Munchausen Syndrome by Proxy

“I’m four,” she said and showed me three fingers.…

“Shut up,” she said. “Shut up, shut up, shut up.”…

The little girl turned to her brother and gave him a shove. “Shut up, you stupid whore,” she said. “Get me a beer.” ¹

Minor physical anomalies appear to be strongly related to hyperactivity and later criminal involvement, but only if the offender was reared in an unstable, nonintact family.² It has recently been found that children with…hyperactivity…have deficiencies in rule-governed behavior. Rules are constructed by the individual or by others such as parents or teachers to describe relationships among behavior, antecedents, and consequences. For example, “When your little brother takes one of your toys, don’t hit him, or you will be sent to your room.” In responding to such rules which describe contingencies — that is, what will happen if certain things occur — hyperactive children have special problems in tracking. Although these children may be able initially to inhibit undesirable behavior in response to a rule, they are unable to use rules to track or maintain their behavior over time (R. A. Barkley, “Attention deficit disorders,” in M. Lewis & S. Miller (Eds.), Handbook of Developmental Psychopathology, (New York: Plenum, 1990)). Probably as a result of their difficulties…[the] children suffer academically.³

Child abuse, child neglect. For a doctor one of the most difficult parts of treating abused children is simply making the diagnosis. In the ER this can be even more difficult because a diagnosis must often be made after only a minute or two of observation. One rule of thumb, I’ve learned, is to be suspicious of any parent who arrives in an ER with an injured child and wants to leave too quickly.

One hot summer night it happened just that way. A mother had her son by the arm — he was about five — and she dragged him up to me.

“How much longer is this going to be?” she demanded.

It should have been obvious that we were all working as fast as we could. I had just intubated someone who had taken an overdose of antidepressants, and was rushing off to see a woman with heart failure. From where I was standing I could see into the room where the woman lay on her bed struggling to breath while a burly looking man sat next to her, holding her hand.

“Ma’am,” I said, “It’s going to be a little while.”

“Well, I don’t have a little while. My son is hurt.” Something in her tone made me pause for a moment and look at her.

“Dear,” I said, “everyone here is very sick tonight.”

“Don’t you ‘dear’ me. I’m going to another ER. I’ve waited over two hours. I want some service.”

Ed, the charge nurse, came hustling over. “I put you in that room exactly ten minutes ago.” He pointed emphatically at his watch. “So don’t tell her you’ve been waiting for hours.” He stopped next to me and whispered in my ear, “I’m worried about this kid.”

I knelt down to look at the whimpering child. He had obviously broken his forearm — the radius. There was swelling at the midshaft of the radius, and the arm beyond canted away at an angle. This was odd. When people fall, they generally fracture the forearm near the wrist. A fracture in the middle of the bone is much rarer and usually occurs from a direct blow. They’re called nightstick fractures because people have gotten them from defending themselves against blows from a police officer’s nightstick. This kid had such a fracture.

“How did this happen?” I asked the boy.

He looked up at his mother and then at me and silently drew away.

“I’m leaving,” the mother said, giving the child’s other arm a tug. He just stood there, rooted to the floor.

“Wait,” I said. “I need to know.”

“Don’t you ‘wait’ me. I’m taking my son and I’m leaving.”

I looked at her. I had seen a thousand women who were fine mothers and who looked just like her, but looks mean nothing. As I gazed up at her from where I knelt, I was sure — well, pretty sure — that she had hurt her child.

I squatted there for a moment, debating this. After all, what proof did I have? Besides, she was going to another ER. She said so. But I was angry. I was angry at her for yanking her child around and for being so damn unreasonable.

“I’m sorry,” I said, standing up. I was conscious that I was standing between this woman and the exit. “You can’t go anywhere with that child.”

She glared at me. “What do you mean?”

“You can’t leave,” I said. Any parent, child abuser or saint, would be angry with this order, but this wasn’t the time for second thoughts. I had taken my stand.

“You mean I can’t leave?”

“You can, but the child can’t.”

“You’re crazy.” She shook her finger in my face and yanked the boy’s arm.⁴

The boy was wailing and trying to back away from her. She yanked at his arm again.…

“Police!” she shouted.⁵

The disorder, named after an 18th-century [German⁶] mercenary known for telling [tall tales⁷] and lies, involves an adult, usually a parent, inducing illness in a child to gain attention for themselves.… First identified in 1977,…10 percent of the children involved died,…[and] it apparently has no medical or psychological solution.⁸

Dr. Jaqueline Farwell, a pediatric neurologist at [Seattle’s Children’s Hospital and Medical Center,] said no one is sure how common the disorder is but acknowledged it is much harder to detect than standard child-abuse cases.

“In most cases of physical abuse the parent will usually admit it when confronted and say, ‘I feel bad, and this is what happened.’ But the psychopathology of Munchausen cases is that the parent will continue to maintain she didn’t do it even if she has been filmed in the act.”

Many Munchausen by proxy cases involve only exaggerations and lies about the child’s condition and do not involve actual assaults.⁹

Dr. Kenneth Feldman, a child-abuse expert who has analyzed about 50 Munchausen cases, said people with the syndrome frequently attack their victims again.¹⁰

Experts outline a host of Munchausen characteristics.…

In general, fathers are uninvolved in the child’s care but tend to protect the mother.

Munchausen mothers often misrepresent the children’s medical history, push physicians to conduct diagnostic procedures, report symptoms that cannot be corroborated, stay close to the child’s bedside, have better than average knowledge of medical terminology and hanker for media attention.¹¹

Often the mother has worked in the medical field.¹²

Often, the child’s illnesses do not make scientific sense.¹³

Endnotes

¹ Pamela Grim, “Taking a stand; an ER rule of thumb: be suspicious of parents with an injured child who want leave quickly,” Discover, July 1997, 18(7), p. 36.

² S. A. Mednick & E. S. Kandel (UCLA), Congenital determinants of violence, Bulletin of the American Academy of Psychiatry and Law, 1988, 16(2).

³ E. Mavis Hetherington & Ross D. Parke, Child Psychology: A Contemporary Viewpoint, 4th ed. (New York: McGraw-Hill, Inc., 1993), p. 629.

⁴ Grim, “Taking a stand,” pp. 36, 38.

⁵ Ibidem, p. 38.

⁶ Richard Seven, “Mother sentenced for child assault has rare disorder,” The Seattle Times, 16 Dec 1995, p. A13.

⁷ Op. cit.

⁸ Richard Seven, “Court restricts visits with son; Mentally ill mother poisoned him,” The Seattle Times, 23 May 1992, p. A14.

⁹ Seven, “Mother sentenced.”

¹⁰ Seven, “Court restricts visits.”

¹¹ TRIMS, “Chronically ill girl’s mother charged with deliberately making her sick,” Knight-Ridder/Tribune News Service, 16 April 1996.

¹² Donna Leinwand, “Sick girl’s mother arrested, charged with deliberately causing illnesses,” Knight-Ridder/Tribune News Service, 16 April 1996.

¹³ TRIMS, “Chronically ill.”

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