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Child or Adult Maltreatment through Problem Falsification/Deception

(Including sub entities/terms, for example: Munchausen by Proxy Maltreatment, Factitious Disorder by Proxy, Malingering by Proxy, Mixed Cases (that include both the two previous terms), Pediatric Condition Falsification, and other terms/labels that mean the same or similar).

The generic term/label/entity, if confirmed and has caused - or may cause - negative consequences to the victim - stands alone as a very dangerous kind of maltreatment – with or without the use of sub-entities/terms.

Definitions, Maltreatment Behaviors, and Comments

Child or adult maltreatment (abuse or neglect) through deliberate problem falsification/deception is simply my generic, descriptive, informal term for a particular pattern of behavior that includes one or a combination of the following behaviors described below. I use this overall, umbrella term because of so many terms being used throughout the world – some mean the same thing – some don’t mean the same thing depending on the concept used, and the terms, meanings, and criteria change, depending on the individual using the particular term. “Terminology confusion” continues to evolve.

All terms used include perpetration of one or more of the following behaviors. One or more of these falsification behaviors constituting child or adult maltreatment must first be established – prior to attempts to determine “the why” of the behavior, and to use any of the sub-terms.

Exaggerate:
The perpetrator embellishes a genuine physical and/or psychological-behavioral-emotional-mental health problem.
Fabricate:
(A) The perpetrator makes up/concocts a physical and/or psychological-behavioral-emotional-mental health problem story – AND/OR (B) makes it look as if a problem exists when, in fact, the problem does not exist.
Induce:
The perpetrator causes/creates/exacerbates a physical and/or psychological-behavioral-emotional-mental health problem.

Comments

1. This kind of abuse and/or neglect – including its sub types/labels – is not currently an officially recognized mental health diagnosis by the American Psychiatric Association - it is a recognized kind of maltreatment. There is no mental health test or evaluation that can determine whether a person is or is not a perpetrator of this kind. However, this is a recognized kind of abuse and/or neglect.

2. Different words, meaning the same behaviors as above, are sometimes used – for example “feign or “create”.

3. Virtually any problem an individual is alleged to “have” or “have had “can be falsified (exaggerated and/or fabricated and/or induced).

4. Situations may be exaggerated and/or fabricated and/or induced as a part of the pattern.

5. The falsification behavior may include deliberate tactics to alienate the victim from one or more others. (I do not use the term or concept, “parental alienation syndrome”.)

6. The falsification behavior may include deliberate false allegations by the perpetrator - (including exaggerating and/or fabricating and/or inducing one or more problems with regard to the victim). For example, sexual abuse (as a problem or suspected problem) may be exaggerated and/or fabricated and/or induced.

7. One or a combination of exaggeration, fabrication, and induction may occur in a particular case situation – and one or more of the falsification behaviors and problem” may change from time to time – as may the methodology. The behaviors may begin and progress in any order.

8. Any one of the three falsification behaviors (exaggeration, fabrication, and induction) may result in negative impact to the victim – past, present, or into the future. Exaggeration and/or fabrication cases should be considered as potentially deadly as those where induction is involved.

9. Exaggeration and/or fabrication kinds of problems should be considered as serious – and potentially harmful to the victim – as cases involving induction.

10. Genuine problems may co-exist with falsified problems.

11. Genuine problems may exist – but may also be exaggerated and/or fabricated and/or induced.

12. Any suspicion of this kind of maltreatment should result in assignment at the highest risk level, regardless of how the case currently appears to present. What is presently known or suspected well may be only the tip of the iceberg.

13. Suspicion should be reported at its earliest stages. Hospital staff and other professionals should not wait until they think they can “prove” the behavior.

14. Genuine physical and/or psychological-behavioral-emotional-mental health problems may occur completely separate from the problem falsification/deception behavior – or the perpetrator may exaggerate and/or fabricate and/or induce problems in addition to genuinely existing problems.

15. This very dangerous kind of abuse or neglect manifests as physical abuse and/or emotional abuse and/or sexual abuse and/or various kinds of neglect – depending on the individual case circumstances and the terms and definitions in the legal statutes of the particular area. It is imperative that confirmed abuse or neglect of this kind be linked to the kinds and definitions of maltreatment contained in the jurisdiction’s legal statutes.

16. Specialized knowledge, investigative activities, and methodology must be utilized. The vast majority of professionals, even those highly regarded and/or well known, do not have the expertise necessary to work with a suspected or a confirmed case of this kind.

This kind of abuse or neglect is very different from other kinds of maltreatment. Working appropriately with suspected or confirmed cases of this kind requires specialized knowledge and skills from suspicion onward through the life of the case.

