Munchausen syndrome by proxy

For patient information click here

Overview
Fabricated or induced illness (FII), or factitious disorders, originally and more commonly known as Munchausen syndrome or Munchausen syndrome by proxy (MSbP), are insidious disorders in which injury is deliberately and gradually inflicted upon a person usually for gaining attention or some other benefit.

The caregiver is usually a parent, guardian, or spouse, and the victim is usually a child or vulnerable adult. Although cases with feigned or induced physical illness receive the most attention, it is also possible for a perpetrator who emotionally abuses a victim to simulate and fabricate conditions that appear to be psychiatric or genetic problems.

Initial description
In 1977, pediatrician Roy Meadow, then professor of Pediatrics at the University of Leeds, England, described the extraordinary behavior of two mothers: One had (Meadow claimed) poisoned her toddler with excessive quantities of salt. The other had introduced her own blood into her baby's urine sample. He referred to this behavior as Munchausen syndrome by proxy (MSbP).

Although it was initially regarded with skepticism, MSbP soon gained a following amongst medics and social workers. Although it's not listed in the DSM-IV manual, a formal name since March 2002 is now fabricated or induced illness (FII) according to the Royal College Of Paediatrics and Child Health. In 2003 however, Earl Howe, the Opposition spokesman on health, accused the professor of inventing a "theory without science" and refusing to produce any real evidence to prove that Munchausen syndrome by proxy actually exists. It is important to distinguish between the act of harming a child, which can be easily verified (and there are plenty of cases to prove that it happens), and motive, which is much harder to verify and which MSbP (controversially) tries to explain. For example, a caregiver may wish to harm a child simply out of malice (similar to domestic abuse by husband or wife) rather than in order to draw attention and sympathy, in which case, harming the child is merely incidental to the main purpose. In the former case, induced illness is likely to be a means of avoiding detection of domestic abuse (a more elaborate form of the excuse that the victim has "fallen down the stairs").

The distinction is often crucial in criminal proceedings, in which the prosecutor must prove both the act and the mental element constituting a crime to establish guilt. In most legal jurisdictions, a doctor can give expert witness testimony as to whether a child was being harmed but cannot speculate regarding the motive of the caregiver. FII merely refers to the fact that illness is induced or fabricated and does not specifically limit the motives of such acts to a caregiver's need for attention and/or sympathy. There are now more than 2,000 case reports of FII in the professional literature. Reports come from developing countries that include, but are not limited to, Sri Lanka, Nigeria, and Oman. Dr. Meadow was knighted for his work for child protection though, later, his reputation, and consequently, credibility of MSbP, become severely damaged when several convictions of child killing, in which he acted as an expert witness, were overturned.

Indications
Caution is required in the diagnosis of FII. Many of the items below are also indications of a child with organic, but undiagnosed illness. An ethical diagnosis of MSbP must include an evaluation of the child, an evaluation of the parents and of the family dynamics. Diagnoses based only on a review of the child's medical chart can be rejected in court.


 * A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling and unexplained.


 * Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible.
 * A parent who appears to be medically knowledgeable and/or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients’ problems.
 * A highly attentive parent who is reluctant to leave their child’s side and who themselves seem to require constant attention.
 * A parent who appears to be unusually calm in the face of serious difficulties in their child’s medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other, more sophisticated, facilities.
 * The suspected parent may work in the health care field themselves or profess interest in a health-related job.
 * The signs and symptoms of a child’s illness do not occur in the parent’s absence (hospitalization and careful monitoring may be necessary to establish this causal relationship).
 * A family history of similar or unexplained illness or death in a sibling.
 * A parent with symptoms similar to their child’s own medical problems or an illness history that itself is puzzling and unusual.
 * A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with serious illness.
 * A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment.
 * A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgment of their abilities.

Prevalence by gender
It has been noted that MS applies mostly to men whereas FII perpetrators are disproportionately females. One study showed that in over 90 percent of cases of Munchausen by proxy, the mother is the abuser. In other cases, the MSbP abuser is another female caregiver. Fathers have been the perpetrators in a handful of professional reports. The female preponderance may be attributed to the typical socialization pattern which encourages females to seek the sympathy and assistance of others while males who do so are considered to be "weak". Neuropsychological testing of perpetrators has shown either normal results or nonspecific abnormalities.

MSbP may also be attributed to another prevalent socialization pattern, that which places females in the primary care taking role. For a psychodynamic model of this kind of maternal abuse see Anna Motz's The Psychology of Female Violence: Crimes Against the Body (Routledge, 2001 ISBN 978-0415126755, 2nd ed. forthcoming 2008 ISBN 978-0415403870).

