Munchausen Syndrome by Proxy
Provided by Allen N. Cowling
The American Psychiatric Association's Diagnostic
and Statistical Manual of Disorders describes Munchausen Syndrome by Proxy as the "intentional
production of physical symptoms."
The term "Munchausen Syndrome by Proxy" (MSBP)
was first named in a 1976 report describing four children who were so severely abused they were
dwarfed. In 1977, Meadow described a somewhat less extreme form of child abuse in which mothers
deliberately induced or falsely reported illnesses in their children. He also referred to this behavior
as Munchausen Syndrome by Proxy.
Munchausen Syndrome by Proxy victims are usually
children, and the perpetrators are almost always parents or parental substitutes. If and when victims
are hospitalized, they may be subjected to multiple, and at times, dangerous diagnostic procedures that
invariably produce negative or mistaken results. When the victim and the abuser are separated, however,
the victim's symptoms cease. When confronted, the abuser characteristically denies any knowledge of
how the child's illness occurred.
In simplicity, those having this disorder will injure or
induce illness in children in order to gain attention and sympathy for themselves. They may induce
breathing difficulties that mimic the symptoms of apnea and sudden infant death syndrome, poison them,
or fabricate illnesses in their children. The offender then revels in the attention afforded them by
relatives, doctors, and hospital personnel. The problem is, however, because the child's illness
has no medical cause, doctors have difficulty making any diagnosis.
Research shows that individuals who initially engaged in
Munchausen Syndrome (self-inflicted injury) may eventually practice Munchausen Syndrome by Proxy. The
degree to which the offspring of Munchausen offenders become the subjects of abuse may increase
proportionately with the number and increased severity of incidents of self-inflicted abuse. MSBP may
occur when the perpetrator of Munchausen Syndrome crosses over the threshold of self-inflicted injury
into abuse of an unsuspecting child. Often times, the offender claims that injuries to the child were
inflicted by a fictitious person and in some cases, offenders injure themselves in order to
substantiate the presence of this unknown perpetrator. Diligent investigation of these allegations
often leads to a dead end.
Although there seems to be a multi-generational link
between Munchausen Syndrome and MSBP, this connection has not been established scientifically to the
level that most courts require.
In the standard offender-victim relationship, suspicion
centers on the biological mother and, in fact, the vast majority of MSBP cases resolved through
investigation have implicated the victim's mother as the sole offender.
You should be aware that the MSBP offender profile has
widened to include other perpetrators, both within and outside the victim's family structure.
Fathers, grandmothers, aunts, and baby-sitters have been identified as offenders. Regardless of the
relationship to the victim, the offenders all had one thing in common. Each acted as the victim's
primary care giver.
In very rare cases, medical professionals also could be
included in the list of potential suspects. While it appears that only immediate family members would
receive the gratification from attention, increased self-esteem, and false sense of belonging afforded
by MSBP, similar motivations lead some health-care workers to cross the line of the Hippocratic Oath
into the realm of child abuse. By inflicting MSBP, and then "saving" the child, these
offending medical practitioners hope to excel within their fields and win acceptance by their peers.
Fortunately, the frequency of cases involving health-care workers has been relatively low. The
possibility does exists, though, that a medical professional's actions might indicate MSBP in
certain circumstances.
The method by which investigators approach suspected
MSBP offenders is the key to resolving these cases. During interviews, the investigator needs to convey
to the suspect that they are keeping an open mind regarding the case. Investigators can expect sound
rationalization on the part of offenders, as well as a series of open-ended allegations that cannot be
substantiated.
The investigators should make every effort to segregate
other family members from suspects during the interview process because relatives probably will voice
support and belief in the allegations if the suspect is present. In those cases where obvious
inconsistencies exist, family members might view facts differently when questioned away from the
suspect.
With continued investigation, the identified MSBP
offender might be linked to the deaths of other children. Often, the original medical examiners may
have incorrectly identified these deaths as resulting from sudden infant death syndrome. If the
deceased child or children have not been cremated, then exhuming their bodies for forensic testing
might be appropriate. When advised of previously identified causes of death within a family, forensic
pathologists or medical examiners might be able to uncover particular toxins or evidence pointing to
homicide.
Whether the child actually knows that the offender has
induced the illness depends on the child's physical age and the offender's covert skills.
Certainly, the longer the abuse continues and the older a child grows, the more likely it becomes that
the victim will understand the offender's actions.
