Munchausen by Proxy

1. Munchausen by Proxy Dr Maha Jassim Bourisly Pediatric Specialist Al-Sabah Hospital

4. Case History Child was diagnosed as ALL he received his chemotherapy as per protocol for 3.5 yrs and over the last year of his treatment he had recurrent admissions for URTI and GE, following completion of his treatment he continued to be admitted for GE , every 15 days with normal investigation and according to the nursing staff he was completely well, the mother approached one of the attending doctors and told them that her husband is getting married and she is trying to get his attention by convincing him his child was sick and in need for his attention.

5. Karl Friedrich Hieronymus, Freiherr von M�nchhausen (11 May 1720 � 22 February 1797) (often spelled Munchausen in English According to the stories, as retold by others, the Baron's astounding feats included riding cannonballs, travelling to the Moon, and escaping from a swamp by pulling himself up by his own hair (or bootstraps, depending on who tells the story).

6. The fictitious Baron von Munchausen was an extravagant raconteur, whose fanciful narrations of his imagined exploits made his name in literature. Physicians have borrowed his name to describe a group of patients whose complaints are fabricated but so convincing that they are subjected to needless hospitalizations, laboratory tests, and even surgery. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) refers to Munchausen syndrome as "factitious disorder" (300.19), and motivations for this bizarre behavior continue to puzzle both medical and mental health professionals.

7. Munchausen by Proxy In is this form of child abuse, adults inflict illness on the child or falsify symptoms in order to obtain medical care for a child, features include: Recurrent episodes of a confusing medical picture Multiple diagnostic evaluations at medical centers( doctor shopping) Unsupportive marital relationship, often marital isolation Compliant over-involved mother Higher level of parental medical knowledge Parental history of extensive medical treatment or illness Condition resolve with surveillance of child in the hospital History of unexplained sibling death John Stirling, Jr, MD and and the Committee on Child Abuse and Neglect PEDIATRICS Vol. 119 No. 5 May 2007, pp. 1026-1030

8. Examples in the literature A mother takes her child to the doctor for frequent evaluations for sexual abuse, even in the absence of objective evidence or history of abuse. Mothers insist their children be treated for attention-deficit/hyperactivity disorder although there is no evidence to make the diagnosis. A parent starves her child because she wrongly believes he has multiple food allergies. Physicians suspect an unusual hematologic disorder after a mother repeatedly and secretly bruises her child with a hammer.

9. Baby Jane was hospitalised for six months, during which time she required resuscitation over 100 times for haemodynamic collapse. Her doctors attributed these episodes to some unique disease, but it was subsequently found that the mother had induced each episode by poisoning Jane. Jon N Jureidini, Allan T Shafer and Terence G Donald MJA 2003 178 (3): 130-132

10. History of the terminology In 1977, Meadow first described cases in which the apparent symptoms of Munchausen syndrome were instead projected onto a dependent child as a parent fabricated symptoms and even signs of a nonexistent illness. When the fabrications involved a dependent individual like this, the condition was likened to Munchausen syndrome experienced "by proxy," and the diagnosis of Munchausen syndrome by proxy entered.

11. History of the definition To alleviate confusion, the American Professional Society on the Abuse of Children has recently made a more explicit distinction between the abuse (pediatric condition falsification) (fell down instead of beaten)and the presumed motive behind most such cases (factitious disorder by proxy)(false symptoms e.g. fever or vomiting). John Stirling, Jr, MD and and the Committee on Child Abuse and Neglect PEDIATRICS Vol. 119 No. 5 May 2007, pp. 1026-1030

12. Why???? Only a minority of parents who deliberately harm their children have exhibited features of Munchausen's syndrome themselves little is known about the psychopathology underlying the fabrication of illness in older children. It probably differs from that described in parents who induce illness in infants by suffocation or other means. Some parents who induce illness in infants have a personality disorder ,or (rarely) a psychotic illness. In the postnatal period women have reported a variety of fantasies, obsessions, and anxieties regarding their babies, including concerns about their ability to care for the child and worries that they might cause them harm. John Stirling, Jr, MD and and the Committee on Child Abuse and Neglect PEDIATRICS Vol. 119 No. 5 May 2007, pp. 1026-1030

13. Questions for Dx To make the diagnosis, the physician must ask 3 questions: Are the history, signs, and symptoms of disease credible? Is the child receiving unnecessary and harmful or potentially harmful medical care? If so, who is instigating the evaluations and treatment?

14. Diagnosis of fabricated disease can be especially difficult, because the signs and symptoms are undetectable (when they are being exaggerated or imagined) or inconsistent (when they are induced or fabricated). Researchers may differentiate between exaggeration and fabrication or induction of symptoms, but action taken by the clinician must be determined by the perception of harm or potential harm to the child.

15. A mother who alleged that Professor David Southall and another paediatrician caused her to develop a psychiatric illness by wrongly diagnosing her child as a possible victim of Munchausen syndrome by proxy is taking her case to the Court of Appeal after it was thrown out by a judge at Chester county court. Judge Hale ruled that Professor Southall and Dr Karen Whiting, a community paediatrician, owed no duty of care to Janet Davies, mother of Michael, and therefore no claim for negligence could proceed against the former East Berkshire Health Authority, Dr Whiting's employer. BMJ. 2002 December 7; 325(7376): 1321.

16. Regardless of the exact nature of the duplicity, health care professionals can be seduced into prescribing diagnostic tests and therapies that are potentially injurious. This is easier than one might think. After all, absolute certainty is a rare thing in medical diagnosis, and physicians have all known empirical therapy to be effective (e.g fever , case 1). On occasion the well-meaning but misguided pursuit of an ever-more-elusive diagnosis or effective treatment can lead medical staff into an ethical dilemma.

17. How to diagnosis Detecting fabricated or induced illness in children may now necessitate controversial surveillance tools such as video surveillance not only at hospital but homes in controversial cases (ethical and legal dilemma

18. When considering treatment for child abuse taking place in a medical setting, the basic principles used in any other type of child abuse case should be applied: Make sure the child is safe. Make sure the child's future safety is also assured. Allow treatment to occur in the least restrictive setting possible.

19. Management A list of possible interventions follows. Some of these options require action by outside agencies (child protective services, private counselors, law enforcement, etc). Use individual and/or family therapy while depending on a primary care physician to be "gatekeeper" for future medical care utilization. Monitor ongoing medical care usage by involving people or institutions outside the medical practice to alert the physician gatekeeper about health care issues.