Munchausen by proxy: a case, chart series, and literature review of older victims

The history of an older child victim of Munchausen by proxy (MBP) is described. He was referred for evaluation after repeated sinus surgeries for recurrent sinus infections believed to be related to a falsified history of an immunodeficiency. The perpetrator was the mother of this 14-year-old victim, consistent with the majority of such cases. This case prompted a review of cases of MBP in older children reported in our hospital as well as a literature search for other cases in older children. METHODS: This study was a chart review of children over 6 years of age who had been evaluated by social services at the Children's Hospital at the Cleveland Clinic and reported as cases of Munchausen by proxy to Child Protective Services between January 2001 and June 2003. Also, an OVID, Psychline, and Pubmed literature review of published cases of Munchausen by proxy were identified, and cases occurring in the older child were selected for review. RESULTS: Older children who are the victims of Munchausen by proxy may have an induced illness, but falsified reports of symptoms and medical history to coerce the child to undergo medical procedures may be more common. Collusion of the victim with the perpetrator may also become a factor as the child ages and adopts the deception. Given the complex relationship that exists between the parent and child, it is difficult to predict whether the victim either will assist the caregiver in maintaining the factitious illness or be able to recognize the falsification. CONCLUSIONS: Older children who are the victims of Munchausen by proxy may fear consequences of revealing the factitious illness. Physicians must consider the possibility of this diagnosis whenever there are discrepancies in a child's illness that makes a factitious illness a consideration.     

Munchausen syndrome by proxy: A family affair

Munchausen syndrome by proxy is an unusual form of child abuse: a child presents with an illness that has been factitiously produced by a parent, typically the mother. A case of chronic illicit insulin administration to a one-year-old girl is described. Despite temporary separation of the child from the mother and long-term psychiatric intervention, factitious illnesses continued, including urine specimen contamination, laxative-induced diarrhea, suspected bladder catheterization, and suspected poisoning. Retrospective review of the medical records of the mother and two siblings demonstrated previously unrecognized evidence of factitious illnesses. The medical records contained evidence of 30 separate episodes of suspected or documented factitious illness in these four members of the same family. This unique family illustrates the significant morbidity of Munchausen syndrome by proxy and a poor response to psychiatric treatment.     

Munchausen syndrome by proxy

Munchausen syndrome by proxy is a form of child abuse in which a disorder of the child is fabricated by a parent. Although often considered rare, it may have been overlooked frequently in the past. The reported cases of children with Munchausen syndrome by proxy range in age from infancy to 8 years. Their "illnesses" consist of fabricated histories, inflicted physical findings, altered laboratory specimens, and induced disorders. The perpetrator usually is the child's mother, who may have Munchausen syndrome. Consequences of the syndrome may include painful tests, frequent hospitalizations, potentially harmful treatment, and death. The diagnosis can be made when medical and social histories are characteristic of the syndrome and clinical findings are absent, suggestive of induced illness, or resolve upon separation of the child and parent. Suspicion of the syndrome should be discussed with the family once the safety of the child is insured, and the case should be reported under the child abuse reporting law of the state. Social, family, and medical histories must be obtained and verified, and court intervention should be considered. Four patients who illustrate typical features of the syndrome are described.     

Web of deceit: A literature review of Munchausen syndrome by proxy

Munchausen syndrome by proxy (MSBP) is a form of child abuse wherein the mother falsifies illness in her child through simulation and/or production of illness, and presents the child for medical care, disclaiming knowledge as to etiology of the problem. From the literature, 117 cases of MSBP were reviewed. The most common presentations of MSBP were bleeding, seizures, central nervous system depression, apnea, diarrhea, vomiting, fever, and rash. Short-term morbidity rate was 100%; long-term morbidity rate was 8%. Mortality rate was 9%. Failure to thrive was associated with MSBP in 14% of cases. All perpetrators of MSBP were the mothers. The origins of this type of aberrant maternal behavior remain abstruse, as do the long-term psychological effects on the child victims. Guidelines for medical, social service, and legal management are provided.     

