We have all heard of cases where a child dies unexpectedly and the investigation reveals that the cause of death was not accidental but intentional and that the perpetrator was the child’s caretaker. This is an example of Factitious Disorder Imposed on Another (FDIA). FDIA is the current term used by the DSM5 for the condition previously known as Munchausen Syndrome by Proxy.
In child protection cases, the plaintiff (usually the state) might argue that parental rights need to be terminated because she subjected the child to unnecessary and possibly dangerous procedures; the defense might argue whether the child was harmed by the mother’s behavior, whether the mother is receptive to psychotherapy, and whether reunification of mother and child is possible.
FDIA has four criteria: fabrication of physical or psychological symptoms or the inducement of a disease or injury on another person and this behavior is deceptive; one person describes the other person as injured, ill, or impaired; the deceptive behavior is apparent and there are no external rewards; the behavior cannot be accounted for by another disorder, such as psychosis or delusions.
FDIA is an extreme form of child abuse. Boys and girls are equally likely to be abused and are often under the age of 5. The abuse occurs in every social class and with any number of children in the family. Often, fathers are not involved in their child’s care because the mothers do not sign HIPAA forms allowing health care providers to speak with the fathers or because mothers don’t tell the father what is going on.
Although these mothers vigorously deny making their child ill, they intentionally deceive the child’s health care providers. Mothers may administer laxatives, inject foreign substances, manipulate hospital equipment, or suffocate the child thereby inducing symptoms of fever, vomiting, sleep apnea, dizziness, back pain, seizures, and bleeding. FDIA files include numerous visits to different providers and providers not to knowing about other providers currently treating the child.
Health care providers suspect FDIA when a child is not responding to the usual course of treatment. The separation test, physically separating the mother from the child to monitor the course of the child’s symptoms, is often conducted. If the child’s symptoms improve, this provides evidence that the mother has been inducing symptoms in her child. In hospitals, covert monitoring corroborates the mother manipulating the child’s medical equipment.
In criminal court, the mother’s actions are considered an act of violence because she subjected the child to invasive and potentially dangerous medical procedures for a condition that may not exist. If a child died as a result of the mother’s behavior, FDIA may be used to mitigate charge of murder to a lesser offense. The prosecutor might argue that the mother is culpable and that her behavior to her child is criminal; the defense might argue that the mother has diminished capacity because she has a mental illness and that the child’s death or injuries were not intentional.
When a mother is alleged to have FDIA, attorneys may consult with a psychologist to assess the mother whether the mother intentionally fabricated her child’s symptoms and intentionally harmed her child or whether the mother is incompetent. Attorneys need to make certain the expert reviews all of the data in the child’s medical file and that all pleadings in such a case are considered. In the document review, the expert will look for various inconsistencies, such as symptoms not matching objective findings, medical history not matching diagnosis, noncompliance with medical recommendations, frequent hospitalizations to different hospitalizations, and lack of continuity of care. Additionally, the expert will review the results of the separation test to see whether alternate hypotheses were offered that could explain the mother’s behavior. Experts need to speak with collateral contacts about the mother and her relationship with the child rather than just rely on what is given to the expert. This type of information will enable the expert conduct a scientifically-based and clinically-informed investigation that will form the basis of the expert’s opinion.