Munchausen syndrome by proxy abuse perpetrated by men

Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA)

Munchausen syndrome by proxy (MSBP) is well-known to clinicians, but its usage is discouraged now in favor of other terms placing emphasis on the victim. This study aims to determine the most common characteristics of perpetrators but only in case reports labeled as MSBP, published in PubMed literature in the past 15 years. MSBP has been described as a rare form of abuse due to illness falsification, where the perpetrator usually receives the diagnosis of factitious disorder imposed on another (FDIA). We extracted data from 108 articles, including 81 case reports. Almost all perpetrators were female (91% female, 1% female and male, 7% unreported). Twenty-three cases (28%) had a perpetrator with psychiatric diagnosis: factitious disorder imposed on self (10%), depression (9%), and personality disorders (7%). In more than one-third (36%) there was familial conflict or abuse. Fourteen cases (17%) had perpetrators working in healthcare. The most common type of falsification was induction (74%); however, 15% of cases had more than one type of falsification. The most common outcomes were: separation (37%); no follow-up (22%); imprisonment (14%); death of victim (12%); treatment of the perpetrator (10%); continued living together (4%); and suicide of perpetrator (1%). Recurrence was present in more than three quarters of cases. Our results reiterate that awareness of the most common findings in MSBP allows physicians to identify them in a clinical context.

Fabricated or induced illness: From "Munchausen by proxy" to child and family-oriented action

BACKGROUND

In fabricated or induced illness (FII), a child is harmed due to caregiver(s) behaviour and actions, carried out to convince mainly doctors that the child's physical and/or psychological health is more impaired than in reality. Harm is caused directly by the caregivers(s) and also often inadvertently by doctors' responses.

OBJECTIVES

To describe: dynamics underlying FII; wider definition of FII; alerting signs for early recognition of possible FII; respective responsibilities of health, social care, education.

METHODS

Literature review, clinical experience, expert opinion.

RESULTS AND CONCLUSIONS

Caregivers are motivated by gain from having their child treated as ill, and/or by erroneous beliefs about their child's health, either way needing medical confirmation about their contentions. Their behaviour is therefore directed primarily towards doctors. Most cases of FII present unexplained discrepancies between caregiver reports/actions and independent observations of the child. More rarely, the child has actual signs of illness, induced by the caregiver, occasionally fatal. Children are harmed in all aspects of life: health, daily functioning including education, and psychologically. Harm emanates directly from the caregiver(s) but also unintentionally from medical responses. Illness induction and clear deception by the caregiver require immediate child protection. Otherwise, the initial focus is on assessing the child's current health and functioning rather than caregiver's mental health. If, beyond verified illness, there is no medical explanation for the child's reported ill-health, the family require help to function better. This requires co-ordinated, multidisciplinary rehabilitation and long-term monitoring. If caregivers refuse rehabilitation, child protection is required. Several unanswered questions remain.

Pulling the Wool Off Our Eyes: Medical Child Abuse

Medical child abuse (MCA) continues to remain a challenging form of abuse to recognize, diagnose, and manage. The perpetrators of MCA have some common features that may heighten the suspicion that a child is the victim of MCA. Once suspected, the development of a multidisciplinary care plan that incorporates all subspecialists and health care providers involved in the child's care is essential. A structured approach to record review can clarify the concerns and discrepancies as well assist in potential future testimony. The use of overt or covert video surveillance systems are potential modalities to aid in making the diagnosis of MCA. If called to testify, it is helpful to understand the court system. Risks to the child from MCA are great and include a high level of long-term morbidity and mortality. Understanding this diagnosis and having a plan in place to address it when suspected can prevent further harm to the child. [Pediatr Ann. 2020;49(8):e354-e358.].

An Overview of Munchausen Syndrome and Munchausen Syndrome by Proxy

Munchausen syndrome and Munchausen syndrome by proxy are complex diseases that are difficult to diagnose and treat. To assist in this process, an overview of diagnostic criteria with common characteristics and red flags are discussed, with case studies illustrating identification and diagnosis of these disorders. Treatment options are addressed within the context of each of these complex syndromes. The provider's knowledge of diagnostic criteria and treatment options for Munchausen syndrome and Munchausen syndrome by proxy promotes better outcomes for patients. Without an early diagnosis and intervention, the patient is at high risk for severe complications, including organ failure and mortality.

