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“Munchausen Syndrome”

Who ran to help me when I fell,
And would some pretty story tell.
Or kiss the place to make it well?
My mother

Ann Taylor

Health professionals should be aware of the existence of a psychiatric disorder called “Munchausen syndrome” by proxy. It is a form of child abuse by the parent, usually the mother, in which she creates symptoms in the child and then seeks medical attention that will get the child into a hospital. She craves the attention the medical staff gives her and her child.

This disorder was named for the legendary Baron von Munchausen, a German soldier who was a calvary officer in the Russian army. He was adventurous and had a daredevil spirit and became an accomplished liar.

Parents with Munchausen syndrome sometimes transfer their behavior to the child. They invent or cause symptoms that require the child to be hospitalized, insist on tests, even surgery. They receive the attention they need at the expense of the child, and this is why it is considered “by proxy.”

These parents show no empathy for putting their child’s life in jeopardy or causing him great discomfort. They have the mistaken notion that being parents and caring for a sick child can gain them social favor.

The mother is usually a pleasant and cooperative parent with some knowledge of the medical field. She sees the child’s needs as separate from her own. Her demeanor may be too calm in proportion to the gravity of the medical problems of the child, and many times she is single or in marital discord.

Though the parent with this disorder is usually the mother, the perpetrator can be the father as well. Fathers are harder to detect. For example, a man named Ken had numerous admissions to the hospital for chest pain, but the results were always the same – normal. His son Kenny had frequent apneic episodes whenever he was in his father’s care. 

The child had many admissions to the hospital for seizures. The mother remained uninvolved in the child’s treatment. Ken was very hostile and demanding of the hospital staff. His behavior caused the staff to focus on him, and he was discovered holding the child down on the mattress. He was diagnosed with Munchausen syndrome and Kenny was placed in foster care where he thrived and had no more apneic episodes.

Diagnosing Munchausen syndrome is very difficult, and many physicians hesitate to put this label on a parent. Strict confidentiality is maintained, and only a few professionals are involved. A management team consists of a pediatrician, a child psychiatrist, a nurse and a social worker. Other colleagues who suspect the diagnosis (such as a laboratory technician) are encouraged to consult. The safety of the child is the first concern.

Information to support a diagnosis of Munchausen syndrome:

•  history of parents’ medical record
•  history of child’s medical record
•  information and verification of sibling’s health and past illnesses
•  evaluation of the parent-child relationship
•  the family dynamics
•  the family dysfunction
•  medication needs and access to medication by parent
•  parental response to improved illness management
•  relationship to the primary care physician

It is important to be suspicious if a child in generally good health suddenly shows signs of a severe illness, or if the symptoms do not follow the usual course of an illness. This disorder has a mortality rate of 5 to 10 percent and poses the greatest damage to infants and very young children.

News story:

Nicky, an eighteen-month-old boy, suffered from intractable diarrhea because of surreptitious administration of laxatives by his mother. Another case concerned chronic insulin administration to a one year-old girl. Despite temporary separation of the child from the mother and long-term psychiatric intervention, the illnesses continued, including urine specimen contamination, laxative-induced diarrhea, suspected bladder catherization and suspected poisoning. The mother and child were permanently separated.

The child is always in danger of death and suffers unnecessary intrusive and dangerous medical procedures.

Consequences to the child because of parents’ actions:

•  painful tests
•  frequent hospitalizations
•  potentially harmful treatments death

The physician is often an unknowing participant. The mother usually files a false medical history. She also changes physicians frequently. She may also move from town to town and out of hospital districts in order not to have histories verified.

The parent may:

•  alter specimens, urine, stool or sputum
•  substitute specimens from other people
•  hinder correct thermometer readings
•  fabricate symptoms
•  give false medical histories
•  give the child nonprescribed medication
•  contaminate intravenous feedings, if child is in the hospital

Lasting effects on the child may be:

•  feeding disorders in an infant
•  hyperactivity in preschool-aged children
•  hysterical disorders in adolescents

Symptoms of Munchausen syndrome by proxy can include:

•  bleeding
•  seizures
•  apnea
•  vomiting
•  fever 
•  rash

News story:

A woman already on probation for trying to kill her daughter was sentenced to thirteen years in prison for slowly poisoning her infant son to death with a drug used to induce vomiting.

