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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 appear to be, ill or impaired and obtains medical
interventions. The name for this disorder is derived from
the adult condition factitious disorder, which is a self-inflicted
or fabricated illness to gain medical attention. In factitious disorder
by proxy, a child may be hospitalized unnecessarily or may receive
inappropriate procedures and treatments that may have devastating
effects on the child.
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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, fabricated, or induced. Factitious
disorder by proxy (FDP) refers to a form of PCF in which
a caretaker abuses a child for personal psychological motivations.
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 different interventions than other forms of child abuse. PCF
is child abuse regardless of the motivation. The historical term
FDP continues to be used by pediatricians and other child advocacy
specialists.1
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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 States2,3;
less dramatic forms are often undetected.
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The self-serving psychological needs in factitious disorder by
proxy 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 or other authority figures. These mothers
appear to have the ability to convince others of their essential
goodness and caring.4 External incentives such
as monetary rewards may be present but are not the paramount
motivation.
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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 manipulations. This is often the case when a perpetuator is
a colleague or someone with medical knowledge.5
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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 they disregard the suspicions of others and
prolong the child’s suffering. Death rates in reported
cases are between 6% and 9%. When a new case occurs,
other siblings who died mysteriously may be discovered.2 In
a study with covert video surveillance of 38 women and one father
suspected of suffocating their children, 33 were observed abusing their
child on camera, and 3 others later admitted abuse. Eventually,
38 out of 39 parents were found to have abused their children. ...