What Is Munchausen Syndrome By Proxy? What Is Fabricated Or Induced Illness?

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Main Category: Psychology / Psychiatry
Also Included In: Pediatrics / Children's Health;  Mental Health
Article Date: 19 Oct 2009 - 9:00 PST

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Munchausen Syndrome by Proxy or fabricated or induced illness (FII) is a form of child abuse or parenting disorder. A parent or caregiver of a child, in most cases the mother, either causes or fakes signs and symptoms of illness in a child in order to gain the attention of health care professionals.

Munchausen Syndrome by Proxy differs from other forms of parenting disorders because the offending person is nearly always the mother, who is generally seen as a very good parent, there is either no or very little family friction, and the abusive behavior is obviously planned - it is not a response to the child's behavior.

In some rarer cases the abuser may not be the mother. Also, the victim might be a vulnerable adult.

Fabricated illness is the most common form of Munchausen Syndrome by Proxy (MSBP). The parent claims the child is ill when no illness is present. The mother may claim her child is having a fit when it is not the case, or she may maintain that her child has blood in his/her urine. She may offer urine samples into which she had added her own blood.

Induced illness is another form of MSBP in which the mother makes the child ill, by either making him/her ingest a substance, or even injecting something into the child to make them sick. Tragically, in some cases the consequences can be fatal.

The abbreviation FII stands for fabricated or induced illness. MSBP is a form of FII.

The motivation is to assume the rick role by proxy (by using a substitute, a stand-in). Munchausen Syndrome differs from Munchausen Syndrome by Proxy. A person with Munchausen Syndrome fakes or induces signs and symptoms themselves - they want to be the patient themselves, while a person with Munchausen Syndrome by Proxy uses a substitute person, usually a child in their care, and less commonly a vulnerable adult in their care.

The term was coined by Professor Roy Meadow in 1997, who was then head of Pediatrics at the University of Leeds, England. He described the bizarre behavior of two mothers. Meadow described one who poisoned her toddler with too much salt, and another who tampered with her baby's urine sample by placing her own blood into it. Initially, the medical community doubted whether MSBP actually existed, but over the years it has gained acceptance as a recognized condition.

The rest of this article will use the term mother as the person with MSBP because in most cases it is the mother. However, it should be made clear that the abuser might be the father, male or female caregiver, or male or female guardian. The terms FII and MSBP (Munchausen Syndrome by Proxy) will be used in the article interchangeably (with the same meaning).

FII or Munchausen Syndrome by Proxy?

Healthcare providers in the United Kingdom and some other countries prefer to use the term FII rather than MSBP because they say that MSBP does not properly describe the full range of behaviors and motives that occur in FII. However, the term MSBP is still widely used in many other countries.

FII is very rare. According to the National Health Service (NHS), UK, there are an estimated 50 new cases each year in the whole country. In most cases the victim is under five years of age. In 85% of cases the abuser is the biological mother. In general, only one child in a family is a victim.

What are the symptoms of fabricated or induced illness?

There are some warning signs which may suggest that a child is being subjected to FII. Examples are:

• The child has repeated and unexplained illnesses.


• The child has unexplained multiple illnesses.


• The child's supposed symptoms only occur when the mother is present.


• The mother appears to know a lot about medicine.


• Although the mother stays with the child all the time while he/she is in hospital and attends to him/her well, she may not appear as concerned about the child's well being as the health care professionals who are providing treatment.


• The father is not involved in the care of the child, or his involvement is minimal.


• The mother talks to the medical team a lot and tries to develop a friendly relationship with them. However, if anything related to her views on what's wrong with the child are challenged she becomes aggressive, confrontational, and may become abusive.


• The mother is keen for her child to undergo tests which most parents would only agree to if they were absolutely necessary. She will even encourage doctors to perform tests and procedures which may be painful for the child.


• Documents or other sources indicate that the mother has changed doctors frequently, and/or has visited different hospitals for her child's treatment.

Six categories of patterns of abuse

There are six categories of patterns of abuse which are found in cases of FII. Below they are listed in order of severity, with the least severe at the top:

• Inventing signs and symptoms and tampering with test results which encourage the diagnosis of an illness.


• Deliberately not providing the child with nutrients.


• Deliberately triggering symptoms, not including smothering or poisoning. An example might be to apply a chemical on the skin to produce a rash or irritation.


• Using a low toxicity poison on the child. An example might be a laxative to give the child diarrhea.


• Using a high toxicity poison on the child. An example might be using insulin to induce hypoglycemia (excessively low blood sugar level).


• Making the child lose consciousness by deliberately smothering him/her.

The most common fabricated symptoms include:

• Fits (seizures)
• Fainting
• Apnea (bouts of breathlessness)
• Hyperactivity, learning difficulties, and other psychological symptoms
• Asthma
• Vomiting
• Diarrhea
• Allergies and rashes

Some mothers manage to get the child's older siblings to back up her claims. This may be because the mother is very convincing, they may be frightened that she will abandon them if they don't, or simply to please their mothers.

How should I deal with a suspected case of FII?

If you suspect that a friend or acquaintance may be fabricating or inducing symptoms in their child, do not confront them. People with Munchausen syndrome or Munchausen syndrome by proxy will never admit to doing anything wrong if confronted directly. In fact, the confrontation may be used by them as a warning and a chance to hide or get rid of evidence of abuse.

If your suspicions occur in your work environment - perhaps you work with children - talk to the person responsible for child protection issues in your organization. Otherwise, contact your local child protection agency.

