Pathophysiology Symptoms Diagnosis

The deceit continues: an updated literature review of Munchausen Syndrome by Proxy

Sheridan, Mary S., Child Abuse & Neglect, 2003

Caveats:

• Caveats:

• Literature review isn’t random

• Diagnoses not equally certain

• Series often span years

• Inconsistent approaches

Male = Female

• Male = Female

• Average age: 48 months

• Time to diagnosis: 22 months

• Outcomes: long-term disability in 7-8%, death in 6-9%

• Siblings: 25% of sibs dead, half under “suspicious circumstances”

Female >> Male

• Female >> Male

• Mothers heavily represented

• Medical background: 14-27%

• Munchausen features in caregiver: 29%

• Psych diagnosis: 23%

• Depression, personality disorders, somatization

Pediatric or Psychiatric diagnosis?

• Pediatric or Psychiatric diagnosis?

• MSBP or MBPS?

• Pediatric focus: identify and mitigate harm to the child

• “Primum non nocere”

APSAC: PCF + FDP = M(S)BP

• APSAC: PCF + FDP = M(S)BP

• Pediatric Condition Falsification, plus

• Factitious Disorder by Proxy, equals

• Munchausen by Proxy

FDP is not a mental disorder

• FDP is not a mental disorder

• PCF and FDP can occur independently

• Examples:

• PCF without FDP
• Harm to the child without PCF or FDP
• “Lookalikes”

What’s a diagnosis?

• What’s a diagnosis?

• “Differential diagnosis”
• Degrees of certainty

• Diagnostic criteria

• Inclusion vs exclusion

How important is the caretaker’s motive?

• How important is the caretaker’s motive?

• How useful is a profile?

Difficult because:

• Difficult because:

• Presentations vary greatly

• Medical personnel are involved in harm

• Multiple institutions, scattered records

• Failure to consider the diagnosis

• Failure to involve other professionals

What’s proof?:

• What’s proof?:

• Confessions?

• Improvement out of home?

• Covert video surveillance?

• Lab findings?

Child’s safety is the first priority

• Child’s safety is the first priority

• Use least restrictive option

• Close observation
• In-home dependency
• Foster care
• Criminal prosecution

Consult child abuse pediatrician

• Consult child abuse pediatrician

• Gather and review all medical records

• Work as multidisciplinary team

• Involve state Child Protection agency prn

• Involve whole family in treatment

Not a single condition, but a variety of presentations along a spectrum of severity

• Not a single condition, but a variety of presentations along a spectrum of severity

• MBP is a dyadic diagnosis; PCF/FDP are individual diagnoses

• Child abuse is child abuse, whatever the context

• Evaluations have to be exhaustive

• …and involve physicians

3yo boy

• 3yo boy

• 14 visits to PCP in past year, 3 to ED, usually after visitation

• Parents share custody

• Allegations of poor care: constipation, abdominal pain, possible sexual abuse

• Father doesn’t adhere to Mom’s special diet

8yo twin girls

• 8yo twin girls

• Mother describes allergic reactions to aero-allergens, behavioral symptoms

• Naturopath supports her

• Children missed 30 days of school last yr

• Sleep on wooden panels, in mylar blankets, wear masks outside

6yo boy with asthma sx per mom

• 6yo boy with asthma sx per mom

• “meds don’t help”

• Peak flow decreased in office, but improves w/ albuterol neb

• Improvements not sustained at home

• Mom asks for steroids

• Wants disability papers filled out