Fabricated or induced illness: From "Munchausen by proxy" to child and family-oriented action.

BACKGROUND: In fabricated or induced illness (FII), a child is harmed due to caregiver(s) behaviour and actions, carried out to convince mainly doctors that the child's physical and/or psychological health is more impaired than in reality. Harm is caused directly by the caregivers(s) and also often inadvertently by doctors' responses. OBJECTIVES: To describe: dynamics underlying FII; wider definition of FII; alerting signs for early recognition of possible FII; respective responsibilities of health, social care, education. METHODS: Literature review, clinical experience, expert opinion. RESULTS AND CONCLUSIONS: Caregivers are motivated by gain from having their child treated as ill, and/or by erroneous beliefs about their child's health, either way needing medical confirmation about their contentions. Their behaviour is therefore directed primarily towards doctors. Most cases of FII present unexplained discrepancies between caregiver reports/actions and independent observations of the child. More rarely, the child has actual signs of illness, induced by the caregiver, occasionally fatal. Children are harmed in all aspects of life: health, daily functioning including education, and psychologically. Harm emanates directly from the caregiver(s) but also unintentionally from medical responses. Illness induction and clear deception by the caregiver require immediate child protection. Otherwise, the initial focus is on assessing the child's current health and functioning rather than caregiver's mental health. If, beyond verified illness, there is no medical explanation for the child's reported ill-health, the family require help to function better. This requires co-ordinated, multidisciplinary rehabilitation and long-term monitoring. If caregivers refuse rehabilitation, child protection is required. Several unanswered questions remain.

El sindrome de Munchausen por poderes: un tipo especial de abuso infantil / Munchausen syndrome by proxy: a special type of child abuse

En el síndrome de Munchausen por poderes (SMpP), uno de los padres, en el 95% de los casos, la propia madre, inventa, falsifica y fabrica síntomas clínicos en su hijo hasta convertirle, de cara a los médicos y pediatras, en un enfermo. La última Clasificación de Enfermedades Mentales (DSM-5), ha introducido en el capítulo de Trastornos Adictivos el Trastorno por juego, abriendo la posibilidad de incorporar otras conductas problemáticas de riesgo adictivo que no se refieren a sustancias, como son los videojuegos, Internet o las compras. Por nuestra parte, proponemos que el perfil psicopatológico del perpetrador/a de un SMpP se corresponde con un trastorno adictivo, ya que tienen un comportamiento compulsivo de búsqueda del ambiente hospitalario que les supone un alto grado de gratificación y recompensa, y que se incrementa progresivamente ante nuevas situaciones de estrés. Se muestran tres casos clínicos de SMpP que pertenecen a la serie de 19 víctimas con diagnóstico confirmado del síndrome, que estudiaron los autores en un conjunto de 54 casos con sospecha de ser víctimas de Munchausen por poderes enviadas desde Pediatría al presentar los signos de alarma que definió Meadow. El propósito de este trabajo es aportar nuevos datos que faciliten una segura y adecuada intervención caso de encontrarse con esta extrafia y sutilmente peligrosa enfermedad (AU)

In Munchausen syndrome by proxy (MSBP), one of the parents, in 95% of the cases the mother per se, invents,falsifies and makes up clinical symptoms in their child until the child becomes a patient for the physicians and pediatricians. The last Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has introduced the Gaming Disorders in the chapter of Addictive Disorders, opening the way to the possibility of incorporating other problematic behaviors of addictive risk not referring to substances, such as video games, Internet, or shopping. On our part, we propose that the psychopathological profile of the author of a MSBP corresponds with an Addictive Disorder, since they share a behavior of compulsive seeking of the hospital setting that means a high grade of gratification and rewards and that progressively increases when their are new stress situations. Three clinical cases of MSBP belonging to a series of 19 victims with confirmed diagnosis of the syndrome studied by the authors in a group of 54 cases with suspicion of being victims of the Munchausen syndrome by proxy referred from pediatrics due to the presentation of Meadow-defined alarm signs are shown. The purpose of this work is to provide new data facilitating 21 safe and adequate case intervention if faced with this rare and subtly dangerous disease (AU)

Munchausen syndrome by adult proxy: a review of the literature.

