Munchausen by proxy

Munchausen by proxy

Munchausen by Proxy Herbert Schreier, MD unchausen by proxy (MBP) is a baffling condition that can wreak havoc not only on the body and mind of a chi...

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Munchausen by Proxy Herbert Schreier, MD

unchausen by proxy (MBP) is a baffling condition that can wreak havoc not only on the body and mind of a child but also on the professionals who encounter it. The abuse in MBP by definition consists of interpersonal dynamics that frequently involve the physician as a necessary agent in the harm that befalls a child. This can occur through needless surgeries, procedures, and medications, but not infrequently by the pediatricians being so taken in by the mother that they defend her against suspicions, thus prolonging the “illnesses” the child suffers. Two of the most common findings are that despite their very convincing presentation of caring deeply for their children, these mothers, when observed for many hours (even days), on surreptitious videotaped surveillance, do not relate or are directly cruel to their children1 and that even when they leave glaring clues of their harming behavior, it often takes physicians a long time to suspect the mother and act to separate and protect the child. Dr David Southall and his colleagues in London evaluated 39 families in which a parent was suspected of suffocating a child.1 In 33 of the 39 cases, the parent (38 were women, 1 was a man) was seen on camera trying to suffocate or do grave bodily harm to the child, and 3 of the other 6 cases were later shown to be correctly diagnosed as abuse. In some instances, 3 days of videotaping passed before the parent engaged in the abusive behavior. Of the 42 siblings of these children, 12 had died previously of suspicious causes; 11 of these were classified as sudden infant death syndrome (SIDS). Two mothers, one grandmother, and the lone father admitted to killing 8 siblings of the index child in the hospital. An additional 15 siblings

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From the Department of Psychiatry, Children’s Hospital and Research Center at Oakland, Oakland, CA. Curr Probl Pediatr Adolesc Health Care 2004;34:126-143. 1538-5442/$ - see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cppeds.2003.09.003

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were abused. In the 46 control children with true apnea there were two deaths; one child had an aplastic ventricle. On more than one occasion, the family doctor had warned the parents about the surreptitious video recording. The three women convicted of murder received suspended sentences, but the man is in an institution for the criminally insane. Southall’s study succinctly captures other of the characteristics of MBP: the potential severity of the abuse, the difficulty of diagnosis, the trouble people have believing the condition exists even in the face of powerful evidence, the gender breakdown of the perpetrators, and at least in some cases, a compulsive need to repeat the process of abuse involving doctors as active participants. The abuse as witnessed on camera invariably involved a peaceably sleeping infant and was inflicted without provocation.

Definition It is essential to distinguish MBP from other forms of child abuse that may involve illness falsification. In the last 5 years, a multidisciplinary group convened by the American Professional Society on the Abuse of Children (APSAC) has developed specific diagnostic criteria with review and input from by several professional societies.2,3 The APSAC definitions created the specific term “pediatric condition falsification” (PCF) to be used for the diagnosis of the abuse in the child. Another term, “factitious disorder by proxy” (FDP) is used to describe the diagnosis in the caretaker who harms her child through PCF with the motivation of “self-serving psychological needs” (see below). MBP is retained in the APSAC guidelines as a descriptor for the disorder that contains both these elements “because of its acceptance and familiarity in the medical community.” This approach to defining the condition recognizes that there are serious forms of illness exaggeration or fabrication (PCF) that pediatricians and other professionals encounter that involve moti-

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vations other than those found in FDP. This report will use the common term, MBP, to refer to cases of PCF by FDP. The importance of separating caretakers who meet the definition of MBP from others who also abuse children through illness fabrication is based on data that demonstrate a very high recidivism rate, so that the prognosis for the child is much worse when the dynamics described for MBP exist in a case. Pediatricians and other professionals form an intrinsic part of the process created by these mothers. Because they often contribute to the harm done to the child through unneeded treatment and chasing down false clues, recognizing their involvement is crucial to bringing timely relief to the child. In addition, interventions and treatment approaches for the child and the mother involved in an MBP dynamic differ significantly from approaches designed for children and parents involved in other types of child abuse. It is intuitively apparent that the mother who falsifies symptoms in her child to get help either for herself (because she might be overwhelmed) or for the child (because she believes that the child is not being treated adequately) or the mother who does so because she has a delusional belief that the child is ill, creates a much different—and likely lesser—risk for the child than the mother whose motivation might be a compulsive-like need to repeatedly fool doctors and/or gain attention for herself as an ideal parent of a “seriously ill” child. Reported recidivism rates and studies of the modus operandi of these parents support this contention.4,5 Some authors object to the separation of MBP from other forms of abuse through illness falsification [PCF] and suggest that knowing another’s motivation is difficult if not impossible. Rosenberg6 proffers a simple definition: “persistent fabrication of illness in one person by another” and further argues that “if intent could not be reliably inferred (and this is often the case) a diagnosis of [MBP] would automatically be excluded. For example, even when we finally videotaped a mother suffocating her ‘chronically apneic’ child, we would be constrained from making the diagnosis if we could not establish or agree upon intent.”6 Though the APSAC group recognized the difficulties inherent in a definition that involves an understanding of motivation, their collective experience strongly pointed to characteristics repeatedly found in MBP cases that distinguish it from other forms of illness fabrication in a child. Clearly, a mother observed suffocating her child in the hospital

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or harming her in another way, no matter what the intent, needs to be stopped immediately. However, the distinctions between MBP and other forms of PCF are essential in the area of suspecting the disorder, the process leading to discovery, and, in particular, in the management following discovery, particularly when lesser degrees of harmful behavior are involved than the most obvious ones of suffocation or poisoning. In the criminal justice system and in fields of psychology, it is not uncommon to base an understanding of motivation on circumstantial or presumptive evidence. The commonalities found in the literature suggest strongly that the motivational needs that drive MBP can be seen as quite distinct from those found in other forms of PCF and certainly from the more common forms of physical and sexual child abuse. The APSAC definitions argue that the diagnosis of FDP is a psychiatric one and appropriately belongs to the caretaker. In a later section, I describe conditions in which a caretaker creates a false condition in a child with motivation other than that found in MBP. The primary motivation in MBP appears to be an intense need for attention from—and manipulation of—powerful professionals.7 The MBP phenomenon almost always involves the participation of this important “other” and perceived-as-powerful figure. The child’s physician is most often the target of the mother’s actions and, unfortunately, the source of most of the physical harm done to her child. In a meta-analysis of early published cases, 75% of the morbidity occurred in hospitals and at the hands of the physician.8 Children have undergone as many as 100 operations for nonexistent conditions. Other “audiences” such as social workers, lawyers, or therapists may become important to the mother after she has been suspected and the child has been removed from her care. At times, the primary (or first) target may be a school psychologist (see below) or professionals charged with evaluating children for sexual abuse.9,10 Bona fide illness may be found in victims of MBP; in one study, 30% had underlying medical illness,8 making suspecting the mother’s hand in the abuse even more difficult. My colleague Judith Libow and I described the dynamics of MBP, based on a review of 25 cases.4 The child’s role in this “drama” is to be an object to be kept close at hand, and provide the mother an entre´ e to the “exciting” ambiance of the hospital and directly to the pediatrician. Despite their very convincing presentation of caring deeply for their children, these mothers,

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when observed for many hours on surreptitious videotaped surveillance, do not relate or are directly cruel to their children.1 Even when they leave glaring clues of their harming behavior, it often takes physicians a long time to suspect the mother and act to separate and protect the child. For example, one mother filled her child’s drainage bag with 10 times the amount of intravenous fluid than the child had received; the inconsistency went unnoticed (or at the least unrecorded) for over a week.4 Delay in recognition and diagnosis can be (and, for many kids, has been) fatal. It is also noteworthy that the simple act of asking for advice from a colleague not involved in the case leads much more quickly to suspecting what is actually going on. Once the physician recognizes warning signs that this type of abuse may be taking place, it is essential that it be investigated thoroughly, even to the point of advocating for separation of the patient from the mother. In cases of MBP, separation often provides the answer to a complex “medical” problem that did not make clinical sense. It is crucial (and may be life-saving) that the child be protected first; the data for understanding the caretaker’s motivation can follow. Occasionally, understanding the motivation may rule out MBP.

