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PubMed1995

The investigation of life-threatening child abuse and Munchausen syndrome by proxy.

The use of covert video surveillance in the investigation of suspected life-threatening child abuse and Munchausen syndrome by proxy raises important ethical questions. That the recently reported provision of this facility in North Staffordshire was not presented to a Local Research Ethics Committee (LREC) for approval as a research exercise raises important questions about the ethical review of research and practice. The case made for avoiding such review is first set out and then examined. The three main premisses which form the basis of the view that LREC approval is not required are identified and tested in turn. The conclusion is that there is an undeniable element of research involved in the procedure and that the welfare of all those subjected to the surveillance would be best protected by the submission of the protocol to an independent committee for ethical assessment.

Behavioral Research↗
PubMed1998

Infectious diseases presentations of Munchausen syndrome by proxy: case report and review of the literature.

Munchausen syndrome by proxy is a form of abuse, usually of a child by a parent, in which a factitious illness is reported or produced in the child, resulting in unnecessary medical evaluations and treatments. A dramatic case of a 17-month-old infant with recurrent polymicrobial bacteremia prompted a review of cases diagnosed by the Pediatric Infectious Diseases consultation service at our referral children's hospital and a review of the infectious diseases presentations in the medical literature. The infectious diseases presentations of the syndrome as well as criteria for the diagnosis are reviewed and discussed.

Child↗
PubMed1998

Munchausen syndrome by proxy.

Munchausen syndrome by proxy is the most difficult form of child abuse. It carries substantial morbidity and mortality. The diagnosis relies on appropriate suspicion and careful investigation. The psychological illness/need of the perpetrator is the main clinical feature. Early recognition and appropriate intervention prevent further abuse and criminal actions.

Adult↗
PubMed1992

Munchausen syndrome by proxy.

This study examined the indicators of possible presence of Munchausen Syndrome by Proxy (MSBP) in pediatric inpatients discharged against-medical-advice (AMA), in cases transferred to another hospital, and in regular discharges. In a two-year period, there were fourteen AMA discharges and twenty-four transfer cases. These were compared to a randomly selected sample of forty-one regular discharges occurring during the same time period, matched for age, sex and pediatric service. The records were scored for the presence or absence of six MSBP characteristics, which had been developed from a review of MSBP literature. The findings indicated a suspicion for MSBP in 64 percent of the AMA cases, 8 percent of the transfer cases, and none in regular discharges. The findings suggest that AMA discharges need to be examined for the possible presence of MSBP.

Depressive Disorder↗
PubMed1998

Culture and Munchausen-by-proxy syndrome: the case of an 11-year-old boy presenting with hyperactivity.

OBJECTIVES: To discuss some of the challenges presented to the clinician who deals with a possible Munchausen-by-proxy (MBP) syndrome. METHOD: The case of an 11-year-old boy presenting with hyperactivity is discussed. Information from the initial assessment and the 9-month follow-up period is presented. We highlight some cultural considerations as they apply to this immigrant family. A commentary by Dr H Schrier follows the presentation. RESULTS: The positive outcome is discussed in relation to the validation of the diagnosis as well as to cultural issues. CONCLUSION: Cultural issues and dynamic factors may be important when we consider the diagnosis of MBP syndrome in an immigrant family with different expectations from our health care system.

Attention Deficit and Disruptive Behavior Disorder↗
PubMed2007

Parent as proxy reporting: implications and recommendations for quality of life research.

Improved disease management in children has resulted in an increased interest in the quality of life in children. Quality of life research in children may enlist either the substitute or complementary perspective. Much of the quality of life literature has been guided by the substitute perspective, which infers that parents may best report their child's quality of life. However, the complementary perspective values both parent and child perspectives equally. The purpose of this article was to critically review the quality of life literature with respect to children with diabetes. Limitations in the literature were addressed as conceptual and methodological, demographic, and underlying proxy perspectives. Benefits and limitations of quality of life measurements and perspectives were also discussed. Recommendations and future implications for quality of life research in children extend current understanding from both substitute and complementary perspectives.

Adaptation, Psychological↗
PubMed2002

Considering suffocatory abuse and Munchausen by proxy in the evaluation of children experiencing apparent life-threatening events and sudden infant death syndrome.

