Factitious Disorder by Proxy


Factitious Disorder by


Presentations in Special


2011 TEDA Conference


• History

• Definition/Diagnostic Criteria

• Impact in educational settings

• Implications for special education

• Symptoms

• Recommendations

• Assistance in research


• better known as Munchausen

Syndrome by Proxy (MBP)

• Munchausen was an 18 th 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


• 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


• Cost of time & money for initial Full Individual


• 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

– 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


• 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:


• Harry & Klinger (2006). Why are so many minority students in special education? Understanding race & disability in schools.

New York: Teachers College Press.

Contact Me!

• Ellen M. Frye, Ed.D.

• efrye@lubbockisd.org

• trap4trivia@aol.com

• ellen.frye@wayland.wbu.edu