The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases

INTRODUCTION

Little is known about the perpetrators of medical child abuse (MCA) which is often described as "Munchausen's syndrome by proxy" or "factitious disorder imposed on another". The demographic and clinical characteristics of these abusers have yet to be described in a sufficiently large sample. We aimed to address this issue through a systematic review of case reports and series in the professional literature.

METHOD

A systematic search for case reports and series published since 1965 was undertaken using MEDLINE, Web of Science and EMBASE. 4100 database records were screened. A supplementary search was then conducted using GoogleScholar and reference lists of eligible studies. Our search yielded a total sample of 796 perpetrators: 309 from case reports and 487 from case series. Information extracted included demographic and clinical characteristics, in addition to methods of abuse and case outcomes.

RESULTS

Nearly all abusers were female (97.6%) and the victim's mother (95.6%). Most were married (75.8%). Mean caretaker age at the child's presentation was 27.6 years. Perpetrators were frequently reported to be in healthcare-related professions (45.6%), to have had obstetric complications (23.5%), or to have histories of childhood maltreatment (30%). The most common psychiatric diagnoses recorded were factitious disorder imposed on self (30.9%), personality disorder (18.6%), and depression (14.2%).

CONCLUSIONS

From the largest analysis of MCA perpetrators to date, we provide several clinical recommendations. In particular, we urge clinicians to consider mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder at heightened risk for MCA. Longitudinal studies are required to establish the true prognostic value of these factors as our method may have been vulnerable to publication bias.

Early recognition and management of fabricated or induced illness in children

Fabricated or induced illness (previously known as Munchausen syndrome by proxy) takes place when a caregiver elicits health care on the child's behalf in an unjustified way. Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders specifies deception as a perpetrator characteristic, a far wider range is encountered clinically and is included in this Review. We describe the features of fabricated or induced illness, its effect on the child, and the psychosocial characteristics of caregivers and their possible motives. Present evidence suggests that somatoform and factitious disorders are over-represented in caregivers, with possible intergenerational transmission of abnormal illness behaviour from the caregiver to the child. Paediatricians' early recognition of perplexing presentations preceding fabricated or induced illness and their management might obviate the development of this disorder. In cases of fully developed fabricated or induced illness, as well as protection, the child will need help to return to healthy functioning and understand the fabricated or induced illness experience. Management of the perpetrator is largely dependent on their capacity to acknowledge the abusive behaviour and collaborate with helping agencies. If separation is necessary, reunification of mother and child is rare, but can be achieved in selected cases. More collaborative research is needed in this specialty, especially regarding close study of the characteristics of women with somatoform and factitious disorders who involve their children in abnormal illness behaviour. We recommend that general hospitals establish proactive networks including multidisciplinary cooperation between designated staff from both paediatric and adult mental health services.

Caregiver-fabricated illness in a child: a manifestation of child maltreatment

Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver who falsifies and/or induces a child's illness, leading to unnecessary and potentially harmful medical investigations and/or treatment. This condition can result in significant morbidity and mortality. Although caregiver-fabricated illness in a child has been widely known as Munchausen syndrome by proxy, there is ongoing discussion about alternative names, including pediatric condition falsification, factitious disorder (illness) by proxy, child abuse in the medical setting, and medical child abuse. Because it is a relatively uncommon form of maltreatment, pediatricians need to have a high index of suspicion when faced with a persistent or recurrent illness that cannot be explained and that results in multiple medical procedures or when there are discrepancies between the history, physical examination, and health of a child. This report updates the previous clinical report "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in the Medical Setting" The authors discuss the need to agree on appropriate terminology, provide an update on published reports of new manifestations of fabricated medical conditions, and discuss approaches to assessment, diagnosis, and management, including how best to protect the child from further harm.

Children intoxications: what is abuse and what is not abuse

The curiosity and the natural tendency to explore the environment put young children at an increased risk of poisoning over older children and adults. Poisonings are a significant area of concern from 1 year of age and progressively contribute more to overall rates of morbidity and mortality until children reach adulthood. Particularly, the abuse of children by poisoning is also highly common with thousands of fatalities. A practical strategy is presented that aims to alert health, forensic, and law enforcement professionals to this problem and to demystify the preconception that it is a rare form of abuse or neglect. Compounds that are foreign to a living organism (xenobiotics) and those present within body (endobiotics), mainly involved in children intoxications and contextual examples related to exposure are also reviewed. Particular concern is given to concepts in the field of children poisoning. The described history and the clinical and toxicological evaluation are discussed, and harmonized protocols regarding correct procedures for sample collection to forensic toxicological analysis are proposed. Since children are particularly vulnerable to the toxic effects of high doses of xenobiotics and endobiotics, special consideration on the preparation of the environment that surrounds children in order minimize all possible risks will be also considered.