BACKGROUND: Munchausen syndrome by proxy (MSBP), more formally known as factitious disorder imposed on another, is a form of abuse in which a caregiver deliberately produces or feigns illness in a person under his or her care so that the proxy will receive medical care that gratifies the caregiver. Although well documented in the pediatric literature, few cases of MSBP with adult proxies (MSB-AP) have been reported. This study reviews existing literature on MSB-AP to provide a framework for clinicians to recognize this disorder. METHODS: We searched Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Knowledge, and PsychINFO, supplemented by bibliographic examination. RESULTS: We identified 13 cases of MSB-AP. Perpetrators were caregivers, most (62%) were women, and many worked in healthcare. The age range of the victims was 21 to 82 years. Most were unaware of the abuse, although in 2 cases the victim may have colluded with the perpetrator. Disease fabrication most often resulted from poisoning. CONCLUSIONS: MSB-AP should be included in the differential diagnosis of patients presenting with a complex constellation of symptoms without a unifying etiology and an overly involved caregiver with suspected psychological gain. Early identification is necessary so that healthcare providers do not unknowingly perpetuate harm through treatments that satisfy the perpetrator's psychological needs at the proxy's expense.

Caregiver-fabricated illness in a child: a manifestation of child maltreatment.

Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver who falsifies and/or induces a child's illness, leading to unnecessary and potentially harmful medical investigations and/or treatment. This condition can result in significant morbidity and mortality. Although caregiver-fabricated illness in a child has been widely known as Munchausen syndrome by proxy, there is ongoing discussion about alternative names, including pediatric condition falsification, factitious disorder (illness) by proxy, child abuse in the medical setting, and medical child abuse. Because it is a relatively uncommon form of maltreatment, pediatricians need to have a high index of suspicion when faced with a persistent or recurrent illness that cannot be explained and that results in multiple medical procedures or when there are discrepancies between the history, physical examination, and health of a child. This report updates the previous clinical report "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in the Medical Setting" The authors discuss the need to agree on appropriate terminology, provide an update on published reports of new manifestations of fabricated medical conditions, and discuss approaches to assessment, diagnosis, and management, including how best to protect the child from further harm.

Factitious disorders and Munchausen syndrome: the tip of the iceberg.

This population-based study evaluates the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy in a clinical setting. All children referred to the Pediatric Unit of the Department of Pediatrics of the Catholic University Medical School (Agostino Gemelli Hospital) in Rome were recruited between November 2007 and March 2010. An experienced interdisciplinary team of medical professionals analyzed all suspected cases. A total of 751 patients were hospitalized. Factitious disorders were diagnosed in 14/751 patients, resulting in a prevalence of 1.8%. Three of 14 (21.4%) patients fulfilled the criteria for Münchausen syndrome. Münchausen syndrome by proxy was identified in four of 751 patients, resulting in a prevalence of 0.53%. The perpetrator was the mother in three of four of these cases. The epidemiological data obtained in this population-based study indicate that the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy is higher than previously observed. Moreover, early detection was possible thanks to the awareness of an expert interdisciplinary team. We suggest that physicians must consider the possibility of these diagnoses whenever there are discrepancies in a child's illness presentation.

Munchausen syndrome by proxy in Mexican children: medical, social, psychological and legal aspects.

