Factitious illness by proxy Munchausen syndrome by proxy Definition and key elements

Factitious illness by proxy is where a parent or carer feigns an impression or produces a state of ill health in a child whom they are looking after. The key elements are parental falsification or deceit, and a triangular interaction between parent, child, and health professional, in which the doctor is misled by the parent, some parental need is met, and the child harmed (directly or indirectly). The harm occurs through: verbal fabrication of symptoms/signs; falsification of reports or specimens; or through inducing ill health (either actively or by withholding essential substances). (38>

Diagnosis

The presentation can be in any bodily system, but common forms are factitious epilepsy, non-accidental poisoning, apparent life-threatening events in infancy (either directly induced suffocation, or fabricated), or multisystem disorders (e.g. gastrointestinal and renal problems).

The diagnosis of fabrication is almost always undertaken by paediatricians, whose awareness of the possibility of fabricated signs or symptoms is now much greater and leads to an earlier diagnosis than when first described by Meadow.(39)

There are several elements to the phenomenon:

1. the harm caused to the child through fabrication;

2. the impact on the child's development, both physically and emotionally;

3. the psychological status of the fabricator.

Psychological services are especially involved in (2) and (3)—assessing the child's developmental status, and considering the mental state of the fabricator and assessing family dynamics. Differentially, factitious illness by proxy needs to be distinguished from parental overanxiety or exaggeration, or frank malingering, though sometimes there are elements of all these.(38)

Epidemiology

The annual incidence among children in the United Kingdom has been calculated to be 0.5 per 100 000, but for those under 1 year it is 2.8 per 100 000. Aetiological and background factors Characteristics of abused children

The majority of children are under 5 years of age, with boys and girls equally represented. Affected infants are likely to have feeding problems; withdrawal and hyperactivity are seen in school-age children, whereas adolescents may develop somatization. Up to three-quarters of the children show evidence of other fabrications, or of physical abuse and neglect.

Abuser characteristics

Most fabricators are female—79 per cent of whom have a somatization disorder themselves and half have a personality disorder, particularly so among fabricators who induce illness. Most abusers deny responsibility, at least initially.

Family characteristics

Unusually, families are often intact, though 40 per cent have serious marital problems. Parent-child attachment difficulties are common, and other siblings in the family may be affected. Typically, fathers are not involved in family life.

Course and prognosis

Affected children may be damaged by the abuse itself, while mortality is between 5 and 10 per cent. About 20 per cent are reabused, though not necessarily in the same way as the original factitious illness by proxy. Emotional harm, conduct problems, and educational difficulties occur in half the children on follow-up.

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