Brenda Bursch, PhD

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Medical, psychiatric, and/or developmental disorders can be falsified in a variety of ways. Know the warning signs often missed by clinicians. 

4 Warning Signs of Illness Falsification

More than a decade ago, an American Professional Society on the Abuse of Children taskforce recommended professionals separate the concepts of child maltreatment and psychopathology when discussing, evaluating, or treating Munchausen by proxy (MBP).

 Although not a formal medical or psychiatric diagnosis, MBP refers to abusive illness falsification that is due to factitious disorder imposed on another (FDIA) in the abuser. FDIA is the DSM-5 psychiatric disorder that describes individuals who persistently falsify illness in another even when there is little or nothing tangible for them to gain from the behavior. It is a compulsive behavior associated with a high degree of denial, akin to that of substance abuse behavior or an eating disorder.

Victims of MBP may suffer from fear, pain, and loss of normal attachment, and from delayed development, growth, social functioning, and/or academic progression.

They may develop physical and psychiatric problems due to being persistently regarded as ill; from deprivation; from unneeded assessments, medications, procedures, or surgeries; and/or from iatrogenic complications.

Some clinicians believe that they can avoid legal action and conflict by simply believing or avoiding parents who regularly present them with false information. It is important to note that clinicians who failed to file a mandated report for suspected illness falsification have been civilly sued for medical negligence and failure to report suspected child abuse.

 Some states, such as Texas and California, also have penal codes outlining criminal punishment for failing to report suspected child abuse.

Can you tell if you are being lied to by a parent/caregiver? Research has consistently found that conscious assessments of veracity are only slightly more accurate than chance.

 Published case reports suggest that any disorder can be successfully falsified. One describes a case of factitious cystic fibrosis that included a falsified history, altered sweat tests and stool fat analyses, and sputum samples stolen from cystic fibrosis patients.

 Another describes a patient with factitious chronic intestinal pseudo-obstruction who received a small-bowel transplant.

 Falsified mental health problems have included learning disorders, attention deficit disorder, autism spectrum disorder, and bipolar disorder.

Many individuals confirmed to have engaged in illness falsification (typically female caregivers) have the ability to appear normal as parents/caregivers.

 Formal psychiatric interview and psychological testing may suggest that no psychopathology is present. Others may be dramatic, aggressive, manipulative, and/or obvious in their lies. Between 30% and 70% of those who falsify illness in children also falsify illness in themselves.

Medical, psychiatric, and/or developmental disorders can be falsified in a variety of ways. 

 lists warning signs of possible illness falsification. While child victims of suffocation, poisoning, or other forms of induction are at highest risk for death, symptom exaggeration or medical noncompliance in a child with a genuine medical disorder can be sufficient to place the child in lethal danger.

Clinicians are required to report child abuse suspicions to authorities. As with physical or sexual abuse, the determination of whether abusive illness falsification has occurred is normally based on careful data analysis-it is rare to directly observe an abusive act. In the case of a suspicious fracture, for example, a skeletal survey may be performed along with a clinical interview. Because the core feature of illness falsification is deception, assessment requires evaluation of objective data and of collateral data.

 lists some general assessment approaches for clinicians.

Medical record analysis can be more helpful than contacting past clinicians because clinical information recorded at the time of the health care visit is less subject to clinician recall bias and defensiveness. Chronologically summarizing each medical contact into a table reveals patterns of health care utilization and parent/caregiver behavior in a format that is easy to analyze.

 Each row describes a health care contact. Columns include date of contact, health care location, reported signs/symptoms as stated by caregiver, objective test results and observations of the health care provider, conclusions/diagnoses made along with the care plan, and other comments or observations.

Mistakes to avoid when conducting an analysis of the medical record include failing to identify who directly observed or reported the documented information, failing to review primary data (test results, rather than interpretation of test results), failing to determine whether diagnoses match objective data, failing to consider whether objective findings could have been falsified or induced, and failing to consider whether the medical record makes clinical sense.

Psychiatric evaluation of suspected abuser

A key feature of an individual with a factitious disorder is the impressive ability to successfully mislead clinicians, including mental health clinicians. With this in mind, a psychiatric interview of the suspected abuser can be helpful to rule out other forms of psychopathology that might account for the abusive behavior and to identify comorbid diagnoses that should be included in the treatment plan of the suspected abuser. Motivation cannot typically be assessed directly because of denial of having engaged in the behavior and/or poor insight.

