Pediatric%20condition%20falsification%20(PCF)%20 %20Factitious%20disorder%20by%20proxy%20(FDP)%20=%20Munchausen%20syndrome%20by%20proxy%20(MSBP) - PowerPoint PPT Presentation

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Pediatric%20condition%20falsification%20(PCF)%20 %20Factitious%20disorder%20by%20proxy%20(FDP)%20=%20Munchausen%20syndrome%20by%20proxy%20(MSBP)

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Pediatric condition falsification (PCF) + Factitious disorder by proxy (FDP) = Munchausen syndrome by proxy (MSBP) Kenneth W Feldman, MD University of Washington ... – PowerPoint PPT presentation

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Title: Pediatric%20condition%20falsification%20(PCF)%20 %20Factitious%20disorder%20by%20proxy%20(FDP)%20=%20Munchausen%20syndrome%20by%20proxy%20(MSBP)


1
Pediatric 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)

2
These cases are albatrosses around your neck
3
Patterns 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

4
Patterns 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

5
Patterns 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

6
Patterns 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

7
Induction 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

8
Munchausen 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

9
You might think someone would need to be nuts to
do this
10
Caretaker/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

11
Caretaker/perpetrator characteristics
  • However, the diagnosis is not made by the
    caretakers profile!

12
Perpetrator 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.

14
Getting at motivation
15
Parents 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).

16
What 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.

17
What 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

18
Transference
  • 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

19
The 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

20
Common 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

21
Psychodynamic 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

22
Psychodynamic 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
23
Perpetrator 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

24
Partner 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

25
Nomenclature-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

26
APSAC 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

27
Other 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

28
Epidemiology
  • 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).

29
Outcome 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

30
Outcome 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

31
Case 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)

32
Should 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?

33
8 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.

34
Making 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

35
Protect 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.

36
Intervention
  • 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.

37
Intervention
  • 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 .

38
Treatment
  • 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

39
Good 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

40
Major goals of treatment
  • Insight into CONTEXT of the abuse
  • More adaptive ways to meet ones needs
  • Development of empathy

41
Professional backlash
  • These are vindictive ladies. Any attention
    desired.
  • Legal media attention are as rewarding to them
    as is medical.
  • A powerful dangerous man

42
Avenues 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

43
Avenues 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

44
Immunity 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)

45
Review 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).
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