INTRODUCTION: The Munchausen Syndrome by Proxy (MSP), is considered as an unusual less frequent variety of child abuse (CA). In this type of abuse the perpetrators purposely provide factitious information, tamper with specimens or actually induce an illness in a child. Nowadays, it is a clinical entity described in pediatrics as more frequently than before. Despite the fact of its presence worldwide, there are still problems in order to get an appropriate diagnostic. It is also difficult to handle both the clinical and legal aspects in various countries. OBJECTIVE: Make our academic fellows aware of various pediatric, psychological, social and legal aspects of a series of cases attended at the Clínica de Atención Integral al Niño Maltratado from Instituto Nacional de Pediatría (CAINM-INP), Mexico [Integral Clinic of Attention for Abused Children, at National Institute of Pediatrics, Mexico]. MATERIAL AND METHODS: From a series of 25 cases, 18 minors of age were considered with this syndrome since we found that they shared medical, psychological, social and legal characteristics. RESULTS: 18 minors of age belonged to 14 families. 4 of those families had two affected children each one. These affected children were girls 13/18, predominant in children under six years in 10/18. Syndrome expression was distributed as follows: fever from a non determined origin, seizures, chronic diarrhea, hematuria, and probable sexual abuse. 14 children were hospitalized. In all cases, the aggressor was the mother. The psychological evaluation of six perpetrators revealed psychotic, histrionic, and compulsive-obsessive traits. The socio-economic condition was low in 50% of the cases. A legal demand was posed for seven patients in which all the children remained under the custody of the mother. CONCLUSIONS: In Mexico, reports of CA have increased within the last years according to experience. Some complex forms as MSP require the participation of an interdisciplinary team for both diagnosis and integral attention.

Psychopathology of perpetrators of fabricated or induced illness in children: case series.

BACKGROUND: Munchausen's syndrome by proxy (recently renamed fabricated or induced illness) is a rare form of child abuse, but relatively little is known about the psychopathology of the perpetrators. AIMS: To examine the medical, psychiatric, social work and forensic records of mothers referred for detailed psychiatric assessment from 1996 to 2009. METHOD: Twenty-eight consecutive individuals with a putative diagnosis of fabricated or induced illness were referred to the authors for detailed psychiatric assessment and recommendations about management (25 from family courts). We scrutinised all medical and psychiatric records and interviewed them, as well as informants. RESULTS: In total, 16 (57%) had evidence of a current somatoform disorder, and factitious disorders (either past or current) were identified in 18 (64%): 11 participants had both somatoform and factitious disorders. Nine participants (32%) had non-epileptic attacks. We found evidence of pathological lying (pseudologia fantastica) in 17 (61%) of the participants; in some there were key links between early abusive experiences, the development of pathological lying and the eventual fabrication of illness in the child victim. CONCLUSIONS: A chronic somatoform disorder or factitious disorder (or both) was detected in almost two-thirds of the participants. Over half of the mothers exhibited pathological lying, in some dating from adolescence, and this often continued into adult life eventually involving the child in a web of deceit and abuse. Psychiatrists whose work brings them into contact with women with chronic somatoform or factitious disorders, especially if there is evidence of lying from an early age, should always be alert to the impact of these illnesses on any dependent children.

Munchausen syndrome by proxy: ongoing clinical challenges.

In 1977, Roy Meadow, a pediatric nephrologist, first described a condition he subsequently coined Munchausen syndrome by proxy. The classic form involves a parent or other caregiver who inflicts injury or induces illness in a child, deceive the treating physician with fictitious or exaggerated information, and perpetrate the trick for months or years. A related form of pathology is more insidious and more common but also damaging. It involves parents who fabricate or exaggerate symptoms of illness in children, causing overly aggressive medical evaluations and interventions. The common thread is that the treating physician plays a role in inflicting the abuse upon the child. Failure to recognize the problem is common because the condition is often not included in the differential diagnosis of challenging or confusing clinical problems. We believe that a heightened "self-awareness" of the physician's role in Munchausen syndrome by proxy will prevent or reduce the morbidity and mortality associated with this diagnosis. In addition, we believe contemporary developments within the modern health care system likely facilitate this condition.

