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  1. 1. Munchausen’s Syndrome by Proxy James H. Johnson, Ph.D.
  2. 2. Definition <ul><li>First highlighted by British Pediatrician, Roy Meadow, and described in a number of publications (1977,1982, 1985) </li></ul><ul><li>A condition in which a parent or other caretaker persistently fabricates symptoms on behalf of another, causing that person to be regarded as ill (Meadow, 1985). </li></ul><ul><li>Considered a type of abuse as the behaviors of the perpetrator (usually the mother) can result in the child having to undergo invasive medical tests and receive treatments that may be harmful. </li></ul>
  3. 3. The Nature of the Problem <ul><li>The nature of the problem can be best highlighted by considering characteristics of 19 cases initially described by Meadow (1982). </li></ul><ul><li>10 boys, 9 girls. </li></ul><ul><li>Mean age 3 years; 2 months </li></ul><ul><li>Children displayed wide range of symptoms, typically suggestive of a “multisystem disorder” </li></ul>
  4. 4. Case Characteristics: Summary <ul><li>False symptoms had persisted on average 13 months prior to diagnosis. </li></ul><ul><li>Most had been seen by numerous doctors, had been referred from hospital to hospital – one had been examined by 28 consultants. </li></ul><ul><li>In each case the mother was the source of the fraudulent history and the fabricator of false symptoms. </li></ul>
  5. 5. Case Characteristics: Summary <ul><li>False histories provided by mothers were “impressive in medical detail and fabricated symptoms were often quite realistic”. </li></ul><ul><li>Meadow notes that “the methods used combined cunning, dexterity and , quite often, medical knowledge. </li></ul><ul><li>It is noteworthy that the perpetrators were not infrequently are individuals with some medical knowledge. </li></ul>
  6. 6. Case Characteristics: Summary <ul><li>Bleeding – generally the result of mother adding her own blood to the child’s vomit, urine, and feces. </li></ul><ul><li>(Have seen one case here where mother put her own blood in child’s feces) </li></ul><ul><li>Fevers – often produced by rubbing thermometer or immersing it in hot liquids. </li></ul><ul><li>In one instance feces were mixed with the child’s vomit to cause abnormal findings. </li></ul><ul><li>Biochemical Chaos – often resulted from diluting or adding chemicals, such as salt, to blood specimens </li></ul>
  7. 7. Case Characteristics: Summary <ul><li>Rashes – fabricated by rubbing the skin, by adding caustic solutions to skin, or by painting the skin with some sort of dye. </li></ul><ul><li>Neurological Symptoms – generally the result of the mother giving the child drugs (sedatives or tranquilizers) that had been prescribed for herself. </li></ul><ul><li>Fabricated symptoms led to a range of unnecessary procedures including many medical procedures and long and expensive hospital stays. </li></ul>
  8. 8. Medical Procedures Incurred <ul><li>Six year old boy – Missed 13 months of school, 1 month of IV fluids, and a range of other procedures such as lumbar puncture, EEG, and brain scans. </li></ul><ul><li>Also had bone, kidney, and skin biopsies as well as being prescribed a range of drugs including antibiotics, steroids and approximately 20 other medications. </li></ul><ul><li>Seven of the 19 mothers had a history of Munchausen’s syndrome themselves </li></ul><ul><li>In two families another child was also involved in the mothers fabricating of symptoms. </li></ul><ul><li>Most carried no diagnostic label and were seen by medical staff as caring and loving of their children. </li></ul>
  9. 9. Hints of Potential Contributors <ul><li>Meadow notes “It would be naïve to seek a single cause for the harmful behaviors for these mothers. </li></ul><ul><li>For some, the child’s illness brought about a closer relationship with the husband, while for others, it seemed to provide a welcome distraction from personal and home difficulties. </li></ul><ul><li>Several mothers thrived on the children’s wards - They seemed to love it, bustling around helping other mothers, helping the nurses, and forming close relationships with junior medical staff. </li></ul><ul><li>They made the medical staff feel that the pediatric service was really good. </li></ul>
  10. 10. Hints of Potential Contributors <ul><li>For some it seemed to be a bizarre game in which they matched themselves against the best specialists and the best hospitals the could find. </li></ul><ul><li>Several of these mothers were individuals with prior nurses training. </li></ul><ul><li>Based on observations made in working with these cases, Meadow has presented a number of tentative “warning signs” that may be helpful in making an earlier diagnosis than would otherwise be possible. </li></ul>
