Münchausen syndrome by proxy

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Münchausen syndrome by proxy
Classification and external resources
DiseasesDB	33167
MedlinePlus	001555
eMedicine	med/3544
MeSH	D016735

Münchausen syndrome by proxy (MSbP or MBP) is a factitious disorder, describing a behavior pattern in which a caregiver deliberately exaggerates, fabricates, and/or induces physical, psychological, behavioral, and/or mental health problems in those who are in their care. Healthcare professionals in the UK prefer to use the term Fabricated or Induced Illness (FII). With deception at its core, this behavior is an elusive, potentially lethal, and frequently misunderstood form of child abuse or medical neglect that has been difficult to define, detect and confirm.

The name "Münchausen syndrome by proxy" is derived from Münchausen syndrome, but it is important to distinguish one from the other, as they describe very different (but related) conditions. People with Münchausen syndrome have a profound need to assume the sick role, and will exaggerate complaints, falsify tests, and/or self-inflict illnesses. MSbP perpetrators, by contrast, are willing to fulfill their need for positive attention by hurting their own child, thereby assuming the sick role by proxy. At times, they are also able to assume the hero role and garner still more positive attention, by appearing to care for and 'save' their child.

Münchausen syndrome by proxy has evoked much confusion and controversy within medical and mental health communities since its initial description in the late 1970s. There is still no clear consensus between experts on the very definition of the condition; some consider MSbP a mental disorder, others, an abusive behavior. Even the name remains unsettled — "Münchausen syndrome by proxy" is the most common layman's term, but a host of alternative names have either been used or proposed. Within the United States, factitious disorder by proxy (FDP or FDbP) is the leading alternative, while in the United Kingdom, it is known as Fabricated or Induced Illness by Carers (FII).

MSbP has also spawned much heated controversy within the legal and social services communities. In a handful of high-profile cases, mothers who have had multiple children die from sudden infant death syndrome have been declared to have MSbP. Based on MSbP testimony of an expert witness, they were tried for murder, convicted, and imprisoned for several years. That testimony was later impeached, resulting in acquittal of those defendants.

General information

In Münchausen syndrome by proxy, an adult caregiver either makes a child appear sick by fabricating symptoms, or actually causes harm to the child, in order to gain the attention of medical providers and others. In order to perpetuate the medical relationship, the caregiver systematically misrepresents symptoms, fabricates signs, manipulates laboratory tests, or even purposefully harms the child (e.g. by poisoning, suffocation, infection, physical injury). Studies have shown a mortality rate of between 6% and 10% of MSbP victims, making it perhaps the most lethal form of child abuse.

A study published in 2003 reviewed 451 documented cases of MSbP. The average age of the victims at diagnosis was 4 years old; slightly over half of the victims were aged 24 months or younger, and 75% of victims were under six years old. The average duration from onset of symptoms to diagnosis was 22 months. Six percent of the victims were dead, mostly from apnea (a common result of smothering) or anorexia, and 7% suffered long-term or permanent injury. About half of the victims have siblings; 25% of the known siblings were dead, and 61% of siblings had symptoms similar to the victim or that were otherwise suspicious. The victim's mother was the perpetrator in 76.5% of the cases, the father in 6.7%.

In the above study, most victims presented with about three medical problems in some combination out of 103 different reported symptoms. The most frequently reported problems are apnea (26.8% of cases), anorexia / feeding problems (24.6% of cases), diarrhea (20%), seizures (17.5%), cyanosis (blue skin) (11.7%), behavior (10.4%), asthma (9.5%), allergy (9.3%), and fevers (8.6%). Other symptoms include failure to thrive, vomiting, bleeding, rash and infections.  Many of these symptoms are easy to fake because they are subjective. For example, reports that "my baby had a fever last night" are impossible to prove or disprove. The number and variety of presented symptoms contributes to the difficulty in reaching a proper MSbP diagnosis.

The primary distinguishing feature that differentiates MSbP from 'typical' physical child abuse is the degree of premeditation involved. Whereas most physical abuse entails lashing out at a child in response to some behavior (e.g., crying, bedwetting, spilling food), assaults on the MSbP victim tend to be unprovoked and planned.

Also unique to this form of abuse is the role that health care providers play by actively, albeit unintentionally, enabling the abuse. By reacting to the concerns and demands of perpetrators, medical professionals are manipulated into a partnership of child maltreatment. Challenging cases that defy simple medical explanations may send health care providers trying in vain to pursue unusual or rare diagnoses, thus allocating even more time to the child and the abuser. Even without prompting, medical professionals may be easily seduced into prescribing diagnostic tests and therapies that are at best uncomfortable and costly, and at worst potentially injurious to the child. If the health practitioner instead resists ordering further tests, drugs, procedures, surgeries, or specialists, the MSbP abuser makes the medical system appear negligent for refusing to help a poor sick child and their selfless parent. Similar to those with Münchausen Syndrome, MSbP perpetrators are known to switch medical providers frequently, until they find one that is willing to meet their level of need; this practice is known as "doctor shopping" or "hospital hopping".

