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_ _ _ _-=..::AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4, 2002/1
WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS: A REVIEW OF FACTITIOUS DISORDER BYPROXY Jose R. Maldonado, M.D.
FACTITIOUS DISORDER BY PROXY (FDP)
Definition
Factitious disorders refer to those conditions that individuals willfully
create by producing signs and/or symptoms of physical or mental illness in
order to assume the sick role. Formerly known as Munchausen's~by-proxy in
DSM-llI-R (1), factitious disorder by proxy (FDP), in DSM~IV, is defined as
the deliberate production or feigning of physical or psychological signs or
symptoms in another person who is under the individua1~s care (2). Thus, in
cases ofFDP, there is a perpetrator and a victim.
The perpetrator is usually an adult in a position of caring for someone
else in a dependent position. Usually the perpetrator is a parent or caregiver
caring for a child or elderly parent or other relative. The victims are usually
children at preverbal or early verbal stages of development (i.e., newborns,
infants, or toddlers), but may also include elderly parents or relatives, usually
a disabled or somehow dependent adult.
History
In 1977, Meadow (3) described the first case in the literature of
with physical symptoms. In 1982, Woollcott and
colleagues (4) used the phrase "doctor shopping with the child as proxy
patient" to define similar cases. In 1984, Fialkov (5) described the
«peregrinating pediatric patient," and in 1992, Waring (6) described the
"persistent parent." Finally, in 1987, Rosenberg (7) described Munchausen
syndrome-by-proxy as ~a form of child abuse wherein the mother falsifies
illness in her child through simulation and/or production of illness, and
presents the child for medical care, disclaiming knowledge as to the etiology
ofthe problem."
In 1993" Fisher and colleagues (8) described the first case of factitious
disorder by proxy, involving psychiatric symptoms. Schreier and Libow (9)
developed the psychodynamic formulations of Munchausen's-by-proxy in
Munchausen'~by~proxy
copyright 2002 American Journal of Forensic Psychiatry, Volume 23, Issue 4. The JoumaJ is a
publication ofthe American CoHege of Forensic Psychiatry, P.O. Box 5870, Balboa Island, Cali­
fOrnia 92662.
21 MALDONADO: WHEN PARENTS DECEIVE THEIR CH~REI!~~1P~ _ _ _ _ _ _.
what has become the classic text on the subject. Meadow (10) and Schreier
(11) both reported on cases where mothers made false accusations of sexual
abuse in which the usual dynamics of FDP were noted. Even though the
diagnosis of Munchausen-by-proxy was included in the formal diagnostic
criteria of DSM-m-R (1), it has now been removed by DSM-IV from the
factitious disorder section and placed in Appendix S, "Criteria Sets and Axes
Provided for Further Study", under the name factitious disorder by proxy (2,
pp.725-727).
Clinical Features
In cases of FDP, there is a perpetrator and a victim. The perpetrator is
usually .an adult in a position of caring for .someone else. Usually this is a
parent, caregiver, babysitter, or other relative caring for a child or an elderly
or disabled parent or relative. The perpetrator usually appears to be a loving
and concerned caregiver and is creative in their induction and report of
symptoms. Often perpetrators are medically sophisticated or at least
somewhat knowledgeable of medical issues. A child's mother is the
perpetrator in 98% of the cases. Rosenberg (7) examined 117 reported cases
in the- literature and found that nearly aU perpetrators of MSBP were the
mothers of the victims. It has been estimated that 27% ofmothers involved in
.the creation of FDP were nurses .(having fonnal medical .training .and access
to medical paraphernalia (7, 12). There was also a high incidence of mothers
presenting false claims of having completed nursing related training (7).
Infrequently, some adults in positions of care (e.g., nurses, paramedics) may
factitiously create symptoms in non-related adults or children (13-16).
The victims are usually children at preverbal or early verbal stages of
development (Le., newborns, infant, or toddlers). Adolescents and dependent
elderly adults (e.g., a demented parent) are victims in a smaller number of
cases. Young victims of FDP are at increased risk for either later
development of FD in themselves or for later becoming the ill-inducing
parent (FDP perpetrator) (17).
Libow (18) reported that a review of the literature of the past 30 years
found 42 cases of illness falsification by children. Her sample did not clearly
differentiate between children who were coached by their parents versus cases
in which the parents created the symptoms with little· conscious participation
from the victim. In her sample, the mean age of the children was 13.9 years,
with a range from 8 to 18 years. In this sample. the majority of patients were
female (71%). She noted that the gender imbalance was greater for cases
involving older clilldren. The mean duration of falsification before detection
was almost 16 months.