This study describes 138 young children admitted to the hospital over a 23 year period for recurrent apparent life threatening events (ALTEs), unexplained deaths, or with Sudden Infant Death Syndrome (SIDS)-related diagnoses. In examining the potential for suffocatory abuse in living children, we utilized characteristics in the literature that distinguish SIDS or ALTEs due to natural disease states from abuse. Findings demonstrate a co-occurrence of risk factors that raise suspicions of suffocatory abuse or Munchausen by Proxy. Of the 35 children who died, SIDS was the presumed clinical diagnosis at the time of death in 71 % of the cases. Comprehensive chart review and autopsy findings revealed a non-SIDS diagnosis in 54% and confirmed or suspicious child abuse in 37% of these deaths. Reports to Child Protective Services were made in 6% of cases. Recommendations for assessment of children including attention to risk indicators, involvement of child protection teams, mandatory autopsies, and eath scene investigations are offered.

Asphyxia↗
PubMed2000

Munchausen syndrome by proxy abuse.

The difficulties in diagnosing Munchausen Syndrome by Proxy Abuse (MSbPA) are examined. The perpetrators of MSbPA are usually the victim's primary care giver. The warning signs of MSbPA include unexplained, prolonged and extraordinary illness with the signs and symptoms only being evident when the suspected perpetrator is present. Confrontation, exclusion and covert video surveillance are all possible routes to gaining further evidence. The problems associated with covert video surveillance are explored.

Adult↗
PubMed1997

My mother caused my illness: the story of a survivor of Münchausen by proxy syndrome.

OBJECTIVE: Münchausen by proxy syndrome (MBPS) is a form of child abuse in which a parent fabricates or produces illness in a child. Although the medical consequences of MBPS have been well described, there is no detailed published account of what it was like to grow up in a family where the mother systematically induced serious illness. This article describes one victim's childhood experiences. METHODS: The medical history was obtained from a review of the original medical records, notes from the primary physician, discussions with two physicians who provided treatment, and several meetings with the victim and the victim's therapist. RESULTS: This article chronicles the actual experiences of an MBPS victim through 8 years of medical abuse at the hands of her mother, reveals the victim's account of what happened to her, describes what her family was like, details the long-term consequences on emotional and physical development, identifies the factors that influence recovery, and details the impact on family relationships. CONCLUSIONS: Child maltreatment and MBPS need to be part of the differential diagnosis when the clinical picture is atypical or does not appear medically plausible. The consequences of MBPS are psychological and physical and impact the entire family. Suggestions to assist heath care providers recognize, assess, and report cases of suspected MBPS are provided.

Adult↗
PubMed2000

Evaluation of covert video surveillance in the diagnosis of munchausen syndrome by proxy: lessons from 41 cases.

OBJECTIVE: In 1993, Children's Healthcare of Atlanta at Scottish Rite (formery Scottish Rite Children's Medical Center, Atlanta, GA) added facilities to perform inpatient covert video surveillance (CVS) of suspected cases of Munchausen syndrome by proxy (MSBP). Forty-one patients were monitored from 1993 to 1997. This study was performed to review our experience with these cases. How useful was video surveillance in making the diagnosis? What were the characteristics of families with children who were victims of MSBP? METHODOLOGY: Medical, social work, security, and administrative records of all children who underwent covert video monitoring at Children's Healthcare of Atlanta at Scottish Rite from 1993 through 1997 were reviewed retrospectively by a team of physicians, risk managers, and social workers. RESULTS: A diagnosis of MSBP was made in 23 of 41 patients monitored. CVS was required to make the diagnosis in 13 (56.1%) of these 23, and supportive of the diagnosis in 5 (21.7%) cases. In 4 patients, this surveillance was instrumental in establishing innocence of the parents. MSBP was more common in Caucasian patients than in other ethnic groups seen at our hospital. Fifty-five percent of mothers gave a history of health care work or study, and another 25% had previously worked in day care. Although many of caretakers fit the profile of MSBP, such as excessive familiarity with medical staff, eagerness for invasive medical testing, and history of health care work, these characteristics were not sensitive indicators of MSBP in our study. Even when present, they were not sufficiently compelling to make the diagnosis. CONCLUSIONS: CVS is required to make a definitive and timely diagnosis in most cases of MSBP. Without this medical diagnostic tool, many cases will go undetected, placing children at risk. All tertiary care children's hospitals should develop facilities to perform CVS in suspected cases.

