Munchausen Syndrome by Proxy: Are There Factitious Illnesses in Children?

This was a term paper I wrote for one of my college classes. I chose this topic to research and report on because I fully believe my SK's BM is suffering from this with my SS' interesting diagnosis of asthma. His diagnosis was days before we were to take my SS on a family vacation. BM did not like this idea, so we fully believe she made him ill to prevent him from going with us. We believe she has continued to make him ill, to the point of hospitalization to get attention (even negative) from my husband. When medical bills were pilling up due to the amount of appointments BM was taking my SKs to, we made the decision to switch insurance providers to a $0.00 copay. This eliminated copay drama/conflict. As soon as this happened, my SS was magically cured and no longer needed asthma medication. This only further adds to our suspicion of MSBP.

It is a very difficult condition to prove, but my SS's pulminologist is beginning to see the signs. This last consultation with my husband he discussed the possibility of MSBP. Although this is reported as a "rare" condition, I fully believe it is under reported due to the difficulty in proving the condition. I believe there should be more research on MSBP along with the underlying factors, such as a mental health condition of the parent, usually the mother.

This paper was written by a college student for their undergraduate degree. Please do not plagiarize.

Abstract

Munchausen Syndrome is a disorder that is displayed in adults. The adult fabricates illnesses about themselves to fulfill their need for attention. Munchausen Syndrome by Proxy is an under recognized type of abuse to a child. The perpetrator is an adult, usually the mother, who fakes or fabricates illnesses in her children. The fictitious illnesses are frequent and usually cause the child to undergo painful procedures or be prescribed unnecessary medication. There is a link between personality and other mental disorders with the mother and the development of Munchausen Syndrome in the victim children later in life.

Key words: Munchausen Syndrome, Munchausen Syndrome by Proxy, Child Abuse, factitious disorder

Factitious Illnesses in Children

Munchausen Syndrome (MS) is a disorder presumably displayed in adults. The adult self-inflicts injuries and fabricates their own illnesses or symptoms in order to gain the attention and treatment from medical facilities and staff (Murray, 1997, p. 343). Munchausen Syndrome by Proxy (MSbP) is a disorder and a form of child abuse caused by an adult, the majority of the time the mother. The mother reports false symptoms or induces illnesses in her child to seek medical attention (Murray, 1997, p. 343). The Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) refers this disorder as a factious disorder (Criddle, 2010; Stirling, 2007). The American Professional Society on the Abuse of Children defines MSbP as pediatric condition falsification for the victim child and factitious disorder by proxy for the perpetrator (Criddle, 2010, p. 47).

Although Munchausen Syndrome by Proxy is considered rare and extremely hard to diagnose, many medical practitioners are becoming more aware of the warning signs. Herbert Schreier, MD and Judith Libow, PhD (1993) surveyed pediatric neurologists and pediatric gastroenterologists who reported over 400 cases of the syndrome (p. 319). Over fifty percent were confirmed cases and the rest they highly suspected the syndrome (Schreier & Libow, 1993, p. 319). Schreier and Libow’s (1993) survey indicated that there is a significant amount of Munchausen Syndrome by Proxy cases and portrayed the possibility they are being misdiagnosed or not diagnosed at all (p. 319). It is the possibility that medical providers are not as aware of the syndrome, so are less likely to report abuse (Schreier & Libow, 1993, p. 319).

Given the nature of this disorder, it can range from minor cases where a mother only exaggerated the child’s symptoms or the syndrome can be much more severe, even fatal if undetected, where the mother induces signs and symptoms in the child (Stirling, 2007, p. 1027). Due to the high mortality and morbidity rates have confirmed and suspected cases, it is critical for medical staff to have knowledge and know when it is appropriate to report a case to their child protective service agency (McGuire & Feldman, 2001; Kahan & Yorker, 1991; Stirling, 2007). 