Epidemiology First described by Meadow in 1977,11 this syndrome is relatively new and continues to be described as a rare condition. If we apply the results of a total population study done in Britain, which found 98 cases of the more serious types of MBP in children under 16, and extrapolate that to the US it comes to about 136 new cases per year. This is considerably less than the 1200 cases I had previously extrapolated from this research, but is likely to represent a considerable underestimation. Firstly, incidence varied 7-fold across the country, suggesting that it was underrecognized in some areas. Also as the group surveyed were hospital-based consultants, cases that were seen in such places as asthma clinics and allergy clinics were likely not included (see below). In another British study, one tenth of the children who had “cot death” (the British term for SIDS) were siblings of children on child abuse lists. A sibling of a child on the abuse list had a one in 26 chance of dying of a cot death. The authors conclude that these cot death figures probably conceal a high rate of abuse by suffocation and that some percentage of these were MBP.13

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Younger children, particularly infants, are the most common victims. However, when undiscovered, the problem can go on for years. Cases clearly representing MBP, though in somewhat older children, appeared in 197214 involving fever falsification by teens to satisfy the needs of a parent. In one case reported by Sneed and Bell,15 in 1976 involving renal stones, they used the term “the dauphin of Munchausen” and compared the dynamics to Munchausen syndrome, though the suspicion was mainly of the child’s self-harming behavior. A meta-analysis of the literature found the length of time from onset of symptoms to diagnosis averaging 21.8 months.16 In another study, Rosenberg8 found a lag of 14.9 months. Sheridan’s16 review of studies in the literature included 451 cases of victims of this form of abuse who had 210 known siblings. Fifty-three of the siblings (25%) were known to be dead. One hundred thirty of these siblings (61%) had symptoms that were similar to those of the victims or symptoms that were suspicious in origin. These numbers may represent the more severe end of the spectrum because they refer to cases reported by doctors working in hospitals. Using the word “mother” for MBP perpetrators is a choice supported by the statistics. At least 93% of MBP cases involve women, mostly mothers, but also female guardians or nurses, a rare finding in any known psychological disturbance. Women involved in MBP are often married, albeit to distant and uninvolved fathers who play a passive role in the process. They are rarely seen in the hospital, and at times it is quite profound to witness the great lengths they would have had to go to miss what is going on with their children. One father paid enormous doctor bills for years for a completely healthy son without questioning what was going on. There are cases in which both parents are involved in active collusion around their children’s illnesses. We have seen a case involving two parents who were both nurses. There are cases involving only men. Meadow,17 who had a very busy consulting practice in England, saw no father perpetrators for 10 years, but in the subsequent decade did see 15 such cases, 13 of them classic MBP. In the Southall1 report, there was 1 father in 39 cases. Unlike the women perpetrators, the fathers did not form close relationships with staff, nor were they seen as wonderful fathers; rather, they appeared overly demanding, overbearing, and antagonistic, at times threatening lawsuits over “poor care.” This can occur

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but is not common in women abusers (see the response of the mother in “Billy’s” case). Grandiose stories of personal achievement were the rule (writing a movie with Steven Spielberg, being a war hero who fought with the British royalty in the Falklands, sports champions). The outcomes for the child in this series were horrific. Ten children in 11 families died, and 8 more suffered severe abuse through FDP. Unlike the children who die at the mother’s hand, who die when sent home within hours, with the male perpetrator, the length of time is weeks. Rather than suggest a different dynamic need in the male perpetrator (as exhibited by his behavior with staff), I suggest it reflects a need to cover their neediness and dependency, which protects them from the profound abandonment the mothers feel when their children are sent home. The recidivism rate in MBP is very high,5 and the lives of the abused child or other children in the family are at grave risk. The study by McClure et al12 reaffirmed the 6% to 10% death rate associated with MBP that was found in an earlier meta-analysis of the extant literature to 1987.8

Pediatric Condition Falsification Not Involving Munchausen by Proxy There are several situations in which illness fabrication can take place and not be a part of MBP. The most common ones are listed below. Masquerade. The so called “masquerade syndrome”18 describes a situation in which a caretaker amplifies or falsifies an illness (or goes along with a child’s doing so) to keep a child with her and, for example, have him stay home instead of going to school. Delusion. When a mother has a delusional belief that her child is ill, she may frequently bring the child to the doctor and insist that tests or procedures be performed. As soon as the cause of the mother’s delusion (eg, psychotic depression) is addressed, unnecessary pediatrician visits cease. One mother had the unshakable belief that her daughter was infested with lice and brought “samples” to the dermatologist in a jar. She suffered from the condition of a monosymptomatic delusion of parasitosis, and we can now add the “proxy” label to that condition. When her delusion was treated with pimozide, the child’s “lice” disappeared. The “Help Seeker.” A teenage mother poured cranberry juice into her baby’s diaper to fabricate a

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symptom in order to get help for herself. She stopped this behavior when she was given the assistance she needed in caring for the child.19 “Doctor-Shopping” and the Overly Anxious Parent. Overly anxious parents “doctor-shop” because they believe that their child is not being diagnosed or treated correctly. These parents may agree to tests but usually will be anxious about them, want to know what they are for, and ask if there are risks. “Doctor shopping” per se is not MBP.19 Only when the motivation for such repeated visits relates to the purposeful deceiving of the professionals involved should this behavior be seen as MBP. This distinction is not always easy to make. Hypochondria. The hypochondriac mother may overreact to the normal conditions of childhood and exaggerate symptoms. If this concern leads to the child being harmed by unnecessary procedures performed by others, then this would be labeled as PCF but would not be MBP.20 Obsessive Compulsive Disorder. Sanders and Bursch20 described mothers with obsessive compulsive disorders who focused on their children being sick and overmedicated them. They did not intentionally falsify information, though they did abuse their children. Perceived Vulnerability Because of Early Traumatic Event. A mother may see her child as very vulnerable because of a traumatic event occurring early in the child’s life. Such mothers will be overly concerned about the health needs of their children and could be mistaken for MBP mothers. Malingering for Secondary Gain. Feigning illness in a child for secondary gain is PCF but not MBP. A mother who instructed her son not to speak and presented him in our clinic as autistic was attempting to gain social security insurance payments. Another mother sought stimulant drugs for her child by describing him as having ADHD in order to sell the drugs on the street. Financial benefits or revenge against an abandoning spouse by convincing a child to accuse the spouse of abuse may occur in cases of MBP. However, if the primary motive is only that, the behavior qualifies as PCF but not as MBP.

