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INTRODUCTION

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Factitious disorder by proxy, previously known as Munchausen by proxy, occurs when a caretaker (usually a mother) directly causes her child to be, or to appear to be, ill or impaired and obtains medical and/or psychiatric interventions. A child may be hospitalized unnecessarily or may receive inappropriate procedures and treatments that may have devastating effects on the child as well as the physician.

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CLINICAL DEFINITIONS AND PREVALENCE

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The American Professional Society on the Abuse of Children (APSAC) proposed pediatric condition falsification (PCF) as a diagnostic description for abuse through illness fabrication. Conditions may be exaggerated, falsified, or induced. Factitious disorder by proxy (FDP) refers to a form of PCF in which a caretaker abuses a child for personal psychological motivations. The Diagnostic Statistical Manual of Mental Disorders, 5th edition, recognizes this condition as factitious disorder imposed on another. Some pediatricians use the term medical child abuse, but this term refers only to the child’s maltreatment, not the psychopathology of the perpetrator. Although often difficult to discern, the motivation in FDP is important to know, because this form of abuse often has a guarded prognosis and may need interventions different from those for other forms of child abuse. PCF is child abuse regardless of the motivation. The historical term Munchausen by proxy continues to be used by some pediatricians, psychologists, and other child advocacy specialists.

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Approximately 140 new cases of the most serious forms of FDP (eg, suffocation, poisoning) can be expected annually in the United States; less dramatic forms are often undetected or not reported.

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ETIOLOGY

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The self-serving psychological needs in FDP vary. Some individuals appear to need or thrive on the attention that results from their own perception as the devoted parent of a sick child; others appear to be motivated by the need to covertly control or deceive clinicians and/or other authority figures. These mothers appear to have the ability to convince others of their essential goodness and caring. External incentives such as monetary rewards or wresting a child from a spouse may be present but are not the paramount motivation. Self-aggrandizement through the use of social media is now commonly found.

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The abuse in FDP frequently involves the physician as an unsuspecting agent in harming the child. Qualities that we value in doctors, such as empathic caring and an interest in and need to solve complicated medical problems, may make some clinicians more susceptible to these manipulations. This is often the case when a perpetuator is a colleague or someone with impressive medical knowledge.

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Despite signs and symptoms that are not consistent or that are ambiguous, or despite surgical procedures and medications that do not change the reported symptoms, the pediatrician is so often taken in that he or she disregards these results and the suspicions of others and prolongs the child’s suffering. ...

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