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Artingstall, Kathryn A., "Munchausen Syndrome By Proxy," FBI Law Enforcement Bulletin, August 1995: Detective Artingstall serves with the Orlando, Florida, Police Department.
Topics covered in this article:
Introduction |
Research on MSBP
Characteristics of the maternal perpetrators
Cross-over from Munchausen Syndrome to
MSBP
Perpetrators:
Biological Mother (Most Commonly)
Perpetrators:
Medical Professionals (Rare Cases)
Investigative Guidelines
Confusion with
Sudden Infant Death Syndrome
Questioning Victims
Victim Safety during investigation
False Allegations of MSBP
Child Custody Cases
Domestic Violence
Shelters
Fate of
Initial Victim & Substitute Victims
Use of MSBP
as a
Homicidal Agent
Conclusion
Sidebars:
Profile of MSBP Offenders | Motivational
Factors |
MSBP Warning Signs
The dawn of the 1990s brought widespread recognition of a once-obscure criminal act, Munchausen Syndrome by Proxy (MSBP), in which subjects injure or induce illness in children in order to gain attention and sympathy for themselves. Since its recognition by the criminal justice community, MSBP has been identified most closely with mothers who induce in their children breathing difficulties that mimic the symptoms of apnea and sudden infant death syndrome (SIDS), who poison them, or who fabricate illnesses in their children. These mothers then bask in the attention afforded them by relatives, doctors, and hospital personnel. However, because the child's illness has no medical cause, doctors have difficulty making a diagnosis.
As the baffling symptoms continue, doctors or hospital administrators may call on law enforcement to investigate the mysterious circumstances surrounding such cases. In fact, as the medical community becomes increasingly familiar with MSBP and its warning signs, doctors and medical staffs seem to be more inclined to request the assistance of local law enforcement agencies.
The growing list of MSBP cases underscores the need for
investigators to understand the various, and often complex,
issues related to MSBP. During the past several years, a
number of variations to the normal offender patterns
have emerged, accompanied by a clearer understanding of how
law enforcement should respond to cases believed to involve
MSBP. The more investigators know about MSBP, the better able
they will be to identify perpetrators, clear innocent
suspects, and most important, protect children.
(top)
Researchers documented the serial nature of MSBP
victimization in a study of 5 families with a total of 18
children.(
Ref.1 ) In this study, 72 percent of the children were
known to be MSBP victims. In each family, only one child
was involved at any given time, and a total of five
children seemed to be unaffected. Of those children affected,
31 percent died. In only one instance was there any other
form of abuse present.
(top)
The research also shows that individuals who initially
engaged in Munchausen Syndrome may eventually practice
Munchausen Syndrome by Proxy.(
Ref.2 ) The degree to which the offspring of Munchausen
offenders become the subjects of abuse may increase
proportionately with the number and increased severity of
incidents of self-inflicted abuse.
(top)
MSBP may occur when the perpetrator of Munchausen Syndrome crosses over the threshold of self-inflicted injury into abuse of an unsuspecting child. Oftentimes, the caregivers (offenders) claim that injuries to the child were inflicted by a fictitious bad guy. In some instances, offenders injure them-selves in order to substantiate the presence of this unknown perpetrator. Cautious, diligent investigation of these allegations often leads to dead ends based on a series of false crime reports.
Although there seems to be a multigenerational link (i.e., mother was MSBP victim, then her child is MSBP victim, etc.) between Munchausen Syndrome and MSBP, this connection has not been established scientifically to the level that most courts require. The level of understanding that members of the criminal justice system possess regarding Munchausen Syndrome and MSBP makes a crucial difference to the outcome of these cases. The ever-present possibility of continued victimization of children at the hands of MSBP offenders further underscores the importance of handling these cases expediently.
Establishing MSBP as a possible extension of Munchausen Syndrome will not be an easy task for investigators and prosecutors if the acts have not advanced to the point of physical abuse. Most courts are unwilling to remove a child from a parent's custody without concrete evidence to support charges of child abuse.