  11. 11. Possible Warning Signs of MSBP <ul><li>An illness that is unexplained, prolonged, and so extraordinary that it prompts experienced colleagues to state that “they have never seen anything like it before.” </li></ul><ul><li>Symptoms and signs are inappropriate or incongruous. </li></ul><ul><li>Symptoms are present only when the mother is present. </li></ul><ul><li>Treatments that are ineffective or poorly tolerated. </li></ul><ul><li>Children who are alleged to be allergic to a great variety of foods and drugs. </li></ul><ul><li>Mothers who are not as worried by the child’s illness as are nurses and doctors. </li></ul>
  12. 12. Possible Warning Signs <ul><li>Mothers who are constantly with their ill child and who will not leave the ward for even brief periods of time. </li></ul><ul><li>Families where sudden unexplained infant deaths have occurred and families with many members who are alleged to have serous medical disorders. </li></ul><ul><li>Symptoms of a very rare disorder (although children can have rare disorders). </li></ul><ul><li>Seizures that do not respond to carefully administered anticonvulsants. </li></ul><ul><li>Note that these are simply “signs” that warrant being more watchful as they many of them may also be associated with other health related factors. </li></ul>
  13. 13. Facts About MSBP From Lasher and Feldman (2001) <ul><li>MSBP is dangerous. It has been estimated that 6 to 10 percent of MBP victims die. </li></ul><ul><li>MSBP is a recognized kind of maltreatment (abuse/neglect). </li></ul><ul><li>MSBP perpetrators deliberately engage in MSBP behavior. </li></ul><ul><li>Cases that appear to involve only false reports or simulation of symptoms should be considered as dangerous as those in which induction of illness has been suspected or confirmed. </li></ul>
  14. 14. Epidemiology (From Huynh, 1998) <ul><li>Determining the incidence and prevalence of MSBP is difficult for a variety of reasons. </li></ul><ul><li>No widespread population-based studies have been conducted </li></ul><ul><li>The true incidence of MSBP is hard to assess because many cases go undetected </li></ul><ul><li>Often, there are case suspicions, but insufficient evidence exists or is gathered, so these cases are never officially reported or investigated </li></ul><ul><li>Furthermore, the diagnosis of MSBP takes time; average time for diagnosis ranges from 6 to 15 months (Parnell, Day, 1997). </li></ul>
  15. 15. Epidemiology: Some Tentative Findings (From Huynh, 1998) <ul><li>Estimated 2-4 cases per million in the general population (Alexander et al, 1990). </li></ul><ul><li>Of the 2.5 million cases of child abuse reported annually, 1000 are related to MSBP (Volz, 1995). </li></ul><ul><li>The fatality rate for MSBP is approximately 10%. </li></ul><ul><li>Physical morbidity rate of 75%; possibly even higher psychological morbidity rate (Rosenberg, 1987) </li></ul><ul><li>25% to 35% of the time, MSBP is perpetrated serially on siblings (Alexander et al, 1990) </li></ul>
  16. 16. Epidemiology: Some Tentative Findings (From Huynh, 1998) <ul><li>Most perpetrators assume the “mother” role; 90% are biological mothers </li></ul><ul><li>5% include the father, babysitter, nanny, or grandmother (Meadow, 1985). </li></ul><ul><li>Boys and girls are equally affected, and all socioeconomic classes are represented </li></ul>
  17. 17. MSBP Outcome: Some Tentative Findings (From Huynh, 1998) <ul><li>Currently, there is limited data available on child victims of MSBP despite increased awareness (Bools et al, 1993); very few follow-up studies conducted </li></ul><ul><li>As many as 10% may die as a result of induction of illness or from diagnostic interventions </li></ul><ul><li>May develop chronic invalidism </li></ul><ul><li>Can experience permanent disfigurement from medical procedures </li></ul>
  18. 18. MSBP Outcome: Some Tentative Findings (From Huynh, 1998) <ul><li>Develop permanent impairment of bodily function from the medical procedures </li></ul><ul><li>Child may show academic delays from “chronic absenteeism,” and problems with concentration, emotions, and behaviors (Libow, 1994). </li></ul><ul><li>Child may show delays in social development from lack of age-appropriate interaction with peers and adults </li></ul><ul><li>Risk of perpetration of MSBP on their own child(ren) as an adult </li></ul>
