Illness induction syndrome: paper I--a series of 41 children from 37 families identified at The Great Ormond Street Hospital for Children NHS Trust

Munchausen syndrome by proxy: A narrative review and update for the dentist and other healthcare professionals

Munchausen syndrome by proxy (MSbP) is a form of abuse in which a caregiver with Factitious Disorder Imposed on Another (FDIA) fabricates or induces signs or symptoms in a person under their care to satisfy a self-serving psychological need. Unnecessary clinical evaluations, procedures, and treatments that are initiated based on falsification by the abuser inadvertently add to the trauma experienced by the victim. It is a form of abuse and the impact on victims can be severe, sometimes fatal, and far-reaching such as prolonged neglect and extension to affected siblings. The long-term exposure to MSbP may predispose the victim to eventually developing factitious disorder imposed on self (FDIS). While MSbP often involves child victims, elderly, adults, and pets have also been reported as victims. MSbP can be a diagnostic challenge, and the important keys to timely identification of MSbP include the ability to detect deception by caregivers through awareness, clinical suspicion, and careful review of available health records; it also involves collecting collaborative information from other relevant healthcare providers including dentists, schoolteachers, and social workers. To date, there are limited published cases of MSbP with oral findings. This paper provides a narrative review of the current understanding of MSbP with a section on cases with oral findings. This paper aims to increase awareness about the clinical presentations and management considerations for MSbP among dentists and other healthcare professionals.

Fabricated or induced illness: From "Munchausen by proxy" to child and family-oriented action

BACKGROUND

In fabricated or induced illness (FII), a child is harmed due to caregiver(s) behaviour and actions, carried out to convince mainly doctors that the child's physical and/or psychological health is more impaired than in reality. Harm is caused directly by the caregivers(s) and also often inadvertently by doctors' responses.

OBJECTIVES

To describe: dynamics underlying FII; wider definition of FII; alerting signs for early recognition of possible FII; respective responsibilities of health, social care, education.

METHODS

Literature review, clinical experience, expert opinion.

RESULTS AND CONCLUSIONS

Caregivers are motivated by gain from having their child treated as ill, and/or by erroneous beliefs about their child's health, either way needing medical confirmation about their contentions. Their behaviour is therefore directed primarily towards doctors. Most cases of FII present unexplained discrepancies between caregiver reports/actions and independent observations of the child. More rarely, the child has actual signs of illness, induced by the caregiver, occasionally fatal. Children are harmed in all aspects of life: health, daily functioning including education, and psychologically. Harm emanates directly from the caregiver(s) but also unintentionally from medical responses. Illness induction and clear deception by the caregiver require immediate child protection. Otherwise, the initial focus is on assessing the child's current health and functioning rather than caregiver's mental health. If, beyond verified illness, there is no medical explanation for the child's reported ill-health, the family require help to function better. This requires co-ordinated, multidisciplinary rehabilitation and long-term monitoring. If caregivers refuse rehabilitation, child protection is required. Several unanswered questions remain.

Fabrication and induction of illness in children: the psychopathology of abuse

Fabricating or inducing illness in children (previously called Munchhausen syndrome by proxy) is a form of child abuse in which a caregiver falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care disclaiming knowledge of the cause of the problem. The behaviour has attracted considerable interest and controversy, and some have questioned its existence. In this article, we assess the prevalence of the behaviour, describing behaviours that have been reported and identified, and discuss its psychopathology. We consider the role of psychiatric expertise in the investigation of such behaviour and in the assessment of those who carry it out, based on what is known to date about their psychopathology. We also outline an approach to management with special reference to the characteristics in the mother that may allow for reunification with the child after the abuse has been established.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

Early recognition and management of fabricated or induced illness in children

Fabricated or induced illness (previously known as Munchausen syndrome by proxy) takes place when a caregiver elicits health care on the child's behalf in an unjustified way. Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders specifies deception as a perpetrator characteristic, a far wider range is encountered clinically and is included in this Review. We describe the features of fabricated or induced illness, its effect on the child, and the psychosocial characteristics of caregivers and their possible motives. Present evidence suggests that somatoform and factitious disorders are over-represented in caregivers, with possible intergenerational transmission of abnormal illness behaviour from the caregiver to the child. Paediatricians' early recognition of perplexing presentations preceding fabricated or induced illness and their management might obviate the development of this disorder. In cases of fully developed fabricated or induced illness, as well as protection, the child will need help to return to healthy functioning and understand the fabricated or induced illness experience. Management of the perpetrator is largely dependent on their capacity to acknowledge the abusive behaviour and collaborate with helping agencies. If separation is necessary, reunification of mother and child is rare, but can be achieved in selected cases. More collaborative research is needed in this specialty, especially regarding close study of the characteristics of women with somatoform and factitious disorders who involve their children in abnormal illness behaviour. We recommend that general hospitals establish proactive networks including multidisciplinary cooperation between designated staff from both paediatric and adult mental health services.