If the abuse has been present throughout the life of the
child, then the victim might believe that whatever action is being done to cause the illness is normal.
Because of this misunderstanding of normal behavior and the attention that the offender lavishes, the
child might not view the offender as anything less than an ideal care giver, even if the abuse is
blatant.
It is normal for many investigators to refrain from
interviewing the victim. Even if a victim is old enough to talk, the child probably will not be able to
assist verbally in the investigation and the investigator must consider the potentially traumatic
consequences should the child be told that a trusted care giver is in fact an abuser. It is wise to
seek the help of professionals when dealing with this aspect of the investigation to lessen the
possibility of further traumatizing the victim.
In MSBP related cases, investigators face additional
concerns for the safety of the child involved. Suspected offenders might react in a number of ways when
confronted. Offenders may deny the allegations and blame the child's apparent illness on an unknown
cause. Often, an increase in the severity of the victim's symptoms follows as the offender attempts
to prove the presence of the illness. Unfortunately, the child might not be able to withstand the
escalating abuse or the increased treatments prescribed to address the symptoms.
In order to reduce the possibility of further abuse to
the child, investigators must work toward a swift conclusion to the case once they have confronted the
suspected offender. Careful planning and caution can be critical, especially since research indicates
that from 9 to 31 percent of all MSBP victims die at the hands of their perpetrators.
Some confronted offenders might react passively and
relocate with the victim and other family members. If there is no protective measure to preclude a
suspect from relocating with the child, the cycle of MSBP probably will continue in a new
locale.
If not arrested, offenders who believe they are under
suspicion might become more cautious, but usually this is only temporarily. The child's apparent
illness might subside until the offender believes it is safe to resume the abuse. Offenders also may
wait until a reasonable time elapses and then re-admit the child into the hospital. In either case, it
appears that as offenders continue their abuse, the danger to the child increases. The
"psychological needs" of these offenders have been compared to that of drug addicts. Through
cycles of abuse and nurturing, MSBP offenders seek to satisfy an ever-increasing need for attention and
self-validation. However, some experts believe that, unlike most drug addicts, MSBP offenders cannot be
rehabilitated.
Despite seemingly strong circumstantial evidence present
in some cases of apparent MSBP abuse, investigators must make every effort to refrain from making false
allegations or wrongful conclusions. Accusations based on insufficient investigation and absent
forensic analysis can have disastrous consequences. In one case, a mother was falsely accused of the
death of her infant son. The child died as a result of apparent ethylene glycol poisoning. When she had
a second child, the doctors discovered that the infant had a rare disease that had caused the death of
the first child. The mother subsequently initiated legal action against the State.
The manner in which charges of MSBP originate must be
considered in the total course of an investigation. Highly disputed child custody cases often generate
charges of child abuse. Sometimes, MSBP offenders accuse the other parent of abuse in order to mask
their own wrongdoing and to keep custody of the child. In cases where an estranged parent involved in a
custody dispute reports illnesses or accuses the other parent of child abuse, investigators should
explore all potential motivations for such accusations. Falsified reports for custodial purposes could
be a valid concern. Any investigator involved in a potential MSBP case needs to ensure that they are
not being used as a tool for secondary gain by the accusing parent.
In cases where reports of abuse originate from a
noncustodial or estranged parent, the question of accuser/inflictor role reversal should be considered
as an alternate cause of the child's ailments. This type of issue often arises in contested divorce
situations involving minor children and also might be linked to parental kidnaping by noncustodial
parents.
When custody has been denied to an offending parent, and
the victimized child has been placed with the other parent, the offender might go to great lengths to
regain custody. Accusations of sexual abuse, especially if the custodial parent is the father, might be
made by offenders as they attempt to disguise their responsibility for the child's
abuse.
The rationalization for the actions of MSBP offenders is
based on their desire to regain lost custody through outward expressions of love. It appears that the
longer offenders are separated from victims, the more desperate and determined they become to regain
custody.
Suspected MSBP offenders who believe that they are being
watched or have been accused of MSBP abuse, might seek assistance by accessing public shelters provided
for victims of domestic violence. In such cases, offenders rely on their highly developed skills of
deception. Because personnel working at these shelters function for the protection and assistance of
traumatized women, they might be reluctant to question an incoming client's account of
victimization. Once a woman settles in an abuse shelter, investigative access might be difficult, and
the support system in the shelter will reinforce her fictitious explanation of the child's injuries
or illness. While in the shelter, the victim temporarily might be spared from further injury to
strengthen the mother's claim that another person is the source of the abuse. Unfortunately, the
child's reprieve usually ends when the offender must leave the shelter and once again is alone with
the victim.