AMERICAN JOURNAl OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4. 200213
Even though most published reports on FDP suggest that the perpetrator
is nearly always the child's mother, cases have also been reported in which
the father was actively involved in the abuse. Confimring the rare instance of
fathers causing factitious illness, Meadow (19) reported on 15 cases he
encountered in 20 years of practice. In nine ofthe 15 families, the index child
or siblings had incurred false apnea or seizures in association with
smothering. The father was the person who witnessed the events, who was
present at and/or involved in their initiation, and/or was involved in
resuscitation procedures. All the children had had the usual range of
investigations seeking cause for bouts of apnea, without a natural cause being
found. Two fathers were observed by staff to be smothering their child in a
hospital. two other smothering incidents were revealed by covert video
surveillance (CVS), and another three confessed to smothering their child in
the course of criminal proceedings. It was uot known how many times the
reported episodes of apnea were merely falsifications, rather than true
episodes of smothering. Two children had incurred repetitive poisoning, one
had blood smeared about his body and in his samples to simulate bleeding,
two suffered from reports of fictitious epilepsy, one had factitious
gastrointestinal problems and two bad factitiously caused fractures.
In Meadow's sample (19), the fathers were of average or above average
intelligence and had attended schools or postgraduate training. Interestingly,
none had regular employment or had been in long-term employment before.
In fact, five were receiving a disability allowance. Six of the fathers had been
previously examined by psychiatrists, who had not identified mental illness
but had commented on features such as "hypochondriacal nature,"
"aggressive personality," "hysterical amnesia," "neurotic panic attacks,., and
"personality disorder with schizoid features." The study suggested that the
degree of direct physical harm and the chance of death were high in those
families in which the father was the petpetrator. Eleven children (73%) died
and another six survived repetitive smothering or poisoning.
In the men displaying features of FDP, it was common to find that they
had previously suffered from bouts of personal false illness behavior which
had gone into remission at the time that they were inventing or causing false
illness in their child, and then re-emerged when the child was healthy or dead.
The fathers also had a history of multiple personal catastrophes (e.g., home
fires, being a victim of burglary), acts of heroism (e.g., having a child
abducted by a stranger who was subsequently rescued by father) or
tremendous personal achievement. Even though, as a group, these fathers
took a prominent role in the care of the child, they were perceived by the
hospital staff as being overly demanding, overbearing, and unreasonable and
were quick to make formal complaints and to seek legal redress for the
41 MALDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
perceived failure of the health care system to provide either satisfactory
service or care for their child.
Modes of Presentation
As in cases of FD, FDP perpetrators may create a factitious scenario by
either falsely reporting .a child's medical histOlY, surreptitiously simulating
medical symptoms, or surreptitiously inducing symptoms. Any of these
patterns generates a response from medical practitioners, initiating a cycle of
inappropriate invasive testing and treatment and further simulation of illness.
Invasive diagnostic tests and inappropriate therapeutic procedures usually
result in extended hospitalizatious. Worse yet, they often create iatrogenic
illnesses or processes, which perpetuate the cycle of factitious symptoms,
illness behavior and further testing. This in turn validates and compounds the
pattern initiated by the perpetrator, which further enhances the perpetrator's
role as caretaker. By unknowingly engaging in this cycle, physicians become
the parent's unwitting accomplices, fulfilling the parent's pathologic wish for
sympathy and attention.
In fact, several authors (20-26) have suggested that by virtue ofeagerness
top.erform .diagnostic tests, failnre to obtain an .adequate history, and a low
threshold to treat these conditions, physicians and nurses are accomplices in
the exacerbation and perpetuation of FDP. Donald (20) argues that, "medical
interest and active participation with the child and parentes) through the
investigative and diagnostic process is the crucial factor in the maintenance of
the [FDP] syndrome."
Methods of Illness/Symptom Induction
The methods of symptom induction used by FDP perpetrators are in
many ways similar to those utilized by adult patients suffering from factitious
disorder. As a rule, these include altering laboratory test results, (e.g., tainting
laboratory samples or specimens with bacteria or blood), injecting or
otherwise administering poisons or medications (e.g., injecting insulin to
cause seizures or hypoglycemia, force feeding emetics or cathartics to create
gastrointestinal symptoms, anticholinergic poisoning to cause mental status
changes [27], or adding sodium to formula to induce seizures), irritating the
child's skin with abrasive products (to create dermatitis), starving or
dehydrating infants leading to failure-to-thrive (28, 29), suffocating children
.mtached toc.a;rdiorespjratorymonitors to mimic infantile .apnea (30, 31), or
directly infecting infants or children to create infectious processes (e.g.,
introducing fecal material into a child's urethra), preventing the healing of a
natural or accidentally occurring event (e.g., contaminating or re-iqjuring
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4,2002/5
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reporting psychological or behavioral symptoms (e.g., reporting tics, "petit­
mal" seizure activity, developmental disability, dissociative symptoms) (32).
or reporting a false histOIY of a troubled past (e.g., sexual or physical abuse
or neglect) (33. 34).
