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Ask the Mental Health Expert Archives 2001-2004

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Munchausen Syndrome by Proxy

Q. I currently have a child on my caseload who's caregiver has been accused of munchausen by proxy. The child is currently placed in protective custody under supervision of the courts. The report made to CPS by an undisclosed party was that the caregiver did not appear to be caring appropriately for the child, often missing lab testing for medications that have at times over the years become so high that he needed to be admitted to the hospital for toxicity.

This case is a very complex and rare one in that this youngster (age 7) has been given a number of major psychiatric diagnosis (by various psychiatrists) which include:

1. Schizoaffective Bipolar Disorder - with rapid cycling
2. Attention Deficit Hyperactive Disorder - severe
3. Obsessive Compulsive Disorder
4. Coprophilia
5. Mild mental retardation

This child was born to a 13-year-old mother, and was drug and alcohol exposed. He has been in placement since birth. This child is reported to rage for hours, kicking, punching, scratching, screaming, and destroying property and will ingest and smear fecal matter. He is currently taking approximately 6 psychotropic medications.

Is it possible to mimic or induce this kind of mental illness in a child - to the point that the psychiatrist would have prescribed these kinds of medications? There must be something that the psychiatrist is seeing that he feels is consistent with these diagnosis. The current pediatric psychiatrist is doing what he calls "stacking meds" in order to control this child's behaviors. I suppose in simple terms he is providing a chemical straight jacket of sorts.

Can you also tell me how it is that munchausen by proxy is diagnosed, and what I should look for in the medical records of this child that could potentially lead me to the same conclusion, or at least convince me that this is a possibility?

A. For the sake of readers who may not be familiar with this syndrome, in Munchausen Syndrome by Proxy (MSBP), a caregiver fabricates or induces illness in another individual. In most cases, the parent is the perpetrator and the child, the victim (D.R. Fulton, 2000).

It seems unlikely to me that any competent psychiatrist would make the diagnoses you have listed and treat the child with so many medications unless there were observable evidence of psychopathology. However, much depends on the sagacity of the evaluators and the quality of the evidence. For example, you say the child is "reported to rage for hours, kicking, punching." etc. Have these behaviors actually been witnessed by mental health professionals when the child was out of reach of the alleged MSBP caregiver for days at a time?

Typically, in MSBP, when the child is evaluated for extended periods away from the abusive caregiver, the supposed psychopathology diminishes or disappears (although if the child has been physically abused, he or she may continue to show signs of post-traumatic stress disorder). So, if the medical records reflect dramatic improvement in the child's behavior when out of reach of the caregiver, this would certainly be a red flag for MSBP.

Unfortunately, the picture may be iatrogenically muddied by the use of all these psychotropic medications--which may themselves lead to abnormalities in behavior, mood, or cognition in some cases. Neuropsychiatric test data may also be helpful, since it could show either bona fide evidence of psychopathology, or evidence of inconsistent and/or exaggerated responses, possibly suggesting that the child had been prompted or coached. If the developmental history is accurate--i.e., the child was exposed in utero to alcohol, cocaine, or other drugs of abuse--it would not surprise me if there were bona fide neurobehavioral abnormalities. There may even be some organically induced mood and attention deficits.

Quite frankly, rather than stacking more medications on the back of this child, I would much prefer to see a progressive unstacking (sequential tapering and discontinuation of medications) during an extended (4-8 week) inpatient evaluation on a pediatric neuropsychiatry unit. Easier said than done, of course, in this age of mismanaged care! But I do not think simply going through the medical records will be of great probative value, absent such extended, hands-on evaluation.

For more information on MSBP and its detection, the following papers may be of help: Bennett K. Munchausen syndrome by proxy abuse. J Child Health Care 2000 Winter;4(4):163-6; Fulton DR. Early recognition of Munchausen Syndrome by Proxy. Crit Care Nurs Q 2000 Aug;23(2):35-42; and Sanders MJ, Bursch B. Forensic assessment of illness falsification, Munchausen by proxy, and factitious disorder, NOS. Child Maltreat 2002 May;7(2):112-24.

Good luck with this very challenging case!

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July 2002

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