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Review Article | DOI: https://doi.org/10.31579/2637-8892/291
(Psychopathology and Clinical Psychology) Clinical Psychologist of the Ministry of Justice France.
*Corresponding Author: O. Moyano, Ph D (Psychopathology and Clinical Psychology) Clinical Psychologist of the Ministry of Justice France.
Citation: O. Moyano, (2024), A mother injures her baby: Münchausen syndrome by proxy, Psychology and Mental Health Care, 8(8): DOI:10.31579/2637-8892/291
Copyright: © 2024, O. Moyano. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 01 August 2024 | Accepted: 22 August 2024 | Published: 02 September 2024
Keywords: munchausen syndrome by proxy ; dysparentality ; baby
Munchausen syndrome by proxy (MSBP) is a very special pathology where an adult produces symp-toms of illness in baby or child/adolescents under his care. Il is a factitious disorder generally produ-ced by the mother. Mother’s intention is to obtain medical treatment and to give part of these treatments. We present a single case of a baby who has been hospitalized four times.
Münchausen syndrome by proxy (MSBP) refers to the notion of dysparentality, or even inaccessible parentality. The first description dates back to 1977 by Meadow in the journal Lancet. Since then, the international literature lists only a few cases (300 cases in 2006 according to De Becker). This picture strikes people by the discrepancy between the maternal feelings displayed and the aggressive nature of the acts committed against her child. The imagination, the strategies displayed to hide the disorder or symptom of the child are always remarkable. The child, a source of pathogenic fantasies on the part of one of the parents, becomes a victim, in whole or in part:
* a simulated disease (passive form) or deliberately produced by the parent (active form), usually the mother according to scientific sources.
* repeated medical investigation with the intention of recognition for the well-being of the child.
* there is still a denial from the parent as to the origin of the symptom.
* an amendment to the symptomatology presented by the child when separated from the parent concerned.
Typically, this syndrome is more common in families where the mother practises a medical or para-medical profession, with infants who have had repeated consultations, mothers very present during the hospitalization of their child, a mother’s medical history related to her child’s illness, symptoms that may involve different physiological spheres and cover the entire pediatric nosography (Binet E.,2001, De Becker E., 2006). Diagnosis is important because of the high associated morbidity and mortality (Yalcin and al., 2022).
Recall that the Münchausen syndrome by proxy (MSBP) is rarely reported in the scientific literature and that there is no scientific consensus about a psychopathological picture in the offending adult. As mysterious as it is fascinating, this disorder often approaches horror and inevitably induces a strong malaise in the clinician confronted with the suffering of a child whose origin is in parental gestures. Originally the name of the syndrome (taken from the Baron de Münchausen, famous affabulator) gave the troubles a fictitious character reported by the parent. In fact, most often these are parental behaviours that are characterized by psychological or somatic symptoms in the child, intentionally produced by the parent.
Currently, the recommendation is that the term MSBP should be used to define the abuse itself, whereas the psychopathology of the perpetrator is referred to as FDIA, factitious disorder imposed on another (Abdurrachid, Marques, 2022).
This syndrome is not common but it is ultimately a quasi-systematic reason for reporting, when suspected or detected, to the judicial authorities. In this article we present a situation encountered during a judicial measure of educational investigation (MJIE) in educational assistance, in order to share the singularity of this endangerment of a child by a parent.
A hospitalized baby for the fourth time:
The situation of Paulin, aged 12 months, is very worrying. The report comes from the hospital where the baby is hospitalized following a burn caused by the mother during the bath. This one is using the pretext of unintentional wrongdoing. But this gesture is unfortunately not isolated.
Paulin will be hospitalized all the time of the investigation, supported by very specialized hospital services: service of major patients at first, then regional hospitalization in specialized rehabilitation center. Telephone interviews with the various staff of the departments concerned will take place. The stakes of this investigation lie in the personality examinations of the parents, in the absence of knowledge on my part, in the writing of the report and the sending to the magistrate, of the conclusions of the criminal investigation.
During the investigation period, the Chamber of Minors of the Court of Appeal issued a judgment confirming Paulin’s order of placement, denying the parents of their request for a lifting of the placement. The judgment of the Court of Appeal recalls that it is essential to determine the origin of the multiple accidents suffered by Paulin. This legitimate question seems to have gone awry, since the context of the accidents is either vague or based on contradictory versions which I cannot verify. I have neither the competence nor the charge.