“This child was tortured and tortured for months on end, often several times a day,” said the assistant state attorney. Doctors said the woman suffered from Munchausen syndrome by proxy, a psychiatric condition in which a parent is driven to harm his or her children to get sympathy and attention.

Doctors were baffled by P.J.’s illness and his subsequent death in May 1990. A year later, the woman gave birth to a baby girl. The girl soon began to show the same symptoms as P.J. When the child was hospitalized, a search of the hospital room uncovered three bottles of ipecac in the woman’s purse. Tests found traces of ipecac in P.J.’s preserved organs. In small doses ipecac induces vomiting, but too much can cause heart failure.

This was a case where the woman almost got away with murder twice. Perhaps in her head she didn’t want to kill the child but that was the end result of such drastic measures. The person with this disorder thrives in the medical atmosphere and a pseudo-sense of being a confidant with the staff of the hospital.

The health professional should recognize suspicious bruises around the child’s buttocks, genitalia, thighs, ears, face, trunk and upper arms. Is a head injury the result of trauma or vigorous shaking? An elevated serum amylase may be the only evidence of abdominal trauma. Where is the child burned? What caused the eye injury? Is the fracture suspicious?

The mothers of some of these unfortunate children have unresolved medical conflicts of their own. A rash can be produced by application of a caustic or dye Some mothers give the children sedatives or tranquilizers to produce a lethargic appearance. A seizure can be induced by carotid sinus pressure.

The physician or nurse who suspects child abuse in an infant with apnea must protect the child while obtaining adequate evidence to ensure that a child welfare agency will act in a manner to protect the child’s future safety. Great care must be taken that a false report is not made, or a false accusation.

All cases need to be documented fully, and no accusations are made to the family until all tests are in. Psychiatric attention is often needed to prevent maternal suicide attempts.

News story:

A mother who is missing when her infant was found dying later critically injured herself in an attempted suicide leap from a freeway overpass. Family members found the ten-day-old infant home alone and not breathing. Paramedics took the baby to the medical center where he was pronounced dead. About ten minutes earlier police had received a report that a woman had jumped from the Hollywood Way overpass onto the eastbound lanes of the freeway. She was identified as the baby’s mother and in “extremely critical condition.”

This story is not over yet, because we don’t know the true facts. All we know is that the baby is dead, and the mother tried to commit suicide.

Proof of abuse is necessary before action can be taken to protect the child. Some investigators have used video to monitor a mother’s interaction with her child. There are several ethical problems connected with this means of detection. In one case, no consent was obtained, and the mother did not know she was being observed. The trust between the mother and the staff had been compromised. The mother may take the child out of the hospital and continue her behavior somewhere else.

In most cases, separating the child and the mother is sufficient. Only hospital staff should care for the child until he is stabilized. Suspicion of the syndrome should be discussed with the family once the safety of the child is ensured. The case is then reported under the child abuse reporting laws of the state. Social, family and medical histories must be obtained and verified, and court intervention can be considered at this time. If the child is to stay with the family, there must be frequent monitoring of the child’s welfare.

Even in cases where the physical disorder could be considered mild, the emotional development of the child is seriously disturbed. It is an especially destructive form of child abuse.

Munchausen syndrome is a difficult diagnosis to arrive at because of the many factors involved. There is a symbiotic tie between the parent and child. The parent has a great deal of denial about the nature of any problems that might occur between them. Legal authorities are reluctant to come between the parent and child unless the abuse is flagrant. Sometimes it is too late then.

Munchausen syndrome by proxy is a form of child abuse by the parent. It is usually the mother.

Munchausen syndrome by proxy is when the parent repeatedly causes the child to experience symptoms that require medical interventions.
The parent falsifies the child’s medical history.
The parent puts the child in harm’s way.
The parent craves medical attention at the endangerment of the child.
The physician is an unknowing participant in the parents’ scheme.
Consequences to the child involve painful tests, frequent hospitalizations and sometimes death.

Information needed to support the diagnosis of Munchausen syndrome by proxy:

•  verified documentation of the child’s medical history
•  medical history of the parents
•  information about other siblings in the family
•  evaluation of the parent-child relationship
•  the family dynamics
•  parental response that the child’s health is improving

Lasting effects on the child may be:

•  feeding disorders
•  isolation and withdrawal
•  hyperactivity
•  emotional dysfunction