Normally, a victim of a MSBP offender is resolved in one
of the three ways. The child dies, the offender is arrested or the victim's advancing age causes
the offender to move on to a younger child within the family.
In cases where a child has either died from abuse or
matured to the point that the care giver believes it is too dangerous to continue the abuse, the
offender might attempt to find another suitable victim. The offender commonly substitutes a younger
sibling for the initial victim. In rare cases, both children might share the abuse simultaneously, but
it is more likely that the offender will concentrate on one victim at a time. Because offenders revel
emotionally in the attention derived from MSBP, it is reasonable to assume that only one child would be
necessary to gain such attention.
Unfortunately, MSBP has become a popular means to
"justify" cases when seeking to establish a link between this syndrome and maternal homicide.
Not all women who kill their children are afflicted with Munchausen Syndrome or MSBP, just as not all
women who kill their children are insane. With MSBP, offenders crave the attention from events
surrounding their child's illness or death. Investigators should certainly consider the possibility
of MSBP if they believe there to be some secondary gain, in the form of attention or notoriety,
afforded the offender at the expense of the victim. If investigators find no warning signs associated
with MSBP cases or no secondary gain in the form of attention, then they should consider the
possibility of homicide without the association of the MSBP factor.
Some possible signs of a MSBP offender
- Most often biological mothers of the victims, but potential
offenders are not limited to this group; fathers and persons outside the family have also been
identified.
- Are often upper class, well-educated persons.
- Remain uncharacteristically calm in view of the victim's
perplexing medical symptoms.
- Praise medical staffs excessively. Most offenders crave the
attention gleaned from hospital staffs, doctors, and family members.
- Mothers who have an unusually close relationship with the
hospital's medical staff.
- Appear to be very knowledgeable about the victim's illness.
Some offenders might receive gratification as they fool the doctors. They derive enjoyment from
knowing what is wrong with the child while medical experts remain baffled.
- Have some medical education, either formal or through
self-initiated study or experience.
- Repeated hospitalizations and extensive medical tests that fail to
produce a diagnosis.
- Symptoms that do not make medical sense.
- Unexplained and prolonged illness that puzzles experienced doctors
who may state that they have "never seen anything like it before."
- A parent who welcomes medical testing of the child, even if
painful.
- Attempts to convince the staff that the child is still ill, when
advised that the child will be released from the hospital.
- Mothers who do not seem worried about their child's illness,
but are constantly at the child's side while in the hospital.
- A care giver who adamantly refuses to accept the suggestion that
the diagnosis is non-medical.
- Persistent failure of the victim to respond to therapy.
- Signs and symptoms that dissipate when the victim is removed from
the suspected offender's presence.
- A family history of sudden infant death syndrome.
- Mothers with previous medical or health-care experience who have a
history of the same type of illness as their child.
- A model family that normally would be above suspicion.
- A care giver with a previous history of Munchausen
Syndrome.
- Typically shelter victim from outside activities, such as school or
play with other children.
- Allows only selected persons close to their children.
- Maintains a high degree of attentiveness to the victim.
- Offenders become more aggressive as time passes.
For further information, see:
- Alexander, R., W. Smith, R. Stevenson, "Serial
Munchausen's Syndrome by Proxy," Pediatrics, vol. 86, 1990, 581-585.
- Meadow, R., "Management of Munchausen Syndrome by Proxy,"
Archives of Disease in Childhood, 1985, 385-393.
- Schreier, H. and J. Libow, "Hurting for Love: Munchausen by
Proxy Syndrome" Guilford, Connecticut: Guilford Press, 1993, 103.
- Hanon, K., "Child Abuse: Munchausen's Syndrome by
Proxy," FBI Law Enforcement Bulletin, December 1991, 8-11.
- Rosenberg, D. A., "Web of Deceit: A Literature Review of
Munchausen Syndrome by Proxy," Child Abuse and Neglect, November 1987, 547-565; R. Meadow,
"Fictitious Epilepsy," Lancet, vol.25, 1984, 8; supra note 1.
- Kinschereff, R. and R. Famularo, "Extreme Munchausen Syndrome
by Proxy: The Case for Termination of Parental Rights," Juvenile and Family Court Journal,
vol.5, 41-49.
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