The most common physical presentations are bleeding (44%), seizures
(42%). eNS depression (190AI), apnea (15%), diarrhea (11%), vomiting
(10%), fevers (10%), and rash (9%) (7, 24, 35). The most common
psychiatric presentations are autistic-like symptoms, psychotic disorders,
dissociative symptoms, reports of physical or sexual abuse, learning
disabilities, attention deficit-like" symptoms, chronic fatigue syndrome,
temporal lobe epilepsy with rages, and Tourette's symptoms (24,35). In rare
occasions, expectant mothers have been known to induce factitious disorder
by proxy in their unborn child. The most likely method of injmy is the self­
injection of contaminant material into the amniotic fluid with the intention of
causing an infection (36-38).
In Rosenberg's (7) sample the most common presentations were
bleeding, seizures, central nervous system depression, apnea, diarrhea,
vomiting, fever, and rash. Failure to thrive was associated with FDP in 14%
of cases. The short-term morbidity rate was 100%, with a long-term
morbidity rate estimated at 8% and a mortality rate of 9%. In Bools' study
(39) of psychopathology of FDP mothers, they found that approximately
one-half of the mothers in their sample had either smothered or poisoned
their child as part of their fabrications. Of note, 20% of the mothers had a
forensic history independent of convictions related to child abuse. In Libow's
study (18) ofchildren presenting with factitiously created physical symptoms,
the most commonly reported falsified or induced conditions were fevers,
ketoacidosis, purpura, and infections, and the fabrications ranged from false
symptom-reporting to active injections, bruising, and ingestions.
Characteristic Behaviors Typical of FOP Perpetrators
Perpetrators often present as the "ideal" concerned parent. Usually, they
are inseparable from their hospitalized child. As a rule, perpetrators insist on
being an integral part of the treatment process, usually developing close
relationships to hospital staff. Their devotion often misleads the staff, thus
minimizing and delaying suspiciousness of their illness-generating behavior.
and thus preventing timely and adequate diagnosis and appropriate
intervention.
In a study of the psychopathology of perpetrators, Bools and colleagues
(39) studied 47 FDP mothers. A clear psychiatric picture was not evident in
61 MALDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
any of them. Nevertheless. it appeared that at some time in their lives, 34
(nearly 80%) of the mothers had suffered from "factitious disorder with
physical symptoms" or somatoform disorder. There had also been many
reports of "somatization disorders." Furthermore, 26 (55%) of the mothers
(perpetrators) bad a history of self-harm, and 10 (21%) had a history of
substance abuse. Regarding their characterological makeup, 36% (17 of 47)
had a history of a personality disorder, predominantly histrionic and
borderline types. Most subjects met the criteria for more than one category of
personality disorder.
Perpetrators appear to be compliant with the medical team, but they tend
to be very controlling. FDP perpetrators usually insist that medical personnel
vigorously pursue medical intervention, often suggesting and even insisting
on obtaining invasive tests and diagnostic procedures, even when the yield
appears low and the risk high. In fact, perpetrators are usually less anxious
than the medical staff about the victim's lack of response to medical
treatment, or the possible dangers or adverse effects of tests, procedures or
medical treatment.
Perpetrators have a tendency to continuously change physicians until the
desired medical response is obtained. They may even praise and console
physicians struggling to treat the perplexing illness afflicting the patient,
especially when the condition fails to respond to treatment. When they are
somehow excluded as part of the treatment plan or their reports are
questioned, perpetrators are quick to accuse physicians and other medical
personnel of incompetence or of failing to recognize the severity of the
medical problem. In fact, when physicians are unwilling to escalate the
diagnostic efforts or the management plan, perpetrators are quick to request a
second opinion, change doctors, or seek treatment at a different facility. As a
consequence, a high incidence of AMA discharges (64%) has been reported .
in suspected and confinned cases of factitious disorder by proxy. This is an
extraordinarily high number, compared to 8% in a matched, comparable
population (40).
The presumed goal of the induced symptoms is for the perpetrator to
vicariously assume the "sick role" through the sick child. Schreier (24) has
described the perpetrator as having "a perverse need to be in an ambivalently
dependentlbostile, controlling relationship with a physician or powerful
public figure." He further postulates, "the motivation usually goes beyond
simple attention-seeking. These relations are seen as an attempt to avenge and
repair past perceived or real humiliations of childhood through an elaborate
scheme that is doomed by its very nature to failure. As a consequence, there
is a corresponding mobilization of interest and support of physicians, nurses,
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4, 200211
social workers, other family members and the community at large. As in the
case of FD in general, and unlike malingering, there are no external financial
incentives. Schreier and Libow (9) have suggested that mothers who induce
factitious symptoms in older children are more disturbed than mothers who
produce symptoms in infants. In the case of children who create factitious
symptoms (with or without parental assistance) their personalities-described
as bland, depressed, and fascinated with health care-are remarkably similar
to adults with factitious disorders (18).
