"To announce that there must be no criticism of the president, or that we are to stand by the president, right or wrong, is not only unpatriotic and servile, but is morally treasonable to the American public." -- U.S. President Theodore Roosevelt during World War I, when Woodrow Wilson was president.
By Kathryn A. Artingstall
Detective Artingstall serves with the Orlando, Florida, Police Department.
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, 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.
Research on MSBP
Researchers documented the serial nature of MSBP victimiza-tion in a study of 5 families with a total of 18 children.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.
The characteristics of the maternal perpetrators in this study indicated the following: 80 percent possessed backgrounds in health professions; 80 percent manifested Munchausen Syndrome (self-inflicted injury) themselves; 80 percent received psychiatric treatment prior to diagnosis; and 60 percent of the mothers attempted suicide. Denial persisted in most cases.
The research also shows that individuals who initially engaged in Munchausen Syndrome may eventually practice Munchausen Syndrome by Proxy.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.
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 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 types of cases. Incidents falsified by offenders and seemingly verified by means of self-mutilation only add to the mystery when a perpetrator cannot be identified.
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.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.4 Fathers, grandmothers, aunts, and babysitters 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.
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.
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. 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.
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.
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.
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.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 ap-parent 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.6
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.
Child Custody Cases
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 kidnaping 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.
Domestic Violence Shelters
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.
Generally, abuse of a victim at the hands of an MSBP offender is resolved in one of the three ways--the child dies, the police apprehend the offender, or 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.
MSBP as a Homicidal Agent
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.
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.
1 R. Alexander, W. Smith, R. Stevenson, "Serial Munchausen's Syndrome by Proxy," Pediatrics, vol. 86, 1990, 581-585.
2 R. Meadow, "Management of Munchausen Syndrome by Proxy," Archives of Disease in Childhood, 1985, 385-393.
3 H. Schreier and J. Libow, Hurting for Love: Munchausen by Proxy Syndrome (Guilford, Connecticut: Guilford Press, 1993), 103.
4 K. Hanon, "Child Abuse: Munchausen's Syndrome by Proxy," FBI Law Enforcement Bulletin, December 1991, 8-11.
5 D.A. Rosenberg, "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 R. Kinschereff and R. Famularo, "Extreme Munchausen Syndrome by Proxy: The Case for Termination of Parental Rights," Juvenile and Family Court Journal, vol. 5, 41-49.
Sidebar 1 Profile of MSBP Offenders
* Are most often biological mothers of the victims, but potential offenders are not limited to this group; fathers and persons outside the family also have been identified
* Are often upper class, well-educated persons
* Remain uncharacteristically calm in view of the victim's perplexing medical symptoms
* Welcome medical tests that are painful to the child
* Praise medical staffs excessively
* Appear to be very knowledgeable about the victim's illness
* Have some medical education_either formal or through self-initiated study/experience
* Might have a history of the same illness as the victim
* Typically shelter victim from outside activities, such as school or play with other children
* Allow only selected persons close to their children
* Maintain a high degree of attentiveness to the victim
* Seem to find emotional satisfaction when the child is hospitalized because of the staff's praise of their apparent ability to be a superior caregiver.
Sidebar 2 Motivational Factors
One or more of the following motivational factors might be present in MSBP cases:
* Most offenders crave the attention gleaned from hospital staffs, doctors, and family members
* Offenders become more aggressive as time passes
* Some offenders in theory might receive gratification as they fool the doctors. They derive enjoyment from knowing what is wrong with the child while medical experts remain baffled
* Some offenders may fear going home or adjusting to a normal daily routine without being the center of attention
* A relatively minor crisis_such as the fear of being left alone or of the child's being released from the hospital_could trigger an attack on a victim
* An offender who is praised as a hero for saving a child might elect to re-create that euphoria by fabricating subsequent incidents of abuse and revival of the victim.
Sidebar 3 MSBP Warning Signs
* Unexplained and prolonged illness that puzzles experienced doctors who may state that they have "never seen anything like it before" * Repeated hospitalizations and extensive medical tests that fail to produce a diagnosis
* Symptoms that do not make medical sense
* Persistent failure of the victim to respond to therapy
* Signs and symptoms that dissipate when the victim is removed from the suspected offender's presence
* Mothers who do not seem worried about their child's illness but are constantly at the child's side while in the hospital
* Mothers who have an unusually close relationship with the hospital's medical staff
* A family history of sudden infant death syndrome
* Mothers with previous medical or health-care experience who have a history of the same type of illness as their child
* A parent who welcomes medical testing of the child, even if painful
* Attempts to convince the staff that the child is still ill when advised that the child will be released from the hospital
* A model family that normally would be above suspicion
* A caregiver with a previous history of Munchausen Syndrome
* A caregiver who adamantly refuses to accept the suggestion that the diagnosis is nonmedical.
From The FBI Magazine - August 1995
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