Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is one of the most difficult and rare form of child abuse. It carries substantial morbidity and mortality and comprises both physical abuse and medical neglect and is also a form of psychological maltreatment. The diagnosis relies on appropriate suspicion and careful investigation. Early recognition and appropriate intervention prevent further abuse and criminal actions. The fabrication of a pediatric illness is a form of child abuse and not merely a mental health disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home. Certain factors are identified that may help the physician recognize this insidious type of child abuse that occurs in a medical setting, and physicians have to report suspicions to their state’s child protective service agency. This paper highlights how Munchausen syndrome by proxy cases is handled.

Munchausen syndrome by proxy: detection, investigation and legal proceedings Munchausen syndrome-by-Proxy (MSBP), also known as Medical Child Abuse (MCA), is a mental disorder in which a parent (usually the mother) abuses her child by creating or falsifying medical symptoms, or by seeking unnecessary medical care for the child, in order to gain attention and sympathy. In 1998 the American Professional Society on the Abuse of Children (APSAC) reported that the constellation of behaviors generally referred to as Munchausen by Proxy actually includes a pediatric diagnosis of child abuse and a psychiatric diagnosis of the perpetrator. Thus Munchausen by Proxy consists of two perspectives – the pediatric and the psychological; the victim and the perpetrator. From the perspective of the child victim, the diagnosis is Pediatric Condition Falsification (PCF) and is defined as “a form of child maltreatment in which an adult falsifies physical and/or psychological signs and/or symptoms in a victim, causing the victim to be regarded as ill or impaired by others.”

From the perspective of the perpetrator, the diagnosis is Factitious Disorder by Proxy (FDP) and is defined as “a psychiatric disorder which is applied to a person who intentionally falsifies signs or symptoms in a victim. The parent may exaggerate, misrepresent, or fabricate symptoms or test results, which can lead to the child undergoing numerous hospitalizations, invasive tests, needless therapies, and even surgeries. “On April 7th the Tucson Police Department arrested and charged a 21 year old mother of two with child abuse. Blanca Montana had taken the children to the University Medical Center reporting flu-like symptoms. Her son was discharged, but her infant daughter’s condition continued to deteriorate. The baby was eventually diagnosed with nine separate rare infections over the course of her hospital stay. Staff noticed that the child’s condition worsened every time she was alone with her mother. They began to suspect Munchausen Syndrome by Proxy and reported their suspicions to the police. The police investigated the abuse and determined that Montano intentionally poisoned her child and had caused her illnesses.

After the mother was barred from visiting the infant, the baby’s condition improved significantly. It was determined that Montana had poisoned her two children in order to get attention”. (ABC news) In classical cases of MSBP, the behavior of the abusive parent towards the child is strongly and directly influenced by the responses of the doctor to the child’s “undiagnosable” disease. The term MSBP can also apply to situations where the parent in some way appears to compromise the medical care of the child. Examples include parental over treating or undertreating of such medical condition such as asthma, epilepsy and cystic fibrosis. MSBP is different from other forms of child abuse. Unlike the typical physical child abuser who seeks to release his or her own frustrations by lashing out at a child, the motivations of the MSBP abuser are more complex.

The perpetrator’s behavior is more premeditated than impulsive, and it doesn’t result from the behavior of the child (serve as punishment for bad behavior). These children are often hospitalized with groups of symptoms that don’t quite fit any known disease. Frequently, the children are made to suffer through unnecessary tests, surgeries, or other uncomfortable procedures. The abusive parent is usually very helpful in the hospital setting and is often appreciated by the nursing staff for the care she gives her child. She is often seen as devoted and self-sacrificing, which can make medical professionals unlikely to suspect the diagnosis of Munchausen syndrome by proxy. By reacting to the concerns and demands of perpetrators, medical professionals are manipulated into a partnership of child maltreatment. The syndrome occurs because of psychological problems in the adult, and is generally an attention-seeking behavior. The syndrome can be life-threatening for the child involved. How do we handle child abuse cases of this nature?