Sometimes adults in positions of care (e.g., babysitters, elderly
caretakers, nurses and paramedics) may factitiously create symptoms in non­
related adults or children (9, 13-16, 4143). The first recorded case of
factitious disorder by proxy caused by a nurse in a patient under her care
occurred in 1974 (44). Yorker (43) suggests that epidemics of factitious
behavior have been recorded in hospitals throughout the world about every
one and a half years. Registered nurses are the largest single group of
caregiver professionals known to have produced factitious (by proxy) damage
to their unwitting patients (45).
Diagnostic Problems
The flIst and perhaps most difficult barrier to overcome is the disbelief
that FDP may be occurring at all. Medical and mental health professionals
often disagree with each other about the possibility of factitious presentation.
Similarly, child protective service workers and the courts often find it too
preposterous to believe. Due to the lengthy and complex behavior
perpetrators engage in to create the factitious symptoms, it is usually an
average of 15 months after initial presentation before the possibility of
factitious disorder by proxy is contemplated (7). Unfortunately, because of
frequent reluctance to act without enough grounds or proof, and frequent
inability to believe a caretaker could cause damage to a loved one, there is the
possibility of ongoing abuse during the hospital stay that is intended to
diagnose or treat the condition. When the condition is finally recognized as a
potential FDP case, the medical and nursing staffs reaction is to feel
betrayed, resentful, angry, and more suspicious, and conversely less trustful
of parents in general (46, 47). Even when the diagnosis is appropriately and
timely considered, the legal system may prevent prompt intervention.
The courts and the general public are suspicious of medical personnel's
interpretation of circumstantial evidence incriminating parents and caretakers
as the causative agents of the patients' illnesses, sometimes fearing that this
may be a plot to cover the doctors inability to treat the condition or outright
incompetence. Similarly, hospital administrators and physicians are worried
81 MALDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
about the potential liability and associated malpractice suits that such a
diagnosis may open the institution to (48).
Even when there is credible evidence to suggest the possibility of FDP,
diagnostic evidence that satisfies the medical standard may often fail to meet
the greater degree of proof required in criminal prosecution. So, even when
the courts acknowledge there may be some validity to the charges, they fail to
convict based on a lack of sufficient evidence. The issues of abuse, neglect
and "good enough parenting skills" are usually raised in these cases. The
usefulness of removing a child from the custody of the potential perpetrator
and placing the child in a foster home for protection has been questioned. The
unwillingness of social services or the court to separate the child from the
perpetrator may fail to provide long-term safety. The unwillingness or
inability to intervene and request mandatory psychiatric treatment or
interventions may also result in failure to protect the child from future abuse.
There are a number of factors that make FDP a difficult condition to
diagnose. One of the most significant blocks to diagnosis is the lack of
awareness. The index of suspicion changes depending on who is caring for
the FDP victim. By far, studies suggest that pediatricians are much better at
identifYing the signs of FDP and are more prompt in making the diagnosis
than are family practitioners (49). Similarly, psychiatrists (96%) are better
than psychologists (69%) or social workers (42%) in making the diagnosis
(50). Second, there is the fear in the physician that in making the diagnosis of
FDP, with its implications (such as reporting the case to the appropriate social
service agencies for potential abuse and its consequences [e.g., removal of the
victim from 'the household]), the child and his/her family may be subjected to
unnecessary discomfort and risk. Third, it is very difficult for most hea1thcare
providers to believe or suspect that the loving parent who is bringing their
child to them for care could indeed be the perpetrator of such abuse (51).
Finally, there is always the possibility that the symptoms presented may
represent a legitimate, but uncommon illness that will go on to be diagnosed
by others if they don't do everything possible to diagnose it properly.
There are a number of warning signs associated with factitious disorder
by proxy cases. FDP should be suspected when the presenting symptoms and
the illness process is extremely unusual or difficult to explain physiologically
(e.g., cases of multiple bacterial strains colonizing a single wound or
abscess), repeated hospitalizations and work-ups fail to reveal a conclusive
diagnosis or etiology, physiologic parameters are consistent with induced
illness (e.g., presence of drugs or medications in toxicology screening), or
when a patient fails to respond to appropriate treatments. FDP should also be
suspected when the patient's health is inconsistent with laboratory findings
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4, 2002/9
(e.g., the patients weight and electrolytes are completely notmal even though
the mother reported a history of "over 20 episodes ofvomiting a day over the
course ofthe last five days").
