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Editorial: The syndrome of munchausen by proxy
Child Abuse & Neglect, Vol. 18. No. 9. pp. 769-771, 1994 Copyright 0 1994 Elsevier Science Ltd Printed in the USA. All rights reserved 0145~2134/94 $6.00 + .OO
Pergamon
01452134(94)00043-3
SPOTLIGHT
EDITORIAL:
ON PRACTICE
THE SYNDROME OF MUNCHAUSEN BY PROXY DAVID P. H. JONES
University
of Oxford,
Park Hospital
for Children,
Oxford,
UK
THIS ISSUE’S
SPOTLIGHT contains two articles on Munchausen Syndrome by Proxy. The first is a systematic study of the psychopathology of a group of mothers who had maltreated their children in this way. It comes from the Leeds group and Professor Roy Meadow, who have been so instrumental in advancing our understanding of this phenomenon over the years. The second is a case report featuring an extremely severe example of the syndrome, and also illustrates some of the difficulties for those who seek to intervene and change this pattern of parental behavior and to provide treatment for the children who are affected. Munchausen Syndrome by Proxy consists of the induction of an appearance, or a state of physical ill health in a child, by a parent, where the child is subsequently presented to health professionals for diagnosis and/or treatment. The mechanism of the harm to the child is through three principal routes: (a) parental fabrication of symptoms and/or signs; (b) alteration of laboratory specimens, such as urine or blood; or (c) through the direct production by the perpetrator of physical signs, or disease itself in the child. In the first two situations the harm to the child is indirect and occurs through the medical profession’s investigation and/or treatment of what they take to be illness in the child. In the last of the three mechanisms the harm is direct, yet may be followed up by further harm through medical and surgical responses to the induced “illness.” Mixed forms and mechanisms of the phenomena are quite common. It is not surprising therefore that the phenomenon of Munchausen Syndrome by Proxy involves considerable deceit and careful planning by the parent in order to cause harm to the child and evoke the desired responses from medical and other health professionals. It is extremely hard to comprehend why parents would resort to such extremes to have their own personal needs met, and not surprisingly friends and relatives of the parents who do this find such bizarre behavior hard to believe, and certainly more so than injuries of a physical or even sexual kind to a child. Indeed some courts have had great difficulty believing evidence about such phenomena when faced with parents who might not be otherwise overtly deviant. The study by Bools and colleagues, published here, underlines the extent to which the personalRequests for reprints should be addressed to David Psychiatrist, and Honorary Senior Lecturer, University Oxford OX3 7LQ, UK.
P. H. Jones, MBChB, FRCPsych, DCH, Child and Family of Oxford, Park Hospital for Children, Old Road, Headington,
769
770
D. P. H. Jones
ity disturbance and even psychiatric history might be skillfully shielded from the cursory examiner. Bools and colleagues provide what we think is the first systematic study of personality and psychiatric disorders in mothers (who most commonly perpetrate this phenomenon). The broad range of nature and types of personality disorder are described and the need for collateral information is amply illustrated through their study. Unless there is a careful analysis of previous health records, as well as some form of collateral interview from an informant, a mental health professional assessing such a parent is liable to miss a great deal of relevance to the personality difficulties lying behind this disorder. Such personality difficulties were found in the majority of those whom the team interviewed. They also point to the common finding of prior somatising behavior in the mothers and discuss the link between this and adult Munchausen Syndrome. The cases contained within the umbrella term, Munchausen Syndrome by Proxy, ranged from situations of simple fabrication where it appeared that the parent was almost asking to be discovered, through complex deceptions that were extremely hard for the professionals to unravel. Denial of the true cause of the problem is evident both from the study by Bools and colleagues as well as the case report of Porter and colleagues (this issue). A small minority of the mothers described by Bools and colleagues take responsibility and acknowledge their deeds, with a subgroup describing their actions in detail to the researchers. This is one of the few studies where, some years after the event, accounts are available of the mechanism of production of the appearance of illness in their child. Nevertheless, it is the denial of the majority which is striking from the two studies. It appears that as each variety of child abuse is explored the density of denial becomes described by successive groups of clinicians. Yet denial was clearly described in the earliest accounts of physical abuse and has constituted a central part of many of the cases (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962; Steele, 1987). For mental health clinicians, working with denial is one of the biggest challenges in child abuse therapy. Nonattendance or nonengagement is the other major challenge for treatment providers. Together, nonattendance and denial constitute the main reasons for lack of success when intervening in child abuse and neglect. Porter and colleagues’ case report is horrific in terms of its manifestations and eventual outcome. Yet the precise mechanism through which the mother created ill health in her child remained unclear at the end of the involvement of the physicians, as her denial was so complete. However, after separation of mother and child, the child recovered, physically. However, psychologically, recovery was much less complete. Abuse occurred up to the age of approximately 2 l/2 years. Nevertheless by the age of 5 or so, he was still evidencing symptoms in keeping with the diagnosis of post traumatic stress disorder, seemingly specifically linked to the abuse he had suffered. He also showed evidence of repeating elements of the abuse to which he had been subjected, to another child and to his pets. In one of my own cases, the child. 