Marcy Rhodes Stephen F. Austin State University April 17, 2008 Munchausen’s Syndrome by Proxy

What is factitious disorder? Diagnostic Criteria (DSM-IV-TR) Intentional production or feigning of physical or psychological signs and symptoms Motivation for the behavior is to assume the sick role External incentives for the behavior are absent

Munchausen’s Syndrome Karl Friedrich Hieronymus, Baron Von Munchhausen (18 th Century) Name given by Asher (1951)

What is Factitious Disorder BY PROXY? By Proxy – indirectly assumes sick role Listed in Appendix B in the DSM-IV-TR Research Criteria Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care. The motivation for the perpetrator’s behavior is to assume the sick role by proxy External incentives for the behavior are absent The behavior is not better accounted for by another mental disorder

Munchausen’s Syndrome By Proxy Coined by Roy Meadow, 1977 Pediatrician in Leeds, England Became convinced that many apparent “cot deaths” were in fact the result of child abuse brought on by MSbP First to describe this disorder & recognize it as a fatal form of child abuse.

Overview of Munchausen’s Syndrome By Proxy (MSbP) Caretaker fabricates, exaggerates, or induces illness in a child, for which he or she seeks extensive medical testing and/or hospitalizations Perpetrator obtains psychological reward in the form of the attention she receives from others Victimization is often lengthy Perpetrator is usually the biological mother (98%) Perpetrator presents as model parent Most victims are preschoolers

Overview of Munchausen’s Syndrome By Proxy (MSbP) Prevalence has not been established; considered uncommon Majority of cases involve the gastrointestinal, genitourinary or central nervous system. More than one child in the family may be abused In as many as 10% of cases, abuse leads to death

Most common induced and simulated illnesses Persistent vomiting or diarrhea Respiratory arrest Asthma Central Nervous Systems dysfunctions (e.g., seizures, loss of consciousness) Fever Infection – “Bacteriologically Battered Babies” Bleeding Failure to thrive Hypoglycemia Electrolyte disturbances Rash

Attachment Representations and MSbP Adshead & Bluglass (2001) Assessed the attachment style of 26 mothers who had exhibited MSbP behaviors 88% exhibited an insecure attachment style Most common pattern: dismissing (77%) Adshead & Bluglass (2005) Assessed attachment style of 67 mothers who had exhibited MSbP behaviors Only 18% exhibited a secure attachment style 85% rated as insecure Dismissing, 46%

Case Study – Kathy Bush Diagnosed with MSbP Charged with aggravated child abuse and Medicaid fraud Jennifer Bush, daughter Between August 1993 and April 1995 Taken to the hospital more than 130 times Underwent 40 surgeries Amassed over $3 million in medical bills

Profile of MSbP Perpetrators Most often biological mothers Appear to be very knowledgeable about victim’s illness Past exposure & experience with healthcare system Often have some previous (usually incomplete) training in nursing or medicine Remain uncharacteristically calm in view of victim’s perplexing medical symptoms

Profile of MSbP Perpetrators Praise medical staff excessively Welcome medical tests, even those that are painful Increased incidence of Munchausen syndrome History of Abuse or at least reported history of abuse Fabrication of info about perpetrator’s life Poor relationship skills Poor coping skills

Profile of MSbP Perpetrators Typically shelter victim from outside activities Maintain a high degree of attentiveness to the victim Often unresponsive to child when unaware of being observed Find emotional satisfaction when the child is hospitalized because of the staff’s praise of their ability to be a superior, attentive caregiver.

Perpetrator Motivational Factors Crave attention from medical staff, doctors, family and friends Might receive gratification for being able to fool those who they perceive as having more power, status Some offenders may fear going home or adjusting to a normal daily routine without being the center of attention An offender who is praised as a hero for saving a child might elect to re-create that euphoria by fabricating subsequent incidents of abuse and revival of the victim.

MSbP Warning Signs Unexplained, persistent, recurring illness Repeated hospitalizations and extensive medical tests that fail to produce a diagnosis Symptoms that do not make medical sense Lab results that are inconsistent with each other or recognized diseases Persistent failure of the victim to respond to therapy

MSbP Warning Signs Signs and symptoms that occur ONLY in the presence of the caretaker Mother who is extremely attentive and always in the hospital Mothers who do not seem worried about their child's illness but are constantly at the child's side while in the hospital Mothers who have an unusually close relationship with the hospital's medical staff

MSbP Warning Signs A family history of sudden infant death syndrome Mothers with previous medical or nursing experience or with an extensive history of illness A parent who welcomes medical testing of the child, even if painful May become angry and demand further procedures, second opinions, further intervention

MSbP Warning Signs Attempts to convince the staff that the child is still ill when advised that the child will be released from the hospital A caregiver with a previous history of Munchausen Syndrome A caregiver who adamantly refuses to accept the suggestion that the diagnosis is nonmedical. Increasingly urgent visits to the same hospital or clinic.

Difficult to Confirm MSbP Practitioners may be reluctant to diagnose Goes against the belief that a parent or caregiver would ever deliberately hurt his or her child. Legal consequences of inaccurate diagnosis Personal consequences of inaccurate diagnosis Sally Clark (1964 – 2007)

M.A.M.A. Mother’s Against Munchausen’s Allegations Mission: To stop the assault on innocent parents from MSbP allegations and to reveal the ulterior motives of the accusers These mother’s claim that they are falsely accused Doctor or institution can evade a medical malpractice lawsuit Doctors can rid themselves of a troublesome mom when frustrated and unable to diagnose a child's condition The false MSBP diagnosis can be gravely detrimental; adding deep emotional stress of maternal deprivation to an ill child

If you do suspect MSbP… Proceed with Multidisciplinary team CPS Law enforcement Psychologist or psychiatrist Prosecutor Hospital social worker Nurse practitioner Pediatrician (especially one specialized in MSbP) Other members of the child’s medical team

If you do suspect MSbP… Review medical records Entries regarding child/parent interactions May establish temporal relationship between symptoms and parent’s presence Direct monitoring of child’s hospital room Sitter Documents time of visits, especially of suspected perpetrator No food or drink allowed except for the provided by hospital staff Video surveillance (controversial) Completely restrict parent’s access (must be court-ordered)

Treatment - Prepetrator Psychotherapy is often ineffective Successful treatment depends upon the patient's ability to break through denial and willingness to undergo therapy Changes in the family system Increased parental sensitivity and responsiveness to child’s needs Plan to prevent relapse If the patient cannot overcome her issues, prognosis for recovery is poor.

Treatment – Child/Victim First, the child must be placed in a safe environment Play therapy and/or individual therapy depending on his or her age. Another important aspect is clarifying the child's health status. A single physician who is familiar with the case should be responsible for monitoring and treating the child. Depending on local laws, child welfare and/or protective services may need to be notified.

Short & Long-Term Implications Short term Pain Mother’s actions Medical procedures Reduced social, educational, and emotional opportunities Long term Long term disability Increased likelihood of developing Munchuasen’s syndrome Libow (1995) PTSD Feelings of inadequacy Poor self-esteem Relationship problems