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: 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.     

Post-traumatic stress as a pathway to psychopathology among adolescents at high-risk for victimization

ObjectiveVictimization by violence elevates adolescents’ risk for developing internalizing and externalizing psychopathology. Recent findings suggest that disruptions in developmental processes associated with post-traumatic stress (PTS) reactions may partially account for the relationship between victimization and the subsequent development of psychopathology during adolescence. The present study tested the temporal sequencing of these associations using multi-informant measurements in a large, diverse sample of adolescents at high-risk for victimization.MethodData were collected from a multi-site consortium of prospective studies, the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Information about 833 youth’s victimization experiences (i.e., direct, indirect, familial, and non-familial violence), PTS, and affective, anxiety, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms were gathered from youth and their caregivers during biannual face-to-face interviews when youth were between the ages of 4 and 14 years, and continuously from official child protective services records.ResultsStructural equation modeling revealed that cumulative victimization contributed to elevations in youth and caregiver reported late childhood and early adolescent psychopathology. While PTS mediated the association between victimization and youth reported ADHD, ODD, CD, major depressive, and generalized anxiety symptoms during adolescence, it only mediated the association between victimization and caregiver reported affective symptoms.ConclusionsPTS reactions following childhood victimization partially accounted for escalations in psychopathology during the transition to adolescence. These findings underscore the importance of integrating trauma-informed assessment and intervention approaches with at-risk adolescents. Researchers should determine whether trauma-focused interventions sufficiently ameliorate other psychopathology among victimized adolescents or if additional interventions components are necessary.     

Different interpretations of Munchausen Syndrome by Proxy

The definition of Munchausen Syndrome by Proxy is reviewed and considered in the context of the overlap with other harmful behaviors of parents. The high incidence of personal abnormal illness behavior in the perpetrators is leading to increasing concern about the safety of children who are cared for by parents who have abnormal illness behavior.     

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.     

The deceit continues: an updated literature review of Munchausen Syndrome by Proxy

OBJECTIVE: This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP). METHOD: Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles. RESULTS: Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury. CONCLUSION: Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.     

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.     

Concerns about research and prevention strategies in Munchausen Syndrome by Proxy (MSBP) abuse

There would seem to be three motives for research into Munchausen Syndrome by Proxy (MSBP) abuse; first to enhance treatment; second to enhance our understanding of the psychopathology of those who carry out the abuse; and third to find interventions to prevent its occurrence. We will argue that only the first justification is valid. The second and third should be questioned for several reasons including: MSBP abuse is the wrong kind of event to think of in terms of categorical diagnosis; rare events are inherently difficult to predict; and better research targets are available. We propose that research energy would be more productively directed towards furthering our understanding of somatization and certain problematic aspects of modern pediatric practice. We offer suggestions as to appropriate areas for research.     

Sibling and peer victimization in childhood and adolescence

This study examined how victimizations by either a sibling or peer are linked to each other and to mental health in childhood and adolescence. The data were from the National Survey of Children's Exposure to Violence which includes a sample of children aged 3–9 (N = 1,536) and adolescents aged 10–17 (N = 1,523) gathered through telephone interviews. An adult caregiver (usually a parent) provided the information for children while self-reports were employed for adolescents. Fifteen percent of each age group reported victimization by both a sibling and peer. Victimization by a sibling alone was more common in childhood than adolescence. Victimization by a sibling was predictive of peer victimization. Children and adolescents victimized by both a sibling and peer reported the greatest mental distress. This work establishes that for some children and adolescents, victimization at the hands of other juveniles happens both at home and school. Programs should consider the role of siblings and target parents and siblings to encourage the development and maintenance of constructive sibling interactions.     

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.     

Predicting resilience in sexually abused adolescents

This research examined factors that predicted resilience in sexually abused adolescents. Using Bronfenbrenner's Process-Person-Context-Time (PPCT) ecological model, this study considered the proximal and distal factors that would contribute to adolescents' reactions to sexual victimization. This correlational study used hierarchical regression analysis (n=237) with cross-sectional data from the National Survey of Child and Adolescent Well-Being Wave I (NSCAW, Dowd et al., 2002). This study found that school engagement, caregiver social support, hope and expectancy, caregiver education and SES predicted resilience. In line with the PPCT model, findings suggest that placing a greater emphasis on the contextual environment could improve support for adolescent resilience. Augmenting interventions that focus on individual change with those that address environmental factors may increase the benefits to adolescents affected by sexual abuse.     

