Diseases

As MSBP involves the caretaker covertly abusing a child by faking or causing symptoms in the child victim, a pediatrician who has experience and training in assessing and treating child abuse is often consulted and may be the primary professional working with the family. That professional will usually work with other professionals to review all medical records that have been kept and to communicate regularly about parents who are thought to seek excessive care since the abusive parent involved may have visited many different practitioners, even using different names in some cases, in an attempt to avoid the scrutiny that is likely harder to avoid if working with one medical practice, since one practitioner has more of an opportunity to get to know the perpetrator and the victim of MSBP over time. Covertly videotaping the interactions of a child with the suspected caretaker/abuser can be useful even when the victim is in a highly monitored setting like an intensive-care unit. While videotaping the child in the hospital may help in confirming or refuting the suspicion that the parent is engaged in harming the child, it is appropriately not seen as a substitute for the hard work of close monitoring, collaboration between all medical professionals, child protective services, mental-health professionals, and community members (for example, teachers, school counselors, clergy, and concerned extended family members) involved.As with other mental-health issues, there is no specific definitive test, such as a blood test, that can accurately assess that a person has MSBP. Therefore, practitioners conduct a mental-health interview that looks for the presence of the symptoms previously described. As with any mental-health assessment, the professional will usually work toward ruling out other mental and physical disorders and ensuring that the individual is not suffering from a primary medical problem or from medical issues that may have symptoms that cause emotional symptoms. He or she will therefore often inquire about when the child has most recently had a physical examination, comprehensive blood work, and any other tests that a medical professional deems necessary to ensure that he or she is not suffering from a true medical condition instead of or in addition to a caretaker potentially manufacturing symptoms in the child. Also of significant importance is the practitioner reviewing any available previous medical records and talking to other people who may be in the child's life (such as the other parent, if available, teachers, and counselors) in order to explore the possibility of a pattern of the caretaker in question making illness up before in this child or in a sibling or other child in their care.Due to the use of a mental-health interview in making the diagnosis, the potentially dire consequences to missing the diagnosis of MSBP or falsely assigning the diagnosis, as well as the fact that this disorder can be quite resistant to treatment, it is of great importance that the practitioner know to conduct a thorough assessment. It is equally important that the medical and mental-health professionals work together very closely and do not make assumptions about how much medical knowledge a parent should have or how they should behave in a situation involving the illness of their child. As only 50% of people with MSBP ever come to the attention of a psychiatrist, the importance of vigilant assessment and insisting on treatment when possible seems all the more important.

Prevention strategies for MSBP currently tend to focus on avoiding continued abuse once MSBP is identified. Given the low frequency with which this disorder is diagnosed, some researchers propose that studies of this disorder would be better focused on its early identification and treatment rather than on prevention.

In the diagnostic manual that is recognized by most mental-health professionals, The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, MSBP is classified as a somatic symptom and related disorder and is referred to as factitious disorder that is imposed by one individual on another.Symptoms of MSBP include the sufferer being induced to experience physical or psychological symptoms or to have symptoms fabricated by another person, usually a caretaker. Specific symptoms in the victim are nearly as varied as the number of victims and perpetrators, with perhaps more emphasis on symptoms that are more feasibly manufactured or induced or are more difficult to measure objectively through laboratory tests (for example, stomach upset, other body aches and pains, and trouble breathing or sleeping). Some more common symptoms presented by victims of MSBP include suffocation, induced seizures, bleeding, or poisoning that presents as vomiting or diarrhea. The abusive parent may describe symptoms in their child that do not exist. The symptoms may get worse only when the suspected caretaker is present or recently visited and may improve when the perpetrator is absent. Theories on what motivates the adult who assumes the sick role by causing a child to be sick might fall into one of three categories of motivation: help seeking, active induction of symptoms, and "addiction" to interactions with doctors. The help seeker is thought to be motivated to fabricate or cause their child's symptoms as a way of getting help for him or herself, assuming the sick role through their association with the supposedly sick child. This may be due to their feeling overwhelmed by their adult relationship, parenthood, or their own physical or emotional problems. The parent who actively induces symptoms of MSBP in the victim is thought to be seeking control of the medical professionals, as well as wanting recognition as an excellent parent by the professionals. Perpetrators who seem to be addicted to doctors are thought to be motivated to be seen as knowing better than the doctors.

If left untreated, the prognosis of MSBP can be quite ominous. It can result in child victims who grow up to be medically, emotionally, or otherwise functionally disabled adults. Research shows that people who were the victim of MSBP as children are more likely to develop weight problems (including anorexia or obesity) and chronic pain as adults. Emotional complications can include depression, anxiety, anger problems, posttraumatic stress disorder (PTSD), and mood swings. People with this disorder are prone to having trouble completing their education and either avoiding or excessively visiting medical practitioners. It can even be fatal in more than 5% of cases, and more than 7% may have long-term or permanent injury as a result. Survivors of this disorder are sadly at higher risk of becoming perpetrators of this and other forms of child abuse as adults.

