Placement and Visitation Issues

Safety—the first and primary management issue for the MBP child victim—often requires removal of the child from the home with no, or at most closely supervised, contact with the perpetrating parent. Placement with another family member may be appropriate if the relative appreciates the meaning and seriousness of the MBP diagnosis. Long-term management should include monitoring, team-based treatment, and case oversight by the court. Children typically recover dramatically from their physical illnesses when they are separated from their perpetrators.

Visitation should be considered very carefully in cases of alleged MBP because the child's victimization is typically significant and chronic. Victimization is likely to continue to occur with few exceptions, even in light of treatment. Children have been revic-timized by perpetrators even during highly structured and well-supervised visits. In addition to the physical danger, visitation can offer enormous potential for psychological harm. Child victims of MBP tend to have long-term and serious sequelae to their abuse that are impacted by contact with their perpetrators. A number of experts (Lasher and Sheridan 2004; Par-nell and Day 1998; Schreier et al. 2009) recommend that no direct or indirect contact be permitted between child and mother (or other family members, who might serve as a proxy for the mother) until a forensic evaluation is complete, a treatment plan for the family is in place, and the mother has made significant progress. If visitation is to be instituted, it should always be professionally supervised. In cases in which the child faces considerable danger of physical or emotional distress, visits should be discontinued. Reduction or discontinuation of visits is strongly recommended when, over time, the mother is unable to acknowledge perpetration, unless special circumstances warrant visitation to meet the child's best interests.

Table 12-3. Comprehensive mental health evaluation for Munchausen by proxy

Areas of focus

Child's illness experience and physical and psychological functioning

Parent's psychological functioning, with attention to differentiating factitious disorder by proxy and other possible psychological etiologies of parent's behavior, attitudes, beliefs, and actions toward child

Components of evaluation

Comprehensive record review and contacts with collaterals, including both professionals and laypersons (e.g., other family members)

Emotional and physical functioning of each parent or primary caregiver, past and present, through a series of clinical interviews and through psychological testing

Interviews with maternal grandparents, fathers and their family members, and any other relatives who have or wish to have contact with child

Review of child's past and present physical and emotional functioning, including but not limited to information about past and current daily routines, symptoms, and behaviors, obtained through observations, record review, and interviews with past and current caregivers

Observations of child with family members, with current caregivers, at school, and with perpetrator unless safety prohibits contact

Child placement is challenging when the possibility of family reunification is unclear. Successful family reunification can be achieved in a few cases only if the abuser and family members acknowledge the pattern of illness falsification, benefit from effective treatment, and accept and use a monitoring and support system. Reunification generally requires a prolonged period of time and necessitates an interim placement plan. In high-risk cases and cases with poor prognostic indicators, a long-term placement plan should be considered. Ensuring the victim's continuing safety requires careful planning by professionals knowledgeable of this condition.

Friends or family members may be caregivers if they genuinely believe the child must be protected from the suspected abuser and if they have the ability to protect the child from the suspected abuser. Caregivers who accept care of the child must also accept responsibility to follow all court orders, which may include the need to prohibit parental access to the child or to closely monitor visits. The caregiver must have a realistic expectation regarding any pressure or hostility he or she may need to endure to abide by the court orders. In Ayoub's (2006) study, one-third of the relative placements failed because of extended pressure on family members by mothers and their representatives. In cases of severe abuse that is met with denial by the confirmed abuser and other family members, adoption or placement in foster care without family access to the foster family is warranted. Termination of parental rights of fathers as well as mothers is often recommended.

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