Effects of the child–perpetrator relationship on mental health outcomes of child abuse: It's (not) all relative

The present study was conducted to better understand the influence of the child–perpetrator relationship on responses to child sexual and physical trauma for a relatively large, ethnically diverse sample of children and youth presenting for clinical evaluation and treatment at child mental health centers across the United States. This referred sample includes 2,133 youth with sexual or physical trauma as their primary treatment focus. Analyses were conducted to ascertain whether outcomes were dependent on the perpetrator's status as a caregiver vs. non-caregiver. Outcome measures included psychiatric symptom and behavior problem rating scales. For sexual trauma, victimization by a non-caregiver was associated with higher posttraumatic stress, internalizing and externalizing behavior problems, depression, and dissociation compared to youth victimized by a caregiver. For physical trauma, victimization by a non-caregiver was also associated with higher posttraumatic symptoms and internalizing behavior problems. The total number of trauma types experienced and age of physical or sexual trauma onset also predicted several outcomes for both groups, although in disparate ways. These findings are consistent with other recent studies demonstrating that perpetration of abuse by caregivers results in fewer symptoms and problems than abuse perpetrated by a non-caregiving relative. Thus, clinicians should not make a priori assumptions that children and adolescents who are traumatized by a parent/caregiver would have more severe symptoms than youth who are traumatized by a non-caregiver. Further exploration of the role of the perpetrator and other trauma characteristics associated with the perpetrator role is needed to advance our understanding of these findings and their implications for clinical practice.     

Victimization and polyvictimization of Spanish children and youth: Results from a community sample

Most research into adolescent victimization and polyvictimization has been carried out in the United States and in northern European countries. The present study aims to determine the prevalence of victimization and polyvictimization in a community sample of Spanish adolescents. The sample consisted of 1,107 youth (M = 14.52, SD = 1.76), 590 males and 517 females, randomly recruited from 7 secondary schools in a north-eastern region in Spain. The Spanish version of the Juvenile Victimization Questionnaire was applied, assessing 6 aggregate categories of childhood victimization (conventional crimes, caregiver, peer and sibling, witnessed and indirect, sexual, and electronic victimization). A total of 83% of adolescents reported at least 1 type of victimization during their lives, and 68.6% during the last year. Boys were generally more exposed to conventional crimes (68.0%), and girls to emotional abuse by caregivers (23.0%) and to sexual (13.9%) and electronic (17.6%) victimization during their lifetime. Age differences obtained in victimization rates for the past year confirmed that peer and sibling victimization peak in early adolescence (33.9%). Witnessing community violence was more frequent in older adolescents (34.7%). Almost 20% of the sample were considered as polyvictims (i.e., experienced victimization in 7 or more forms of victimization). Adolescent polyvictims experienced victimization in 4 or more domains during their lifetime. This study adds new information on the epidemiology of victimization in the international context and is the first to do so from the perspective of a country in south-western Europe. It illustrates that Spanish youth experience a higher level of victimization than official records suggest, and that gender and age should be taken into account when analyzing this complex area of study.     

Adaptation and psychometric properties of the ISPCAN Child Abuse Screening Tool for use in trials (ICAST-Trial) among South African adolescents and their primary caregivers

Child abuse prevention research has been hampered by a lack of validated multi-dimensional non-proprietary instruments, sensitive enough to measure change in abuse victimization or behavior. This study aimed to adapt the ICAST child abuse self-report measure (parent and child) for use in intervention studies and to investigate the psychometric properties of this substantially modified tool in a South African sample. First, cross-cultural and sensitivity adaptation of the original ICAST tools resulted in two preliminary measures (ICAST-Trial adolescents: 27 items, ICAST-Trial caregivers: 19 items). Second, ICAST-Trial data from a cluster randomized trial of a parenting intervention for families with adolescents (N = 1104, 552 caregiver-adolescent dyads) was analyzed. Confirmatory factor analysis established the hypothesized 6-factor (adolescents) and 4-factor (caregivers) structure. Removal of two items for adolescents and five for caregivers resulted in adequate model fit. Concurrent criterion validity analysis confirmed hypothesized relationships between child abuse and adolescent and caregiver mental health, adolescent behavior, discipline techniques and caregiver childhood abuse history. The resulting ICAST-Trial measures have 25 (adolescent) and 14 (caregiver) items respectively and measure physical, emotional and contact sexual abuse, neglect (both versions), and witnessing intimate partner violence and sexual harassment (adolescent version). The study established that both tools are sensitive to measuring change over time in response to a parenting intervention. The ICAST-Trial should have utility for evaluating the effectiveness of child abuse prevention efforts in similar socioeconomic contexts. Further research is needed to replicate these findings and examine cultural appropriateness, barriers for disclosure, and willingness to engage in child abuse research.     

