In 1977, Roy Meadow, a British pediatrician, coined the term Munchausen by proxy (MBP) to describe illness-producing behavior in a child that is exaggerated, fabricated, or induced by a parent or guardian. Meadow adapted the term from a disorder identified as Munchausen syndrome by Dr. Richard Asher in 1951, who noted similarities between several of his patients and the exaggerated storytelling propensity of the infamous eighteenth-century military mercenary Baron Karl Friedrich Hieronymus, Freiherr von Munchausen. Asher applied the term to patients who were exaggerating, fabricating, or inducing illness in themselves to get attention.

Over the last 30 years, a significant body of literature describing MBP has accumulated that includes perspectives from pediatrics, psychology, social work, psychiatry, education, law, and ethics (see Shaw et al. 2008 for a review).1 MBP has been widely recognized as a legitimate and quite dangerous form of child abuse in the pediatric literature; an Axis I disorder of deception in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association 2000); a crime to be investigated by child protection and law enforcement agencies; and a serious juvenile justice issue in courts around the country (Kinscherff and Ayoub 2000). Over 1,200 papers and more than a dozen books have appeared in the medical and psychological literature on MBP. Major pediatric and child psychiatric texts now contain descriptions of MBP. The synthesis of definitional constructs presented below exemplifies the current multidisciplinary consensus in the field.

MBP experts focus on both the child's victimization and the parent's psychiatric disorder; many authors expand the discussion to include not only the interaction between the parent and the child but also the relationships between the parent and the child's various health care providers. MBP is also characterized as a disorder of family and marital dysfunction, all aimed at perpetuating abuse of the child.

MBP is both a pediatric and a psychiatric disorder that belongs to a group of maladies called "disorders of deception." This form of victimization involves the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care. Specifically, it is the exaggeration, fabrication, and/or inducement of an illness, a series of symptoms, or a

1 A number of alternative terms have been used to describe MBP. These have included Munchausen syndrome by proxy, factitious disorder by proxy, Polle syndrome, and medical child abuse, to name the most common. Because this disorder has been described across multiple disciplines, a unifying diagnostic nomenclature has been sorely needed to allow for discussion of the presentations of both the child and the parent, as well as the dynamic between them.

condition in another person, most often a child. The interaction between parent and child leads to abuse of the child by a mentally ill parent or caregiving perpetrator. Definitional guidelines proposed by a mul-tidisciplinary task force of the American Professional Society on the Abuse of Children (APSAC; Ayoub et al. 2002a) address the inconsistencies across definitions that have arisen for this disorder over time. The goal of providing clear and representative multidisciplinary definitions is met in the definition above (see Figure 12-1).

MBP is a disorder that involves two components: 1) the diagnosis of abuse in the child and 2) the identification of psychiatric difficulties in the adult perpetrator. Specifically, the component related to the child's victimization is a form of child abuse called abuse by pediatric illness or condition falsification (Ayoub et al. 2002a). A child who is subjected to this behavior is a victim of pediatric condition (illness, impairment, or symptom) falsification and should be coded as such (995.5 when focus is on the victim and V61.21 when focus is on the perpetrator; see DSM-IV-TR, p. 738).

The second component of the disorder refers to the perpetrator's behaviors and motivations; the psychiatric diagnosis for the perpetrator is called factitious disorder by proxy. Factitious disorder is described in DSM-IV-TR as intentional behavior to assume the sick role by proxy (most often a child). Diagnostic coding for the adult perpetrator is factitious disorder by proxy or factitious disorder not otherwise specified. Terms used to describe the perpetrator's behavior include "imposturing" (Schreier and Libow 1993), "disorders of simulation" (Feld-man 2004), and "disorders of deception" (Ayoub 2006).

The APSAC task force (Ayoub et al. 2002a) suggested dropping the word syndrome from "Munchausen by proxy syndrome" because of the different meanings of the word across professions. This change avoids the legal use of "syndrome," which implies a concrete checklist of characteristics always present or absent in each case. Because illness is feigned in many different ways, a simple symptom checklist is difficult to construct. However, for pedi-atric disorders in which a proliferation of MPB cases have occurred, such as suffocatory abuse (Truman and Ayoub 2002) and intestinal pseudo-obstruction (Hyman et al. 2002), algorithms have been developed based on research findings to offer red flags for differentiation of feigned presentations from legitimate ones.

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