Management of Munchausen syndrome proxy · Management of Munchausen syndrome by proxy 387 fortheir...

Archives of Disease in Childhood, 1985, 60, 385-393

Personal practice

Management of Munchausen syndrome by proxy

ROY MEADOW

Department of Paediatrics and Child Health, St James's University Hospital, Leeds

The label of Munchausen syndrome by proxy maybe applied to anyone who persistently fabricatessymptoms on behalf of another so causing thatperson to be regarded as ill.1 In paediatrics it isusually the mother who is the persistent fabricator ofsymptoms and signs so causing illness, danger, andunnecessary investigations and treatments for herchild. There is considerable overlap with otherforms of child abuse as well as with the usualbehaviour of normal parents when a child is ill. Eventhough the fabrication of symptoms and signs maycontinue for several years and be gross, it can bemost difficult to detect. Nevertheless effective man-agement for the child and the family is even moredifficult. In the past six years I have had unusualopportunities to learn about the condition, meet thefamilies concerned, and be involved in the manage-ment. This article discusses some of the commonand difficult management problems.

Background information

Since the 1982 article on Munchausen syndrome byproxy in this journal2 many paediatricians have sentme detailed information of other cases. Of the 90British cases for which I had details by the end of1984, I had been involved personally with thefamilies in just under half, either by virtue of thedeception coming to light in my own region, theparents contacting me privately, or paediatric orsocial service colleagues in other parts of the countryseeking my help. A further source of informationhas been colleagues from abroad who have writtenor telephoned to discuss similar problem families. Itis relevant that only for a minority of cases-thosewhich came to light locally or in which the parentscontacted me directly-was I the paediatrician trulyresponsible for the continuing long term care of thechild.The clinical features of these families are similar

to those described in the earlier review of 80 cases;3but there has emerged a clearer picture of what

happens to these children if the deception is notuncovered and the fabrication continues. As thechildren become older, there is a tendency for themto participate in the deception and to becometeenagers and adults with Munchausen syndrome.There is also a tendency for the children to grow upbelieving themselves disabled. (An example is the22 year old confined to a wheelchair having beenbrought up in the belief that he has spina bifida andis unable to walk even though his legs and back arenormal.) In addition to the fatalities mentioned inthe earlier reports there have been three moredeaths and another child who incurred severe braindamage resulting in spastic diplegia and mentalsubnormality; thus with increased numbers andfollow up, the morbidity and mortality are greaterthan was apparent at first. An important associationwith cot death, particularly recurrent cot deathwithin one family has emerged.As management is easier if diagnosis is certain

and speedy, it is appropriate to list the warningsignals that may alert a paediatrician to the presenceof factitious illness:

(1) Illness which is unexplained, prolonged, andso extraordinary that it prompts experienced col-leagues to remark that they 'have never seenanything like it before'.

(2) Symptoms and signs that are inappropriate orincongruous, or are present only when the mother ispresent.

(3) Treatments which are ineffective or poorlytolerated.

(4) Children who are alleged to be allergic to agreat variety of foods and drugs.

(5) Mothers who are not as worried by the child'sillness as the nurses and doctors, mothers who areconstantly with their ill child in hospital (not evenleaving the ward for brief outings), and those whoare happily at ease on the children's ward and formunusually close relationships with the staff.

(6) Families in which sudden unexplained infantdeaths have occurred, and families containing many

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members alleged to have different serious medicaldisorders.

Mild cases

Exaggeration and mild deception are part of every-day behaviour: for a parent to exaggerate her child'ssymptoms or to perceive problems that are notapparent to medical and nursing staff or even toothers in the family is common. All paediatriciansare accustomed to mothers who perceive problemsin their children that are inconspicuous to others,and also to mothers who press for investigation andoperations for states that others readily tolerate.Similarly, it is not rare for a parent occasionally toalter a temperature chart, tamper with a sample, orinvent a seizure in order to get their child away fromthem for the night, into hospital, or to keep theirchild there longer. Paediatricians who are accus-tomed to this and to helping the mothers with theirproblems will not over react to this behaviour. It ispart of outpatient practice to shepherd along suchmothers with their children, to support them withtheir problems, and to prevent them from causingtheir child an abnormal life or referral for needlessinvestigations and treatments. It is an important skillfor the paediatrician to acquire because its absencewill cause the mother to seek investigation andtreatment elsewhere.

