In 1951 British physician Richard Asher introduced the term Munchausen syndrome to describe patience that falsified their medical history and fabricated stories about their medical condition. He named this syndrome after Baron Karl Friederich von Munchausen (1720-1791). Munchausen was from Germany and he served as a soldier with the Russian army. He became famous for his elaborate fairy tales of his travels and he fabricated stories about his adventures of a soldier and a hunter. (Murray 1997). This title is fitting because Munchausen syndrome patients are often deceitful. They fabricate stories about their own medical history and condition. This deception is done in an attempt to gain attention and sympathy from the medical community and others. This often leads to repeated falsifications that would possibly pilot unnecessary procedures and probable hospitalization. (Abdul-Kader 1998).
In 1977 British physician Roy Meadow coined the term Munchausen syndrome by proxy (MSbP) to describe patients who, caused harm to their children and lied about medical problems in order to gain unnecessary services and to gain sympathy and attention. At times, extensive and needless procedures are performed on a child. This may lead to permanent damage or even death. (Davis, McClure, Rolfe, Chessman, et al. 1998).
MSbP is a bizarre form of child abuse. The mother is typically the person responsible for concocting elaborate stories or inflicting harm upon the child to induce sickness. The perpetrator seems insistent on receiving medical attention for the child and may request many unnecessary procedures. (Murry 1997).
By nature (MSbP) is based on deceptive behavior and therefore, very difficult to diagnose. It may take several months or years for a diagnosis to be made. When the abuse is minor, a physician may not be able to recognize the syndrome. He may be inclined to listen to the mother, especially if she is apparently loving and supportive. An entire history is needed to determine a pattern of abuse which requires a lengthy process. To further complicate things, often times, there is a history with several different physicians and one may not know of the other.
Distinctive Characteristics of (MSbP)
Although MSbP is very hard to recognize and diagnose, there are several distinguishing characteristics that can play a role in recognizing a possible case of MSbP. The following are features that are usually associated with MSbP (Meadows 1982 as cited in Bennett, Bennett, Prinsley, Wickstead 2005) :
– Unrelenting or frequent sickness without explanation
– Discrepancies between examination results and the health of the child
– Knowledgeable physicians have never witnessed such a case
– symptoms only happen when the mother is present
– Mothers seem overprotective and refuse to leave the child
– Treatments not tolerated
– The initial diagnosis is of a rare disorder
– Mothers have a strange reaction and may insist that there is more that can be done
– Mothers with a history of Munchausen Syndrome or abuse
– Mothers have knowledge of medical procedures or past experience
– Absent fathers
– Mothers document symptoms with pictures or video
These characteristics may be able to signal a physician to suspect MSbP. The mothers psychological profile and background should offer valuable insight when compared to the medical events. If the mother has a background or familiarity with medical procedures and has unusual or odd behavior then steps should be taken to ensure the safety of the child. Transfers to other hospitals and discharges againtst medical advice are quite common. When the mother feels that her manipulation and deceit is being recognized she will go somewhere else for medical treatment (Abdul-Kader, Keith, Cunningham 1998).
Cases of Munchausen Syndrome by Proxy
An eight-month old boy was taken to an Ear, Nose and Throat Doctor by his mother and grandmother. They complained of a sticky, and sometimes bloody discharge that was coming from the child’s left ear.
After several doctors examined the patient they determined that his ears were basically normal. Three days later the mother brought in videotaped evidence to support his history with the discharge. The video showed dark blood settled in the ear and smeared across the face. At the examination the patient showed no evidence of damage, just a little mucus. They decided to admit him to the hospital and do an examination under anesthesia. He had a little blood in his ear canal but no trauma to his inner ear.
At the follow-up exam, an initially dry ear was filled with mucus after returning from the audiology department. The area of the mucus was suspicious and nurses began to notice that the mucus would only appear after mother and child were alone together. It was later determined that the mucus was probably maternal saliva.
The mother initially denied accusations and the grandmother took responsibility. During the case investigation it was revealed that both mother and grandmother had a history of abuse. Eventually the mother admitted guilt, accepted responsibility and the child was turned over to foster care (Bennett, Bennett, Prinsley, Wickstead 2005).
In another case a 2 1/2 year old boy was put in the hospital because he suffered from cramps, diarrhea, vomiting and convulsions. Over a 13 month period he was hospitalized 16 times. The mother appeared very loving and was very attentive and often reported symptoms to the medical staff.
Almost a year after the first hospitalization MSbP was suspected. After running toxicology reports the analysis showed propyphenanzone and doxylamine were present in the blood and urine. Neither of these medications had ever been prescribed to the child.
The recognition and intervention saved this little boys life and he went on to make a full recovery (Vennemann, Bajanowski, Karger, Pfeiffer, Kohler, Brinkmann (2004).