 The diagnostic differential should minimally include the disorders listed in 

. Because of reporting of false personal history, collateral data collection is strongly recommended.

Illness falsification due to FDIA is unlikely to stop simply on exposure and confrontation.

 Although the abusive behaviors might temporarily stop, they normally resume over time without significant progress in psychotherapy. In fact, illness falsification can increase after confrontation in an attempt by the suspected abuser to prove that he or she is not to blame. While it is helpful to have one clinician serving as a gatekeeper for all health care, this safeguard is not sufficient to ensure safety in the home. Placement with the abuser is especially dangerous to the child in cases of illness induction, when caregivers can afford to pay cash for medical care, or when the parent-child dynamic is highly dysfunctional.

Clinicians caring for children with warning signs of or confirmed illness falsification provide a basic level of safety when they are conservative in prescribing practices and other treatment recommendations, as well as in their support for school accommodations. They take suspected parent reports of symptoms with a dose of skepticism and engage the other parent in the care of the child. Effective clinicians provide ongoing feedback to the suspected parent about problematic behavior they witness. They do not allow themselves to be pressured to provide unnecessary treatments or recommendations. They document clearly and with details, maintain professional boundaries with the family, and consult with colleagues and experts as needed.

Recommended interventions for the child maximize the child’s normal functioning (physical, social, academic, etc), support developmental milestones, and assist the child to develop a sense of self that is not based on medical problems. Some need permanent protection from the abuser.

 Common psychotherapy themes for victims include denial of abuse, anger, enmeshment, attachment, dominance versus self-efficacy in relationships, control over one’s body, sick-role behavior, iatrogenic PTSD, self-esteem, defining family relationships, and grief.

Abusers who acknowledge illness falsification are more likely to benefit from psychotherapy. Treatment includes efforts to increase awareness and to reduce the risk of relapse. Indicators of successful treatment include the abuser admits to the abuse, including specific details; the abuser experiences an appropriate emotional response to the harm caused to the child; the abuser develops better coping skills; and the abuser demonstrates the ability to refrain from illness falsification over a significant period of time.

Dr Bursch is Clinical Director of the Pediatric Psychiatry Consultation Liaison Service and Professor in the departments of psychiatry & biobehavioral sciences and pediatrics at the UCLA David Geffen School of Medicine in Los Angeles. She regularly serves as an expert witness on the topic of Munchausen by proxy.

 Ayoub CC, Alexander R, Beck D, et al; APSAC Taskforce on Munchausen by proxy, Definitions Working Group. Position paper: definitional issues in Munchausen by proxy [published correction appears in Child Maltreat. 2004;9:337]. 

 Ayoub CC. Emotional impact of Munchausen by proxy on the child victims: a five-year follow-up study. Munchausen by proxy: psychiatric presentations, treatment findings, what to do when a new child is born. Presented at: American Academy of Child & Adolescent Psychiatry Annual Meeting; October 1999; Chicago.

 Bools CN, Neale BA, Meadow SR. Follow-up of victims of fabricated illness (Munchausen syndrome by proxy). 

 McGuire TL, Feldman KW. Psychologic morbidity of children subjected to Munchausen syndrome by proxy. 

 Perman CM. Diagnosing the truth: determining physician liability in cases involving Munchausen syndrome by proxy. 

 Ten Brinke L, Stimson D, Carney DR. Some evidence for unconscious lie detection. 

 Orenstein DM, Wasserman AL. Munchausen syndrome by proxy simulating cystic fibrosis. 

 Kosmach B, Tarbell S, Reyes J, Todo S. “Munchausen by proxy” syndrome in a small bowel transplant recipient. 

 Ayoub CC, Schreier HA, Keller C. Munchausen by proxy: presentations in special education. 

 McNicholas F, Slonims V, Cass H. Exaggeration of symptoms or psychiatric Munchausen’s syndrome by proxy? 

 Kinscherff R, Famularo R. Extreme Munchausen syndrome by proxy: the case for termination of parental rights. 

 Ayoub CC. Munchausen by proxy. Shaw RJ, DeMaso DR, eds. 

Textbook of Pediatric Psychosomatic Medicine

. Washington, DC: American Psychiatric Publishing, Inc; 2010:185-198.