It becomes more difficult when the mother isimposing a special diet or restriction to activities andeducation because of the perceived illness. It be-comes a matter of fine judgement whether themother is abusing her child or not-child abusevaries from age to age and culture to culture.Essentially, a child is considered to be abused if theparents' behaviour is sufficiently deviant from thatcurrent in their locality at that time, and if thebehaviour is harmful to the child's growth anddevelopment. But though a paediatrician might notagree with a parent who, for instance, puts her childon a strict vegan diet in order to stop the child'sseizures (which no-one except the mother hasobserved and which probably do not occur), it islikely to be inappropriate to intervene too abruptlysince the diet is unlikely to harm the child and if themother believes it will stop the imagined seizuresthen it probably will do so. The paediatrician's rolemust surely be to continue seeing the child regularlyand, as the symptoms recede, discussing with themother any possible social disadvantages, for thechild in having a rigid and difficult diet whenattending school or visiting friends. Other imposi-tions, however, that parents inflict on children forfictitious illness may amount to a lifestyle that is, inmost people's opinion, unfair, unpleasant, or harm-

ful to the child-for instance the pseudo-allergic girlrecounted by Warner4 who had to sleep each nighton the back of an upturned wardrobe clad inaluminium foil and tissue paper in order to avoidcontact with substances to which the mother con-sidered her allergic. Similarly, the schoolgirl whosemother insisted she had osteogenesis imperfecta andwho found herself being excluded from most activi-ties, wheeled to school in a pushchair and round theshops in a supermarket trolley. Though those girlsare not in immediate physical danger, most of uswould consider them to be abused and interventionto be necessary.As has been observed for adults with Munchausen

syndrome the chief reinforcing factors for hospitaladdiction can be the medical and nursing personnelthemselves rather than the medical and nursingprocedures.5 Doctors and nurses feel compelled toact, to investigate, and to prescribe drugs when thepatients may merely want concern and support.Therefore in our treatment of a potential Mun-chausen syndrome by proxy child we need to modifyour own behaviour, for abuse to the child arises as aresult of a follie a deux involving mother anddoctors. Both parties need to act differently and weneed to support without frenetic investigation of thechild.

The suspected case

The realisation that a child's prolonged illness mayhave been fabricated tends to come slowly. Thepossibility may have been raised earlier but notexplored energetically. There is understandablereluctance by medical and nursing staff to believethat a parent may have been deceiving. Part of thisstems from a wish to think good of parents, and partfrom a wish to avoid facing the fact that all one'sinvestigations and treatments have been both in-appropriate and harmful, that one has been hood-winked, and has made a completely wrong diagnosisup to that moment. When the possibility seemslikely it is worth making every effort to establishwith certainty that fabrication is taking place be-cause without that certainty it is extraordinarilydifficult to act helpfully. This at once poses prob-lems because some of the illnesses being created bythe mother are dangerous to the child and there is aworry that delay to accumulate more evidence mayend in catastrophe for the child. This happened withone child who was suffering seizure/apnoeic spellscaused by maternal suffocation; delay to prove thatit was the mother causing these spells lead todisasterous suffocation for the child. On the otherhand paediatricians are reluctant to intervene earlyfor fear of being wrong in their accusation. Parents


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Management of Munchausen syndrome by proxy 387

for their part when later accused vary between thosewho say 'if you suspected it earlier why didn't you

tell us so that it could have been stopped' to thosewho say 'it is outrageous that we should be accusedof these things until there is definite proof'. Thestage at which intervention will seem most appropri-ate is likely to depend on the degree of proof andalso the degree of danger that the mother's actionsmay be creating for the child. Some parental actionshave much more dangerous implications thanothers: for mothers who repeatedly poison theirchild, it only needs a small alteration in dose to kill;and those who are suffocating their child (either byhand, plastic bag, or carotid sinus pressure) needextend it only a small degree and the child is braindamaged or dead. It is clear from my records thatchildren under the age of 5 years are most likely tohave a sudden catastrophic end.

Establishing with certainty that the mother isfabricating the illness requires painstaking enquiry.The paediatrician is in the best position to do thisbecause he is seen by the family as a helper andsomeone for whom the child's interests areparamount: he starts off with the confidence of thefamily. Far more detailed and inoffensive enquiryand access is possible for a paediatrician than forsocial services, police, or most other agencies.

Investigation follows several directions and thoselisted are not in priority order, they are concurrent:

(1) By studying the history it should be possibleto decide which events were likely to be fabricatedand which real. Whenever an event, whether it be a

seizure or a nose bleed, is said to have taken place inthe presence of someone other than the mother itshould be possible to check with that person exactlywhat happened. Sometimes all that is needed is a

few brief telephone calls to the school, the playgroup, or a neighbour. It is important to rememberthat there may be genuine illness within the fabri-cated illness, for instance a child who has mildepilepsy but whose mother multiplies the number ofseizures by a factor of 20 or more. Therefore the factthat one episode of genuine illness is establisheddoes not rule out the possibility that many fabricatedevents are happening also. Several illness eventsshould be investigated in detail.

