Munchausen by Proxy Syndrome

Misunderstood Child Abuse

Teresa F. Parnell, Deborah O. Day

• Publisher: SAGE Publications, Inc
• Year: 1997
• ISBN:
  9781506339719
• Edition: 1
• Topic: Psychology
• Subtopic: Interpersonal Relations in Psychology
• Index: Psychology

Munchausen by Proxy Syndrome (MBPS), a form of child abuse in which a caretaker--usually a mother--fabricates and/or induces illness in a child, is one of the least understood forms of child abuse and mental illness. Examining the current knowledge about the manifestations and consequences of this perplexing behavior, Munchausen by Proxy Syndrome assists all professionals working with chronically ill children in identifying and intervening with this bizarre and often deadly form of abuse. Drawing from their firsthand experience with the complexities of such cases, the editors and contributors address critical issues of not only identification and assessment but also longterm psychotherapy. Therapy with the mother/perpetrator has traditionally been markedly unsuccessful, but this book provides a much-needed framework for the successful treatment of acknowledged perpetrators. Emphasizing the important role of efficient multidisciplinary cooperation in handling MBPS cases, Munchausen by Proxy Syndrome also features perspectives from experts in the fields of medicine, child protection, education, social work, hospital administration, and law.Munchausen by Proxy Syndrome demystifies the mother/perpetrator?s deception and gives professionals the knowledge to save children from induced life-threatening illnesses and consequent medical procedures. Professionals, academics, researchers, and students in a variety of fields, including clinical/counseling psychology, social work, nursing/health sciences, criminal justice, and law, will need the information presented in this book to help stop this form of abuse.

Part I

Identifying and Managing the Munchausen by Proxy Syndrome Case

1	An Overview
	Teresa F. Parnell

---

Some patients consistently produce false stories and fabricate evidence, so causing themselves needless hospital investigations and operations. Here are described parents who, by falsification, caused their children innumerable harmful hospital procedures—a sort of Munchausen Syndrome by proxy,

—Roy Meadow, “Munchausen Syndrome by Proxy: The Hinterland of Child Abuse,” 1977

---

As a pediatrician in Leeds, England, Roy Meadow (1977) encountered two young patients with puzzling symptoms that he described in a seminal paper.¹ The first case was that of a 6-year-old child, Kay, who was seen at three medical centers due to recurrent passing of foul-smelling, bloody urine throughout her young life. Since the age of 3 years, she had been on continuous antibiotics that produced secondary symptoms such as drug rashes, fever, and candidiasis. Medical professionals were especially puzzled by the intermittent nature of her symptoms. Purulent, bloody urine specimens were followed by clear ones within hours. Similarly, foul discharges on her vulva would be gone within the same day. Curiously, she otherwise appeared to be a healthy girl who was developing normally.

Kay’s parents were described as most cooperative, and her mother always stayed with her in the hospital. The mother was further described as loving and concerned, but not as worried about the cause of the symptoms as were the doctors. Suspicions were thus raised by what seemed an unsolvable problem, the inconsistency of facts, and the mother’s temperament.

Meadow and his colleagues decided to work under the assumption that everything about Kay’s history and the subsequent medical investigations was false. They set out to test this theory by comparing urine specimens collected under strict supervision with those collected by the mother or left unattended in the mother’s presence. Of the 57 specimens collected, the 45 collected by a nurse were normal, whereas the 12 collected by the mother or left in her presence were grossly abnormal. Analysis of a urine sample provided by Kay’s mother further suggested that the unsupervised specimens contained some of the mother’s urine.

The evidence suggested to Meadow and his colleagues that the mother had been adding her own urine or menstrual discharge to specimens of her daughter’s urine. The consequences of her actions for Kay included

12 hospital admissions, seven major X-ray procedures . . . , six examinations under anaesthetic, five cystoscopies, unpleasant treatment with toxic drugs and eight antibiotics, catheterisations, vaginal pessaries, and bactericidal, fungicidal, and oestrogen creams; the laboratories had cultured her urine more than 150 times and had done many other tests; sixteen consultants had been involved in her care. (p. 344)

The mother denied interfering with her daughter’s care. However, during the mother’s outpatient psychiatric treatment, Kay’s health remained good, with no urinary problems.

The second case involved Charles, who, since the age of 6 weeks, had recurrent, sudden attacks of vomiting and drowsiness associated with hyper-natraemia. Upon arrival at the hospital, his plasma-sodium concentrations were elevated and his urine contained a great excess of sodium. However, extensive investigations at three medical centers showed his endocrine and renal systems were normal and that he excreted salt load efficiently. Between attacks, Charles, like Kay, appeared healthy and seemed to be developing normally.

By the time Charles was 14 months old, it became clear that his attacks happened only at home. His mother was then deliberately excluded from a prolonged hospital stay for Charles, and no illness recurred until the weekend she was allowed to visit. Thus the doctors believed that the illness must be caused by sodium administration, probably by the mother. Tragically, during the period in which arrangements were being made for the child, he “arrived at hospital one night, collapsed with extreme hypernatraemia, and died” (Meadow, 1977, p. 344).