The role of nonperpetrating fathers in Munchausen syndrome by proxy: a review of the literature

Munchausen syndrome by proxy (MSBP) is a psychiatric condition and form of child abuse in which a caregiver, usually a mother, induces illness in a child to gain attention for herself. Because children that are abused by a MSBP perpetrator are likely to be hospitalized multiple times, it is important for the nurse to know warning signs and symptoms of MSBP. Of particular interest is the role of the child's parent that is not involved in the abuse, usually the father. This article presents a review of literature on MSBP, focusing on the role of the nonperpetrating fathers.

Psychopathology of perpetrators of fabricated or induced illness in children: case series

BACKGROUND

Munchausen's syndrome by proxy (recently renamed fabricated or induced illness) is a rare form of child abuse, but relatively little is known about the psychopathology of the perpetrators.

AIMS

To examine the medical, psychiatric, social work and forensic records of mothers referred for detailed psychiatric assessment from 1996 to 2009.

METHOD

Twenty-eight consecutive individuals with a putative diagnosis of fabricated or induced illness were referred to the authors for detailed psychiatric assessment and recommendations about management (25 from family courts). We scrutinised all medical and psychiatric records and interviewed them, as well as informants.

RESULTS

In total, 16 (57%) had evidence of a current somatoform disorder, and factitious disorders (either past or current) were identified in 18 (64%): 11 participants had both somatoform and factitious disorders. Nine participants (32%) had non-epileptic attacks. We found evidence of pathological lying (pseudologia fantastica) in 17 (61%) of the participants; in some there were key links between early abusive experiences, the development of pathological lying and the eventual fabrication of illness in the child victim.

CONCLUSIONS

A chronic somatoform disorder or factitious disorder (or both) was detected in almost two-thirds of the participants. Over half of the mothers exhibited pathological lying, in some dating from adolescence, and this often continued into adult life eventually involving the child in a web of deceit and abuse. Psychiatrists whose work brings them into contact with women with chronic somatoform or factitious disorders, especially if there is evidence of lying from an early age, should always be alert to the impact of these illnesses on any dependent children.

Monsters in the closet: Munchausen syndrome by proxy

This syndrome is associated with a high incidence of recidivism, morbidity, and mortality.

Lamotrigine poisoning presenting as seizures: a case of deliberate poisoning

Features of Lamotrigine poisoning are not clearly described in children. We report a child who presented with seizures and bizarre neurological symptoms, later attributed to lamotrigine poisoning.

Wenn Mediziner ungewollt zur Kindesmisshandlung verführt werden: Münchhausen-by-proxy-Syndrom

Reports on seemingly caring mothers, who at the same time fabricate or provoke clinical symptoms in their children and subsequently expose them to potentially harmful medical procedures, are hardly believable at first sight. Nevertheless the steadily growing number of reports on this kind of child abuse, known as Munchausen-by-proxy syndrome, points to a significant number of undetected cases. The interactional involvement of health care professionals in the abuse tends to impede diagnosis, and, as a consequence of the syndrome, usually leads to violent emotional reactions, which require careful analysis and professional handling.

[Munchausen syndrome by proxy]

This review deals with bibliography on Munchausen syndrome by proxy (MSbP). The name of this disorder was introduced by English psychiatrist Roy Meadow who pointed to diagnostic difficulties as well as to serious medical and legal connotations of MSbP. MSbP was classified in DSM-IV among criteria sets provided for further study as "factitious disorder by proxy", while in ICD-10, though not explicitly cited, MSbP might be classified as "factitious disorders" F68.1. MSbP is a special form of abuse where the perpetrator induces somatic or mental symptoms of illness in the victim under his/her care and then persistently presents the victims for medical examinations and care. The victim is usually a preschool child and the perpetrator is the child's mother. Motivation for such pathological behavior of perpetrator is considered to be unconscious need to assume sick role by proxy while external incentives such as economic gain are absent. Conceptualization of MSbP development is still in the domain of psychodynamic speculation, its course is chronic and the prognosis is poor considering lack of consistent, efficient and specific treatment. The authors also present the case report of thirty-three year-old mother who had been abusing her nine year-old son both emotionally and physically over the last several years forcing him to, together with her, report to the police, medical and educational institutions that he had been the victim of rape, poisoning and beating by various individuals, especially teaching and medical staff. Mother manifested psychosis and her child presented with impaired cognitive development, emotional problems and conduct disorder.