(2) Look for a temporal association betweenillness events and the presence of the mother. Oneshould also look for such an association with adultsother than the mother but it is most unusual for thefather to be a participant in the deception (I onlyknow of two fathers who may have been involvedand one other father who was definitely involved).In more than 95% of the cases it is the motherfabricating the illness, sometimes with the assistanceof her child.

(3) Check the details of the personal, social, andfamily history that the mother has given. It iscommon to find a host of fabrication within it andunless one knows the truth it is impossible to help.Fabrication may extend to the number of pregnan-cies, family numbers and relationships, details offinancial circumstances, the home, and the mother'sprevious work and training. Case conferences arenot a reliable source of information about families.Although there may be 15 or 20 different people atthe case conference each of whom is meant to knowsome particular aspect of the child or family, it iscommon for each to recite more or less the samestory which has been given them by the mother sothat sometimes the whole group has been deceivedon such elementary details as numbers within thefamily, whether the mother has a job, whether thereare any grandparents nearby, and how many peoplelive at home. The solution is for the paediatrician togo to the home without invitation. Once there it isnot difficult to find an excuse to meet everyone andto visit all the rooms in the home. Moreover, there isan obvious difference between the sort of look asurprised parent gives you when you arrive unex-pectedly on their doorstep and they are embarrassedbecause they have not washed up the supper things,and the look they give you when they are devastatedby realising that you are about to find out that all theinterpersonal and home information they gave youis false and that there is not a bedridden grand-mother living with them, and that their living roomis littered with empty bottles of alcohol. If the dooris literally shut in one's face and access denied, thatitself shows a great deal. On the rare occasions thatit has happened I have said words to the effect 'Iknow what you are doing; I understand and I havecome to help'; they eventually let one in.

(4) Making contact with other family members isvital. Though the mothers may have been everpresent with their child at the hospital, the husbandsmay have been seen little or not at all. Talking withthem about the child's illness and their home life canreveal many discrepancies. One mother who mademuch of her previous nursing qualifications and whoenjoyed teaching nursing techniques to traineenurses on the wards had said that she met herhusband when she was taking her final nursingexams. In casual, if deliberate, conversation withthe husband he told me how he had met his wifewhen she was a cleaner in the canteen of the factoryin which he worked: she had never been a nurse.Grandparents have been a potent source of informa-tion and sometimes have had far more insight intowhat their duaghters might be doing to theirchildren than anyone else. Sometimes the informa-tion from them has been breathtaking in its revela-


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tion. One grandmother said to me of her daughter'she was always a strange girl I think she wouldreally have done nurse training if she had been ableto, she used to spend all her money buying these bigmedical books. I have been wondering for a longtime if she has been causing his illnesses but I didn'tlike to say so and the doctors never spoke to me'.

(5) Discuss with the family doctor the illnessepisodes within the family. In about 20% of cases itbecomes clear that the mother has Munchausensyndrome herself or at least multiple unexplainedillnesses. Sharing one's worries with the generalpractitioner and enrolling his active help is ex-tremely useful but unfortunately some are unwillingto become involved, perhaps feeling that they mustkeep complete confidence with the mother, and areunwilling to consider the suggestion that there maybe fabrication.

(6) Look for a motive for the behaviour. Thereasons mothers behave in this way have beendiscussed extensively elsewhere ;3 8 there isusually an element of gain in terms of status for themother (the child's illness giving her status andfriendship in hospital and in her neighbourhood),improved family relationships perhaps with husbandor in-laws, and also direct and indirect financialbenefit. One mother whose child was having aprolonged fabricated illness investigated in differenthospitals received during a six month illness £57-00collected by the local church (following a service inwhich prayers had been offered on behalf of thechild); a new pushchair, refrigerator and washingmachine from social services department; and£250-00 collected by other parents whose childrenwere admitted to the same ward. Find out exactlyhow the mother behaved when resident, or visitingher child in hospital, for it is those who have formedvery close relationships with the hospital staff, whogo to the disco with the nurses in the evening orcook meals for the resident doctors at night, who areenjoying the hospital most-and unnaturally.

Establishing motives helps us to understand themother and help the family better. For thosemothers with whom I have had continued contact Ihave come to understand, and at times sympathise,with their extraordinary actions; the group whom Ido not understand are the minority who haveMunchausen syndrome themselves or who categori-cally claim and cling to facts that are demonstrablyfalse.

If the child is in hospital further manoeuvres areneeded.

(7) Ensure that all charts and records are notaltered by the mother. Remember that manynursing observation records (for instance of seizure

frequency, feeding, and input/output fluid balance)are often a record of what the mother tells the nursewho then records.9 A system must be devisedwhereby items which are verified by the nurse, forexample her seeing the child vomit or start to have aseizure, are identified separately from those re-corded from the mother's account. Such detailedrecord keeping will sometimes quickly show that allillness events and abnormalities are perceived onlyby the mother and occur only in her presence.

