Children are victimized by a variety of means, limited only by the perpetrator's imagination. They are subjected to unnecessary hospitalizations, tests, procedures, and treatments for disabilities that are physical, psychological, or educational (attention-deficit/hyperactivity disorder [ADHD] and learning problems). Disease falsification includes symptom exaggeration and distortion; false reports; manipu
Figure 12-1. The diagnoses that jointly constitute Munchausen by proxy.
lation of medication, food, and activity; and inducement of symptoms by any number of means. Cases documented in the literature include a variety of overt and sadistic injuries, such as repeated pounding with a hammer described in an autobiographical article (Byrk and Siegel 1997); administration of substances, such as ipecac or salt water, that cause vomiting; injection of feces, pine tree fungus, rat poisoning, or menstrual blood; administration of insulin; and suffocation.
In Ayoub's (2006) study of 30 children with MBP, 23% had gastrointestinal symptoms including vomiting, failure to thrive or grow, reflux, esophagi-tis, chronic secretory diarrhea, neurological intestinal pseudo-obstruction, and chronic abdominal pain; 30% were reported to have recurrent seizures; 20% had repeated episodes of apnea; 13% experienced abnormal serum insulin levels either as uncontrolled diabetes or as unexplained hypoglyce-mia; 10% were diagnosed with rare autoimmune or genetic disorders; and 10% had unexplained exacerbations of asthma (Ayoub 2006). In addition, 7% were poisoned and had feigned bleeding difficulties. A final group of children in Ayoub's (2006) prospective study had psychiatric or learning disabilities that were exaggerated, fabricated, or induced ( 10%) ; their problems included ADHD, bipolar disorder, and psychosis.
According to Sheridan's (2003) meta-analysis of 451 cases of MBP, children had multiple symptoms in at least three and as many as seven different organ systems; victims averaged 3.25 medical problems (range 0-19). Perpetrators actively induced symp toms in 57.2% of the cases reviewed by Sheridan, and at least half induced symptoms while the victims were in the hospital. The most common symptom induction methods were suffocation and poisoning with prescribed medications or other agents. A typical medical history included many office visits, often to a variety of specialists, and a number of major and minor surgical procedures to relieve symptoms that were exaggerated, fabricated, and/or induced. On average, the time from onset of symptoms to diagnosis was 2 years (Sheridan 2003).
Sheridan (2003) found that 6% of the child victims and 25% of their siblings died. The children most likely to die were those presenting with suffo-catory abuse or apnea (Alexander et al. 1990; Ayoub 2006; Sheridan 2003). Although the majority of victims of MBP are younger than age 6 years, cases of serious MBP also occur with older children and adolescents (Awadallah et al. 2005). Boys and girls are equally affected.
The child's medical care occurs in the context of a caregiving relationship, and perpetration often occurs in forms difficult for a child to detect or understand as victimization, such as misadministration of medication or misrepresentation of medical history; as a result, the child's failure to detect or appreciate the perpetration supports continuing trauma in the child victim. These children often learn that the way to get attention is to be sick. The parent's deception also makes it easier for a child to misapprehend, deny, or compartmentalize his or her victimization. These children seldom recognize their abuse or identify it to others.
In the face of persistent fabrication, children not only risk potentially serious physical injury due to exposure to unnecessary procedures but also almost universally have serious and long-lasting psychological trauma. The psychological impact of victimization through MBP is significant and chronic. Basic problems with attachment, relationship building, and social interaction, as well as attention and concentration, are common in these children (Ayoub 2006; McGuire and Feldman 1989). The presence of oppositional disorders in these victims is significant, as are patterns of reality distortion, poor self-esteem, lying, and attachment difficulties with adults and peers. Although these children can present as socially skilled and superficially well adjusted, they often struggle with basic relationships.
Libow (1995) found that adult survivors of MBP frequently reported that abuse not only continued throughout childhood but also extended well into adulthood. Schreier and Libow (1993) noted that children often are at serious physical risk even while in state protective custody, because some parents may attempt to increase their harm to the child or attempt abduction as they are confronted.
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