Assessment Process

Identification of MBP always involves a two-step diagnostic process. First, the child's victimization is documented so that a diagnosis of abuse by pediat-ric condition or illness falsification can be verified. Second, with information based on the child's diagnosis, the psychiatrist should evaluate the parents to assess the nature of their psychological and relational characteristics in light of the child's illness falsification. Psychological evaluation should be performed with full awareness of the victimization of the child and access to all medical and other relevant records for both the child and the parents.

Identification of MBP typically entails an extended and comprehensive multidisciplinary evaluation (Sanders and Bursch 2002). Two critical features should guide all evaluations. First, identification of child abuse does not require a psychiatric evaluation of the perpetrator. Second, a standard psychiatric interview or series of interviews with a parent in situations in which MBP has been raised is in no way sufficient to rule out the diagnosis of FDP. Because MBP is a disorder of deception, information from individuals who have had contact with the perpetrator must be a part of the evaluation process. Careful review of medical histories and records of the focus child, siblings, and adults involved is also critical to the diagnostic process.

In a limited number of cases, direct evidence of inducement of illness is available. For instance, covert video surveillance may have been used for direct observation, or laboratory evidence from the child (e.g., the presence of foreign substances or drugs in the bloodstream) may be available (Hall et al. 2000; Southall et al. 1997). In most cases, however, evidence of PCF abuse consists of careful documentation of patterns of exaggeration, fabrication, and inducement in which the child's presentation to health care providers is repeatedly inconsistent with the history provided by the parent, or the symptoms with which the child presents are overtly inconsistent with the expected presentation of a given illness or disorder. In these cases, a wealth of diagnostic information on the child is often accumulated in an attempt to find the cause of the child's difficulty. In addition, proven treatment regimens tend to fail repeatedly with these children when they are left in the care of the perpetrating parent but work well when the children are under alternative care.

Diagnoses based solely on verbal reports from the suspected parent or caregiver should be identified, and the records should be assessed for warning signs, inconsistencies, exaggerations, signs of simulation, episodes of induction, and other patterns of illness falsification. Chronologically summarizing the medical contacts into a table can reveal patterns of health care utilization, trajectories of illness and medical treatment, and behaviors of family members (Sanders and Bursch 2002). If the caregiver is actively inducing illness, the medical record summary can be used to evaluate the logic and likeli hood of the medical presentation and to search for signs of induction. If illness falsification is not present, the chronological summary may aid in determining a correct diagnosis.

Schreier et al. (2009) suggested that evaluators should review the summary for the following:

1. Recurrent illness that appears unusual: Examples include persistent and severe vomiting or diarrhea with no other signs or symptoms of illness.

2. Symptom occurrence: Examples include symptoms occurring only in the presence of specific health care providers or on particular days, and unexpected similar symptoms in multiple family members.

3. Lack of continuity of care: Examples include false representation of health care contacts, refusal to release records, or insistence on unnecessary medical treatment while refusing reasonable treatment of the child.

4. Inconsistencies: Examples include reported symptoms that do not match objective findings (e.g., a caretaker reports severe anorexia and abdominal pain for 5 days in a child who appears well hydrated with no weight loss); reported medical history that does not match previous medical records (e.g., the parent reports the presence of a diagnosis of a more serious illness that was mentioned to the parent in passing as something to be ruled out, or the parent reports that test results are abnormal just because the test was done); a pattern of frequent diagnoses that do not match objective findings (e.g., a toddler with reported intestinal pseudo-obstruction eats ravenously with no resulting symptoms during lengthy hospitalizations); behavior of a parent that does not match expressed distress or reports of symptoms; other false or disturbing history provided by the parent; or medical record names and numbers that do not match. Collateral records and interviews with others can be helpful to determine the truth of inconsistencies.

Most primary care physicians are extremely hesitant to include MBP in a differential diagnosis unless they have ample evidence. In contrast to the identification of other forms of abuse, raising the question of PCF almost always results in a strong, aggressive, and often litigious response from the perpetrating parent. Mothers tend to be convincingly persistent and bold in their denial and often work relentlessly to engage others in authority in an at tempt to vindicate themselves. They are deliberate and persistent in their attacks on those professionals who bring to light their orchestration of their child's abuse. The intensity of such denial is another sign of the contribution of the parent's imposturing role to the maintenance of his or her personality functioning.

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