(8) At the time of any unexplained coma,gastrointestinal upset, or other major event retainany samples that may be useful for poisons analysis.These should include vomit, urine, and a bloodsample. These samples are precious; the laboratoryshould store them carefully until the best plan foranalysis has been worked out. Toxicological screen-ing is very difficult in that most hospital laboratoriesand poisons centres can only search for the fewdrugs that are most likely to have been given, andone may not be able to suggest which until one hasconsulted with the general practitioner and thefamily. In the absence of this information a generalscreen for poisons is needed. In Britain the fullestscreening is likely to be done either by the publicanalysts' laboratory (who are reluctant to take onwork from hospitals which is not directly related totheir public health and hygiene responsibility) or bythe police forensic laboratories who are meant toaccept work only from police officers. Since 'com-prehensive screening' of a blood sample costs about£800 and even then does not include many unusualdrugs (for example, several cytotoxic drugs), prob-lems abound. The paediatrician is likely to get thebest advice by contacting the regional home officepathologist-his name will be available from thecoroner's office or from the police station-whoshould be able to advise how the sample can beanalysed best.

(9) If there is haematuria, haematemesis, orother bleeding, various manoeuvres may be used tocheck that the blood is human (and not from rawmeat) and is the child's rather than anotherperson's.10 The local pathology laboratory may beable to help but it is likely that the police forensiclaboratory will have more sophisticated techniquesinvolving detailed blood grouping or red cell enzymeassay. When there is doubt about the origin of anabnormal urine specimen the child can be given anoral marker, for example regular vitamin C, which iseasily detectable using Ames dipstix C. If the urinedoes not contain vitamin C it means that the urinesample is not from the child.1' Though if it doescontain vitamin C, it does not rule out the possibilitythat the mother has added chemicals or othercontaminants to it.


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(10) More careful surveillance of mother andchild has to be arranged and this can be difficult notonly because of staff shortages and a busy paediatricward but because of reluctance by ward staff toaccept the possibility that the mother may beharming her child. Even when ward meetings todiscuss such plans have been arranged with care andtact, the senior nurse may burst into tears, refuse totake part in the surveillance, or accuse the paediatri-cian of uncaring outrageous behaviour. This isunderstandable when, as has happened, the motherhas been living in the paediatric unit from the firstfew months of the child's life and formed suchattachments with the staff that they have been madethe child's godparents, the child has been namedafter one of the junior doctors, and the child's teddybear named after another doctor. Careful surveill-ance is extraordinarily difficult in a modern chil-dren's ward in which mothers are resident andparents are welcome at any time. It is necessary toenrol the help of a few key members of the staffwhom one can rely on to be obsessional. Sometimesone is let down even then, for instance by a mostreliable person who did not admit she had stoppedsurveillance for a critical one hour meal time periodwhen a massive fabrication occurred, and whosubsequently told me that it was not that she was toolazy to continue the surveillance but that she knewthe mother very well and could not believe that shewould ever do anything harmful to her child-'it wasall too incredible'. Giving the staff reprints aboutthe condition is helpful, particularly if they containexplanations for the mother's behaviour; the staffbecome more readily prepared to identify thatbehaviour in others. Surveillance by video has beenused12 and may provide the sort of conclusive proofthat many would welcome-for instance of a mothersuffocating her infant with her hand,12 a motherinjectin contaminated solution into an intravenousline,13 14 and a mother who, after her child had beenfed, took a nasogastric tube out of her pocket andwith a syringe aspirated the milk from her baby'sstomach (the baby was being investigated for failureto thrive). Setting up video surveillance is not toodifficult technically because in most areas the policewill have a specific surveillance unit and will beprepared to use it without demanding the right toprosecute subsequently. They can do it unobtrus-ively even in a busy hospital. For most paediatriciansthe problem will be an ethical one and beforeembarking on surveillance it is important to discusswith the hospital administration and the appropriatesocial services or child protection agency exactlyhow this information is likely to be used. For thepaediatrician the legal admissibility of filmed evi-dence is not the issue: the great benefit is that as a

result of a film the paediatrician may become certainfor the first time that the mother is harming the childdirectly.

(11) It is relatively easy to find out from doctorsand relatives what poisons or substances might bebeing administered to the child, but it is much moredifficult to consider searching a mother or herpossessions for such agents. At times it has to bedone and a particular problem is that though aconsultant paediatrician might be willing to do it, hemay be in a poor position to do so inconspicuously.Mothers do leave the lockers in their rooms andtheir bags unattended for brief periods. For a juniordoctor to check that there is no drug or poison canbe done speedily and without upset. I am reluctantto ask my juniors to do it and would prefer to do itmyself if it is needed but acknowledge that I wouldbe less likely to do it inconspicuously. My practice isto discuss it with the junior staff and to work out aplan that is acceptable to all of us, though whateverhappens the final responsibility is the consultant's. Ido not know of either junior or senior doctors whohave been discovered searching through a mother'spossessions. If I were discovered I would explain tothe mother why I was doing it; that it was because Iknew of other children who had been poisoned bytheir parents, who had seemed to me to be lovingcaring people; and that I had not wanted to upsether by suggesting this possibility but for her child'ssake was anxious to exclude it.