Síndrome del niño maltratado: aspectos médico-legales / Battered child syndrome: forensic aspects

El maltrato infantil constituye un problema de profundas repercusiones psicológicas, sociales, éticas, jurídicas y médicas. En el presente trabajo se realiza una revisión histórica, conceptual y médica del problema (AU)

Child abuse is a problem with serious psychological, social, ethic, legal and medical repercussions. In this paper an historical, conceptual and medical review of the problem is performed (AU)

Síndrome de Münchausen by proxy: enfoque forense / Munchausen syndrome by proxy: forensic approach

El síndrome de Münchausen by proxy es una forma de maltrato infantil cuyas consecuencias pueden ser tan graves como la muerte del niño, víctima de enfermedades ficticias provocadas por un cuidador del que es muy dificil sospechar.

Characteristics of hospital-based Munchausen Syndrome by Proxy in Japan.

OBJECTIVE: This article explores characteristics of Munchausen Syndrome by Proxy (MSBP) in Japan, a country which provides an egalitarian, low cost, and easy-access health care system. METHODS: We sent a questionnaire survey to 11 leading doctors in the child abuse field in Japan, each located in different hospital-based sites. Child abuse doctors answered questions regarding the characteristics of MSBP cases for whom they had helped care. RESULTS: Twenty-one MSBP cases (20 families) were reported. Characteristics of the victims included: no differences based on sex, 4.6 years of age on average when MSBP was confirmed, and an average of 1.9 years duration of MSBP abuse. Biological mothers were at least one of the perpetrators in 95% of cases. Among the 12 cases (57%) who remained with their families, 2 victims died. Only 5% of perpetrators had a medical background or relatives who engaged in healthcare work. CONCLUSION: There are similar features of MSBP cases between Japan and other English-speaking countries, such as the UK or the US. However, perpetrators of MSBP in Japan did not have a medical background. Easier access to hospital resources in Japan may give greater opportunities for perpetrators to obtain medical knowledge from doctors or nurses. PRACTICE IMPLICATIONS: The findings suggest that perpetrators of MSBP should not be assumed to possess a medical background in a country which provides universal medical care such as Japan. A contributory factor of MSBP may be the high frequency of medical consultations and equal level of accessibility of medical resources for Japanese citizens. Social welfare services that need to decide on custody for MSBP victims should recognize the relatively high risk of life-threatening danger in their family of origin. Further collaboration between hospital staff including pediatricians, nurses, medical social workers and staff at the social welfare services is needed to protect children from MSBP.

[Factitious disorder by proxy].

Factitious disorder by proxy remains one of the least known and most controversial disorders in psychiatry. The following review refers to the contemporary approach to the disorder, its prevalence, risk factors, diagnostic problems, treatment and coping.

Renal and urologic manifestations of pediatric condition falsification/Munchausen by proxy.

Renal and urologic problems in pediatric condition falsification (PCF)/Munchausen by proxy (MBP) can pose frustrating diagnostic and management problems. Five previously unreported victims of PCF/MBP are described. Symptoms included artifactual hematuria, recalcitrant urinary infections, dysfunctional voiding, perineal irritation, glucosuria, and "nutcracker syndrome", in addition to alleged sexual abuse. Falsifications included false or exaggerated history, specimen contamination, and induced illness. Caretakers also intentionally withheld appropriately prescribed treatment. Children underwent invasive diagnostic and surgical procedures because of the falsifications. They developed iatrogenic complications as well as behavioral problems stemming from their abuse. A PCF/MBP database was started in 1995 and includes the characteristics of 135 PCF/MBP victims examined by the first author between 1974 and 2006. Analysis of the database revealed that 25% of the children had renal or urologic issues. They were the presenting/primary issue for five. Diagnosis of PCF/MBP was delayed an average of 4.5 years from symptom onset. Almost all patients were victimized by their mothers, and maternal health falsification and somatization were common. Thirty-one of 34 children had siblings who were also victimized, six of whom died. In conclusion, falsifications of childhood renal and urologic illness are relatively uncommon; however, the deceits are prolonged and tortuous. Early recognition and intervention might limit the harm.

Hiperfrecuentación en pediatría y sistema de atención a la infancia / Over-attendance at paediatrics and the child care system

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Hiperfrecuentación en pediatría y sistema de atención a la infancia. Respuesta de los autores / Over-attendance at paediatrics and the child care system. Response

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