Pathophysiology Symptoms Diagnosis



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  • Pathophysiology

  • Symptoms

  • Diagnosis

  • Treatment

  • Polite applause



It’s an eponym

  • It’s an eponym

  • It’s not really a syndrome

  • It’s not really a disease

  • It’s not really a diagnosis

  • It’s medical… and psychiatric… and social

  • It’s very hard to treat

  • It’s hard to spell





What to call it?

  • What to call it?

  • Who can diagnose?

  • Where’s the threshold?

  • When to involve the authorities?



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





To remind pediatricians:

  • To remind pediatricians:

  • Children are injured by factitious illness

  • Harm often requires physician’s complicity

  • We can’t usually diagnose it alone (much less treat it), but

  • Medical input is essential to diagnosis

  • Our focus is on harm to the child





Asher, 1951: “Munchausen Syndrome”

  • Asher, 1951: “Munchausen Syndrome”

  • Kempe, 1975: “Uncommon manifestations of Battered Child Syndrome”

  • Meadow, 1977: “Munchausen Syndrome by Proxy: The hinterland of child abuse”

  • Rosenberg, 1987: “The web of deceit”





Rosenberg (1987):

  • Rosenberg (1987):

  • Illness in a child which is simulated and/or produced by someone in loco parentis

  • Presentation of the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures

  • Denial of knowledge by the perpetrator

  • Acute symptoms abate with separation



DSM-IV (1994) “Factitious Disorder by Proxy”:

  • DSM-IV (1994) “Factitious Disorder by Proxy”:

  • (A) Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care.

  • (B) The motivation for the perpetrator's behavior is to assume the sick role by proxy.

  • (C) External incentives for the behavior (such as economic gain) are absent.

  • (D) The behavior is not better accounted for by another mental disorder. (p. 727)



Jenny (2008),“Medical Child Abuse”:

  • Jenny (2008),“Medical Child Abuse”:

  • A child receiving unnecessary and harmful or potentially harmful medical care at the instigation of the caretaker.



Factitious Disorder Imposed on Another (previously, Factitious Disorder By Proxy)

  • Factitious Disorder Imposed on Another (previously, Factitious Disorder By Proxy)

  • To make this diagnosis, all 4 criteria must be met. Note that the perpetrator, not the victim, receives this diagnosis.

  • 1.   A pattern of falsification of physical or psychological signs or symptoms in another, associated with identified deception.

  • 2.   A pattern of presenting another (victim) to others as ill or impaired.

  • 3.   The behavior is evident even in the absence of obvious external rewards.

  • 4.   The behavior is not better accounted for by another mental disorder such as delusional belief system or acute psychosis.



Spectrum:

  • Spectrum:

  • Exaggeration of symptoms

  • Fabrication of symptoms

  • Induction of symptoms

  • resulting in harm to child,

  • through actions of caregiver,

  • in a medical setting



Top ten:

  • Top ten:

    • Apnea/cyanosis
    • Feeding problems/anorexia
    • Seizures
    • Behaviors
    • Asthma/allergy
    • Fever/pain…
    • No common presentation!


Symptoms actively produced in 57%

  • Symptoms actively produced in 57%

    • Suffocation, drugs, poisons, etc.
    • Half while child was in the hospital!
  • Many had unrelated injuries, neglect, FTT

  • Average of 3.25 medical conditions



  • Web of deceit: a literature review of Munchausen Syndrome by Proxy

  • Rosenberg, Donna A., Child Abuse & Neglect, 1987

  • 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?



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






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