Excluding the parents

If a parent is fabricating the illness, then thesymptoms and signs should go when they areexcluded. This is the ideal diagnostic test and inmodern paediatrics it is a difficult one: unfortu-nately for children with Munchausen syndrome byproxy, it tends to be used as a last resort.

In Britain and America it seems that the childwith prolonged Munchausen syndrome by proxy hasusually suffered a vast number of blood tests,radiodiagnostic tests, examinations under anaes-thetic, and biopsies before separation from themother is used as a diagnostic test. I doubt if this isbecause we all believe that a brief period ofseparation is so harmful for the child: more likely itreflects our diffidence and inadequacy in persuadingthe parents not to visit the child. Lacking thecourage of our convictions we must, nevertheless,act in the good sense of our suspicions. If therecurrent 'illnesses' are happening several times aday it should be possible to persuade the mother tobe absent for an afternoon, evening or weekend 'tosee the rest of the family at home', leaving her childin hospital. It is more difficult, however, if the


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periodicity of the illness is so infrequent that onereally needs the mother to be away for 10 days ormore. I have not found a satisfactory method ofexcluding mothers. Sometimes I have talked inpsychological terms about the need for them to havea break. Sometimes I have been more frank and saidthat their child has a very unusual illness, we arehaving to consider rare possibilities, and that themother's presence may in some way be interactingharmfully with the child either through emotional orallergic factors or as a result of something that theyare doing to each other. This is not necessarily seenas a direct accusation and is usually accepted by theparents. For many mothers it is a major event andsupport must be given during the difficult exclusionperiod by regular telephone contact and home visitsby anyone who may be helpful to them.

Excluding parents from their ill child in hospital isupsetting for the child and parents and contrary tothe beliefs of the staff, some of whom may suggestthat it ought to be adequate merely to arrange morestrict supervision when the mother is on the wardwith the child. The degree of supervision required,however, is not one for which medical and nursingstaff are trained; it is too easy for a crafty mother tooutwit hospital staff. One mother for whom limitedvisiting had been arranged with strictly controlledobservation by selected staff who were instructednever to be more than five yards away from her,arrived on the ward slightly early for her visit. It isthought that she went to the toilet and then whenshe arrived by her child's bed at the appointed timeand met the escort smoke was seen to be comingfrom beneath a toilet door where there was a smallfire of toilet paper. All staff including the escortrushed to help and the mother was left alone withher child despite the agreed plan that under nocircumstances should this be allowed during the fourweeks of restricted visiting. Therefore trial separa-tion has to be total exclusion.

If a period of parental exclusion cannot bearranged by mutual agreement, it may need to beimposed statutorily. Though it is usual to allowparents to visit when their child is kept in hospitalunder a place of safety order, it is possible for theorder to specify exclusion of the parents. Such legalsanctions involve a degree of confrontation with theparents and this raises many difficulties whendefinite proof of parental harm to the child may belacking and the paediatrician is uncertain. There-fore, voluntary agreement is preferable. When theparents are excluded full use must be made of thattrial period to ensure that there is no possibility ofadverse effects on the child. Two or three specificmembers of the ward staff need to be allocated totake a particular mothering interest in that child,

and if there is any possibility of previous poisoning,anything in which the mother might have left behinda poison should be removed; thus sweets, drinks,toothpaste, paint box etc are best removed so that atthe end of the trial period there is certainty that thechild could not have been harmed by the parentsdirectly or indirectly.

Child protection agencies

When child abuse is suspected it is customary inBritain to notify the social services departmenteither through the hospital social work departmentor the department near the family home. The stageat which the social services department is contactedwill depend on many factors. Sometimes the familywill already be known to the social services depart-ment and there may be a social worker alreadyinvolved. The responses of British social servicesdepartments to children suffering from Munchausensyndrome by proxy have varied. In the early yearsthere was disbelief and some unwillingness to takeaction. With more publicity, however, the depart-ments no longer disbelieve the possibility, thoughmany have difficulty investigating it vigorously.There can be few more difficult cases of child abuseto deal with than a Munchausen by proxy family,because it is so difficult to disentangle truth fromuntruth, yet all too often the social workerdesignated to the case is rather young and inexperi-enced. (An important difference between medicalpractice and social services practice is that inmedicine the most difficult case is dealt with by themost experienced clinician whereas in the socialservices the most experienced worker is involvedonly in administration and few do case work.) Thepolice representatives at case conferences are rarelyinstigators of action but will respond helpfully torequests for help. Even they are unlikely, however,to devote a great deal of energy or time unless theythink there may be a criminal prosecution. For mostof the British cases there has been no active policeinvolvement. In a minority there have been policeinvestigations including what seems to be theirstandard three to four hour interrogation of themother in the local police station and a search of thehome for evidence. More mothers, however, haveconfessed to killing a previous child, or harming thechild under investigation, to a doctor, social worker,or kindly probation officer than they have duringformal police interrogation.At the case conference it is essential that the

paediatrician or other doctor who has known thefamily a long time, and has identified that factitiousillness and abuse are occurring, is present. Thiscreates some difficulties since many of the decep-


