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[Recurrent ingestion of foreign bodies. Unusual presentation of Munchausen by Proxy syndrome].

A case with unusual presentation of Munchausen syndrome by proxy is reported. It was shown through reiterated ingestion of foreign bodies (two earrings, probably a button but not confirmed, a 5 cm. screw and two sewing needles) perpetrated by a 22-year-old mother with a psychiatric record of behavior disorders and family dysfunctions on a 10-month-old infant with a history of prematurity, repeated visits to emergency rooms, and nonjustified multiple hospital admissions. The difficulties in the diagnosis and the need for an early detection are brought up, making considerations in regard to indicators, diagnostic criteria, and management procedure.

Adult↗

Repeated false allegations of sexual abuse presenting to sheriffs: when is it Munchausen by Proxy?

Munchausen by proxy syndrome, wherein a caretaker (most often a mother) simulates or fabricates illness in a child in order to assume the sick role through another has now been described involving a variety of psychiatric problems and false allegations of sexual abuse. Given that a proposed dynamic appears to be a need in a dependent and/or hostile relationship with powerful transferential people from the past, it was expected that professionals (school psychologists, social workers, lawyers) other than doctors would be involved. A case involving law enforcement agents as a primary "target" is described and its significance discussed.

Child Abuse, Sexual↗

Factitious disorder by proxy: awareness among mental health practitioners.

Factitious disorder by proxy (FDP) is a form of abuse in which a caregiver surreptitiously simulates or induces illnesses in a person for whom he or she cares. Typically, a mother is the perpetrator and at least one of her children is victimized. FDP has a high morbidity and mortality rate, and a knowledgeable health team increases the primary physician's confidence in making this difficult diagnosis. The purpose of this study was to determine the levels of awareness of FDP among mental health practitioners and their sources of information. Anonymous questionnaires were sent to 687 primary care physicians and mental health practitioners. Psychiatrists (89%) and psychologists (69%) were more aware of the disorder than were social workers (42%). Years in practice were not associated with awareness of FDP. Psychiatrists were more likely than psychologists or social workers to have had exposure through an actual case or through their professional journals. These findings were statistically significant. Awareness of FDP varies significantly among mental health professionals and may reflect the availability of information during training and in journals. Since social workers and psychologists often have earlier and broader opportunities than psychiatrists to interface with families, enhancements in training and the professional literature in these disciplines are needed if FDP is to be consistently considered and identified.

Alabama↗

Criminal poisoning: Munchausen by proxy.

The diagnosis and subsequent prosecution of Munchausen by proxy (MBP) cases require the collaborative teamwork of health care teams, laboratory personnel, law enforcement, and social services. Poisoning occurs in a significant number of the MBP cases with a diverse variety of agents used. To aid laboratory professionals in determining the appropriate toxicology tests to perform in such criminal cases, health care professionals must focus their testing requests on substances that correspond to the victim's signs, symptoms, and ancillary test values. This article reviews MBP, with particular focus on poisoning agents that have been used in past reported cases.

Forensic Pathology↗

Munchausen syndrome by proxy (MSBP): an extreme form of child abuse with a special forensic challenge.

Munchausen syndrome by proxy (MSBP) is a special form of child abuse in which an adult repeatedly produces symptoms of illness in a person under his/her care. In most cases the perpetrators are mothers who repeatedly and in different ways produce or feign symptoms of illness in their children in order to obtain medical treatment for them. MSBP is thus a special form of child abuse that is also of importance in the field of forensic medicine and a particular challenge to the medicolegal expert. We report two cases of poisoning with different substances (clozapine and clonidine) detected by toxicological investigations at our Department of Legal Medicine. The relevance of the problem for the medicolegal expert and the importance of an interdisciplinary co-operation are pointed out.

Antipsychotic Agents↗

Interpreting parental proxy reports of (health-related) quality of life for children with unilateral cochlear implants.

