Munchausen syndrome by proxy

SHORT REPORT

Expect the unexpected: favourable outcome in Munchausen by proxy syndrome

Jörg Klepper & Anja Heringhaus & Cornelius Wurthmann & Thomas Voit

Received: 12 June 2007 /Revised: 3 October 2007 /Accepted: 3 October 2007 /Published online: 7 November 2007 # Springer-Verlag 2007

Abstract Munchausen by proxy syndrome (MBPS) is a form of child abuse wherein the mother fabricates or produces illness in her child. The condition is hard to diagnose and few successful interventions have been described. Long-term outcome is associated with high family disruption, reabuse, mortality and morbidity. We report on a six-month-old girl that experienced eight hospital admissions within five months. Symptoms of repeated vomiting, bloody diarrhoea and acute life-threatening events (ALTE) were never substantiated. Finally, blood in diapers and napkins presented by the mother was shown to be of maternal origin. When confronted, the mother agreed to psychiatric admis- sion. Following five months of treatment, her mental state stabilised and she entered supported living. She remained separated from the child, who was given to the father and developed normally on close paediatric follow-up. We report a definite diagnosis and successful intervention in MBPS. The case highlights characteristic features of this entity and

illustrates that a favourable outcome depends on early intervention with separation of the child and perpetrator, as well as concomitant long-term psychiatric treatment.

Keywords Munchausen by proxy syndrome . Child abuse .

Vomiting . Bloody diarrhoea . Treatment

Abbreviations MBPS Munchausen by proxy syndrome ALTE Acute life-threatening event RFLP Restriction fragment length polymorphism

Introduction

Munchausen by proxy syndrome (MBPS), also called factitious illness by proxy [1], is a form of child abuse in which a parent or guardian, usually the mother, fabricates or induces illness in a child [5]. This entity, first described by Meadow in 1977 [8], is associated with high mortality, morbidity, family disruption, reabuse and harm to siblings [4, 14]. The terminology remains confusing [14] but the condition has since been recognised in more than 100 patients worldwide [6, 11, 12]. The diagnosis is based on the following criteria, modified by Rosenberg and Meadow [10]:

1. Illness in a child which is fabricated by a parent or someone who is in loco parentis.

2. The child is presented for medical assessment and care, usually persistently, often resulting in multiple medical procedures. The perpetrator denies the aetiology of the child’s illness.

Eur J Pediatr (2008) 167:1085–1088 DOI 10.1007/s00431-007-0627-4

J. Klepper (*) Children’s Hospital, Am Hasenkopf, 63739 Aschaffenburg, Germany e-mail: [email protected]

A. Heringhaus : C. Wurthmann Department of Psychiatry, Philippusstift, Essen, Germany

T. Voit Institut de Myologie-AIM, Groupe Hospitalier Pitié Salpêtrière, 47-83 boulevard de l’hôpital, F-75651 Paris cedex 13, France e-mail: [email protected]

3. Acute symptoms and signs of illness cease when the child is separated from the perpetrator.

The condition is difficult to diagnose because clinical features are unspecific. They often involve multiple organ systems and are, therefore, difficult to substantiate. Among the most preferred symptoms are haemorrhages (44%), seizures (42%), loss of consciousness (19%), apnea (15%), recurrent diarrhoea (11%), recurrent vomiting (10%) and rashes (9%) [11]. The “disease” is usually fabricated by the mothers, most of them suffering from a substantial personality disorder [7, 11]. They are skilled in deceiving medical staff, enjoy the attention and sympathy they receive from their child’s apparent illness, and often are not accessible for psychiatric intervention. Once MBPS is diagnosed, the likelihood of successful rehabilitation is poor if the child remains in the family and the risk of reabuse in patients and siblings is high if they remain unprotected. In a cohort of 119 cases, 40% of children with non-accidental poisoning and 50% of children with suffo- cation experienced further abuse [4]. Paediatric follow-up is essential; even in MBPS without physical harm, 17% of children allowed home were reabused in a two-year follow- up period [4].

Patient and methods

The patient is the first child of unmarried, non-consanguineous parents of Turkish origin. She was born prematurely at 36 gestational weeks to a 16-year-old mother because of maternal asthma following an uneventful pregnancy. Birth weight was 2,700 g, length 47 cm, APGAR score 10/10 and cord pH 7.37. The postnatal period was normal except for mild hyper- bilirubinaemia. Breastfeeding was initiated and the child was discharged. At three weeks, she was admitted to hospital for vomiting and failure to thrive. Clinical observation and investigations were normal and the child was discharged after three days. One day later, she was readmitted to the same hospital with identical symptoms, which, again, could not be substantiated in an additional three days of clinical observa- tion. At the age of 12 weeks, the infant was sent to a second hospital because of vomiting and bloody diarrhoea reported by the mother. Here, vomiting and loose stools were observed three times and quickly responded to intravenous fluids within one day. Further clinical assessment and laboratory parameters, in particular, the workup for infections and inflammatory disease, were normal. Bloody diarrhoea could not be con- firmed. A heart murmur was classified by electrocardiogram (ECG) and echocardiography as accidental. Two days after discharge, the girl was readmitted to a third hospital for febrile gastroenteritis and conjunctivitis. She was treated with anti- biotics and intravenous fluids, and was discharged after