Munchausen syndrome by proxy: a survey of professionals' knowledge

This study examined professionals' knowledge of a relatively rare form of child abuse, Munchausen syndrome by proxy (MSBP). Eighty-six professionals representing hospital or other medical settings, community services programs, the state children's service agency, and various law enforcement agencies were surveyed. Results indicated that professionals employed in medical or hospital settings were three times more likely to have heard of the syndrome than those employed by community service agencies. Journal articles and colleagues were the most popular sources of information pertaining to MSBP. Respondents identified 77 possible cases of MSBP in their caseloads over the past year. Findings suggest the need for educating community professionals as well as the possibility that the incidence of MSBP has been grossly underestimated. Implications for future research and preventive efforts are discussed.     

The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) – A systematic review of 796 cases

IntroductionLittle is known about the perpetrators of medical child abuse (MCA) which is often described as “Munchausen’s syndrome by proxy” or “factitious disorder imposed on another”. The demographic and clinical characteristics of these abusers have yet to be described in a sufficiently large sample. We aimed to address this issue through a systematic review of case reports and series in the professional literature.MethodA systematic search for case reports and series published since 1965 was undertaken using MEDLINE, Web of Science and EMBASE. 4100 database records were screened. A supplementary search was then conducted using GoogleScholar and reference lists of eligible studies. Our search yielded a total sample of 796 perpetrators: 309 from case reports and 487 from case series. Information extracted included demographic and clinical characteristics, in addition to methods of abuse and case outcomes.ResultsNearly all abusers were female (97.6%) and the victim’s mother (95.6%). Most were married (75.8%). Mean caretaker age at the child’s presentation was 27.6 years. Perpetrators were frequently reported to be in healthcare-related professions (45.6%), to have had obstetric complications (23.5%), or to have histories of childhood maltreatment (30%). The most common psychiatric diagnoses recorded were factitious disorder imposed on self (30.9%), personality disorder (18.6%), and depression (14.2%).ConclusionsFrom the largest analysis of MCA perpetrators to date, we provide several clinical recommendations. In particular, we urge clinicians to consider mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder at heightened risk for MCA. Longitudinal studies are required to establish the true prognostic value of these factors as our method may have been vulnerable to publication bias.     

Malingering-by-proxy: Need for child protection and guidance for reporting

The feigning of disabling illness for compensation at the direction or pressure by others, which is called malingering by proxy (MBP), has been the subject of several spirited articles. Chafetz and Prentkowski (2011) suggested that MBP has the potential for real harm to the child. In a poster at the AACN scientific session in 2011, Chafetz and Binder (2011) pursued a case of MBP that showed the child had clearly suffered and failed to progress in the 6 years that had passed since she was first evaluated as an 11 year old. In the present article, we identify three cases that compare and contrast effects of MBP, illustrating that child abuse and/or neglect can be a serious and reportable consequence of MBP behavior. To illustrate how MBP behavior can cause child abuse, we compare MBP behavior with Munchausen Syndrome by Proxy (MSBP), another condition of volitional noncredible behavior produced in a vulnerable person at the direction or pressure by others. Guidance criteria for reporting MBP as child abuse/neglect are introduced in this article.     

Factitious Disorder by Proxy in Educational Settings: A Review

Factitious disorder by proxy (FDP), historically known as Munchausen syndrome by proxy, is a diagnosis applied to parents and other caregivers who intentionally feign, exaggerate, and/or induce illness or injury in a child to get attention from health professionals and others. A review of the recent literature and our experience as consultants indicate clearly that FDP has emerged in educational settings as well. Variants of educational FDP include parents of children with real or fabricated physical disabilities who request excessive or unneeded school health services and parents who request extensive education-related evaluations for children who do not demonstrate any educational need. If such cases continue to emerge, school districts will be asked to test more students who do not have disabilities under the Individuals with Disabilities Education Act. Also, special educational directors will be weighing the cost of providing unneeded testing and educational services against the cost of defending themselves in litigation to prove that the testing and services are unnecessary. A table of guidelines is provided for school and other personnel confronted with repeated requests for unwarranted special education services. Suggestions for future research are included.     

