P Ip

Introduction

Munchausen Syndrome by Proxy (MSBP) was first used by Roy Meadow in 1977¹ to describe illnesses in children fabricated by their mothers. As a result, the children underwent numerous investigations and treatment causing unnecessary suffering and even death. Although once thought to be an uncommon form of child abuse, as awareness of the condition increases, reports have appeared in many parts of the world² including one from Singapore³ but rarely in other areas of south-east Asia. The following case history illustrates a form of MSBP whereby the doctor shopping behaviour of the mother of a 12 year old boy caused him unnecessary treatment and suffering for many years.

Case Report

A 12 year old boy was admitted with a 3 year history of intermittent low grade fever and a multitude of other symptoms.

His mother was said to have recurrent abdominal pain in the antenatal period and delivered him at home during one of these episodes. He was noted to have speech delay at the age of 4 years and was assessed to have moderate mental retardation at a child assessment centre. Attendance at a special school was recommended.

At the age of 8 years he was admitted into a psychiatric unit because of behavioural problems including self-giggling, temper tantrums, biting people and playing with faeces. He was transferred to the psychiatric unit of another hospital 6 months later as his mother was also a patient in that hospital. After another 3 months he was discharged. At out-patient visits, his mother complained that he had either constipation or soiling, urinary incontinence and sleep disturbances. He was therefore prescribed 2 to 5 drugs each visit, to tackle these problems. His mother frequently complained of insufficient drugs.

Over the next 3 years, there were other health complaints including intermittent low grade fever, recurrent colds, allergy to eggs/cakes, urticaria, spontaneous bruises, abdominal distention, chronic constipation and blood in the stool. His mother attributed these symptoms to the inflammation of his face, nose, airway, nerves and subcutaneous tissues.

Over these years he attended 4 public hospitals' Accident and Emergency Departments, Paediatric Units, Surgical and Psychiatric units; government polyclinics, general practitioners, and herbalists. He undertook numerous blood tests, chest radiographs and a lymph node biopsy. In addition, his mother prescribed him concoctions containing 10 to 18 Chinese herbs to remove "toxins". He could be taking simultaneously herbs, cough mixtures, antibiotics, antacids, laxatives, antipyretics, sedatives and skin preparations. He was missing his boarding school 3 days a week. Although his behaviour was not noted to be unusual in school, after each period of home leave, he would be dull, had abdominal distension and constipation. His mother would bring along a large collection of drugs for him to take in school. When the teachers refused to accept the drugs unless they were prescribed by a registered medical practitioner, his mother poured herbal medicine into western medicine bottles and altered the drug dosages on the labels.

His father aged 53 years was a cleaner in a restaurant. He had a head injury in the past and was noted to be hot tempered but slow in verbal response. He left the family when the boy was 10 years old.

His mother was a 41 year old housewife. She had learned herbal medicine by apprenticeship although she said she had not "graduated". She was obsessed with handwashing, bathing, water drinking and toileting and talked incessantly. Four years earlier, she was diagnosed to have Briquet Syndrome, or somatization disorder, with complaints of unilateral body pain, tightness in the throat, fainting attacks, feverish feelings, black marks on her body, urticaria and abnormal bowel habits. She herself was attending the Psychiatric, Medical, Gynaecological, Dermatological, Orthopaedic outpatient clinics and government polyclinics. Apart from taking drugs prescribed, she also had a practice of self-medication.

He had one sister aged 6 years who was in foster care because his mother could not cope with 2 children.

After his admission, he was observed to have no major behavioural problems but he became unsettled after his mother's visits. His mother was found to be over protective so that the boy lacked skills in selfcare. He clinged to her and she treated him like her "patient" rather than her child. He uttered self-directed foul language which appeared to be a reiteration of his mother's language towards him when they were alone. Physical examination was normal except for tinea pedis.

He had some blue stains on his back which could be rubbed off although his mother claimed such stains were classical signs of "rheumatic purpura". No fever was documented and no blood was found in his stool. He was gradually weaned from his laxatives While his other medications were stopped altogether.

A case conference was held with representatives from his school, social workers, the psychiatric nurse, the psychiatrist and the paediatrician. Child abuse was established with a majority vote, the nature being a case of Munchausen by Proxy Syndrome. One non-medical member at the case conference thought it was a case of inappropriate parental care and another thought the child was not abused but at risk only. After much discussion the majority recommended a Care and Protection Order with separation from his mother.

Case Discussion

Rosenberg⁴ included the following as the criteria for the diagnosis of MSBP: (l)illness in a child which is simulated and/or produced by a parent, or someone who is in loco parentis; (2) the child is presented for medical assessment and care, usually persistently, often resulting in multiple medical procedures, (3) the perpetrator denies the aetiology of the child's illness; (4) acute Munchausen Syndrome by Proxy symptoms and signs of illness cease when the child is separated from the perpetrator.

Presentations include perceived illness, doctor shopping, enforced invalidism and fabricated illness.⁵ Over 60 signs and symptoms have been reported,⁴ the most common being bleeding followed by seizures, central nervous system depression, apnoea, diarrhoea, vomiting, fever and rash.