Meadow noted that the cases of Kay and Charles were similar, and reminiscent of Munchausen syndrome.² However, instead of an individual presenting him- or herself to a physician with false or induced symptoms, the individual (the parent) presented her child, thus a “by proxy” form of Munchausen was described. Meadow’s astute analyses and observations in this brief paper raised questions that are still being considered.

Specifically, Munchausen by proxy syndrome, or MBPS, is a form of child abuse in which a caretaker fabricates and/or induces illness in a child.³ The caretaker then presents the child repeatedly for medical attention, all the while denying any knowledge of symptom origin. This form of child abuse can lead to physical and/or psychological damage to the victim, owing either to the direct actions of the perpetrator or to the intrusive medical procedures performed by doctors to diagnose the child’s suspected illness. In 95% of cases, the child’s mother is the perpetrator (Schreier & Libow, 1993a).⁴

Mother-perpetrators’ actions cover a broad spectrum, from misrepresenting symptoms (Griffith & Slovik, 1989) to tampering with lab specimens (Verity, Winckworth, Burman, Stevens, & White, 1979), to actually creating symptoms of illness in their children. Symptom induction may range from seemingly innocuous under- or overmedicating (Meadow, 1982b; Schreier, 1992) to life-threatening actions such as suffocating (Boros & Brubaker, 1992), chronic poisoning (Nicol & Eccles, 1985), and injection of various substances (Halsey et al., 1983; Saulsbury, Chobanian, & Wilson, 1984). Perpetrating mothers are often quite ingenious in their techniques of misrepresenting or producing symptoms while avoiding detection. Reports in the literature include cases in which perpetrators spit into a central venous line (Rosenberg, 1987); injected oral, fecal, or vaginal excretions into an intravenous line or into the child (Halsey et al., 1983; Kohl, Pickering, & Dupree, 1978); contaminated urine or stool specimens with blood (Crouse, 1992; Outwater, Lipnick, Luban, Ravenscroft, & Ruley, 1981); and gave large doses of laxatives to the child (Berkner, Kastner, & Skolnick, 1988).

The resulting symptom profile in the child-victim often involves multiple organ systems, with a preponderance of gastrointestinal symptoms and seizures. This results in an often dizzying array of medical subspecialists becoming involved in the care of the child. The most commonly reported symptoms include bleeding, seizures, unconsciousness, apnea, diarrhea, vomiting, fever, and lethargy (Rosenberg, 1987; Schreier & Libow, 1993a). However, Schreier and Libow (1993a) have identified almost 100 additional symptoms presented in suspected cases.

The mother-perpetrator’s chilling behavior often occurs against the backdrop of what is described as perfect, nurturing, self-sacrificing, and attentive parenting (Leeder, 1990). That a mother may deliberately harm her child in such a way, endangering the child’s life and manipulating medical professionals, is, for many, unthinkable; the mere suggestion challenges a basic tenet of human motherhood. When expressed, these suspicions often engender passionate disbelief among physicians, nurses, and hospital administrators, who may rally to support the mother (Blix & Brack, 1988; Waller, 1983). Once this wave of resistance is partially squelched by confrontation of the perpetrator, the disbelief often extends to others who are drawn into the case, such as mental health professionals, child protection workers, attorneys, and judges (Feldman, 1994; Sheridan, 1989; Waller, 1983; Zitelli, Seltman, & Shannon, 1987). When confronted, these mothers invariably deny or seriously minimize their actions in spite of evidence to the contrary. They are quite convincing, and the literature is replete with examples of their persuasiveness.

Identification of Munchausen by proxy has been difficult at best. The mothers’ attentiveness to their ill children and their cooperation with hospital staff belie their dangerous behavior. Additionally, the medical establishment has depended upon an obviously valid medical tradition of using parent-supplied medical histories and symptom reports for young child patients. As physicians are challenged with unexplained symptoms, they generally investigate more rigorously to determine the suspected illness.

In spite of detection difficulties, developing awareness and understanding of MBPS are resulting in increasing identification of cases. A library literature search completed in 1990 yielded 77 references to Munchausen by proxy syndrome between 1966 and May 1990; a similar search covering only May 1990 to July 1993 yielded 88 additional references. This included the first book on MBPS (Schreier & Libow, 1993a). More recently, even the popular media have turned their attention to these cases (Kellerman, 1993; “My Sister-in-Law,” 1991; Wartik, 1994).

General guidelines for suspecting and then confirming cases of MBPS have emerged largely from the case study-based literature. They highlight aspects of the victim’s illness, characteristics of the mother-perpetrator, and family dynamics. In the last of these areas there appears to be the least agreement. The dynamics of the Munchausen by proxy family system and of the perpetrator’s family of origin are addressed only superficially in the early case studies. More information is currently emerging in the literature, but case studies are still being published that fail to report whether the researchers even asked pertinent questions regarding family dynamics—specifically, questions concerning perpetrators’ histories of sexual and physical victimization.