Controversy
During the 1990s and early 2000s, Meadow was an expert witness in several murder cases involving FII, some of which resulted in parents being wrongly convicted of murdering their children and imprisoned. In 2003, a number of high-profile acquittals brought Meadow's ideas into serious disrepute. Around 250 cases resulting in conviction in which Meadow was an expert witness were reviewed, with few changes. Meadow was investigated by the British General Medical Council over evidence he gave as an expert witness for the prosecution in the Sally Clark trial where he asserted that the odds of there being two unexplained infant deaths in one family were one in 73 million, a figure considered crucial in sending her to jail but a claim hotly disputed by the Royal Statistical Society, who wrote to the Lord Chancellor to complain. It was subsequently shown that the true odds were much lower, i. e. there was a much higher possibility of two deaths happening as a chance occurrence. The GMC in July 2005 came to a verdict of guilty of "serious professional misconduct" and he was struck off the register for giving "misleading" evidence in the Sally Clark case. At appeal High Court judge Mr Justice Collins described this as "irrational" and set it aside. Meadow was involved as a prosecution witness in 2 other high profile cases resulting in mothers being imprisoned and subsequently cleared of wrongdoing - those of Trupti Patel and Angela Cannings. Collins' judgment raises important points concerning the liability of expert witnesses - his view is that referral to the GMC by the losing side is an unacceptable threat and that only the Court should decide whether its witnesses are seriously deficient and refer them to their professional bodies.

In 2003, Sickened, an autobiographical account of the Munchausen syndrome by proxy abuse Julie Gregory suffered as a child, was published.

In 2003, the documentary film MAMA/M.A.M.A. was released, which questioned the validity of Munchausen syndrome by proxy, arguing that in many cases doctors' overmedication of infants may be the real cause of their infirmity rather than the mother's mental illness. The film contains an interview with Sir Roy Meadow.

In June 2007, The American author Darin Strauss's novel, "More Than It Hurts You" was published; it is an account of, among other things, a Munchausen by proxy scandal.

Legal status in Australia and UK
In the majority of legal jurisdiction, doctors are only allowed to give evidence in regard to whether the child is being harmed. They are not allowed to give evidence in regard to the motive as it would be prejudicial to the determination of the guilt. Furthermore, It has been specifically established in legal precedents in Australia and the U.K. that Munchausen syndrome by proxy does not exist as a medico-legal entity.

In a June 2004 appeal hearing, the Supreme Court of Queensland, Australia stated:

The Queensland Supreme Court further ruled that the determination of whether or not a defendant had caused intentional harm to a child was a matter for the jury to decide and not for the determination by expert witnesses:

Principles of law and implications for legal processes which may be deduced from these findings are that:


 * 1) Any matters brought before a Court of Law should be determined by the facts, not by suppositions attached to a label describing a behavior. i.e. MSBP/FII/FDBP;
 * 2) MSBP/FII/FDBP is not a mental disorder (i.e. not defined as such in DSM IV) and the evidence of a psychiatrist should not therefore be admissible;
 * 3) MSBPFII/FDBP has been stated to be a behavior describing a form of child abuse, and not a medical diagnosis of either a parent or a child. A medical practitioner cannot therefore state that a person `suffers’ from MSBPFII/FDBP and such evidence should also therefore be inadmissible. The evidence of a medical practitioner should be confined to what they observed and heard, and what forensic information was found by recognized medical investigative procedures;
 * 4) A label used to describe a behavior is not helpful in determining guilt and is prejudicial. By applying an ambiguous label of MSBP/FII to a woman is implying guilt without factual supportive and corroborative evidence;
 * 5) The assertion that other people may behave in this way i.e. fabricate and/or induce illness in children to gain attention for themselves (FII/MSBP/FDBY) contained within the label, is not factual evidence that this individual has behaved in this way. Again therefore, the application of the label is prejudicial to fairness and a finding based on fact.

The Queensland Judgment was adopted into English law in the High Courts of Justice in Case No. WR03C00142 [A County Council v A Mother and A Father and X,Y,Z children] on 18 January 2005 by Mr. Justice Ryder. In his final conclusions regarding Factitious Disorder, Ryder states that :-

In his book, Playing Sick (2004) Marc Feldman notes that such findings have been in the minority among U.S. and even Australian courts. Pediatricians and other physicians have banded together to oppose limitations on child abuse professionals whose work includes FII detection. Meadow is among the individuals specifically mentioned as having been inappropriately maligned in the April 2007 issue of the journal Pediatrics.

Munchausen syndrome by proxy: pet
The medical literature includes a number of descriptions of a subset of Munchausen syndrome by proxy (MSbP) caretakers, whose cases are labeled Munchausen syndrome by proxy: pet (MSbP:P). This is a factitious disorder with pet proxies, malingering with animal proxies, or even instances of "battered pet syndrome" (in reference to battered woman syndrome). In these cases, pet owners correspond to caretakers in traditional MSbP presentations involving human proxies. No extensive survey has yet been made of the extant literature, and there has been no speculation as to closely MSbP:P tracks with human MSbP.

In Media
In the novel Keeping Faith by Jodi Picoult, the protagonist (Faith)'s mother is accused of inflicting wounds on her child, symptoms associated to the psychiatric condition Munchausen syndrome by proxy.

Darin Strauss' latest novel, More Than It Hurts You tracks the fictional lives of a Long Island family after the mother is accused of afflicting injuries on their infant son, therefor showing signs of Munchausen syndrome by proxy.

In the 1999 film, The Sixth Sense, a young boy is able to converse with the dead. In one segment of the film, the boy aides the ghost of a young girl that was slowly poisoned to death by her mother who exhibits symptoms of Munchausen syndrom by proxy.

In an episode of the 2008 Televisa drama La Rosa de Guadalupe, Saber Amar, a mother poisons her child with arsenic in an attempt to gain attention from her separated husband.