Munchausen's syndrome by proxy
Introduction
What is fabricated or induced illness?
Fabricated or induced illness (FII) is a rare form of child abuse. A carer, usually the biological mother, fakes or actually causes the symptoms of illness in a child who is under their care.
The term 'mother' will be used in the rest of this article to describe the perpetrator of FII, although it should be made clear that a small number of cases of FII have involved the father, foster parent, other guardian, or a healthcare or childcare professional.
FII is also known as Munchausen Syndrome by Proxy. Munchausen Syndrome is a condition in which a person pretends to be ill, or actually causes illness or injury to themselves. The term Munchausen Syndrome by Proxy can be used to describe when somebody fabricates or causes illness or injury to others.
However, healthcare professionals in the UK now prefer to use the term fabricated or induced illness, as it was thought that Munchausen Syndrome by Proxy did not properly describe the full range of behaviour and parental motives that can occur in FII. The term Munchausen Syndrome by Proxy is still widely used in other countries.
Cases of FII can range from moderate to severe. Previous case reports of FII have uncovered evidence of:
- mothers lying about their child's symptoms,
- mothers deliberately contaminating or manipulating clinical tests to fake evidence of illness, such as adding blood to urine samples or heating thermometers to suggest the presence of fever,
- poisoning their child with unsuitable medicine,
- infecting their child's wounds with dirt or faeces, and
- inducing unconsciousness by suffocating their child.
It is estimated that 6% of all children involved in cases of FII will die as a result of their abuse.
How common is FII?
Thankfully, cases of FII are extremely rare. One study estimated that only 50 new cases of FII occur in the UK every year.
Most cases of FII involve children under the age of 5, with the average age being 20 months. In around 85% of the cases, the abuse was carried out by the child's biological mother. Usually only one child in a family is affected.
Why do mothers want to hurt their child?
It is not fully understood why FII occurs, but a number of theories have been suggested. It could be that the mother enjoys the attention involved in playing the role of the 'caring mother'.
A large number of mothers who have been involved in cases of FII have had a previous history of often unresolved psychological and behavioural problems, such as a history of self harming, drug or alcohol abuse, or have experienced the death of another child.
Protecting the child
FII is a child protection issue and cannot be treated by the NHS alone. Medical professionals who suspect FII is taking place will liase with social services and the police.
The first priority is to protect the child. This may involve removing them from their mother's care. Once the child is safe, it is sometimes possible to treat the underlying psychological problems of the mother, and if they successfully respond to treatment, then place the child back into their care.
Controversies surrounding FII
There have been some recent controversies surrounding the issue of FII. This is due to a number of women who were convicted of murdering their children being exonerated and freed by the Court of Appeal. The Court of Appeal judged that the medical evidence given by the expert witness in these cases, Professor Roy Meadows, was unsafe and misleading.
As Professor Meadows was the doctor who first coined the term Munchausen Syndrome by Proxy, and became a leading expert in cases of FII, this led many media commentators to conclude that FII was not a real phenomenon.
While this article cannot comment on individual cases, there is a great deal of compelling evidence that FII does actually occur. The evidence includes hundreds of case files, confessions from mothers, the testimony of children, and covert videotape evidence of abuse.
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Symptoms
The warning signs of Fabricated or Induced Illness (FII)
The following warning signs may indicate that a child may be being subjected to Fabricated or Induced Illness (FII).
- The child has repeated, unexplained and sometimes multiple illnesses.
- The child's symptoms do not correspond to the results of clinical tests.
- The child's reported symptoms only occur in the mother's presence.
- The mother often has a good medical knowledge or medical background.
- The mother is very attentive to the child and stays with them constantly in hospital, yet appears less worried about their child's health than the doctors who are treating the child.
- The mother often tries to maintain a close and friendly relationship with medical staff, yet can quickly become abusive or argumentative if her own views on what is wrong with the child are challenged.
- The father has little, or no, involvement in the care of the child.
- The mother encourages medical staff to perform often painful tests and procedures on the child (tests that most parents would only agree to if they were persuaded that it was absolutely necessary).
- The mother has a history of frequently changing GPs, or visiting different hospitals for treatment, especially if her own views on her child's treatment are challenged by medical staff.
Patterns of abuse
The patterns of abuse found in cases of FII usually fall into one of six categories, which are ranked below from least severe to most severe. However, in the more severe cases of FII, the mother may carry out behaviour from several, or possibly all, categories.
