Munchausen syndrome by proxy, abbreviated as MSbP, is a term devised by a Professor of Pediatrics Roy Meadow in 1977, who named the syndrome after a German horse soldier Baron von Munchausen (1720-1797) that was famous for his widely stagy and feigned stories. Munchausen syndrome by proxy (MSbP), also known in the United Kingdom as Fabricated or Induced Illness by Carers (FII), is a form of fictitious disorder of mental sickness in which a person behaves in a manner that suggests a need of another individual of being taken care of when there is no such a necessity in fact, and is explained by a mental or physical health condition of the first one (Parnell & Day, 1998). The adult with MSbP unswervingly fabricates and imposes the illnesses on another person under his/her care, mostly a minor one under the age of the 6 years. This act is considered as a method of abuse by the American Professional Society on the Abuse of Children. Parents with MSbP usually have an inward desire for their children to be seen as sick or hurt. MSbP persons do this not in order to achieve any tangible benefit, as a financial gain, for example. They are willing to subject the patient or child to agonizing and risky examinations, or operations so that people could sympathize with them and treat with a special attention, which is usually given to the family, whose members are really sick (Parnell & Day, 1998). Factitious ailments are classified into four major categories: (1) those with mostly psychological signs, (2) those with physical signs, (3) those with both the psychological and the physical signs, and (4) those that do not fit the situations of the above three types (Matthews, 2004). The forth category includes MSbP, which is, fortunately, very rare, as it happens with 2 out of 100,000 children.
Keywords: Munchausen syndrome by proxy, fabricated or induced illness by carers, fictitious disorder, mental sickness, mental health condition, physical health condition
Munchausen by Proxy Syndrome
MSbP is usually very difficult to diagnose, which makes it a reason why many children die before doctors comprehend what the child has been undergoing. Similarly, a treatment and a complete understanding of the causes of Munchausen Syndrome are limited. For this reasons, it is imperative to raise the awareness of MSbP among people, and to ensure that children will no more become victims of a fabricated illness and, consequently, death caused by their own parents or caregivers (Gregory, 2003). This syndrome is considered as a criminal offense of one of the forms of a child abuse, requiring the prompt actions of the child protection services.
This syndrome can result in the severe short- or long-term consequences, including the persistent abuses of the child, multiple hospitalizations, and what is worse the fetal outcomes of the victims (Eminson & Postlethwaite, 2000: Shannon, 2009). In some cases, a victim of a physical, psychological and emotional abuse may learn to associate the receiving of attention with a state of being sick, thus develops Munchausen syndrome himself or herself (Matthews, 2004). The purpose of this paper is to study and analyse the behavior and motivation of perpetrators suffering from MSbP/ FIIC, namely: why and how the disorder manifests through the symptoms; which characteristics has parents with the disorder; the legal issues associated with the disorder under the assistance of the criminal psychologists; the treatment and interventions that it requires (Allison & Roberts, 1998).
Who Perpetrates the MSbP/ FIIC?
MSbP perpetrated by mothers. A bigger percentage of MSbP or FIIC is observed among mothers mostly, though, it may be experienced by fathers in isolated cases as well. The mothers purposely hurt their own children, or describe symptoms of the imaginary disease, so that they could get the attention which is majorly given to family members of a sick person. Someone who has MSbP mostly use the numerous hospitalizations instances as a method of gaining praises from the other people for their dedication to the care of the child. Finally, they tend to exploit the ill child in order to develop an affiliation with the doctors or other health care providers. The person suffering from MSbP ordinarily does not depart from the bedside of the patient, and deliberately feign the signs of a deep concern to prove that he or she is a good caregiver. Sometimes the signs may vanish while in hospital but may reappear when the caregiver is no longer alone with the patient (Roesler & Jenny, 2009).
Fabricated or induced illness by caregivers. Another case of MSbP is propagated by the caregivers, who fabricate or intrude the illness in children being under their guardianship. The major task for psychologists is to determine whether the caregivers who falsify the illness in children experience a disorder of a personality (Lasher and Sheridan 2004), and are able to validate the protective concerns about the child (Fish, Bromfield & Higgins, 2005).
The rate of fictional or induced sickness by carers usually varies from one country to another. For example, in the United States, an estimated number of two forms of MSbP involving a suffocation and non-accidental poisoning reported in 1996 is six hundred instances (Ayoub et al., 2002). Approximately eighteen cases are reported every year in New Zealand, about fifty instances registered in the UK, and twenty four more different countries monitor the accidences of the same syndrome (Pritchard 2004).