Case Example

Tona McGuire, PhD and Kenneth Feldman, MD (1989) report the psychological morbidity of children who have been the victims of Munchausen Syndrome by Proxy in the following case (p. 289):

A documented case reports a 3-year-old female who was having unmanageable vomiting since she was an infant. She was hospitalized on multiple occasions and eventually IV hyperalimentation was ordered, yet no organic causes for her illness were diagnosed. The mother had reported frequent vomiting and on one occasion the child had vomited blood. The medical staff later discovered that the child’s IV line was tampered with. It was documented that the child’s symptoms increased only when the mother was present and resolved when she wasn’t. The mother was seen as an attentive mother and staff members were sympathetic towards her. Eventually the staff referred the case to Child Protective Services. The toddler’s symptoms decreased at the birth of her younger brother. The infant was admitted to the hospital shortly after birth for lethargy and bloody gastroenteritis. He too required IV hyperalimentation. The mother’s emotions would range from excited to angry as her child became ill. The test results and drug screens came back negative, but the infant would make significant progress towards recovery in the mother’s absence. When the mother was present the infant would relapse. The case was referred to Child Protective Services. The infant was allowed to return back home with the mother for lack of proof. The infant was hospitalized on many more occasions for blood in his stool until his toddler years (McGuire & Feldman, 2001, p. 290).

History of the Syndrome

In 1951, a British physician, Richard Asher, discovered Munchausen Syndrome (Murray, 1997; Criddle, 2010). The syndrome was named after an 18^th century politician by the name of Baron Von Munchausen. Baron Von Munchausen was well known for his tall tails of his travels and military experiences (Kahan & Yorker, 1991; Castiglia, 1995). In 1786, Rudolph Eric Raspe wrote and published Baron Von Munchausen’s stories into children’s books called, The Amazing Travels and Adventures of Baron Von Munchausen (Kahan & Yorker, 1991; Criddle, 2010). The patients who were diagnosed with Munchausen Syndrome were known to tell lies like the characters in all of the Munchausen stories (Kahan & Yorker, 1991, p. 76). This syndrome was then recognized as Munchausen Syndrome.

In 1977, a British pediatrician and professor, Roy Meadow, later discovered Munchausen Syndrome by Proxy after finding that many of his patients’ mothers had fabricated lies about the child’s symptoms or purposely poisoned their children (Kahan & Yorker, 1991; Castiglia, 1995). It has been of great speculation that Baron Von Munchausen’s own child died of unknown causes (Libow & Shreier, 1986, p. 603).

Diagnosis, Signs, and Symptoms

            MSbP does not have a sequence of events and is very hard for physicians to detect.  Medical providers need to be conscious of this disorder when determining what is medically necessary and appropriate for the child. Do the medical history, signs, and symptoms make sense? (Stirling, 2007, p. 1027). Is the treatment the child receiving harming him or her or is it going to potentially become harmful? (Stirling, 2007, p. 1027). The most crucial factor medical providers need to consider is who is instigating the treatments (Stirling, 2007, p. 1027).

            The most commonly reported signs and symptoms of the most severe include the central nervous system, such as seizures (Criddle, 2010, p. 49). Other MSbP patients have reported bleeding, apnea, diarrhea, vomiting, fever, rash, allergies, and asthma (Criddle, 2010, p. 49). All of which, are hard symptoms to disprove a caregiver of reporting. The child could be having unexplained, recurrent symptoms even when under the proper medical care. The symptoms could also flare up, but only in the presence of the caregiver. The child is repeatedly hospitalized and enduring extensive medical examinations (Castiglia, 1995, p. 80).

            The caregiver has a previous nursing or medical career background, or is very proficient in medical terminology and procedures (Castiglia, 1995, p. 80). In some cases, the mother appears to be overprotective. The mother may claim the same history of illness that she is reporting with the child (Castiglia, 1995, p. 80).  The mother may even be pushing for more tests to be completed (Castiglia, 1995, p. 80). 

The caregiver is used in making the determination of the diagnosis and report of child abuse in a medical setting. When the signs and symptoms are near undetectable, fabricated, or induced the medical provider still needs to make the determination if the child is being harmed or is potentially at risk to be harmed (Stirling, 2007, p. 1028). When a medical provider suspects MSbP, they should consult with other professionals to gather information and observe the child and caregiver by using covert videotape surveillance (CVS) (Striling, 2007, p. 1028). The use of CVS can confirm the suspicion of abuse by monitoring the caregiver when with the child. This helps determine if the reported symptoms are exaggerated or induced (Striling, 2007, p. 1028). If this disorder is left undiagnosed, the medical professional, a mandated reporter, leaves the chance for the child’s induced illness to result in death.