48 hours. At the age of 17 weeks, the child was admitted to a fourth hospital for vomiting and abdominal pain. Again, four days of observation and a medical workup did not confirm any gastrointestinal symptoms. An outpatient paediatric cardiolo- gist appointment for congenital heart disease independently confirmed the heart murmur as accidental. At 21 weeks, she was acutely admitted for an acute life-threatening event (ALTE). The mother described that the sleeping child suddenly stopped breathing, became cyanotic and required resuscitation. The arriving emergency physician did not observe any abnormalities in the child and admitted her to hospital. The clinical observation, routine blood parameters, electroenceph- alogram (EEG) and polysomnography were normal. Follow- ing discharge, another ALTE event at home three days later resulted in the seventh hospital admission. It was then that MBPS was suspected for the first time, especially as clinical observation and investigations remained entirely normal. The treating paediatrician convinced the parents to admit the child to our institution for a detailed gastrointestinal workup. In summary, the child experienced eight admissions to four different hospitals, one outpatient appointment with a paedi- atric specialist and spent 44 days in hospital within the first six months of her life (see Table 1).

Molecular analysis was performed on DNA isolated from blood traces on the patient’s diaper and napkin, as well as from buccal swabs obtained from the mother and patient using standard protocols. Restriction fragment length polymorphisms (RFLP) was performed. Defined DNA sequences were amplified using specific primers and Taq-polymerase, and separated by electrophoresis.

Results and follow-up

Molecular analysis by RFLP showed that the allelic combinations determined from the diaper and napkin blood traces were identical to those determined from the DNA of the mother (the biostatistical probability of occurrence of this specific DNA profile is 4.33×10−12, which is equivalent to 1 in 231 billion people).

Psychiatric assessment of the mother (N.S.)

The child’s mother (N.S.) was a 16-year-old Turkish female born and raised in Germany. Her father, an alcoholic, frequently physically abused his wife and elder sister and forced N.S. to witness the violence. Her mother tried to run away seven times unsuccessfully. When she finally sepa- rated from her husband, subsequent new partnerships increased her distance to her daughter N.S., who grew up in intermittent foster care. She did not achieve a school degree nor started job training. When she met her future husband at the age of 16 years, the relationship triggered conflicts with her mother and sister that escalated to a loss

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of contact for 18 months. Her husband was very occupied at work and shared very little time with her. The resulting feeling of loneliness, the fear from her father and her desire to establish contacts with her family sparked further conflicts in her partnership, including asthma attacks that required emergency treatment. Her pregnancy was un- planned and complicated by significant weight gain and recurrent asthma attacks. After delivery, her husband was mostly unavailable. He felt that N.S.’s care for the baby was warm and emotional. Within six months after delivery, N.S. re-established contact with her mother and sister to tell them about the recurrent bleeding of her child. When both relatives visited N.S. in hospital, they were surprised to find the that child was well and happy.

Follow-up

The child

Following the confirmation of maternal blood in the child’s diaper, the mother and child were separated and the child was put under the authority of the local child protection service. No evidence was found that the father was informed or involved in the manipulation of symptoms. Once he became capable of caring for the infant with the assistance of his own family, the child was discharged. Three follow-ups in a community paediatric centre within the next year by one author (J.K.) documented normal growth, body weight and psychomotor development. None of the previously reported symptoms recurred.

The mother (N.S.)

N.S. was hospitalised for 4.5 months and received psychotherapy. On admission, she denied child abuse and any knowledge about the origin of the blood stains in the diaper. In contact, she was very friendly, well adapted and eager to obtain attention and acknowledgement. In this, she

appeared to be very insecure and unable to realise and differentiate her own feelings. She showed no aggressive behaviour, but in her conduct and actions, a great amount of unmet personal needs and a lack of conflict-solving strategies became apparent. She was allowed to see her child on a regular basis in the continuous presence of nursing staff. During these visits, the staff noted a great insecurity in handling the child. She had great difficulties in realising the needs of her child and responding to them adequately. Even when discharged, she insisted on amnesia of the mental situations that led to the child abuse. However, at this stage, she was closer to her memories and emotionally significantly more involved when talking about this subject. She was aware that something had indeed happened. Based on these observations, a return of N.S. to the husband and child following the inpatient treatment was not advisable. N.S. agreed to concentrate on her personal development and entered supported housing. Supervised contacts with her child were arranged with the support of child care institutions and outpatient psycho- therapy was initiated to work up her severe traumatic experiences and to allow her to mature within a supportive therapeutic setting.