Beyond collusion: active illness falsification

OBJECTIVE: This article explores the relationship between factitious disorder by proxy victimization and the genesis of factitious disorder in young people. It is hoped that this will aid in our understanding of how some illness falsification behaviors may be learned and transmitted within the family system. METHOD: A discussion of the origins of adult factitious disorder and recent findings on the phenomenon of illness falsification in children and adolescents is integrated with some of the more ambiguous or "blended" cases which combine primary falsification by the youngster with caregiver collusion. Those less easily classified cases of factitious illness which fall in the gray areas, containing elements of both independent illness falsification by a child or adolescent with an earlier history of collusion with a parent's Munchausen by Proxy disorder, are proposed as a type of transitional case which may help us better understand the process by which illness falsification is learned. RESULTS: The literature on illness falsification in adults supports the possibility that adult factitious disorder may have its origins in adolescence or perhaps even earlier. Several cases are identified which suggest that some youngsters independently falsifying illness may have had earlier experiences of Munchausen by Proxy victimization or perhaps experienced the modeling or encouragement of illness falsification by a caregiver. Certain elements of the child victim experience, including efforts to overcome feelings of powerlessness, chronic lack of control, and disappointment in the physician are suggested as possible dynamics in the eventual development of independent illness falsification behaviors. CONCLUSIONS: The many unanswered questions in our understanding of the development of factitious illness in children and adolescents suggest avenues for further research. It is hoped that increased understanding will eventually allow more rapid, reliable identification of these patients and more effective interventions within the family system, with positive implications for future generations.     

Characteristics of hospital-based Munchausen Syndrome by Proxy in Japan

OBJECTIVE: This article explores characteristics of Munchausen Syndrome by Proxy (MSBP) in Japan, a country which provides an egalitarian, low cost, and easy-access health care system. METHODS: We sent a questionnaire survey to 11 leading doctors in the child abuse field in Japan, each located in different hospital-based sites. Child abuse doctors answered questions regarding the characteristics of MSBP cases for whom they had helped care. RESULTS: Twenty-one MSBP cases (20 families) were reported. Characteristics of the victims included: no differences based on sex, 4.6 years of age on average when MSBP was confirmed, and an average of 1.9 years duration of MSBP abuse. Biological mothers were at least one of the perpetrators in 95% of cases. Among the 12 cases (57%) who remained with their families, 2 victims died. Only 5% of perpetrators had a medical background or relatives who engaged in healthcare work. CONCLUSION: There are similar features of MSBP cases between Japan and other English-speaking countries, such as the UK or the US. However, perpetrators of MSBP in Japan did not have a medical background. Easier access to hospital resources in Japan may give greater opportunities for perpetrators to obtain medical knowledge from doctors or nurses. PRACTICE IMPLICATIONS: The findings suggest that perpetrators of MSBP should not be assumed to possess a medical background in a country which provides universal medical care such as Japan. A contributory factor of MSBP may be the high frequency of medical consultations and equal level of accessibility of medical resources for Japanese citizens. Social welfare services that need to decide on custody for MSBP victims should recognize the relatively high risk of life-threatening danger in their family of origin. Further collaboration between hospital staff including pediatricians, nurses, medical social workers and staff at the social welfare services is needed to protect children from MSBP.     

论医疗机构在“错误出生”中的法律责任

提供医疗服务的医务人员或者医疗机构由于过失没有检查出胎儿有严重的疾病,致使父母误以为胎儿健康而未堕胎生下残疾儿,父母因此可以享有医疗损害赔偿权.赔偿范围应当包括原告母亲及先天缺陷儿的医疗费用,对缺陷儿的人力照顾费用及特殊教育费用.但由于产前诊断存在一些难以避免的误差,某些特殊情况下,不能在错误出生之诉中要求医疗机构承担违约或侵权责任.     

