Factitious Disorder by
Proxy
Presentations in Special
Education
2011 TEDA Conference
AGENDA
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History
Definition/Diagnostic Criteria
Impact in educational settings
Implications for special education
Symptoms
Recommendations
Assistance in research
History
• better known as Munchausen
Syndrome by Proxy (MBP)
• Munchausen was an 18th century
German baron who entertained his
friends with tales from his military
experience that grew more
exaggerated with each re-telling
History cont’d
• Richard Asher, M.D., first described
‘Munchausen Syndrome’ in 1951 after
treating patients who intentionally
injured themselves
• Roy Meadow, M.D., coined term
“MBP” in 1977 to describe caregivers
who induced illness in children
Definition
• According to DSM-IV (1994) Factitious
Disorder is:
– ‘intentional production or feigning of
physical or psychological signs or
symptoms’
– Motivation—assume role of sick person
without external incentives, i.e.,
economic gain
– Factitious Disorder by Proxy (FDP) falls
under category of “Factitious Disorder,
Not Otherwise Specified”
Definition (cont’d)
• According to DSM-IV-TR uses same
definition with 3 subtypes
–Primarily physical symptoms
–Primarily psychological symptoms
–Both physical & psychological
symptoms
–Again, FDP falls under ‘Factitious
Disorder, Not Otherwise Specified’
Other diagnostic criteria used by
different authors
• Children do not demonstrate symptoms of
illness when child is away from caretaker
• Initially, parents constantly at child’s bedside;
later parents tend to spend time elsewhere
• Parents welcome medical tests, even when
told they are painful
• Parents sometimes have background in
health profession
Other diagnostic criteria used by
different authors
• Add or change physicians frequently
• Appear overly attached to children even
though physical affect is unworried or
inappropriate
• Develop close relationships with medical
personnel
• Resistant to psychiatric involvement
• Over time of hospitalization, spend less
time with child
Pay-off for parent
• Attention from family, friends, &
hospital staff members for being longsuffering, patient parent of
chronically-ill child
• Satisfaction of being smart enough to
outwit highly respected medical
professionals who cannot diagnose
what is wrong with their child
Differential Diagnosis
• Malingering—definite external
incentive for falsifying illness or
injury (paid leave from job, disability
benefits)
• Child custody battles between
divorced parents—one parent
falsifies injury and blames other
parent
What does this have to do with
Special Education?
• Small body of literature indicating
that FDP scenario is occurring in
educational settings
• Pay-off appears to be similar
attention from family, friends, &
educational personnel without
requirement of physically harming the
child
Two Ways FDP presents in Special
Educational Settings
• Child with genuine medical problems that
are aggravated/exaggerated by caregiver
– Parent may request extensive,
unnecessary nursing care at school
• Child who is physically healthy but parent
requests/demands repeated evaluation for
SLD, ADHD, Autism, and other eligibilities
FDP & Educational Settings
• Conditions from research literature that
have been falsified include
– Attention Deficit/Hyperactivity
Disorder (most prevalent)
– Specific Learning Disabilities
– Autism
– Behavioral difficulties/emotional
disturbance
– Neuropsychological problems
Prevalence Estimate
• Ayoub reported an incidence of 11.5% of
her subjects (child victims of FDP) had
falsified conditions that would require
special education services
• No conclusive way to estimate prevalence
of FDP in educational settings (still difficult
to estimate incidence of FDP in medical
settings)
Implications for Special
Education
• Cost of time & money for initial Full Individual
Evaluations
• Cost of additional psychological or medical
evaluations (and possibly others)
• Cost of providing services to children who are
genuinely NOT eligible for services
• Cost of going to due process hearing to defend
school district’s stand that child is not eligible and
additional services are not appropriate
Parental symptoms in special
education
• Called ‘high-maintenance’ parent or ‘overinvolved’ parent
• IEP meetings MUST include presence of every
person who works with child (i.e. SLP, OTR, RPT
cannot send reports)
• IEP meetings known to last 2+ hours
• Parents bring their own specialists, sometimes
attorneys
• Parents repeatedly bring up other issues before
they sign IEP
Other Considerations
• Harry & Klingner (2006) called 4 eligibilities
under IDEA ‘judgment calls’ because diagnosis
requires clinical judgment rather than verifiable
data
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Mild Mental Retardation
Specific Learning Disability
Serious Emotional Disturbance
Speech/Language Impairment
• Possibly increases chance of disabilities being
falsified
Other Considerations
• Schreier and Libow (1993) theorize that
FDP evolves over time
– caregivers may initially bring child to physician
for genuine reason, enjoy attention, and then
gradually aggravate or induce illness
– Possible for caregivers to begin getting
attention by demanding educational services
and progress to demanding medical care (or
vice-versa)
What can you do?
• When you suspect you may be dealing
with FDP parent, must decide how far you
can go accommodating them
• As in dealing with difficult child, don’t
threaten anything unless you are prepared
to follow through
• Do your homework & be prepared to
defend decision not to proceed with
further evaluations or services
What can you do?
• Expect parents to get angry with you &
insult your training, intelligence,
competence
• Be prepared for the worst, (parent going
to press)
• May need legal counsel for yourself
separate from school district’s lawyer
Have you had similar
experiences?
• Difficult to research
– Not supposed to evaluate & diagnose parents
– Not trained for psychological evaluations or
diagnoses
– FDP rarely identified or diagnosed until child
is actually physically near death
• Meet many Ed. Diags. who have similar
stories to tell
Want to help?
• Give demographics
– Enrollment data of school district
– Years of experience as Ed.Diag.
– Anecdotal information with no identifying
information on student or parents
– Any other information you feel comfortable
giving
– Contact information on you
Sources
• Bucuvalas, A. (2003). Munchausen by proxy in school
settings: an interview with Associate Professor Catherine
Ayoub. Harvard Graduate School of Education News,
January 1, 2003.
• Feldman, M. (2004) Playing sick? Untangling the web
of Munchausen syndrome, Munchausen by proxy,
malilngering, and factitious disorder. New York:
Brunner-Routledge
• Harry & Klinger (2006). Why are so many minority
students in special education? Understanding race &
disability in schools. New York: Teachers College Press.
Contact Me!
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Ellen M. Frye, Ed.D.
[email protected]
[email protected]
[email protected]
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Factitious Disorder by Proxy