The categories are:
- fabricating symptoms and manipulating test results to suggest the presence of illness,
- withholding nutrients from the child,
- inducing symptoms by means other than poisoning or smothering, such as using chemicals to irritate their skin,
- poisoning the child with a poison of low toxicity, such as using a laxative to induce diarrhoea,
- poisoning the child with a poison of high toxicity, such as using insulin to lower a child's blood sugar level (causing hypoglycaemia), and
- deliberately smothering the child to induce unconsciousness.
Commonly reported fabricated symptoms
The most commonly reported fabricated symptoms in cases of FII are:
- seizures,
- fainting,
- vomiting,
- diarrhoea,
- allergies,
- asthma,
- episodes of breathlessness (apnoea), and
- psychological symptoms, such as hyperactivity or a learning difficulties.
Older children will often take part in their mother's deception, and confirm their mother's claims about symptoms. This can be due to a desire to please their mother, or a fear that their mother will leave them if they do not back up her claims, or because they actually become convinced that there is something wrong with them.
What to do if you suspect a case of FII
If you suspect that somebody you know may be fabricating or inducing illness in their child, it is not recommended that you confront them directly. A direct confrontation is not likely to make a person admit to doing anything wrong, and it may give them the opportunity to dispose of any evidence of abuse.
If your job involves working with children, such as a nursery worker or teacher, you should inform the nominated person in your organisation responsible for child protection issues. If you do not know who this is, your immediate supervisor or manager should be able to tell you.
Otherwise contact your local social services department or telephone the NSPCC's child protection helpline on 0808 800 5000.
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Causes
The exact causes of Fabricated or Induced Illness (FII) are unknown, but previous traumatic experiences in the mother's life seem to play an important role.
Some experts agree that mothers who are involved in FII have a borderline personality disorder. Personality disorders are a type of mental health condition where an individual has a distorted pattern of thoughts and beliefs about themselves, and others. These thoughts and beliefs can lead them to behave in ways that most people would regard as disturbed and abnormal.
Most personality disorders can be traced back to an initial traumatic event during childhood. Many mothers involved in FII also have a history of abuse or neglect, have experienced the loss of a loved one, or grew up in dysfunctional families. Of course, the same is true of thousands of other people who do not go on to abuse their children.
Many people with personality disorders often find a kind of reward in behaviour or situations that other people would find intensely distressing. It is thought that mothers who carry out FII are not doing it out of any genuine malice or dislike of their child, but that they find the situation of their child being under medical care and supervision rewarding and comforting.
Why this should be is still open to interpretation. Many of the women involved in the most serious cases of FII have denied all wrongdoing and refused to co-operate with psychiatric treatment, so there is little available insight into their motives.
One theory is that FII is a kind of role-playing. It allows a mother to adopt the role of a caring and concerned mother, while at the same time allowing her to pass the responsibility of caring for a child off onto the medical staff.
Another theory is that it is a way for the mother to escape from her own negative feelings and unpleasant emotions. By creating a permanent crisis situation surrounding her child, she can concentrate all her thoughts on her child's treatment, keeping her own negative feelings and emotions at bay.
More research is needed to discover the definitive causes of FII.
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Diagnosis
Diagnosing a case of Fabricated or Induced Illness (FII) can be extremely difficult for medical professionals.
Doctors, especially paediatricians (doctors who specialise in the treatment of children) are taught that 'mother knows best'. In the vast majority of cases, mothers have a natural and instinctive ability to spot when something is not right with their child, and their opinions should always be taken seriously.
Medical professionals will naturally assume that a mother always acts in the best interest of their child, unless there is compelling evidence to suggest otherwise.
What happens when FII is suspected
If a medical professional suspects a case of FII, they will usually refer the case to a senior paediatrician. The senior paediatrician will then examine the medical evidence to see if there is a clinical explanation for the child's symptoms, and may seek further specialist advice and arrange further testing.
In the case of older children, the medical staff will try to speak to them without the mother being present. However, this can prove difficult as many mothers will refuse to leave their child alone.
Tests may also be carried out to check for evidence of FII, such as the presence of unprescribed medicine, such as insulin, in the child's blood, or whether tests results have been tampered with, such as adding adult blood to a child's urine sample.
If no clinical explanation can be found for the symptoms, and/or there is clinical evidence of FII, the case will then be referred to the social services and police. The social services, police and medical staff will then meet to assess the evidence and the likely risk to the child.