Commonly Induced or Fabricated Illnesses

            There are many documented illnesses that caregivers have induced or fabricated. The illnesses specifically fall into four major categories, which include poisoning, bleeding, infections, and injuries (Criddle, 2010, p. 48).

The different poisons include, but are not limited to: ipecac, salt, insulin, laxatives, lorazapam, corrosives, and clonidine (Criddle, 2010, p. 48). Injecting insulin can cause a non-diabetic child to have hyperinsulinemic hypoglycemia (Criddle, 2010, p. 48). Epecac is a liquid that can induce severe emesis if given too much, just the same as laxatives can induce severe diarrhea if given too much. Both can cause dehydration.

A caregiver can induce hematuria, gastrointestinal bleeding, and bruising by using many different methods (Criddle, 2010, p. 48). One in particular is the caregiver placing their blood into a specimen jar with the child’s urine or in a soiled diaper.

Infections where a caregiver reports their child was running a fever are hard to disprove (Criddle, 2010, p. 48). Some induced methods that cause infections include: applying fecal matter to an open wound, injecting urine into the child, rubbing dirt into orthopedic pin sites, or rubbing saliva or fecal matter into IV catheters (Criddle, 2010, p. 48).

Injuries caused by an MSbP caregiver are not the common injuries that are found in physical abuse cases. They are more common in regards to child maltreatment (Criddle, 2010, p. 48). Injuries suffered by the victims include: non-healing wounds, recurrent conjunctivitis, fractures that never heal, and osteomyelitis (Criddle, 2010, p. 48). One common injury is apnea. The child is suffocated to the point that they stop breathing and usually in this instance, the caregiver attempts to revive the child.

The methods picked to induce an illness are dependent upon the disease severity. In the mildest form a caregiver fabricates the illness, claiming the child experienced symptoms of apnea (Criddle, 2010, p. 48). The syndrome in a moderate form would consist of falsifying medical records or tampering with medical specimens (Criddle, 2010, p. 48). The most severe form is when the caregiver begins inducing the symptoms in the child, which include diarrhea or seizures (Criddle, 2010, p. 48).

Due to the signs and symptoms being very subtle, it could take years for a proper diagnosis. The delay in diagnosing MSbP causes irrefutable harm to the child’s psychological wellbeing (Criddle, 2010, p. 49). In most cases, the child is between infancy and 5 years of life, but in some cases MSbP can continue into a child’s adolescence years (Criddle, 2010, p. 49). The older child could be coerced into providing medical personnel with factitious symptoms. The child craves attention, and this could be the way he or she has learned to gain positive maternal attention (Criddle, 2010, p. 49). It has been documented that most child victims come to abuse their children later in life or develop Munchausen Syndrome (Criddle, 2010, p. 49).

Perpetrators

            A physical child abuser’s motivations are usually out of frustration or anger. They will release their frustration out by kicking or hitting the child. Laura Criddle, PhD, (2010) references that an MSbP perpetrator’s motivations are significantly different and subtle (p. 49). The mother goes to great lengths to satisfy her social and emotional needs, even though it is emotionally and physically traumatizing her child (Criddle, 2010, p. 49). Libow and Schreier (1986) place the perpetrators into three different categories: help seekers, active inducers, and doctor addicts (p. 604).

            A child whose mother is a help seeker is more likely to have infrequent hospitalizations or only have one factitious illness (Libow & Schreier, 1986, p. 605). The mother is only seeking out her needs through the medical community. Once she is confronted, it gives her the opportunity to communicate her problems that exist; marital discord, domestic violence, stress, or anxiety (Libow & Schreier, 1986, p. 605). She is not as likely to flee when approached by child protective services. She is more likely to feel relief and be more willing to cooperate with treatment (Libow & Schreier, 1986, p. 605).

            The active inducers are the most common of the MSbP cases (Libow & Schreier, 1986, p. 606). The parent actively induces symptoms and illnesses in their child. These mothers are described as trustworthy, loving, concerned, and cooperative (Libow & Schreier, 1986, p. 606). This mother is more likely to flee when suspected of MSbP and often refuse to cooperate with treatment, unless a court has ordered treatment on the condition of home placement of the child (Libow & Schreier, 1986, p. 606). Libow and Schreier (1986) describe this type of mother as anxious, depressed, in an extreme state of denial, dissociative, controlling, and paranoid projection (p. 606).