 Bools C, Neale B, Meadow R. Munchausen syndrome by proxy: a study of psychopathology. 

 Sheridan MS. The deceit continues: an updated literature review of Munchausen syndrome by proxy. 

 Sanders MJ, Bursch B. Forensic assessment of illness falsification, Munchausen by proxy, and factitious disorder, NOS. 

 Feldman MD. Denial in Munchausen syndrome by proxy: the consulting psychiatrist’s dilemma. 

 Rogers R. Diagnostic, explanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception. 

 Bursch B. Individual psychotherapy with child victims. Munchausen by proxy: psychiatric presentations, treatment findings, what to do when a new child is born. Presented at: American Academy of Child & Adolescent Psychiatry Annual Meeting; October 1999; Chicago.

Articles

Why do you need to know about Munchausen by Proxy? Answers here.

Munchausen by Proxy and Factitious Disorder Imposed on Another

A key role of mental health providers is to educate communities about the impact of combat deployments on service members, veterans, and their families. Through increased awareness about multiple systems of care, a national public health response can increase awareness and education, screening and early identification, mitigation of risk and promotion of resiliency factors, and access to treat-ment for veterans and their families.

Most military families successfully adapt to a service member’s deployments for military duties.

 Nevertheless, almost a decade of wartime stress associated with the current wars in Iraq and Afghanistan has presented unprecedented challenges for military families.

 These families have negotiated a cycle of recurrent and prolonged deployments; faced parental absences and caregiving changes; and endured parental combat stress, safety worries, and disrupted routines.

The majority of military children appear to be functioning well despite these demands; however, increased child anxiety and behavioral changes have been identified across developmental ages.

 Factors that increase children’s vulnerability to these stressors include preexisting psychological disorders, past trauma, parental mental health symptoms, and cumulative deployment separation.

 Factors that enhance resilience include family support and positive communication.

In addition to deployment stressors, some service members return home with combat-related mental health problems, traumatic brain injury, or serious physical injuries. The risk of combat-related mental health problems increases during the year following return from combat and for those who have had multiple deployments. Parents-particularly younger parents with young children-who experience repeated or pro-longed deployments are at higher risk for increased marital conflict, domestic violence, and/or child maltreatment or neglect.

 Reunions and reintegrations are marked by an array of emotional and logistical challenges, particularly for military families facing physical or psychological injuries in a parent.

Numerous studies have described the impact of posttraumatic stress disorder (PTSD) on families, including parenting impairment and the potential for “secondary traumatization” of spouses and children.

 Traumatized parents may have difficulty in reconnecting with family members, be overly concerned about family safety, and/or be excessively emotionally reactive. Parents with blunted emotions and reduced ability to connect emotionally with loved ones are at higher risk for marital distress and problematic parent-child relationships.

Trauma reminders that trigger abrupt changes in the mood and behavior of the parent may confuse or frighten his or her children and spouse. Hypervigilance and hyperreactivity to perceived threat can lead to irritability, a rigid authoritarian parenting style, and an inability to tolerate normal family interactions (eg, children arguing or engaging in physical play).

Families of service members with PTSD tend to be less cohesive, adaptive, and supportive.

 Sadly, some military families have to cope with the loss of a loved one due to combat, accidental death, or suicide.

What is already known about mitigating risk and promoting resilience in children and families of military service members? 
? Studies have shown that many military families successfully adapt to a service member’s deployment, and the majority of military children appear to be functioning well despite the challenges of parental absence, caregiver changes, parental worries, and disrupted routines. Despite this, new research is emerging that indicates increasing risk of emotional and behavioral symptoms in children and spouses affected by wartime deployment. New studies suggest that risk factors for child distress include parental distress and cumulative months of deployment, and protective factors include social support and family communication.

What new information does this article provide? 
? This article examines factors related to recent study findings of increases in military children’s vulnerability as well as factors that promote resilience to the stressors associated with deployment. Children face new challenges at every stage of deployment and at every developmental age; this article provides strategies for recognizing and mediating children’s signs of stress as well as for enhancing resilience in military children and families.