Pediatric Conditions Falsified in Munchausen by Proxy MBP may present in a wide variety of symptoms and symptom complexes. One report on dermatology pre-

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sentations suggested that as many as 5% of attendees in an dermatological practice presented with factitious illness,21 and Godding and Kruth22 found that 1% of asthma outpatient clinic attendees were victims of condition falsification. In 1993, case reports involving 105 different symptom presentations were published (see appendix in Schreier and Libow, 1993,4 and Sheridan, 2003,16 for lists of references). The most common “disorders” on those lists are gastroenterological, neurological, infectious, dermatological, and cardiopulmonary. The conditions presented within these broader categories have changed: Although vomiting and diarrhea per se were common originally, we now see many cases diagnosed as pseudo bowel obstruction. Along with grand-mal seizures, we now have cases diagnosed as mitochondrial encephalopathy (MELAS). Many of these diagnoses are attributable to physicians grasping to explain symptoms that do not make sense. Reports suggesting a genetic component to SIDS have been confounded by cases of MBP involving multiple suffocations. One notorious case involved five SIDS deaths in one family. Data from this family were used to support a researcher’s hypothesis that there was a genetic component to SIDS. The mother was convicted 25 years later of the murder of all five of the children.23 Algorithms have been developed for the most common presentations, such as apnea or acute life-threatening event, to help distinguish them from cases of suffocation, and for pseudo bowel obstruction.24 I have suggested an algorithm culled from the literature for suspicion of suffocation that involves: ● multiple episodes of apnea or reported apnea ● a child older than 6 months ● a sibling with another major illness ● a sibling who has died ● the index child or a sibling on the abuse list ● blood in the nose and/or mouth of the child with an acute life-threatening event (ALTE)25 ● ALTEs that occurs only when the suspected parent/guardian is present In any family in which a second child dies of SIDS, there should a sensitive but careful investigation. Psychiatric illnesses and those involving psychological symptoms can also appear as part of MBP.26 Commonly falsified conditions include attention deficit hyperactivity disorder (ADHD) and learning disabilities, multiple chemical sensitivities, multiple personality disorder, and psychosis. Psychiatric presentations present the clinician with even greater

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difficulties in detection. Examples of psychiatric MBP will be discussed later in this report.

Case Study: Kathy Bush The case of J. Bush, the daughter of Kathy Bush, originally presented in Child Abuse and Neglect,27 illustrates many of the dynamics and interpersonal and legal issues found in many MBP cases. Because of a series of illnesses that appeared suspicious in number and form during repeated hospitalizations up to the age of 4 years, hospital workers asked the child protective service in Florida (HRS) to investigate the possibility that J. was being abused by her mother. When J.’s physician refused to heed their concerns, 21 nurses went to speak to the hospital administrator, who took the unusual step of ordering an analysis of samples of J.’s vomitus. In response, Mrs Bush sued the hospital, which then hired an expert in MBP to review the records. The expert was critical of the quality of care delivered by the attending physician who “. . .did not sufficiently establish an objective professional relationship with (J.’s) mother and did not pursue appropriately important leads. . .” He cited a hospitalization for sepsis (an unusual one because it involved more than one bacteria) and multiple admissions for suspicious gastrointestinal symptoms, seizures, immunodeficiency, fevers, and urinary tract infections. Lab results revealed carbamazapine in J.’s blood in toxic ranges over several days, at a time when she was not receiving the medication because she was hospitalized with the intent to wean her off the drug. There were also hints of the possibility of ipecac ingestion. Many of J.’s “illness” symptoms could be attributed to these high levels of carbamazapine and/or induced vomiting. After an 8-month investigation, HRS closed the case without taking action. J. then continued to present with various serious problems and was receiving parenteral feeding. When, as required by law, the state informed the parents that they were under investigation, J. improved dramatically. In the 18 months before this notification, she was hospitalized 18 times, and for the 18 months following it, only once. On the day

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of her mother’s arrest, J. was removed from the family’s home and within a couple of weeks was taken to a children’s hospital out of state, where she was immediately able to eat normally. All feeding lines were removed, and she has been essentially totally physically well since. By April 1996, when J. was removed from her parents’ care, she had some 200 hospitalizations, 40 surgical procedures, and a dozen serious infections, including two bouts of sepsis with multiple organisms and one with two loci. Her feeding pump “failed” on several occasions, causing J. to be dramatically overfed to the point of serious and painful bloating, nausea, vomiting, and diarrhea. More than 8 years passed from the time of initial suspicions of abuse (when J. was 3 years old) to bringing the case to trial. Despite overwhelming evidence that Kathy Bush had repeatedly caused her daughter grave harm through creating several life-threatening illnesses, all six members of the jury at her trial said that they believed that she loved her daughter. In his November 1999 summation at the trial, the defense attorney echoed the jury’s beliefs: “She loved her daughter. They (the prosecution) did not give one reason, one motivation to explain why (she) would ever want to make. . .her own daughter sick, override(ing) the presumption of motherly instinct and motherly love.” The defense was correct in asserting that there was no evidence presented concerning Mrs Bush’s motivation. In fact, the prosecution was precluded from raising the issue of motivation of Mrs Bush, partly because of the testimony of the only expert witness who testified in the Kelly Frye pretrial hearing that MBP is “a pediatric, not psychiatric diagnosis.”6 (The Kelly Frye pretrial hearing involves a presentation of the acceptability of a particular diagnosis or test or scientific approach.) The judge ruled that MBP was a valid diagnosis under Frye. However, based on the expert’s testimony “that the diagnosis belongs to the child,” he assiduously excluded mention of Mrs Bush’s motivation in front of the jury. Thus, the jury was left to decide, based on circumstantial evidence alone, that Mrs Bush, despite appearances that she deeply loved her daughter, over a period of most of her 8 years of life, repeatedly, directly, or through physicians attempting to diagnose and treat nonexistent conditions, caused J. grave bodily harm.

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Motivation in MBP: What the Case of Kathy Bush Teaches Us The diagnosis of MBP appropriately belongs to the caretaker. Once the child is protected, understanding the intent of the perpetrator is essential to differentiate MBP abuse from other forms of illness falsification, because that will affect the outcome for the child and the prognosis for the treatment of the perpetrator. Although currently our knowledge of the specific dynamic issues is limited, there are sufficient commonalities in presentation to support clinical hypotheses concerning motivation in MBP. That few reports have addressed the issue of motivation and few hypotheses have been put forth using this evidence may stem from the fact that most MBP cases are seen by pediatricians who (with some exceptions), are neither trained nor inclined to delve into the kind of psychodynamic and interpersonal issues involved. The dynamics described in this report may be accurate only for the more extreme MBP cases. However, an approach that looks at the more extreme cases in a new and complex disorder is an accepted one and in this case has proven fruitful in delineating a process that demonstrates a fair degree of consistency.7 Need for Attention. Meadow reported on some MBP mothers who have confessed to their behavior and have talked about an intense need to be in the spotlight or to keep the attention of the doctor, parent, or spouse that having a “sick” baby provided them.28 A US television documentary showed an obese mother saying that she suffocated and revived her 2-year-old in the hospital “because she needed help and no one was listening.” The difficulty that besets the endeavor to understand MBP is how to judge the veracity of such “confessions” by people who repeatedly dissimulate. If taken at face value, this mother’s statements would point to PCF motivated by seeking attention to obtain otherwise unavailable help, in this case for her rather than the child. This particular need was described earlier in the section about PCF that is not a part of MBP. However, seeking attention as a way of seeking help differs from seeking attention as a more narcissistic endeavor. After suffocating the child and calling for help three times in a single day, this mother appeared to bask in being the person able to revive her child. Her behavior contradicted her statements: It

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appeared that she sought to be seen as an exemplary parent in a critical situation. The Excitement of the Hospital. Rosenberg pointed out that 75% of the abuse takes place in the hospital.8 Although this number was derived from published papers, little has changed since Rosenberg’s 1987 review. Few of us, even as we may work in hospitals, can appreciate how the hospital ambiance for the parent of a chronically ill child may be experienced. The mother (not a MBP case) of one such child with liver disease described to me how despite her child’s serious condition, it felt strongly exciting when she and her child were helicoptered in for a quasi-emergency and her child received intense care and notice because of this; also how her child’s “interesting case findings” were a source of excitement. The physician specialists who she met with daily, often only for 15 minutes, were the “most important people in her life.” Her situation called forth a huge amount of care from family members. She also perceptively described that the hospital was a place where social class barriers were broken in ways that would not be possible outside of that situation. In the cafeteria at 2 in the morning, parents of ill children met with a commonality and shared presence that forged a bond that had its own rewards. It is little wonder that as in many other MBP cases, just as J. appeared better and was ready for discharge, she would suddenly become ill again. The Challenge to Outsmart. Mrs Bush’s motivation appeared to be a dare, a challenge about who would outsmart whom. The dynamics of MBP can be problematic for some perpetrators: On the one hand, they seek the pediatrician’s admiration; on the other, their ability to repeatedly make a fool of the physician makes this person’s feelings for the mother less valued. Obvious Clues. The obviousness of the clues left by MBP perpetrators is only matched in incredulity by the fact that they are so often missed not only by professionals unfamiliar with this disorder but by those who are completely knowledgeable (see case of Joan V., in Schreier and Libow, 1993, Reference 4, pages 42 through 44). The leaving of clues does not seem to indicate that the mother wants to be stopped from her behavior, as is sometimes seen in more typical forms of child abuse. One possible explanation is that leaving clues increases the excitement of the “game” (one mother was overheard by nurses gleefully describing the “action” at a code for her child whose cardiac arrest she probably caused).4 Another explanation may

