Munchausen Syndrome by Proxy as a Possible Factor When Abuse is Falsely Alleged

Deirdre Conway Rand^*

ABSTRACT: Munchausen syndrome by proxy (MSP) is a reportable form of child abuse in which a physical or mental disorder of the child is either fabricated or induced by a parent or other adult caretaker.  While most often diagnosed in medical settings, a contemporary-type MSP has emerged in which the parent fabricates or induces the idea that the child has been abused by someone else, with the accusing parent/caretaker then gaining recognition from helpers as the protector of an abused child.  The case illustrated in Bad Moon Rising: A True Story, is discussed.  Professionals are reminded of the importance of thorough fact-finding and the need for a multidisciplinary approach in diagnosing MSP.
  

Persons coming in contact with child abuse cases, especially cases where sex abuse is alleged, should be aware of a clinical syndrome called Munchausen syndrome by proxy (MSP).  Munchausen syndrome by proxy is a specialized form of child abuse in which a physical or mental disorder of the child is either fabricated or induced by a parent or other adult caretaker.  A related psychiatric disorder, Munchausen syndrome, refers to the individual who either fabricates or induces a medical or psychological problem in themselves.  The name Munchausen comes from a notorious 18th century teller of tall tales, Baron Von Munchausen.  Whereas in Munchausen syndrome the person gains positive attention from medical personnel for their own factitious illness, in MSP the perpetrator gains attention as the concerned caretaker of a sick child, who is the proxy.

The parent/child cases in the literature involve the mother as perpetrator, but the possibility of father/child cases cannot be ruled out.  There is one report of an adult male perpetrator abusing two female adults (Sigal, AItmark, & Carmel, 1986).  In another notorious case, authorities in Texas investigated a daycare operator after they became aware of the abnormal frequency with which she was requesting emergency medical care for the young children in her care, reporting seizures in each case.  The daycare operator was suspected of inducing the seizures, and one child actually died.

Examples of what could be called classical MSP run the gamut from fabricating the child's medical history, to altering laboratory specimens, to inducing or inflicting physical findings on the child.  Jones et al. (1986) state that false reports of seizures are particularly common, or the mother/caretaker may actually induce seizures in the child by suffocation.  Further instances are described where rashes have been simulated by dying the skin, pricking the skin, or rubbing the child's skin with caustics.  Cases have been reported in which the child was given poison to induce symptoms, or in which contaminated fluid was introduced into the child's intravenous tubing.

The physical consequences of classical MSP may include the child: 1) undergoing painful tests; 2) receiving unnecessary treatments and surgeries; 3) being subject to frequent and/or prolonged hospitalizations.  In more extreme cases of classical MSP, the child may actually die.  Meadow (1982) estimated a mortality rate of 10%, while Kaufman, Coury, Pickrel, and McCleery (1989) placed the figure at 22%.  With young children, the child is what might be termed a simple victim.  When an older child is involved, the child may accommodate the MSP mother and go along with the mother's deception in a kind of folie â deux.

In the past, MSP has been considered rare, but most authors agree that the incidence of the syndrome has been grossly underestimated.  In fact, the incidence of MSP may actually be on the increase, due to a contemporary variation of the syndrome that is unique to the 1980s.

Contemporary-type MSP involves fabricating or inducing the idea that the child has been abused by someone else, with the accusing parent/caretaker then gaining recognition from helpers as the protector of an abused child.  Upsurge over the last decade of social concern about child abuse has created new opportunities for the MSP parent.  In addition to attention, the adult accuser in contemporary MSP may accomplish additional agendas such as strengthening her symbiotic bond with the child, or being awarded custody of the child in divorce proceedings.

Libow and Schreier (1986) describe an MSP mother who became obsessed with the idea that her daughter had, at age two, been molested by a female relative.  The mother began taking her daughter to emergency rooms and to outpatient clinics, asserting, despite lack of medical findings, that her child had been permanently damaged by the alleged molestation.  Eventually, by providing misleading clinical data, mother convinced a new pediatrician to do a vaginal examination of the child under anesthesia.  She also managed to have the daughter hospitalized for observation twice.  This case is contemporary in the aspect that the mother alleged the child was the victim of abuse, but classical in the mother's insistence on repeated medical examinations of the child.  In other contemporary cases, the MSP parent pursues repeated contacts with police, the courts, Child Protective Services, and mental health workers.  The child may be subjected to numerous psychological and/or legal examinations, as well as intrusive sexual assault exams.  Contemporary variations of MSP can become very complicated because of all the professionals and agencies that become involved and who may actually participate, however unwittingly, in the perpetuation of MSP (Zitelli, Seltman & Shannon, 1987).