Often, the FDP perpetrator (usually the mother) appears less concerned
than the medical staff about the doctor's inability to identifY the cause of the
illness (52). Commonly, the perpetrator appears to thrive in the hospital
setting and often becomes unusually close to the staff. Usually the perpetrator
refuses to go home, insisting on caring for the patient herself and rarely
leaving the child's side while on the ward (12t 52, 53). It is almost always the
case that the perpetrator is the only witness to the onset of signs and
symptoms (e.g., seizures, apnea). When the mother is the perpetrator, the
father is rarely seen in the hospital and appears uninvolved in the case.
A careful review of the immediate family medical history usually reveals
that either the patient's mother or other children in the house suffer from
unexplained diseases or there is a history of unexplained death of another
child in the family. Often the perpetrator has a medical background (e.g.,
nurse, paramedic, physician, phlebotomist. physician's assistant or medical
office personnel). Often the perpetrator has had exposure to models of the
illness afflicting the child (e.g., having cared for a family member who had
the condition she now recreates in the child). The perpetrator often welcomes
or even suggests invasive and painful procedures with the stated purpose of
diagnosing or treating the condition.
As in cases of FD, the primary clue in FOP is a description presented by
the mother that does not make clinical sense. Usually this is noted only after
careful examination of the records and lengthy follow-up of the case.
Unfortunately, the mother usually prevents the timely collection of necessary
data by not providing or by falsifYing records, or by not providing timely
consent for medical personnel to obtain necessary records and communicate
with important sources ofinfotmation. Unfortunately, important data may not
be available until after a FOP case is already uncovered or there is a tragic
outcome.
The perpetrator usually becomes defensive if the infOtmation she
provides is questioned or parental lying is proven (4, 54) and usually
becomes anxious if the child improves. Masterson and colleagues (55)
describe how an initial good rapport between doctor and caregiver changes
into a conflict between the perpetrator and medical staff as organic causes for
the illness are eliminated. Despite their unusual interest and knowledge ofthe
case, past medications and tests perfOtmed "at previous hospitals" or "by a
prior physician," perpetrators often report that medical records are missing or
have been lost or that the original physician has moved, died or since retired.
10 I MALDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
Finally, clinical observation yields infonnation that is inconsistent with the
perpetrator's report. One of the most important clues to suggest FDP is when
the reported signs and symptoms disappear when the mother is removed from
the environment or the child is removed from her care.
Morbidity and Mortality
About 8% of FDP victims experience a protracted period of morbidity
(7). In cases where children remain under the custody of the perpetrator there
is a risk of further fabrication (9%) and of long-term effects (20%) of
ongoing or original abuse (e.g., school absences, behavioral problems,
impaired concentration) (56). When these children reach adolescence, they
often exhibit symptoms of persistent insecurity, posttranmatic stress disorder­
like symptoms, occasional deficits in reality testing, and avoidance of needed
medical testing or procedures (57).
While death is rarely associated with adult FD, the mortality rate in FDP
infants and small children may be as high as 9% (7, 9). The mortality rate is
even higher (55%) in older children and adolescents (7, 58). When death
occurs, it is usually due to miscalculation of damage (e.g., too much
toxin/poison, extended airway obstruction), the result of a prolonged
condition or the effects of repeated assanlt, or iatrogenic complications (e.g.,
damage caused by the procedures or medical interventions initially intended
to diagnose or treat the condition).
Differential Diagnosis
The differential diagnosis of FDP includes overanxious, usually first time
parents who anxiously bring their children to the emergency department
inadvertently exaggerating symptoms, thus exposing their children to
unnecessary diagnostic tests and complications, as well as parents of children
recovering from a crisis (e.g., premature birth). In some cases, parents have
been known to exaggerate symptoms or factitiously create additional
symptoms in order to obtain attention for symptoms that may have been of
concern to the parents but did not impress physicians during a previous
presentation. Other conditions to consider may include the discontinuation of
treatment by caretakers due to concerns regarding treatment side effects thus
causing exacerbations of symptoms, relapse of the initial condition, or a new
set of symptoms.
It is also important to consider the possibility that the parents may not be
the perpetrators ofthe child's symptoms, but an older sibling may be. Finally,
it is important to always consider the possibility that the inexplicable
symptoms may indeed represent a true, but rare, medical disorder.
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4,2002/11
Ethical and Legal Issues
While factitious disorder is considered a psychiatric condition, FDP is a
criminal act, constituting child or elder abuse, depending on the age of the
victim. As such, there are legal reporting requirements in cases of child or
elder abuse, which supersede all and any claims to confidentiality insofar as
the report is reasonable and made in good faith.
When the condition is suspected and a report is to be moo, physicians
must carefully document all laboratory testing, positive and negative pertinent
signs and symptoms, conversations with caregivers and family, and all
circumstantial evidence essential to prove the case or used to arrive at the
suspicion or conclusion. When a case of FDP is suspected, the primary
responsibility is to protect the rights and safety of the child while preventing
further abuse. Once FDP is considered, physicians and other medical
personnel should meet, share data and gather information, and express
concerns with all members of the treating team in an effort to either confirm
the suspicion or absolve the parents of culpability. In these cases, FDP should
be included in the differential diagnosis, steps should be taken to ensure that
the child is not exposed to further trauma from either the perpetrator or
medical personnel (e.g., iatrogenic damage), and that only necessary tests or
procedures needed to confirm or eliminate suspicions or correct damage
already caused (iatrogenically or by the perpetrator) should be performed.
