What is Münchausen syndrome by proxy?
Münchausen syndrome by proxy may occur in different forms. In its least invasive form, this syndrome involves lying about a child’s medical problems. For example, a father may claim that his child stopped breathing or had a seizure. The harm to the child comes from the medical studies that are ordered by the physician in an attempt to evaluate and diagnose the condition. A second situation involves the simulation of symptoms in the child. For example, a mother may maintain that her child is experiencing hematuria, and examination of the urine reveals the presence of blood. The blood comes not from the child but from some external source, such as the mother’s menstrual blood or animal blood from packaged meat. Again, the child is subjected to needless diagnostic tests, some of which can be invasive.
The most injurious form of Münchausen syndrome by proxy comes when a parent induces the symptoms in the child. This can be done in many ways: The parent can administer syrup of ipecac to induce vomiting, administer substances such as diphtheria-tetanus-pertussis (DTaP) vaccine to cause a fever, or inject fecal materials into already existing intravenous lines to induce a bacterial bloodstream infection. Parental induction of an apparent life-threatening event (ALTE) has been documented through the use of covert video surveillance. Parents have been observed placing their hands or other objects over the infant’s face. Many of these children demonstrated bleeding from the mouth or gums, a finding not reported in any of the control infants who were experiencing an ALTE.
In addition to being subjected to multiple and invasive diagnostic procedures, some children die as a direct result of their parents’ actions. Some families have a history of sudden or unexplained deaths of siblings that may be attributable to Münchausen syndrome by proxy or other types of child abuse.
A physician should become concerned about the possibility of Münchausen syndrome by proxy in a child with multiple health care visits in whom an explanation for the problems is elusive. The most common complaints include bleeding, vomiting, apnea, seizures, and fever. In each case, the chronic nature of the problems and the constant switching of health care providers should be clues. Statements by experienced physicians such as “I’ve never seen anything like this” should also signal that the child may be the victim of Münchausen syndrome by proxy. Some physicians become trapped in the process of ordering multiple studies for fear of missing an exotic disease.
On the other hand, some parents represent the “worried well.” These people bring their children in for many minor complaints: every runny nose, low-grade temperature, or nonapparent skin rash. Their motivation is not personal attention. Rather, they are fearful and view their children as vulnerable.
The psychologic profile of the parent helps to distinguish the overly concerned mother from the one with Münchausen syndrome by proxy. The usual perpetrator is the child’s mother. The father is often detached, distant, and not involved in the child’s care, although cases in which the father is the perpetrator have been documented. Most perpetrators are believed to have borderline personalities and narcissistic personality disorders. They enjoy the attention that they receive in a medical setting. Medical staff members often characterize these individuals as excellent parents because they are knowledgeable about their child’s health, attentive to his or her needs, and cooperative with the staff. Many of the mothers have some type of medical or science background, which facilitates their understanding of medical conditions. Some have worked in physicians’ offices, making them knowledgeable about medical terminology or procedures. Psychological assessment is needed to help define parental pathology. Members of the medical staff may be disbelieving of the diagnosis, since they often find the parent to be nice and helpful. Many parents deny the accusations and are resistant to psychiatric intervention.
The task of the medical team is to entertain the diagnosis, obtain evidence, and protect the child. In some institutions, covert video surveillance is used to catch the parent in the act of inflicting the symptoms. Although there is concern about issues of privacy, legal counsel at most institutions has supported the use of covert video surveillance because it assesses the situation of the child.
Münchausen syndrome by proxy was initially described by Roy Meadow in 1977. In the twenty years after his initial report, more than three hundred cases were reported in the literature. The diversity of ways in which this syndrome is inflicted on children has expanded with each case report. In many cases, the prognosis for affected children is somewhat guarded because of the complexity of establishing the diagnosis on a legal level.
Once the child and the parent are separated, the symptoms resolve. Cases may be difficult to substantiate in court, without the presence of concrete evidence. Some children suffer from long-term sequelae, sometimes behaving like invalids because of the role in which they have been cast since childhood. There are reports of self-destructive behavior and Münchausen syndrome in some survivors. Psychological counseling is critical to ensure the well-being of these children. In most cases, the children cannot be returned to the parental perpetrator because of the intractable nature of the parent’s problem.
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