The English paediatrician Roy Meadow in 1977 published two cases in which mothers had secretly made their children sick: In one case the mother had from the child’s birth until the age of 6 years mixed blood and pus into the child’s urine, so that the child had to endure the endless torture of medical examinations and treatments. Only at the age of 6 was the correct diagnosis made. A completely healthy child was the victim of a hitherto unknown form of child abuse. Meadow called the disease Munchausen by-proxy syndrome, because these mothers systematically deceive the doctor with fictitious stories about diseases, not in their own body, but rather that of the child as a stand-in. Other names include MSBP (Munchausen Syndrome by Proxy) and FDP (Factitious Disorder by Proxy). The term “Munchausen syndrome” was introduced in 1951 by the English internist R. Asher and very indiscriminately applied to all artificial disturbances.
Doctor as “friend” of the mother
In nine cases out of ten it is the mother who resorts to the use of poison or a knife in such ways. They usually have basic medical training and tend to not separate themselves from the child. The children’s symptoms are for the attending physician often not rationally explainable. These mothers seek intense contacts with doctors and nurses, build partially friendly relations with them and happily “talk shop” about the case history of the child. The number of unreported cases of MSBP is understandably high.
The classic instance of this syndrome does not exist. Bloody diarrhea, cramps, unexplained fever, bacteremia, electrolytic misregulation and skin rashes are just a few options found in the “Munchausen’s catalogue”. In order to turn their own children into patients needing help, the mothers reach for razor blades, broken glass, laxatives, administer acid or tricyclic antidepressants, press cushions onto the face of the defenceless child to the point of apnea, or dip their heads into water. The falsification of laboratory results by the addition of parental blood in sputum, urine and stool are also some other conceived ways.
Then the warning bells should ring:
- Persistent or recurrent symptoms without a plausible explanation
- Discrepancy between history and clinical findings, unusual patterns of progress
- Symptoms and clinical picture improve alongside separation from the mother
- Resistance to therapy without clinical justifiability
- Relative to the seriousness of the clinical picture, little distress on the part of the parent, who continuously consoles the doctors
- Repeated hospitalisations and comprehensive, interventative diagnoses without clear results
- One parent is always present at the bed, praises the staff and concerns herself or himself a great deal with other patients
- Ever newer medical examinations are welcomed, even if they are painful for the child
- A parent suffers from Munchausen syndrome
Definition not clear
The paediatrician Donna Rosenberg published an analysis of 117 cases of MSBP in 1987. Her definition is still today employed unchanged:
- The symptoms of a child are feigned, augmented, or both of these, by a parent or other person responsible for the care of the child.
- The child is often presented to physicians and examined there and treated numerous times.
- The causing party denies knowing anything about the origin of the child’s discomforts.
- Acute symptoms of the child subside when the child is separated from the causing party.
In the DSM IV (Diagnostic and Statistical Manual of Mental Disorders) any effort to look up the factitious disorder MSBP ends up fruitless, it is able to be categorised under “unspecified feigned disorder” – presumably in order to not give legal openings to the mothers. In ICD-10, artificially imposed disorders are only classified in a general sense. In the current edition of the text revision of the DSM-IV-TR our “culprit” moves into the spotlight, four criteria are listed for diagnosis.
- Deliberate inducing or feigning physical signs of illness in a person for whom the causing party carries parental or care responsibility.
- The motivation of the offender is the contriving of the role of ill person through someone else.
- External incentives for the behaviour are not present (eg. financial gain).
- No other mental disturbance can better account for the behaviour of the offender.
Meadow is of the opinion that the mother’s motive should be involved in the diagnosis. This way an excessive use of the term would be avoided.
Separate diagnoses for mother and child
The Committee on Child Abuse and Neglect recommends in relation to MSBP the division into two disorders: a paediatric diagnosis pediatric condition falsification and the psychiatric diagnosis factitious disorder by proxy. The Committee is a working group of the American Academy of Pediatrics, an American association of paediatricians.
The term MSBP should be considered to be a unifying description for both diagnoses.
- The diagnosis paediatric condition falsification is provided for the child that was abused by his mother. The diagnosis is valid, independent of the motivation of the mother, and can therefore be made independent of MBPS.
- The diagnosis factitious disorder by proxy describes persons who deliberately distort other people’s medical histories, symptoms and appearance in order to satisfy their own psychological needs. The motivation may be, among others, achieving recognition, but may also be the desire to manipulate clinical staff.
Through this separation of MSBP into two diagnoses the possibility is created to diagnose the abuse of the child, without simultaneously needing to prove or explain the motivation of the mother.
4 steps in the ordeal
The psychologist Dr. Meiniolf Noeker, Centre for Clinical Psychology and Rehabilitation Bremen, describes four levels, increasing in severity:
Level 1: deliberately exaggerated description of symptoms
Level 2: misstated alleged symptoms outside the examination environment
Level 3: active manipulation of examination material
Level 4: active manipulation of the body of the child
Mother often early trauma victims
This psychoneuro disorder of mothers often involves the search for a “strong protector” as its cause. The protective and authoritarian doctor meets these needs unconsciously. The child is abused as a monitoring tool in the doctor-patient relationship. Frequently the cause of the massively disturbed mother-child relationship resides in her own childhood. Not infrequently she or he was as a child also abused.
Welfare office, court and medicine need to cooperate
The physician has to become a detective in a white coat and put together a comprehensive social history. Without the support of authorities and agencies, however, getting help for the child is impossible. Only a multidisciplinary approach helps uncover the mother’s illness and saves the child before he or she falls “accidentally” to Munchausen’s bullet. It’s often the case that years go by before the correct diagnosis is made. If a doctor becomes suspicious, the mother goes to another. So-called “doctor hopping” is hard to expose. The denial and treatment refusal rate of mothers is extremely high even with complete demonstration of proof by video etc., the recurrence rate after therapy is as well. The only life supporting therapy for the child, therefore, is usually conducted not by the doctor or psychologist, but by a judge. He or she may order a removal of custody rights and a spatial separation.