Many have advocated the use of covert surveillance methods in cases of
suspected factitious disorder by proxy. Despite the controversies surrounding
the use of covert surveillance and monitoring due to issues of privacy and
confidentiality, given that the safety and life of defenseless children is at
stake, the argument for its use without parental permission is more
compelling, but the issue is still equally difficult. In fact, there have been
many reports of instances in which hidden video cameras have provided the
necessary evidence to successfully prosecute an FDP perpetrator (17,30,31,
59-62). Certain jurisdictions may allow for the use of such tactics, though
often in coordination with local legal authorities who secure the court's
permission. Before one gets involved with the use of covert video monitoring
of a suspected factitious case, the matter should first be discussed with
hospital counsel, ethicist(s), risk management, and all members ofthe treating
team.
In a study by Southall and colleagues (63), 39 children referred for
investigation of apparent life-threatening events (ALTE) in which induced
illness was suspected were followed using covert video surveillance (CVS).
In the sample, CVS revealed abuse in 33 of 39 suspected cases, with
documentation of intentional suffocation observed in 30 patients. Poisonings
121 MALDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
(with disinfectant or anticonvulsant), a deliberate fracture, and other
emotional and physical abuse were also identified under surveillance. The use
of CVS helped understand other symptoms presented by the perpetrators.
Bleeding from the nose and/or mouth was reported in 11 of the 38 patients
with ALTE undergoing CVS. Four patients who had been subjected to
recurrent suffocation before CVS had developed permanent neurological
deficits and/or required anticonvulsant therapy for epileptic seizures resulting
from hypoxic cerebral injury. The 39 patients undergoing CVS had 41
siblings, 12 of whom had previously died suddenly and unexpectedly. Eleven
of the deaths had been classified as sudden infant death syndrome but after
CVS, four parents admitted to suffocating eight of these siblings. One
additional sibling who had died suddenly with rotavirus gastroenteritis was
reinvestigated after CVS of her sister revealed poisoning, and-death was
found to be cansed by deliberate salt poisoning. Twenty~three of the abusive
parents were diagnosed by a psychiatrist as having personality disorders.
Yorker (64) suggests that a sentence added to the consent form signed by
the patient's parents upon admission for treatment, indicating that "I consent
to the taking and publishing of stin or motion pictures of the patient's
diagnosis and treatment, and to closed circuit monitoring of patient care for
educational or clinical pmposes unless I request otherwise" may provide the
necessary consent for the use of covert video surveillance.
Treatment, Management and Outcome
A successful and comprehensive management plan usually involves the
confrontation and discussion of the factitious behavior with the perpetrator,
other family members and medical personnel, and pertinent social service
personnel. This is one of the most difficult issues in the treatment plan. If
confrontation occurs too early, before the suspicions are validated and there is
enough evidence to prosecute or at least justify the removal of the child from
the injurious environment, the parent/perpetrator may remove the child from
the hospital and flee, leaving physicians with too little data upon which child
protective services (CPS) and legal authorities can build a case. On the other
hand, if the verification period is extended in order to gather adequate data,
the safety of the child may be compromised.
Prior to confronting the suspected perpetrator, a multidisciplinary team
should be created to study and address the problem. Its pmpose is to share
information about the suspected FDP and to develop a management plan that
serves the best interest of the child. The team should include members of
various aspects of the treatment staff and at a minimum should include the
primary care physician, a consulting psychiatrist, a representative from each
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4, 2002/13
of the involved consulting teams (i.e., gastroenterology, infectious diseases,
neurology), a representative from the nursing stafI: an ethicist, and a
representative from the social service department, as well as risk
management The team's mission is to determine the degree of concern with
respect to the child's safety while in the hospital, what forensic evidence must
be gathered in order to prosecute the case, what amount of delay may be
legally provided before confronting parents or suspected perpetrator(s) in
order to procure the necessary data, and the ethical and legal dilemmas of
covert surveillance methods in order to confrrm the abuse and protect the
child (50). Whether the physician has the right to remove a child from a
suspected perpetrator, perform tests, or place surveillance cameras to
document the abuse depends on the individual state's or jurisdiction's
mandatory reporting laws for abuse. On the other hand, there is a federal
mandate in all 50 states to report all cases of child abuse to the appropriate
child protective service agency.
