MUNCHAUSEN SYNDROME BY PROXY

DEBRA LYNNE BLACK

DR. BOB BARON

ENGLISH 102

AUGUST 4 1997

"Truth exists, only falsehood has to be invented " George Braque

The siren screams as the ambulance rushes its tiny patient to the local emergency room for treatment. The lifeless baby girl is quickly handed over to an awaiting physician, who frantically continues the mouth-to-mouth resuscitation that had begun while en route to the hospital. Her limp body has already changed to a pale blue color, as her anxious mother watches in horror. Several tense moments pass as the doctor continues to work on the small, frail body. Finally, she gasps for air. Cheers of joy echo loudly throughout the halls of the emergency room. Once again, this tiny child has narrowly escaped death and now lies quietly in her mother's protective arms. A precious life almost lost at the hands of a cruel and unexpected perpetrator: the child's mother. Could this be possible? How could a mother purposely inflict harm on her own child? Unfortunately, this of child abuse does happen by those who are afflicted with a psychiatric disorder known as Munchausen Syndrome by Proxy (MSP). What is Munchausen Syndrome by Proxy, and how is it diagnosed?

Munchausen Syndrome by Proxy is one of many "Factitious" disorders, "Factitious" referring to something that is not real, genuine or natural (American). "Factitious disorders are ... characterized by physical or psychological symptoms that are intentionally produced or feigned" (American). The term "Munchausen Syndrome" was coined by Dr. Richard Asher in 1951, after an 18th century soldier who became widely known for his tall tales (Karlin). Karl Friedrich Hieronymous Freihess von Munchausen was a soldier in the Russian Calvary who loved to embellish the battle stories he shared with friends. Over the years, his outrageous tales grew in popularity, were published in book form, and even evolved into a German fairy tale. In 1794, at age 74, Munchausen married a 17 year old girl named Bernadine Brun (Boros 16). One year later, she gave birth to a son named Polle. At the tender age of one year old, Polle died amid suspicious circumstances, thus, the inspiration by Dr Asher to identify this disorder. Dr Roy Meadow, Chairman of Pediatrics, at the University of Leeds in England, expanded on the name coined 26 years earlier by adding the words, "by Proxy", after several of his epileptic patients' mothers had fabricated their children's symptoms (See Appendix 1). It was his way of distinguishing that type of behavior from one in which a person inflicts harin to himself or herself. Over the years, this disorder has also been referred to as Polle Syndrome or Meadow Syndrome (Boros 16). Who are the victims affected by this deceit?

In Munchausen Syndrome by Proxy, a child can be exposed to countless diagnostic tests, which are both painful and unnecessary. "Some children have had as many as 300 clinical visits and 14 hospitalizations in their first 18 months of life" (Feldman and Ford). Children under six years of age are the most common victims of this disorder. Among a medical study containing II7 MSP cases, 9% of those victims died (Feldman and Ford 147). In one such case, a nine-month-old boy had repeatedly been treated for recurring apnea, a cessation of breathing (Boros 17). His mother administered mouth-to-mouth resuscitation during his first episode of apnea, at seven weeks of age. During the next nine months, the child had endured ten clinic visits and seven hospitalizations. Eight of those emergencies required mouth-to-mouth resuscitation. The doctors and nursing staff had become suspicious of the mother when they realized that she was the only one that had witnessed the child's apnea episodes. The little boy was later sent home with nursing care. The nurse noted that he would not eat while his mother was present in the room. The boy was then admitted back into the hospital, into a room where both he and his mother could be secretly videotaped. On the sixth day, the mother was observed inducing her child's apnea by lifting him from the bed, forcing him into her chest, and smothering him. When the boy was limp, she placed him back onto the bed, called for help, and began resuscitating him. During the investigation, which followed, it was noted that she had been the dominant parent and that she had been involved in all of the major decision dealing with the child's care (Boros 17).

In another tragic case, a mother had reported her son's chronic diarrhea at only two days of age. At three months of age, he was admitted into the hospital and underwent many costly tests, which resulted in normal findings. After two months of hospitalization, his diarrhea suddenly stopped, and he was sent home where he remained healthy for the next six months. Once again, he was readmitted for chronic diarrhea, and he was given many antidiarrheal medications. These medications were unable to control his diarrhea, and as a result of his condition, he had to be fed through a catheter. It was noticed that the child's diarrhea would subside while he was sleeping and while he was out of the room for tests. The common factor in all of his episodes was his mother, who had stayed by his side both day and night. The doctors finally convinced the mother to take a rest from the hospital. While she was away, her child improved, and when she returned, so did his chronic illness, The doctors and hospital staff decided to investigate the mother and child with the use of video equipment. Only 24 hours after beginning the surveillance, the mother was observed giving the child three doses of a harmful substance, which she gave orally with a syringe. Later she was apprehended and committed to a psychiatric hospital for treatment (Feldman and Ford 159).

The perpetrator of MSP, (usually the biological mother), uses many different methods to induce an illness into her child. One method is to induce apnea by suffocating the child until the child has become unconscious. Other mothers may, secretly place a drop of blood into their child's urine specimen in order to obtain false test results (Feldman). Behind closed doors, the perpetrator may scrub the child's arms with ordinary oven cleaner to cause a baffling, blistering rash that lasts for months (Feldman). Is it possible to understand this horrendous form of child abuse?

