| Introduction
The dawn of the 1990s brought
widespread recognition of a once-obscure criminal act,
Munchausen's
Syndrome by Proxy (MSP), in which subjects injure or
induce illness in children in order to gain attention and
sympathy for themselves. Since its recognition by the criminal
justice community, MSP has been identified most closely with
mothers who induce in their children breathing difficulties
that mimic the symptoms of apnea and sudden infant death
syndrome (SIDS), who poison them, or who fabricate illnesses in
their children. These mothers then bask in the attention
afforded them by relatives, doctors, and hospital personnel.
However, because the child's illness has no medical cause,
doctors have difficulty making a diagnosis.
As the baffling symptoms
continue, doctors or hospital administrators may call on law
enforcement to investigate the mysterious circumstances
surrounding such cases. In fact, as the medical community
becomes increasingly familiar with MSP and its warning signs,
doctors and medical staffs seem to be more inclined to request
the assistance of local law enforcement agencies.
The growing list of MSP cases
underscores the need for investigators to understand the
various, and often complex, issues related to MSP. During the
past several years, a number of variations to the normal
offender patterns have emerged, accompanied by a clearer
understanding of how law enforcement should respond to cases
believed to involve MSP. The more investigators know about MSP,
the better able they will be to identify perpetrators, clear
innocent suspects, and most important, protect children.
Research
on MSP
Researchers documented the serial
nature of MSP victimization in a study of 5 families with a
total of 18 children.( Ref.1 ) In this
study, 72 percent of the children were known to be MSP victims.
In each family, only one child was involved at any given time,
and a total of five children seemed to be unaffected. Of those
children affected, 31 percent died. In only one instance was
there any other form of abuse present.
Characteristics
of the maternal perpetrators
- The characteristics of the
maternal perpetrators in this study indicated the following:
- 80 percent possessed
backgrounds in health professions
- 80 percent manifested
Munchausen's
Syndrome (self-inflicted injury) themselves
- 80 percent received psychiatric
treatment prior to diagnosis
- 60 percent of the mothers
attempted suicide. Denial persisted in most cases.
The research also shows that
individuals who initially engaged in Munchausen's Syndrome may
eventually practice Munchausen's Syndrome by Proxy.(
Ref.2 ) The degree to which the offspring of Munchausen's
offenders become the subjects of abuse may increase
proportionately with the number and increased severity of
incidents of self-inflicted abuse.
Cross-over
from Munchausen's Syndrome to MSP
MSP may occur when the
perpetrator of Munchausen's Syndrome crosses over the threshold of
self-inflicted injury into abuse of an unsuspecting child.
Oftentimes, the caregivers (offenders) claim that injuries to
the child were inflicted by a fictitious bad guy. In some
instances, offenders injure them-selves in order to substantiate
the presence of this unknown perpetrator. Cautious, diligent investigation
of these allegations often leads to dead ends based on a
series of false crime reports.
Although there seems to be a
multigenerational link (i.e., mother was MSP victim, then her
child is MSP victim, etc.) between Munchausen's Syndrome and MSP,
this connection has not been established scientifically to the
level that most courts require. The level of understanding that
members of the criminal justice system possess regarding
Munchausen's Syndrome and MSP makes a crucial difference to the
outcome of these cases. The ever-present possibility of
continued victimization of children at the hands of MSP
offenders further underscores the importance of handling these
cases expediently.
Establishing MSP as a possible
extension of Munchausen's Syndrome will not be an easy task for
investigators and prosecutors if the acts have not advanced to
the point of physical abuse. Most courts are unwilling to remove
a child from a parent's custody without concrete evidence to
support charges of child abuse.
Understandably, detectives
experience considerable frustration when working on these cases.
Incidents falsified by offenders and seemingly verified by means
of self-mutilation only add to the mystery when a perpetrator
cannot be identified.
Perpetrators:
Biological Mother
In the standard
offender-victim relationship, suspicion centers on the biological
mother. In fact, the vast majority of MSP cases resolved
through investigation have implicated the victim's mother as the
sole offender.( Ref.3 )
Investigators should be aware,
however, that the MSP offender profile has widened to
include other perpetrators, both within and outside the victim's
family structure.( Ref.4 ) Fathers,
grandmothers, aunts, and baby-sitters have been identified as
offenders. Regardless of the relationship to the victim, the offenders
all had one thing in common: each acted as the victim's
primary caregiver.
Perpetrators:
Medical Professionals in Rare Cases
In very rare cases, medical
professionals also could be included in the list of
potential suspects. While it appears that only immediate family
members would receive the gratification from attention,
increased self-esteem, and false sense of belonging afforded by
MSP, similar motivations lead some health-care workers to cross
the line of the Hippocratic Oath into the realm of child abuse.
By inflicting MSP, and then "saving" the child,
these offending medical practitioners hope to excel within their
fields and win acceptance by their peers. Fortunately,
the frequency of cases involving health-care workers has been
relatively low thus far. The possibility exists, though, that a
medical professional's actions might indicate MSP in certain
circumstances.