The next case involves a 2 month old little girl that was allegedly found lifeless in her crib, her nose and mouth were covered by a pillow and the girls arm was lying on that pillow. Resuscitation was initially successful and the baby was taken to the intensive care unit. After extensive medical care, the child died 18 hours later. The cause of death remained unknown while suffocation was suspected.
Nine months later the mother gave birth to a son. Due to the death of his little sister cardiorespiratory monitors were placed in the home. During the next 9 months the child was hospitalized 10 times.
The head of the pediatric department grew suspicious of the mother and informed law enforcement of his doubts. The mother, an assistant nurse, was charged with grievous bodily harm with fatal consequences. In court she admitted to having obstructed the nose and mouth of her son, apparently in order to be seen as a loving mother with a sick child. She had been under psychiatric care for 8 years because of depression and anxiety.
Despite the fact that there were suspicious circumstances surrounding the death of her first child, she was only sentenced to 2 years of prison for attempted suffocation of a child (Vennemann, Bajanowski, Karger, Pfeiffer, Kohler, Brinkmann (2004).
Recognition and Prevention
Recognizing, diagnosing, reporting and following up on victims of MSbP can be an intense experience for a physician. As soon as physicians suspects the possibility of a diagnosis the emotionally draining experience begins. The physician may come to the realization that his patient is being abused and that many unnecessary test have been performed.
Many physicians may suspect diagnosis but not feel convinced enough to report the case. (Golfarb 1998). The transition from suspicion to proof is not a very easy task. It is vital to document every incident and every consultation with great detail. Careful review of the latest reports concerning MSbP in conjunction with legal advice should help in facilitating an proper diagnostic plan(Abdul-Kader, Keith, Cunningham 1998). .
When the diagnosis seems certain, the safety of the child is first prority. This can only be accomplished if the child and mother are separated. Delaying the separation could endanger the childs life. Therefore, getting the police, child protective services and social services involved immediately is the best course of action. This act will help facilitate the process of obtaing the legal documents necessary to pursue legal action (Abdul-Kader, Keith, Cunningham 1998).
Hidden video surveillance is usually performed in conjunction with the police. Although the number of cases are small the prosecution rate is high. This is most likely because the video surveillance provides good quality evidence. Since suffocation is a serious possibility, the video surveillance video will help to ensure safety and protect many victims effectively. (Davis, McClure, Rolfe, Chessman, et al. 1998).
After the child’s safety is secured, the next step should be obtaining psychiatric help for mother and child. The child psychiatrist would help ensure that the victim and siblings are getting the emotional care they need. Older children may be at risk for assuming the same kind of behavior. They may also be resistant to getting the help they need. Efforts should be made to include family members and medical staff in the therapy. An explanation of the mothers behavior and the nature of the illness can prove to be helpful. Above all the child needs to understand that they will be protected and that this will not happen again (Abdul-Kader, Keith, Cunningham 1998).
The mother’s psychiatrist should also reassure the mother that they are there to help and that her mental illnes will not be ignored during legal proceedings. Significant efforts should be made to treat the mother for her depression and any other personality disorders she may suffer from (Abdul-Kader, Keith, Cunningham 1998).
It is crucial that the physician that uncovers the dishonesty continue to take part in the therapeutic process. The physicians role is to ensure the long-term safety and well-being of the child and any siblings they may have (Abdul-Kader, Keith, Cunningham 1998).
Participating in marital counseling or family therapy can be effective. The goal would be to help the family deal with and grasp the realization of the mothers mental illness. They would also help them deal with the circumstances surrounding her actions and behavior ((Abdul-Kader, Keith, Cunningham 1998).
Establishing the diagnosis of Munchausen syndrome by proxy requires significant skill and judgment by the health care providers. Deciding how and when to confront a family with the dianosis can be difficult. Social Services and law enforcement need to be involved cautiously
to avoid confronting the parent too soon (Golfarb 1998).
Effective intervention starts with shifting the view from the child’s illness to the emotional perspective of the family to the broader relational context. This type of approach may leave the dangerous, abusive behavior less necessary (Abdul-Kader, Keith, Cunningham 1998).
Effective treatment, management and long term outcome of Munchausen syndrome by proxy are still poorly understood. It is imperative that professionals involved in such cases maintain good collaborative relations with each other (Abdul-Kader, Keith, Cunningham 1998).
Caring for a family with Munchausen syndrome by proxy involves extreme attention to detail, perseverance and dedication to the long term care of the child. The process will involve working closely with social health services, various agencies and the judicial system. The experience can be intense, both in terms of hours and emotions spent by the health care professional involved in the case (Golfarb 1998).
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