How MSbP/ FIIC is Performed
Individuals with MSbP are likely to fabricate or exaggerate the disease signs of the child in various ways. For example, they usually overstate or lie about symptoms, discrediting the reliability of the diagnostic tests by contaminating the urine or feces samples of the child in order to forge the medical records (Feurtado, 2004). Occasionally, the caregivers with MSbP may impose the symptoms of particular diseases through poisoning, starving, suffocating, or contaminating of the baby. In this case, the observed complications may signal about the behavioral or psychiatric disorders (Feurtado, 2004).
It has also been discovered that the behaviour of the perpetrators sometimes involves a physical, psychological, and emotional harming of the child with the further transportation of the child to the hospital with an unexplained medical condition (Feurtado, 2004). The hospitals mostly fall victim to the fabrication whereby they pursue the unnecessary medical procedures. Pediatric study has also established that a number of the children admitted into hospital pediatric sections and emergency wards usually suffer from unexplained diseases that are consequently determined to have been instigated by their parents or caregivers through a physical, emotional, or psychological violence (Stirling, 2007: Roesler & Jenny, 2009).
Reasons for Engaging on MSbP or FIIC
There are several theories researched to explain the causes of Munchausen Syndrome by Proxy and why caregivers or mothers are engaged in it. According to Fish, Bromfield and Higgins (2005), mothers may feel that the presence of a sick child can be a factor to reunite them or bring them closer to their spouses. This reason indicates that mothers suffering from MSbP may have experienced an emotional deprivation and physical abuse from their spouses in the past (Allison & Roberts, 1998). Such women in most cases feel depressed and insecure, thus direct their personal inadequacies through the offensive behavior towards the minors, which subsequently leads to a self-satisfaction and gratification of themselves. Some may also feel that invoking the illnesses in the child is a way of punishing their spouses who eventually pay the hospital bills whenever the child is hospitalized.
The hospital environment also gives the mother or caregiver an opportunity to free themselves from parental responsibility at least for a while, when the medical personnel attend on the child, and gives the individuals with this disorder a chance to move around the hospital and share the experience with other parents. In this case, their sick children help them to create a connection with other mothers in the hospital, thus making them feel satisfied and full of a sense of belongingness. This reason is common for mothers who feel that they are overwhelmed by the demanding needs of their child. The caregivers, in their turn, feel that the parents of the child have neglected their parental duty, and overburden them with the responsibility. Such impression make the caregivers fabricate the illnesses of the child to get free time to relax. Schreier and Libow (1993) assert that long-awaited but absent fathers are also a major reason that lead to the manifestation of the disorder among women according to the clinical data in hospitals. The FIIC disorder may also develop when the mother notes that there is an increasing detachment among the father, the child, and the whole family, prompting the mother to resort to hurting her child to capture the attention of the father in order to reestablish cohesiveness in the family (Fish, Bromfield & Higgins, 2005). In addition, an absent spouse also gives the mother an ample opportunity to inflict a harm on the child that she, however, would not do in the presence of her spouse (Matthews, 2004).
Symptoms of MSbP
MSbP is relatively one of the most challenging psychiatric disorders to be diagnosed. This makes approximately 9% of victims of FIIC abuse perish (Feldman, 1998). According to Feurtado (2004), the symptoms of a parent or caregiver that may be suffering from MSbP include, but do not exhaust the next signs such as (1) an inconsistency between the complaints and the results of the medical tests, (2) the symptoms presented by the child that do not respond to treatment as they are supposed to, (3) illnesses that only become severe in the presence of the caregiver or parent who is the perpetrator of the abuse, (4) disease symptoms that vanish when the perpetrators is absent, and resumes when the caretaker or parent is informed that the child is recuperating, or (5) when similar symptoms are also exhibited by the siblings or other family members of the victim (Lasher, 2004: Feldman, 1998). It is worth noting that it is impossible for doctors to diagnose Munchausen syndrome by proxy during the first observation of the patient. Therefore it is vital that the medical personnel to consider the behavioral patterns related to the syndrome, and be very attentive to the actions and reactions of the individuals for some period of time. For example, having the same child suffering from various illnesses within a short duration together with a slow response to treatment is ordinarily an indicator of a possibility of the disorder (Artingstall, 1999).