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be found in the fact that despite acutely sharp perceptual abilities, these mothers may exhibit cognitive “slippage,” that is, their conceptual thinking is “off.” Such deficits can be seen in some of the psychological testing when carried out by testers familiar with diagnosing psychopathy.4 A third possibility is that at least some of these mothers (or other care providers) have a need that goes beyond being seen as a very good and admirable caretaker, that is, also to be seen as powerful. Therefore, it may be necessary for someone to see the mother’s hand in this elaborate charade in order for her to experience that sense of power.

False Appearance of Intense Caring After a review of our cases and of those with sufficient details in the literature, I hypothesized that the MBP mother’s concern for the child is not only not real, but that their children mattered little to these women.7 The real purpose of the abuse was to keep the doctors “going.” When Southall and colleagues1 first reported on their surreptitious video surveillance tapes, they noted that the mothers who were believed to be deeply caring by most who knew them were capable of totally ignoring their children when observed during hours— even days— of taping.

“Compulsivity” of the Process Abuse by MBP perpetrators has a compulsive quality.4 However, if necessary, the mothers can control their impulses. Waneta Hoyt, after suffocating five of her own children (two on the day after they were discharged from the hospital), went on to adopt a child who later appeared quite healthy at his mother’s murder trial and conviction 25 years later.23 In other cases, mothers stopped harming their children because they found another outlet for their needs. Attorneys have incorrectly attempted to use the attribute of compulsivity to show that a mother does not have MBP because she is able to stop this behavior for extended periods of time.

Psychiatric Falsification in MBP Cases of MBP involving psychiatric conditions include falsification of multiple personality disorder, bipolar disorder, psychosis, chronic fatigue syndrome, attention-deficit/hyperactivity disorder, and various psychological symptoms associated with severe allergies.26 Recently, I consulted on the case of a 9-yearold boy who was placed in a special long-term psychiatric unit after multiple hospitalizations for

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acute psychosis. It took some 8 months before he admitted that he went along with his mother’s false description of his mental state. It should not be surprising that the disorder would appear in the mental health context. The relationships these mothers establish with social workers, psychological evaluators, therapists, law enforcement agents, and (when they are suspected or apprehended), even lawyers, appear to mirror those that they had with the child’s doctors.4 In some of these cases, the process may begin with these other agents. Manipulations involving the same dynamics as MBP have also been described in the context of the school system, where school psychologists have been the major “targets.” In several cases, the MBP process was played out in an intense protracted battle with school psychologists and learning center administrators in a special education setting.29 Another situation in which the target seems to be someone other than a physician is seen in some cases of false allegations of sexual abuse.9,10 Generally, false accusations of sexual abuse involve secondary gain, such as wresting custody from a spouse in a divorce. However, there have been several cases that involve typical MBP motivation and occur along with medical presentations of MBP as well.9 For a critique of this approach expanding the definition outside of the medical arena see Jones.30 It should be noted that contrary to what the Diagnostic and Statistical Manual of Mental Disorders states, non-MBP motivations such as monetary gain or gain of custody may coexist with motives characteristic of MBP, but in MBP, these other motivations are secondary to the dynamics described in this report.

Difficulties Involved When Psychological Problems Are the Mode of Presentation Psychiatric MBP is likely to be more difficult to uncover, but it fortunately seems to be much less common than medical presentations.26 In cases involving therapists and school personnel with presentations of learning disabilities, ADHD, bipolar symtomatology, dissociative disorders, or behaviors associated with temporal lobe epilepsy or Tourette’s syndrome, a contrast between the mother’s reports and the child’s behavior during an evaluation may not be a particularly useful warning, because such discrepancies are not uncommon in true psychiatric illnesses. A further complication is that several variables—a dis-

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turbed parent-child relationship, the coaching involved in getting a child to appear ill, prescribed psychotropic medications, or prior therapies or hospitalizations— may themselves produce symptomatic behavior in the child. Also, in bona fide psychiatric illness, some children respond to the structure of inpatient units and can be weaned from medication only in that environment; such occurrences may be confused with illness falsification. As is often the case in psychiatric MBP, if an older child whose complicity is needed is involved, the mothers may appear more disturbed than those who present with infants. However, such disturbances may also be found in parents of truly psychiatrically ill children.

Munchausen Syndrome in Teens Munchausen syndrome, that is, self-harming behavior, in a teenager for purposes similar to those seen in MBP, is at times a continuation of a process (when the teen was a child victim of MBP abuse) but can arise de novo, even in young teens.31 It is possible that given the number of MBP mothers who have Munchausen syndrome and/or somatization problems earlier in life, we are missing an opportunity to intervene early. In the Southall study, 25 of 39 MBP parents had fabricated or induced illness in themselves as teens.1 Beverly Allitt, a nurse who was convicted of killing several children in a British hospital, was being seen at a hospital facility next door for Munchausen syndrome. The youngest case I know of is of an 11-yearold who took various substances to cause diarrhea not for purposes of losing weight but to present himself as ill. One teenager self-administered coma-inducing levels of insulin just after her mother had visited her in the hospital, causing the staff to suspect that the mother was poisoning her child. I saw another teenager who demanded and received pain medication in our hospital for her nonexistent sickle cell disease; this has been described in the literature.32 She is so convincing at presenting a picture of serious asthmatic symptoms that she has been intubated unnecessarily on several occasions. A Munchausen “asthma” has been described in which vocal cord adduction produces chest sounds similar to those heard in patients with asthma.33 Many of the MBP mothers describe inducing illness in themselves in their teenage years. False reports of having been sexually abused are not uncommon, though there is certainly more abuse or perceived neglect in the childhood of many MBP mothers.

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When Pediatric Condition Falsification May Be Suspected but Is Absent Cover-Up of Abuse. The behavior of parents who describe accidental injury to cover their own abuse of that child should not be categorized as pediatric condition falsification, nor MBP. In their case, the false condition is invented to describe an existing medical problem caused by (usually) violent or abusive behavior. For example, a parent may fracture a child’s bone by hitting the child, and then claim the child fell down the stairs, or, as in one case, that the child suffers from osteogenesis imperfecta. Difficult Parents. A parent who seems difficult because of personality problems or who has clashes of temperament with the doctor should not be diagnosed with MBP. Although many MBP mothers can be quite ingratiating, some can be aggressive with medical staff who do not do their bidding. Distinguishing MBP from situations in which parents exhibit contentious interpersonal styles, especially those who disagree with the treatment, can also be difficult.34 Culturally Specific Practices. Culturally specific practices and beliefs can be confused with PCF. In one case, a Hmong family believed that Western medications were too strong and diluted their child’s antiseizure medication without telling the physician. The child had repeated seizures and eventually died of a prolonged seizure that physicians could not stop.35 Although culturally specific “healing practices” and beliefs can cause grave medical risks at times, this behavior should not be confused with MBP.36 True Conditions That Seem Suspicious. There are bona fide medical conditions that can raise suspicions of being caused by a parent. For example, we have seen cases of cyclical vomiting in which a doctor who was unfamiliar with this condition as a likely migraine equivalent suspected the parent of PCF. We also saw a child with repeated ALTEs associated with vasovagal episodes caused by strong emotions associated with sobbing. One study involving covert video surveillance found that the taping helped make a medical diagnosis in 4 of 41 cases.37