Investigations of this type are
highly sensitive. Often, medical personnel are wrongly accused
by actual offenders who perceive that they have come under
suspicion. Still, an investigator's decision to suspect or
accuse medical professionals of MSP should be based on the same
standard of investigation used for other suspects. However, the
primary caregiver status inherent in the most common offender
profiles continues to place mothers at the height of suspicion.
Investigative
Guidelines
The methods by which
investigators approach suspected MSP offenders are the keys
to resolving such cases. During interviews, investigators should
not express open disbelief in their accounts of criminal
incidents. Rather, investigators need to convey to the
suspect that they are keeping an open mind regarding the
case. Investigators can expect sound rationalization
on the part of such offenders, as well as a series of open-ended
allegations that cannot be substantiated.
Confusion
with SIDS (Sudden Infant Death Syndrome)
Investigators should make every
effort to segregate other family members from suspects
during the interview process because relatives probably will
voice support and belief in the allegations if the suspect is
present. In those cases where obvious inconsistencies exist,
family members might view facts differently when questioned away
from the suspect. With further investigation, identified MSP
offenders might be linked to the deaths of their other children.
Often, the original medical examiners incorrectly identified
these deaths as resulting from sudden infant death syndrome (SIDS).
If the deceased child or
children have not been cremated, then exhuming their bodies for
forensic testing might be appropriate. When advised of previously
identified causes of death within a family, forensic
pathologists or medical examiners might be able to uncover
particular toxins or evidence pointing to homicide.
(top)
Questioning
Victims
Whether the child actually
knows that the offender has induced the illness depends on the child's
physical age and the offender's covert skills.
Certainly, the longer the abuse continues and the older a child
grows, the more likely it becomes that the victim will
understand the offender's actions.
If the abuse has been present
throughout the life of the child, then the victim might
believe that whatever action is being done to cause the
illness is normal. Because of this misunderstanding of
normal behavior and the attention that the offender lavishes,
the child might not view the offender as anything less than an
ideal caregiver, even if the abuse is blatant.
Law enforcement officers
generally should refrain from inter-viewing the victim
for two reasons. First, even if a victim is old enough to
talk, the child probably will not be able to assist officers
verbally in the investigation. Second, officers must
consider the potentially traumatic consequences should the child
be told that a trusted caregiver is in fact an abuser. For these
reasons, it would be wise to elicit the help of professionals
when dealing with this aspect of the investigation to lessen the
possibility of further traumatizing the victim.
Victim
Safety
In MSP-related cases,
investigators face additional concerns for the safety of the
child involved. Suspected offenders might react in a number
of ways when confronted by the police. Generally, offenders deny
the allegations and blame the child's apparent illness on
unknown causes. Often, an upsurge in the severity of the
victim's symptoms follows as the offender attempts to prove
the presence of the illness. Unfortunately, the child might not
be able to withstand the escalating abuse or the increased
treatments prescribed to address the symptoms.
In order to reduce the
possibility of further abuse to the child, investigators must
work toward a swift conclusion to the case once they have
confronted the suspected offender. Accordingly, case
parameters and guidelines regarding evidence collected
should be established prior to informing the subject of
the investigation. Careful planning and caution in this
area can be critical; research indicates that from 9 to 31
percent of all MSP victims die at the hands of their
perpetrators.( Ref.5 )
Some confronted offenders might
react more passively by relocating with the victim and
other family members. If the courts do not enact protective
measures to preclude a suspect from relocating with the child,
the cycle of MSP probably will continue in a new locale.
To avoid this scenario,
investigators should ensure that adequate measures to protect
the victim are in place via social services or judicial avenues
before informing subjects that they are under suspicion. These
measures should remain in place until the case is concluded.
If not arrested, offenders who
believe they are under suspicion might become more cautious, but
only temporarily. The child's apparent illness might subside
until the offender believes it is safe to resume the abuse.
Offenders also may wait until a reasonable time elapses and then
re-admit the child into the hospital.
In either case, it appears that
as offenders continue their abuse, the danger to
the child increases. The needs-oriented behavior
of such offenders has been compared to that of drug
addicts. Through cycles of abuse and nurturing, MSP
offenders seek to satisfy an ever-increasing need for
attention and self-validation. However, some experts believe
that, unlike most drug addicts, MSP offenders cannot be
rehabilitated.( Ref. 6 )
False
Allegations
Despite seemingly strong
circumstantial evidence present in some cases of apparent MSP
abuse, law enforcement officers must make every effort to
refrain from making false allegations. Accusations based on
insufficient investigation and absent forensic analysis can have
disastrous consequences. In one such case, a mother in Missouri
was falsely accused of the death of her infant son. The child
died as a result of apparent ethylene glycol poisoning. However,
upon the birth of a second baby, doctors found that the infant
had a rare disease, methylmalonic acidemia, which in fact, had
caused the death of the first child. The mother subsequently
initiated legal action against the State.
Such cases reinforce the need
for investigators to explore all avenues when suspicion of MSP
arises. The importance of medical evaluation cannot be
overstated. In fact, without properly collected medical
documentation to support the thesis of MSP abuse, it is unlikely
that prosecutors can establish probable cause to support
custodial arrest.
