Kaplan and Sadocks Comprehensive Textbook of Psychiatry, 11e

1925

Chapter 19. Factitious Disorder

Table 19–7. Pediatric Factitious Disorder Imposed on Another— Basic Principles of Management

own, relinquishing the defense of denial, and learning to seek help and to express themselves in more appropriate ways. Sanders et al. in 2019 outlined a system of therapeutic goals for perpetrators to adhere to, the ACCEPTS treatment model: ACKNOWLEDGE (AC): acknowledgment and taking respon sibility for inappropriate behaviors that harmed or could have harmed the child by describing their maladaptive behaviors in detail and to accept and understand how these behaviors placed the child victim(s) at risk. COPING (C): development of a wider range of effective coping strategies to manage personal emotional needs, recognizing that abusive behavior is no longer a coping option. EMPATHY (E): development of the ability to empathize with the child and experience an appropriate emotional response to the harm and suffering that the child experienced as a result of the abuser’s past maladaptive behaviors. PARENTING (P): development of appropriate parenting skills and the ability to prioritize the child’s needs over those of the abuser. TAKING CHARGE (T): recognition of the perpetrator’s own power and how to utilize it appropriately. SUPPORT (S): As abusive behaviors may persist despite inter vention, a support and monitoring system by child protective services and/or health professionals is necessary. If reunifica tion occurs, a primary pediatrician should act as a gatekeeper who monitors and approves all medical care. Although the literature on factitious disorder imposed on another focuses on the most severe cases, mild cases do occur. Meadow advo cated that in these mild cases, parents should be supported and pre vented from putting their children through needless investigations and treatments. Psychotherapy should be undertaken. The prognosis in these cases may not be so grim. Factors associated with positive outcomes according to Bools et al.’s study included (1) continuous positive input from spouse or grandparents; (2) successful short-term foster care before returning to live with the perpetrating caregiver; (3) the perpetrator’s long-term relationship with a social worker; (4) successful remarriage for the perpetrator; (5) early adoption of the victim; and (6) long-term foster care placement. There is little literature on the treatment of factitious disorder imposed on another between adults. In these cases, removal of the victim through legal means is usually not an option if the victim is a legally independent adult, even if they might be emotionally depen dent on and enmeshed with the perpetrator. Unless the victim has a legally dependent status, adult victims must initiate separation. Psychiatric comorbidity in the victim, if severe enough, may ren der the individual incapacitated and requiring hospitalization or even guardianship. Adult protective services and/or agencies overseeing the protection of developmentally disabled individuals must be noti fied when adult factitious disorder imposed on another is suspected. In cases in which health care providers are suspected of perpetrat ing illness among their patients, legal prosecution should be instituted. Simply removing the provider is not adequate because the perpetrator is likely simply to seek another job, where more patients will be at risk. FUTURE DIRECTIONS Further studies are needed to elucidate risk factors for developing factitious disorder, best practices for management, and outcomes of specific treatments. With an understanding that deception in the medi cal setting is commonplace, research into the underpinnings of this behavior may help to identify means of reducing episodes of decep tion both in patients with factitious disorders and in the general public.

Make sure the child is safe. Make sure the child’s future safety is also assured.

When gathering clinical information and evidence, clinicians should keep in mind that if the mother feels that she is suspected or is losing control of the situation, she is likely to remove the child and seek care elsewhere. When evidence of factitious disorder imposed on another is felt to be sufficient, both parents should be informed together. In this manner, a nonperpetrating parent, usually the father, might be enlisted as an ally. Child protective services should be informed, and a legal hold should be instituted if clinicians feel that parents might flee with the child. If harm has been done to the child, reporting of factitious disorder imposed on another to child abuse protection authorities is mandatory in all 50 states. In Rosenberg’s review of 117 cases of factitious disorder imposed on another, 9% of the involved children died, several of whom were sent home with their parents after parents were confronted with the diagnosis. Given the high rate of mortality and morbidity, children should be removed from the parents until further assessment indi cates that it is safe for the family to be reunited. Child protective services usually take responsibility for this action. When this is done, there is a high likelihood that the mother will need intervention for suicidal ideation. Investigation into possible abuse of siblings should also be initiated. After separation, the child must be treated for ongoing medical problems, as well as for psychological problems. For many children, longstanding refractory medical illnesses will resolve once they are separated from perpetrators. Many such children suffer from post traumatic stress disorder and should be treated. As is typical of those with post-traumatic stress disorder, many victims avoid medical care as adults. On the other hand, others develop factitious disorder. By adolescence, many victims of factitious disorder imposed on another collude with parents in perpetrating deception. The perpetrator, usually the mother, should also undergo treat ment to diagnose and address underlying psychiatric conditions. The perpetrator should be evaluated to determine whether it is likely that they will ever achieve “good enough” parent status and whether reunification with their child is a realistic goal. Those who actively induce illness in their children are less likely to ever be adequate par ents. If reunification is unrealistic, then psychotherapy should focus on the parent’s underlying psychopathology, as well as the loss of a child. If reunification is the goal, then treatment should address emotional maturation, the ability to put the child’s needs before their The possibility should be considered of admitting the child to an inpatient or partial hospital setting to facilitate diagnostic monitoring of symptoms and to institute a treatment plan. The child may require placement in another family. The perpetrating parent may need to be removed from the child through criminal prosecution and incarceration. Allow treatment to occur in the least restrictive setting possible. A pediatrician should serve as “gatekeeper” for medical care utilization. All other physicians should coordinate care with the gatekeeper. Child protective services should be informed whenever a child is harmed. Family psychotherapy and/or individual psychotherapy should be instituted for the perpetrating parent and the child. Health insurance companies, school officials, and other nonmedical sources should be asked to report possible medical abuse to the physician gatekeeper. Permission of a parent or of child protective services must first be obtained.

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