Book Review

Munchausen Syndrome by Proxy Abuse: A practical approach

N Engl J Med 2000; 343:744September 7, 2000

Article

Munchausen Syndrome by Proxy Abuse: A practical approach
Edited by Mary Eminson and R.J. Postlethwaite. 321 pp. Boston, Butterworth–Heinemann, 2000. $50. ISBN: 0-7506-4072-3

Munchausen syndrome by proxy (a parent inducing illness in a child) is an uncommon condition that commonly causes diagnostic difficulty and misunderstanding of its true nature. The perpetrators are notoriously difficult to work with, and many pediatricians, child psychiatrists, and other professionals have major problems dealing with the condition. The aim of this book is to provide a practical approach to a difficult problem. It largely succeeds in this aim and is therefore welcome.

Many pediatricians and child psychiatrists working in the field believe that Munchausen syndrome by proxy is a term that is emotive and not necessarily accurate. This term is used in the title of the book, although “factitious illness by proxy” is used frequently throughout the text. The authors consider that parents' concern for their children's health is a spectrum from gross neglect to gross overconcern. This is a main theme of the book. They believe that definition by harm is a more valuable way of considering the problem than definition by motivation, as in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. They also believe that a definition by harm has the advantage of bringing Munchausen syndrome by proxy into the wider understanding of abuse. It allows clear responses to emotional abuse. This view coincides with the view that Munchausen syndrome by proxy is a problem with the child, not the perpetrator, even though the perpetrator may clearly have personality problems or a psychiatric illness.

Perhaps this book is most useful in considering the steps that are needed to make the diagnosis of Munchausen syndrome by proxy, from the dawning of private concern about the identification of factitious illness to treatment. Much of the advice is aimed at the nonspecialist pediatrician; the need to obtain clear confirmation of reported symptoms and to ensure that the information about the child's previous illness is confirmed. Clearly, all contacts must be checked. The issue of what to tell parents initially is also discussed. The line taken is that it is appropriate to tell parents that the explanation of the findings is unclear but that there is no need to share all one's thoughts. The book does, however, emphasize the importance of sharing information with others — a valuable lesson for everyone who deals with this difficult condition. The information could be shared with a colleague, a medical expert, a medicolegal expert, an emotional-abuse panel, or a hospital ethics committee.

The steps that must be taken to confirm factitious illness are noted in the book, including admission of the child to the hospital, forensic analysis of specimens, and close observation by the nursing staff. Preventing visits by the parents is theoretically valuable but very difficult in practice. Covert video surveillance is discussed, but the section is short and does not answer all the practical difficulties the technique appears to entail.

Not all cases of factitious illness are obvious, and the book discusses fabricated episodes of loss of consciousness and poisoning, factitious presentations of sexual abuse, and nonconsent to medical treatment. Perhaps most interesting of all is what parents gain from exceptional children: achievement by proxy.

The theme of the psychiatric disorders and histories of perpetrators is prominent throughout the book. Many perpetrators have a history of abuse themselves. Parents who commit the severest forms of physical abuse on the youngest children will be found to have substantial abnormalities of personality on systematic assessment. Pediatric settings provide an exquisite opportunity for displays of the difficulties of the most severely disturbed parents. These are the parents who are the most difficult to identify and are most likely to accept high-technology solutions to nonorganic problems. There are clear dangers of Munchausen syndrome by proxy in a world of pediatric subspecialization.

This book discusses the process of protecting the child only in the British context. A discussion of the processes used in the United States and Europe and a comparison of these approaches would have been helpful for physicians dealing with this difficult condition. The section on risk assessment is based largely on psychiatric analysis and observation of the child and parent. There has been little work on assessing the inherent risks of the condition, which with some manifestations, such as nonaccidental suffocation, are very serious.

All practitioners who encounter the factitious illness syndrome find it a difficult condition that challenges the doctor–patient relationship. This book offers many important messages for specialist and generalist pediatricians. A more international perspective would have been helpful.

Jonathan R. Sibert, M.D.
University of Wales College of Medicine, Penarth CF64 2XX, United Kingdom