Münchausen by Proxy can also have many long-term emotional effects on a child. Child victims learn that they are most likely to receive the positive maternal attention they crave when they are playing the sick role in front of health care providers. Many case reports describe MSbP victims who grow into Münchausen syndrome patients or continue the pattern of MSbP abuse in their own children. Seeking personal gratification through illness can thus become a lifelong and multi-generational disorder.

It has been suggested that this form of ill treatment is driven not only by the attention that the child and parent/caregiver receive because of the diagnostic tests that must be run, but also by the satisfaction of being able to deceive individuals whom the abuser feels are more important or powerful than he or she.^{[citation needed]}

Initial description

Named after the German nobleman Baron Münchhausen, "Münchausen syndrome" was first described by R. Asher in 1951 as when someone invents or exaggerates medical symptoms, sometimes engaging in self-harm, to gain attention or sympathy.

The term "Münchausen syndrome by proxy" was first coined by John Money and June Faith Werlwas in a 1976 paper titled Folie à deux in the parents of psychosocial dwarfs: Two cases in order to describe the abuse-induced and neglect-induced symptoms of the syndrome of abuse dwarfism. That same year, Sneed and Bell wrote an article titled The Dauphin of Münchausen: factitious passage of renal stones in a child.

According to other sources, the term was created by the British pediatrician Roy Meadow in 1977. In 1977, Roy Meadow — then professor of pediatrics at the University of Leeds, England — described the extraordinary behavior of two mothers. According to Meadow, one had 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 behavior as Münchausen syndrome by proxy (MSbP).

The medical community was initially skeptical of MSbP's existence, but it gradually gained acceptance as a recognized condition. There are now more than 2,000 case reports of MSbP in the professional literature. Reports come from developing countries that include, but are not limited to, Sri Lanka, Nigeria, and Oman.

Terminology Confusion

Still widely used, the term "Munchausen syndrome by proxy" has led to much confusion in the literature. The term is not officially recognized in the latest Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association, which applies the label factitious disorder by proxy (FDP or FDbP), and lists it as a proposed disorder.

Initially referring only to harmful medical care, the appellation has been extended to cases in which the only harm arose from medical neglect, noncompliance, or even educational interference.

Ongoing lack of consensus has led to much confusion over terminology, and MSbP has been given many names in different places and at different times. A partial list of alternate names that have been used or proposed (with approximate dates) includes the following:

• Factitious Disorder by Proxy (FDP, FDbP) (U.S., 2000) American Psychiatric Association, DSM-IV-TR
• Fictitious Disorder by Proxy (FDP, FDbP) (U.S., 1994) American Psychiatric Association, DSM-IV
• Fabricated or Induced Illness by Carers (FII) (U.K., 2002) The Royal College of Paediatrics and Child Health
• Factitious Illness by Proxy (1996) World Health Organization
• Pediatric Condition Falsification (PCF) (U.S., 2002) American Professional Society on the Abuse of Children proposed this term to diagnose the child/victim; Perpetrator would be diagnosed "Factitious disorder by proxy"; MSbP would be retained as the name applied to the 'disorder' that contains these two elements, a diagnosis in the child and a diagnosis in the caretaker.
• Induced Illness (Munchausen Syndrome by Proxy) (Ireland, 1999–2002) Department of Health and Children
• Meadow's Syndrome (1984–1987) named after Roy Meadow. This label, however, had already been in use since 1957 to describe a completely unrelated and rare form of cardiomyopathy.
• Polle Syndrome (1977–1984) Coined by Burman and Stevens, from the then common belief that Baron Münchhausen's second wife gave birth to a daughter named Polle during their marriage. The baron declared that the baby was not his, and the child died from "seizures" at the age of 10 months. The name fell out of favor after 1984, when it was discovered that Polle was not the baby's name, but rather was the name of her mother's hometown.

Indications

Caution is required in the diagnosis of MSbP/FII/FDP. 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 an evaluation of the family dynamics. Diagnoses based only on a review of the child's medical chart can be rejected in court. The adult care provider who is abusing the child often seems comfortable and not upset over the child's hospitalization. While the child is hospitalized, medical professionals need to monitor the caregiver's visits in order to prevent any attempt to worsen the condition of the child. In addition, in most states, medical professionals have a duty to report such abuse to legal authorities. Warning signs of the disorder include:

• 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 patient's presentation or 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 child's 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 child's 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 child's illness do not occur in the parent's 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 child's 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 acknowledgment of their abilities.
• A patient who unexplainably deteriorates whenever discharge is planned.