6 years after removal from the parental home, repeated the injury, this time to herself. These two reports help clinicians to recognize the severity of the psychological disturbance lying behind the phenomenon of Munchausen Syndrome by Proxy, as well as the potential seriousness of the effects upon the child. We should not be misled into thinking that children’s memory for traumatic events is nonexistent during the first few years of life. All the evidence, both from clinical accounts, such as these, as well as the experimental literature, is that some form of memory of severe maltreatment in early years often persists, even though recalled in a rudimentary form and expressed perhaps through the mechanism of repetition by the child to self and others, or evidenced through posttraumatic states. Given the contemporary concern with false memories of childhood maltreatment by older children and adults, this raises extreme difficulties for therapists now. Just as those who investigate cases of child abuse have come
Spotlight
on Practice:
Editorial
771
to feel they are “damned if they do and damned if they do not discover maltreatment,” the same can now be said for those providing treatment. Long-term follow-up studies of those children who have been known to have suffered severe forms of maltreatment can be extremely illuminating in this respect (e.g., Bools, Neale, & Meadow, 1993). However, there is a need now for very detailed long-term case follow-up of children known to be abused during different developmental stages (i.e., infants, preschoolers, school-aged children, and adolescents) to examine in detail the nature of their recall of events during later childhood and young adult years, and relating these memories to intervening rehearsal, in order to inform the debate on so-called false memory. It is unfortunate that rhetoric and entrenched professional positions, often asserted with confidence in courts and in public, has preceded genuine research-based knowledge and careful study of clinical cases in this field. These two articles will be of great help to clinicians, we hope, and additionally, will raise some interesting issues to stimulate further research into both MSBP and children’s recall and processing of trauma.
REFERENCES Bools, C. N., Neale, B. A., & Meadow, S. R. (1993). Follow up of victims of fabricated illness (Munchausen Syndrome by Proxy). Archives of Disease in Childhood, 69, 625-630. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., & Silver, H. K. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. Steele, B. (1987). Psychodynamic factors in child abuse. In R. E. Helfer and R. S. Kempe (Eds.), The battered child (4th ed., pp. 81- 114). London: University of Chicago Press.
Pergamon
01452134(94)00043-3
SPOTLIGHT
EDITORIAL:
ON PRACTICE
THE SYNDROME OF MUNCHAUSEN BY PROXY DAVID P. H. JONES
University
of Oxford,
Park Hospital
for Children,
Oxford,
UK
THIS ISSUE’S
SPOTLIGHT contains two articles on Munchausen Syndrome by Proxy. The first is a systematic study of the psychopathology of a group of mothers who had maltreated their children in this way. It comes from the Leeds group and Professor Roy Meadow, who have been so instrumental in advancing our understanding of this phenomenon over the years. The second is a case report featuring an extremely severe example of the syndrome, and also illustrates some of the difficulties for those who seek to intervene and change this pattern of parental behavior and to provide treatment for the children who are affected. Munchausen Syndrome by Proxy consists of the induction of an appearance, or a state of physical ill health in a child, by a parent, where the child is subsequently presented to health professionals for diagnosis and/or treatment. The mechanism of the harm to the child is through three principal routes: (a) parental fabrication of symptoms and/or signs; (b) alteration of laboratory specimens, such as urine or blood; or (c) through the direct production by the perpetrator of physical signs, or disease itself in the child. In the first two situations the harm to the child is indirect and occurs through the medical profession’s investigation and/or treatment of what they take to be illness in the child. In the last of the three mechanisms the harm is direct, yet may be followed up by further harm through medical and surgical responses to the induced “illness.” Mixed forms and mechanisms of the phenomena are quite common. It is not surprising therefore that the phenomenon of Munchausen Syndrome by Proxy involves considerable deceit and careful planning by the parent in order to cause harm to the child and evoke the desired responses from medical and other health professionals. It is extremely hard to comprehend why parents would resort to such extremes to have their own personal needs met, and not surprisingly friends and relatives of the parents who do this find such bizarre behavior hard to believe, and certainly more so than injuries of a physical or even sexual kind to a child. Indeed some courts have had great difficulty believing evidence about such phenomena when faced with parents who might not be otherwise overtly deviant. The study by Bools and colleagues, published here, underlines the extent to which the personalRequests for reprints should be addressed to David Psychiatrist, and Honorary Senior Lecturer, University Oxford OX3 7LQ, UK.
