Munchausen syndrome by proxy: the importance of behavioral artifacts.

In the 1990s, two unrelated mothers living in different parts of the United States had a lot in common. Both cared for children with significantly complex medical problems. One woman's daughter suffered from constant intestinal problems, and the other woman's two foster daughters experienced a multitude of ailments that left them weak and emaciated. In addition, both women spent most of their time escorting their sickly girls from doctor to doctor. The daughter of the first mother was eventually hospitalized 200 times, and all three children had to undergo surgery to place feeding tubes into their stomachs. Furthermore, both parents received national praise for their motherly care and devotion to their young girls. Prosecutors maintain that both women shared one more feature, a dark secret eventually exposed to television and newspapers around the world. They were accused of exhibiting symptoms of a bizarre psychiatric ailment called Munchausen syndrome by proxy (MSBP) that led them to fabricate the girls' illnesses to fulfill their own needs for attention and sympathy. (1)

Doctors, emergency medical services (EMS) personnel, members of protective service agencies, and law enforcement officers may unwittingly participate in MSBP when they fail to recognize MSBP behavior, treat the offender, and create a favorable outcome for the child. Protecting America's children is immeasurably important; therefore, law enforcement personnel and EMS providers need to know the significance of behavioral artifacts in the recognition, investigation, and prosecution of MSBP offenders.

HISTORY

Munchausen syndrome was named after an 18th century dignitary named Baron von Munchausen who was known for telling exaggerated stories. Individuals who exhibit the characteristics of Munchausen syndrome fabricate or exaggerate illness or sickness, usually for the purpose of attracting attention to themselves. Munchausen syndrome by proxy is the practice of fabricating or exaggerating illness or sickness onto another person, usually a child. MSBP is a form of child abuse and can prove fatal. Children subjected to this form of abuse may be hospitalized repeatedly and undergo numerous surgeries.

Researchers first began to recognize this pattern of abuse in the 1970s. Sudden infant death syndrome (SIDS) became the default judgement when no cause of death could be identified. Further, several cases where multiple children from the same family perished were attributed to SIDS because of no apparent causes of death. As research on SIDS progressed, the likelihood of a family experiencing multiple infant deaths due to SIDS became unlikely. On the eve of this realization in the 1970s, MSBP became a routinely published topic highlighting its terrible effects on children. Law enforcement personnel have become important players in the fight against MSBP because their position enables them to recognize the affliction in its earliest stages.

RECOGNITION

Law enforcement personnel should remember that MSBP is not a diagnosis.(2) Instead, investigators should recognize it as a form of abuse. In short, MSBP is not what someone has, but what someone does. The majority of people associated with MSBP are women. Often, investigators, along with friends, family, and neighbors, view these women as very caring and loving parents who try to do everything they can for children afflicted with devastating illnesses. Offenders usually exhibit knowledge of diseases and medical procedures beyond what most parents may know. They typically have a medical background or have been around the medical profession in some capacity. A family history of frequent moves and lengthy visits to multiple health care professionals also may exist. MSBP offenders are not associated with any specific ethnic group or level of economic status. Some researchers believe that the behavior of MSBP perpetrators is a character disorder; it does not follow social norms. The satisfaction sought from misleading caregivers at the expense of their children is thought to be the sole reason for committing the abuse.

The methods that offenders use to exaggerate or fabricate illness are quite extensive and designed to deceive health care professionals. MSBP perpetrators convincingly fabricate and lie even when confronted with contrary information. Offenders need attention, and they often seek it through their actions with health care professionals. To feign illness, perpetrators go to great lengths, such as suffocating to mimic apnea, tainting urine with blood, poisoning to resemble gastric complications, inducing vomiting with ipecac to look like reflux problems, and producing unexplainable rashes with chemical irritants.

INVESTIGATION

Often, the first contact with a patient/victim of MSBP occurs in the prehospital arena. Law enforcement and EMS personnel need to not only understand the characteristics of MSBP perpetrators and victims but also realize that this determination is made over time, not just a single occurrence. In the event of an infant or child illness, police and EMS personnel should request information about the history of the illnesses from the parents. Generally, they view parents as individuals who want the best for their children, an assumption that perfectly suits MSBP offenders. Further, police and EMS personnel see parents as knowledgeable, caring individuals extremely attentive to their children's needs and illnesses, which stands in direct opposition to what law enforcement personnel learn as the characteristics of child abusers. As mandated reporters of child abuse, however, police and EMS personnel must understand the differences in behaviors and characteristics found in MSBP as opposed to other forms of abuse.

Police and EMS personnel not only must remain aware of offenders' characteristics but also must be observant of MSBP signs at a child abuse or illness scene. MSBP often goes unrecognized because many law enforcement officers have never encountered, or are unfamiliar with, the disorder. Thus, when dealing with a suspected case of MSBP, law enforcement personnel must alert colleagues of the abuse to ensure correct management of the investigation. They also can employ certain guidelines to help in determining a case of MSBP, including--

* a described medical problem that does not respond to the normal course of treatment;

* multiple responses to the same location for the same patient with similar complaints or a variety of illnesses;

* a family history of similar incidents with siblings, including multiple SIDS within the family;

* signs and symptoms disappear upon the child's removal from the parent; and

* attempts by a caregiver to convince others of illness even in the absence of signs and symptoms.

These guidelines, along with understanding the behavioral artifacts that may exist, are critical to the recognition of MSBP. Artifacts can be both behavioral characteristics and linguistics exhibited by those who fall under MSBP. Because MSBP often leads to the victim's death, recognizing its existence often occurs only after the death of a child and a review of the case.

