Pathophysiology Symptoms Diagnosis

• 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?

• 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

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