Fabricated Or Induced Illness

February 20, 2008

Fabricated or Induced Illness

From Wikipedia, the free encyclopedia

Fabricated or Induced Illness

Classification & external resources

DiseasesDB 33167

eMedicine med/3544 ped/2742

MeSH D016735

Fabricated or Induced Illness (FII), or factitious disorders,

originally and more commonly known as Munchausen Syndrome or

Munchausen Syndrome by Proxy (MSbP), are insidious disorders in which

injury is deliberately and gradually inflicted upon a person usually

for gaining attention[1] or some other benefit[2].

The caregiver is usually a parent, guardian, or spouse, and the

victim is usually a vulnerable child or adult. Although cases with

feigned or induced physical illness receive the most attention, it is

also possible for a perpetrator who emotionally abuses a victim to

simulate and fabricate conditions that appear to be psychiatric or

genetic problems.

Contents

1 Initial description

2 Indications

3 Prevalence by gender

4 Controversy

5 Legal status in Australia and UK

6 Munchausen Syndrome by Proxy: Pet

7 See also

8 References

9 External links

Initial description

In 1977, pediatrician Roy Meadow, then professor of Paediatrics at

the University of Leeds, England, described the extraordinary

behavior of two mothers: One had (Meadow claimed) poisoned her

toddler with excessive quantities of salt. The other had introduced

her own blood into her baby's urine sample. He referred to this

behavior as Munchausen Syndrome by Proxy (MSbP). Although it was

initially regarded with skepticism, MSbP soon gained a following

amongst medics and social workers. Although it's not listed in the

DSM-IV manual, [3] a formal name since March 2002 is now Fabricated

or Induced Illness (FII) according to the Royal College Of

Paediatrics and Child Health.[4] In 2003 however, Earl Howe, the

Opposition spokesman on health, accused the professor of inventing

a " theory without science " and refusing to produce any real evidence

to prove that Munchausen Syndrome by Proxy actually exists. It is

important to distinguish between the act of harming a child, which

can be easily verified (and there are plenty of cases to prove that

it happens), and motive, which is much harder to verify and which

MSbP (controversially) tries to explain. For example, a carer may

wish to harm a child simply out of malice (similar to domestic abuse

by husband or wife) rather than in order to draw attention and

sympathy, in which case, harming the child is merely incidental to

the main purpose. In the former case, induced illness is likely to be

a means of avoiding detection of domestic abuse (a more elaborate

form of the excuse that the victim has " fallen down the stairs " ).

The distinction is often crucial in criminal proceedings, in which

the prosecutor must prove both the act and the motive of a crime to

establish guilt. In most legal jurisdictions, a doctor can give

expert witness testimony as to whether a child was being harmed but

cannot speculate regarding the motive of the carer. FII merely refers

to the fact that illness is induced or fabricated and does not

specifically limit the motives of such acts to a carer's need for

attention and/or sympathy. There are now more than 2,000 case reports

of FII in the professional literature. Reports come from developing

countries that include, but are not limited to, Sri Lanka, Nigeria,

and Oman. Dr. Meadow was knighted for his work for child protection

though, later, his reputation, and consequently, credibility of MSBP,

become severely damaged when several convictions of child killing, in

which he acted as an expert witness, were overturned. [5]

Indications

Caution is required in the diagnosis of FII. Many of the items below

are also indications of a child with organic, but undiagnosed

illness. An ethical diagnosis of MSbP must include an evaluation of

the child, an evaluation of the parents and of the family dynamics.

Diagnoses based only on a review of the child's medical chart can be

rejected in court.

A child who has one or more medical problems that do not respond to

treatment or that follow an unusual course that is persistent,

puzzling and unexplained.

Physical or laboratory findings that are highly unusual, discrepant

with history, or physically or clinically impossible.

A parent who appears to be medically knowledgeable and/or fascinated

with medical details and hospital gossip, appears to enjoy the

hospital environment, and expresses interest in the details of other

patients' problems.

A highly attentive parent who is reluctant to leave their child's

side and who themselves seem to require constant attention.

A parent who appears to be unusually calm in the face of serious

difficulties in their child's medical course while being highly

supportive and encouraging of the physician, or one who is angry,

devalues staff, and demands further intervention, more procedures,

second opinions, and transfers to other, more sophisticated,

facilities.

The suspected parent may work in the health care field themselves or

profess interest in a health-related job.

The signs and symptoms of a child's illness do not occur in the

parent's absence (hospitalization and careful monitoring may be

necessary to establish this causal relationship).

A family history of similar or unexplained illness or death in a

sibling.

A parent with symptoms similar to their child's own medical problems

or an illness history that itself is puzzling and unusual.

A suspected emotionally distant relationship between parents; the

spouse often fails to visit the patient and has little contact with

physicians even when the child is hospitalized with serious illness.