Once the team has gathered all the pertinent information, the appropriate
agency (e.g., CPS) must be notified and a report filed. Usually, the parents,
including the perpetrator, must be notified within 24 hours after having filed
a report with CPS. Once this has been done; it may be impossible to gather
any further data regarding ongoing abuse.
Before the confrontation takes place, a hold order, facilitated by local
authorities or child protective services, should be in place to prevent the
parents from removing the child from the hospital. CPS must coordinate
custody arrangements. As in the case of FD, the primary physician must
direct the confrontation. It is often useful for other members of the team to be
present, but this should only include medical staff. That is, administrative
personnel, although useful in the planning stages, should not be directly
involved in the treatment phase. During the confrontation, the primary
physician explains the findings and explains the steps that have been taken in
order to ensure the safety of the child (e.g., notification to CPS). Other team
members present during the intervention are welcome to echo the decision
and reinforce the need for treatment of both the victim and the perpetrator.
The psychiatric consultant should be available to offer counseling and initiate
an evaluation ofthe family system after the confrontation.
The primary goal of management is the protection of the child. Data
suggest that the efficacy of therapeutic intervention with the perpetrator is
discouraging, especially in the case of parents who deny culpability. In most
cases, the child's safety can only be ensured by removing the child from the
home. Usually, reunification of families should be undertaken only if the
child's continued safety can be guaranteed.
141 MALDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
The treabnent of the victim usually begins with the removal from the
abusive home and placement in a custodial situation that will ensure safety. A
pediatrician with knowledge about FDP should become the court-mandated
gatekeeper of the child's health care needs. The following steps are directed
at addressing the physical problems created by the perpetrator's factitious
behavior as well as at the need for psychiatric evaluation.
Often, removal from the abusive environment results in immediate
improvement of the child and little additional treabnent is needed to correct
ongoing medical problems. Unfortunately, in some instances permanent
damage may have been inflicted by the factitious behavior and further
medical treatment may be required. It is recommended that the most
conservative treatment plan be followed. Further invasive procedures and
surgery should be avoided and performed only if absolutely needed.
The need and intensity for psychiatric treabnent will depend on the age of
the victim and their level of awareness of the situation. In newborn and other
small children there may be little need for immediate intervention, although
this may be necessmy later to explain why they were removed from their
family. In the case of older children or adolescents, intensive psychiatric
intervention is usually needed. The victims are usually pathologically
enmeshed and dependent on the perpetrator/caregiver and usually report
disbelief on the physician's claims of harm. In fact, not uncommonly, the
older child may express disbelief or denial and experience profound sadness
or depression when removed from the perpetrator's care.
As discussed above, FDP victims may go on to develop FD themselves
and/or become the perpetrators of FDP in their children. Part of the
psychiatric intervention is directed at preventing this behavior from
developing in the future. These children may also develop multiple somatic
preoccupations in older life, including any form of somatoform disorder,
after having learned to obtain attention and love via somatic symptoms. This
too needs to be addressed.
The treatment of the perpetrator is more difficult. As mentioned before,
FDP perpetrators are not considered patients, but criminals. Nevertheless,
they may indeed suffer from any nwnber ofpsychiatric conditions. Ifpresent,
these should be identified and treated; In most known cases of FDP,
psychosis or other significant form of mental illness has not been identified.
In fact, to date, mental illness has not been successfully used to excuse from
culpability in any case of FDP. Thus, the most significant intervention may
be preventing them from causing further damage to the identified victim or
new victims. Because some time may pass before the perpetrator is brought
to justice, shelhe may be allowed to return home. Periodic audits ofthe health
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4,2002/15
status of other children (e.g., siblings of the FDP victim) who have remained
in the custody of the mother or any child born after the removal of the index
child must be perfonned for an extended period, given the pervasiveness of
the perpetrator's behavior and .the ongoing vulnerability ofthe children.
Bools and colleagues (56) followed 54 children for a mean of 6 years
after the fabrication of illness had been identified. Of these, 30 (55%) of the
children were living with their biological mothers and 24 were with other.
family members or in foster homes. Of those living with their mothers,
further fabrications were identified in 10 children (33%), and there were
"other concerns" in an additional eight (26%) cases. That is, there was
suspicion or confinnation of further illness fabrication or abuse in 59% ofthe
cases returned to the care of the original perpetrator. About 50% of all
children followed were diagnosed with a variety of psYchiatric conditions,
including conduct and emotional disorders as well as problems related to
school, including difficulties in attention, concentration and non-attendance.
Overall, 49% of those successfully followed bad outcomes that were
considered to be unacceptable.