OBJECTIVE: To examine what factors are associated with EuroQol EQ-5D scores in children after unilateral cochlear implantation and to explore parental conceptualisations of health-related quality of life (HRQL) and quality of life (QoL). METHODS: Face to face interviews were conducted with the parents of 222 implanted children, in an attempt to elicit information on their child's HRQL and QoL. Post-implant, the child's HRQL was measured using the EQ-5D, completed by parental proxy. Regression analysis was undertaken in order to estimate the association between the child EQ-5D score and child characteristics, child performance, and parental characteristics, in order to assess the construct validity of the EQ-5D. HRQL was also measured using the EuroQol visual analogue scale (VAS), where the endpoints were the best and worst imaginable health state, and a VAS was also used to measure QoL (endpoints: best/worst imaginable QoL). Parents were asked to estimate scores on both these VAS measures both post-implantation and (retrospectively) pre-implantation. Throughout the HRQL and QoL elicitation process, subjects' comments, and observations were noted. RESULTS: Children who had an additional disability (p<0.001), were male (p<0.05) or had a lower level of auditory perception (p<0.001) were estimated to have lower EQ-5D scores, as were children whose parents who left school before age 18 years (p<0.05). According to the EuroQol VAS the mean difference between pre- and post-implantation score was 0.14, compared to 0.35 for the QoL VAS, demonstrating that parents tended not to see HRQL and QoL as equivalent. As 67% of parents deemed there to be no difference between the pre- and post-implant EuroQol VAS scores we also infer that the majority of parents rejected the notion of deafness being a HRQL issue. CONCLUSION: The evidence relating to the construct validity of the EQ-5D is variable-though it was able to discriminate between children with certain levels of auditory performance, it could not discriminate between children who differed in other ways. By limiting outcome from cochlear implantation to HRQL, as opposed to QoL, the benefits of cochlear implants are likely to be underestimated.

Child↗

Munchausen's syndrome by proxy and Lyme disease: medical misogyny or diagnostic mystery?

Chronic, tertiary Lyme disease, a vector-borne infection most accurately designated neuroborreliosis, is often misdiagnosed. Infectors of the human brain, Lyme borrelial spirochetes are neurotropic, similar to the spirochetes of syphilis. Symptoms of either disease may be stable and persistent, transient and inconsistent or severe yet fleeting. Characteristics may be incompatible with established knowledge of neurological dermatomes, appearing to conventional medical eyes as anatomically impossible, thus creating confusion for doctors, parents and child patients. Physicians unfamiliar with Lyme patients' shifting, seemingly vague, emotional, and/or bizarre-sounding complaints, frequently know little about late-stage spirochetal disease. Consequently, they may accuse mothers of fabricating their children's symptoms--the so-called Munchausen's by proxy (MBP) "diagnoses." Women, following ancient losses of feminine authority in provinces of religion, ethics, and healing - disciplines comprising known fields of early medicine, have been scapegoated throughout history. In the Middle Ages, women considered potentially weak-minded devil's apprentices became victims of witch-hunts throughout Europe and America. Millions of women were burned alive at the stake. Modern medicine's tendency to trivialize women's "offbeat" concerns and the fact that today's hurried physicians of both genders tend to seek easy panaceas, frequently result in the misogyny of mother-devaluation, especially by doctors who are spirochetally naïve. These factors, when involving cases of cryptic neuroborreliosis, may lead to accusations of MBP. Thousands of children, sick from complex diseases, have been forcibly removed from mothers who insist, contrary to customary evaluations, that their children are ill. The charges against these mothers relate to the idea they believe their children sick to satisfy warped internal agendas of their own. "MBP mothers" are then vilified, frequently jailed and publicly shamed for the "sins" of advocating for their children. In actuality, many such cases involve an unrecognized Lyme borreliosis causation that mothers may insist is valid despite negative tests. Doctors who have utilized MBP tactics against mothers are likely to be unaware that in advanced borreliosis, seronegativity is often the rule, a principle disagreed upon by its two extant, published, peer-reviewed, Standards of Care. These are guidelines for Lyme disease management--the older system questioning the existence of persistent Lyme and the newer system relying on established clinical criteria. Mothers must be free to obtain the family's preferred medical care by choosing between physicians practicing within either system without fear of reprisal. Doctors and mothers together may then explore medical options with renewed mutual respect toward the best interest of children's health.

Diagnostic Errors↗

Validity of parent ratings as proxy measures of pain in children with cognitive impairment.

Parent-assigned pain scores have been used as proxy measures of pain for children, such as those with cognitive impairment (CI), who cannot self-report. However, the accuracy of parent-assigned pain ratings for children with CI has not been studied. This study evaluated the construct and criterion validity of parental pain scores of children with CI. Fifty-two children aged 4 to 19 years with CI and their parents/guardians were included in this observational study. Children were observed and assessed for pain by parents using the Faces, Legs, Activity, Cry, and Consolability (FLACC) observational tool and the 0 to 10 Numbers Scale, and simultaneously by nurses using the FLACC. Children who were cognitively able scored pain using simplified scales. Parent scores decreased after analgesic administration (6.4 +/- 2.5 vs. 3.1 +/- 2.3; p = .004), supporting their construct validity. Parents' FLACC and Numbers ratings correlated well with nurse ratings (intraclass correlation coefficient = 0.78 [confidence interval = 0.63-0.87] and intraclass correlation coefficient = 0.73 [confidence interval = 0.59-0.83], respectively). The parents' coded Numbers ratings correlated moderately with their child's ratings (rho = 0.57; p = .05) and agreed in 20% to 100% of cases (kappa = 0.388). There was better overall agreement between parents' FLACC scores and child ratings (33%-67% agreement; kappa = 0.43). The parent underestimated the child's pain with FLACC ratings in only one case (8%), but overestimated pain in three cases (25%). This study suggests that parents of children with CI provide reasonable estimates of their child's pain, particularly when using a structured pain tool. Parents may, however, tend to overestimate their child's pain during the early postoperative period.