What are the implications for psychiatric practice? 
? It is widely recognized that military children and families are resilient; however, recent studies have shown that military children are at increased risk for anxiety and behavioral changes. Findings indicate that the resilience of these children can be enhanced and the risks mediated when families receive greater education regarding deployment stress, combat-related stress, and developmental stress reactions in children as well as resiliency skills training related to emotional regulation (including traumatic stress reminder management techniques), goal setting, problem solving, and family communication.

More than 1 million US children have experienced a parental combat deployment. The majority of these children are younger than 10 years; 40% are younger than 5 years. Parental deployments present an array of developmental and psychological challenges to children. Younger children may have spent their entire lives anticipating or experiencing a parent’s deployment. Feelings of loss are normal for both parent and child when a parent misses important moments in the child’s life, such as when the child learns a new skill, participates in an exciting event (eg, a school play, a prom, or a sporting event), or specific milestones (eg, graduations, birthdays).

Chronic worry about the safety of the deployed parent and the stress level of the remaining parent can take a toll. Cell phone and Internet communication with a deployed parent may assist parents and children in maintaining their relationship at a distance. Yet these same technologies may make the experience of war more immediate for the children, including an increased awareness of risk.

There are many available resources to strengthen and support children of military service members and their families. High-quality social and health care services are available to military families, particularly those living near a military base. The military community also provides a network of advocacy, information, resources, and social support. Military families often report a positive sense of mission and values that are central to their family’s identity and that provide meaning and strength. Finally, some children and parents convey that the challenge of moves and separations provides opportunities for developing new skills as children assume and master new responsibilities and contribute to the well-being of the family in meaningful ways.

Primary care and mental health clinicians should be attuned to common responses of children to deployment and reintegration stress. Symptoms or dysfunction in any family member should serve as an indicator of risk across the entire family. A proactive approach is recommended, with a focus on early identification and prevention as well as treatment.

Parents may notice a change in their distressed infant, such as changes in eating patterns, increased or decreased activity, impaired sleep, and/or increased crying or irritability. Separation anxiety may be exacerbated among those experiencing deployment cycle stress. Parents of distressed toddlers may notice increases in clinging behavior, changes in eating patterns, increased or decreased activity and social behavior, impaired sleep, and/or increased crying or irritability.

Young children may have confusing assumptions and misunderstandings about the deployment experience. For example, preschoolers may believe they “caused” the parent to leave but may not talk about this with anyone. Consequently, they may feel responsible and guilty without anyone knowing. In dealing with other stressors, preschool-aged children may exhibit self-soothing behaviors or distress signals that they previously used as infants or toddlers (such as thumb sucking, bed-wetting, or sleep problems). Stress-related somatic symptoms, such as functional abdominal pain, may be present. Research with preschool-aged children found that those with a deployed parent had higher levels of both internalizing and externalizing behaviors than same-aged children without a deployed parent.

School-aged children may exhibit deployment stress symptoms in the school setting (such as attention, academic, or behavior problems) that may be misattributed to mental health problems.

 Like younger children, school-aged children may develop difficulties with sleep routines and may express increased worries around bedtime separations. Boys may feel a sense of responsibility for being the “man in the family” during paternal deployments.

A recent study with Army and Marine Corps families affected by wartime deployments found that about one-third of these military children had anxiety symptoms; this is significantly higher than the rate in community samples. Notably, the increased prevalence of anxiety was present both for the children currently separated from a combat-deployed parent and for those whose parents had returned from combat in the past year.

 This study also found cumulative deployment separation over the child’s lifetime to be a risk factor for greater psychological distress in school-aged children. Psychological distress among both active duty and non–active duty parents, including depression and PTSD symptoms, also correlated with the child’s symptoms.

Similar to younger school-aged children, adolescents with deployed parents may exhibit anger, defiance, or aloofness.

 Like their younger counterparts, teens had greater psychological stress when the caregiving parent had greater cumulative deployment separation and psychological distress.

 Teens with strong coping skills may derive meaning and satisfaction from assuming additional family responsibilities and providing support to others. Teens with less effective coping skills may isolate themselves and/or become resentful of the additional burdens associated with parental deployment. Positive family communication appears to buffer distress in military teens and their families.

The level of exposure to sustained sacrifice and stress, and the scope of the population affected by the wars in Afghanistan and Iraq, indicate the need for a public mental health response for our military families that includes a tiered approach to early identification, prevention, and treatment services. The objective of preventive interventions is the reduction of disease or disorder by using programs designed for those who may be at greatest risk.