Prevalence by gender

One study showed that in 93 percent of cases of MSbP, the abuser is the mother or another female guardian or caregiver. The female preponderance of the perpetrator may be attributed to socialization patterns that encourage females to seek the sympathy and assistance of others, and to the prevalence of women as the primary care giver within such patterns. Neuropsychological testing of perpetrators has shown either normal results or nonspecific abnormalities.

MSbP may also be attributed to another prevalent socialization pattern, which places females in the primary care-taking role. A psychodynamic model of this kind of maternal abuse exists.

MSbP may be more prevalent in the parents of those with a learning difficulty or mental incapacity, and as such the apparent patient could in fact be a grown adult.

Fathers and other male caregivers have been the perpetrators in only 7% of the cases studied. When they are not actively involved in the abuse, the fathers or male guardians of MSbP victims are often described as being distant, emotionally disengaged, and powerless. These men play a passive role in MSbP by being frequently absent from the home and rarely visiting the hospitalized child. Usually, they will vehemently deny the possibility of abuse, even in the face of overwhelming evidence or their child’s pleas for help.

Overall, male and female children are equally likely to be the victim of MSbP. In the few cases where the father is the perpetrator, however, the victim is three times more likely to be male.

False accusations

The case has been made that diagnoses of Münchausen syndrome by proxy are often false or highly questionable.

Controversy

During the 1990s and early 2000s, Meadow was an expert witness in several murder cases involving MSbP/FII. Dr. Meadow was knighted for his work for child protection, though later, his reputation, and consequently the credibility of MSbP, became severely damaged when several convictions of child killing, in which he acted as an expert witness, were overturned. The mothers in those cases were wrongly convicted of murdering two or more of their children, and had already been imprisoned for up to six years.

The pivotal case was that of Sally Clark. Clark was a lawyer wrongly convicted in 1999 of the murder of her two baby sons, largely on the basis of Meadow's evidence. As an expert witness for the prosecution, Meadow asserted that the odds of there being two unexplained infant deaths in one family were one in 73 million. That figure was crucial in sending Clark to jail but was hotly disputed by the Royal Statistical Society, who wrote to the Lord Chancellor to complain. It was subsequently shown that once other factors (e.g. genetic or environmental) were taken into consideration, the true odds were much greater, i.e., there was a significantly higher likelihood of two deaths happening as a chance occurrence than Meadow had claimed during the trial. Those odds in fact range from a low of 1:8500 to as high as 1:200. It emerged later that there was clear evidence of a Staphylococcus aureus infection that had spread as far as the child’s cerebral spinal fluid. Mrs Clark was released in January 2003 after three judges quashed her convictions in the Court of Appeal in London、but suffering from catastrophic trauma of the experience, she later died alcohol poisoning. Meadow was involved as a prosecution witness in three other high-profile cases resulting in mothers being imprisoned and subsequently cleared of wrongdoing — those of Trupti Patel, Angela Cannings, and Donna Anthony.

In 2003, Lord 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 Münchausen syndrome by proxy actually exists. It is important to distinguish between the act of harming a child, which can be easily verified, and motive, which is much harder to verify and which MSbP tries to explain. For example, a caregiver may wish to harm a child simply out of malice then attempt to conceal it as illness to avoid detection of abuse, rather than in order to draw attention and sympathy.

The distinction is often crucial in criminal proceedings, in which the prosecutor must prove both the act and the mental element constituting a crime to establish guilt. In most legal jurisdictions, a doctor can give expert witness testimony as to whether a child was being harmed but cannot speculate regarding the motive of the caregiver. FII merely refers to the fact that illness is induced or fabricated and does not specifically limit the motives of such acts to a caregiver's need for attention and/or sympathy.

In all, 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 in the Sally Clark trial. In July 2005, the GMC declared Meadow guilty of "serious professional misconduct", and he was struck off the medical register for giving “erroneous” and “misleading” evidence. At appeal, High Court judge Mr. Justice Collins said that the severity of his punishment "approaches the irrational" and set it aside.

Collins's judgment 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.

In addition to the controversy surrounding expert witnesses, an article appeared in the forensic literature that detailed legal cases involving controversy surrounding the murder suspect. The article provides a brief review of the research and criminal cases involving Münchausen Syndrome by Proxy in which psychopathic mothers and caregivers were the murderers. It also briefly describes the importance of gathering behavioral data, including observations of the parents who commit the criminal acts. The article references the 1997 work of Southall, Plunkett, Banks, Falkov, and Samuels, in which covert video recorders were used to monitor the hospital rooms of suspected MSbP victims. In 30 out of 39 cases, a parent was observed intentionally suffocating their child; in two they were seen attempting to poison a child; in another, the mother deliberately broke her 3-month-old daughter's arm. Upon further investigation, those 39 patients, ages 1 month to 3 years old, had 41 siblings; 12 of those had died suddenly and unexpectedly. The use of covert video, while apparently extremely effective, raises controversy in some jurisdictions over privacy rights.