Victims of MSbP also commonly exhibit the accurate symptoms of illness together with the exaggerated ones. This usually complicates the diagnosis of MSbP owing to the fact that physicians have to distinguish the real illnesses from the fabricated. Another symptom of a possibility of the factitious disorder by proxy is a strong reaction of a caregiver or parent showing a ‘righteous indignation trait’ when questioned by the physician about the fabricated medical history of their child. Such parents usually become defensive and may threaten to file a lawsuit against a malpractice, or in some occasions may instigate the child to become acutely ill to prove their point (Schreier & Libow, 1993).
Characteristics of Parents Engaged in MSbP
According to Pritchard (2004), the fictitious or induced illness is commonly provoked by women, particularly mothers that form 95 per cent of the MSbP cases. However, there have been a few cases reported to be committed by fathers, adoptive parents, or other involving care givers (Artingstall, 1999). A big disparity proves the disproportionate number of women caring about children in comparison to men (Pritchard, 2004).
The common characteristics exhibited by parents or caregivers who falsify or impose an illness on children sometimes are also similar to the characteristics naturally exhibited by many parents who are not suffering from the MSbP (Lasher & Sheridan, 2004). Among other distinguished characteristics, perpetrators are ordinarily the principal caregiver of a child with an intention to manipulate the people around them, especially doctors, that are supposed to be more competent in this sphere, thus giving the offender a delightful feeling of controlling theme (Fish, Bromfield & Higgins, 2005). In such a scenario, the absence of the caregiver results in a disappearance of the symptoms or illnesses. Parents with the MSbP may also have normal mental health evaluations, showing no previous engagement in the services of child protection, they may seem to be phobic, overprotective, or deluded, with an experience and deep knowledge of the health condition, and may seek publicity or consideration from a range of people (Fish, Bromfield & Higgins, 2005). In most cases, the caregivers and parents with this syndrome do not stop the abusive behavior once being suspected but instead change the health establishment and deny the accusations even when there are overwhelming evidences against them. Moreover, they tend to accuse their prosecutors and shift the blames against the others (Lasher & Sheridan, 2004). Most of these characteristics are similar to those that a regular parent would demonstrate, thus complicating the process of diagnosis MSbP (Shannon, 2009).
Legal Issues and Court Trials with the Help of Criminal Psychology
There are several legal pieces of a background information that children safety practitioners need to consider while dealing with a possible case of MSbP. The cases of care and protection measures in which a child is purported to be at risk of harm from their caregivers or parents can be presented before the court using the grounds of intervention through the legislation established in each state. The grounds used must match the individual evidences in a particular case, and the suggested danger those facts present to the victim who is the subject of the application (Fish, Bromfield & Higgins, 2005).
It is also imperative to differentiate the criminal trials from the child protection cases. The focus of a criminal trial is on a hearing of charges against the accused individual alleged to have committed a crime in order to prove the accusations that the person had perpetrated particular acts with a felonious intent. Child protection hearings, on the other hand, focus on determining whether the child is a victim of MSbP, and does require a protection from the perpetrator or not (Fish, Bromfield & Higgins, 2005). In such cases, the purpose of the child protection services is to evidence that a parent or caregiver has done or failed to do certain acts that have consequently made the child suffer from any kind of harm.
Standards of Proof
The rules of evidence presented in the child protection cases are less strict as compared to those applied in criminal trials. The reason for this is the diverse legal aims and different standards of proof needed for a particular case (Fish, Bromfield & Higgins, 2005).
To substantiate a criminal case, the prosecution must avail itself of the evidence that indicts the accused according to a standard referred as ‘beyond reasonable doubt’. On the contrary, the standard of proofs used in child protection cases, is based on the balance of probabilities (Fish, Bromfield & Higgins, 2005). For example, in Australia, the courts trying a case on a child abuse by the employing of the lower standard of proofs may consider appropriate findings from the criminal proceedings if such are available in the court hearing. However, statements related to law on a criminal trial where MSbP is mentioned as an issue, may not be applicable child protection case (Fish, Bromfield & Higgins, 2005). The criminal psychologists involved in this case must present a psychiatric report to determine if the perpetrator is truly suffering from the syndrome to validate the proof.
The evidence needed to authenticate the necessity for protection according to Fish, Bromfield and Higgins (2005) are usually categorized into three wide groups: (1) direct proofs that involve what has been observed, heard and acquired, or treatment that has been felt through the intellectual analysis by the witness, (2) factual or bodily evidence that may comprise documents, videos, photographs, x rays, diaries, reports, and other relevant objects, and finally, (3) opinion evidence, which may involve a professional conclusion proceeding on the pertinent qualifications. Such individuals are the criminal psychologists and psychiatrists authorized to assess the level of disorder, and to conclude whether the child needs a protection from the authorities.