Child
Custody Cases
The manner in which charges of
MSP originate must be considered in the total course of an
investigation. Highly disputed child custody cases often
generate charges of child abuse. Sometimes, MSP offenders accuse
the other parent of abuse in order to mask their own
wrongdoing and to keep custody of the child. In cases where
an estranged parent involved in a custody dispute reports
illnesses or accuses the other parent of child abuse,
investigators should explore all potential motivations
for such accusations. Falsified reports for custodial purposes
could be a valid concern. Any investigator assigned to a
potential MSP case needs to ensure that the agency is not being
used as a tool for secondary gain by the accusing parent.
In cases where reports of abuse
emanate from a noncustodial or estranged parent, the question of
accuser-inflictor role reversal should be considered as an
alternate cause of the child's ailments. This type of issue
often arises in contested divorce situations involving minor
children and also might be linked to parental kidnapping by
noncustodial parents.
When custody has been denied to
an offending parent, and the victimized child has been placed
with the other parent, the offender might go to great lengths to
regain custody. Accusations of sexual abuse, especially if the
custodial parent is the father, might be made by offenders as
they attempt to disguise their responsibility for the child's
abuse.
The underlying rationalization
for the actions of MSP offenders stems from their desire to
regain lost custody through outward expressions of love. It
appears that the longer offenders are separated from
victims, the more desperate and determined they become to
regain custody.
Domestic
Violence Shelters
Suspected MSP offenders who
believe that they are being watched, have been accused of MSP
abuse, or sense the need for self-vindication might seek
assistance by accessing public shelters provided for victims of
domestic violence. In such cases, offenders rely on their highly
developed skills of deception.
Because personnel working at
these shelters function for the protection and assistance of
traumatized women, they might be reluctant to question an
incoming client's account of victimization. This situation
highlights the need for a concrete investigative protocol when
suspicion falls on an MSP offender.
Once a woman gravitates to an
abuse shelter, police access might be difficult, and the support
system in the shelter will reinforce her fictitious
explanation of the child's injuries or illness. While in the
shelter, the victim temporarily might be spared from further
injury to strengthen the mother's claim that another person is
the source of the abuse. However, the child's reprieve usually
ends when the offender must leave the shelter and once again is
alone with the victim.
Fate
of Initial Victim & Use of Substitute Victims
Generally, abuse of a victim at
the hands of an MSP offender is resolved in one of the three
ways:
1. The child dies
2. The police apprehend the offender
3. The victim's advancing age causes the offender to move
on to a younger child within the family.
In cases where a child has
either died from abuse or matured to the point that the
caregiver believes it is too dangerous to continue the abuse,
the offender might attempt to find another suitable victim. The
offender commonly substitutes a younger sibling for the
initial victim. In rare cases, both children might share the
abuse simultaneously, but it is more likely that the offender
will concentrate on one victim at a time. Because
offenders revel emotionally in the attention derived from MSP,
it seems reasonable to assume that only one child would be
necessary to gain such attention. However, investigators would
be remiss to assume singular victimization because MSP offenders
maintain their own peculiar index of rationalization.
MSP as a
Homicidal Agent
Unfortunately, MSP has become a
popular means to "dump" cases when agencies seek to
establish a link between this syndrome and maternal homicide.
Not all women who kill their children are afflicted with
Munchausen's Syndrome or MSP, just as not all women who kill their
children are insane.
With MSP, offenders crave the
attention gleaned from events surrounding their child's illness
or death. Thus, investigators should consider the possibility of
MSP if they believe there to be some secondary gain, in the form
of attention or notoriety, afforded the offender at the expense
of the victim. If investigators find no warning signs
associated with MSP cases or no secondary gain in the
form of attention, then they should consider the
possibility of homicide without the association of the
MSP factor.
Conclusion
Despite the evolving
understanding of Munchausen's Syndrome by Proxy within the medical
and law enforcement fields, police investigators still might
find it difficult to believe that a child's caregiver, someone
who appears sincerely concerned about the victim's health, could
be the cause of a child's symptoms. However, a growing list
of cases involving Munchausen's Syndrome by Proxy confirms
that this disorder represents a substantial challenge to the
criminal justice system. By understanding the motivations,
needs, and methods of MSP offenders, the law enforcement
community can better identify perpetrators and protect innocent
victims.
Motivational (Profile) Factors
One or more of the following
motivational factors might be present in MSP cases:
- Most offenders crave the
attention gleaned from hospital staffs, doctors, and family
members
- Offenders become more
aggressive as time passes
- Some offenders, in theory,
might receive gratification as they fool the doctors. They
derive enjoyment from knowing what is wrong with the child
while medical experts remain baffled
- Some offenders may fear
going home or adjusting to a normal daily routine without
being the center of attention
- A relatively minor crisis,
such as the fear of being left alone or of the child's being
released from the hospital, could trigger an attack on a
victim
- An offender who is praised
as a hero for saving a child might elect to re-create that
euphoria by fabricating subsequent incidents of abuse and
revival of the victim.
|
What
is MSP?