{'fraction_non_alphanumeric': 0.020736698499317873, 'fraction_numerical': 0.0032742155525238743, 'mean_word_length': 5.353552859618717, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Munchausen syndrome by proxy or factitious illness spectrum disorder of childhood.

EDITOR,-Your recent series on Munchausen syndrome by proxy was a useful critiquel-3; however we have points of disagreement with each of the articles. Morley rightly criticises bad practice,' but he offers no alternative advice about dealing with those cases of severe child abuse generally classified as Munchausen syndrome by proxy. He seems more inclined to dismiss their existence on the basis of poor history taking. Medicine can err in overdiagnosis, but ofmore concern to us is the role of doctors in the creation of Munchausen syndrome by proxy. Morley misses this. His position seems to be overly defensive of both parents and doctors. Fisher and Mitchell argue convincingly for distinguishing 'prototypical' Munchausen syndrome by proxy from other clinical situations incorrectly labelled as Munchausen syndrome by proxy.2 They attempt to clarify classification by reference to the categorical model of Libow and Schreier, and the dimensional model of Eminson and Postlethwaite. Both of these models have contributed positively to the debate on this syndrome, but each has significant flaws. For example, Libow and Schreier suggest the 'active inducers' constitute prototypical Munchausen syndrome by proxy; however this formulation neglects the fact that without the ongoing involvement of the medical profession active illness induction does not result in the full range of prolonged morbidity characteristic of prototypical Munchausen syndrome by proxy. With regard to the dimensional model, Fisher and Mitchell state 'the same case may present on different parts of the dimension at different times'. This implies that prototypical Munchausen syndrome by proxy may have previously manifested as anxiety about symptoms, then as symptom exaggeration, and finally as symptom induction. We are not aware of any empirical evidence to support this claim. Abuse/damage to the victim can coexist with any degree of parental 'desire to consult', and is not on a qualitative continuum with, say, overanxious parenting. Therefore damage to the child must be considered a separate dimension that determines the need for child protection. Meadow regards cases of extreme induced illness as child abuse, but claims that they require different management.3 We know of no empirical evidence that indicates that the application of standard child abuse management principles hampers the management of Munchausen syndrome by proxy. Meadow's agreement with DSM IV that the diagnosis of Munchausen syndrome by proxy be applied to a perpetrator whose behaviour is motivated by 'the need to assume the sick role' is open to more criticism. While we respect Meadows unequalled experience, there is no research that demonstrates that such motivation is universal in this condition. Indeed, attempts to assess the motivation of the perpetrator are notoriously unrewarding, and potentially delay diagnosis, further increasing the risk to the victim. We argue for (1) recognition of the critical role of the medical profession in the aetiology of Munchausen syndrome by proxy, (2) explicit attention to its abusive nature, (3) a standard approach to the management of any form of serious abuse, including Munchausen syndrome by proxy as defined in these articles, to ensure child safety and facilitate optimal treatment, and (4) restriction of the label Munchausen syndrome by proxy to apply to a transaction between doctor, perpetrator and victim, rather than to any one protagonist.4 TERENCE DONALD JON JUREIDINI Women's and Children's Hospital, North Adelaide, South Australia 5006, Australia