Adolescent↗

The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy.

PURPOSE: The aim of this study was to determine what percentage of childhood central venous catheters (CVC) are placed in victims of Munchausen syndrome by proxy (MSBP) and to evaluate the clinical indications and complications of CVCs in MSBP. METHODS: Study design was by retrospective chart review. Data were obtained from the regional children's hospital and regional child abuse consultation network. Patients in the MSBP series were all children who on consultation were determined to be victims of MSBP, from 1974 through 1996. Patients in the central catheter series were all children who had central venous catheters placed 1991 through 1995, excluding children whose catheters were placed for cancer chemotherapy or for chronic renal failure. Consultation records of MSBP cases were abstracted noting the clinical characteristics of victims and perpetrators. Hospital procedure codes were reviewed for children who had CVCs placed. Those who had discharge diagnostic codes that commonly require CVC placement were not reviewed, but charts of children with diagnoses not usually requiring CVCs were evaluated. Descriptive statistics and chi2 and Fisher's Exact test were used for comparisons. RESULTS: Sixteen of ninety-three (17%) of MSBP victims had central lines, including two deaths caused by assault through the lines. Line sepsis occurred in 9 of 16 (56%) patients. Primary reasons for CVC were for administration of medicines that can normally be administered orally or subcutaneously (7) or for severe nutritional depletion (8). All but one of the children had symptoms of multiple organ system involvement. Siblings had frequently been victimized. The mean age of symptom onset was 19 months, yet the mean age at diagnosis was delayed until 82 months. All perpetrators were the mother. Fathers were usually physically or emotionally unavailable. Nearly one third of mothers had prior medical training and one third had themselves been victims of prior physical or sexual abuse. Ten of fifteen mothers previously exhibited Munchausen behavior themselves. Of children at our institution who had central venous catheter placement, 8 of 709 (1.1%) were MSBP victims. CONCLUSIONS: CVCs are frequently placed in MSBP victims for physiological problems, malnutrition, or failure to respond to normal treatments. Surgeons should consider requesting systematic evaluation for MSBP in patients seeking CVC placement for diagnoses not usually requiring CVCs lest they become unintentional collaborators in abuse of these children.

Adult↗

Munchausen by proxy syndrome: a modern pediatric challenge.

Munchausen by proxy syndrome is a condition in which a mother pretends her infant or child is ill or causes the infant or child to be ill in order to engage in an intensely ambivalent but often destructive relationships with a physician. Despite appearances to the contrary, evidence indicates that the infant serves as little more than an object to regulate this relationship. The harming of the child takes place in a fully conscious nonpsychotic state and is a by-product of the dynamics of this relationship. We see the mother's actions as an example of imposturing good mothering. Physicians are susceptible to these mothers in ways that lead them to delays in uncovering these dynamics that can have disastrous consequences for the infant. Social and interpersonal forces that contribute to the unfolding of this syndrome are worthy of our study.

Female↗

Overinterpretation of gastroduodenal motility studies: two cases involving Munchausen syndrome by proxy.

Two children were thought to have an atypical gastroduodenal motility disorder because of the history and clinical course; both had received parenteral alimentation because of claims of inability to tolerate enteral feedings, and both continued to have unusual medical problems during parenteral alimentation. Both children had motility studies that were interpreted by a pediatric gastroenterologist to be "abnormal" and "diagnostic" of a motility disorder, but each was eventually shown to have a behavioral abnormality related to Munchausen syndrome by proxy.

Child, Preschool↗

Different interpretations of Munchausen Syndrome by Proxy.

The definition of Munchausen Syndrome by Proxy is reviewed and considered in the context of the overlap with other harmful behaviors of parents. The high incidence of personal abnormal illness behavior in the perpetrators is leading to increasing concern about the safety of children who are cared for by parents who have abnormal illness behavior.

Child Abuse↗

Munchausen by Proxy in an international context.

