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Munchausen by Proxy in School Settings
An Interview with Associate Professor Catherine Ayoub

Harvard Graduate School of Education
January 1, 2003

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Associate Professor Catherine Ayoub
Associate Professor Catherine Ayoub (photo: Benjamin Messinger)  
Co-director of HGSE's Risk and Prevention Program, Associate Professor Catherine Ayoub is a developmental and licensed counseling psychologist with research and practice interests in the developmental impact of childhood trauma across the lifespan and the development and implementation of prevention and intervention systems to combat risk and promote resilience with emphasis on young children. Her present research centers on the developmental consequences and emotional adjustment of children who have experienced child maltreatment, including child sexual abuse, chronic illness, difficult parental divorce, witnessed domestic violence, and Munchausen by Proxy (MBP). In this interview, Ayoub discusses her research in a component of MBP called pediatric condition falsification (PCF) as engendering a condition or disability related to a child's learning.

Q: Could you explain the difference between pediatric condition falsification (PCF) and factitious disorder by proxy (FDP), as components of MBP?

A: MBP is a disorder that consists of two components: a component that addresses the child’s abuse and a component that addresses the parent’s motivation and emotional difficulty. These two components are child abuse by pediatric condition falsification and factitious disorder by proxy. Child abuse by pediatric condition/illness falsification is the condition of the child; the abuse is defined when a parent or caregiver exaggerates, fabricates, or induces the symptoms of an illness or disability (psychological, physical or socio-educational) in the child.

One maternal interest in MBP? Attracting the attention of powerful professionals in order to compete with them and to demonstrate intellectual superiority by “fooling” the experts.

Factitious disorder by proxy is the mental health diagnosis given to the perpetrator in MBP. In 95% of the reported cases in the literature the adult responsible for this abuse is the child’s mother. Factitious disorder by proxy is one of several presentations of factitious disorder, one of a group of mental illnesses that are described in the Diagnostic and Statistical Manual of Mental Disorders—IV (DSM-IV). The mother’s psychological motivation is to intentionally falsify or induce symptoms in her child or “proxy” to meet self-serving psychological needs. These needs are focused around “impostering” as a good, or great, mother.

In the context of this relationship, the child is used as an object to bring the mother attention for her devotion, knowledge, and sacrifice on behalf of her ill or handicapped child. Many authors argue that a second important maternal interest is in attracting and maintaining the attention of powerful professionals-pediatricians, teachers, and mental health professionals—in order to compete with them and to demonstrate intellectual superiority by “fooling” the experts.

Q: What sparked your interest in studying PCF as the creator of a condition or disability related to a child’s learning, when the majority of previous studies have focused on physical and psychological conditions?

A: I initially became interested in MBP in the late 1970s, after seeing a family fitting this description while I was serving as the coordinator of a hospital’s child protection team. When I began to do more work with the juvenile courts I was asked to evaluate several mothers and children where MBP was raised as a possibility. Among these were cases of children who were identified through their school systems as having psycho-education difficulties. After seeing several children referred from school settings, I began to wonder if such cases of MBP were more common that we had initially believed.

Two years ago, with the help of an HGSE faculty grant, we began a study of MBP families and found that a significant subset of the children demonstrated PCF in educational settings.

Q: Do you believe that MBP’s manifestation in the area of education is relatively recent?

A: I believe that MBP’s manifestation in education is now being recognized more often than it was prior to the recent increase in public awareness of MBP in general. As special-needs assessment and education services have become common components of public school systems across the country, the potential for a parent to misuse an educational disability or other issue as a vehicle to gain attention has increased as well.

Q: If you had to approximate, what proportion of MBP cases might be best described as pertaining to a child’s learning and/or learning abilities?

A: Our current study of 52 child victims of MBP includes 6 children with educational problems that were fabricated or exaggerated; this is 11.5 % of our sample. Although this is far from an epidemiological estimate, it is a large enough sub-sample of children to raise questions about presenting patterns in such systems.

Q: Might the number of these cases be increasing as the diagnosis of learning problems and attention deficit hyperactivity disorder (ADHD) becomes more common?

The ultimate test for determining MBP is established by documenting the child’s academic abilities and the discrepancies between the parent’s report and that of school personnel and other professionals.

A: There certainly may be a relationship between MBP presenting in educational settings and the diagnosis of disorders like ADHD, for a number of reasons. First, ADHD is a diagnosis that relies upon observation and history rather than any diagnostic blood test or laboratory assessment. This makes the diagnostician dependant upon the child’s history, as provided by the parent, to make the diagnosis. Second, children who are abused in this way are more likely to present with complex posttraumatic stress disorder in which difficulty in attention and concentration is common. Currently, there is a tendency to misdiagnose some trauma-related symptoms, including both distractibility and difficulty with concentration, as ADHD. Together, these two variables are likely to add to the misdiagnosis of ADHD.

Illnesses or disabilities that are difficult to diagnose, that are misdiagnosed, and that depend upon parental report are more likely to be seen in MBP situations. As we become more careful and systematic about the diagnosis of ADHD, I suspect that more MBP cases may be uncovered.

Q: Do you have any suggestions about which may be the most practical, efficient, and/or necessary methods of informing school personnel of this type of MBP?

A:School personnel may participate in workshops, be part of consultation, and also learn from reading about MBP in their settings. Often this disorder does not come to mind until professionals encounter a child and mother with these characteristics.

Q: Could you site any surefire ways to distinguish between MBP and other circumstances of similar parental behavior (i.e., resulting from the parental search for nonexistent treatment for children’s actual conditions)?

A:Many parents of disabled or special-needs children search for new and different interventions for their children. There is no simple way to differentiate them from the MBP except though careful observation and assessment. MBP victims frequently do not appear as disabled as their mothers describe them to be. They are children who are not responsive to intervention, according to their mothers, but may appear quite responsive to teachers. Mothers of many of these children become more agitated when a solution is found for the child’s difficulty; for parents genuinely searching for an intervention, the reaction is the opposite and is characterized by relief and gratefulness. Ultimately, the test for determining MBP is established by documenting the child’s academic abilities and the discrepancies between the parent’s report and that of school personnel and other professionals. Careful documentation and consultation with a knowledgeable expert is critical for ensuring accurate diagnosis.

For More Information
More information about Cathy Ayoub is available in the Faculty Profiles.

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