Factitious Disorder Imposed on Another

Introduction

This chapter focuses on a form of psychopathology in a caregiver that can severely, sometimes fatally, affect a child. Given the low prevalence of some of the preceding diagnoses reviewed, it is important that professionals are aware that severe psychiatric disorders in childhood are sometimes falsified by their caregivers. Thus, the objectives of this chapter are to review the literature and provide recommendations related to the identification and management of factitious disorder imposed on another (FDIA).

Definition/Symptom Criteria

FDIA is a psychiatric diagnosis characterized by an individual using deceptive tactics to falsify illness or impairment in another without obvious external incentives to fully explain the behavior. FDIA is classified within the somatic symptom and related disorders category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ). The actions of people who qualify for this diagnosis can cause substantial suffering, and even death, for their victims. The DSM-5 describes FDIA as the “falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.” To meet full criteria for the disorder, an individual must present “another individual (victim) to others as ill, impaired, or injured.” In addition, the deceptive behavior must be “evident even in the absence of obvious external rewards.” Furthermore, such behavior cannot be “better explained by another mental disorder, such as delusional disorder or another psychotic disorder.” The DSM-5 includes the specifiers “single episode” and “recurrent episodes,” the latter applying to cases involving “two or more events of falsification of illness and/or induction of injury.” It is important to note that this diagnosis applies only to the perpetrators of abuse, not their victims.

Abusive illness falsification was first described in the medical literature by the British pediatrician, Dr Roy Meadow, in his seminal paper entitled “Mu¨nchausen syndrome by proxy: The hinterland of child abuse.” The introduction of Dr Meadow’s paper includes the following excerpt that does a good job of describing the insidious nature of FDIA:

Doctors dealing with young children rely on the parents’ recollection of the history. The doctor accepts that history, albeit sometimes with a pinch of salt, and it forms the cornerstone of subsequent investigation and management of the child.

Although the word “syndrome” has been dropped for the term, Munchausen by proxy, which has never been a formal ICD or DSM diagnosis, remains the most commonly used term to describe abusive illness or condition falsification due to FDIA.

There are several terms that are used to label the child abuse separately from the psychopathology of the abuser. In 1996, a task force created by American Professional Society on the Abuse of Children coined the term “pediatric condition (illness, impairment, or symptom) falsification” to label the child maltreatment in which a caregiver intentionally falsifies physical and/or psychological signs and/or symptoms in a child victim. With a call for increased action and responsibility by pediatricians, Roesler and Jenny advocated that pediatricians use the term “medical child abuse” to describe when a child receives unnecessary and harmful, or potentially harmful, medical care at the instigation of a caretaker. More recently, the American Academy of Pediatrics proposed the term “caregiver-fabricated illness in a child” to describe this type of abuse/neglect of a child victim. Although there are some minor differences among these terms, they all generally refer to the same type of child abuse/neglect. Because it is the most comprehensive term, one that includes presentation of the child to professionals who are not pediatricians (such as mental health clinicians), we will use the term pediatric condition falsification (PCF) to label the abuse throughout this chapter.

Epidemiology

FDIA is often considered to be a rare diagnosis; however, reliable data regarding its incidence and prevalence are limited. This lack of data is due in large part to the deceptive practices that are inherent to FDIA. A 2-year prospective study by McClure and colleagues yielded the estimation that at least 0.5 per 100,000 youths under 16 years of age in the United Kingdom are the victims of abusive condition falsification, nonaccidental poisoning, and/or nonaccidental suffocation, annually. The rate for children under 1 year of age was estimated to be at least 2.8/100,000. The mortality rate among the abused children was 6.25%, and the mother of the victim was the perpetrator in 85% of cases. A study from Italy by Ferrara and colleagues discovered that abuse associated with FDIA was present in 4 out of 751 youth between the ages of 11 months and 16 years, yielding a prevalence of 0.53%. Similar to the studies listed above, the perpetrator of abuse was the child’s mother in three out of four cases. Some have viewed FDIA as a problem of modernized Western cultures; however, a review of the literature by Feldman and Brown yielded descriptions of PCF from 24 countries. Congruent with other reports, 86% of the identified cases from this review involved a mother who was the sole perpetrator of abuse.