Berg and Jones (65) followed a total of 17 children suspected of
suffering from FDP. Follow-up infonnation was obtained from general
pmctitioners and social workers. About half of the subjects and caregivers
were interviewed. They found that all patients were at the severe end of the
abuse spectrum. Twelve cases involved direct induction of illness, one
involved tampering with samples to mimic illness, and four involved
sYWptom fabrication. The biological mother was the abuser in 100% of the
cases. In 13 of the 17 cases, patients were hospitalized for assessment (and
treatment) to decide whether family reunification was viable. Those admitted
to the family unit were selected on the basis of the likelihood of successful
intervention. Many more were seen in the outpatient clinic but were
considered unsuitable for psYchiatric treatment-usually because of persistent
parental denial or the severity of the perpetrator's personality disorder.
Admission to the unit was offered in cases where the perpetrator showed a
degree of acknowledgement of the nature of the problem, and where the team
considered that psYchological treatment was possible. The presence of
personality strengths was considered an optimistic prognostic sign. Other
family members or friends were asked to assist in the treatment process,
which was comprised of psYchological assessments and interventions targeted
at the parent-child relationship, the quality of the child's attachment to each
parent, the abuser's own childhood experiences, and the current social
network and family dynamics, together with work with the parental couple, as
well as intensive liaison work with key professionals from the family's local
area. Following discharge, most families were followed for a mean of 27
161 MAlDONADO: WHEN PARENTS DECEIVE THEIR CHILDREN'S DOCTORS
months. Of the 13 treatment cases, 10 were reunited with parents after a mean
of 7 112 weeks' admission, whereas three were discharged to out foster
homes. The results suggest there was a further episode of induced illness in
one of the reunited children. Although some mothers had continuing mental
health difficulties, only one of the other reunited cases had appreciable
parent-child relationship difficulties (not requiring referral to psychiatric
services). The children did well in their development. growth, and
adjustment. suggesting that in vel)' selected and adequately screened cases,
family reunification is feasible, but long-term follow-up is necessaI)' to
ensure the child's safety and to identity deterioration in parent's mental
health.
Meadow (66) studied the health and social service records of 81 children
judged by criminal and family courts to have been killed by their parents. He
discovered that, initially, 42 (52%) children had been certified as dying from
sudden infant death syndrome (SIDS), and 29 (36%) were given another
cause of natural death. In 24 families, where more than one child died, 58
(72%) died before the age of 6 months and most died in the afternoon or .
evening. Seventy percent had experienced unexplained illnesses, with over
half having been admitted to the hospital within the previous month.
Furthermore, 15 (19%) died within 24 hours ofhaving been discharged. Most
patients came from disadvantaged or low-income families, and most received
income support. Half of the perpetrators had a history of somatization or
factitious disorder themselves. Death was usually by smothering, with up to
43% of children having bruises, petechiae, or blood on the face at autopsy
examination.
In the case of children who create their own factitious symptoms, many
admit to their deceptions when confronted, and some have positive outcomes
when appropriate treatment is provided (18).
In October 2000, a Florida circuit court jury found 42-year-old Kathy
Bush guilty ofaggravated child abuse and Medicaid fraud after a three month
trial. She had been charged of fabricating illnesses in her 12-year-old
daughter, Jennifer, in an attempt to gain attention and sympathy for herself
Because of the deceitful behavior that Mrs. Bush used to create her
daughter's symptoms, the victim was hospitalized 200 times and underwent
about 40 operations, including removal of her gall bladder, appendix and a
portion of her intestines. The state of Florida had been involved in the case
years earlier and had removed Jennifer from the custody of her mother in
Apri11996. Since her custody was taken over by the state, Jennifer had not
AMERICAN JOURNAL OF FORENSIC PSYCHIATRY, VOLUME 23, ISSUE 4,2002/17
been hospitalized. Yorker (64) provides an excellent summary of other
pertinent legal cases offactitious disorder by proxy and their outcomes.
Some patients with factitious disorder and factitious disorder by proxy
initiate lawsuits (17, 67). There are several scenarios associated with
malpractice liability. The first of these scenarios includes denial of factitious
behavior and subsequent suing of the physician, accusing himlher of
factitious behavior, for defamation. The second scenario involves the issue of
negligence, that is, the physician's inability or failure to consider and/or
identifY the factitious behavior as part of the differential diagnosis. Thus, the
claim would be that unneeded procedures should have been avoided by an
astute clinician. Usually, these follow complications associated with
unnecessary diagnostic tests or procedures.
CONCLUSION
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ABOUT THE AUTHOR
Jose R. Maldonado, M.D. is an Assistant Professor and Chief of the
Medical and Forensic Psychiatry Section in the Department of Psychiatry and
Behavioral Sciences at Stanford University. He is the Medical Director of the
ConsultationILiaison Psychiatry Service and co-Chair of the Ethics
Committee, Stanford University Hospital; and Director of the Medical
Psychotherapy Clinic, Stanford University School of Medicine, Stanford,
California. Dr. Maldonado was the 2001 recipient of the Teacher of the Year
Award, presented at the 14th U.S. Psychiatric and Mental Health Congress in
Boston, Massachusetts.