P. H. Jones, MBChB, FRCPsych, DCH, Child and Family of Oxford, Park Hospital for Children, Old Road, Headington,
769
770
D. P. H. Jones
ity disturbance and even psychiatric history might be skillfully shielded from the cursory examiner. Bools and colleagues provide what we think is the first systematic study of personality and psychiatric disorders in mothers (who most commonly perpetrate this phenomenon). The broad range of nature and types of personality disorder are described and the need for collateral information is amply illustrated through their study. Unless there is a careful analysis of previous health records, as well as some form of collateral interview from an informant, a mental health professional assessing such a parent is liable to miss a great deal of relevance to the personality difficulties lying behind this disorder. Such personality difficulties were found in the majority of those whom the team interviewed. They also point to the common finding of prior somatising behavior in the mothers and discuss the link between this and adult Munchausen Syndrome. The cases contained within the umbrella term, Munchausen Syndrome by Proxy, ranged from situations of simple fabrication where it appeared that the parent was almost asking to be discovered, through complex deceptions that were extremely hard for the professionals to unravel. Denial of the true cause of the problem is evident both from the study by Bools and colleagues as well as the case report of Porter and colleagues (this issue). A small minority of the mothers described by Bools and colleagues take responsibility and acknowledge their deeds, with a subgroup describing their actions in detail to the researchers. This is one of the few studies where, some years after the event, accounts are available of the mechanism of production of the appearance of illness in their child. Nevertheless, it is the denial of the majority which is striking from the two studies. It appears that as each variety of child abuse is explored the density of denial becomes described by successive groups of clinicians. Yet denial was clearly described in the earliest accounts of physical abuse and has constituted a central part of many of the cases (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962; Steele, 1987). For mental health clinicians, working with denial is one of the biggest challenges in child abuse therapy. Nonattendance or nonengagement is the other major challenge for treatment providers. Together, nonattendance and denial constitute the main reasons for lack of success when intervening in child abuse and neglect. Porter and colleagues’ case report is horrific in terms of its manifestations and eventual outcome. Yet the precise mechanism through which the mother created ill health in her child remained unclear at the end of the involvement of the physicians, as her denial was so complete. However, after separation of mother and child, the child recovered, physically. However, psychologically, recovery was much less complete. Abuse occurred up to the age of approximately 2 l/2 years. Nevertheless by the age of 5 or so, he was still evidencing symptoms in keeping with the diagnosis of post traumatic stress disorder, seemingly specifically linked to the abuse he had suffered. He also showed evidence of repeating elements of the abuse to which he had been subjected, to another child and to his pets. In one of my own cases, the child. 6 years after removal from the parental home, repeated the injury, this time to herself. These two reports help clinicians to recognize the severity of the psychological disturbance lying behind the phenomenon of Munchausen Syndrome by Proxy, as well as the potential seriousness of the effects upon the child. We should not be misled into thinking that children’s memory for traumatic events is nonexistent during the first few years of life. All the evidence, both from clinical accounts, such as these, as well as the experimental literature, is that some form of memory of severe maltreatment in early years often persists, even though recalled in a rudimentary form and expressed perhaps through the mechanism of repetition by the child to self and others, or evidenced through posttraumatic states. Given the contemporary concern with false memories of childhood maltreatment by older children and adults, this raises extreme difficulties for therapists now. Just as those who investigate cases of child abuse have come
Spotlight
on Practice:
Editorial
771
to feel they are “damned if they do and damned if they do not discover maltreatment,” the same can now be said for those providing treatment. Long-term follow-up studies of those children who have been known to have suffered severe forms of maltreatment can be extremely illuminating in this respect (e.g., Bools, Neale, & Meadow, 1993). However, there is a need now for very detailed long-term case follow-up of children known to be abused during different developmental stages (i.e., infants, preschoolers, school-aged children, and adolescents) to examine in detail the nature of their recall of events during later childhood and young adult years, and relating these memories to intervening rehearsal, in order to inform the debate on so-called false memory. It is unfortunate that rhetoric and entrenched professional positions, often asserted with confidence in courts and in public, has preceded genuine research-based knowledge and careful study of clinical cases in this field. These two articles will be of great help to clinicians, we hope, and additionally, will raise some interesting issues to stimulate further research into both MSBP and children’s recall and processing of trauma.
REFERENCES Bools, C. N., Neale, B. A., & Meadow, S. R. (1993). Follow up of victims of fabricated illness (Munchausen Syndrome by Proxy). Archives of Disease in Childhood, 69, 625-630. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., & Silver, H. K. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. Steele, B. (1987). Psychodynamic factors in child abuse. In R. E. Helfer and R. S. Kempe (Eds.), The battered child (4th ed., pp. 81- 114). London: University of Chicago Press.