“I currently have a student that has missed over 30 full days of school this year, each with grand illnesses, incidents, and injuries, and always an explanation and visit from mom each time.  This student is fine, but mom needs the attention.” -Jakob

 In Part One of this two part series I discussed the rather disturbing, and often life-threatening, condition known as Munchausen syndrome.

To recap last week’s column, Munchausen syndrome is a very serious mental disorder in which an individual with a deep need for attention or sympathy repeatedly acts as if he or she has a physical or mental disorder when, in truth, he or she has caused the symptoms.  Munchausen syndrome belongs to a group of psychiatric conditions known as factitious disorders which is a group of conditions in which people purposely exaggerate, invent or even cause disease symptoms.  Many will create symptoms by injecting themselves with foreign substances (such as toxins) or taking unnecessary medications, or secretly harm themselves in order to construct signs of illness.

Munchausen syndrome by proxy (MSBP) is a potentially lethal variant of Munchausen syndrome.  It is a secretive and frequently misunderstood form of child abuse whereby an adult caregiver, usually the mother, deliberately makes a child sick by either exaggerating, fabricating, and oftentimes actually inducing physical and/or psychological problems, as well as attempting to convince others that the child is indeed sick.  The parent or caregiver will mislead others into thinking that the child has medical problems by lying and reporting fictitious episodes.  This oftentimes leads to doctors ordering unwarranted tests, attempting various medication interventions, and may actually result in the child being hospitalized or even undergoing surgery in order to try and determine the cause of these fabricated symptoms.  It is often during a hospitalization that the abuse actually intensifies.  In one well documented case of MSBP a mother injected her child with fecal material.  In another, the mother repeatedly suffocated and then revived her child.

Because the parent or caregiver portrays them self as being very involved, caring and attentive, often there is never any suspicion of wrongdoing.  The perpetrators know all too well their behavior is wrong, but take great care to conceal their actions and rarely admit to their abusive activities.  They are typically calm and relaxed even in the face of the confusing medical picture their child is experiencing, and often push for more and more diagnostic and treatment alternatives regardless of the pain and discomfort they may cause their child.  A physician’s suspicion or unwillingness to continue extensive work-ups may lead the offender to take the child to another facility for further consultation and evaluation.

A puzzling aspect of this disorder is the ability of the offender to deceive and manipulate even the most experienced doctors and health care professionals.  Oftentimes the caregiver is well versed and familiar with the medical field, and is able to use this knowledge to further perpetrate the fraud.  It is understandable how medical personnel can easily overlook the possibility of Munchausen syndrome by proxy as the concept itself flies in the face of the belief that parents and caregivers would deliberately harm their child.

Interestingly MSBP offenders often shield their victims from outside activities, such as school or playing with other children, allowing only certain individuals to be close to them. They may even speak for the victims when others approach them. Perpetrators are usually extremely attentive to their victims, even though they are harming them.   Typically, the person behind the deception feels satisfied by gaining the attention and sympathy of health care professionals and others the child-victim comes in contact with.  Some experts feel this form of abuse is not only driven by this attention, but also the satisfaction of being able to deceive individuals they perceive as being more powerful or important than themselves.  Although the symptoms of MSBP can generally be recognized by the time the victim reaches 18 months of age, it is usually not diagnosed until the child is of preschool age.  Victims are found in equal numbers of boys and girls.  98% of the architects of this fraud are female, more than 95% of the time the mother, and sadly the mortality rate for this type of child abuse is quite high.

Some of the more commonly faked symptoms or conditions by the parent or caregiver include allergies, vomiting, diarrhea, infections, seizures and failure to thrive.  These tend to be the most easily forged symptoms because in the doctor’s office the offender can just say that their child is experiencing these symptoms.

Diagnosis of Munchausen syndrome by proxy is extremely challenging. The following are some of the warning signs professionals use in attempting to make the diagnosis:

• a child who has multiple medical problems or complaints that do not respond to treatment or that follow a unrelenting and perplexing course
• a family history of similar or unexplained illness or death in a sibling
• an overly attentive parent who is reluctant to leave their child’s side and who themselves seem to require constant attention
• laboratory and/or physical findings that are extremely unusual, do not correspond with the child’s medical history, or are clinically or just physically impossible
• the signs and symptoms of a child’s illness do not occur in the parent’s absence
• a parent or caregiver who is not reassured by “good news” when test results and examinations find no medical problems, but continues to believe that the child is sick
• a parent  or caregiver with symptoms similar to that of their child’s and/or an illness history that is itself baffling and unusual
• a parent or caregiver who appears to be medically conversant and/or captivated with medical details and appears to enjoy the hospital gossip and atmosphere
• a parent or caregiver who appears to be unusually calm in the face of serious difficulties in their child’s medical course
• a suspected parent  or caregiver may work in the health care field themselves or acknowledge interest in a health-related job
• a parent or guardian who appears to have a voracious need for praise and admiration

Oftentimes older children victimized by Munchausen syndrome by proxy conspire with their mothers by corroborating even the most improbable stories about their medical histories, sometimes out of fear of disagreeing with their mothers and other times because of their mothers’ influence over them.  Some of these children believe that they actually are ill with an unexplained disorder that the physicians cannot figure out.  In other cases they are aware that their mother’s explanation is unlikely but fail to say anything fearing their mother’s retribution or that no one will believe them.

Similar to those victimized by other types of abuse, children who become unwilling accomplices to Munchausen syndrome by proxy can have long-term emotional and psychological problems.  Many are left with serious insecurities and symptoms of post-traumatic stress disorder.  When it is your mother that is intentionally hurting you, and then pretending to be your most entrusted caregiver, children are going to be incredibly damaged by such a violation of trust. 

Much like the disorder itself, the causes of Munchausen syndrome by proxy are not easy to determine.  In some cases the parent or caregiver them self were abused physically, sexually, and emotionally as children.  The perpetrators own personal needs prevail over their capacity to see the child as a person with feelings and rights, possibly because the parent or caregiver may have grown up being treated like that as well.  They may have come from families in which being sick was a way to get love and attention.

No confirmed data exists on the number of cases of the MSBP in all of its forms.  However, researcher of this disorder report, on average, approximately 600 cases of suffocation and poisoning related to Munchausen syndrome by proxy occur each year in the United States, and that about one of every seven such cases proves fatal.

Given both the potential significant legal issues and complications of the child abuse inherent in this disorder, along with the noteworthy psychiatric underpinnings of the perpetrator, it is critical to have an experienced Psychiatrist involved as early as possible in the process once the diagnosis is being considered by other health care workers or law enforcement.