Recognizing Munchausen Syndrome by proxy

WWhether fictional or based on fact, Munchausen syndrome by proxy grips the public. Media representations in The sixth Sense It is Sharp objects and the real-life news coverage of Gypsy Rose Blanchard’s December 2023 prison release is hard to look away from. The best-known cases – real or dramatized – are often the most serious, but Munchausen, by proxy, also appears in more subtle and difficult-to-detect forms.

“The media is fascinated, but tends to portray the most extreme cases,” says Dr. Marc D. Feldman, Distinguished Life Fellow of the American Psychiatric Association and author of Dying to Get Sick: True Stories of Medical Mistake.

So how do more healthcare providers develop the skills to recognize this form of child medical abuse and report it to the appropriate authorities?

What is Munchausen by proxy?

Munchausen by proxy “is a form of abuse in which a caregiver fakes, exaggerates, or induces illness in another person. Typically, the caregiver is the mother and the victim is her child,” says Feldman.

Although this deception can result in tangible benefits — like funds for the disabled or opioid medications that the caregiver later abuses — the perpetrator’s main motivation is typically attention, says Mary Sanders, a professor of clinical psychology at Stanford University School of Medicine.

You may hear this type of abuse referred to by many names. Although it was once mostly called Munchausen syndrome by proxy, many experts now omit the word “syndrome” because it implied that there was a clean, organized checklist for diagnosing a perpetrator. There are some commonalities among caregivers who inflict this type of abuse, but not everyone meets the same criteria, Sanders says.

Increasingly, the phenomenon is called Munchausen abuse by proxy (MBP) to emphasize the negative effects on the victim or a type of medical child abuse, says Brenda Bursch, professor of clinical psychiatry and biobehavioral sciences and pediatrics at the School of Medicine. David Geffen. at UCLA.

Child medical abuse does not specify why a caregiver is over-medicalizing a child, Sanders explains. But if the caregiver is intentionally misleading about a child’s illness, he or she is also said to have factitious disorder imposed on another (FDIA), according to changes made in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a glossary of mental health diagnoses. Whatever the behavior is called, it is pernicious – and often difficult to detect.

“In the past, making a diagnosis of Munchausen by proxy was challenging because understanding the caregiver’s motivations was part of the definition,” says child abuse pediatrician Dr. Amy Gavril, former board member of the American Academy of Pediatrics (AAP). . on Child Abuse and Neglect and associate professor at the West Virginia University School of Medicine. “An adult’s motivation is an incredibly challenging thing to figure out, and as a pediatrician, when it’s not your patient, it’s even harder.”

Experts believe this form of abuse is largely underreported because it is so difficult to recognize. The official incidence is about 0.5 to 2.0 cases per 100,000 children under the age of 16, according to a 2013 study. Pediatrics report, but things could be much more serious than that.

“My feeling is that it’s very underrecognized by doctors because many haven’t even heard the term Munchausen abuse or child medical abuse, or don’t really know what it is,” says Feldman. “You can’t diagnose something you don’t understand or have never heard of.”

See more information: 6 things to do if your doctor isn’t listening to you

Deception is key for Munchausen by proxy

It makes sense that MBP abuse is difficult to recognize, considering that the perpetrator decided to deceive everyone. “If parents are really trying to deceive, they will get away with it for a while,” says Sanders.

To spend as much time as possible, caregivers often change medical practices before the health care provider has time to become suspicious, Feldman says. But even qualified experts can have difficulty detecting MBP abuse. “The basis of this is invention, and it is very difficult to identify when a caregiver is not telling you the truth, because we are trained to listen and take very seriously what a child’s caregiver has to say,” says Gavril.

Sometimes seemingly harmless cases of deception can be an early giveaway. “I had a mother who said her son was born premature, weighing 4 pounds, 3 ounces. But when I get the birth records back, it says 8 pounds, so that’s a clear forgery,” says Sanders.

