Death from Munchausen Syndrome by Proxy
is overestimated
by: Brian Morgan
UK Freelance Journalist

Jones and Lynch1 have made mistaken claims, purportedly drawn from the epidemiological study by McClure et al.2  They failed to notice that the study collected data on non-accidental poisoning and non-accidental suffocation as well as Munchausen syndrome by proxy. They say that McClure et al identified 128 cases of "factitious illness by proxy." The actual figure was 97; 128 is the global figure. They also say that eight children died from Munchausen syndrome by proxy. Again this is a global figure, and closer reading of the study shows these cannot all have been from Munchausen syndrome by proxy, and
in fact only one of them may have been.

The study took the convening of a first case conference for suspected abuse as confirmation of a diagnosis of Munchausen syndrome by proxy. Case conferences are not called for a dead child. Therefore, for a death from Munchausen syndrome by proxy to have been recorded the child must have died after referral and registration at a case conference or have had a sibling thus registered for the first time, both of which are likely to be rare. I put it to one of the authors of the epidemiology study that there could not have been as many as eight deaths from Munchausen syndrome by proxy during the study, and he confirmed that only one of the deaths may have been the result of Munchausen syndrome by proxy (P M Davis, personal communication). Indeed, two children died of carbon monoxide poisoning in a car when their father committed suicide.

Of course, absence of evidence of deaths from Munchausen syndrome by proxy is not evidence of no deaths. Finding only one possible death over two years will not persuade expert Munchausen syndrome by proxy "finders" to modify their opinion about the extreme dangerousness of the abuse. However, if the mortality is around 15% in index cases plus siblings, as some claim, then McClure et al might reasonably have come across around 15 deaths attributable to Munchausen syndrome by proxy rather than just a possible one. Mortality from this type of abuse may not be as great as some would have us believe.

Brian Morgan, Freelance journalist. .
4 Rawden Place, Riverside, Cardiff CF1 8LF

1.  Jones DPH, Lynch MA. Diagnosing and responding to serious child abuse. BMJ 1998; 317: 484-485. (22 August.)
2.  McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental  poisoning, and non-accidental suffocation. Arch Dis Child 1996; 75: 57-61[Medline].


Diagnosis of Munchausen Syndrome By Proxy
should be viewed with extreme caution

By: Charles Pragnell

Dip.S. L.R.C.C.
UK Social Care Management Consultant.

In 1994 Professor R. Meadows declared in regard to Munchausen Syndrome By Proxy [MSBP], "There is a danger of the term being overused." Journal of Clinical Forensic Medicine. (1994) 1 121-127. It would seem that his strictures are however being ignored.

In several of the cases of MSBP I have studied in detail, there were clear indications that the guidelines for diagnosis as set out by Meadows had not been observed and in some cases the diagnostic criteria defined by Meadows were not present. In at least one case the paediatrician had failed to obtain previous medical records and history before making the diagnosis. If he had done so he would have found that both children involved had experienced serious illnesses from birth and symptoms had been witnessed from birth by several health professionals without either parent being present. In two other cases the MSBP diagnosis was made after the parents had initiated legal action against the paediatrician for medical incompetence and the possibility of retaliatory action has therefore to be considered.

In none of the cases was there clear evidence of parents seeking attention for themselves which has been claimed to be the principle diagnostic criteria. Their embellishments and distortions of the children's symptoms appeared to be directed at increasing the paediatrician's interest in their child and to obtaining a diagnosis of their child's condition, and motivated by their own helplesness and frustration.

If, as has been claimed, the personality disorder in parents leading to an MSBP diagnosis is untreatable, where is the research evidence that parents who have been so diagnosed and who have retained the care of their children, have continued in their behaviours of harming their children in order to gain attention for themselves. From my studies in such cases, the converse is in fact, true. Such parents have avoided any further contacts with health professionals and because of the social stigma of the MSBP diagnosis, have become social isolates. In consequence the children have failed to receive medical attention when needed even for serious illnesses. In this respect, the MSBP diagnosis is per se being harmful to children.

The covert video surveilllance of parents is of dubious validity as it does not appear to conform to the requirements of the Memorandum of Good Practice for such video recordings for use in child protection proceedings and is of poor quality for forming an informed opinion on the actions and behaviours of parents. There also appears to be a need for debate on the ethical considerations of covert video
recording and the conduct of paediatricians observing parents harming their children for considerable periods of time, without intervening to prevent serious harm to the child such as the breaking of an arm.

Jones and Lynch rightly take issue with Dr. Southall et al regarding the disregard of working in partnership with parents. Working in partnership on an "Equal and Genuine Basis" is not only a legal requirement under the Children Act 1989 but a fundamental human right of parents to be involved in decision making processes concerning their children, no matter what discomfort or difficulty this may present for the professionals.

There is also evdience in the cases I have studied that social workers are ignoring the findings of the Cleveland Inquiry and the particular recommendations of Justice Butler-Sloss that social workers should not act solely on the basis of a medical diagnosis but that a full investigation and social assessment should be carried out. This is also a requirement of `Working Together' the DOH Guidelines for child protection investigations. The unquestioning acceptance of MSBP by social workers seems to have parallels with the anal dilatation test used in Cleveland and the Repressed Memory Syndrome which was more widely used and which also led to harmful effects on families.

MSBP does not appear to have been verified and validated by any national medical body in the U.K. following trial conditions, nor does there appear to have been any period of independent monitoring and review of its implementation, and yet it has spread into liberal usage by some paediatricians supported by a small group of other professionals.

The validity of MSBP as a diagnosis must therefore be seriously questioned and any research into cases of MSBP can only be valid if the pre-history is examined, whether the diagnostic criteria and guidelines have been followed in each case, and the post-diagnosis behaviours of parents reinforce the accuracy of the original diagnosis. A far more rigorous and critical approach to research into MSBP is needed, otherwise it will continue to be seen simply as an endorsement of the position of MSBP devotees.

Charles Pragnell
Dip.S. L.R.C.C.
Social Care Management Consultant.
74 Redcar Lane, Redcar and Cleveland
TS10 2JN

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