Adult↗
PubMed2005

Factitious hyperinsulinism leading to pancreatectomy: severe forms of Munchausen syndrome by proxy.

Clinical history and inappropriate insulin secretion during hypoglycemic episodes permit the diagnosis of hyperinsulinism. We report 2 cases of factitious hyperinsulinism leading to partial pancreatectomy. Case 1 was an 8-year-old girl who presented with severe hypoglycemia and elevated insulin and C-peptide levels. Catheterization of pancreatic veins was performed to localize the excess insulin secretion. Insulinoma was suspected, and partial pancreatectomy was performed. Ten days after surgery, severe hypoglycemia recurred with severely elevated plasma insulin levels (x100) but very low C-peptide plasma levels, suggesting factitious hyperinsulinemia. Hypoglycemic episodes before surgery were provoked by oral sulfonamides; postoperative episodes were caused by parenteral insulin. Falsified prescriptions for sulfonamides and insulin by the mother, a nurse, were found. Case 2 was a 6-month-old girl who presented with seizures and hypoglycemia but had a symptom-free interval of many months afterward. At 2 years of age, repeated hypoglycemic seizures and elevated insulin plasma levels suggested congenital hyperinsulinism. C-peptide plasma level, measured once, was normal, but blood sampling was performed 15 minutes after a hypoglycemic episode. Partial pancreatectomy was performed. Two weeks after surgery, hypoglycemic seizures recurred, and the patient was admitted for pancreatic vein catheterization. This investigation was performed during hypoglycemia and revealed high insulin levels and undetectable C-peptide levels, suggesting factitious hypoglycemia. Insulin/C-peptide ratio analysis is crucial to assess factitious hypoglycemia, although sulfonamide-induced hypoglycemia is not thereby detected. One percent (2 of 250) of all cases of hyperinsulinemic hypoglycemia in our unit have been identified as Munchausen syndrome by proxy. Atypical disease history should raise the question of factitious hypoglycemia.

Blood Glucose↗
PubMed1994

Denial in Munchausen syndrome by proxy: the consulting psychiatrist's dilemma.

OBJECTIVE: The purpose of this review, which also includes the report of a new case, is to discuss the pervasive denial of responsibility among individuals who have engaged in Munchausen syndrome by proxy (MSBP) behavior. In MSBP, a caretaker (almost always the mother) fabricates or induces illness in her child; she then presents the child for medical treatment, disclaiming knowledge of the etiology of the illness. METHOD: Literature searches of several computer databases were performed, and ninety-two citations dealing with MSBP, culled from medical, legal, and lay publications, were examined for descriptions of caretakers' responses to being confronted with the allegation of MSBP. Thirty-four citations contained relevant material, which was combined with observations from cases in which the author has served as a consultant. RESULTS: Caretakers engaging in MSBP consistently deny any role in the dissimulation, even when confronted with compelling evidence. This denial complicates management, though intervention must focus on ensuring the safety of the child regardless of the caregiver's response. CONCLUSIONS: Techniques sometimes advocated in factitious disorders in general may be useful in stopping the abusive behavior; however, no consistently effective strategy for overcoming denial in MSBP has yet been described.

Adult↗
PubMed2001

An explanatory model for Munchausen by proxy abuse.

OBJECTIVE: In Munchausen by proxy (MBP) abuse, a caretaker fabricates or induces illness in another person to obtain emotional gratification. In representative cases, a mother is the perpetrator and her child is the victim. In view of the limits of current explanatory models, we use personal accounts of MBP perpetrators, physicians, and family members as a window into understanding this counterintuitive behavior. METHOD: As subspecialty clinicians and consultants, we supplemented our extensive direct experience with MBP with a review of published reports of MBP located via MEDLINE and PsycINFO (1980 onward). We also examined the books devoted to the subject and incorporated personal accounts of MBP perpetrators and of family members and professionals involved with them. RESULTS: Factors contributing to the onset and continuation of MBP are the perpetrator's experiencing a particular drive (e.g., intense anger or frustration); lacking or overcoming internal inhibitions against abusive actions; and overcoming external inhibitions, such as the potential intercession of a spouse or pediatrician. As a result, the MBP parent experiences release from unpleasant emotions and a sense of renewed control. MBP behavior gains "habit strength" each time it occurs. CONCLUSIONS: Psychodynamic explanations of MBP, while favored by some authors, are inherently speculative and tend to be low in predictive value. We suggest broadening these traditional explanations by emphasizing observable behaviors and verifiable background factors. The behavioral perspective we outline helps explain how MBP behavior is learned, why it is more prevalent among mothers, and why it is so difficult for perpetrators to stop.