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tions first come to light in a specialist centre far awayfrom the child's home. Initially I referred the childback to the medical and social services departmentof the home locality, sending them a written report.One or two tragedies have convinced me, however,that this is not the correct course. The paediatricianwho has uncovered the deception is likely to knowthe family better than anyone else at that momentbecause he has been worrying about, investigating,and treating the child for a long time. He knows wellall that has happened and has a close relationshipwith the parents and child. He will understand thedangers for the child and is more likely to berespected and trusted by the parents and relatives.Thus his presence at the case conference is vital andhe is also likely to be the most appropriate person todeal directly with the parents in the difficult negotia-tions ahead. If the social services department do notseem prepared to take up the case actively analternative child protection agency (for example theNational Society for the Prevention of Cruelty toChildren) may be approached. As a last resort afirmly worded letter from the paediatrician to thedirector of social services for the town or cityconcerned is likely to produce a speedy response.Members of a case conference, rather like magis-

trates in a juvenile court or the officers in a highercourt, do need to have the dangers of Munchausensyndrome by proxy explained to them clearly andcategorically, that:

(1) There is a risk of permanent handicap ordeath.

(2) Hospital admissions, investigations, andtreatments are unpleasant and dangerous for thechild. Many of us have faced barristers in court whohave remarked that 'my child rather enjoyed beingin hospital when he was 4-I don't think it can reallybe considered unpleasant'. (Yet they would have nohesitation in condemning a mother who herself hadstuck needles into the veins of a small child morethan 200 times or who had given the child drugs thatsuppressed growth, that could render him sterile,and that caused seizures and serious gastrointestinalbleeding.)

(3) Children who have fabricated illness thrustupon them in early life acquiesce to it, and at olderages participate in it themselves, some adoptingabnormal illness behaviour as an adult and retainingit for the rest of their lives. After early limitation ofactivity and school attendance they grow up tobelieve themselves incapable of employment,marriage, or normal life. They are disabled.

Confrontation

Telling a mother that you know she has been lying,

harming her child, or deceiving doctors is difficult.At the time one has to do it one may not be able toexplain all the facets of the child's illness story andthere may be areas of doubt; it is best to confineoneself to those areas in which one feels sure of thetruth. Although many of us in ordinary practice maygive important news about children to both parentstogether, this is one disorder where approach to theoffending parent, the mother, should be made first.If one tries to talk to both parents together thefather, who will know nothing about the deception,is likely to dominate the subsequent interview byanger or forceful denial. Talking to the mother onecan approach it along the lines that one knows whatshe is doing, understands it, and that one is going tohelp the child and her. It is very rare for the mothersto become angry; usually their response is 'what astrange suggestion', or 'why should I be doing that',or 'you can never prove that'. It is useful to be ableto present clearly the evidence for part of thedeception. Usually they will not deny it but try tolead the interview on to another happening (whichperhaps one cannot explain). One must not be sidetracked but simply stick to the facts and the truthsthat one does know and say quite openly that otherunsolved incidents are irrelevant.The purpose of confrontation is not to prove that

one is right and they are wrong. As in the handlingof mothers who perceive symptoms in their childthat are not observable to others, the aim is tounderstand and respect the meaning of the symp-toms in order to help them. As Richtsmeier andWalters'5 have written, there is no point in declaim-ing to them what is really going on when it becomesclear that the family is unable to hear it: explana-tions seldom change behaviours that are illogicallyderived, and direct challenge of the defence willusually only drive the patient away. Subsequentlythe aim is not so much to get the family to look backon what was really happening but to look forward tothe future and feel good about the positive stepsthey are taking.