Reactive attachment disorder

This single case study, written from the personal perspective of an adoptive parent, tells the story of Anna, a child who experienced many difficulties adjusting to her life at home and at school. Sue Chapman, who is a teacher as well as being Anna's mother by adoption, describes her frustration with the ineffective behaviour management strategies she is initially encouraged to use. Her discovery of information about reactive attachment disorder and her consequent use of 're-nurturing' approaches led to a transformation in Anna's behaviour, outlook and achievements. This successful experience encourages Sue Chapman to speculate about the relevance of these approaches.     

Munchausen Syndrome by Proxy: medical diagnostic criteria

Medical diagnostic criteria for Munchausen Syndrome by Proxy are presented. The strength of the known facts may vary from case to case, and thus there may be different degrees of diagnostic conviction. Therefore, diagnostic criteria for a definitive diagnosis, and a possible diagnosis of Munchausen Syndrome by Proxy are provided. Because the gathering of evidence in a case may, ultimately, diminish or exclude the diagnosis of Munchausen Syndrome by Proxy, diagnostic criteria for the inconclusive determination and the definitely excluded diagnosis are also enunciated.     

The murder of children by fathers in the context of child abuse

OBJECTIVE: This study examined the backgrounds of fathers who fatally abuse their children and the contexts within which these homicides occur. The type of relationship between victim, perpetrator, and the victim's mother was a particular interest. METHODS: Data were gathered from 26 cases of fatal child abuse perpetrated by fathers derived from the wider Murder in Britain study. Quantitative and qualitative data were collected from extensive prison case files of men serving life sentences for child murder. RESULTS: This was a group of undereducated, underemployed men with significant criminal histories. All except one victim had been subjected to previous violence by the offender, almost three-quarter of whom had also perpetrated violence against their intimate partners (the child's birth mother). Many men had unreasonable expectations and low tolerance levels of normal childhood behaviors, and many appeared jealous and resentful of these young children. All 26 victims were under 4 years of age. Sixty-two percent of the offenders were stepfathers and in only four cases was the perpetrator a birth father married to the birth mother. Stepfathers had more disrupted and disadvantaged backgrounds and experiences than birth fathers. CONCLUSIONS: Findings suggest that fathers who perpetrate fatal child abuse have a propensity to use violence against children in their care and intimate partners, raising questions about the gender dynamics and generational boundaries operating in these families. The nature and type of intimate relationship (whether married or cohabiting) and fathering relationship (whether birth or de facto) were important differentiating factors in these homicides as well as characteristics of the offender. PRACTICE IMPLICATIONS: Professionals working in child protection strive to provide effective services to children and families, ever vigilant to the possibility of the death of a child as a consequence of an assault. By and large, fathers (either biological or de facto) as the perpetrators of such assaults have received minimal attention in both policy and practice. Findings from this study suggest that practitioners need to be cognizant of men's attitudes towards and expectations of fathering (particularly stepfathering) which may present increased levels of risk to both children and intimate partners.     

The untreatable family

The untreatable family is defined as one in which it is unsafe to permit an abused child to live. Despite the fact that many families turn out to be resistive to treatment, they have received very little attention. In the field of physical abuse, 16-60% of parents reabuse their children following the initial incident. Sexual reabuse is estimated to occur in 16% of cases. Treatment of abusive families also aims to alter family functioning. From studies in physical abuse we find 20-87% of families are unchanged or worse at the end of treatment. In sexual abuse the equivalent figures are 16-38%. Parental factors associated with a poor outcome include parental history of severe childhood abuse, persistent denial of abusive behavior, refusal to accept help, severe personality disorder, mental handicap complicated by personality disorder, parental psychosis with delusions involving the child, and alcohol/drug abuse. Parents lack empathy for their child and fail to see the child's needs as separate from their own. Severe forms of abuse (fractures, burns, scalds, premeditated infliction of pain, vaginal intercourse or sexual sadism) are more likely to prove untreatable. Munchausen by proxy, nonaccidental poisoning, and severe forms of nonorganic failure to thrive are similarly resistant. An early recognition of untreatability may help to reduce burnout by diverting precious resources from the untreatable to the families for whom there is relatively more hope.     