Ferguson's (1988) Bad Moon Rising: A True Story (reviewed in the Book Review section of this journal) details one such case.  The book covers events that occurred from 1984 to 1986 and is presented as a divorce drama, which is how it was viewed by many of the participants.  The diagnosis of MSP was not made until 1987, when subsequent events made the diagnosis more apparent to the court appointed psychologist/evaluator.

In this case, as a divorced father and his wife, who raised the older of father's two children, agree to let the teenage boy try living with his biological mother.  During the nightmare that ensues, first the boy's sister, then the boy himself make allegations of sexual abuse against relatives.  The allegations become so numerous that the authorities remove the children from the mother's home, while simultaneously indicting the relatives for sexual abuse.  The investigation that follows shows how the mother, with her sister as confederate, induced the children to allege abuse.  The children were subjected to exorcism rituals and brainwashing sessions.  The mother obtained the children's cooperation in presenting a fabricated history to various mental health professionals, in an effort to convince them that abuse by relatives had actually occurred.  To gain further sympathy for herself, the mother falsely alleged that she, too, had been abused as a child.  This similarity of symptoms in mother and child is one indicator that MSP may be operating (Zitelli et al, 1987).  Mother's fabricated history of abuse in her own past is also not uncommon among Munchausen adults (Hyler & Spitzer, 1978).

In the case of Bad Moon Rising, there was reason to believe that the MSP mother, and to a much lesser extent the son, already displayed Munchausen syndrome proper prior to the allegations of abuse.  The emergence of Munchausen syndrome by proxy, when the mother became the protector of allegedly abused children, may have been in response to external stressors such as the boy returning to live with her after so many years and the intense sibling rivalry that developed between the boy and his younger sister.  The distinction made by Nadelson (1979) between episodic MSP in response to external events such as divorce or the threat of out of home placement, and MSP as an ongoing way of life, may be blurred.  As Meadow (1984) reports,

There are several instances of children who have taken over the false illness behavior completely and begun to act like adults with Munchausen syndrome.  Other children have grown up as chronic invalids, remaining in the family home as adults and being told falsely by parents that they have fits at night and still have epilepsy.  Child abuse does not cease when the child reaches adult age — childhood ends when you lose your parents" (p. 673).

Thus, once initiated, the consequences of MSP can be long lasting.  In contemporary-type MSP, there may also be devastating and long-term consequences for the person falsely accused of abuse by the MSP parent/child dyad.

Although Munchausen syndrome by proxy is a reportable form of child abuse, many professionals have never heard of it (Kaufman, Coury, Pickrel, & McCleery, 1989).  This is not so surprising when one realizes that the first professional article on the subject was published only twelve years ago (Meadow, 1977).  While Munchausen syndrome (factitious disorder) appears in the Diagnostic and Statistical Manual III-R, Munchausen syndrome by proxy does not.

Munchausen syndrome by proxy, with its prominent deceptive aspect, should remind professionals of the importance in all cases of verifying information that is presented as fact, as well as additional, independent fact-finding.  Releases should be obtained to talk with all persons who may have relevant information.  Professionals should be open to a multi-disciplinary approach, which is often a prerequisite for recognizing the possibility of MSP and for confirming the diagnosis.
  

References

Ferguson, D. (1988). Bad Moon Rising: A True Story (). Nashville, TN: Winston-Derek, Inc.

Jones, J .G., Butler, H. L., Hamilton, B., Perdue, J. D., Stern, H. P., & Woody, R. C. (1986). Munchausen syndrome by proxy. Child Abuse & Neglect, 10, 33-44.

Kaufman, K. L., Coury, D., Pickrel, E., & McCleery, J. (1989). Munchausen syndrome by proxy: A survey of professionals' knowledge. Child Abuse & Neglect, 13(1), 141-148.

Libow, J., & Schrier, H. (1986). Three forms of factitious illness in children: When is it Munchausen syndrome by proxy. American Journal of Orthopsychiatry, 56(4), 602-610.

Meadow, R. (1977). Munchausen syndrome by proxy: The hinterland of child abuse. Lancet, 2, 342-345.

Meadow, R. ((1982). Munchausen syndrome by proxy. Archives of Diseases in Childhood, 57, 92-98.

Meadow, R. (1984). Munchausen by proxy and brain damage. Developmental Medicine and Child Neurology, 26(5), 672-674.

Nadelson, T. (1979). The Munchausen spectrum: Borderline character features. General Hospital Psychiatry, 2, 11-17.

Sigal, M., AItmark, D., & Carmel, I. (1986). Munchausen syndrome by adult proxy: A perpetrator abusing two adults. The Journal of Nervous and Mental Disease, 174(11), 69&698.

Zitelli, B., Seltman, M., & Shannon, R. (1987). Munchausen's syndrome by proxy and its professional participants. American Journal of Diseases of Children, 141, 1099-1102.