Roy Meadow first described Munchausen by proxy (MBP) in 1977 in England. Since then, there have been over 400 reports in the world s pediatric and child psychiatry literature. Although it is often described as a rare disorder, when the results of a very carefully conceived, total population study done in England are transposed to the United States, some 1200 new cases of suffocation and poisoning alone would be expected to occur each year. (1) As the condition became more known through professional as well as popular media (some 20 television news-magazine programs), there was a loosening of definitions so that even some workers in the field came to regard medical falsification of a condition in a child sufficient for the diagnosis. (2) Through brief examples, this article will illustrate the essentials of definitional guidelines compiled by a multidisciplinary group convened by the American Professional Society on the Abuse of Children (APSAC), (3) which were reviewed and modified with the input from several professional societies. (4) These definitions create a specific term to be used for the medical diagnosis in the child, to wit "pediatric condition falsification" (PCF). But this approach recognizes that there are many serious forms of illness exaggeration or fabrication that pediatricians and others encounter that involve motivations other than those found in MBP. Factitious disorder by proxy (FDP) is the diagnostic category for the caretaker who harms her child though PCF for particular self-serving psychological needs. MBP then is retained as the name applied to the disorder that contains these 2 elements, a diagnosis in the child and a diagnosis in the caretaker.

The APSAC group's definition recognized that the usual clinical presentation, motivation, and prognosis in MBP is such that distinguishing it from other forms involving PCF is essential for the protection of the child. The mother who falsifies symptoms in her child to get help either for herself (because she might be overwhelmed) or the child (because she truly believes that the child is not being treated adequately), or the mother who does so because she has a delusional belief that the child is ill, will pose much different risks for that child than the mother whose motivation might be a compulsive need to repeatedly fool the doctor an/or garner attention for herself as an ideal parent. This is not an a priori belief; rather, it has been demonstrated that the recidivism rate of mothers suffering from FDP is exceptionally high even in the moderately serious cases, (5) as is the death rate of 6%. (1) These mothers (a) have even been known to kill their children on supervised visits.

Although others have argued that it is difficult to know another's motivation, even that it is unknowable, it is very common both in the criminal justice system and the fields of psychology for an understanding of motivation to be based on circumstantial evidence. In the case of FDP, there have been enough cases studied intensively that show commonalities that strongly suggest motivational needs that can be seen as quite distinct from those found in other forms of PCF and from the more common forms of child abuse. These data have been elaborated on in greater detail elsewhere (6,7) and can only be touched on here. The primary motivation seems to be an intense need for attention from, and manipulation of, powerful professionals, (4) most frequently, but not exclusively a physician. (8-10) It is important to understand that this phenomenon almost always involves the participation of the child's physician, who at times might be the agent of harm to her child. (11) In a meta-analysis of early published cases, 75% of the morbidity occurred in hospitals (1 mother suffocated and revived her 2-year-old 3 times in 1 day) and at the hands of the physician, (12) and 40 to 100 operations for nonexistent conditions are not uncommon. Other "audiences" (social workers, lawyers, therapists) may become important to her after the mother has been suspected and the child removed from her care. The child is kept close at hand, and serves the mother by providing an entrance to the exciting ambiance of the hospital and directly to the pediatrician. Despite a very convincing presentation of deep caring for their children, these mothers, when observed for many hours through surreptitious videotaped surveillance, do not relate or are directly cruel to their children. Even when they leave glaring clues of their actions, it is astonishing to see how long it often takes for suspicion to lead to separating her from the child. Frequently, it is only on such separation that it becomes apparent that there is nothing medically wrong. These guidelines recognize that pediatricians will usually initially recognize and respond to the harm and abuse of their patient. Teasing out the motivation of the caretaker may be more difficult and at times requires the skills and efforts of others. However, although the prognosis for caretaker's treatment will vary by her diagnosis, the responsibility of the pediatrician to report to protective services must be defined by the child's harm. What follows are cases that exemplify the use of the APSAC definitions.

PEDIATRIC CONDITION FALSIFICATION IN FACTITIOUS DISORDER BY PROXY: MBP

A 6-year-old boy was hospitalized on a major University medical center gastroenterology unit. He had exhibited failure to thrive as an infant and was subjected to repeated tests including biopsies, for various gastrointestinal (GI) problems including chronic diarrhea and vomiting. The only positive finding was mild gastroesophageal reflux. During an extensive hospitalization that lasted 6 months, he exhibited findings that made no clinical sense, eg, gastrostomy drainage volumes 5 to 6 times what he was being given. He also had 2 acute life-threatening events (ALTEs) during which he stopped breathing. These occurred late in the hospitalization, and during revival efforts the mother was overheard by a nurse "gleefully" describing the events. However, it was not until the second ALTE that the child was separated from her. He recovered totally except for residua from his apnea events.

He was returned wheelchair-bound to his mother after a 6-month course of court-ordered psychotherapy. The mother remarried during this time to a man who participated in some of her psychotherapy sessions.

Years later an infant child of this mother was being evaluated at several centers, including one affiliated with the first university hospital, for a puzzling severe growth retardation (the child weighed 7 pounds at 7 months old). He had been subjected to numerous tests including muscle biopsies. The geneticist at one hospital called this author, knowing of his familiarity with FDP because she had discovered that the mother had been treated for pseudo-seizures. When the author went to meet with the GI staff in the hospital where the infant was being evaluated, he recognized from the names in the history that this was the parent of the first child who had the ALTEs and GI problems. The infant was separated from the mother and gained 2 pounds in 2 days in the hospital. Furthermore, investigation revealed that the mother's pseudo-seizures had ceased when she became pregnant with this child's older sibling, who also exhibited FTT. That child started gaining weight when the mother became pregnant with the child that was now being starved.

Not only did the father of these 2 infants support his wife at her family court trial, the therapist who treated her in court-ordered therapy relating to the first child testified that she did not have MBP, and believed that she was being falsely accused.

There is no doubt that this mother was involved in multiple episodes of pediatric condition falsification, some of which were fabrications and some were direct harm induction. Both types were potentially lethal. In each case, the mother's motivation seemed to be to seek involvement with the medical staff, either through herself (pseudo-seizures, pregnancy) or her children. She left glaring clues that were not recognized, even by a physician very familiar with MBP. (6)