A parent who reports dramatic, negative events, such as house fires,

burglaries, or car accidents, that affect them and their family while

their child is undergoing treatment.

A parent who seems to have an insatiable need for adulation or who

makes self-serving efforts for public acknowledgment of their

abilities.

Prevalence by gender

It has been noted that MS applies mostly to men whereas FII

perpetrators are disproportionately females. One study showed that in

over 90 percent of cases of Munchausen by proxy, the mother is the

abuser.[6] In other cases, the MSbP abuser is another female

caregiver. Fathers have been the perpetrators in a handful of

professional reports. The female preponderance may be attributed to

the typical socialization pattern which encourages females to seek

the sympathy and assistance of others while males who do so are

considered to be " weak " . Neuropsychological testing of perpetrators

has shown either normal results or nonspecific abnormalities.

MSbP may also be attributed to another prevalent socialization

pattern, that which places females in the primary care taking role.

For a psychodynamic model of this kind of maternal abuse see Anna

Motz's The Psychology of Female Violence: Crimes Against the Body

(Routledge, 2001 ISBN 978-0415126755, 2nd ed. forthcoming 2008 ISBN

978-0415403870).

Controversy

During the 1990s and early 2000s, Meadow was an expert witness in

several murder cases involving FII, some of which resulted in parents

being convicted of murdering their children and imprisoned. In

addition, several children were taken into care. In 2003, a number of

high-profile acquittals brought Meadow's ideas into serious

disrepute. Around 250 cases resulting in conviction in which Meadow

was an expert witness were reviewed, with few changes. Meadow was

investigated by the British General Medical Council over evidence he

gave as an expert witness for the prosecution in the Sally Clark

trial where he asserted that the odds of there being two unexplained

infant deaths in one family were one in 73 million, a figure

considered crucial in sending her to jail but a claim hotly disputed

by the Royal Statistical Society, who wrote to the Lord Chancellor to

complain. It was subsequently shown that the true odds were in the

region of one in 200. The GMC in July 2005 came to a verdict of

guilty of " serious professional misconduct " and he was struck off the

register for giving " misleading " evidence in the Sally Clark case.[7]

At appeal High Court judge Mr Justice Collins described this

as " irrational " and set it aside. Meadow was involved as a

prosecution witness in 2 other high profile cases resulting in

mothers being imprisoned and subsequently cleared of wrongdoing -

those of Trupti Patel[8] and Angela Cannings.[9] Collins' judgment

raises important points concerning the liability of expert witnesses -

his view is that referral to the GMC by the losing side is an

unacceptable threat and that only the Court should decide whether its

witnesses are seriously deficient and refer them to their

professional bodies[citation needed].

In 2003, Sickened, an autobiographical account of the Munchausen

Syndrome by Proxy abuse Julie Gregory suffered as a child, was

published.

In 2003, the documentary film MAMA/M.A.M.A. was released, which

questioned the validity of Munchausen Syndrome by Proxy, arguing that

in many cases doctors' overmedication of infants may be the real

cause of their infirmity rather than the mother's mental illness. The

film contains an interview with Sir Roy Meadow.

Legal status in Australia and UK

In majority of legal jurisdiction, doctors are only allowed to give

evidence in regard to whether the child is being harmed. They are not

allowed to give evidence in regard to the motive as it would be

prejudicial to the determination of the guilt. Furthermore, It has

been specifically established in legal precedents in Australia and

the U.K. that Munchausen Syndrome By Proxy does not exist as a medico-

legal entity.

In a June 2004 appeal hearing, the Supreme Court of Queensland,

Australia stated:

In some person's opinions, the term factitious disorder (Munchausen

Syndrome By Proxy) is merely descriptive of a behavior, not a

psychiatricly identifiable illness or condition. American experts

mostly disagree, however, and perpetrators' legal actions in the U.S.

to quash descriptions and use of Munchausen Syndrome By Proxy have

almost always failed. [R v LM [2004] QCA 192.].

The Queensland Supreme Court further ruled that the determination of

whether or not a defendant had caused intentional harm to a child was

a matter for the jury to decide and not for the determination by

expert witnesses:

The diagnosis of Doctors Pincus, Withers, and O'Loughlin that the

appellant intentionally caused her children to receive unnecessary

treatment through her own acts and the false reporting of symptoms of

factitious disorder (Munchausen Syndrome) by proxy is not a diagnosis

of a recognised medical condition, disorder, or syndrome. It is

simply placing her within the medical term used for the category of

people exhibiting such behavior. In that sense, their opinions were

not expert evidence because they related to matters able to be

decided on the evidence by ordinary jurors. The essential issue as to

whether the appellant reported or fabricated false symptoms or did

acts to intentionally cause unnecessary medical procedures to injure

her children was a matter for the jury's determination. The evidence

of Doctors Pincus, Withers, and O'Loughlin that the appellant was

exhibiting the behavior of factitious disorder (Munchausen Syndrome

By Proxy) should have been excluded.