Attachment representations in mothers with abnormal illness behaviour by proxy

BACKGROUND

Abnormal illness behaviour by proxy (also known as factitious illness by proxy or Munchhausen syndrome by proxy) is a type of child maltreatment, the origins of which are poorly understood.

AIMS

To describe attachment representations in a cohort of mothers demonstrating abnormal illness behaviour by proxy.

METHOD

Sixty-seven mothers who had shown this behaviour took part in a semistructured interview assessing their attachment representations.

RESULTS

Only 12 mothers (18%) were rated secure in terms of their own childhood attachments. There was evidence of unresolved trauma or loss reactions in 40 mothers (60%). Eighteen mothers (27%) gave unusually disorganised and incoherent accounts of attachment relationships in their own childhoods. The frequency of these attachment categories is higher than in normal non-clinical samples.

CONCLUSIONS

Insecure attachment is a risk factor for this type of child maltreatment. Therapeutic interventions could be offered in relation to unresolved traumatic stress or bereavement responses. Further study of similar groups, such as mothers with sick children or mothers with histories of traumatic experience, would be a useful next step.

Munchausen Syndrome by Proxy: two case reports and an update of the literature

OBJECTIVES AND METHODS

Munchausen Syndrome by Proxy (MSP) may significantly hamper the normal development of children. Our aim was to describe the first two Israeli children who fit this diagnosis.

RESULTS

Case #1 was diagnosed at the age of seven months with failure to thrive, severe recurrent vomiting, and recurrent unexplained fever. Medical tests performed were normal. No improvement was noted following prolonged treatment, which included several surgical interventions. Case #2 was hospitalized at the age of four years because of recurrent convulsive episodes. Medical examinations performed were normal, and there was no improvement in the reported seizure disorder despite continuous treatment. In both cases, MSP was suspected because of a persistent illness that could not be explained by adequate medical basis, and because the symptoms and signs occurred only in the mother's presence. A confrontation was made, leading to rapid deterioration of the hitherto devoted relationship of the mother of case #1 with her child, and of the previous cooperative relationship of both mothers with the medical staff. Removal of both children from their families ensued, with considerable improvement within a brief period, which continued in a one- to two-year follow-up period.

CONCLUSIONS

The study reviews the required diagnostic criteria for MSP and possible treatment options.

The deceit continues: an updated literature review of Munchausen Syndrome by Proxy

OBJECTIVE

This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP).

METHOD

Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles.

RESULTS

Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury.

CONCLUSION

Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.

Different interpretations of Munchausen Syndrome by Proxy

The definition of Munchausen Syndrome by Proxy is reviewed and considered in the context of the overlap with other harmful behaviors of parents. The high incidence of personal abnormal illness behavior in the perpetrators is leading to increasing concern about the safety of children who are cared for by parents who have abnormal illness behavior.

'Battered pets': Munchausen syndrome by proxy (factitious illness by proxy)

Nine cases of suspected Munchausen syndrome by proxy (MSBP), involving pets as proxies, were identified among 448 cases of non-accidental injury to small animals. These cases, recorded by a random sample of small animal practitioners in the UK, demonstrated several combinations of features, including attention-seeking behaviour by the owner, real and apparently factitious clinical signs, deliberate injury, markedly abnormal biochemical profiles, serial incidents, interference with surgical sites, recovery after separation from the owner, and 'veterinarian-shopping' by the owner. All of these features are consistent with those identified in the well documented MSBP in which children are the victims. Furthermore, one of the cases involved serial attempts at poisoning other animals and a child.

Maternal behaviors associated with smothering: a preliminary descriptive study

OBJECTIVES

To describe maternal behavior in 15 women identified as having smothered their children.

DESIGN

A descriptive study of maternal behavior and interaction with her child, using videotapes of mother and child together. These were obtained by covert video surveillance in a hospital setting. Maternal behavior was rated using an assessment schedule designed to be used with video.

RESULTS

The mothers showed a range of behaviors. Three groups emerged; one whose interaction with the child resembled normal maternal behavior, a second who interacted in a hostile way, and a third who showed a paucity of interaction.

CONCLUSION

These preliminary data suggest that smothering may reflect more than one type of abnormal maternal relationship or attitude towards children. This may have implications for treatment and prognosis.

Outcome of psychiatric intervention in factitious illness by proxy (Munchausen's syndrome by proxy)

OBJECTIVE

To determine the outcome for children after psychiatric intervention in cases of factitious illness by proxy.

METHODS

All 17 children from 16 families, selected for admission to the Park Hospital Oxford family unit 1992-96 were followed up after a mean of 27 months. Information was obtained on the children and their carers from general practitioners, social workers or both; 13 of the children and carers were interviewed.