Diagnosis of fabricated disorders is especially difficult because clinical findings are undetectable when they are exaggerated or imagined and are inconsistent when fabricated. When a clinician suspects that a disease has been falsified, this hypothesis must be pursued vigorously and the diagnosis must be confirmed if the child is to be spared further harm. MSBP should be considered whenever a child is presented with an unusual illness and has a negative workup or an abnormal response to standard therapy. Following confirmation of a diagnosis of MSBP, it is the duty of child protection agencies and mental health teams to plan for the future care and safety of the child who has been harmed. Identifying and responding to this unusual and complex form of child abuse requires a carefully coordinated multidisciplinary intervention of several disciplines and agencies is essential for identifying and responding to cases of suspected MSBP. Each discipline should approach MSBP cases from its own area of expertise with the common goal of ensuring the safety of the victims.

Pediatricians or family physicians initiate the assessment, If at any point in the medical assessment process, the treating physician or any other member of the medical team have “reasonable cause to suspect child abuse or neglect” he or she should make a report immediately to Children’s Protective Services (CPS) as required by law (N.Y. SOS. LAW § 413). The CPS worker, in turn, should begin the investigation including contacting and collaborating with the medical team as they complete the medical assessment. CPS will coordinate the medical assessment, facilitate obtaining medical and other records regarding the child and the family, consult with legal counsel, law enforcement, and initiate legal proceedings if required to protect the child or to further the investigation. In cases of Munchausen Syndrome by Proxy, it is advised that parents be excluded from discussions of the investigation in order to not place the children’s lives at further risk of suffering significant harm, which in the most serious cases may lead to their death.

Most perpetrators who induce symptoms will continue to do so during hospitalization because maintaining the child in the sick role is the only way to keep fulfilling the abuser’s need. For example, in 2008 Amber Brewington was charged with attempted homicide for poisoning her infant son by repeatedly injecting salt water into his feeding tube (at least 5-6 times) while he was a patient in Tennessee and Pennsylvania hospital (usatoday.com). If a child is admitted to hospital, detection of induced illness will be facilitated by keeping a record of all parent visits and activities, looking for associations. Recurrent symptoms may warrant close observation with one-to-one nursing. In order to stop the cycle of abuse, investigators must obtain sufficient admissible evidence to convict the abuser. A particularly effective way to obtain proof in MSBP cases is to use concealed cameras to videotape evidence (court ordered). Prosecution

Munchausen syndrome by proxy can be hard to prosecute because many of the cases lack evidence and witnesses. Care must be taken not to allow a “label” or diagnosis to influence the way in which the case is conducted. If the case is really one which used to be called “cruelty”, it should be dealt with accordingly. Sally Clark was convicted in November 1999. The convictions were upheld at appeal in October 2000 but overturned in a second appeal in January 2003, after it emerged that the prosecutor’s pathologist had failed to disclose microbiological reports that suggested one of her sons had died of natural causes. She was released from prison having served more than three years of her sentence (BBC news). The sally Clark story shows why strong evidence is required to prosecute MSBP cases. The party who makes an allegation must prove that the child is suffering or likely to suffer significant harm which is attributable to the care being given to him. Mere suspicion is not enough to justify making a case, significant harm has to be proven. A guardian ad litem is appointed by the court to represent and safeguard the interests of children in public law cases.

The guardian should have experience in representing children and be familiar with the dynamics of Munchausen by Proxy. Existing law gives the guardian considerable power to obtain all necessary reports and to consult with various parties and other experts. If successful in convincing the court, by probable cause, that the child is abused, the guardian may ask the court to protect the child pending trial by placing the child in an out of home placement. A period of separation, although generally necessary to protect the child from further physical and mental harm, could also serve as a “diagnostic separation” to further confirm the MSBP diagnosis. Doing so not only ensures the child’s immediate safety but leads to dramatic reversal physical, or psychological. Example; In a notorious case in Florida, an 8-year-old child who had been featured in local news for her courage in the face of terrible illness was diagnosed with MSBP in 1995. According to the mother, the girl had digestive problems, seizures, and an immune deficiency. Her primary diagnosis had been pseudo-obstructive bowel disease. The child had had 40 surgeries and more than 200 hospitalizations.