Discussion

Paediatricians are trained to rely on a detailed medical history provided by parents and caretakers. In MBPS, this most valuable tool is invalid. Without intent, the physician might even contribute to the abuse of the child by ordering expensive or invasive tests searching for increasingly unlikely and rare diseases. As such, MBPS represents a modern paediatric challenge [2, 13]. No population-based prevalence data exists and the true number of cases in any population is almost impossible to determine [13]. Accord- ing to Davis et al. [4], the annual incidence of MBPS in the UK is 0.5 per 100,000 for children under 16 years of age.

Table 1 Summary of hospital admissions and presenting symptoms

Admission Age (weeks) Stay (days) Presenting symptoms Diagnosis

Hospital A 3 3 Vomiting, failure to thrive Not confirmed Hospital A 4 3 Vomiting, failure to thrive Not confirmed Hospital B 12 3 Vomiting, bloody diarrhoea Not confirmed Hospital C 13 2 Vomiting, bloody diarrhoea Not confirmed Hospital D 17 4 Vomiting, bloody diarrhoea Not confirmed Cardiologist 18 – Congenital heart disease Not confirmed Hospital D 21 3 Acute life-threatening event (ALTE) Not confirmed Hospital A 22 5 Acute life-threatening event (ALTE) Not confirmed

MBPS? Not confirmed Hospital B 26 21 Vomiting, bloody diarrhoea Not confirmed

MBPS? Confirmed

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Many cases will remain undiagnosed as physicians are reluctant to consider the diagnosis and, even so, some clinicians doubt the existence of such a condition.

Our case remarkably follows the general pattern of MBPS. Vomiting, bloody diarrhoea and ALTE score within the top symptoms described in this condition [9, 11, 13]. In the child, these symptoms were never independently confirmed and did not occur again once the perpetrator and child were separated. The child’s mother changed physicians regularly, involving four hospitals in quick succession and a clock-like fashion (Table 1). It took six months to establish the diagnosis, which is slightly less than the average time generally required in MBPS cases [13]. She reflected many aspects of the stereotype of a MBPS mother who is unusually friendly with the medical staff, seems unconcerned when the doctor is unable to make a diagnosis and finds for herself a curious sense of purpose and safety in the midst of the disasters which she herself has created [11]. Like many of the mothers involved, she reported a history of abuse and neglect as a child. Three types of motivation have been postulated in perpetrators of MBPS [13]:

1. The parents wanting attention and sympathy for their own anxiety or depression (help-seekers).

2. Parents needing a relationship with the doctor to deal with earlier traumatic losses.

3. Those who are convinced that their child is actually ill.

The overall profile of the child’s mother described here appeared as help-seeking. Giving care and raising a child in view of significant personal neglect and deficits in personal relationships represented an extreme hardship for her. This was further aggravated by the loss of contact with her original family and her inability to distinguish between her own needs and the needs of her child. She repeatedly sought help from the medical profession fuelled by the lack of alternative solutions to cope with her fears and by the excessive demands of her environment.

Once the diagnosis was secured, the perpetrator and child had to be separated. Previous studies have shown that cases of MBPS had the best outcome if the child was taken into long- term care at an early age without access to their mothers; children remaining with their mothers without further control fared the worst [3, 4, 12]. Also, at least one risk factor for poor outcome identified by Meadow [7], namely, a child under five years of age, was met.

In general, the spectrum of abuse in MBPS includes many severe cases with significant mortality, long term morbidity and family disruption. This report recalls many characteristic features of this condition to the physician’s attention but it also emphasises the potential of a joint effort of physicians and health authorities to establish an early

diagnosis and, thus, improving outcome in MBPS [4]. The case is, nevertheless, exceptional, in that the mother complied with the genetic analysis that secured the diagnosis and accepted separation from her child and psychiatric assistance. Her compliance enabled paediatric and psychiatric intervention, and facilitated a favourable outcome, which is unusual in this entity.

Of note, Baron K.F.H. von Münchausen was a respected 18th century cavalry captain who entertained friends with wartime stories, having served with the Russians against the Turks. It was one of these friends, Rudolph Erich Raspe, who published “Baron Münchausen’s Narrative of his Marvellous Travels and Campaigns in Russia” in need for money [9]. Very much to the discomfort of Münchausen himself, Raspe thus established a new literate standard for fabulous, exaggerated fiction.

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