Once a diagnosis of MBPS is suspected, a multidimensional approach is imperative, in order to secure confirmation of the diagnosis and plan for long-term management of the family. Confirmation of the suspected diagnosis is best obtained through a multidisciplinary panel that includes the professionals who have been working with the family and an expert consultant in this type of abuse. Only a team approach can ensure that the necessary components are present for confirmation of the diagnosis (i.e., a thorough medical evaluation of the child, verification of the child’s medical history, independent review of medical records, psychosocial and psychological assessment of all family members, gathering of concrete evidence of intentional harm to the child, and ongoing collaboration of all caregivers involved with the family) while preventing continued deception by the alleged perpetrator through the splitting of professionals (Meadow, 1985; Rosenberg, 1987; Schreier & Libow, 1993a). Long-term management of the family must also include support from the judicial system.

Unfortunately, even when cases are identified, most professionals are ill equipped to deal with either the perpetrators or the child-victims of Munchausen by proxy syndrome (Kaufman, Coury, Pickrell, & McCleery, 1989). This may be especially true of psychologists and other mental health professionals. Schreier and Libow (1993a) report that only about 10% of journal papers on this topic have appeared in the psychological or psychiatric literature; the vast majority have appeared in pediatric journals. Additionally, these articles have mainly been case presentations, with little direction given regarding treatment. Nevertheless, mental health professionals are called upon increasingly, as in other types of child abuse, to help with these cases. The lack of therapy experience with MBPS is particularly problematic for clinicians, as treatment models are just beginning to be explicated.

The potentially fatal outcome of undetected Munchausen by proxy syndrome makes our understanding of this disorder gravely important. Significant accomplishments have been made in this field since Meadow’s (1977) initial article. We now have some guidelines that provide direction for identification and verification of cases. However, much work is still needed if we are to understand the dynamics underlying MBPS (including the obvious gender issues raised by the predominance of mother-perpetrators) and to develop treatment models for the perpetrator, the child-victim, and the family. Additionally, efficient interdisciplinary collaboration is imperative if we hope to intervene effectively with these families. Early detection and effective intervention can be accomplished only through the continued education of all professionals who work with families of chronically medically ill children. The following chapters provide information for all practitioners who are struggling to deal with this mystifying disorder and all of its ramifications.

Notes

1. Money and Werlwas (1976) had previously used the term Munchausen by proxy in describing a case of psychosocial dwarfism. In addition, cases had previously been described in the literature of parents’ focus on their children’s illness (Green & Solnit, 1964; Yudkin, 1961) and of nonaccidental poisoning (Kempe, 1975; Lansky & Erickson, 1974; Rogers et al, 1976). However, Meadow (1977) was the first to bring attention to the phenomenon of deliberate, persistent, and covert deception by a mother to meet her own needs with the result that unnecessary medical procedures were carried out on the child.

2. Munchausen syndrome is a psychiatric disorder in which otherwise healthy individuals seek surgical or other medical treatment for feigned or self-induced symptoms. Although there are earlier reports of fabricated illness in the medical literature, Dr. Richard Asher first applied the term Munchausen syndrome in 1951. Asher named the syndrome after an 18th-century German baron, Karl Freidrich Hieronymus von Münchhausen, who recounted dramatic tales based on his travels and was known as a skilled storyteller (Meadow & Lennert, 1984). These stories became the basis for R. E. Raspe’s (1785) collection of fictitious tales of the travels and adventures of Baron von Munchausen (the corrupted English spelling), and the name of Munchausen became associated in general with outlandish storytelling.

3. The terms Munchausen syndrome by proxy, Munchausen by proxy, and Munchausen by proxy syndrome are used interchangeably to refer to the same disorder. However, Schreier and Libow (1993a) suggest that the name Munchausen syndrome by proxy erroneously implies that the syndrome is simply a variant of Munchausen syndrome. They argue that the similarity in names has engendered confusion about the relationship between these two distinct disorders. Therefore, they prefer the term Munchausen by proxy syndrome. Although Deborah Day and I are not sure this term provides much distinction, as the editors of this volume we have also chosen to use it throughout, in deference to the originality of Schreier and Libow’s book and to the growing use of the shortened term Munchausen by proxy. The term factitious disorder by proxy is also used interchangeably with these terms, as discussed in Chapter 2.

4. Because only a small number of documented cases have involved fathers or other caretakers as perpetrators, the term mother is used in this volume interchangeably with terms such as perpetrator and abusing parent. Female pronouns are also used to refer to MBPS perpetrators.

2	Defining Munchausen by Proxy Syndrome
	Teresa F. Parnell

---

For those cases that seem to fall at the edges of the definition of [Munchausen syndrome by proxy], it is worth remembering that the name applied to the child’s circumstances is not as material as a careful assessment of the threatened harm to the child.

—Donna Rosenberg, “Munchausen Syndrome by Proxy,” 1994

---

Dr. Richard Asher (1951) coined the term Munchausen syndrome when he saw similarities between his patients and the exaggerated storytelling of the infamous Baron von Münchhausen (see Parnell, Chapter 1, note 2, this volume). Dr. Asher worked with patients who told dramatic and plausible, but ultimately untruthful, stories about their medical symptoms, resulting in an astounding number of hospital admissions. He observed that his patie...