  19. 19. MSBP Outcome: Some Tentative Findings (From Huynh, 1998) <ul><li>Child may develop disturbed understanding of proper mother-child relationship </li></ul><ul><li>The child may develop significant adjustment problems </li></ul><ul><li>In general, it seems that the prognosis is likely to be quite poor. </li></ul><ul><li>Although many children return to the family and survive, there is no convincing case in the professional literature demonstrating successful treatment </li></ul>
  20. 20. Psychology Clinic Case: An Interdisciplinary Team Approach <ul><li>Specially called health care meeting attended by total of 12 professionals. </li></ul><ul><ul><li>Private practice pediatricians </li></ul></ul><ul><ul><li>Shands Pediatricians (Continuity of Care) </li></ul></ul><ul><ul><li>Child Protection Team members </li></ul></ul><ul><ul><li>Psychologist (that would be me!) </li></ul></ul><ul><ul><li>Social Workers </li></ul></ul><ul><ul><li>Staff from the Nurturing Program </li></ul></ul>
  21. 21. Reasons for Convening the Meeting <ul><li>Meeting was prompted by a referral from ENT . </li></ul><ul><li>This in related to a recent hospitalization of a 15 month old male who had tubes placed in ears and an adenoidectomy. </li></ul><ul><li>Was sent home when deemed appropriate, with mom being very upset – thought it was too early for him to be discharged. </li></ul><ul><li>Was put on extra fluids. </li></ul><ul><li>Mom called indicating that he would not take fluids, was dehydrated, was having seizures, and DEMANDED that he be hospitalized. </li></ul><ul><li>No evidence of either dehydration or seizures was found.. </li></ul>
  22. 22. Data Suggestive of MSBP <ul><li>Call from mother indicating that was child running, fell and head head – Mother reports that child had a subdural hematoma </li></ul><ul><li>No medical evidence was found </li></ul><ul><li>Call from mother indicating that child fell and hit head – Call was made 4 hours after presumed fall with mother indicating that child had fluid draining from ears </li></ul><ul><li>Child was air lifted to Shands – No evidence of fluid or any serious injury. </li></ul><ul><li>Alleged that child swallowed Christmas tree bulb – No bulb was found. </li></ul>
  23. 23. Data Suggestive of MSBP <ul><li>Mother took child for immunization – Child bite marks found – Nurse practitioner finds bruising in the area of the genitals and questions mother – Later mother ends up at ER stating that child was bitten by Brown Recluse spider. </li></ul><ul><li>Child’s 5 year old sister repeatedly taken to physician with claims that she had been sexually abused by her father, the mothers ex-husband, when child had gone to visit. </li></ul><ul><li>Allegations resulted in child undergo multiple examinations with no physical findings being noted and mother continuing to allow visits. </li></ul>
  24. 24. Other Data Suggestive of MSBP <ul><li>By age 15 months the younger child had experienced: </li></ul><ul><ul><li>Four hospitalizations at two different hospitals </li></ul></ul><ul><ul><li>Nine emergency room visits </li></ul></ul><ul><ul><li>52 total medical visits </li></ul></ul><ul><ul><li>81 call slips were documented by one private practice pediatrician. </li></ul></ul><ul><ul><li>Child had also been seen by Shands pediatrics after original pediatrician told mom they would not continue to see child unless mother became involved in counseling. </li></ul></ul>
  25. 25. Team Meeting Conclusions <ul><li>It was determine that strong support existed for Munchausen’s by Proxy. </li></ul><ul><li>It was concluded that the mother fabricated physical symptoms for the 15 month old boy. </li></ul><ul><li>Both children were removed from the home </li></ul><ul><li>Mother had also fabricated allegations of sexual abuse for her 5 year old daughter </li></ul>
  26. 26. Sexual Abuse Allegations as Munchausen’s by Proxy <ul><li>Regarding the issue of sexual abuse allegations made by this parent it is noteworthy that professionals have highlighted the fact that this can be a contemporary variation on Munchausen’s Syndrome by Proxy. </li></ul><ul><li>Goodwin (1982) and Wakefield and Underwager (1988) have cited examples of this type of MSBP (e.g., use of tampons to create physical findings) </li></ul><ul><li>Lasher and Feldman (2001) have authored an article having to do specifically with this variation. </li></ul><ul><li> </li></ul>
  27. 27. Sexual Abuse Allegations as Munchausen’s by Proxy <ul><li>It should be noted that, this variation on Muchausen’s by Proxy can in fact represent sexual abuse itself in some instances. </li></ul><ul><li>In cases where there are repeated allegations, the repeated physical evaluations resulting from these claims may represent a type of abuse by proxy. </li></ul><ul><li>One also wonders about the contribution of this type of MSBP to “false memories”. </li></ul>
  28. 28. Questions??