Preventive mental health strategies provided within a strength-based framework of psychological resiliency are consistent with military culture and training. Such interventions promote psychological health and reduce distress by building on family strengths and encouraging the regular use of adaptive coping behaviors to reach desired goals. An example of this type of program is FOCUS (Families OverComing Under Stress), which was developed at the University of California, Los Angeles, and Harvard University for military families facing wartime deployments.

Currently being implemented as a large-scale service project through the US Navy Bureau of Medicine and Surgery, FOCUS family resiliency training is a strength-based, trauma-informed, preventive intervention for military families and is designed to promote resiliency and mitigate the impact of wartime deployment stress.

 It provides parents and children with training that addresses the impact of wartime deployment and helps them learn emotional regulation and communication and problem-solving skills to address their specific challenges. Early evaluation of this program indicates that parents and children who participated in FOCUS experienced significant improvement in emotional and behavioral adjustment.

Lessons from FOCUS provide guidance for clinicians, such as the following interventions to consider when working with military families:

• Education regarding family deployment stress, combat-related psychological stress, and developmental stress reactions in children

• Resiliency skills training related to emotional regulation (including traumatic stress reminder management techniques), goal setting, problem solving, and family communication

In FOCUS, a deployment time line and family narrative framework are used to increase family understanding, communication, support, and cohesion. An essential component of family-based treatment lies in developing and strengthening skills that support parental leadership and positive parent-child interactions in the face of heightened stress.

Parents benefit from information about typical child development, expected emotional and behavioral reactions of children to stressful situations, and ways to mitigate the effects of deployments on children. For example, parents can be reminded to help infants by providing a calm, consistent environment. Likewise, they can help toddlers feel protected by providing a predictable routine and additional attention when one parent is deployed.

Preschoolers benefit from repeated explanations of a parent’s departure and separation, along with assurances that the separation is not the child’s fault. If a child regresses to past behaviors, parents can recognize this as a sign of distress. Efforts designed to increase self-sufficiency, reduce stress, and increase emotional support may be effective. School-aged children sometimes need encouragement to express themselves and reassurance that it is acceptable to feel sad and cry. Parents can support emotional awareness and regulation through modeling communication and effective coping regarding their own reactions to stress.

During deployments, concrete representations of the deployed parent and of the parent-child relationship (maps, transitional objects, images) are helpful and provide opportunities for communication about the context and meaning of the separation. Strategies that support the deployed parent’s participation in the child’s life enhance the parent-child relationship. If possible, it is helpful for the deployed parent to send regular messages to each child (separate letters or sections of audio tapes or videotape). Calendars, schedules, plans for communication, and other orienting tools can help the child perceive a sense of time left until a family reunion.

Encouraging children to engage in an activity or hobby they enjoy and do well can enhance their self-sufficiency and provide social support. Regular family communication should be a goal of all parents. Discussions about how things might be different when the family is reunited are often overlooked; however, the family is encouraged to have these discussions before and during reintegration. Topics may include how family roles have changed, meaningful interim experiences, and ways in which the children have matured. It may be helpful to plan time to become reacquainted with each other.

The monitoring and regulation of emotional states and related behaviors can be used to identify daily fluctuations in feelings, including stress reactions. A feeling thermometer can help families monitor their emotional states and the effectiveness of the strategies they use to lower their emotional distress. Key emotions to monitor include anger, sadness, guilt, shame, and anxiety/fear. It is then possible to identify internal and external reminders that contribute to these emotional reactions and escalations of distress and discuss how these responses affect interpersonal behavior in the family. For example, a parent may come to see how his combat-related hypervigilance leads to an overly authoritarian parenting style and increased family conflict.

Coping strategies for parents typically include communicating with other family members when they are experiencing a stress reminder; developing a plan for how family members can respond supportively; and practicing ways, such as relaxation or distraction techniques, to alter arousal and unhelpful reactions when they are triggered or while in potentially triggering situations.

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Most military families successfully adapt to a service member's deployments for military duties. Nevertheless, almost a decade of wartime stress associated with the current wars in Iraq and Afghanistan has presented unprecedented challenges for military families.

Brenda Bursch, PhD

Articles

4 Warning Signs of Illness Falsification

Munchausen by Proxy and Factitious Disorder Imposed on Another

The Long War Comes Home