17. It is a misconception that most cases of this type are suspected or occur in a hospital or other inpatient atmosphere. It is my experience that the vast majority of cases present in the outpatient setting.

18. It is a misconception that proof of this kind of maltreatment must include secret audio and/or video surveillance. Certainly recorded behavior can be “icing on the cake” but not necessary – if a thorough and appropriate investigation and determination process is completed.

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Criteria for Confirming Problem Falsification

1. Criteria for confirming the generic term, child or adult maltreatment (abuse or neglect) through deliberate problem falsification/deception:

A. Evidence/proof (direct and/or circumstantial - usually strong circumstantial) of deliberate exaggeration and/or fabrication and/or induction of a physical and/or psychological/behavioral/emotional/mental health problem (Evidence of the behavior).

B. Negative or risk of negative impact on the victim due to exaggeration and/or fabrication and/or induction by the perpetrator.

Remember that if A and B are confirmed, the individual has perpetrated very dangerous child or adult maltreatment – and is very likely to continue, in one way or another.

2. Criteria for confirming the sub entities (having to do with the motivation, “the why” for the proven behavior).

A. Evidence/proof (direct and/or circumstantial - usually strong circumstantial) of deliberate exaggeration and/or fabrication and/or induction of a physical and/or psychological/behavioral/emotional/mental health problem. (As per Criteria 1 above).

B. Negative or risk of negative impact on the victim due to exaggeration and/or fabrication and/or induction by the perpetrator (as per Criteria 1 above.)

C. Depending on the sub entity explained below, the kind or kinds of needs the perpetrator was/is attempting to meet through use of the victim:

  • Munchausen by Proxy Maltreatment, Munchausen Syndrome by Proxy, Munchausen by Proxy Syndrome, and Factitious Disorder by Proxy are terms that mean the same thing – unless the term and concept of Pediatric Condition Falsification is used.
  • Strong rationale that the deliberate falsification behavior is, primarily, an attempt by the perpetrator to meet his/her own emotional/internal needs. For example: attention, sympathy, jealousy, revenge, etc. This can usually be accomplished as result of an appropriate, specialized investigation and determination process by an expert specific to this subject area.
  • Malingering by Proxy Maltreatment: Strong rationale that the deliberate falsification behavior is, primarily, an attempt by the perpetrator to meet his/her own external needs. For example money or other resources/”stuff”. This can usually be accomplished as a result of an appropriate, specialized investigation and determination process by an expert specific to this subject area.
  • Mixed Cases: Strong rationale that the deliberate falsification behavior is an attempt by the perpetrator to meet both internal and external needs. This can usually be accomplished as a result of an appropriate, specialized investigation and determination process by an expert specific to this subject area.

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Pediatric Condition Falsification – A Different Concept, with Different Terminology and Meanings

Pediatric Condition Falsification (PCF) concept is a proposal that originated from an APSAC (American Professional Society on the Abuse of Children) task group.

I was instrumental in causing the creation of the task group, was a member of the task group for a time – but resigned due to what I felt were significant problems with content and process – and I was unwilling to lend my name as one of the proposal authors. This term has not been accepted - nor is it being used – within the overall community of professionals who provide services in this subject area. The following are major differences between two concepts are compared below:

MBP/FDP Concept PCF Concept
MBP and FDP mean the same thing. MBP and FDP do NOT mean the same thing.
Criteria 1 for MBP/FDP Maltreatment is confirmed if there is direct or circumstantial evidence of deliberate exaggeration and/or fabrication and/or induction behavior. Confirmed exaggeration and/or and/or induction behavior is called Pediatric Condition Falsification (PCF)
Criteria 1 constitutes maltreatment behavior. PCF constitutes maltreatment behavior.
Criteria 2 for MBP/FDP Maltreatment is met if there is strong rationale that the exaggeration and/or fabrication and/or Induction behavior qualifies as MBP/FDP Maltreatment – rather than something else. This involves, in part, looking at other possible reasons for the Criteria 1 behavior and having rationale for ruling out the other possibilities. The suspected perpetrator is “diagnosed” as “having” Factitious Disorder by Proxy - mental health diagnosis – but there is no such mental health diagnosis.