MBP: The Role of the Physician or Other Health Care Professional Understanding the role doctors play in MBP is central to understanding the dynamics of this condition.4,38 It appears that the doctor closest to the case,

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particularly long-term, is the one taken in and believes in the mother the most. Physicians will often defend the mother even if they have referred the case to a specialist on the basis of their own suspicions. In my experience, it is not uncommon for physicians who referred a case because they suspected MBP to become angry at the team as it begins to confirm the suspicions, at times even discharging the team from the child’s care. In the Bush case, J.’s pediatrician not only allowed the mother to communicate orders of J., he refused to investigate the nurses’ concerns and became angry with them. The average period of time from occurrence to diagnosis, even where blatant abuse is involved, is quite long. The ability of the MBP perpetrator to manipulate so successfully cannot be explained only by her facility at lying or our susceptibility to lying. Although most of us are poor at detecting lying, the lying of these mothers is often blatant and the explanations they offer can be absurd. For example, in her capacity as a secretary in J.’s doctor’s office (where she relayed orders on J.’s medication), Mrs Bush confessed to stealing several thousand dollars from him. When asked about the theft in relation to J.’s case, Mrs Bush justified it by saying that because there was tension in the relationship between J.’s pediatrician and his wife over his caring for J., and she wanted to give him a way of saving face, when (as she assumed he would), he fired her. At least some MBP mothers appear to have an uncanny ability as impostors. They can simulate someone a pediatrician will “fall for,” an ability akin to that of the psychopath.4 As a result, physicians and other health care workers sometimes miss glaring clues. At times, the discrepancies or incongruities can be astonishingly undisguised and present beyond the health care environment. For example, Mrs Bush went to the White House to support Clinton’s health care initiative because of the family’s claim that medical bills had bankrupted her family, in the face of their building a new swimming pool and buying three new motor vehicles the same year. Jureidini and Donald39 argue that MBP involves a triadic process that requires a dependent, a caretaker, and a doctor. They point out that that some doctors were more prone to be “engaged in a case of MBP.” These physicians may be “competent and well-respected pediatricians who tend to see things in black and white terms. . .(have a penchant for) a high level of investigating (zeal) . . . . . .(that some susceptibility)

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comes in part from anxiety about missing a diagnosis but also from an attraction to the possibility of establishing a rare diagnosis that colleagues have missed” (Reference 39, page 46). To this, I would suggest that some of the qualities we all value as physicians—a wish to appear altruistic and caring, and to be able to solve complex problems to help our patients—add to the potential of being “trapped.” This is especially true when one is dealing with the child of a colleague (many MBP caretakers are in the nursing or child care professions) and a parent who appears to be exceptionally caring and dedicated to her child, that is, the typical MBP mother. (See a more detailed discussion in Chapter 7 in Hurting for Love.4) Although this section focuses primarily on physicians, other professionals perceived as powerful, such as sheriffs investigating sexual abuse and school psychologists, have been primary targets for MBP manipulation. In one case, a psychologist who claimed to be familiar with MBP treated a mother for a year of court-ordered therapy. He reported to the court that she had not abused her child and did not have MBP. To support his statement, he pointed to the “fact” that the child continued to be ill despite being separated form the mother when his only source of this information was the mother’s report!

A Case With Many Doctors Fooled A Grand Rounds published in the Journal of American Academy of Child Psychiatry in 1991,40 described “Billy,” a 3-year-old child, who was separated from his mother because she was suspected of causing his chronic diarrhea after the hospital found phenylthalene in his stool. During this separation period and while in the hospital, Billy “became so spiritless, withdrawn, and passive that he. . .needed to be carried.” His electrolytes and other physiological parameters were normal, and “one of the doctors took him on a (weekend) family outing.” However, the outing was to little avail. On the third day of separation, the mother called but Billy would not “engage on the phone.” She was concerned and planned to return to the hospital the next day, but that night the resident was called to see Billy because he appeared very

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listless. While they were talking, “(he) stopped breathing and could not be revived.” 40 A supervisor on the case described how “uncertainty abound(ed): Initially we didn’t know why the patient wasn’t responding to standard treatments. As the case progressed, we were plagued by the uncertain history, the absent father, and the mother’s role throughout the case. And at the tragic end. . .we didn’t know the cause of the child’s death, the part our medical and psychiatric ministrations played in its outcome, or if the death could have been averted.” The staff had been strongly split as to the mother’s role, but “she showed no anger, then or subsequently, toward the hospital or its staff.” She even came for help to the adult outpatient clinic because she was “distraught and anxious.” (As a teen she had been admitted to a psychiatric hospital because of suicidal thoughts.) During a session with a psychiatry fellow whom she liked and who had also been involved with Billy’s evaluation in the hospital, she expressed concern about Billy’s younger brother, Lee, “. . .who, she said, had recently started vomiting after eating.” In 1996, I was consulting at another hospital in the same city. I was presented a case that involved a child referred in by a pediatrician because of difficulty in diagnosing his cachexia and diarrhea. This 6-year-old child had a seizure disorder at age 1, around the time of his brother’s unexplained death. From the history, the staff and I recognized that this patient was Billy’s younger brother. They considered a diagnosis of MBP but were discouraged from investigating by the child’s pediatrician. Also, a consultant in the hospital, who was experienced with factitious disorders, felt that this was not MBP and that such a formulation would only be harmful to the diagnostic and therapeutic process. After discharge, two other consulting psychiatrists ruled out MBP. One of these evaluating psychiatrists had stated that he was “deeply impressed with the mother-child interaction.” Because of the experts’ opinions, no further action was taken and Child Protective Services was not notified. Years later, I mentioned this case when presenting at a child abuse conference. A pediatrician who was a child abuse expert in the audience recognized the case and reported the following:

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“Lee” (the name given to the sibling of “Billy” in the 1991 paper) was admitted at age 14 to a hospital in a different state for deteriorating neurological status from presumed mitochondrial encephalopathy lactic acidosis and stroke-like syndrome (MELAS). Because some elements of his presentation suggested narcotic and/or benzodiazepine poisoning (palliative medications that had been discontinued weeks earlier) and because all tests for MELAS including muscle biopsy were now definitively negative, an intensivist sent a urine sample for a toxicology screen. The urine sample was positive for benzodiazepines and opiates. Later, the laboratory results came back indicating an unexpectedly very high salicylate level. Chronic salicylate poisoning clearly explained Lee’s clinical deterioration over the preceding several months, if not years. Lee’s mother was immediately removed from the hospital. Within days, Lee, who had been bedbound, who hadn’t been fed anything by mouth for months, and who was receiving end-of-life care for MELAS, began ambulating and eating normally. Two years later, he lives in foster care and continues to be completely physically healthy. He is receiving mental health services but wishes to reunite with his mother when he is 18, because he does not believe she injured him. Many professionals, including at least two mental health professionals, were convinced of Billy’s and Lee’s mother’s deep caring in the face of serious concerns about abuse voiced by others. I would suggest that there are powerful interpersonal forces at work here and that these mothers have “skills” and show weaknesses that rival even most expert impostors.4

Lessons from Billy’s Case Evaluation. A mental health evaluation of a mother and child should not be used to rule out MBP. Only professionals who are experienced with the disorder and who can read the medical records or get experienced help with the medical aspects of the case should be involved in reviewing cases. In Billy’s case, the mother had unexplained medical symptoms, and a careful family history may have revealed a very disrupted childhood. The cunning of the mothers in producing hard-to-figure-out illnesses is often matched