Understandably, detectives experience considerable
frustration when working on these cases. Incidents falsified
by offenders and seemingly verified by means of
self-mutilation only add to the mystery when a perpetrator
cannot be identified.
(top)
In the standard offender-victim relationship, suspicion centers on the biological mother. In fact, the vast majority of MSBP cases resolved through investigation have implicated the victim's mother as the sole offender.( Ref.3 )
Investigators should be aware, however, that the MSBP
offender profile has widened to include other
perpetrators, both within and outside the victim's family
structure.(
Ref.4 ) Fathers, grandmothers, aunts, and baby-sitters
have been identified as offenders. Regardless of the
relationship to the victim, the offenders all had one
thing in common: each acted as the victim's primary
caregiver.
(top)
In very rare cases, medical professionals also could be included in the list of potential suspects. While it appears that only immediate family members would receive the gratification from attention, increased self-esteem, and false sense of belonging afforded by MSBP, similar motivations lead some health-care workers to cross the line of the Hippocratic Oath into the realm of child abuse. By inflicting MSBP, and then "saving" the child, these offending medical practitioners hope to excel within their fields and win acceptance by their peers. Fortunately, the frequency of cases involving health-care workers has been relatively low thus far. The possibility exists, though, that a medical professional's actions might indicate MSBP in certain circumstances.
Investigations of this type are highly sensitive. Often,
medical personnel are wrongly accused by actual offenders who
perceive that they have come under suspicion. Still, an
investigator's decision to suspect or accuse medical
professionals of MSBP should be based on the same standard of
investigation used for other suspects. However, the primary
caregiver status inherent in the most common offender
profiles continues to place mothers at the height of
suspicion.
(top)
The methods by which investigators approach
suspected MSBP offenders are the keys to resolving
such cases. During interviews, investigators should not
express open disbelief in their accounts of criminal
incidents. Rather, investigators need to convey to the
suspect that they are keeping an open mind regarding
the case. Investigators can expect sound
rationalization on the part of such offenders, as well
as a series of open-ended allegations that cannot
be substantiated.
(profiles)
(top)
Investigators should make every effort to segregate other family members from suspects during the interview process because relatives probably will voice support and belief in the allegations if the suspect is present. In those cases where obvious inconsistencies exist, family members might view facts differently when questioned away from the suspect. With further investigation, identified MSBP offenders might be linked to the deaths of their other children. Often, the original medical examiners incorrectly identified these deaths as resulting from sudden infant death syndrome (SIDS).
If the deceased child or children have not been cremated,
then exhuming their bodies for forensic testing might be
appropriate. When advised of previously identified
causes of death within a family, forensic pathologists
or medical examiners might be able to uncover particular
toxins or evidence pointing to homicide.
(top)
Whether the child actually knows that the offender has induced the illness depends on the child's physical age and the offender's covert skills. Certainly, the longer the abuse continues and the older a child grows, the more likely it becomes that the victim will understand the offender's actions.
If the abuse has been present throughout the life of the child, then the victim might believe that whatever action is being done to cause the illness is normal. Because of this misunderstanding of normal behavior and the attention that the offender lavishes, the child might not view the offender as anything less than an ideal caregiver, even if the abuse is blatant.
Law enforcement officers generally should refrain from
inter-viewing the victim for two reasons. First,
even if a victim is old enough to talk, the child probably
will not be able to assist officers verbally in the
investigation. Second, officers must consider the
potentially traumatic consequences should the child be told
that a trusted caregiver is in fact an abuser. For these
reasons, it would be wise to elicit the help of professionals
when dealing with this aspect of the investigation to lessen
the possibility of further traumatizing the victim.