MBP Does Not Mean The Same Thing As PCF

  1. Under the PCF concept, terminology is different from the MBP/FDP concept – and is confusing to most people.
  2. The PCF concept is not widely used within the major MBP Maltreatment community of professionals.
  3. The process leading to the PCF concept did not include anywhere near the majority of credible experts in the field – even though some asked to provide input.
  4. Determining MBP Maltreatment under the PCF concept depends on a mental health diagnosis – but there is no such mental health diagnosis.
  5. All situations where Criteria 1 behavior (the same evidence as Pediatric Condition Falsification) constitutes extremely dangerous child abuse or neglect - but do not necessarily qualify as MBP Maltreatment.
  6. Regardless of the label used – confirmation of Criteria 1 (again, the same as PCF) constitutes very, very serious child or adult abuse or neglect – that manifests as physical abuse, sexual abuse, and neglect of various kinds – depending on the wording of the particular state statutes.
  7. MBP concept Criteria 1 does NOT equate to the second part of the PCF concept. Under both concepts the goal is to form an opinion on what the exaggeration and/or fabrication and/or induction behavior constitutes. Under the PCF concept – a decision that the behavior has been, for the most part, due to internal/emotional reasons – the part A behavior - would be termed “Factitious Disorder by Proxy” - and PCF plus FDP would equal Munchausen by Proxy (MBP).
  8. As discussed in detail above, none of these terms or concepts has ever been placed in DSM - IV by the American Psychiatric Association as a formal mental health diagnosis. Under the PCF concept, FDP is considered a mental health diagnosis – which is bogus.
  9. If Criteria 1 is confirmed, it is important to attempt to establish whether the behavior constitutes MBP Maltreatment – Malingering by Proxy Maltreatment – overanxious/overprotective caregiver – overwhelmed caregiver etc. Appropriate case plan design is heavily impacted by Criteria 2 findings - or lack of findings. Criteria 2 methodology is more comprehensive that the part two of the PCF concept – and Criteria 2 does not, and should not - rest on a mental health evaluation.
  10. There are times when it is not possible to complete a Criteria 2 assessment in a short period of time. I have designed a case plan, with accompanying case management, appropriate to that situation as well as case plans appropriate to findings.
  11. I am fully aware that the above is very confusing to most people – particularly as a result of the changed terminology under the PCF concept. That is one of the points I am trying to make.

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Some Major Suspicion Indicators of Problem Falsification/Deception

  1. Difference between reported history and what is seen, or what makes sense physically and/or psychologically, emotionally, behaviorally, mental health.
  2. Problem does not respond to treatment as expected.
  3. Problem appears to originate only in association with suspected perpetrator’s presence. This does not mean that the suspected perpetrator must be in the room with the suspected victim when the problem(s) occurs or seems to occur.
  4. Problem disappears or begins to improve when suspected victim is separated from suspected perpetrator.
  5. Problem resumes after suspected perpetrator is told suspected victim has recovered, is improving, or is soon to be released from the facility, program, course of treatment, etc. – OR problem resumes shortly after suspected victim goes home, treatment is discontinued, etc.
  6. Unexplained symptoms, illness, or death of other nuclear or extended family members.
  7. A pattern of “Usual Perpetrator Characteristics” in combination with one or more other suspicion indicators.
  8. Behavior that appears to be consistent with exaggeration and/or fabrication and/or induction of physical and/or psychological-behavioral-emotional-mental health problems regarding the suspected victim.

Common Perpetrator Characteristics of Problem Falsification (not a “profile”)

Remember that direct and/or circumstantial evidence proving BEHAVIOR is what should be used to confirm “child or adult maltreatment (abuse and/or neglect) through problem falsification/deception.” There simply is no “profile that can serve as appropriate evidence that a person is or is not a perpetrator of this kind.

I include this list only because there are some individuals who think there is a “profile,” and that a combination of the following “proves” the case that someone is or is not this kind of perpetrator.

  1. These perpetrators are usually mothers – but not always.
  2. These perpetrators usually present initially as at least “normal”, “good” caregivers – but not always.
  3. These perpetrators are liars, deceivers, and manipulators - and usually very believable, convincing, and superb in their ability to give seemingly plausible reasons for their behavior.
  4. These perpetrators know what they are doing. They are not simply overanxious and/or over-protective caregivers. There is a difference. For example: overanxious and/or overprotective caregivers usually stick close to the truth and express relief when told their child does not have, or is unlikely to have, the problem or problems in question. This is frequently not true of “problem falsification” perpetrators.
  5. These perpetrators may have extensive health care knowledge – or they may not.
  6. These perpetrators usually deny all or part of the maltreatment they have perpetrated, even when there is extensive evidence – but not always.
  7. When perpetrators do admit, the admission is usually only to what they have been caught doing – but not to the overall pattern of maltreatment falsification/deception and/or to the related pattern of falsification/deception within the overall umbrella of their lives.
  8. These perpetrators cannot be counted on to stop their problem falsification/deception behavior when they are suspected or even caught - but the behavior methodology may change as well as the kind of problems they exaggerate and/or fabricate and/or induce.
  9. These perpetrators may add or change health care providers or “doctor shop” - or they may not.
  10. These perpetrators may have “normal” mental health evaluations - or there may be identifiable mental health pathology.
  11. These perpetrators may have a history of problem falsification with regard to themselves – or they may not.
  12. These perpetrator-victim dynamics usually initially appear on the surface to be good - even excellent – but not always.
  13. These perpetrators may or may not have previous child protection or law enforcement agency involvement.
  14. These perpetrators should be considered even more potentially dangerous than before if/when they learn they are suspected.
  15. These perpetrators use their victims as objects in trying to satisfy their own needs. Needs may include trying to obtain internal gain (for example: attention from one or more others, professional and/or non professional – sympathy – revenge – to be seen by others as a hero caregiver, etc.) -----or to seek external gain (for example: financial gain, services, or other “stuff”-----or to seek both internal and external gain.
  16. These perpetrators may have a “dramatic flair” or be involved in exciting or dramatic events….or they may not.
  17. These perpetrators may change their maltreatment methodology and/or the “roblems they falsify – or they may not.