A series of red flags

MBP abuse remains confusing to health care providers, legal professionals, and the public, according to a 2020 review article in Annals of Pediatrics and Child Health by Bursch. But this is not the fault of any doctor or specialty; it’s a problem with medical education and child welfare systems. “Most doctors do not have the training and guidance necessary to professionally, ethically, and skillfully protect victims of PMB,” she wrote.

Even without intensive training, however, it is possible to be more alert to warning signs, the most common being inconsistency. “You’re looking for this mismatch between what’s happening to the child and what you’re seeing objectively,” says Gavril. “It is these ongoing inconsistencies rather than a specific symptom” that raise suspicions, she adds, because the caregiver may claim that a range of medical problems are afflicting the child.

Perpetrators of Munchausen by proxy are often very involved in the child’s medical care. They may be active in advocacy organizations for the rare condition they say the child has, or they may try to act as if they are your friend as the child’s doctor, Sanders says.

Another telltale sign is if symptoms subside when the child is separated from the abusive caregiver. “I often hear parents say, ‘My ex-wife presents her son as autistic, but when he’s with me on vacation, he’s perfectly fine’ or ‘His dietary restrictions are severe and imposed by his mother. When he’s with me, he eats whatever he wants. This type of information is invaluable,” says Feldman.

One 2007 Pediatrics An article from the AAP Council on Child Abuse and Neglect suggests that doctors ask themselves the following three questions to help determine whether a child may be a victim of MBP abuse:

Any suspicion is enough to report

Doctors are required to report suspected child abuse. But that doesn’t mean doctors have to be sure of what they’re seeing. “You don’t have to know for sure that this abuse is happening. If you have reasonable suspicion, it is not a choice; you’re a mandatory reporter,” says Sanders.

Still, it’s not uncommon, says Feldman, “to find cases where 20 pediatricians were consulted in a very obvious case and no one documented any suspicions of abuse.”

This is a problem because “the longer it goes undiagnosed, the more likely it is that permanent or serious harm will occur to the child,” says Gavril.

Pediatricians and mental health care providers are more likely to notice something out of the ordinary. But all professionals should at least be aware of the possibility of MBP abuse because victims often rotate between many different specialists, such as gastroenterologists, pediatric neurologists and infectious disease doctors, says Gavril. These specialists likely have even less training in recognizing child medical abuse than pediatricians.

Oftentimes, caregivers are “a little scared to document their concern because they are averse to lawsuits and worry that it will be provocative if the caregiver finds out,” says Feldman. For example, in the high-profile case of Olivia Gant in Munchausen, who died at age 7 in 2017, many caregivers had suspicions but none expressed concerns because “they were afraid of the bossy, domineering mother and what she might do if they made a report to child protective services,” he says. Gant’s mother is now serving 16 years in prison.

“Most doctors say ‘I didn’t report it because I couldn’t prove it.’ That’s the job of child protective services or the police. We have to recognize our professional duties to the patient, and that patient is the child,” says Feldman.

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Systematic issues prohibit further advancement

Child protective services does not currently have a specific code or label for MBP abuse, so it is typically considered medical neglect, says Feldman. This makes it difficult to track prevalence, says Bursch.

But if advances can be made in this coding system, it could open the door to better training and education. “If we are successful in advocating for a specific category for child/adult protective services to use to correctly label and track MBP, then mandatory training will be required to educate caseworkers on appropriate investigation and management approaches. of suspected cases”, says Bursch. This support would help doctors who have a duty to report suspected abuse, even when they are not sure it has occurred.”

A more universal approach to electronic medical records could also help. “We should all advocate for the standardization of electronic health records so that we can easily query records from other facilities,” says Feldman, making it easier to recognize fraud patterns.

As Sanders emphasizes, it’s essential for doctors to trust their intuition when a situation seems wrong. “If something just doesn’t make sense, look further,” she says. “And not in the sense of doing more invasive investigations, but recognizing that you may not be getting accurate information.”