PROTECTION

MSBP makes child protection very difficult. An interview with a previous director of social services at a children's hospital in Chicago revealed that once hospital personnel became aware of MSBP in the late 1980s they began to take steps to protect children. High risk of injury or death exists while a child remains in the care of the perpetrator; therefore, incidents where the child already has been hospitalized contain less risk.

Based on the existing laws in Illinois, (3) video surveillance in a child's hospital room may be permissible for various reasons, such as security of the child, constant monitoring/assistance in diagnosis and treatment, or protection of the facility and employees from allegations of negligence. For years, discussions about videotaping suspected MSBP offenders finally led to placing a camera in a room at the aforementioned children's hospital in Chicago. In this particular case, a 14-month-old girl was hospitalized for apnea. While in her hospital room, the child periodically would stop breathing for no apparent reason. She remained hospitalized for 30 days, and medical personnel could not uncover anything medically wrong with her. However, hospital personnel did make a connection between the mother's presence and the child exhibiting symptoms of apnea. The hospital decided to videotape the child's room and place a heart monitor on the child. After another episode of apnea, a review of the videotape revealed that the child's mother had put a pillow over the child's face to induce the symptoms. The physician immediately took protective custody of the child. After being removed from her mother, the girl exhibited no more symptoms of apnea. Prosecutors eventually charged the mother with endangering the life and health of a child, a minor misdemeanor. The videotape became the proof beyond a reasonable doubt along with the fact that the child did not show any symptoms of apnea when removed from the mother's supervision.

PROSECUTION

An interview with a Cook County, Illinois, State's Attorney revealed that the Illinois Department of Children and Family Services (IDCFS) initiates MSBP cases in juvenile court for the purpose of custody hearings. However, IDCFS receives very few allegations of MSBP because most suspected cases cannot even be called into the child abuse hotline due to a lack of evidence. When doctors do report MSBP cases to the hotline, they normally already have taken protective custody of the child. In these cases, doctors are positive of MSBP, and they generally have some means of proving it. In many cases, though, only a hunch exists, which does not provide a preponderance of evidence. (4)

Preponderance of Evidence

A supervisor at the IDCFS disclosed that very few MSBP cases advance to court for custody hearings because the IDCFS frequently does not have enough evidence. Varying greatly from a criminal court of law, IDCFS custody hearings can convict with only a preponderance of evidence. However, with cases of suspected MSBP, a preponderance of evidence remains difficult to prove, and, in Illinois, a preponderance of evidence must exist to remove a child from the home. Three reasons for removal include--

1) neglect, which is an environment injurious to the welfare of the child;

2) abuse, which entails inflicted injuries or substantial risk of injury other than by accidental means; and

3) dependent, which denotes a mental disability of a parent.

Evidence for Trial

Law enforcement personnel also incur the burden of obtaining evidence for trials against MSBP perpetrators because officers generally have initial contact with victims and parents involved in child abuse. Therefore, investigators must remain cognizant of behaviors typical of MSBP. For example, officers must document how many times they have visited homes for child-related problems and how many times they have accompanied parents and children to the hospital. An abnormal number of visits coupled with indicators of MSBP behavior can help tip off investigators and prompt them to begin watching suspects more closely for evidence. The evidence presented in a custody hearing originates in four ways.

1) Statements made by the suspect as to the condition of the child

2) Statements made by the child

3) Hospital records

4) Testimony of hospital personnel

Criminal Intent

For criminal prosecution, Illinois prosecutors must prove criminal intent, which means knowingly, intentionally, or recklessly committing the act. Prosecutors also must show that the reason the perpetrator committed the act was criminal. Working against prosecutors, though, is the high standard of proof carried by a criminal act. The suspect overtly must have done an act or consciously omitted an act, and the act must be provable beyond a reasonable doubt. MSBP remains difficult to prove because perpetrators generally do not make statements about the abuse. A witness to the abuse remains the only proof beyond a reasonable doubt, and witnesses to MSBP are rare. Law enforcement personnel can be very helpful in this stage of prosecution, however, because they may have had contact with the child or the perpetrator and heard them discuss illnesses or behavior.

CONCLUSION

Law enforcement officers and EMS personnel may inadvertently become involved in a case of MSBP. Therefore, they need to be able to recognize behavior related to MSBP so that they can investigate the abuse, help rehabilitate the offender, and couple a prosecution of the offender with a favorable outcome for the child.

Distinguishing between MSBP and other forms of child abuse remains extremely difficult because parents can deceive law enforcement officers by creating the illusion of true caregivers. In addition to uncovering parents living the lie of MSBP, officers and EMS personnel have a second burden of providing support in the prosecution of MSBP offenders. Police and EMS providers have contact with victims and perpetrators prior to reaching the hospital and when the child is hospitalized, the two crucial times for recognition of MSBP. By identifying behavioral artifacts, law enforcement and EMS personnel can detect MSBP at an early stage and can help remove the child from the dangerous environment of abusive parents.

(1) Marc D. Feldman, M.D., "A Parenthood Betrayal: The Dilemma of MSBP," Self Help Magazine, March 28, 1998. For more information on MSBP, see Kathryn A. Hanon, "Child Abuse: Munchausen's Syndrome by Proxy," FBI Law Enforcement Bulletin, December 1991, 8-11, and Kathryn A. Artingstall, "Munchausen Syndrome by Proxy," FBI Law Enforcement Bulletin, August 1995, 5-11.

(2) This conclusion is based on the authors' experience and research regarding MSBP.

(3) Law enforcement officers in other states should be aware of their states' laws regarding video surveillance and all issues related to child abuse and MSBP.

(4) Preponderance of evidence is comparable to the phrase "beyond a reasonable doubt" in a criminal case.