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by professionals’ disbelief that such a “loving” and attentive mother could possibly be harming her child in this fashion. Few of us are able to extract ourselves from engagement with those truly capable of posing as good mothers. The effect of Lee and Billy’s mother’s presentation as a loving, self-sacrificing “saint” (as one physician called her) cannot be underestimated. Securing the Child’s Safety. Diagnosing MBP requires that abuse through PCF be demonstrated first. Stopping the mother’s visitation may be life-saving, as it was for Lee (though not for his brother). Attempts to understand the mother’s motivation, usually discernible from the way the case unfolds over time, can wait until the child’s safety is guaranteed. Professionals must take utmost care in choosing placement for the child. Often well-meaning relatives come forward to offer a home. If they do not believe that the mother has been an abusing parent, the child can be at great risk. In one family, the mother, who had her infant taken away after she tried to poison him, killed this child while feeding him during what was supposed to be a supervised visit at the grandparents’ house where he was placed. “Separation Test.” Separation must be for a sufficient length of time to be valid. All tests must be done with the utmost of care in fairness to the mother and child. The possibility of false-positives, such as certain foods causing a false-positive test for laxatives in a stool sample, or the child having a rare disease, should be considered carefully and ruled out. It is unwise for the mother to have any contact with the child unless there is total confidence in the ability of ward personnel to supervise and protect the child. The “separation test” is not foolproof. If Billy’s mother did do something to cause the boy’s death, the time to have acted with a separation trial was when an early stool sample showed phenolphthalein. The clinical situation was near-catastrophic in Lee’s case as well. It was only because an astute clinician ordered a toxicology screen and called in a forensic pediatrician, CPS, and law enforcement, which resulted in an immediate order to remove the mother from the hospital, that Lee survived. Had Lee died while his medical providers still believed he had MELAS, an autopsy probably would not have been done (or if done, toxins may not have been investigated), and his true illness would never have been discovered. Expert witnesses may contest the validity of the separation test. In three of the cases reported in the Southall study,1 in which covert video surveillance could not be carried out, an expert was

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found to say that the child’s condition had spontaneously resolved when no more apnea occurred outside the care of the mother. In another case, an 8-year-old with more than 100 reported apnea events each month over a 4-year period, had a “spontaneous cure,” according to a university apnea expert, the very day a nurse was stationed in his room. This child has never had another illness since that day. Forensic Postmortem Tests. A forensic or postmortem evaluation is only as good as it is thorough. A negative postmortem toxicology screen in Billy’s case appeared to include only arsenic. One child who went to sleep and was difficult to arouse after his mother had lunch with him was taken to the emergency room, where a toxicology screen was reported back as normal. The panel of tests performed was unfortunately very limited and did not include tricyclic antidepressants, which the mother was taking at the time. Space limits a complete guide to laboratory diagnostics, but a few other common examples are worth noting. Induced vomiting, a common presentation in MBP, requires a screen for ipecac poisoning, which is only done at certain laboratories in the United States. The test may be falsely positive if a child was involved in a resuscitation effort, and the laboratory must be told this information to control for substances used during a code that can give a false reading. Phenolphthalein is commonly used in MBP to cause serious diarrhea, but it can cross-react with substances found in some foods. The forensic evaluation needs to be carefully done, using the most expert of consultants if necessary. In a notorious case, a mother was convicted of feeding her infant antifreeze and sent to jail for life when she refused to admit her guilt. A second child born to her in jail began vomiting outside her care and a geneticist found that the alcohol in her babies blood was caused by a metabolic defect passed on genetically.4 It has been recommended that a clinical pharmocologist be consulted and the presentation of the child discussed for suggestions as to where to look for poisons if the pediatrician suspects illness fabrication. Extra serum should be stored for later evaluation. Covert Video Surveillance. There are many factors that need to be considered in the decision to videotape a mother and child in a hospital room without their knowledge. Covert video surveillance (CVS) has been used since the early 1980s in cases of suspected MBP. The controversy over the ethics of this method have been debated not only in the medical literature but in

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the popular media as well, and there is a web site for mothers who feel they have been wrongly accused. Indeed, attacks on Southall and his colleagues who carried out groundbreaking work in this area led to an investigation during which they were suspended from practice. More recently Dr Roy Meadow has come under attack for testimony in several cases involving mothers convicted of abuse in what was otherwise thought to be a cot death. The attorney general of England has decided to do a review of some 258 cases of women to see if there were problems with the convictions. Neither Dr Meadow nor Dr Southall and his colleagues were permitted to comment in public on the accusations. The reviews take months even years to come to conclusions. The press accounts of these investigations have been described as lurid and have had a chilling effect on pediatricians’ willingness to see cases of suspected child abuse in England.41 Professor Southall was reinstated after a year suspension with the conclusion that he “always acted in a way that promoted the best interests of children under his care, and that he took decisions in collaboration with colleagues from other agencies. [The investigators] did not find evidence of inappropriate diagnosis. . .” but recommended that in the future covert video surveillance should be carried out under police supervision.42 CVS is useful in the diagnosis of MBP for a number of reasons. First, a parent perpetrates the abuse secretly, often producing symptoms in a child who lacks the ability to describe the situation or in a preverbal infant. The suspected parent is usually highly thought of by at least some doctors, nurses, and, in particular, relatives [eg, the father], who then cannot be relied upon to make the necessary and often tedious documented observations that are needed to present a case in a court. The courts have minimized or disallowed evidence based on hearsay, opinion, and circumstantial evidence, even though in cases of child endangerment testimony by a physician as an expert witness based on such sources is admissible. Finally, the “separation test,” although useful in producing circumstantial data (eg, the child gets completely well away from the mother), is open to many challenges, technical, and emotional. When guidelines are carefully followed, the effectiveness of CVS is excellent. In the Southall report, CVS was successful in documenting abuse in 33 of 39 cases; based on conviction or confessions, the suspi-

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cion rate was even more accurate, 36 of 39.1 Twentyeight of the 39 patients had a total of 41 siblings, of whom 12 “had died suddenly and unexpectedly. Death was attributed to SIDS in 11 of these children. After surveillance, 4 parents admitted deliberate suffocation in 8 other of their children.”1 Equally important, CVS may exonerate a suspected abuser: Hall et al37 demonstrated the value in covert video surveillance in making a bona fide medical diagnosis in which MBP was suspected. Arguments against CVS include the parent’s right and presumption of privacy as delineated in the Fourth Amendment to the US Constitution, which protects against unreasonable searches. The most stringent interpretation of Fourth Amendment protection applies to government institutions, police, state, and national hospitals, and so forth. Private parties, including doctors in other kinds of institutions, are given much more latitude. However, for either kind of institution, a search warrant by the courts protects the process. For urgent (ie, life-threatening to the child) situations, the courts have held that the delay involved in obtaining a search warranted can be avoided. Some experts have argued that “if the video surveillance has primarily a diagnostic purpose, obtaining a search warrant should not be necessary.”43 It has been argued that the expectation of privacy in a hospital room is less than in other settings. Patients expect nurses to enter unannounced, and there are many recording machines, including sound wired to the nurses’ station. Others point out that the helpless infant who cannot give an accurate history is the patient, and doctors have great flexibility in making a diagnosis. To date, no use of CVS has been successfully challenged in court, and CVS is routinely used in a few institutions in the United States. Taping a mother and child interaction to look for abuse entails risk because of the lack of a constant live monitor of the situation. In one case, a mother suspected of repeatedly suffocating her child broke the child’s arm, leading to intervention before the sought after evidence of suffocation could be obtained. Children have been harmed even when a police officer or nurse has been monitoring in real time. Real-time observations can also be time-consuming: In the Southall study, it sometimes took 3 days for the mother to act on her infant. There are several suggestions made by people working in the field to minimize the invasiveness of this procedure, although some of these create difficulties.