I am sure that the person who conducts thisinterview should be the paediatrician who hasknown the family and the child longest and who hasuncovered the deception. I prefer these interviewsto be private but accept that it is helpful for thesocial worker with subsequent responsibility for thefamily to hear all that goes on, though it may limitthe amount of information that emerges. The task isto explain to the mother the way in which heractions are harming her child and the dangers thesehave for the child's future. An outline is given of thesteps that are being taken for the care of the childand help for her and the family. I discuss with themother what is to be told to the father, and likely


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family reactions are anticipated. At this stage thereis sometimes tacit admission by the mother of whathas been going on; in other cases that only emergeslater. For another group there is never directadmission, though a few years later they may comeout with a comment such as 'I suppose I had a sort ofnervous breakdown'. The doctor meanwhile istrying not to be hostile or condemnatory but to seemunderstanding and to act in a supportive way. 16 It isa dangerous time and three mothers have madesuicide attempts at this stage.The long term therapeutic aim is to stop the abuse

and protect the child and secondly to get the motherto understand the consequences of her actions, andto try and achieve motivation for continued treat-ment and help. Since most mothers have enjoyedsome personal gain from their actions one tries toreplace hospital care and child illness as the mainsource of satisfaction in their life with other things.

Statutory procedures

At a case conference the abused child and siblingsare likely to be put on the 'at risk' register at onceand the child at that stage may well be in the hospitalchildren's ward under a place of safety order. Thedebate will centre on what should happen at the endof that temporary period. Many factors will be takeninto account but those that are most worrying from apaediatric viewpoint and have been found to bemost dangerous for the child include:

(1) Abuse that has involved suffocation orpoisoning.

(2) Abuse of a child under the age of 5 years.(3) Previous 'cot deaths' or other sudden unex-

plained death of siblings.(4) A lack of understanding by the mother of

what has been happening and little feasibility ofcontinued help for her and the family.

(5) Mothers who themselves have overt Mun-chausen syndrome; because rational conversationand management is impossible without truth.

(6) Major adverse social factors such as drugdependency or alcoholism.

(7) Persistence of fabrication even after somedegree of confrontation with the mother. i7

Statutory arrangements have usually been con-tested, in some cases only as a result of the husbandbeing unable to accept the possibility of his wife'sdeception and demanding legal help. In Britain mostchild abuse cases come to the juvenile courts wherethey are considered by three lay magistrates, butMunchausen syndrome by proxy cases are likely tobe inappropriate for that court. They can beincredibly complex and the degree of medicalevidence and the length of the case together with

interposed adjournments means that they are bestdealt with by higher courts. Applying for wardship(ward of court) for the child gives automatic accessto a higher court. This procedure has been usedincreasingly in recent years for complicated cases ofchild abuse and may well be the ideal, even though itis expensive. For a child who is a ward of court thewelfare of the child is paramount and mattersrelating to that child are dealt with by the familydivision of the high court. As in a juvenile court,proceedings will be held in camera (that is noproceedings can be reported in the press.) It is worthbearing in mind that in high court actions the localauthority is compelled to disclose all documents atthe court hearing, which is not so for juvenile courts.This means that any document one has writtenabout the child will be available to all parties. Thepractical advantage of wardship over care proceed-ings at a juvenile court is the immediate recourse tothe expertise of a high court. It has been noteworthythat the judges in the high courts have been quick tobelieve and understand the way in which mothershave behaved. They have not doubted the facts andthey have understood clearly the dangers in a waythat has not always happened in the lower court.They do appreciate being given reprints of articlesabout the condition that have been published inmedical journals. Mitchels18 has pointed out that afurther advantage of wardship is the way that it canbe used in emergencies without the need to establishthat any harm, mental, physical, or emotional hasalready been sustained by the child: it is sufficient ifthe court believes that there is a risk of such harm. Ifa paediatrician were in the unusual position where asocial services department was unwilling or unableto act, he or she could, as could any private person,apply for wardship from the court registrar. Almostcertainly before the full and costly hearings, thelocal social services department would have beenstimulated into action.Whatever arrangements are made for the child,

the paediatrician must agree to continue to see thechild for a long time. It is helpful to have thisincorporated into the legal agreement. This isparticularly important if the child has an additionalgenuine chronic illness, and important anywaybecause all children will have an occasional genuineillness. There have been some bizarre happeningswhen children, returned to the family home but stillunder supervision, have become ill. One childdeveloped tonsillitis whereupon a conscientioussocial worker notified the police who searched thehouse from top to bottom for poisons (that mighthave caused the tonsillitis) and took the motheraway to jail for the night. The paediatrician mustliaise closely with the family doctor and agree with


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him and the supervisory agency to adjudicate on theauthenticity of any illness.

