Factitious Disorder by Proxy

1. Factitious Disorder by Proxy Presentations in Special Education 2011 TEDA Conference

2. AGENDA • History • Definition/Diagnostic Criteria • Impact in educational settings • Implications for special education • Symptoms • Recommendations • Assistance in research

3. 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

4. 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

5. 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”

6. 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’

7. 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

8. 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

9. Pay-off for parent • Attention from family, friends, & hospital staff members for being long-suffering, 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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. Parental symptoms in special education • Called ‘high-maintenance’ parent or ‘over-involved’ 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

17. 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

18. 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)

19. 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

20. 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

21. 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

22. 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

23. 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.

24. Contact Me! • Ellen M. Frye, Ed.D. • efrye@lubbockisd.org • trap4trivia@aol.com • ellen.frye@wayland.wbu.edu