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.     

Diagnostic, expanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception

OBJECTIVE: The overriding objective is a critical examination of Munchausen syndrome by proxy (MSBP) and its closely-related alternative, factitious disorder by proxy (FDBP). Beyond issues of diagnostic validity, assessment methods and potential detection strategies are explored. METHODS: A painstaking analysis was conducted of the MSBP and FDBP literature as it relates diagnostic and assessment issues. Given the limitations of this literature, extrapolations were provided from the extensive theory and research on malingering as a related response style. RESULTS: Diagnostic formulations for both MSBP and FDBP de-emphasize the clinical characteristics of the perpetrator. In the case of FDBP, inferential judgments about motivation (e.g., adoption of a sick role) are challenging on conceptual and clinical grounds. When explanatory models from malingering are applied, most research has focused pathogenic models, often allied with psychodynamic thought. Finally, clinical methods for the assessment of MSBP and FDBP are not well developed. CONCLUSIONS: Refinements in the conceptualization of MSBP and FDBP can be provided through prototypical analysis. Drawing from malingering research, explanatory models should be expanded to include adaptational and criminological models. Finally, detection strategies for MSBP and FDBP must be formally operationalized and rigorously validated.     

African-American women who use crack cocaine: a comparison of mothers who live with and have been separated from their children

OBJECTIVE: This study examined factors that influenced caregiver status for African-American mothers who use crack cocaine but are not receiving drug treatment and participated in an HIV prevention study in North Carolina. METHOD: Caregiver mothers who were living with at least one of their children at intake (n = 257) were compared with non-Caregivers who were separated from all of their children (n = 378). Bivariate analyses and logistic regression were used to compare these mothers at intake on current drug use, risky sex practices, psychological symptoms, victimization, and aggression. RESULTS: Compared with Caregiver mothers, non-Caregivers reported higher frequencies of drug use, risky sex practices, psychological distress, and victimization experiences. Caregiver mothers were more likely than non-Caregiver mothers to have health insurance, but were less likely to have received drug treatment. Logistic regression found that non-Caregiver mothers were significantly more likely than Caregiver mothers to be older, to have been physically abused as children, to trade sex more frequently, to be homeless, and to have no health insurance. Recent crack use, psychological symptoms, and victimization were not significantly related to caregiver status. CONCLUSIONS: Findings that socio-environmental factors were more strongly associated with caregiver status than crack use underscore the importance of contextual issues such as housing, victimization history, and resources in serving maternal crack users. Community outreach and interventions that engage mothers who use drugs and live with their children may be more effective strategies than formal office-based services to link mothers who use crack and their children to needed drug treatment and family and child services.     

Extending poly-victimization theory: Differential effects of adolescents’ experiences of victimization on substance use disorder diagnoses upon treatment entry

BackgroundAlthough victimization is a known contributor to the development of substance use disorders, no research has simultaneously examined how characteristics of victimization experienced over time, such as the type of abuse, the presence of poly-victimization, closeness to perpetrator(s), life threat or fear, and negative social reactions to disclosing victimization, cluster into profiles that predict substance use disorders.ObjectiveThe aim of the current study is to assess how profiles of victimization and trauma characteristics are associated with substance use disorders and assess potential gender differences.Participants and SettingParticipants were 20,092 adolescents entering substance use treatment.MethodsWe used latent class and multi-group latent class analysis to extract classes of victimization and associated characteristics. Emergent classes were used to predicted substance use disorder status at treatment intake.ResultsFive classes were extracted: poly-victimization + high harmful trauma characteristics, sexual abuse + negative social reaction and perceived life threat, emotional abuse + trusted perpetrator, physical abuse and low all. Similar classes were found for the multi-group model. In both the overall and female-specific models, the poly-victimization + high harmful trauma characteristics class was more severe than all other classes in terms of opioid use disorder, tobacco use disorder, and dual diagnosis. Other class differences were found across gender.ConclusionsAdolescents entering treatment can be distinguished by their profiles of victimization experiences and associated characteristics, and these profiles evidence different associations with substance use disorder diagnoses. Results point to a need for more nuanced assessment of victimization experiences and gender-specific interventions.