The role of nonperpetrating fathers in Munchausen syndrome by proxy: a review of the literature

Munchausen syndrome by proxy (MSBP) is a psychiatric condition and form of child abuse in which a caregiver, usually a mother, induces illness in a child to gain attention for herself. Because children that are abused by a MSBP perpetrator are likely to be hospitalized multiple times, it is important for the nurse to know warning signs and symptoms of MSBP. Of particular interest is the role of the child's parent that is not involved in the abuse, usually the father. This article presents a review of literature on MSBP, focusing on the role of the nonperpetrating fathers.

Collection of biological samples in forensic toxicology

Forensic toxicology is the study and practice of the application of toxicology to the purposes of the law. The relevance of any finding is determined, in the first instance, by the nature and integrity of the specimen(s) submitted for analysis. This means that there are several specific challenges to select and collect specimens for ante-mortem and post-mortem toxicology investigation. Post-mortem specimens may be numerous and can endow some special difficulties compared to clinical specimens, namely those resulting from autolytic and putrefactive changes. Storage stability is also an important issue to be considered during the pre-analytic phase, since its consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample. The knowledge on degradation mechanisms and methods to increase storage stability may enable the forensic toxicologist to circumvent possible difficulties. Therefore, advantages and limitations of specimen preservation procedures are thoroughfully discussed in this review. Presently, harmonized protocols for sampling in suspected intoxications would have obvious utility. In the present article an overview is given on sampling procedures for routinely collected specimens as well as on alternative specimens that may provide additional information on the route and timing of exposure to a specific xenobiotic. Last, but not least, a discussion on possible bias that can influence the interpretation of toxicological results is provided. This comprehensive review article is intented as a significant help for forensic toxicologists to accomplish their frequently overwhelming mission.

Munchausen syndrome by proxy: ongoing clinical challenges

In 1977, Roy Meadow, a pediatric nephrologist, first described a condition he subsequently coined Munchausen syndrome by proxy. The classic form involves a parent or other caregiver who inflicts injury or induces illness in a child, deceive the treating physician with fictitious or exaggerated information, and perpetrate the trick for months or years. A related form of pathology is more insidious and more common but also damaging. It involves parents who fabricate or exaggerate symptoms of illness in children, causing overly aggressive medical evaluations and interventions. The common thread is that the treating physician plays a role in inflicting the abuse upon the child. Failure to recognize the problem is common because the condition is often not included in the differential diagnosis of challenging or confusing clinical problems. We believe that a heightened "self-awareness" of the physician's role in Munchausen syndrome by proxy will prevent or reduce the morbidity and mortality associated with this diagnosis. In addition, we believe contemporary developments within the modern health care system likely facilitate this condition.

Wenn Mediziner ungewollt zur Kindesmisshandlung verführt werden: Münchhausen-by-proxy-Syndrom

Reports on seemingly caring mothers, who at the same time fabricate or provoke clinical symptoms in their children and subsequently expose them to potentially harmful medical procedures, are hardly believable at first sight. Nevertheless the steadily growing number of reports on this kind of child abuse, known as Munchausen-by-proxy syndrome, points to a significant number of undetected cases. The interactional involvement of health care professionals in the abuse tends to impede diagnosis, and, as a consequence of the syndrome, usually leads to violent emotional reactions, which require careful analysis and professional handling.

Meadow, Southall, and the General Medical Council of the United kingdom

In this article we address the recent actions of the General Medical Council in the United Kingdom affecting 2 pediatricians who are major contributors to pediatric knowledge about the intentional suffocation of infants. The General Medical Council struck one of them from the register of licensed medical practitioners, but the decision was appealed successfully. The council restricted the practice of the other pediatrician. After a review of the transcripts of the hearings, we conclude that the opinions given by both doctors were responsible, and the transcripts suggest that the conduct of the hearings was unfair. Licensing boards may have difficulty in competently regulating doctors' expert testimony, at least in cases involving child maltreatment.