Grounds for Intervention
Legislation that lay grounds of the child care and protection trials in courts usually differs from state to state and from country to country. In Australian courts there are major similarities on the jurisdictions (Fish, Bromfield & Higgins, 2005). The legal child protection authorities are plenipotentiary to respond in the case, when the acts of a caregiver or parent jeopardize the well-being of the child or cause the child either emotional, social, psychological or physical harm (Shannon, 2009). The harm may comprise such acts of physical abuse as an assault, psychological abuse, sexual abuse, or neglect (Bromfield and Higgins 2005). Such cases when caregivers expose children to fabricated or induced illness are usually brought to the courts and substantiated on a direct evidence stipulating the acts which support such charges, including the opinions of an appropriately qualified expert such as the criminal psychologist that are able to provide an interpretation of the stated acts and subsequent risks the child is subjected to (Fish, Bromfield & Higgins, 2005).
Defense Mechanisms in Court
The perpetrators of the MSbP usually defend themselves in court in several ways. One defense mechanism entails emphasizing on the accurate symptoms of illnesses that the victims of Munchausen syndrome by proxy exhibit. Considering the amount of the exaggeration of symptoms of illness, doctors in most instances confirm the presence of the disorder. This makes the perpetrators justify their claim of medical need to their children. Moreover, this may weaken the case against them, since such mother suffering from the disorder usually present herself to the court as a very protective and more caring person. This usually complicates the diagnosis of MSbP owing to the fact that it is relatively difficult for the physicians to distinguish the real illnesses from the fabricated one (Gregory, 2003).
Some of the culprits also do not have any previous records made of an engagement with the child protection service (Fish, Bromfield & Higgins, 2005).This gives them a defensive point in the courts to deny all the accusations claiming that the prosecution is malicious.
Occasionally, some of the perpetrators presented in the court are experienced in the medical field, and may have a solid knowledge giving them the power to challenge any accusation made against them, and even seek publicity or consideration from a range of other doctors to interpret the symptoms that are manifested by the child. Similarly, the mothers or caregivers with this syndrome often do not change their behaviors when suspected, but change the professionals and consultants instead.
Treatment of Munchausen by Proxy Syndrome
MSbP is a very complicated disorder to treat, and often needs a long-period therapy and support that involve a social service, child protective service, law enforcement, and a teamwork of the physicians to improve a health state of the patient (Hanon, 1991). The first step to take is to safeguard and protect any real or potential victims by placing the child under the care of another person in order to avert the further maltreatment of the sufferer (Stirling, 2007). Successful treatment of individuals with this disorder usually proves to be difficult since such people often deny that there is a problem. Equally, the success of treatment is dependent on telling the truth, which MSbP individuals do not do, but instead become the accomplished liars. The known treatment involves an administering psychotherapy and cognitive-behavioral therapy aimed at helping the individual to detect the thoughts and feelings that are causing the behavior, and teaching to develop relationships not related with being ill (Stirling, 2007).
Munchausen by Proxy Syndrome is a disorder that is extremely difficult to diagnose since it is exhibited in various forms with accurate disease symptoms, making it complicated and uneasy to detect. It involves the parent or caregiver inducing illnesses, or inflicting injuries on their children or children under their care (Gregory, 2003). This disorder is difficult to believe especially when involving real mothers, owing to the fact that it is the responsibility of the mothers to protect and ensure that their children are safe from all kinds of harm. It is, therefore, important for the good of a society and a nation to study more the reasons for such a disaster.
It seems to me that MSbP can result from a state of a personal unhappiness. The factors causing that may depend or do not depend on a personal choice. Nevertheless, I am in favor of making everything possible to direct things that totally are in our power in a right place. I believe, what can help to improve this difficult situation and to prevent such anomalies in a behavior is a proper education of children and adults in a matter of a personal relationship and social communication, namely, practical psychology.
Not the less important is that the perpetrators suffering from MSbP should be treated as criminals in order to discourage people from being involved in such practices, especially after the confirmation of the characteristics with the help of a criminal psychologist. More research should also be conducted on the same topic to highlight and distinguish the causes and symptoms so that they can be addressed in good time, such as the use of family psychotherapy to improve cohesiveness and to minimize depression that have been identified as the causes of MSbP (Shannon, 2009).