Although there is no specific cause for MSBP, like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model). Little is known about the specific biological vulnerabilities of individuals with MSBP. Psychologically, MSBP perpetrators tend to have trouble forming a healthy bond (attachment) with their children. Personality traits of individuals who have a history of inducing symptoms in the children they care for include trouble managing anger or frustration. Socially, those who feign or induce symptoms in others tend to have suffered from some sort of major negative event (trauma) during their own upbringing, including the death of a parent or other caretaker or having been themselves the victim of child abuse or neglect.

Munchausen syndrome by proxy (MSBP) features a caretaker covertly abusing a child by faking or causing symptoms in the victim. MSBP is also called Munchausen by proxy (MBP), factitious disorder that is imposed by one individual on another, or factitious disorder, by proxy induced illness, or fabricated illness and is a mental disorder that belongs to the group of mental illnesses called somatic symptom and related disorders. It is characterized by a feigning or intentional production of physical or mental-health symptoms in another person for the sole purpose of placing the other person in the sick role. While the reported frequency with which MSBP occurs seems low at one to three in 100,000, it is likely that the actual number of undiscovered MSBP cases is much higher. International statistics indicate that this condition is being increasingly assessed when it is severe, and as many as 1% of children with asthma have experienced MSBP at least once. MSBP tends to affect males as victims as often as females. Affected individuals are usually 4 years old or younger and mothers are typically the perpetrators most of the time. The tendency toward maternal perpetrators may be more a result of women continuing to be the primary caregiver role than any gender-based predisposition to the disorder. MSBP can take two years or more from the beginning or onset of symptoms to when it is diagnosed. Victims of MSBP are ominously found to have a sibling who is either deceased or to have had medical problems very similar to the current victim of the disorder.This disorder was named for Baron Karl Friedrich von Munchausen. He lived from 1720-1797, was born in Germany, joined the Russian military, and was known to tell fantastic tales about the battles he participated in against the Ottoman Turks. For example, he apparently told stories about riding cannonballs and traveling to the moon. As opposed to MSBP (factitious disorder imposed on another person), factitious disorder imposed on self is a mental illness in which what are initially thought to be symptoms of illness in the sufferer are in reality a fabrication of the illness by the sufferer rather than fabrication of illness by a third person. The motivation for factitious disorder imposed on self also tends to be an attempt by the sufferer to be seen as sick (assuming the sick or patient role). Emotional problems that tend to co-occur in people with MSBP include depression, anxiety, and some personality disorders like borderline personality disorder and sociopathy.

The involvement of a comprehensive child-protective-services team is of paramount importance in the treatment of MSBP. As with any other child abuse, achieving and maintaining the safety of the child in the least restrictive setting is a key focus. If professionals, family members other than the perpetrator, and community support systems can successfully maintain the safety of the victim and any other child in the home, refraining from removing children from the home may be encouraged. However, if keeping the child in the same home is thought to put him or her at continued risk of harm, steps will likely be taken to move the victim and/or other children to a safer placement. With effective treatment progress by the victim and the abuser, professionals may consider slowly reintroducing the child to the home while closely monitoring the child's safety. In the event that such reintegration is not possible, the child might be permanently placed outside the home of the perpetrator. In severe cases, professionals may seek the prosecution and incarceration of the perpetrator and permanently prevent the abuser's access to the victim.In working with the child, therapists often teach the victim techniques for changing dysfunctional ways of behaving while helping the child understand the underlying feelings and motivations for those behaviors. While psychiatric medications like antidepressant, anti-anxiety, mood stabilizer, and antipsychotic medications may be used to alleviate specific symptoms for the perpetrator or victim, medication by no means cures the illness completely.Individual psychotherapy for both the perpetrator of MSBP and the victim, as well as family therapy for members of the household involved are often incorporated into the treatment program. At the same time, the ongoing use of medical services is closely monitored by medical, mental-health, and child-protection professionals. Sometimes, the primary-care doctor (for example, pediatrician) will be notified by the insurance company of future use of medical services by the MSBP victim or the victim's siblings. The professional might also be notified when the child is absent from school. Access to such information is either granted through child protective services or by a parent. School officials may agree not to excuse an absence unless approved by the primary-care physician.

Child Welfare Information GatewayChildren's Bureau1250 Maryland Avenue, SW, Eighth FloorWashington, D.C. 200241-800-394-3366703-385-3206http://www.childwelfare.govNational Child Abuse Hotline1-800-4-A-CHILDNational Indian Welfare Association (NICWA)5100 SW Macadam Avenue, Suite 300Portland, OR 97239Phone: 503-222-4044Fax: 503-222-4007http://www.nicwa.orgPrevent Child Abuse America500 North Michigan Avenue Suite 200Chicago, Ill. 60611312-663-3520http://www.preventchildabuse.orgAmerican Psychiatric Association1000 Wilson Blvd. Suite 1825Arlington, Va. 22209http://www.psych.orgAmerican Psychological Association750 First Street, N.E.Washington, D.C. 20002- 4242http://www.apa.orgNational Alliance for the Mentally Ill (NAMI)Colonial Place Three2107 Wilson Blvd. Suite 300Arlington, Va. 22201-3042http://www.nami.orgNational Institute of Mental Health (NIMH)Office of Communications6001 Executive Blvd. Room 8184MSC 9663Bethesda, Md. 20892-9663http://www.nimh.gov