Mothers are the perpetrators in the majority of cases.⁶ They are very co-operative with the medical staff and appear to be totally devoted to their children although when alone with them they may show little interest in them.⁷ They often have some medical knowledge but may themselves suffer from somatization disorders or adult Munchausen Syndrome.⁸ The fathers usually play a passive role by being away or absent altogether.

MSBP in the foetus has been reported⁹ but in Rosenberg's review of 117 cases⁴ the mean age at diagnosis was 40 months. The mean time from onset of symptoms to diagnosis was 15 months but ranged from days to 20 years. All children suffered short-term morbidities as the result of investigations and treatment but there were also long term consequences of unnecessary surgery, physical and mental handicap, emotional and psychiatric problems. The mortality rate was 9%. Even siblings had higher rates of morbidity and unexplained death as reported by Bools, et al.¹⁰

In the case reported, the mother's "medical knowledge" came from learning herbal medicine. She herself was diagnosed to have somatization disorder. Although superficially "caring" towards the child, there were suggestions that she was at least verbally abusive when they were alone. The child was supposed to have fever and other symptoms which could not be documented in his mother's absence although the continued disturbance of his bowel habit could be the result of the chronic use of laxatives.

Doctor shopping behaviour is not uncommon in Hong Kong. Ho and Donnan found 28% of patients consulted more than one doctor during the same episode of a common illness.¹¹ Self medication is also common. Granek-Catarivas, et al. reported that one-third of patients attending general practitioners in Hong Kong used self-medications, some up to 5 items,¹² but the behaviour exhibited by the mother of this case far exceeded these levels. Schreier and Libow⁸ also pointed out that the usual overanxious mother does not want her child ill. She does not push for investigations and is relieved when the tests are negative. She acknowledges her own anxiety rather than focus only on her child's medical illnesses.

Although MSBP was established in this case after years of symptomatology, the opinion was not uniform. This is not surprising as local reports are uncommon and knowledge of the syndrome amongst non-medical professionals is expected to be less. A survey of professionals' knowledge of MSBP done by Kaufman and Coury¹³ found that professionals employed in medical or hospital settings were three times more likely to have heard of this syndrome than those employed by community service agencies. Another problem is that MSBP does not fit easily into the four categories of child abuse - physical abuse, gross neglect, sexual abuse and psychological abuse stated in the local procedures for handling child abuse cases.¹⁴ McGuire and Feldman¹⁵ commented "The possibility of Munchausen syndrome by proxy behavior by mother seems as preposterous to most people today as child sexual abuse seemed 20 years ago" and sexual abuse is only surfacing as a problem in Hong Kong.¹⁶ Much education is needed before the true local incidence is known. Early diagnosis is important in view of the short and long term sequelae.

References

1. Meadow R. Munchausen syndrome by proxy: The hinterland of child abuse. Lancet 1977;ii:343-5.

2. Rosenberg D. Munchausen syndrome by proxy. In Reece R M (ed). Child abuse: Medical diagnosis and management. Lea & Febiger, Philadelphia 1994;266-78.

3. Lim LC, Yap UK, Lim JW. Munchausen syndrome by proxy. J Singapore Paediatr Soc 1991;33:59-62.

4. Rosenberg DA. Web of deceit: A literature review of Munchausen syndrome by proxy. Child Abuse Negl 1987;11:547-63.

5. Meadow R. Munchausen syndrome by proxy. In Meadow R (ed). ABC of child abuse. BMJ Publishing Group, Bristol 1993;43-6.

6. Meadow R. Factitious illness: The hinterland of child abuse. In Meadow R (ed). Recent advances in paediatrics. Churchill Livingstone, Edinburgh, 1984:217-32.

7. Samuels MP, McClaughlin W, Jacobson RR, et al. Fourteen cases of imposed upper airway obstruction. Arch Dis Child 1992;67:162-70.

8. Schreier HA, Libow JA. Defining the Syndrome. In: Hurting for love: Munchausen by proxy syndrome. The Guilford Press, New York 1993;3-34.

9. Goss PW, McDougall PN. Munchausen syndrome by proxy - A cause of preterm delivery. Med J Aust 1992;157:814-7.

10. Bools CA, Neale BA, Meadow SR. Co-morbidity associated with fabricated illness (Munchausen syndrome by proxy). Arch Dis Child 1992;67:77-9.

11. Ho SC, Donnan SPB. Dietary practices and illness behaviour among Hong Kong community. J HK Soc Com Med 1985;15:5-14.

12. Granck-Catarivas M, Lam CLK, Munro C. The use of self-medication among patients attending general practitioners. Hong Kong Practitioner 1994;16:488-503.

13. Kaufman KL, Coury D. Munchausen syndrome by proxy: a survey of professionals' knowledge. Child Abuse Negl 1989;13:141-7.

14. Social Welfare Department, Hong Kong. Procedures for handling child abuse cases. 1993; Appendix I.

15. McGuire TL, Feldman KW. Psychological morbidity of children subjected to Munchausen syndrome by proxy. Pediatrics 1989;83:289-92.

16.Social Welfare Department, Hong Kong. Quarterly statistics on child abuse cases. 1990-4.