Legal status in Australia and the UK

In most legal jurisdictions, doctors are only allowed to give evidence in regard to whether the child is being harmed. They are not allowed to give evidence in regard to the motive. Australia and the UK have established the legal precedent that MSbP does not exist as a medico-legal entity.

In a June 2004 appeal hearing, the Supreme Court of Queensland, Australia, stated:

As the term factitious disorder (Munchausen's Syndrome) by proxy is merely descriptive of a behaviour, not a psychiatrically identifiable illness or condition, it does not relate to an organised or recognised reliable body of knowledge or experience. Dr Reddan's evidence was inadmissible.

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 Doctors Pincus, Withers, and O'Loughlin that the appellant intentionally caused her children to receive unnecessary treatment through her own acts and the false reporting of symptoms of factitious disorder (Münchausen 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 behavior. 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 jury's determination. The evidence of Doctors Pincus, Withers, and O'Loughlin that the appellant was exhibiting the behavior of factitious disorder (Münchausen syndrome by proxy) should have been excluded.

Principles of law and implications for legal processes that may be deduced from these findings are that:

1. Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behavior, i.e., MSBP/FII/FDBP;
2. 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;
3. MSBP/FII/FDBP has been stated to be a behavior 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 MSBP/FII/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 recognized medical investigative procedures;
4. A label used to describe a behavior 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;
5. 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 Judgment was adopted into English law in the High Court of Justice by Mr. Justice Ryder. In his final conclusions regarding Factitious Disorder, Ryder states that:

I have considered and respectfully adopt the dicta of the Supreme Court of Queensland in R v. LM [2004] 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 "Münchausen syndrome by proxy" and "factitious (and induced) illness (by proxy)" are child protection labels that are merely descriptions of a range of behaviors, not a pediatric, psychiatric or psychological disease that is identifiable. The terms do not relate to an organized or universally recognized 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 pediatricians and of findings of fact by a court concerning fabrication, exaggeration, minimization 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 pediatricians, psychiatrists and psychologists for some while. That is not to minimize the nature and extent of professional debate about this issue which remains significant, nor to minimize 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 behaviors that should then be accurately set out (and even then only in the hands of the pediatrician or psychiatrist/psychologist). I cannot emphasis 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 carer's behavior. 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. The April 2007 issue of the journal Pediatrics specifically mentions Meadow as an individual who has been inappropriately maligned.

Münchausen syndrome by proxy involving pets

Medical literature describes a subset of MSbP caregivers, where the proxy is a pet rather than another person. These cases are labeled Münchausen syndrome by proxy: pet (MSbP:P). In these cases, pet owners correspond to caregivers in traditional MSbP presentations involving human proxies. No extensive survey has yet been made of the extant literature, and there has been no speculation as to how closely MSbP:P tracks with human MSbP.

Notable cases

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Wendi Michelle Scott, a mother accused of harming her child.

The book Sickened: The Memoir of a Munchausen by Proxy Childhood, by Julie Gregory, details her life growing up with a mother suffering from Münchausen by Proxy, who took her to various doctors, coached her to act sicker than she was and to exaggerate her symptoms, and who demanded increasingly invasive procedures to diagnose Gregory's enforced imaginary illnesses.

In popular culture

The American movie Yes Man features a band called Münchausen by Proxy, featuring Zooey Deschanel's character as lead vocalist.

The 1999 film The Sixth Sense portrays Münchausen syndrome by proxy during a scene in which a stepmother is caught on video adding floor cleaner to her ill daughter's food.

The plot of the 2003 Japanese J-horror film One Missed Call (着信アリ Chakushin ari) revolves around an older sister with a case of Münchausen syndrome by proxy.

In "The Calusari" episode of The X-Files, Agent Scully initially believes that one of the characters is inducing illness in her grandson and makes reference to Münchausen syndrome by proxy.

Stephen King's novel It, Eddie Kaspbrak's mother bullied him into believing he had a severe case of asthma, using Münchausen syndrome by proxy in order for Eddie to continue to care for her.

Lisa Gardner's novel Catch me: Charlie Grant, the main character, was abused in childhood by her mother who had Münchausen by Proxy, until she fought back and was placed under her aunt's care, while her mother was taken away to a psychiatric hospital.

See also

• Beverley Allitt
• Sally Clark
• Waneta Hoyt
• David Southall
• Marybeth Tinning
• Münchausen by Internet
• Münchausen syndrome
• Mythomania
• Parental alienation/Parental alienation syndrome
• Psychosomatic illness
• Victim playing

References

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