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For example, focusing the camera only on the child may miss many acts of abuse. The mother may take the child into a bathroom or out of their crib to do the harm. In one case, the mother diluted the baby’s formula in a closet. Muting the sound to avoid picking up private conversations has missed conversations in which the mother is lying about the child’s symptoms. Few hospitals have been willing to tackle the thorny issues raised by covert video surveillance. Acceptance by staff (especially those sympathetic to the involved parent) is essential to the success of CVS. Educational programs for health care personnel, hospitals, and judges likely to be involved in such cases are essential. At least one hospital has set up a committee to monitor investigations when suspected MBP is reported to them. Hospitals may want to consider involving law enforcement agencies that have been educated in advance about MBP to assist in setting up the equipment and monitoring it. In summary, it is because MBP presents with so many difficulties in detection and protection of the child that an apparently draconian measure such as CVS has come into being. Although CVS is challenging for many reasons, the biggest obstacle so far has been the extraordinary cost of the procedure.

Effects on the Child Victim Initial reports on how children abused by MBP mothers fared in the long term were based on limited numbers44 and described horrific outcomes. In a more recent study, Ayoub45 presented the results of a long-term follow-up on 40 children identified as victims of MBP. Of the 40 children she has followed, 43% were placed in foster care, 54% were placed with a relative, and one child was returned to his mother without treatment. In most cases, the mothers visited regularly, anywhere from once a month to every day. Only two of the mothers confessed to having abused their children and entered into treatment focused on MBP. All of the children with significant exposure to falsification of symptoms had serious psychological sequelae that have the potential for being long-term. The psychological difficulties most common among these children included oppositional-defiant disorders, posttraumatic stress disorder, attentional disturbances, basic problems with attachment and social interaction, poor self-esteem,

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and patterns of reality distortion. Although these children can present as socially skilled and superficially welladjusted, they often struggle with basic relationships. The sooner children were placed in permanent safe alternative homes, the better they fared.

Treatment Therapy for the Child Common therapeutic challenges addressed in psychotherapy with MBP victims include denial of abuse, intense but diffuse anger, issues involving control over one’s body, sick-role behavior, and immense grief. Psychotherapy for the older child that is initially based on objectively reviewing facts (such as medical records or court document review and observations of improvements in health and functioning) can be an effective way to assist the older child in addressing their own denial and misperceptions. Once the child reformulates his understanding of the past, he can then more readily cognitively link the other challenges to past experiences.46 For children who are not ready for fact review, storytelling and play therapy can be a less threatening way to begin. Latency-age children exhibit many of the characteristics of abused children in general, though there is an inherent greater confusion, partly because the parent had more “caring” qualities. Some children never recognize that abuse has occurred.

Therapeutic Issues for the Abuser and Spouse The treatment of the person with MBP has two purposes: (1) helping the mother overcome her illness and (2) allowing for the best possible relationship with her children, while ensuring their safety. MBP has a very high recidivism rate. Reabuse recurred in 37% of the cases in which the courts permitted even limited reunification.5 Women with MBP may have cognitive deficits that may appear on psychological testing and explain some of their behavior, such as illogicality of certain thoughts, which may be caused by cognitive slippage.4 This can seriously complicate the therapy of these offenders. Although abusers who admit MBP are considered to be more likely to benefit from psychotherapy, a major issue for the therapist is in assessing the veracity of the patient’s admissions. This is exponentially more difficult for a patient with impostoring skills or those with psychopathic styles of relating. Similar to other forms

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of child abuse, some indicators of successful treatment include (a) the abuser admits to the abuse and has been able to describe specifically how she abused her child, (b) the abuser has experienced an appropriate emotional response to her behaviors and the harm she has caused her child, (c) the abuser has developed strategies to better identify and manage her needs to avoid abusing her child in the future, and (d) she has demonstrated these skills, with monitoring, over a significant period of time. It is often important that the partners of the suspected abusers also be included, as they have frequently colluded with the abuser (consciously or unconsciously) or have been unable to protect their child for other reasons.47 Treatment approaches vary in the theoretical framework used and the degree of confrontation used, but they all include efforts to increase awareness and to reduce the risk of relapse. For example, one therapeutic approach with individuals who have allegedly engaged in MBP behaviors includes the construction of the story of how the parent proceeded down the path of engaging in MBP behaviors and the creation of an alternative story, which does not allow the MBP behaviors to occur in the future. Through the construction of this story, the parent may be able to acknowledge her behaviors and provide for safety in the future.47 The offending parent may engage in couples and dyadic therapies with the child (or children) as they move toward reunification. If reunification is not possible, the child should not be introduced to the dyadic therapy with the offender. The child’s therapist may find it in the best interest of the child to have some conjoint sessions with the parents. These sessions may be helpful to the child if the parent is able to acknowledge her MBP behaviors and take responsibility for her behaviors with the child. This may also give the child the opportunity to ask questions of the parent, which the therapist can help the mother answer.

Reunification In his article “The Untreatable Family,”48 Jones listed some predictors associated with poor outcome in general cases of child abuse. These include parental factors of a history of severe childhood abuse, persistent denial of abusive behavior, refusal to accept help, severe personality disorder, mental handicap, psychosis, and alcohol and/or drug abuse. An especially poor prognosis for successful reunification includes the parent’s lack of empathy for the child, inability to put the child’s needs first, and severe forms of abuse. He reported that nonac-

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cidental poisoning and MBP are both associated with poor prognosis and involve significant risk of death for the child as well as a high proportion of families that prove resistant to treatment efforts. If partial or no progress has been made in therapy, reunification is not recommended. If it appears that progress is not being made in a timely manner (perhaps within 6 months), the court might consider a more rapid progression toward termination of parental rights. If significant progress has been made in therapy, reunification may be considered. In such cases, a slow progression of increasing monitored and unmonitored visits is recommended. If the child’s health care needs increase during a particular level of contact with the child without verification from the primary physician that the illness is genuine, it is probably too soon to consider reunification. Generally, the more severe the previous abuse to the child, the greater the future risks to the child. The level of monitoring should reflect the degree of risk if reunification is considered. Because of the extreme difficulty of treating MBP abusers, reunification failures should be expected.

Legal Issues Though MBP was first described more than 25 years ago, there is little uniformity in how it is treated in different jurisdictions in the United States and even within a particular jurisdiction in a state. Many factors are involved in a district attorney’s deciding whether to press forward with criminal charges, and the vast majority of abuse cases do not result in criminal action. In the case of MBP, the problems of evidence are usually greater. A higher standard of proof (beyond a reasonable doubt) in criminal trials may play a role in a District Attorney’s reluctance to take these cases. A number of researchers have recommended that the threat of criminal prosecution be used as a “club” to gain an admission from the perpetrator and that this would make the protection of the child in juvenile court easier. However, because of the satisfaction obtained by people with MBP from being litigious, this has not turned out to be particularly useful. As the standards for the admissibility of scientific evidence are currently in a state of flux, judges have varied enormously in their decisions to allow testimony that a mother has MBP into evidence. Some jurisdictions seek to balance relevance against the

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prejudicial nature that testimony about MBP may incur. Prior codes of federal evidence (the so-called Kelly Frye standard) have been applied to MBP as far back as 1981 in a murder trial (People vs Phillips49) and upheld at appeal (175 Cal Rptr. 703 ct App. 1981). This case upheld the ability of a psychiatrist to diagnose the mother with MBP, based on reviewing the literature and the records without interviewing the mother. MBP has been handled in a variety of ways since, for example, a judge ruled that the MPB diagnosis was inadmissible unless the mother raised the issue of her good character. The US Supreme Court, in a pre-MBP case in 1972,50 upheld evidence of prior criminal behavior, usually excluded from criminal prosecution. The court said in “the crime of infanticide. . .evidence of repeated incidence is especially relevant because it may be the only evidence to prove the crime.” This presentation appears to be little contested in the cases I have participated in and reviewed. Traditionally, an expert’s opinion on whether a witness is lying is inadmissible because detecting lying exceeds the ability and specialized knowledge of an expert. It is considered best left to the juries to decide whether a witness is lying. Therefore, in United States vs Shay,51 a lower court ruled to exclude an expert’s testimony concerning Munchausen disorder (not by proxy) even though lying is characteristic of the condition. However, the first Circuit revised the lower court’s decision. The reversal of the decision reflects the importance of expert testimony in cases of MBP. In most cases of MBP that come to trial, there is usually only circumstantial evidence, and the mother’s appearance of caring can be quite persuasive of her innocence despite the weight of numerous unexplained illnesses. When the doctor is responsible for much of the morbidity or even mortality, the jury should be able to know that this picture is not at all uncommon and has been repeatedly documented (through confessions) to exist in MBP. Without this testimony, even the most horrendous abuse of a child may be ignored when the mother appears loving and caring.

