Munchausen syndrome by proxy (MSBP): an extreme form of child abuse with a special forensic challenge☆
Introduction
The term “Munchausen syndrome by proxy (MSBP)” is derived from the Munchausen syndrome. The latter was first described in 1951 by Dr. Richard Asher and is a mental disorder belonging to the factitious disorders. The affected individuals invent illnesses or fabricate them by manipulation, thus injuring themselves. In most cases this leads to travelling from doctor to doctor and to complex medical investigations and hospitals procedures, including extensive surgery [1]. In 1977, Dr. Roy Meadow, a British pediatrician, described an extreme form of child abuse, in which mothers make false statements about symptoms of illness in their children, or deliberately produce such symptoms by internal or external manipulation [2]. The offenders do not suffer from MSBP, they inflict it on their victims. The Diagnostic and Statistical Manual of Mental Disorders (DSM) defines MSBP as “the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care for the purpose of indirectly assuming the sick role” [3]. In this extreme form of abuse, the caregiver produces symptoms of illness in a child or in an elderly or disabled person. The deception is usually repeated on numerous occasions, resulting in a high morbidity of the victims with many hospitalizations and sometimes even death.
In the medicolegal assessment of children it is important to recognize signs of child abuse. There are active and passive forms of child abuse, and MSBP is an active form. It is part of the “battered child syndrome” and represents a special form of child abuse since the diagnosis is made difficult on account of several aspects [4]. MSBP is distinctive from other forms of child abuse because the testimony, cooperation and convincing of medical personnel is often compulsory for establishing criminal proof of the existence of MSBP, and this is often intertwined with criminal investigation procedures. Two categories of MSBP can be distinguished: (1) simulation (mild and rare form) and (2) production (severe and most frequent form). Simulation occurs when the perpetrator feigns an illness of the victim by verbally presenting an untrue history of a non-existent illness or condition; in the second form, the perpetrator actively produces symptoms of illness in the victim, either by internal or by external manipulation. The methods most frequently used are suffocation attempts in order to produce apnea and poisonings [4]. There are many reasons why it is difficult to recognize the abuse that the victim endures. The following two cases of poisoning are presented to demonstrate the difficulties encountered in establishing a diagnosis and to illustrate the importance of legal medicine in this connection.
Section snippets
Case history 1 and toxicological findings
In a family with five children the youngest daughter suddenly fell ill at the age of 18 months and had to be taken to hospital. The parents stated that she was no longer able to stand, had a choking fit, and became unconscious. The child was in a peripheral hospital for two days and recovered quickly, so that no further treatment was necessary. Three weeks later the child had another “attack of weakness”, as the mother reported, and was hospitalized in the same hospital again. No remarkable
Discussion
More than 700 cases of MSBP have been described worldwide within the last 25 years [7]. It is an extreme form of child abuse associated with high morbidity, mortality, disruption of families, and harm to siblings. The occurrence of harm to siblings suggests that in half of the families having a child with suffocation attacks and in 40% of the families with non-accidental poisoning of a child there will be further abuse, sometimes with a fatal outcome [8], [9]. This illustrates the serious
Conclusions
Regarding the assessment of children in medicolegal practice and the autopsy of children with SIDS, the following warning signs that may suggest a case of MSBP should be heeded: (1) recurrent symptoms of illness; (2) repeated hospitalization and/or consultation of physicians; (3) multiple diagnostic procedures without establishment of a clear-cut diagnosis; (4) a certain resistance to therapy; (5) illnesses or death of siblings; (6) one-time or even repeated detection of foreign substances in
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This work has been presented orally at the 11th Meeting of the Region North of the German Society of Legal Medicine on 31 May 2002 in Potsdam, Germany.