Different interpretations of Munchausen Syndrome by Proxy

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Abstract

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.

Résumé

L’article passe en revue la définition du syndrome de Munchausen par procuration lorsqu’il est accompagné d’autres comportements nuisibles de la part des parents. On remarque chez les agresseurs une incidence élevée de comportements pathologiques anormaux relatif à la maladie, ce qui porte à s’inquiéter pour la sécurité des enfants qui sont à charge de parents démontrant ces comportements anormaux.

Resumen

Se revisa la definición del Sı́ndrome de Munchausen por Poder y se considera en el contexto de la superposición con otras conductas de los padres. La alta incidencia de enfermedades conductuales anormales en los perpetradores está indicando un aumento en la preocupación acerca de la seguridad de los niños que están al cuidado de padres que sufren de enfermedades conductuales anormales.

Introduction

Since 1977 the term ‘Munchausen Syndrome by Proxy’ (MSbP) has been used widely and sometimes overused. The development of the term will be described. Its extension to repetitive smothering and poisoning, as well as to a range of harmful parental behaviors to ill children, will be appraised.

Most authors have used the term to describe particular forms of child abuse; however, others have applied it as a diagnostic label to the perpetrator (usually the child’s mother) of the abuse. It is worth considering the way in which it was used originally.

The paper “Munchausen Syndrome by Proxy—the hinterland of child abuse” (Meadow, 1977) described two children, one of whom had incurred repetitive salt poisoning before dying (of salt poisoning), and the other of whom had innumerable investigations and procedures for factitious renal disease, which was created by her mother giving a false story and tampering with urine samples. The paper pointed out that the children had incurred numerous needless and painful hospital admissions, investigations, and procedures because of a false story and factitious signs, just as happens for a person who has ‘Munchausen Syndrome,’ but that in this case the falsification was not by the patient themselves, but by another person acting on their behalf (a proxy). Hence the appellation ‘Munchausen Syndrome by Proxy’ to describe the suffering and abuse which the two children had incurred. Most descriptions of similar abuse followed that approach, so that by the time of Rosenberg’s important literature review (Rosenberg, 1987), the definition was listed as a syndrome cluster of:

  • 1.

    Illness in a child that is simulated (faked) or produced by a parent or someone who is in loco parentis;

  • 2.

    Presentation of the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures;

  • 3.

    Denial of knowledge by the perpetrator as to the etiology of the child’s illness; and

  • 4.

    Acute symptoms and signs of the child abate when the child is separated from the perpetrator.

Rosenberg specifically excluded children who had incurred physical abuse only, sexual abuse only, and nonorganic failure to thrive only. That list of exclusions was important, but in practice many found that it was not exclusive enough, and that all too often the term MSbP (or Munchausen by Proxy Syndrome, or Factitious Illness by Proxy) was being applied to children who had incurred mixed forms of abuse over a long period of time, and for whom there had been extreme delay in the diagnosis of abuse, until eventually someone categorized it as MSbP. Other problems have arisen from the overlap between MSbP and the commoner ways in which parents, by their unusual perceptions or care of an ill child, may cause harm: by doctor shopping, enforced invalidism, delusions about their child’s ill health, and from maternal separation anxiety (Meadow, 1984). Rosenberg described the difficulty that she encountered in differentiating between MSbP and “intentional poisoning, infanticide, pathological doctor shopping, extreme parental anxiety, or thought disorder,” and considered the probability that the underlying psychology overlapped (Rosenberg, 1987). There has been continued interest in the spectrum of abnormal parent/child relationships, in the context of both health and illness, and the recognition that extreme MSbP abuse might lie at one end of that spectrum (Eminson & Postlethwaite, 1992). Though some parents may behave in unusual and harmful ways to their children’s health, most such behavior has only been categorized as MSbP when it has sought the sick role or major attention for the parent.

Many authors have addressed the use of the term MSbP and suggested alternatives Ayoub and Alexander 1998, Bools 1996, Fisher and Mitchell 1995, Jones and Bools 1999, Meadow 1995, Schreier and Libow 1993. In some ways the discussion may seem irrelevant because, in most countries, the guidelines for dealing with child abuse are clear, and the terminology used by the legislature is established. In the United Kingdom, it is uncommon to hear the term ‘Munchausen Syndrome by Proxy’ (or one of its synonyms) used in court because the child protection and medical agencies seek to identify whether a child has been abused, the detail of it, and whether that child is at risk of significant harm in the future. Their task is to establish whether or not an infant has incurred repetitive salt poisoning over a period of 6 months, or whether a 5-year-old has had a genuine intestinal motility disorder, necessitating a gastrostomy, rather than a false illness provided and caused by the mother. The term MSbP is irrelevant to those decisions. However, once the fact and degree of abuse is established, then it becomes more relevant to establish why the parent behaved in a particular way, and such understanding may influence how best to help the family. Assessment of the perpetrators personality, motivation, and behavior is an important second stage.

Although rather too many examples of child abuse have been categorized as MSbP, there is no doubt that awareness of MSbP has been helpful in drawing attention to many previously unrecognized ways in which young children were being seriously abused. The extent of such abuse has horrified those encountering it, and has been beyond the imagination of most professionals. Anyone who has been involved with children, who have been made totally blind or deaf, or who have received a small bowel transplant because of repetitive factitious disease caused by their mother realizes that there are no boundaries to the way in which parents may abuse children.

Recognition of MSbP led to much wider recognition of nonaccidental poisoning and of smothering, and the realization that a substantial proportion of dead infants previously categorized as Sudden Infant Death Syndrome had been smothered by their parents. However, at the same time some professionals began to refer to any child who had been covertly killed as having incurred MSbP. That is likely to be a misconception. The 2-year epidemiologic survey of MSbP, nonaccidental poisoning, and smothering occurring in the UK and Ireland (McClure, Davis, Meadow, & Sibert, 1996) indicated that, though about half of the cases of smothering and nonaccidental poisoning appeared to occur in the context of MSbP abuse, the other half did not and, therefore, it was inappropriate to use the term for every case of smothering or poisoning.

Section snippets

DSM IV research criteria

The criteria for using the term MSbP have been discussed widely and remain open to debate. Inevitably, the widest division lies between those (usually pediatricians) who use the term to describe certain forms of child abuse, and psychiatrists and psychologists who seek a diagnostic label for the perpetrator. The most recent text revision of DSM IV from the American Psychiatric Association (DSM-IV-TR, 2000) considered that there was insufficient information to warrant its inclusion as official

Abnormal illness behavior in the perpetrators

Most of the literature on MSbP, and particularly the early literature, has been written by pediatricians and other medical specialists, and has concentrated on the recognition and diagnosis of such forms of child abuse. Many of these papers have contained relatively little information about the perpetrators. Even those papers which have included information about perpetrators often have lacked the detailed information about the perpetrator’s own health records that is necessary when assessing

Current definition of MSbP

The frequency of personal abnormal illness behavior in perpetrators lends credence to those who seek more precise terminology for the large groups of abusive behaviors that are currently labeled MSbP. Most pediatricians prefer to use the term Munchausen Syndrome by Proxy to describe a collection of features characterizing a particular type of child abuse, rather than as a label for the perpetrator. It is the task of psychiatrists and psychologists to use their classification systems to describe

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    Factitious Illness by Proxy

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