She was receiving nutrition artificially by means of a gastrostomy tube and a central venous catheter. An investigation supported the finding of MSBP. The child was removed to foster care, where she regained normal bowel function and normal nutritional intake, and returned to school. (sunsentinel.com) The safe setting should be a placement in which the parent does not have the ability to have unsupervised contact with the child and does not have the capacity to impact on the daily care and medical treatment of the child. In some circumstances, the caseworker and the treatment team will recommend seeking termination of parental rights and adoption or some other permanent alternative home for the child at the hearing. The parental offenses may be so serious that Criminal prosecution may also be appropriate, for example; In New York 1972-1985, Marybeth Tinning had killed at least eight of her children while suffering from Munchausen Syndrome by Proxy. She was sentenced to 20 years to life for “depraved indifference to human life. (nytimes.com)

The testimony at trial should focus on harms suffered by the child due to the parent’s conduct. Is this child being abused or not? The court process will test the evidence and reasoning of the professionals. If successful, before a judge or a jury, in proving by preponderance of the evidence that the child is abused or neglected, the case proceeds to the dispositional phase. A court-ordered disposition depends on a comprehensive, objective forensic psychological assessment of the offending parent, the other parent and the child. The child’s medical and psychological needs should also be assessed as a foundation for the court’s dispositional order. If the prognosis for rehabilitation is poor, perhaps termination of parental rights is appropriate? Perhaps referral for criminal prosecution is appropriate? The dispositional plan is very important.

The guardian should assure that the service plan and court-ordered disposition responds to the dynamics present in the family and if applicable, rehabilitation of the family and to allow for safe reunification of the child and the family. On the other hand, the guardian needs to carefully consider expert opinion and pursue termination of parental rights or another permanent plan instead of reunification where necessary. The assessment and diagnosis of Munchausen by Proxy child is a complex and emotionally charged task. This potentially fatal form of child abuse requires the most current data and expertise to protect the child’s physical and psychological safety. Health care providers, child protection agencies, and the legal profession must appreciate the special issues involved in this form of child abuse. MSBP cases

CHARLOTTE, N.C. — A judge sentenced Meredith Stilwell, who pleaded guilty to trying to smother her young daughter in January 2009, to 52 to 72 months in prison Monday. Meredith Stilwell pleaded guilty Friday to felony child abuse, inflicting serious injury after hidden cameras at the Levine Children’s Hospital recorded her trying to smother her baby. http://www.wsoctv.com/news/news/judge-sentences-young-mother-to-years-in-prison/nG75g/ When five of Waneta Hoyt’s six children died between 1965 and 1971, doctors suspected sudden infant death syndrome (SIDS). The case was even featured in prominent medical journals. But when New York State Prosecutor William Fitzpatrick read about the case, he grew suspicious.

His investigation led to Hoyt’s arrest in 1994. When she was interrogated, Hoyt broke down and admitted that she had killed her children in an attempt to quiet them. She was sent to prison for life. Hoyt lived in Oswego, New York at the time of the murders http://www.people.com/people/archive/article/0,,20101784,00.html Genene Anne Jones is a former pediatric nurse who killed somewhere between 11 and 46 infants and children in her care. She used injections of digoxin, heparin and later succinylcholine to induce medical crises in her patients, with the intention of reviving them afterward in order to receive praise and attention. http://www.crimezzz.net/serialkillers/J/JONES_genene.php

Sources

•Monsters in the Closet: Munchausen Syndrome by Proxy. Laura Criddle, RN,