Munchausen syndrome by proxy: the importance of behavioral artifacts

FBI Law Enforcement Bulletin,The, August, 2003 by Deborah Chiczewski, Michael Kelly

In the 1990s, two unrelated mothers living in different parts of the United States had a lot in common. Both cared for children with significantly complex medical problems. One woman's daughter suffered from constant intestinal problems, and the other woman's two foster daughters experienced a multitude of ailments that left them weak and emaciated. In addition, both women spent most of their time escorting their sickly girls from doctor to doctor. The daughter of the first mother was eventually hospitalized 200 times, and all three children had to undergo surgery to place feeding tubes into their stomachs. Furthermore, both parents received national praise for their motherly care and devotion to their young girls. Prosecutors maintain that both women shared one more feature, a dark secret eventually exposed to television and newspapers around the world. They were accused of exhibiting symptoms of a bizarre psychiatric ailment called Munchausen syndrome by proxy (MSBP) that led them to fabricate the girls' illnesses to fulfill their own needs for attention and sympathy. (1)

Doctors, emergency medical services (EMS) personnel, members of protective service agencies, and law enforcement officers may unwittingly participate in MSBP when they fail to recognize MSBP behavior, treat the offender, and create a favorable outcome for the child. Protecting America's children is immeasurably important; therefore, law enforcement personnel and EMS providers need to know the significance of behavioral artifacts in the recognition, investigation, and prosecution of MSBP offenders.

HISTORY

Munchausen syndrome was named after an 18th century dignitary named Baron von Munchausen who was known for telling exaggerated stories. Individuals who exhibit the characteristics of Munchausen syndrome fabricate or exaggerate illness or sickness, usually for the purpose of attracting attention to themselves. Munchausen syndrome by proxy is the practice of fabricating or exaggerating illness or sickness onto another person, usually a child. MSBP is a form of child abuse and can prove fatal. Children subjected to this form of abuse may be hospitalized repeatedly and undergo numerous surgeries.

Researchers first began to recognize this pattern of abuse in the 1970s. Sudden infant death syndrome (SIDS) became the default judgement when no cause of death could be identified. Further, several cases where multiple children from the same family perished were attributed to SIDS because of no apparent causes of death. As research on SIDS progressed, the likelihood of a family experiencing multiple infant deaths due to SIDS became unlikely. On the eve of this realization in the 1970s, MSBP became a routinely published topic highlighting its terrible effects on children. Law enforcement personnel have become important players in the fight against MSBP because their position enables them to recognize the affliction in its earliest stages.

RECOGNITION

Law enforcement personnel should remember that MSBP is not a diagnosis.(2) Instead, investigators should recognize it as a form of abuse. In short, MSBP is not what someone has, but what someone does. The majority of people associated with MSBP are women. Often, investigators, along with friends, family, and neighbors, view these women as very caring and loving parents who try to do everything they can for children afflicted with devastating illnesses. Offenders usually exhibit knowledge of diseases and medical procedures beyond what most parents may know. They typically have a medical background or have been around the medical profession in some capacity. A family history of frequent moves and lengthy visits to multiple health care professionals also may exist. MSBP offenders are not associated with any specific ethnic group or level of economic status. Some researchers believe that the behavior of MSBP perpetrators is a character disorder; it does not follow social norms. The satisfaction sought from misleading caregivers at the expense of their children is thought to be the sole reason for committing the abuse.

The methods that offenders use to exaggerate or fabricate illness are quite extensive and designed to deceive health care professionals. MSBP perpetrators convincingly fabricate and lie even when confronted with contrary information. Offenders need attention, and they often seek it through their actions with health care professionals. To feign illness, perpetrators go to great lengths, such as suffocating to mimic apnea, tainting urine with blood, poisoning to resemble gastric complications, inducing vomiting with ipecac to look like reflux problems, and producing unexplainable rashes with chemical irritants.

INVESTIGATION

Often, the first contact with a patient/victim of MSBP occurs in the prehospital arena. Law enforcement and EMS personnel need to not only understand the characteristics of MSBP perpetrators and victims but also realize that this determination is made over time, not just a single occurrence. In the event of an infant or child illness, police and EMS personnel should request information about the history of the illnesses from the parents. Generally, they view parents as individuals who want the best for their children, an assumption that perfectly suits MSBP offenders. Further, police and EMS personnel see parents as knowledgeable, caring individuals extremely attentive to their children's needs and illnesses, which stands in direct opposition to what law enforcement personnel learn as the characteristics of child abusers. As mandated reporters of child abuse, however, police and EMS personnel must understand the differences in behaviors and characteristics found in MSBP as opposed to other forms of abuse.