Munchausen by Proxy Syndrome: What Healthcare Workers Should Know
How to identify and confront this terrifying condition
A panicked mother carries her six-month-old infant into the ER and states that the baby has stopped breathing again. The baby has been through a number of tests and has been placed on an apnea monitor in her home. This is her seventh trip to the emergency room in three weeks. Three-year-old Brady has been hospitalized for chronic diarrhea, nausea, and fevers. Multiple tests indicate no known cause, and the medications that were prescribed do not appear to be working. An IV has been inserted and he is now being closely monitored. His mother, Lida, is at his bedside and shows extreme concern. Nina is a librarian whose third child has died of SIDS. The nurses comfort her in an outpouring of kindness and support, but Rachel, an RN who has been on staff only a year, suspects foul play.
Munchausen Syndrome Defined
DSM-IV labels it Factitious Disorder, but it is otherwise known as Munchausen’s Syndrome By Proxy. The word Munchausen comes from the 18th century’s Baron von Munchausen, who was well-known for making up stories. Munchausen’s Syndrome is a psychiatric disorder in which patients pretend to be ill for love and attention. They will even go to the extreme of having multiple surgeries for medical conditions they don‘t even have. Munchausen’s Syndrome By Proxy is a condition in which a parent, mother or father, but usually a mother, causes her child to be sick in order to receive this love, even to the point of murder. It is one of the most extreme forms of child abuse in the world, and one of the hardest to diagnose.
None of us wants to imagine that a mother could smother her child with a blanket, revive him, smother him again, revive him, and do it repeatedly. None of us wants to think that a father could poison his child’s bottle, baby food, IV, medicine, or syringe. At one time the disorder seemed obscure. Today there appears to be a growing understanding and recognition.
In 1999, a Florida courtroom convicted Kathleen Bush, a seemingly devoted mother, of child abuse. Prior to this, she was nationally recognized by Hillary Clinton, but this was before the allegations were made. It was discovered that Kathleen caused her daughter, then 8 years old, to be hospitalized 200 times, put feces in her feeding tube, and caused her to have 40 surgeries. Yvonne Padron, a Texas mother, was sentenced for smothering her twenty-one-month-old baby. The child languished on life support for 3 months after that. The mother confessed that she had smothered the child two times before—one of those times being when the child was in the hospital. A phlebotomist, Brian Stewart, was convicted of first-degree assault in 1998 after he administered to his son an injection of HIV-tainted blood.
• 98% of all Munchausen By Proxy perpetrators are women.
• 90% of all mothers and fathers with Munchausen’s have a remarkable store of medical knowledge.
• The mortality rate of MSBP is 9%.
• 25% or more of MSBP cases involve two or more siblings.
• Most cases start in infancy, or before 2 years of age.
• Most victims are under the age of 6. Children who are school-aged are out in the public and are more likely to be identified.
• 8% of victims suffer long-lasting medical conditions.
• Psychological effects on child victims can range from hyperactivity to fear, temper tantrums to withdrawal, aggression to developmental delays.
Some of the gruesome methods of injury include:
• Laxatives that will induce diarrhea.
• Blocking airways with objects or food.
• Smothering with pillows, blankets, clothes, or hands.
• Causing the child to ingest nail polish remover.
• Poisoning with salt or sugar.
• Causing rashes with abrasives or oven cleaners.
Identifying the Syndrome
There are several reasons MSBP is difficult to identify. The perpetrator, normally the mother, appears to be the perfect, loving, committed parent. What mother doesn’t rush her child to the hospital if he or she is ill, whenever necessary? What mother doesn’t want to be deeply involved with her child’s medical care and treatment, to the point of sacrificing her own health and well-being?
The symptoms of the young MSBP victims are those common to childhood ailments everywhere: Fevers, diarrhea, headaches, vomiting, allergies, infections, etc. Why would any nurse or doctor attribute these symptoms to anything but normal childhood sicknesses? Even the more serious of symptoms such as seizures, malnutrition, and failure to thrive don’t raise the Munchausen’s flag immediately. What choice does a doctor have but accept the patient history provided by the mother and father?
Even though identifying MSBP has its challenges, and one or two of the following symptoms alone don’t conclusively diagnose the syndrome, here are the classic red flags to watch for:
• The child shows signs of starvation or poison with no identifiable origin.