Adult↗
PubMed2003

Munchausen Syndrome by Proxy: two case reports and an update of the literature.

OBJECTIVES AND METHODS: Munchausen Syndrome by Proxy (MSP) may significantly hamper the normal development of children. Our aim was to describe the first two Israeli children who fit this diagnosis. RESULTS: Case #1 was diagnosed at the age of seven months with failure to thrive, severe recurrent vomiting, and recurrent unexplained fever. Medical tests performed were normal. No improvement was noted following prolonged treatment, which included several surgical interventions. Case #2 was hospitalized at the age of four years because of recurrent convulsive episodes. Medical examinations performed were normal, and there was no improvement in the reported seizure disorder despite continuous treatment. In both cases, MSP was suspected because of a persistent illness that could not be explained by adequate medical basis, and because the symptoms and signs occurred only in the mother's presence. A confrontation was made, leading to rapid deterioration of the hitherto devoted relationship of the mother of case #1 with her child, and of the previous cooperative relationship of both mothers with the medical staff. Removal of both children from their families ensued, with considerable improvement within a brief period, which continued in a one- to two-year follow-up period. CONCLUSIONS: The study reviews the required diagnostic criteria for MSP and possible treatment options.

Adult↗
PubMedDate not supplied

Nurses' knowledge of and experience with Munchausen Syndrome by Proxy.

Because of their proximity to children and families, pediatric nurses are in a key position to identify warning signs of Munchausen Syndrome by Proxy (MSBP) and alert other team members to the possible diagnosis. MSBP knowledge and experience of 132 pediatric nurses was assessed and compared with the results of two previously published articles. Consistent with previous reports, approximately half of the respondents had heard of MSBP. They were most likely to have received information about MSBP from direct experience (23.5%) and the media (19%). Only 25% of the nurses reported that they seriously suspected they had seen a case of MSBP during the past year. Despite the fact that 95% of the pediatric nurses responded that it was "very important" to know about MSBP, only one reported having learned about it from his or her academic training, and only 12 (9%) had read about it in a professional journal.

Adult↗
PubMed1995

Nursing interventions in Münchausen syndrome by proxy.

1. Münchausen syndrome by proxy is a rare but serious and potentially lethal form of child abuse in which a primary care giver induces or reports factitious symptoms in a child. 2. The child suffers from the caregiver's actions and health care providers unknowingly become accomplices when they provide unnecessary testing and therapies. 3. The child's physical and psychological welfare can be protected through the efforts of the forensic nurse specialist coordinating a multidisciplinary health care team's work to detect the syndrome and intervene early on.

Child↗
PubMedDate not supplied

Misdiagnosis of Munchausen syndrome by proxy: a literature review and four new cases.

The term "Munchausen's syndrome by proxy" (MSBP) was first used in the 1970s to describe a potentially lethal variant of abuse. In representative cases a mother deceives physicians into treating her child for illness that she has fabricated or induced, her motivation being to accrue the intangible benefits of the "sick role." Increased efforts to identify and protect victims have sometimes resulted in misdiagnosis of MSBP, leading authorities to remove children from the home and/or bring criminal charges against an innocent parent. The authors believe that Improved child protection can be achieved by examining "what went wrong" in cases of erroneously diagnosed MSBP. A review of more than 200 articles and books yielded seven reports of misdiagnosed MSBP in the medical/surgical, psychiatric, nursing, social work, legal, and lay literature. These isolated reports are discussed, and four new cases are presented. The paper concludes with a discussion of lessons to be learned and a table showing situations in which the risk of an erroneous diagnosis of MSBP is increased.

Child, Preschool↗