Institutional abuse: tubal sterilization in a population at risk of ill-treating their children

Among the 145 patients at risk of child abuse and neglect who were seen in 1980 in our institution in the prevention of child abuse and neglect prenatal clinic, 19 were sterilized after giving birth. The criteria applied to these 19 patients were compared to the common criteria applied to our general maternity population. We were able to prove that these common criteria were systematically disregarded in the case of a mother at risk of ill-treating her child. We further studied our approach from the angle of the conflict which could exist for health care professionals between the choice of leaving these women with the right to reproduce or putting an end to a history of ill-treatment of children.     

A description of a mother's play guidance for her child with autism in the process of playing by the rules

The purpose of this study is to describe the strategies used by a mother with a child with autism during games activities with peers to provide the child with social skills. The research method of this study is ‘a qualitative single‐subject case study’. The participants in this research are a mother and her 9‐year‐old child with autism, one brother and three typically developing peers. The research data were collected through field notes, interviews, audio and videotape recordings during natural interactions between the mother and her child. The strategies the mother used were analysed using video records during games activities in a natural park. The interactions of the mother with her child were examined in the context of a hide‐and‐seek game. Micro‐ethnographic‐analysis techniques were used in the analysis of the video records. According to the research data, it was found that the mother with a child with autism made extensive use of 13 different verbal strategies and seven different non‐verbal strategies. It was observed that the mother guided her child and the group during the hide‐and‐seek game, arranged the environment of the games, carried out routine activities both at the beginning and at the end of the games and arranged the games in accordance with the abilities and preferences of the child. These applications bear a resemblance to the model of integrated game groups. As a result, the data from the present research reveal that a mother having a child with autism acts as a guide during the games and uses verbal and non‐verbal interaction strategies in this guidance process and by doing so contributes to the process of participation in the games by the child with autism and in the child's social interaction with his peers.     

Texts as Artefacts Crossing Sites: Map Making at Home and School

This article compares a child’s drawings at home with a child’s drawings at school. The drawings were of maps, which had been a school topic. As part of a longitudinal study looking at children’s text making at home and at school three particular homes were focused on for eighteen months. This article looks at one home – that of a six year old Turkish boy who lives with his mother and brother. The case study illustrates how children can take something learned at school and transform it at home. The article starts with discussing the text created in the home, then compares this to texts created at school. The point is made that children can activate meaning in a different way at home than at school. While this is one case study, it suggests that transforming artefacts across sites may be something children do that often goes undocumented.     

The development of children with down syndrome: the influence of maternal adaptation,mother-child interaction and early forms of support

In this paper, we present a longitudinal case study involving four dyads with babies with Down syndrome from birth until the age of 7 years – the moment at which the children were observed for the last time before they began compulsory schooling. At each data collection point, the mother was given a semi-directive interview and we filmed a free interaction situation. The objective of our study was to carry out an indepth analysis of the ways in which mothers adapt to the birth of a ‘different baby’, the evolution of their expectations in relation to the child's development, mother–child interaction and early support for both the child and the family, and the way in which these aspects of the overall situation relate to the children's development. The data of our longitudinal study show that there is an interaction between children's development and family characteristics and patterns, particularly mother–child interaction and the way in which the mother deals with the stress factors associated with the fact that she has a disabled child. We found that the four dyads experienced different models of early support, which to some extent reflect what really does happen in Portugal in cases involving children with disabilities, and that the programmes' impact was not identical in every situation. The most successful was the one which best suited the family's wishes, and involved both the mother and later on the kindergarten teacher.