Paulin’s story includes several incidents/accidents observed by the medical community:
- Femur fracture at 5 weeks
- the break in the 3-month weight curve without a rational explanation from the parents
- a hematoma on the thigh at 5 months
- bruises on forehead and cheeks during the eighth month
- a new state of malnutrition at 9 months in hospital
- 1 black eye at 10 months
- burns (2° and 3° degrees) at 12 months over 40% of body surface
The succession of these episodes is more than worrying: either the parental couple fails to adapt to the fact of raising a child in a safe environment and shows an obvious disability, or the child is mistreated. In this last hypothesis, in view of the parental discourse, it is there that the Münchausen syndrome by proxy could be evoked from the hospitalization of the child by the staff of the hospital and the center of reception of the victims.
Mother’s personality :
In educational assistance proceedings, the magistrate is given the opportunity to ask the psychologist conducting the judicial investigation for an examination of the parent or parents of the minor named on the order.
The mother is present at all the appointments offered. His words are freely expressed, without reticence or pathological distrust. Aged 25, she is an only child. She practises as a caregiver in a medical facility. Of very small stature, she makes the link between her own weight/height ratio and the concern evoked about the break in the weight curve of Paulin: mother and son could be carriers of the same genetic disease said-This is a factor that is frequently identified in the Münchausen syndrome by proxy: the mother’s medical history is related to the child’s disease or diseases. The mother repeatedly evokes a psychological and physical abuse against her during her childhood, perpetrated by her mother. When I ask her to clarify, she talks about severe punishment, hair drawn, a very bad maternal character in a context that seems to be more on the side of more or less continuous moral harassment than serious physical harm. No one would have taken into account the girl’s suffering at the time.
Concerning all the somatic episodes of Paulin, the mother develops arguments to counter the hypotheses of a failure or a will to want to harm her child: on weight, in particular, She made amends and explained that she misunderstood the composition of the bottle and that she needed clarification from medical staff to correct the error. She had continued to give him too liquid bottles instead of feeding the baby with a spoon. But it is noted that Paulin presents twice weight loss. This repetition makes sense: either the mother does not understand the needs of an infant, or it is an unconscious manoeuvre to «shape» her child in her image, like a true double narcissist, the image of the child’s body becoming an analogy to the image of the maternal body, through disturbed feeding. In this perspective, the weight ratio of the baby will become consistent with that of the mother. This type of pathogenic cross-identification has already been identified in the context of disrupted mother/child interactions, including in the case of proxy Münchausen syndrome, where difficulties in differentiating a paradoxically symbiotic mother/child situation are noted (Binet, 2001).
The origin of the fracture of the femur cannot be more fuzzy: either it is due to parental maneuvers to relieve Paulin of gastric pain, or it is due to improper handling of the manipulator in radiology according to the mother. The latter claims that there was medical negligence with a first diagnosis of non fracture, then a radiological X-ray that confirms the injury.
We can note, in the maternal discourse, this occurrence on several occasions, that is, the questioning of other people to explain the incidents that happened to his son: as another example there was not, According to her, from blue to thigh before going to the kindergarten assistant, suggesting that it was at her that her son was injured.
Regarding the burns, the mother evokes an unfortunate gesture on her part. The baby was in the bathtub, and as he retreated, leaning over him, his hip activated the hot water lever. It takes time to react, takes out the child, the swaddle and the diaper. In the morning, she discovers the burns on most of the body of her child who would not complain during the night. The emergency department blames him for the too long delay between the burn and the drive to the hospital which occurs only the next day. The mother denies any intention and never takes offence at this type of question. I’m probing her again. She very passively accepts all my questions. It evokes the event without too much affect. She says she represses them so as not to have to crack, especially at work. The story of events is very factual, it includes a lot of rationalizations.
On examination, the young woman does not have a sleep disorder. She brings back a few memories of dreams, not nightmares. On the other hand, since his absence, the parents sleep with a Paulin comforter in the parental bed. In terms of food, the mother describes herself as a “soft drink addict” and a fan of snacking. It does not consume coffee, tobacco or any narcotic. She only drinks alcohol on rare family occasions.