Principles of law and implications for legal processes which may be

deduced from these findings are that:

Any matters brought before a Court of Law should be determined by the

facts, not by suppositions attached to a label describing a behavior.

i.e. MSBP/FII/FDBP;

MSBP/FII/FDBP is not a mental disorder (i.e. not defined as such in

DSM IV) and the evidence of a psychiatrist should not therefore be

admissible;

MSBPFII/FDBP has been stated to be a behavior describing a form of

child abuse, and not a medical diagnosis of either a parent or a

child. A medical practitioner cannot therefore state that a person

`suffers' from MSBPFII/FDBP and such evidence should also therefore

be inadmissible. The evidence of a medical practitioner should be

confined to what they observed and heard, and what forensic

information was found by recognized medical investigative procedures;

A label used to describe a behavior is not helpful in determining

guilt and is prejudicial. By applying an ambiguous label of MSBP/FII

to a woman is implying guilt without factual supportive and

corroborative evidence;

The assertion that other people may behave in this way i.e. fabricate

and/or induce illness in children to gain attention for themselves

(FII/MSBP/FDBY) contained within the label, is not factual evidence

that this individual has behaved in this way. Again therefore, the

application of the label is prejudicial to fairness and a finding

based on fact.

The Queensland Judgment was adopted into English law in the High

Courts of Justice in Case No. WR03C00142 [A County Council v A Mother

and A Father and X,Y,Z children] on 18 January 2005 by Mr. Justice

Ryder. In his final conclusions regarding Factitious Disorder, Ryder

states that :-

I have considered and respectfully adopt the dicta of the Supreme

Court of Queensland in R v. LM [2004] QCA 192 at paragraph 62 and 66.

I take full account of the criminal law and foreign jurisdictional

contexts of that decision but I am persuaded by the following

argument upon its face that it is valid to the English law of

evidence as applied to children proceedings.

The terms `Munchausen Syndrome by Proxy' and `Factitious (and

Induced) Illness (by Proxy)' are child protection labels that are

merely descriptions of a range of behaviors, not a pediatric,

psychiatric or psychological disease that is identifiable. The terms

do not relate to an organized or universally recognized body of

knowledge or experience that has identified a medical disease (i.e.

an illness or condition) and there are no internationally accepted

medical criteria for the use of either label.

In reality, the use of the label is intended to connote that in the

individual case there are materials susceptible of analysis by

paediatricians and of findings of fact by a court concerning

fabrication, exaggeration, minimization or omission in the reporting

of symptoms and evidence of harm by act, omission or suggestion

(induction). Where such facts exist the context and assessments can

provide an insight into the degree of risk that a child may face and

the court is likely to be assisted as to that aspect by psychiatric

and/or psychological expert evidence.

All of the above ought to be self evident and has in any event been

the established teaching of leading paediatricians, psychiatrists and

psychologists for some while. That is not to minimize the nature and

extent of professional debate about this issue which remains

significant, nor to minimize the extreme nature of the risk that is

identified in a small number of cases.

In these circumstances, evidence as to the existence of MSBP or FII

in any individual case is as likely to be evidence of mere propensity

which would be inadmissible at the fact finding stage (see Re CB and

JB supra). For my part, I would consign the label MSBP to the history

books and however useful FII may apparently be to the child

protection practitioner I would caution against its use other than as

a factual description of a series of incidents or behaviors that

should then be accurately set out (and even then only in the hands of

the pediatrician or psychiatrist/psychologist). I cannot emphasis too

strongly that my conclusion cannot be used as a reason to re-open the

many cases where facts have been found against a carer and the label

MSBP or FII has been attached to that carer's behavior. What I seek

to caution against is the use of the label as a substitute for

factual analysis and risk assessment.

In his book, Playing Sick (2004) Marc Feldman notes that such

findings have been in the minority among U.S. and even Australian

courts. Pediatricians and other physicians have banded together to

oppose limitations on child abuse professionals whose work includes

FII detection.[10] Meadow is among the individuals specifically

mentioned as having been inappropriately maligned in the April 2007

issue of the journal Pediatrics.

Munchausen Syndrome by Proxy: Pet

The medical literature includes a number of descriptions of a subset

of Munchausen Syndrome by Proxy (MSbP) caretakers, whose cases are

labeled Munchausen Syndrome by Proxy: Pet (MSbP:P). This is a

factitious disorder with pet proxies, malingering with animal

proxies, or even instances of " battered pet syndrome " (in reference

to battered woman syndrome). In these cases, pet owners correspond to

caretakers in traditional MSbP presentations involving human proxies.

[11] No extensive survey has yet been made of the extant literature,

and there has been no speculation as to closely MSbP:P tracks with

human MSbP.

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