Although the induction of illness in a victim, such as via poisoning or suffocation, is not a necessary requirement for the diagnosis of FDIA, such behavior is not unusual. In McClure’s prospective study, of the 128 identified victims, ∼57% included some form of induction. A review of 451 published cases by Sheridan also showed that perpetrators induced illness in roughly 57% of the cases. Furthermore, nearly half of the instances of illness induction occurred during hospital admissions, under the noses of the victims’ treatment providers.

Any medical condition can be created, falsified, or exaggerated, and children with genuine medical or psychiatric problems are often targets. Caregivers with FDIA might target all children in their care or serially focus on a subset or one child, such as the youngest child, the child with highest needs, the child with genuine medical or psychiatric problems, or the child with whom they have a disrupted attachment. Intergenerational abuse of this type can be a contributing factor.

Etiology

A common hypothesis regarding origins of FDIA is that it is born out of childhoods beset by abuse and/or neglect. Some have offered explanations based on psychodynamic thinking wherein abusers with factitious disorders attempt to reenact earlier forms of abuse or neglect, on themselves and/or others, as a means of reliving and correcting disruptions in childhood attachment. Such a perspective on the origin of factitious disorders is summarized succinctly by R.J. Carlson who wrote, “The fabrication of symptoms may serve as a mechanism whereby these individuals can temporarily relate to others, overcome their isolation, obtain caring, have certainty of their needs being met, and possibly act out previous family dynamics.” Although the above ideas may be quite useful for understanding and treating perpetrators of abuse with FDIA, there is no identified “cause” for this condition. As with all forms of child abuse and neglect, each story is unique. The current literature does not provide clear indicators of the genetic, epigenetic, or neuroanatomic correlates of FDIA.

Screening

FDIA always includes a caretaker knowingly giving or producing false information. The DSM-5 characterizes of the types of actions constituting illness falsification as the exaggeration, fabrication, simulation, or induction of physical or psychologic impairments. An example of illness exaggeration might involve a child with mild gastroenteritis being reported by a caregiver to have extreme symptoms (e.g., constant retching and vomiting with an inability to take fluids over many days along with explosive diarrhea). In this situation, genuine symptoms are exaggerated to suggest that they are more severe and dangerous than is objectively true. Supporting such a conclusion, clinicians might observe that the caregiver assertions are not supported by objective findings (e.g., physical and/or mental status examination, blood work, imaging). Illness fabrication is reporting symptoms that are not present at all. An example would be the case just described, except the child does not have a mild gastroenteritis at baseline. Illness simulation refers to behaviors that directly cause medical tests or records to appear pathological. Examples include altering urine samples, interfering with equipment involved in medical tests, and doctoring medical records. Finally, induction means directly causing symptoms, most commonly by poisoning, nonadherence to medical instructions, or suffocation.

Warning signs include caregivers who provide medical histories that are inconsistent, convoluted, odd, and/or incapable of being verified for unusual reasons (e.g., parents who refuse to provide a release of information despite repeated requests). Another red flag occurs when children provide verbal accounts of their illness that do not match their developmental level and/or the known course of a disease (e.g., a neurotypical and apparently normally developing toddler whose parents claim that the child tells them about vividly detailed auditory and visual hallucinations, or the same child who describes symptoms to a clinician with advanced language, suggestive of coaching). Even toddlers and teens can be effectively coached by their abusers to portray themselves as ill (e.g., walking with a limp, feigning seizures). A child may or may not be aware that the behavior request is deceptive. Some children have been known to adopt behaviors associated with an illness on their own in response to being portrayed to others as sick or impaired for a long time.

It is important to note that underlying medical or psychiatric disorders in the child that are congruent with the symptoms being reported do not need to be ruled out for a conclusion of abusive condition falsification or neglect to be made. Examples include a child with epilepsy that the caregiver exacerbates by withholding antiseizure medication or a child with a benign mitochondrial defect that the parent falsely claims, causing an array of symptoms and impairment in the child.

Differential Diagnosis

It is important to note that there are many cases of suspected PCF that are not due to FDIA. Some examples include false allegations in the settling of a child custody dispute for purposes of winning custody, the presence of a genuine, rare medical condition that is being described accurately, and medical abuse or neglect driven by other factors (e.g., financial incentives for having a medically impaired child; untreated severe mental illness and/or substance use disorder in a parent). Although individuals with FDIA can have any type of cooccurring mental disorder, there are some diagnoses that can mimic the condition and/or commonly cooccur.