OBJECTIVE: The professional literature on Munchausen by Proxy (MBP) abuse consists of more than 400 articles, chapters, and books. Most have come from a handful of English-speaking industrialized countries. Our aims were to establish the extent to which published work about MBP has emerged from outside these countries, and to determine the characteristics of any reported cases. METHOD: Numerous health care computer databases were queried, and the results supplemented by materials accumulated less formally. RESULTS: We identified 59 articles from 24 countries describing at least 122 cases in 9 different languages. Among cases in which the information was available, the mother was the sole perpetrator in 86%, the victim was aged between 3 years and 13 years in 52%, and the victim was male in 54%. The presentations of MBP appear to be similar across the world with the exception of induced apnea, which emerged as notably uncommon in this review. An extensive table presents the characteristics of each case. CONCLUSIONS: MBP clearly is not a phenomenon unique to Western or highly medicalized societies. This form of abuse is being increasingly recognized and reported throughout the world. The literature from the US, Canada, UK, Australia, and New Zealand often presupposes access to resources, such as subspecialists and social service agencies, that may be seriously constrained in other countries. The contributions of professionals elsewhere will be vital in ensuring that the efforts in English-speaking industrialized settings to develop standards of care encompass an international perspective.

Child↗

Concerns about research and prevention strategies in Munchausen Syndrome by Proxy (MSBP) abuse.

There would seem to be three motives for research into Munchausen Syndrome by Proxy (MSBP) abuse; first to enhance treatment; second to enhance our understanding of the psychopathology of those who carry out the abuse; and third to find interventions to prevent its occurrence. We will argue that only the first justification is valid. The second and third should be questioned for several reasons including: MSBP abuse is the wrong kind of event to think of in terms of categorical diagnosis; rare events are inherently difficult to predict; and better research targets are available. We propose that research energy would be more productively directed towards furthering our understanding of somatization and certain problematic aspects of modern pediatric practice. We offer suggestions as to appropriate areas for research.

Adult↗

Concurrent factitious disorder and factitious disorder by proxy. Double jeopardy.

Two forms of medical dissimulation-factitious disorder and factitious disorder by proxy-present enormous challenges to clinicians accustomed to receiving valid symptom reports from their patients. The consequences of such "disease forgery" are heightened when a patient simultaneously engages in both forms of deception. We discuss a 34-year-old nurse who simulated or induced a panoply of physical and psychological ailments in both herself and her daughter. The staff's insistence on access to outside information sources proved indispensible in establishing both diagnoses, facilitating ongoing treatment for the patient and ensuring appropriate protection of the child.

Adult↗

Bleeding ears: a case of Munchausen syndrome by proxy.

A case is presented of a child who initially presented with genuine aural symptoms and pathology. Over a period of time it became apparent that the persistent aural bleeding, which is an uncommon feature of Chronic Suppurative Otitis Media, was the result of trauma inflicted by its mother; a case of Munchausen syndrome by proxy (MSBP).

Ear Diseases↗

Persistent cerebrospinal fluid otorrhea: a case of Munchausen's syndrome by proxy.

A case is presented of a young child who initially presented with recurrent bacterial meningitis 1 year after significant head trauma and was found to have cerebrospinal fluid (CSF) leakage into the middle ear. Surgical procedures were devised to attempt to stop this abnormal flow, but inexplicably clear otorrhea biochemically identical to CSF persisted for weeks. The child's mother was apparently soaking the surgical dressings with CSF obtained through a lumbar drain and confessed to this activity after she was found to have tampered with an intravenous catheter. This activity resulted in a prolonged hospital stay and several presumably unnecessary procedures. Munchausen's syndrome, typified by intentional mimicry of symptoms of serious illness backed by plausible medical history, is well-described. Rarer is the syndrome by proxy, where parents and/or caregivers, by falsifying histories, fabricating laboratory evidence, or deliberately generating bodily lesions, cause unneeded diagnostic and therapeutic procedures to be performed on their young victims. This form of child abuse is hidden by the perpetrator's apparent concern and involvement in the care of the victim. The literature is reviewed, this form of abuse is discussed, and the role of communication of suspicion between the various health care workers is stressed. The medical and social settings in which this disorder is prevalent are covered. Early detection of this entity is essential in rescuing the victim from life-threatening abuse and in obtaining appropriate therapy for the abuser.

Cerebrospinal Fluid Otorrhea↗

Proxy informed consent in pediatric research: a review.

This paper is aimed at discussing the issue of proxy consent for medical research with children carried out in the context of developed countries. First, requirements for valid informed consent are reviewed, and differences with clinical practice highlighted. In the second part the findings from empirical studies, and implications for improving the consent process, are discussed. Perceived benefit for their child is the most important factor motivating parents to grant consent, but also a desire to contribute to medical research and benefit others are frequently mentioned. Abstract concepts such as randomization are more difficult to grasp and remember than practical issues. The type and style of the consent-seeking process (quality of the information, physician's attitude, allocated time, readability of consent forms) have an influence on how the invitation to participate is received. Rather than as a one-sided delivery of information, consent should be viewed as a continuous, two-way communication process developing in a context of transparency and partnership between the investigator and potential research subjects.

Adult↗