RESULTS

All patients were at the severe end of the abuse spectrum; 12 involving direct induction of illness, 1 tampering with samples to mimic illness, and 4 fabrication of symptoms. The biological mother was the abuser in all cases. Four children and their parents had been initially admitted for assessment, and 13 for treatment to decide whether family reunification was viable. The 4 assessments clarified diagnosis, enabling improved care plans to be made. Of the 13 treatment cases, 10 were reunited with parents after a mean of 71/2 weeks' admission, whereas 3 were discharged to out of home care. There was a further episode of induced illness in 1 of the reunited children. Although some mothers had continuing mental health difficulties, only 1 of the other reunited cases had appreciable parent-child relationship difficulties (not requiring referral to psychiatric services). The children did well in their development, growth, and adjustment.

CONCLUSION

Family reunification is feasible for certain cases, but long term follow up is necessary to ensure the child's safety and to identify deterioration in parent's mental health. The outcome for reunited children compared well with reported untreated cases.

Munchausen syndrome by proxy abuse perpetrated by men

Fifteen families are described in which one or more child incurred factitious illness abuse as a result of the father's false story and actions. The degree of direct physical harm, and the chance of death, was high in those families in which the father had Munchausen syndrome or marked somatising disorder. Eleven children died and another six survived repetitive smothering or poisoning. Although the extent of the risk to children living with a parent who has marked somatising disorder is unsure, there must be vigilance on behalf of those children.

Covert video recordings of life-threatening child abuse: lessons for child protection

OBJECTIVE

To describe historic markers and clinical observations of life-threatening child abuse as diagnosed using covert video surveillance (CVS).

DESIGN

A descriptive, retrospective, partially controlled case study.

SETTING

Two hospitals (in London and North Staffordshire, UK) receiving referrals for the investigation of apparent life-threatening events (ALTE), with the availability of CVS.

PATIENTS

A total of 39 children (age range at CVS, 2 to 44 months; median, 9 months) in whom hospital CVS was used to investigate suspicions of induced illness. Thirty-six were referred for investigation of ALTE, one with suspected epilepsy, one with failure to thrive, and one with suspected strangulation. A control group consisted of 46 children with recurrent ALTE proven on physiologic recordings to be attributable to a natural medical cause (9 attributable to epileptic seizures, and 37 attributable to respiratory problems).

INTERVENTION

Collection of historic details from medical, social service, and police records; interagency collaboration in planning, investigations, and management; development and use of CVS as a clinical tool in the investigation of patients in whom there was suspicion of induced illness.

OUTCOME

Confirmation of attempted suffocation or other child abuse from CVS.

RESULTS

CVS revealed abuse in 33 of 39 suspected cases, with documentation of intentional suffocation observed in 30 patients. Poisonings (with disinfectant or anticonvulsant), a deliberate fracture, and other emotional and physical abuse were also identified under surveillance. The first ALTE occurred at a median age corrected for the expected date of delivery of 3.6 months in the CVS patients and of 0.3 months in controls. Three CVS patients and 27 of the control children (including 20 at <32 weeks' gestation) were born prematurely. Bleeding from the nose and/or mouth was reported in 11 of the 38 patients with ALTE undergoing CVS but in none of the 46 controls. Four patients who had been subjected to recurrent suffocation before CVS had permanent neurologic deficits and/or required anticonvulsant therapy for epileptic seizures resulting from hypoxic cerebral injury. The 39 patients undergoing CVS had 41 siblings, 12 of whom had previously died suddenly and unexpectedly. Eleven of the deaths had been classified as sudden infant death syndrome but after CVS, four parents admitted to suffocating eight of these siblings. One additional sibling who had died suddenly with rotavirus gastroenteritis was reinvestigated after CVS of her sister revealed poisoning, and death was found to be caused by deliberate salt poisoning. Other signs of abuse were documented in the medical, social, and police records of an additional 15 of the siblings. In the 52 siblings of the 46 controls, 2 had died: one from hypoplastic left heart at 5 days and the other suddenly and unexpectedly (classified as sudden infant death syndrome) at 7 weeks. Twenty-three of the abusive parents were diagnosed by a psychiatrist as having personality disorders.

CONCLUSIONS

Induced illness is a severe form of abuse that may cause death or permanent neurologic impairment. It may be accompanied by other severe forms of abuse, may result in behavioral disorders, and may be accompanied by immeasurable suffering. Detection of this abuse requires careful history-taking; thorough examination of the health, social, and police records; and close and focused collaboration between hospital and community child health professionals, child psychiatrists, social workers, and police officers. CVS may help investigate suspicions and ensure that children are protected from additional abuse. When parents have failed to acknowledge that they have deceived health professionals, partnership with them in seeking to protect their children may be neither safe nor effective.