Fabricated or Induced Illness

# Overview
Fabricated or Induced Illness (FII), originally and more commonly known as Munchausen Syndrome by Proxy (MSbP), involves a caregiver whom feigns or induces an illness in another person, usually to gain power and control over the victim as well as attention or sympathy from others. The caregiver is usually a parent, guardian, or spouse, and the other person is usually a vulnerable child or adult. Although cases with feigned or induced physical illness receive the most attention, it is also possible for a perpetrator who emotionally abuses a victim to simulate and fabricate conditions that appear to be psychiatric and/or genetic problems.

# Initial description
In 1977, pediatrician Roy Meadow, then professor of Paediatrics at the University of Leeds, England, described the extraordinary behaviour of two mothers: One had (Meadow claimed) poisoned her toddler with excessive quantities of salt.  The other had introduced her own blood into her baby's urine sample. He referred to this behaviour as Munchausen Syndrome by Proxy (MSbP). Although it was initially regarded with skepticism, MSbP soon gained a following amongst medics and social workers.  Although it's not listed in the DSM-IV manual,  a formal name since March 2002 is now Fabricated or Induced Illness (FII) according to the Royal College Of Paediatrics and Child Health. In 2003 however, Earl Howe, the Opposition spokesman on health, accused the professor of inventing a "theory without science" and refusing to produce any real evidence to prove that Munchausen Syndrome by Proxy actually exists.  That said, there are now more than 2,000 case reports of FII in the professional literature.  Reports come from developing countries that include, but are not limited to, Sri Lanka, Nigeria, and Oman. Dr. Meadow was knighted for his work on FII.

# Indications
Caution is required.  Many of the items below are also indications of a child with organic, but undiagnosed illness. An ethical diagnosis of MSbP must include an evaluation of the child, an evaluation of the parents and of the family dynamics. Diagnoses based only on a review of the child's medical chart are now frequently being rejected in court.
- A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling and unexplained.
- Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible.
- A parent who appears to be medically knowledgeable and/or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients problems.
- A highly attentive parent who is reluctant to leave their childs side and who themselves seem to require constant attention.
- A parent who appears to be unusually calm in the face of serious difficulties in their childs medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other, more sophisticated, facilities.
- The suspected parent may work in the health care field themselves or profess interest in a health-related job.
- The signs and symptoms of a childs illness do not occur in the parents absence (hospitalization and careful monitoring may be necessary to establish this causal relationship).
- A family history of similar or unexplained illness or death in a sibling.
- A parent with symptoms similar to their childs own medical problems or an illness history that itself is puzzling and unusual.
- A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with serious illness.
- A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.
- A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgement of their abilities.

# Prevalence by gender
It has been noted that MS applies mostly to men whereas FII perpetrators are disproportionately females.  One study showed that in over 90% of cases of Munchausen by proxy, it is the mother who is the abuser.  In other cases, the MSbP abuser is another female caregiver.  Fathers have been the perpetrators in a handful of professional reports.  The female preponderance may be attributed to the typical socialization pattern which encourages females to seek the sympathy and assistance of others while males who do so are considered to be "weak".   It is not known whether this predilection to seek sympathy also has a gender-based genetic component.  Neuropsychological testing of perpetrators has shown either normal results or nonspecific abnormalities.
MSbP may also be attributed to another prevalent socialization pattern, that which places females in the primary caretaking role. For a psychodynamic model of this kind of maternal abuse see Anna Motz The Psychology of Female Violence: Crimes Against the Body (Routledge, 2001 ISBN 978-0415126755, 2nd ed. forthcoming 2008 ISBN 978-0415403870).