Ensuring the safety of the child
If the child is thought to be at immediate risk of physical harm, social services will remove the child from the mother's care. The child could be placed under the care of another relative, or under the care of social services.
If it is thought that there is no risk of physical harm to the child as the mother is only fabricating (faking), and not causing actual symptoms, a child protection plan will be drawn up. The child protection plan will not only consider the child's health and safety needs, but also their educational or social needs. For example, a child may have been deprived of regular education because his mother kept him away from school due to a fabricated illness.
As part of the child protection plan, the mother may be asked to agree to psychiatric treatment or family therapy. Refusing to comply with the child protection plan may mean that the child is removed from her care.
If the level of abuse warrants criminal charges, the police will begin investigating the case. As part of the investigation they can use covert video surveillance to check if the mother is inducing symptoms, though this option is only used if there is no other way of obtaining information to explain the child's symptoms.
Only the police have the legal authority to carry out covert video surveillance.
For a more in-depth examination of the current government guidelines regarding the protection of children in cases of FII see the 'selected links' section. This information may be of particular use to healthcare and childcare professionals.
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Treatment
Treatment for the child
The first goal of treatment for a child who has been affected by fabricated or induced illness (FII) is to restore the child to good health. Younger children and babies who do not understand that they were victims of abuse often make a good recovery once their mother’s abuse stops.
Older children, particularly those who have been abused for many years, will have more complex problems and needs. For example, many older children who are affected by FII believe that they are really ill and will need help and support to develop a more realistic understanding of their health. They may also need to learn how to tell the difference between their mother’s lies and reality.
Children affected by FII may also need help rehabilitating back into a normal lifestyle, for example, returning to school. It is also common for older children to feel loyalty towards their mother and a corresponding sense of guilt if their mother is removed from the family.
Treatment for the mother
Treatment for the mother will require a combination of:
The psychotherapy aims to uncover and resolve the issues that caused her to fabricate (fake) or induce (cause) illness in her child.
Family therapy will attempt to resolve any tensions within the family, improve the mother's parenting skills and try to repair the relationship between the mother and child.
In more severe cases, the mother may be compulsorily detained in a psychiatric ward under the Mental Health Act so her relationship and contact with her child can be closely monitored.
The best results occur in cases where the mother:
- understands and acknowledges the harm that she has caused to her child
- is able to communicate the underlying motivations and needs that led her to fake or cause illness
- is able to work together with healthcare and other professionals
Many mothers will experience feelings of guilt and depression for which they will need to receive additional treatment.
However, treating women who are involved in this type of abuse is often very challenging because they can lack a clear understanding of what they have done to their child and remain in a state of denial about the consequences of their actions. Many women need to be referred to a specialist psychiatric unit because their needs are too complex to be dealt with by local adult psychiatric services.
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Q&A
How can I tell if a child is being abused?
There are four types of cruelty that are considered child abuse: physical abuse, sexual abuse, emotional abuse and neglect. A child who is being abused may experience more than one kind of cruelty.
It can be difficult to know whether a child is being abused, even if you have a lot of contact with the family concerned, as the abuser may be secretive about their actions. However, there are signs of child abuse to look out for.
Physical signs can include unexplained cuts, bruises, burns, bite or welt marks on the child's body and/or soreness, pain or bruises around the genitals or mouth.
Other signs of abuse can show up in the child's behaviour, including:
- becoming withdrawn, secretive or very clingy,
- a fear of adults,
- problems in school,
- nightmares and bedwetting, and
- aggression or antisocial behaviour.
The child may also self-harm, have an eating disorder, depression, a drug or alcohol problem, or suicidal behaviour.
Common signs of a neglected child may include the child being unwashed, often seeming very hungry, or wearing unsuitable clothing for the weather (for example, no coat when it's cold). The child may constantly have head lice or you may notice wounds that haven't been treated. Another sign is that the child may never seem to have any adult supervision.
If the abuse is sexual, then the child may also express inappropriate interest or knowledge of sexual acts. On the other hand, they may avoid talking about anything related to sexuality and sex.
The signs listed above do not necessarily mean that a child is being abused. For example, bedwetting is a common condition that can affect any child. Use your own judgement but don't be afraid to speak up if you're worried about a child.
If you are concerned that a child you know is being abused then contact your local social services, the police, or ring the 24 hour NSPCC Child Protection Helpline on 0808 800 5000.
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