The Pediatrician’s Preparation for Testifying in Court MBP most often involves indirect evidence. The involved health care and social service providers as well as the prosecutors must be ready to present a believable res ipsa loquiter argument, that is, even

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without direct evidence, given the data there is but one likely conclusion of the cause. Peculiar illnesses or unexpected deaths in siblings or others in a mother’s care, or lack of symptoms in the index child when the mother is absent, or the presence of symptoms only in the mother’s presence requires careful documentation. Law enforcement agents may call on physicians to testify when they ask the courts for a “separation test,” as few mothers will voluntarily consent to this. As professional opinions and hearsay (ie, statements of other professionals or other relatives) are often admissible evidence, these must be gathered with great care, either through direct contact or very careful review of the records of other physicians or hospitals. It is best to speak with other caretakers, as these mothers very frequently misquote what has been told to them or utilize a letter written by a sympathetic doctor that may be somewhat exaggerated, because it was requested to prod a social agency. Furthermore, these caretakers may have been misinformed by a false family history given by the mother or have recorded symptoms in the child that were reported as if they were actually witnessed. Mothers may give elaborate family medical histories that differ from practitioner to practitioner. These discrepancies are important to document. Suspected cases call for taking family medical histories anew and not simply copying them from previous chart notes. While tedious, a careful review of prior charts can ultimately be the most important source of discrepancies.

Liability Issues Reporting by professionals is mandated to protect children and to protect the hospital and staff against the possibility of a suit by the nonabusing parent of a child victim. The danger of false diagnosis has received much media attention recently, and these may increase, as MBP accusations have now appeared with increasing frequency in divorce proceedings involving custody. Physicians have been sued for malpractice in misdiagnosing MBP as well as violating a mother’s constitutionally protected rights to have access to her family. I know of no successful lawsuits in such instances. In a recent ruling, Judge Wexler of the US District Court for the Eastern District of New York stated, “it is without question that these doctors (reporting doctors and experts hired by the prosecution) are entitled to absolute witness immunity with respect to their testimony in court. That such testimony is

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alleged to have been without basis and contradictory to acceptable medical practice is irrelevant.”52

Guidelines for Hospitals Protective service workers and guardians ad litem need to be aware of or have access to persons knowledgeable about this condition in order to evaluate suggestions about mother’s wellness, improvement with treatment, or lack of dangerousness. A description by a court-appointed psychiatrist of a mother as having a “mild case of MBP” was based on a misreading of the potential lethality of the methods of abuse and also reflected a lack of understanding of the possibility of a mother going from relatively mild abuse to very severe abuse without warning. Independent, outside verification is essential in deciding on the future potential harm to a child, and suspicion should be raised about the knowledge of this condition of any examiner that does not insist upon this. It cannot be emphasized enough that there is no particular psychological profile or checklist of symptoms that definitively confirms or excludes the diagnosis of MBP. Rather, there are common patterns that should raise suspicion and should be examined on a case-by-case basis. Although personality problems are found quite often in MBP, perpetrators may appear relatively healthy on the usual psychological tests and interviews, especially to the uninformed examiner. Up to 75% of MBP mothers had somaticizing problems when younger, and as many as one third will have factitious disorders themselves. Regarding motivation, it should be noted that (contrary to the DSM-IV definitions), external incentives such as monetary gain or seeking revenge on an abandoning spouse may be present along with the dynamics above and do not preclude the diagnosis. MBP mothers will often find as much satisfaction in their “day in court” as they did in the hospital and will not always take the easy way out, however advantageous. Suspected cases of MBP should be handled with proper coordination of the various agencies involved, ideally in a face-to-face meeting. This meeting should include (1) as many physicians involved in the case as possible; (2) someone who has gathered the information from as many prior treating physicians as possible; (3) if in a hospital, a representative from administration or the hospital’s legal department; (4) a nursing supervisor, a child protective service worker, a social services worker; and (5) a representative from law enforcement and/or district attorney’s office. A

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detailed written plan should be worked out either for further investigations or for confronting the parent. Personnel with doubts about a particular case, particularly doctors, may hear details of importance to their diagnosis for the first time at such meetings. It is essential that all agencies involved in these cases document their findings as well as their opinions with the utmost of detail. If covert surveillance is indicated, it should be decided who will be in charge, hospital personnel (unless it is a public hospital) or the police. Steps should be taken to guard the parents’ privacy as much as possible, but not to the point of making a needed observation too difficult. Nurses and other staff who might be “organized” by the mother should be given the opportunity to be excused during the time this is taking place. All personnel must act totally professionally in the interest of the child, excusing themselves from care if they feel they cannot do that. Several hospitals have instituted MBP teams, whose role is to review cases and make recommendations. A consultation liaison psychiatrist, psychologist, or other professional familiar with the disorder in all its presentations should be a part of this team and brought in on a case as early as possible. This ideal approach is often not possible. Children may remain attached (at least initially) to even the most abusive parents. If the child is removed, it is the job of the pediatrician to make sure that workers involved with the child are aware of the potential risks of maternal contact. Visits, including all conversations, must be carefully monitored and fully documented. Medical issues should not be discussed, and the parent should not feed the child. This runs against the grain of many children’s protective services workers, especially when the mother appears caring and benign, as these mothers often do. A typical observation is that the parent seemed more interested in talking to the monitor than interacting with the child. If relatives of the child are employed as caretakers, they must be carefully screened and must understand the potential severity of the situation. Relatives who serve as guardians pose a risk to the child if they believe the mother incapable of such abuse.

Conclusions MBP is a condition that challenges those who work in the fields of medicine and psychology in profound ways. Though MBP could be seen as an esoteric problem that most can escape, it is becoming clear that

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health care professionals must have more than just a passing awareness of its presentation. There may still be a strong reluctance to “see” child abuse in general. Such reluctance may even be even more likely at major tertiary care hospitals, where a larger number of MBP cases may aggregate.23,25 The ability to consider the possibility of a mother being involved in MBP is the single most difficult step in the management of this disorder. Following close on the heels of that necessary step is to avoid involvement of well-meaning “expert” evaluators who are unfamiliar with MBP. It is not surprising, given the special problems this report has outlined in suspecting and acting on it, that much of MBP still goes undiagnosed. Lesser forms may be common in children in allergy clinics or dermatology practices, many of which are never even suspected. As a very experienced consultation-liaison psychiatrist said after the death of Billy (see case), “As clinicians. . .we can respond to such cases and the inherent uncertainty by fleeing, leaving consultation work or not working with seriously ill patients and families. We can on the other hand embrace such uncertainty as part, parcel and the challenge of our work.”40 The same could easily be said for the pediatrician who has faced a case of Munchausen by proxy.

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