What are the causes of FII?

Experts are not sure what the exact causes of fabricated or induced illness (FII) are. Most psychologists and psychiatrists believe that some traumatic experience in the abuser's life may be a key factor.

A significant number of experts believe that mothers with Munchausen syndrome by proxy have a borderline personality disorder. People with a borderline personality disorder have an abnormal pattern of thoughts and beliefs about themselves and other people. Their thought patterns and beliefs can make them behave in a way that others would find abnormal and disturbed.

The majority of personality disorders are linked to some traumatic childhood event or experience. A significant percentage of mothers involved in FII have a history of neglect or abuse when they were children, or experienced a tragic loss of a family member, or were brought up in dysfunctional families. It is important to remember that millions of non-abusive parents and caregivers also had similar childhoods.

Situations and events which would distress and upset mentally healthy people may provide a bizarre form of comfort and reward for some people with personality disorder. Having your child undergo painful medical procedures and tests and talking to lots of health care professionals about it would be a very unpleasant experience for most people, but a source of comfort and fulfillment for a mother involved in FII.

Gathering useful data on why this happens is difficult. Most people involved in serious cases of FII are in complete denial and do not cooperate or adhere to any kind of treatment for their mental disorder.

Some say that having a sick child gives the mother the role of concerned parent and caregiver, while at the same time the responsibility of caring for the child is given to health care providers.

An alternative theory is that by focusing all her thoughts on the child's serious health problems, the mother can shut out and forget about her own inner sadness and unpleasant experiences and emotions.

How is FII diagnosed?

As MSBP is extremely rare, and doctors generally take everything a mother says about her child as being true, it is extremely difficult for health care providers to diagnose a case of fabricated or induced illness.

If the doctor suspects FII

If a GP (general practitioner, primary care physicians) and some other types of doctors suspect there may be a case of FII they will usually refer the case to a senior pediatrician. The senior pediatrician will try to determine, by examining the medical evidence, whether the child's signs and symptoms have a clinical explanation. Many senior pediatricians may consult with other specialists and order further testing.

If the child is old enough, the doctor may attempt to talk to him/her when the mother is not around. This might not be possible, though, because a mother involved in FII tends to stay next to her child all the time.

The medical team will double check the blood and urine samples for evidence of added substances, including unprescribed medicines, toxins, or blood (in urine samples).

If the senior pediatrician in the UK, for example, cannot find a clinical explanation for the symptoms and there is some clinical evidence of FII the case will be referred to the police and social services. They will have a meeting - police, medical staff and social services - and discuss the evidence and assess the likely risk to the child.

If they conclude that there is an immediate risk, the child will be removed from the mother's care by social services. The child may be cared for by another relative, or social services (this may include foster care).

If it is determined that the mother has not harmed the child, has just fabricated (faked, invented, lied about) symptoms but not caused any, a child protection plan will be set up. In the UK the child protection plan takes into account the child's health, safety, educational, and social well-being. In some cases a child's education may have suffered because the mother kept him away from school due to hoax illnesses.

The mother may have to agree to receive psychiatric treatment or family therapy as part of the child protection plan. If she does not adhere to the child protection plan she may risk that child being removed from her care.

If it is determined that the level of abuse is severe enough, the police will investigate the case. This investigation may include the use of covert video surveillance to find out whether the mother is deliberately making the child ill (inducing symptoms). Covert video surveillance is generally a last resort if there is no other way to get information which explains the child's symptoms. In the UK, and most other countries, only the police are allowed to carry out covert video surveillance; and even then, they would have to apply for a warrant from a judge.

What are the treatment options for FII?

Treatment for Munchausen syndrome by proxy involves two patients, the mother (or caregiver) and the child (or victim).

• Treatment for the mother or caregiver - this will include both intensive psychotherapy and family therapy.
  
  Effective treatment for people with MSBP is difficult because the people with the disorder tend to deny they have a problem, lie and don't cooperate. Successful treatment depends on the person telling the truth.
  
  Psychotherapy focuses on what caused the mother to fake or induce symptoms and illness in the child, and then resolve the problem; this will include learning to form relationships that are not associated with being ill.
  
  Family therapy focuses on dealing with family tensions, improving the mother's parenting skills, and attempting to restore the relationship between the child and the mother.
  
  If it is a severe case of FII the mother may be forcibly kept in a psychiatric facility in order to carefully monitor her relationship and contact with the child.
  
  Treatment is generally effective for patients who accept they have a problem, admit what they have done, and cooperate with a treatment program. Eventually the mother may get her child back. Unfortunately, a significant number of patients stay in denial and refuse to cooperate.


• Treatment for the child or victim
  
  Managing such cases usually involves a team that includes a medical team, social services (social workers), foster care organizations, and the police.
  
  The medical team's aim is to get the child back to good health. This may be followed by long-term therapy or counseling to help overcome the trauma and stress caused by the abuse.
  
  A significant number of children may have a delay in their development and experience behavioral problems and anxiety. The belief that they really are ill may persist for a long time and may require psychiatric help later on in life.

What are the complications of FII?

• Continued abuse.
• Multiple hospitalizations.
• Dangerous and unnecessary surgical procedures and tests.
• Serious psychological and physical damage to victim.
• Death of the victim.
• The break-up of the family, which affects the victim, mother (or caregiver) and everyone else.

Written by Chrisitan Nordqvist
Copyright: Medical News Today
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