            The last and most severe type of perpetrator along side the active inducer is the doctor addict. This mother is obsessed with obtaining medical treatment for her child (Libow & Schreier, 1986, p. 606). This mother believes that her child is ill, even though diagnostic test results show otherwise (Libow & Schreier, 1986, p. 607). These mothers are seen more as paranoid, angry, and distrustful to a medical professional (Libow & Schreier, 1986, p. 607). Libow and Schreier (1986) describe this mother as having an over attached, symbiotic relationship with her child (p. 607). This mother is more likely to flee and not be cooperative with treatment (Libow & Schreier, 1986, p. 607).

            When the victim child dies or becomes too old a mother will move onto a sibling (Criddle, 2010, p. 50). The mother usually is very good at manipulation and deception, that when a family member or friend catches her, they will insist that she was not abusing the child and was wrongly accused (Criddle, 2010, p. 50). Kahan and Yorker (1991) document that the perpetrator has been psychiatrically diagnosed with either hysteria, sociopathy, narcissism, or borderline personality disorder (p. 78).

Treatment

            There is no cure for MSbP besides completely separating the mother from the child (Criddle, 2010, p. 53). This protects the child and will help confirm MSbP. The child should have a drastic change in symptoms and improve (Criddle, 2010, p. 53). Family therapy is an option to help the mother with her mental disorders. John Stirling (2007) makes reference to utilizing a third party outside of the medical field to report true symptoms of the child when in the care of the mother (p. 1029).

Involving child protective services in placement of the child or third party decision making is yet another option but does not completely solve the underlying problems (Stirling, 2007, p. 1029). Placing the child in foster care and prosecuting the mother will stop the current abuse and prevent any further attempts (Stirling, 2007, p. 1029).

Discussion

            Munchausen Syndrome by Proxy, pediatric condition falsification, or factitious disorder by proxy are all a very serious form of child abuse. MSbP has a high rate of mortality, morbidity, and recidivism (Criddle, 2010, p. 54). The mother is known to be extremely deceitful and manipulative. She seeks out the attention of medical professionals and their staff to feed their obsession. The mother plays on the emotions of others to coerce them into potentially harmful or unnecessary treatment of her child (Criddle, 2010, p. 54). All medical professionals and their staff should consider MSbP when presented with an unusual case or a case where the child only experiences symptoms or reports of symptoms when in the care of the perpetrator (Criddle, 2010, p. 54). If a physician suspects MSbP, they should seek to involve all medical personnel that have treated the child. The perpetrator more often then not, may seek out medical attention from multiple professionals until she receives the diagnosis she wants (Stirling, 2007, p. 1029). In the most severe cases, law enforcement and child protective services agencies should be contacted to help protect the child and ensure his or her safety away from the perpetrator (Stirling, 2007, p. 1029). If the diagnosis is immediate, there is the chance that mental health professionals can use effective behavioral health therapy to help reverse the psychological damage to the victim child (Stirling, 2007, p. 1029). 

References

Castiglia, P. (1995). Munchausen Syndrome by Proxy. Journal of Pediatric Health Care, 9(2), 79-80.

Criddle, PhD, L. (2010). Monsters in the Closet: Munchausen Syndrome by Proxy. Critical Care Nurse, 30(6), 46-55.

Kahan, MD, B., & Cofts Yorker, RN, JD, B. (1991). Munchausen Syndrome by Proxy: Clinical Review and Legal Issues. Behavioral Sciences and the Law, 9, 73-83.

Libow, PhD, J., & Schreier, MD, H. (1986). Three Forms of Factitious Illness in Children: When is it Munchausen Syndrome by Proxy? American Orthosychiatric Association, 56(4), 602-611.

McGuire, PhD, T., & Feldman, MD, K. (1989). Psychologic Morbidity of Children Subjected to Munchausen Syndrome by Proxy. Pediatrics, 83(2), 289-292.

Murray, J. (1997). Munchausen Syndrome/Munchausen Syndrom by Proxy. The Journal of Psychology, 131(3), 343-352.

Schreier, MD, H., & Libow, PhD, J. (1993). Munchausen Syndrome by Proxy: Diagnosis and Prevalence. American Orthopsychiatry Association, 63(2), 73-83.

Stirling, MD, J. (2007). Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting. Pediatrics, 119, 1026-1030.