(top)
In MSBP-related cases, investigators face additional concerns for the safety of the child involved. Suspected offenders might react in a number of ways when confronted by the police. Generally, offenders deny the allegations and blame the child's apparent illness on unknown causes. Often, an upsurge in the severity of the victim's symptoms follows as the offender attempts to prove the presence of the illness. Unfortunately, the child might not be able to withstand the escalating abuse or the increased treatments prescribed to address the symptoms.
In order to reduce the possibility of further abuse to the child, investigators must work toward a swift conclusion to the case once they have confronted the suspected offender. Accordingly, case parameters and guidelines regarding evidence collected should be established prior to informing the subject of the investigation. Careful planning and caution in this area can be critical; research indicates that from 9 to 31 percent of all MSBP victims die at the hands of their perpetrators.( Ref.5 )
Some confronted offenders might react more passively by relocating with the victim and other family members. If the courts do not enact protective measures to preclude a suspect from relocating with the child, the cycle of MSBP probably will continue in a new locale.
To avoid this scenario, investigators should ensure that adequate measures to protect the victim are in place via social services or judicial avenues before informing subjects that they are under suspicion. These measures should remain in place until the case is concluded.
If not arrested, offenders who believe they are under suspicion might become more cautious, but only temporarily. The child's apparent illness might subside until the offender believes it is safe to resume the abuse. Offenders also may wait until a reasonable time elapses and then re-admit the child into the hospital.
In either case, it appears that as offenders continue
their abuse, the danger to the child
increases. The needs-oriented behavior of such
offenders has been compared to that of drug
addicts. Through cycles of abuse and nurturing, MSBP
offenders seek to satisfy an ever-increasing need for
attention and self-validation. However, some experts
believe that, unlike most drug addicts, MSBP offenders cannot
be rehabilitated.(
Ref. 6 )
(top)
Despite seemingly strong circumstantial evidence present in some cases of apparent MSBP abuse, law enforcement officers must make every effort to refrain from making false allegations. Accusations based on insufficient investigation and absent forensic analysis can have disastrous consequences. In one such case, a mother in Missouri was falsely accused of the death of her infant son. The child died as a result of apparent ethylene glycol poisoning. However, upon the birth of a second baby, doctors found that the infant had a rare disease, methylmalonic acidemia, which in fact, had caused the death of the first child. The mother subsequently initiated legal action against the State.
Such cases reinforce the need for investigators to
explore all avenues when suspicion of MSBP arises. The
importance of medical evaluation cannot be overstated. In
fact, without properly collected medical documentation to
support the thesis of MSBP abuse, it is unlikely that
prosecutors can establish probable cause to support custodial
arrest.
(top)
The manner in which charges of MSBP originate must be considered in the total course of an investigation. Highly disputed child custody cases often generate charges of child abuse. Sometimes, MSBP offenders accuse the other parent of abuse in order to mask their own wrongdoing and to keep custody of the child. In cases where an estranged parent involved in a custody dispute reports illnesses or accuses the other parent of child abuse, investigators should explore all potential motivations for such accusations. Falsified reports for custodial purposes could be a valid concern. Any investigator assigned to a potential MSBP case needs to ensure that the agency is not being used as a tool for secondary gain by the accusing parent.
In cases where reports of abuse emanate from a noncustodial or estranged parent, the question of accuser-inflictor role reversal should be considered as an alternate cause of the child's ailments. This type of issue often arises in contested divorce situations involving minor children and also might be linked to parental kidnapping by noncustodial parents.
When custody has been denied to an offending parent, and the victimized child has been placed with the other parent, the offender might go to great lengths to regain custody. Accusations of sexual abuse, especially if the custodial parent is the father, might be made by offenders as they attempt to disguise their responsibility for the child's abuse.
The underlying rationalization for the actions of MSBP
offenders stems from their desire to regain lost
custody through outward expressions of love. It appears
that the longer offenders are separated from victims,
the more desperate and determined they become to
regain custody.