• Laboratory tests reveal unusual, unexplained, or unexpected results.
• A child has multiple medical difficulties that show again and again, and do not respond to treatment and have no logical explanation or cause.
• A mother who seems infatuated with the hospital scene, who relates exceptionally well to staff, who seems to thrive on interacting with nurses and discussing medical topics. She may even work as a healthcare professional herself.
• A mother who appears to be as clingy and needy as her child, who gives little comfort and support to the child when outside the presence of nurses and doctors.
• A hostile parent who complains about the medical care her child is getting, who insists on more or different tests, and who wants to take her child to a different hospital or clinic if things aren‘t carried out to her specifications.
• A mother whose partner seems distant, absent, or unsupportive during the child‘s hospital stay.
• The child’s physical symptoms lessen or disappear when not in the care of his or her parent.
• A mother who complains that she has the same unusual or unexplained symptoms as her child.
• A parent who enjoys relating tragedies (fires, accidents, suicides, etc.) during her child’s hospitalization.
• Deaths or unexplained illnesses of the child‘s siblings.
• Multiple cases of SIDS in the same family.
Why Do They Do it?
An intelligent, concerned mother creates her child’s illness, or lies about it. These mothers want attention and love for themselves via their child. They appear selfless and devoted, but crave recognition and sympathy. They want to be hailed as a martyr caregiver, and will sacrifice their own child for it. In many cases they have an impressive knowledge of medicine, including symptoms, diseases, diagnoses, medications, and treatment. Doctors and nurses are often taken aback by the parent’s level of medical knowledge, concern, and competency relating to the child’s medical condition. Unfortunately, this only fuels the mother to perpetuate her cycle of abuse. She has sad, deep, unmet emotional needs that can only be met by her poisonous relationship with the medical staff and her ill child. The attention lifts her perverse sense of self-esteem, and her willingness to continue this is intoxicating, irresistible, and insatiable. We should note that MSBP has more to do with the mother’s emotional bond to the hospital, nurses, and doctors than to her child. Her offspring is just a tool to have her own childlike needs met by the parental figures of the hospital staff.
If You Suspect
If you suspect that a child patient in your care is the victim of MSBP, report your concerns to your nurse supervisor, the physician, the police, or child protection agency. This disorder usually comes to light after the fact. Always make sure the child (patient) is not left alone and, is indeed watched by a healthcare person who understands just how serious Munchausen by Proxy can be. Don’t be fooled by the “nice” parent.
It is imperative to thoroughly document your observations of the parent/child interactions and not jump to premature conclusions. It would not be advised to confront the parent directly, as this could impede an investigation. Reporting it immediately is the first step, and let the authorities tell you what your level of involvement could be.
You may be asked to monitor the child, parent, or both. You may be asked to act as if nothing is wrong, to prevent a parent fleeing with the child. In many cases, a court order is required to videotape a suspected perpetrator without their knowledge or consent. Sadly, only a small portion of these MSBP cases will ever be recorded on video. But if and when this type of evidence is collected, the child will be placed in protective custody, possibly with no offending relatives, given correct medical care, and the parent can receive psychiatric attention. In all cases, information and awareness are the nurse’s two of best methods of identification and intervention.
If any specimens are collected, consult with the laboratory and most probably, the police department for advice on maintaining the integrity of the evidence. A wily attorney can have a court case dismissed by creating doubt regarding how evidence was collected, transported, and tested.
PJ Bodin, RN works as a Navy medical photographer, where she documents cases of child abuse, including Munchasen. She advises: “If you think a mother is intentionally making her child sick, don’t confront the parent, simply notify someone in authority. Be prepared to provide documentation or justification for your suspicions if you have it, and don’t worry if you can’t prove or provide everything. Proving it is the job of the authorities. Once you’ve voiced your concerns, you’ve done your part. The authorities may ask you to monitor the situation. If that happens, follow their instructions, and be aware that you may need to give court testimony at a later date if the case goes to court.”
Munchausen’s by Proxy can be difficult for a healthcare team to prove, yet if intervention is effective, significant recovery can be made for the abused child.
Tammy Ruggles, BSW, MA, has over 10 years experience as a social worker in the fields of mental health, hospice care, and child/adult protection. www.geocities.com/teeruggles/tammyruggles.htm.
This article is from workingnurse.com.