Victims

  • Victims can be of any age – and victims may be children, adults, or even animals.
  • Victims do not usually know that this kind of maltreatment has been perpetrated upon them.
  • The youngest known victim was a fetus.
  • Most identified victims to date have been young children.
  • When older children are identified as victims, an appropriate and thorough investigative process frequently reveals a pattern that has been going on for a long time.
  • Victims may or may not have further problems (physical and/or psychological- behavioral-emotional-mental health) as a result of the problem falsification/deception behavior, and such problems may surface immediately and/or into the future.
  • It is imperative that details of the confirmed problem falsification/deception history accompany victims into foster care, relative placement, adoption, etc.

Spouses/Partners/Relatives/Friends/Foster Parents, etc.

  • One or more of these individuals very frequently believes in and supports the perpetrator - even when there is overwhelming evidence of the problem falsification/deception behavior. It is unlikely that they will have the capacity to be objective. It is also very unlikely that they will comply with the kind of protection procedures necessary – even if there is a court order or they sign an agreement to do so.
  • There may not have been a reason for them to suspect any wrongdoing.
  • It is dangerous to place victims or potential victims of this kind with those who do not fully believe that the perpetration behavior has occurred or, if there is not a definitive finding yet, that the behavior may have occurred. A specialized assessment, over and above the usual process for approving a placement, must take place as a part of placement decision making. The old adage “if you don’t believe, you won’t protect” is never truer than with this kind of maltreatment or maltreatment suspicion.

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Factitious Disorder (Including Munchausen Syndrome)

  1. It is important to differentiate between the terms indicating maltreatment to others from maltreatment regarding oneself. Terms are often used incorrectly.
  2. Factitious Disorder, including its sub type, Munchausen Syndrome, is self abuse and/or neglect in which an individual deliberately exaggerates and/or fabricates and/or induces physical and/or psychological/behavioral/emotional/mental health problems with regard to himself/herself.
  3. Individuals frequently use the term “Munchausen”, “Munchausen’s”, or Factitious Disorder when they are really referring to maltreatment with regard to others.
  4. One must be careful to use the correct term - and to question what is meant if the term “Munchausen”, “Munchausen’s”, or Factitious Disorder is used in written or verbal form. I have been involved in several court actions in which the cases were temporarily dismissed due to use of the wrong terminology and, hence, to the wrong meaning.
  5. Factitious Disorder/Munchausen Syndrome is maltreatment to self.
  6. Both falsification resulting to maltreatment to self and falsification resulting maltreatment to others may be present in the same case situation.

The following figure is also from the Lasher – Sheridan book. The generic term, child or adult maltreatment (abuse or neglect) through deliberate problem falsification/deception, was not used in the book, but would overarch the items indicated with a *.

Comparison of Factitious Disorder/Munchausen Syndrome with Factitious Disorder by Proxy/Munchausen by Proxy

  Factitious Disorder & Subtype Munchausen Syndrome Factitious Disorder by Proxy, Munchausen Syndrome by Proxy (etc.)
Victim Self Someone in the care of the perpetrator (child, dependent adult, patient, animal, etc.)*
Perpetrator Self Someone caring for the victim*
Classification Mental disorder Maltreatment
Methods Exaggeration, fabrication, induction Exaggeration, fabrication, induction*
Motives Gratifications intrinsic to the sick role, such as attention, care, and lenience. “The perpetrator’s principal motivation is usually to attract attention, sympathy, care, and concern as the parent of a child with problems.” (Lasher and Feldman, 2001)

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