(top)
Suspected MSBP offenders who believe that they are being watched, have been accused of MSBP abuse, or sense the need for self-vindication might seek assistance by accessing public shelters provided for victims of domestic violence. In such cases, offenders rely on their highly developed skills of deception.
Because personnel working at these shelters function for the protection and assistance of traumatized women, they might be reluctant to question an incoming client's account of victimization. This situation highlights the need for a concrete investigative protocol when suspicion falls on an MSBP offender.
Once a woman gravitates to an abuse shelter, police
access might be difficult, and the support system in the
shelter will reinforce her fictitious explanation of the
child's injuries or illness. While in the shelter, the victim
temporarily might be spared from further injury to strengthen
the mother's claim that another person is the source of the
abuse. However, the child's reprieve usually ends when the
offender must leave the shelter and once again is alone with
the victim.
(top)
Generally, abuse of a victim at the hands of an MSBP offender is resolved in one of the three ways:
1. The child dies
2. The police apprehend
the offender
3. The victim's advancing age causes the
offender to move on to a younger child within the
family.
In cases where a child has either died from abuse or
matured to the point that the caregiver believes it is too
dangerous to continue the abuse, the offender might attempt
to find another suitable victim. The offender commonly
substitutes a younger sibling for the initial victim.
In rare cases, both children might share the abuse
simultaneously, but it is more likely that the offender will
concentrate on one victim at a time. Because offenders
revel emotionally in the attention derived from MSBP, it
seems reasonable to assume that only one child would be
necessary to gain such attention. However, investigators
would be remiss to assume singular victimization because MSBP
offenders maintain their own peculiar index of
rationalization.
(top)
Unfortunately, MSBP has become a popular means to "dump" cases when agencies seek to establish a link between this syndrome and maternal homicide. Not all women who kill their children are afflicted with Munchausen Syndrome or MSBP, just as not all women who kill their children are insane.
With MSBP, offenders crave the attention gleaned from
events surrounding their child's illness or death. Thus,
investigators should consider the possibility of MSBP if they
believe there to be some secondary gain, in the form of
attention or notoriety, afforded the offender at the expense
of the victim. If investigators find no warning signs
associated with MSBP cases or no secondary gain in the
form of attention, then they should consider the
possibility of homicide without the association of the
MSBP factor.
(top)
Despite the evolving understanding of Munchausen Syndrome
by Proxy within the medical and law enforcement fields,
police investigators still might find it difficult to believe
that a child's caregiver, someone who appears sincerely
concerned about the victim's health, could be the cause of a
child's symptoms. However, a growing list of cases
involving Munchausen Syndrome by Proxy confirms that this
disorder represents a substantial challenge to the criminal
justice system. By understanding the motivations, needs, and
methods of MSBP offenders, the law enforcement community can
better identify perpetrators and protect innocent
victims.
(top)
1. Alexander, R., W. Smith, R. Stevenson, "Serial Munchausen's Syndrome by Proxy," Pediatrics, vol. 86, 1990, 581-585.
2. Meadow, R., "Management of Munchausen Syndrome by Proxy," Archives of Disease in Childhood, 1985, 385-393.
3. Schreier, H. and J. Libow, "Hurting for Love: Munchausen by Proxy Syndrome" (Guilford, Connecticut: Guilford Press, 1993), 103.
4. Hanon, K., "Child Abuse: Munchausen's Syndrome by Proxy," FBI Law Enforcement Bulletin, December 1991, 8-11.
5. Rosenberg, D. A., "Web of Deceit: A Literature Review of Munchausen Syndrome by Proxy," Child Abuse and Neglect, November 1987, 547-565; R. Meadow, "Fictitious Epilepsy," Lancet, vol.25, 1984, 8; supra note 1.
6. Kinschereff, R. and R. Famularo, "Extreme Munchausen Syndrome by Proxy: The Case for Termination of Parental Rights," Juvenile and Family Court Journal, vol.5, 41-49. (top)
One or more of the following motivational factors might be present in MSBP cases:
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