A case of Munchausen syndrome by proxy with subsequent suicide of the mother

Munchausen syndrome by proxy is a subtle and difficult to diagnose form of child abuse in which the carer (usually the mother) simulates, manipulates or produces symptoms of illness in the victim. In most cases the detrimental effect is caused by applying foreign substances or by airway obstruction. In the presented case a 20-month-old girl developed a spreading soft-tissue infection resistant to treatment on the left upper arm after vaccination, which required a number of surgical interventions. Repeatedly, microorganisms from the intestinal flora were isolated from the wound secretion. After the girl suffered respiratory and circulatory arrest, which required resuscitation measures, chemical toxicological tests revealed not medically prescribed benzodiazepines in serum and urine. When the mother, a trained nurse, was confronted with the allegation to have manipulated the symptoms of the illness she committed suicide. The forensic autopsy of the suicide produced numerous hints suggesting chronic self-damaging behaviour described as Munchausen syndrome. This case shows a number of manipulation forms with the maintenance of a chronic skin and soft tissue infection belonging to the rarer forms of inflicting damage to the child. It also illustrates that confrontation with the allegation of Munchausen syndrome by proxy creates a very stressful emotional situation that may lead to a suicidal act.

Suffocation and poisoning?the hard-hitting side of Munchausen syndrome by proxy

Munchausen syndrome by proxy (MSBP) is a severe and difficult to diagnose form of child abuse characterised by the simulation, aggravation or production of symptoms of illness in a child by an adult. MSBP often leads to multiple hospitalisations and has a high mortality and long-term morbidity. This study describes the cases of 5 families with 8 children affected who presented with unexplained neurological or gastrointestinal symptoms or even loss of consciousness. All were victims of poisoning or suffocation by their mothers. Two of those children died and were initially diagnosed as SIDS or natural death, respectively. They were only recognised as MSBP victims after another sibling had fallen ill with similar symptoms. The cases are discussed in consideration of the relevant literature. In addition warning signs of this forensically relevant syndrome and a strategy for the management of suspected MSBP cases are described.

Munchausen Syndrome by Proxy: two case reports and an update of the literature

OBJECTIVES AND METHODS

Munchausen Syndrome by Proxy (MSP) may significantly hamper the normal development of children. Our aim was to describe the first two Israeli children who fit this diagnosis.

RESULTS

Case #1 was diagnosed at the age of seven months with failure to thrive, severe recurrent vomiting, and recurrent unexplained fever. Medical tests performed were normal. No improvement was noted following prolonged treatment, which included several surgical interventions. Case #2 was hospitalized at the age of four years because of recurrent convulsive episodes. Medical examinations performed were normal, and there was no improvement in the reported seizure disorder despite continuous treatment. In both cases, MSP was suspected because of a persistent illness that could not be explained by adequate medical basis, and because the symptoms and signs occurred only in the mother's presence. A confrontation was made, leading to rapid deterioration of the hitherto devoted relationship of the mother of case #1 with her child, and of the previous cooperative relationship of both mothers with the medical staff. Removal of both children from their families ensued, with considerable improvement within a brief period, which continued in a one- to two-year follow-up period.

CONCLUSIONS

The study reviews the required diagnostic criteria for MSP and possible treatment options.

The deceit continues: an updated literature review of Munchausen Syndrome by Proxy

OBJECTIVE

This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP).

METHOD

Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles.

RESULTS

Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury.

CONCLUSION

Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.

Different interpretations of Munchausen Syndrome by Proxy

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.

On the importance of motivation in Munchausen by Proxy: the case of Kathy Bush

The recent trial and conviction of Kathy Bush for abusing her daughter is used to illustrate (1) the nature of the motivation, in at least some cases of MBP, and (2) the importance of distinguishing the motivation found in MBP from that found in other forms of child abuse and other conditions involving factitious illness production.

An explanatory model for Munchausen by proxy abuse

OBJECTIVE

In Munchausen by proxy (MBP) abuse, a caretaker fabricates or induces illness in another person to obtain emotional gratification. In representative cases, a mother is the perpetrator and her child is the victim. In view of the limits of current explanatory models, we use personal accounts of MBP perpetrators, physicians, and family members as a window into understanding this counterintuitive behavior.

METHOD

As subspecialty clinicians and consultants, we supplemented our extensive direct experience with MBP with a review of published reports of MBP located via MEDLINE and PsycINFO (1980 onward). We also examined the books devoted to the subject and incorporated personal accounts of MBP perpetrators and of family members and professionals involved with them.

