. - Case plans contain specific and unique elements
and activities that must be successfully
completed prior to consideration of
reunification. - Without a case plan appropriate to MBP
maltreatment, it is unlikely that the victim will
be protected in the short and long term.
37Intervention
- Lasher and Rosenberg note that placement with
relatives is potentially very dangerous in MBP
cases - A specialized relative evaluation process must be
completed in addition to usual relative
evaluation activities - Falsification often familial
- Goal is to ensure there is no potential for
allowing access to the child by the parent .
38Treatment
- There is very limited literature about long term
treatment for these mothers with psychotherapy - The high level of denial is a barrier to
successful treatment - Of those who do enter treatment, many do it only
to mollify the system and to have their children
returned - Consider dual therapists-one to be reality check
for primary therapist
39Good Prognostic IndicatorsFor Success
- Early admission of MBPS (may be partial)
- Awareness of harm to child victim
- Developing empathy for child
- Belief that child's health will improve
- Motivation for treatment
- Intelligence
40Major goals of treatment
- Insight into CONTEXT of the abuse
- More adaptive ways to meet ones needs
- Development of empathy
41Professional backlash
- These are vindictive ladies. Any attention
desired. - Legal media attention are as rewarding to them
as is medical. - A powerful dangerous man
42Avenues for complaint/intimidation
- Complaint to ones superiors
- Complaints to hospital board
- State medical disciplinary board
- DSHS- ombudsman, administrators, legislators,
governor - Hospital/university/NIH- research impropriety
- Freedom of information act
43Avenues for complaint/intimidation
- State hospital commission
- JCAH
- Law suits for referring or evaluating case,
slander, negligent evaluation - State good faith reporting immunity
- Criminal liability for failure to report
- DSHS Child Protection Team-unprotected
- Future testimony- Youve been sued X times for
false diagnosis. - When all else fails, theres always the media
44Immunity from civil liability
- Previously explicitly for referring and
testifying in child abuse. - Reasonable cause to believe/good faith (?
whos) - Legal precedent for evaluating mongolian spot
case - Good faith, without gross negligence cooperates
in an investigation of a report (WAC 26.44.060
(5)
45Review articles
- Rosenberg. Web of deceit. (CAN 198711547).
- Sheridan. The deceit continues. (CAN
200327431). - Kinscherff. Extreme MSBP The case for
termination of parental rights. (Juvenile
Family Court J. 199141).