Munchausen Syndrome by Proxy: A Deadly Disorder

The Most Lethal Form of Child Abuse

On April 7^th the Tucson Police Department arrested and charged a 21 year old mother of two with child abuse.  Blanca Montana had taken the children to the University Medical Center reporting flu-like symptoms.  Her son was discharged, but her infant daughter’s condition continued to deteriorate.  The baby was eventually diagnosed with nine separate rare infections over the course of her hospital stay.   Staff noticed that the child's condition worsened every time she was alone with her mother. They began to suspect Munchausen Syndrome by Proxy and reported their suspicions to the police.  The police investigated the abuse and determined that Montano intentionally poisoned her child and had caused her illnesses.   After the mother was barred from visiting the infant, the baby's condition improved significantly. It was determined that Montana had poisoned her two children in order to get attention. 

What is Munchausen Syndrome by Proxy?

Some individuals fake illnesses, produce physical symptoms, or injure themselves in order to get attention.  This is referred to as Munchausen syndrome.  When an individual inflicts illness or injury to someone that they have proxy over to gain attention it is called Munchausen Syndrome by Proxy. The primary motivations for both syndromes are receiving attention, sympathy, care and concern.  A parent holds an automatic right of proxy in certain interests of their child.  The disorder is named for Baron Karl Friedrich Hieronymus von Munchausen, a German nobleman, soldier, and huntsman who was famous for making up exaggerated stories of his exploits

The question is; are people like Blanca Montano mentally ill or simply evil?  Munchausen Syndrome by Proxy (MSBP) is often incorrectly referred to as a specific psychiatric diagnosis. Offenders frequently do have symptoms of other mental illnesses; the most significant is a factitious disorder.  Fundamentally MSBP is child abuse; in fact, it is the most lethal form of child abuse.  Approximately 10 percent of MSBP victims die.  There were around 2,000 reported cases of MSBP last year, however most cases are never reported. 

The vast majority of MSBP perpetrators are the victim’s biologic mother.  80% of these mothers had backgrounds in the medical profession. However other primary caregivers, such as, fathers, grandmothers, aunts, and babysitters have been the offenders. In rare cases, medical professionals may be the perpetrator of Munchausen Syndrome by Proxy.

Additionally, of the mothers, 80% had a history or previous psychiatric treatment.  80% had a history of self-inflicted injury.  60% attempted suicide.  Denial was persistent.  There is obviously a degree of mental illness in the majority of MSPB cases. 

The most common methods of MSBP include:

• Poisoning:  Ipecac, salt, insulin, laxatives, corrosives, lorazepam
• Infections:  Applying fecal matter or rubbing dirt into wounds, injecting urine, spit or feces into IV catheters.
• Injuries:  Suffocations, foreign bodies, nonhealing wounds or fractures

The FBI has provided the following Munchausen Syndrome by Proxy warning signs for law enforcement:

• Unexplained, prolonged illness that is so extraordinary that it prompts medical professionals to remark that they've "Never seen anything like it before."
• Repeat hospitalizations and medical evaluations without definitive diagnosis.
• Inappropriate or incongruous symptoms and/or signs that don't make medical sense.
• Persistent failure of a child to tolerate or respond to medical therapy without clear cause.
• Signs and symptoms that disappear when away from the parent. A differential diagnosis consisting of disorders less common than MSBP.
• Mothers who are not as concerned by their child's illness as the medical staff, who are constantly with their ill child in the hospital, who are at ease on the children's ward, and who form unusually close relationships with the medical staff.
• Families in which sudden, unexplained infant deaths have occurred and that have several members alleged to have serious medical disorders.
• Mothers with previous medical experience and who often give a medical history similar to the child's.
• Parent who welcomes medical tests of the child, even if painful. Increased parental uneasiness as child "recovers" or approaches discharge.
• Parental attempts to convince the staff that the child is more ill than what is apparent.

Problems with Investigating Alleged MSBP

Any case of suspected Munchausen by proxy needs to be reported to child protective services and law enforcement.   Both agencies will need to investigate the situation.  They will need to use a multidisciplinary approach that also includes medical staff, social services, hospital administrators and prosecutors.  Charges may range from battery, child abuse, neglect of a dependent, child endangerment, attempted murder or sometimes murder.  Expect the following hurdles during your investigation:

• Most of the victims are too young to talk
• The suspect will appear unlikely: loving, attentive, concerned
• The suspect is usually an experienced liar and will be in relentless denial
• Suspects frequently move from doctor to doctor and/or hospital to hospital making it difficult to establish a pattern of the abuse.

The FBI has the following tips for investigating suspected Munchausen Syndrome by Proxy cases: 

• Investigators assigned to work child abuse cases should investigate cases of MSBP as they do similar cases of abuse. In general, however, when confronted with possible cases of MSBP, investigators should:
• Review the victim's medical records to determine condition and illness
• Determine from contact with medical personnel the reporting parent's concerns and reactions to the child's medical treatment
• Compile a complete history of the family to determine previous involvement with law enforcement agencies, medical facilities, and social and child protection services
• Compile a detailed social history of the family, including deaths, injuries, and illnesses
• Interview family members, neighbors, and babysitters
• Use video surveillance in the hospital in accordance with State law, and
• Use a search warrant for the family's residence when collecting evidence of the assaults.

False accusations do occur, but are rare according to research.  There are organized groups of mothers, such as M.A.M.A. (Mothers Against Munchausen Syndrome by Proxy Allegations) that actively claim that MBP is comparable to a witch hunt.

Conclusion

Abuse of a victim of MSBP is resolved in one of the three ways:  the child dies; the perpetrator is caught and brought into the justice system; the perpetrator moves on to a younger child within the family. Unfortunately, the consensus is that Munchausen Syndrome by Proxy is not that rare.  It does not respond to therapy, and has a very grim prognosis. Hopefully, the information presented in this article will alert the law enforcement community to the warning signs of MSBP so that they can better identify perpetrators and protect innocent victims.

Web Links:

• Munchausen Syndrome by Proxy
• Munchausen Syndrome by Proxy Case Accounts

Pamela Kulbarsh, RN, BSW has been a psychiatric nurse for over 25 years. She has worked with law enforcement in crisis intervention for the past ten years. She has worked in patrol with officers and deputies as a member of San Diego's Psychiatric Emergency Response Team (PERT) and at the Pima County Detention Center in Tucson. Pam has been a frequent guest speaker related to psychiatric emergencies and has published articles in both law enforcement and nursing magazines.