Child Maltreatment

Child Maltreatment

A case report and literature review: Factitious disorder imposed on another and malingering by proxy

Ilana C. Walters BA&Sc MSc, Rachel MacIntosh MD, Kim D. Blake MD FRCP


Factitious disorder imposed on another (FDIA) and malingering by proxy (MAL-BP) are two forms of underreported child maltreatment that should remain on physicians’ differential. This case of a 2-year- old boy, which spans 6 years, reveals the complexity in and difficulties with diagnosis. Key features include the patient’s mother using advanced medical jargon to report multiple disconnected concerns and visits to numerous providers. As a result, the patient underwent many investigations which often revealed normal findings. FDIA was suspected by the paediatrician, especially following corroboration with the child’s day care and past primary health care provider. This case demonstrates the possible overlap in diagnoses, which are characterized by a lack of consistent presentation and deceitful care- givers, often complicated by true underlying illness. The authors use clinical experience and limited existing literature to empower paediatricians to confidently diagnose and report FDIA and MAL-BP to limit future harm to children.

Keywords: Child abuse; Factitious disorders; Malingering; Munchausen syndrome by proxy

Factitious disorder imposed on another (FDIA), and malinger- ing by proxy (MAL-BP) are two forms of child maltreatment that are often unrecognized and underreported (1–3). FDIA has previously been called Munchausen syndrome by proxy, caregiver fabricated illness, and medical child abuse (1,4,5). This evolution reflects the current view that FDIA is a psychi- atric diagnosis given to the perpetrating caregiver (6). These disorders must remain on physicians’ differential as both can re- sult in significant harm to the child and a burden on society (3).

FDIA is the falsification of signs/symptoms or induction of injury or disease in a proxy, associated with identified decep- tion and without external reward (6). The signs/symptoms are induced by the caregiver and can result in the child receiving unnecessary and potentially harmful care (1). Long-term impli- cations of FDIA for the child include behavioural, emotional, or intellectual challenges (7,8). Mortality is estimated in 6 to 30% of the cases (5,8,9). FDIA should be suspected if the care- giver fabricates a history of illness, exaggerates a real disease, or

underreports signs/symptoms. The paediatrician should rec- ognize common behaviour patterns, such as seeking alternate medical opinions, resisting reassurance that the child is healthy or reporting unexplained signs/symptoms (1,2,10).

MAL-BP is maltreatment caused by a caregiver intentionally inducing or reporting false or exaggerated signs/symptoms in a proxy, motivated by external incentives (3,11). The distin- guishing factor between FDIA and MAL-BP is the presence of external reward which is exclusionary of FDIA and diagnostic of MAL-BP. Critical to the paediatrician’s role in such cases is to identify and reduce harm to the child, rather than formalizing caregiver motive and diagnosis (1,2,12). See full paper click here

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