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Munchausen by Proxy Syndrome

By the time she was 8 years old, J.B. had been hospitalized 200 times
and had undergone more than 40 operations, including the removal of
most of her intestines.

K.C., a 2-year-old boy, was hospitalized more than 20 times due to
complications from asthma, severe pneumonia, mysterious infections,
and sudden fevers. His doctors were baffled and unable to determine
the cause of these illnesses.

What do these seemingly unrelated cases have in common? They were the
result of Munchausen by proxy syndrome (MBPS), or Factitious Disorder
by Proxy, as it's listed in the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition,
Text Revision, also known as DSM-IV-TR).

This relatively uncommon condition involves the exaggeration or
fabrication of illnesses or symptoms by a primary caretaker. One of
the most harmful forms of child abuse, Munchausen by proxy syndrome —
also commonly called Munchausen syndrome by proxy (MSBP) — was named
after Baron von Munchausen, an eighteenth-century German dignitary
known for telling outlandish stories.

J.B.'s medical history was traced to her mother, who manufactured her
daughter's illnesses. Similarly, when K.C. was thought to have AIDS,
he eventually complained to his mother's friend that his thigh was
sore because "Mommy gave me shots" (indicating that the mother was
giving her son something to cause his symptoms).

About MBPS
In MBPS, an individual — usually a mother — deliberately makes another
person (most often his or her own preschool child) sick or convinces
others that the person is sick. The parent or caregiver misleads
others into thinking that the child has medical problems by lying and
reporting fictitious episodes. He or she may exaggerate, fabricate, or
induce symptoms. As a result, doctors usually order tests, try
different types of medications, and may even hospitalize the child or
perform surgery to determine the cause.

Typically, the perpetrator feels satisfied by gaining the attention
and sympathy of doctors, nurses, and others who come into contact with
him or her and the child. Some experts believe that it isn't just the
attention that's gained from the "illness" of the child that drives
this behavior, but also the satisfaction in being able to deceive
individuals that they consider to be more important and powerful than
themselves.

Because the parent or caregiver appears to be so caring and attentive,
often no one suspects any wrongdoing. A perplexing aspect of the
syndrome is the ability of the parent or caregiver to fool and
manipulate doctors. Frequently, the perpetrator is familiar with the
medical profession and is very good at fooling the doctors. Even the
most experienced doctors can miss the meaning of the inconsistencies
in the child's symptoms. It's not unusual for medical personnel to
overlook the possibility of Munchausen by proxy syndrome because it
goes against the belief that a parent or caregiver would never
deliberately hurt his or her child.

Children who are subject to MBPS are typically preschool age, although
there have been reported cases in children up to 16 years old. There
are equal numbers of boys and girls; however, 98% of the perpetrators
are female.

Diagnosis is very difficult, but would involve some of the following:

a child who has multiple medical problems that don't respond to
treatment or that follow a persistent and puzzling course
physical or laboratory findings that are highly unusual, don't
correspond with the child's medical history, or are physically or
clinically impossible
short-term symptoms that tend to stop when the perpetrator isn't
around
a parent or caregiver who isn't reassured by "good news" when test
results find no medical problems, but continues to believe that the
child is ill
a parent or caregiver who appears to be medically knowledgeable or
fascinated with medical details or appears to enjoy the hospital
environment
a parent or caregiver who's unusually calm in the face of serious
difficulties with the child's health
a parent or caregiver who's highly supportive and encouraging of the
doctor, or one who is angry and demands further intervention, more
procedures, second opinions, or transfers to more sophisticated
facilities
Causes of MBPS
In some cases, the parents or caregivers themselves were abused, both
physically and sexually, as children. They may have come from families
in which being sick was a way to get love. The parent's or caregiver's
own personal needs overcome his or her ability to see the child as a
person with feelings and rights, possibly because the parent or
caregiver may have grown up being treated like he or she wasn't a
person with rights or feelings.

Other theories say that Munchausen by proxy syndrome is a cry for help
on the part of the parent or caregiver, who may be experiencing
anxiety or depression or have feelings of inadequacy as a parent or
caregiver of a young child. Some may feel a sense of acknowledgement
when the child's doctor confirms their caregiving skills. Or, the
parent or caregiver may just enjoy the attention that the sick child —
and, therefore, he or she — gets.

The suspected person may also have symptoms similar to the child's own
medical problems or an illness history that's puzzling and unusual. He
or she frequently has an emotionally distant relationship with a
spouse, who often fails to visit the seriously ill child or have
contact with doctors.

What Happens to the Child?
In the most severe instances, parents or caregivers with Munchausen by
proxy syndrome may go to great lengths to make their children sick.
When cameras were placed in some children's hospital rooms, some
perpetrators were filmed switching medications, injecting kids with
urine to cause an infection, or placing drops of blood in urine
specimens.

Some perpetrators aggravate an existing problem, such as manipulating
a wound so that it doesn't heal. One parent discovered that scrubbing
the child's skin with oven cleaner would cause a baffling, long-
lasting rash.

Whatever the course, the child's symptoms — whether created or faked —
don't happen when the parent isn't present, and they usually go away
during periods of separation from the parent. When confronted, the
parent usually denies knowing how the illness occurred.

According to the DSM-IV-TR, some of the most common conditions and
symptoms that are created or faked by parents or caregivers with
Munchausen by proxy syndrome include: failure to thrive, allergies,
asthma, vomiting, diarrhea, seizures, and infections.

The long-term prognosis for these children depends on the degree of
damage created by the perpetrator and the amount of time it takes to
recognize and diagnose MBPS. Some extreme cases have been reported in
which children developed destructive skeletal changes, limps, mental
retardation, brain damage, and blindness from symptoms caused by the
parent or caregiver. Often, these children require multiple surgeries,
each with the risk for future medical problems.

If the child lives to be old enough to comprehend what's happening,
the psychological damage can be significant. The child may come to
feel that he or she will only be loved when ill and may, therefore,
help the parent try to deceive doctors, using self-abuse to avoid
being abandoned. And so, some victims of Munchausen by proxy syndrome
later become perpetrators themselves.

Getting Help for the Child
If Munchausen by proxy syndrome is suspected, health care providers
are required by law to report their concerns. However, after a parent
or caregiver is charged, the child's symptoms may increase as the
person who is accused attempts to prove the presence of the illness.
If the parent or caregiver repeatedly denies the charges, the child
should be removed from the home and legal action should be taken on
the child's behalf.

In some cases, the parent or caregiver may deny the charges and move
to another location, only to continue the behavior. Even if the child
is returned to the perpetrator's custody while protective services are
still involved, the child may continue to be a victim of abuse. For
these reasons, it's always advised that these cases be resolved
quickly.

Getting Help for the Parent or Caregiver
Most often, abusive Munchausen by proxy syndrome cases are resolved in
one of three ways:

the perpetrator is apprehended
the perpetrator moves on to a younger child when the original victim
gets old enough to "tell"
the child dies

To get help, the parent or caregiver must admit to the abuse and seek
psychological treatment. But if the perpetrator doesn't admit to the
wrongdoing, psychological treatment has little chance of remedying the
situation. Psychotherapy depends on truth, and MBPS perpetrators
generally live in denial.

Reviewed by: Barbara P. Homeier, MD
Date reviewed: March 2005
Originally reviewed by: Leslie A. Gavin-Devitt, PhD

Note: All information on KidsHealth is for educational purposes only.
For specific medical advice, diagnoses, and treatment, consult your
doctor.

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URL: http://kidshealth.org/parent/general/sick/munchausen.html