Role of psychiatry

Many mothers who have perpetrated Munchausensyndrome by proxy have been referred to psychi-atrists, and many have had detailed psychologicaltesting. Usually the tests are normal and no disorderis apparent to the psychiatrist. It is customary duringcourt proceedings for the mother's legal representa-tive to produce a document stating that she has beenseen by a psychiatrist and a psychologist who havefound her to be normal and who do not believe shecould be acting in this way. This is not surprisingbecause the mothers do seem normal (the exceptionbeing the small minority who have Munchausensyndrome themselves). Fewer mothers have beenseen by child or family psychiatrists and this is a pitybecause an experienced child psychiatrist might welldetect more. Nevertheless, quite a large number ofBritish mothers have been seen by child psychiatristswho have not found any apparent disorder, and thepsychiatrists themselves have written that theycannot believe the accusations that have been madeagainst the mother. (Some have suggested one ortwo even rarer organic disorders as the reason forthe child's illness!) This is understandable, since it isvery difficult on meeting these mothers for the firsttime to envisage all that has happened, and certainlyno specialist, however skilled, can understand aswell as a doctor who has known the mother forseveral months, and on whom the deception hasbeen practiced and gradually revealed. Addition-ally, in Britain, child psychiatrists have tended tocontribute little to the care of families in which childabuse is occurring and have limited experience of it.This is not universal and there are many countrieswhere psychiatrists play an important role in themanagement of child abuse.7 These psychiatrists arelikely to be as effective as anyone in helping. Earlyinvolvement is preferable, if possible before andduring the stressful confrontation period, so thatthey will have a stronger role and be more effectivetherapeutically. I can envisage a child psychiatristtaking on the major role in the long term help forthe family. Evtn when it is more appropriate forthat role to be taken by the paediatrician, there islittle doubt that he would welcome help from thechild psychiatrist, if only in the form of discussionand moral support, because these families areexceedingly difficult and stressful to manage.

Postscript

Many paediatricians, including myself, are criticalsometimes of child protection and social services,case conferences and court procedures for children.But this should not deter us from using these properprocedures early. Within this series of cases areseveral in which experienced paediatricians sus-pected bizarre abuse for a long time but failed torequest formally a case conference. Similarly, thereare examples of case conferences failing to appreci-ate the gravity of the problem and failing to test thecase legally in court. Both these omissions havecaused the needless death and permanent handicapof children.

References

Meadow R. Munchausen syndrome by proxy-the hinterland ofchild abuse. Lancet 1977;ii:343-5.

2 Meadow R. Munchausen syndrome by proxy. Arch Dis Child1982;57:92-8.Meadow R. Factitious illness-the hinterland of child abuse.In: Meadow R, ed. Recent advances in paediatrics No. 7.Edinburgh: Churchill Livingstone, 1984:217-32.

4Warner JO, Hathaway MJ. Allergic form of Meadow's syn-drome (Munchausen by proxy). Arch Dis Child 1984;59:151-6.O'Shea B, McGennis A, Cahill M. Mcllroy: some of theanswers. Irish Journal of Psychiatry 1984;5:5-8.

6 Rogers D, Tripp J, Bentovim A, Robinson A, Berry D,Goulding R. Non-accidental poisoning: an extended syndromeof child abuse. Br Med J 1976;i:793-6.

7Waller DA. Obstacles to the treatment of Munchausen by proxysyndrome. J Am Acad Child Psychiatry 1983;22:80-5.

8 Lee DA. Munchausen syndrome by proxy in twins. Arch DisChild 1979;54:646-7.

9 Meadow R. Fictitious epilepsy. Lancet 1984;ii:25-8.'1 Kurlandsky L, Lukoff JY, Zinkham WH, Brody JP,

Kessler RW. Munchausen syndrome by proxy; definition offactitious bleeding in an infant by 5"Cr labeling of erythrocytes.Pediatrics 1979;63:228-31.Nading JH, Duval-Arnould B. Factitious diabetes mellitusconfirmed by ascorbic acid. Arch Dis Child 1984;59:166-7.

12 Rosen CL, Frost JD, Bricker T, Tarnow JD, Gillette PC,Dunlavy S. Two siblings with recurrent cardiorespiratory arrest:Munchausen syndrome by proxy or child abuse? Pediatrics1983;71:715-20.

13 Liston TE, Levine PL, Anderson C. Polymicrobial bacteremiadue to Polle syndrome: the child abuse variant of Munchausenby proxy. Pediatrics 1983;72:211-3.

14 Halsey NA, Tucker TW, Redding J, Frentz JM, Sproles T,Daum RS. Recurrent nosocomial polymicrobial sepsis secon-dary to child abuse. Lancet 1983;ii:558-60.

15 Richtsmeier AJ, Walters DB. Somatic symptoms as a familymyth. Am J Dis Child 1984;138:855-7.

16 Bayliss RIS. The deceivers. Br Med J 1984;288:583-4.17 Palmer AJ, Yoshimura GJ. Munchausen syndrome by proxy.

J Am Acad Child Psychiatry 1984;4:503-8.18 Mitchels B. Munchausen syndrome by proxy-protection or

correction? New Law Journal 1983;133:165-8.

Correspondence to Professor S R Meadow, Department ofPaediatrics and Child Health, St James's University Hospital,Leeds LS9 7TF.


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