# Controversy
During the 1990s and early 2000s, Meadow was an expert witness in several murder cases involving FII, some of which resulted in parents being convicted of murdering their children and imprisoned.  In addition, several children were taken into care.  In 2003, a number of high-profile acquittals brought Meadow's ideas into serious disrepute. Around 250 cases resulting in conviction in which Meadow was an expert witness were reviewed, with few changes. Meadow was investigated by the British General Medical Council over evidence he gave as an expert witness for the prosecution in the Sally Clark trial where he asserted that the odds of there being two unexplained infant deaths in one family were one in 73 million, a figure considered crucial in sending her to jail but a claim hotly disputed by the Royal Statistical Society who wrote to the Lord Chancellor to complain. It was subsequently shown that the true odds were in the region of one in 200. The GMC in July 2005 came to a verdict of guilty of "serious professional misconduct" and he was struck off the register for giving "misleading" evidence in the Sally Clark case. At appeal High Court judge Mr Justice Collins described this as "irrational" and set it aside. Meadow was involved as a prosecution witness in 2 other high profile cases resulting in mothers being imprisoned and subsequently cleared of wrongdoing - those of Trupti Patel and Angela Canning. Collins' judgement raises important points concerning the liability of expert witnesses - his view is that referral to the GMC by the losing side is an unacceptable threat and that only the Court should decide whether its witnesses are seriously deficient and refer them to their professional bodies.  The case of Dr Jayne Donegan may also be relevant to this.
In 2003, Sickened, an autobiographical account of the Munchausen Syndrome by Proxy abuse Julie Gregory suffered as a child, was published.
In 2003, the documentary film MAMA/M.A.M.A. was released, which questioned the validity of Munchausen Syndrome by Proxy, arguing that in many cases doctors' overmedication of infants may be the real cause of their infirmity rather than the mother's mental illness.  The film contains an interview with Sir Roy Meadow.

# Legal status in Australia and UK
It has been established in legal precedents in Australia and the U.K. that Munchausen Syndrome By Proxy does not exist as a medico-legal entity.
In June 2004 in an Appeal Hearing, the Supreme Court of Queensland, Australia stated:
In some person's opinions, the term factitious disorder (Munchausen Syndrome By Proxy) is merely descriptive of a behaviour, not a psychiatrically identifiable illness or condition. American experts mostly disagree, however, and perpetrators' legal actions in the U.S. to quash descriptions and use of Munchausen Syndrome By Proxy have almost always failed.  QCA 192.].
The Queensland Supreme Court further ruled that the determination of whether or not a defendant had caused intentional harm to a child was a matter for the jury to decide and not for the determination by expert witnesses:
The diagnosis of Drs. Pincus, Withers, and OLoughlin that the appellant intentionally caused her children to receive unnecessary treatment through her own acts and the false reporting of symptoms of factitious disorder (Munchausen Syndrome) by proxy is not a diagnosis of a recognised medical condition, disorder, or syndrome. It is simply placing her within the medical term used for the category of people exhibiting such behaviour. In that sense, their opinions were not expert evidence because they related to matters able to be decided on the evidence by ordinary jurors. The essential issue as to whether the appellant reported or fabricated false symptoms or did acts to  intentionally cause unnecessary medical procedures to injure her children was a matter for the jurys determination. The evidence of Drs. Pincus, Withers, and OLoughlin that the appellant was exhibiting the behaviour of factitious disorder (Munchausen Syndrome By Proxy) should have been excluded.
Principles of law and implications for legal processes which may be deduced from these findings are that:
- Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behaviour. i.e. MSBP/FII/FDBP;
- MSBP/FII/FDBP is not a mental disorder (i.e. not defined as such in DSM IV) and the evidence of a psychiatrist should not therefore be admissible;
- MSBPFII/FDBP has been stated to be a behaviour describing a form of child abuse, and not a medical diagnosis of either a parent or a child. A medical practitioner cannot therefore state that a person `suffers from MSBPFII/FDBP and such evidence should also therefore be inadmissible. The evidence of a medical practitioner should be confined to what they observed and heard, and what forensic information was found by recognised medical investigative procedures;
- A label used to describe a behaviour is not helpful in determining guilt and is prejudicial. By applying an ambiguous label of MSBP/FII to a woman is implying guilt without factual supportive and corroborative evidence;
- The assertion that other people may behave in this way i.e. fabricate and/or induce illness in children to gain attention for themselves (FII/MSBP/FDBY) contained within the label, is not factual evidence that this individual has behaved in this way. Again therefore, the application of the label is prejudicial to fairness and a finding based on fact.
The Queensland Judgement was adopted into English law in the High Courts of Justice in Case No. WR03C00142   on 18 January 2005 by Mr. Justice Ryder. 
In his final conclusions regarding Factitious Disorder, Mr. Justice Ryder states that :-
I have considered and respectfully adopt the dicta of the Supreme Court of Queensland in R v. LM  QCA 192 at paragraph 62 and 66.  I take full account of the criminal law and foreign jurisdictional contexts of that decision but I am persuaded by the following argument upon its face that it is valid to the English law of evidence as applied to children proceedings.The terms Munchausen Syndrome by Proxy and Factitious (and Induced) Illness (by Proxy) are child protection labels that are merely descriptions of a range of behaviours, not a paediatric, psychiatric or psychological disease that is identifiable.  The terms do not relate to an organised or universally recognised body of knowledge or experience that has identified a medical disease (i.e. an illness or condition) and there are no internationally accepted medical criteria for the use of either label.In reality, the use of the label is intended to connote that in the individual case there are materials susceptible of analysis by paediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimisation or omission in the reporting of symptoms and evidence of harm by act, omission or suggestion (induction).  Where such facts exist the context and assessments can provide an insight into the degree of risk that a child may face and the court is likely to be assisted as to that aspect by psychiatric and/or psychological expert evidence.All of the above ought to be self evident and has in any event been the established teaching of leading paediatricians, psychiatrists and psychologists for some while.  That is not to minimise the nature and extent of professional debate about this issue which remains significant, nor to minimise the extreme nature of the risk that is identified in a small number of cases.In these circumstances, evidence as to the existence of MSBP or FII in any individual case is as likely to be evidence of mere propensity which would be inadmissible at the fact finding stage (see Re CB and JB supra).  For my part, I would consign the label MSBP to the history books and however useful FII may apparently be to the child protection practitioner I would caution against its use other than as a factual description of a series of incidents or behaviours that should then be accurately set out (and even then only in the hands of the paediatrician or psychiatrist/psychologist).  I cannot emphasise too strongly that my conclusion cannot be used as a reason to re-open the many cases where facts have been found against a carer and the label MSBP or FII has been attached to that carers behaviour.  What I seek to caution against is the use of the label as a substitute for factual analysis and risk assessment.
In his book, Playing Sick (2004) Marc Feldman notes that such findings have been in the minority among U.S. and even Australian courts. Pediatricians and other physicians have banded together to oppose limitations on child abuse professionals whose work includes FII detection.  Dr. Meadow is among the individuals specifically mentioned as having been inappropriately maligned in the April 2007 issue of the journal Pediatrics.