RESULTS

Factors contributing to the onset and continuation of MBP are the perpetrator's experiencing a particular drive (e.g., intense anger or frustration); lacking or overcoming internal inhibitions against abusive actions; and overcoming external inhibitions, such as the potential intercession of a spouse or pediatrician. As a result, the MBP parent experiences release from unpleasant emotions and a sense of renewed control. MBP behavior gains "habit strength" each time it occurs.

CONCLUSIONS

Psychodynamic explanations of MBP, while favored by some authors, are inherently speculative and tend to be low in predictive value. We suggest broadening these traditional explanations by emphasizing observable behaviors and verifiable background factors. The behavioral perspective we outline helps explain how MBP behavior is learned, why it is more prevalent among mothers, and why it is so difficult for perpetrators to stop.

Oronasal blood in sudden infant death

Oronasal secretions are observed frequently in sudden infant death syndrome (SIDS), but overt blood is uncommonly reported. The literature on oronasal blood in sudden infant death is limited. The goal of this study was to determine the frequency of oronasal blood in sudden infant deaths and to examine possible causative factors. Oronasal blood was described in 28 (7%) of 406 cases of sudden infant death. Oronasal blood could not be attributed to cardiopulmonary resuscitation in 14 cases, including 10 (3%) of 300 cases of SIDS, 2 (14%) of 14 accidental suffocation cases, and 2 (15%) of 13 undetermined cases. Eight of the 10 infants in cases of sudden infant death were bedsharing: 5 with both parents, 2 between both parents. The infant in 1 SIDS case was from a family that had had three referrals to Child Protective Services. Oronasal blood not attributable to cardiopulmonary resuscitation occurs rarely in SIDS when the infant is sleeping supine in a safe environment. Bedsharing may place infants at risk of suffocation from overlaying. Oronasal blood observed before cardiopulmonary resuscitation is given is probably of oronasal skin or mucous membrane origin and may be a sign of accidental or inflicted suffocation. Sanguineous secretions that are mucoid or frothy are likely of remote origin, such as lung alveoli. The use of an otoscope to establish the origin of oronasal blood in cases of sudden infant death is recommended.

A 4-year-old girl with manifestations of multiple chemical sensitivities

Multiple chemical sensitivities (MCS) syndrome, also known as idiopathic environmental intolerance, is a controversial diagnosis that encompasses a wide range of waxing and waning, subjective symptoms referable to more than one body system and provoked by exposure to low levels of chemicals, foods, or other agents in the environment. Although MCS has been studied extensively, a unifying mechanism explaining the illness remains obscure, and clinicians are divided as to whether such a medical entity exists separately from psychosomatic syndromes. MCS is an adult diagnosis; there is little reference to pediatric cases in the scientific literature. In this case from the Pediatric Environmental Health Subspecialty Unit at Boston's Children's Hospital, I present the case of a preschool child who had suffered from milk allergy and poor weight gain as an infant, and then later developed asthma, allergic symptoms, sinusitis, headaches, fatigue, and rashes precipitated by an expanding variety of chemicals, foods, and allergens. I review definitions, mechanisms, diagnostic strategies, and management, and discuss some uniquely pediatric features of MCS as illustrated by this case.

Unnatural sudden infant death

AIM

To identify features to help paediatricians differentiate between natural and unnatural infant deaths.

METHOD

Clinical features of 81 children judged by criminal and family courts to have been killed by their parents were studied. Health and social service records, court documents, and records from meetings with parents, relatives, and social workers were studied.

RESULTS

Initially, 42 children had been certified as dying from sudden infant death syndrome (SIDS), and 29 were given another cause of natural death. In 24 families, more than one child died; 58 died before the age of 6 months and most died in the afternoon or evening. Seventy per cent had experienced unexplained illnesses; over half were admitted to hospital within the previous month, and 15 had been discharged within 24 hours of death. The mother, father, or both were responsible for death in 43, five, and two families, respectively. Most homes were disadvantaged--no regular income, receiving income support--and mothers smoked. Half the perpetrators had a history of somatising or factitious disorder. Death was usually by smothering and 43% of children had bruises, petechiae, or blood on the face.

CONCLUSIONS

Although certain features are indicative of unnatural infant death, some are also associated with SIDS. Despite the recent reduction in numbers of infants dying suddenly, inadequacies in the assessment of their deaths exist. Until a thorough postmortem examination is combined with evaluation of the history and circumstances of death by an experienced paediatrician, most cases of covert fatal abuse will go undetected. The term SIDS requires revision or abandonment.