MSP is perpetrated most commonly against infants and toddlers who are too young to talk. When the child begins to talk and can describe things, the probability is much higher that the parent will be detected. However, MSP doesn't necessarily end with the development of the child's verbal skills. Young children are not always able to see relationships between events and people, so children who are being victimized through illness may not make the connection that a parent or trusted other is making them sick. Besides, parents of legitimately sick children must usually fight to get medicine down a child's throat, so children who are the target of MSP aren't necessarily going to understand when ipecac or a laxative is being forced in them needlessly (Feldman and Ford 149).

In some MSP cases children may not exhibit age-appropriate behavior, and they may show anger or anxiety, and later, helplessness. Sometimes these children blame their illness on themselves, and feel that they did something wrong. They feel as though they "deserve" their sickness (Feldman).

In 1986, Dr. Libow and Dr. Schreier described three major types of MSP perpetrators: Help Seekers, Active Inducers, and Doctor Addicts. They described Help Seekers as those mothers who seek medical attention for their children in order to communicate their own anxiety or inability to care for the child. Active Inducers cause illness in their children by the use of extreme methods, and they enjoy the attention and acclaim they receive as outstanding caregivers. Doctor Addicts believe that their children are ill, refuse to accept evidence to the contrary, and then develop their own treatment for their children. These mothers tend to be antagonistic and paranoid, and they are obsessed with obtaining medical treatment for nonexistent illnesses in their children (Karlin). 'Herbert Schreier ... says most mothers with MSP were themselves neglected as youngsters, leaving them unable to love or to feel another person's pain: even their own child's' (Brownlee). Most perpetrators have severe personality disorders and may not have learned more appropriate ways to gain attention or nurturing. They are often very selfish and harm the children in order to benefit themselves (Feldman and Ford119). These mothers know that with sickness comes tender loving care (Feldman).

Unfortunately, most people afflicted with Munchausen Syndrome by Proxy do not get the help the desperately need. Many perpetrators flee when they are confronted with allegations of child abuse. Often, they take the child to another hospital and begin their web of deceit again (Feldman). Doctors are not adequately trained to decipher vague descriptions of an illness and medical history from patient, so it could take several years of treatment for them to become suspicious. While MSP only accounts for less than 1,000 of the more than 2.9 million cases of child abuse (Feldman), MSP often resembles SIDS cases and, therefore, is not immediately identified (Feldman). It is unfortunate that at times some individuals are falsely accused. What are the possible repercussions?

False accusations of Munchausen Syndrome by Proxy can be very damaging to a family already burdened with both emotional and financial stress. Those who are suspected of MSP are placed on a nationwide electronic registry, which tracks and flags them. Even for those parents who are found innocent of causing harm to their children, there is no way to get their name off of the list. Many falsely accused couples are plagued with the fear of seeking medical attention for their children again (M.A.M.A.). Very often, children are taken away from their homes by Child Protective Services for many months until all documents can be reviewed. This agonizing separation between the child and the family causes even more undue stress to the family. Sometimes, the fact that a parent has been accused of Munchausen Syndrome by Proxy, is all that the legal system needs to influence custodial decisions (M.A.M.A.). Munchausen Syndrome by Proxy is both a unique and difficult disorder to fully understand. As Dr. Feldman states in his book, Patient or Pretender, "There are few Cinderella stories ... for 99 percent of factitial patients, it is always midnight, a pumpkin is just a pumpkin, and no shining heroic figure ever arrives to snatch them from the twisted fantasy world they have created." Perhaps with more awareness by doctors and other health care providers, Munchausen Syndrome by Proxy could dissolve back into a fairy tale.

BIBLIOGRAPHY

American Psychiatric Association. "Factitious Disorders." Diagnostic and Statistic Manual for Mental Disorders. Washington: American Psychiatric Assoc., 1987.

Boros, Stephen J. and Larry C. Brubaker. "Munchausen Syndrome by Proxy: Case Accounts. SIRS 1992 Mental Health. 4.74 (1992). Online. Retrieved from FBI Law Enforcement Bulletin. (9 July 1997): 16-20.

Brownlee, Shannon. "Mother: Love Betrayed." U.S. News Dec. 1995: np.

Feldman, Marc D., M.D. "Parenthood Betrayed: The Dilemma of Munchausen Syndrome by Proxy." Self-HeIp & Psychology Magazine 1994: np

Feldman, Marc D., M.D., and Charles V. Ford, M.D. Patient or Pretender. New York: John Wiley & Sons, Inc., 1994.

Hollandsworth, Skip. "Hush, Little Baby, Don't You Cry." Texas Monthly Aug. 1995: 70-3+.

Karlin, Nina J. "Munchausen Syndrome by Proxy." Psychiatric Review Dec. 1995: np.

M.A.M.A. "You Shall Not Bear False Witness Against Your Neighbor." Online. Retrieved e-mail:,angelofg@gmi.net (7 July 1997): np

McCormick, John, "Why Parents Kill." SIRS 1994 Family. 5.39 (14 Nov. 1994). Online. Retrieved from Newsweek. (9 July 1997): np

"My Sister-in-Law was Starving her 'Baby." @.Housekeeping Oct. 1991: 26-29.