# Munchausen Syndrome by Proxy: Pet
The medical literature includes a number of descriptions of a subset of Munchausen Syndrome by Proxy (MSbP) caretakers, whose cases are labeled Munchausen Syndrome by Proxy: Pet (MSbP:P), factitious disorder with pet proxies, malingering with animal proxies, or even dubbed instances of "battered pet" (in reference to "battered woman" syndrome). In these cases, pet owners correspond to caretakers in traditional MSbP presentations involving human proxies. No extensive survey has yet been made of the extant literature, so there can be no basis for speculations about just how closely MSbP:P tracks with MSbP (human).

# In popular culture
- (1992) In 1992, the American Dialect Society voted Munchausen Syndrome by Proxy one of its words of the year, in the "Most Amazing" category.
- (1997) On October 8 1997, the CBS medical drama Chicago Hope had an episode entitled "The Adventures of Baron Von Munchausen... by Proxy". 
- (1999) In 1999, the the film The Sixth Sense featured a character whose mother had killed her, due to Munchausen by Proxy. The lead character Cole met the ghost of a young girl, Kyra Collins, and helped her to expose how her mother had slowly poisoned her.
- (2007) On July 7 2007, the British ITV crime drama Wire in the Blood had an episode entitled "The Colour of Amber", in which Dr. Tony Hill and Detective Inspector Alex Fielding were investigating the abduction and murder of a young girl, Janita. It turned out however, that Janita was actually murdered by her mother (a perpetrator of Munchausen by Proxy), due to refusing to take her "medicine". Janita's younger brother and dead twin sister were also victims of her mother.