The psychological examination refers to vocabulary in the standard. It does not present any disorder of the current thought, no dam, no cocks to the donkey, no diffluence of the thought, no confusion. It does not declare any organized phobia. She has never experienced a depressive turn and, even now, she describes rather a gloom waiting for the return of her son, than a true depressive collapse. Nor does she suffer from any surge of anxiety, either now or before in her biography. She is free from any symptom of the psychotic series: no hallucination, no break in the course of thought, no delirium, no strangeness in contact, no immoderate smile, no break in contact with reality.
The testing makes it possible to specify the organization of his personality (Rorschach tests, Scale of Dissociative Experiments, Alexithymy questionnaire). The young woman does not present any alexithymy: she brings, she says, an important consideration to the place of emotions in her life (even if she seems to put aside her emotions), she says she is able to identify them in her as to express them, even if she doesn’t do it often. In spite of everything, there is a more or less constant repression of its affects in its communication. She reported no dissociative experiences, no memory problems, and never had partial or lacunar amnesia. Productivity at Rorschach is quite low. This young mother is able to put the projective process into action, but she fights against this projection, again by repressing her abilities. These are more conscious mechanisms of repression and control than a real mechanism of repression (which, in turn, is unconscious). Sometimes the mentalization abilities are in difficulty and the answers are replaced by multiple manipulations of the test boards (motor activity comes to support and replace faulty thinking). We observe the recurrence of anatomical responses to the point that it itself makes the remark «I focus on the human body» and in particular the belly/uterus area. No disorganization of thought appears through this protocol.
I ask the young mother about the notion of pleasure in her daily life and her life choices, given the relatively disused character that emerges during the interviews: the most important for her was to build a family, a family cocoon, «I wanted this family cocoon quickly». « I set myself goals to achieve them, it’s not really a pleasure ». She says she feels a certain pleasure in sexuality. She does not necessarily get any oral pleasure from eating, or even from drinking the sodas of which she calls herself «addict». Rather, she describes herself as someone who maintains a restraining attitude.
She plans her son’s return home, with his continued presence to provide the necessary care. She projects herself into this return, ignoring the suffering of her son. She speaks as a care technician, which she is through her profession (often raised in Münchausen syndrome by proxy). Hospital services confirm the strong parental investment in the care and follow-up of the child. At no time during our meetings did she spontaneously address the suffering that her baby endured. Not for burns, not for fractures or bruises. This point questions me, because it shows a self-centred or self-centred maternal preoccupation, with as its main driver what she has done, must do and will do for her son, as a perfect organizer. What matters today is the facts: do and do well. The decentralization on the intimate experience and the baby’s affects were not spontaneously evoked by this young mother. It questions me about his ability to feel commiseration for others outside of himself. This young mother, after having known a childhood described as unhappy, by the presence of a rejecting mother and the quolibets of her peers in relation to her small stature, presents an atypical emotional expressiveness, not really absent from this woman’s psychic field, but muted. She feels affects and emotions, but she represses them. One can thus note a certain coldness in the contact and an egocentric centering of his needs and concerns. She is not worried about possible legal action (with her possible indictment). Paulin is very present in his speech which is built today only on the project of exit and all the time that she will devote to him for the care that he will need. It is an operational project in which the intimate experience of the child, past present and future has not yet its place (for example, she did not discuss what her child’s experience or questions might be in relation to burns, when he is older, his after-effects, etc.).
Meetings with the father
The father is met alone. Paulin has been in a rehabilitation center more than two hundred kilometers away for a few weeks, he goes to see him as soon as possible, that is to say very often despite the distance, almost every weekend.
This man is very affected by what happened to his son. He understands the response of the Court of Appeal (confirmation of the emergency placement of his son) and does not dispute it. He remembers that a magistrate had told the parents during the hearing that if the child was returned to them, she would be remiss to discover the name of the family in the various facts a few months later. I ask the father about this remark : what can this really mean? Has he understood the fear of the magistrate? What does he think about ? The father is unable to answer my question and remains very evasive. He stays outside of a full understanding of the issues that revolve around his son's situation. He read the various reports, he inquired with his wife on the internet to verify what this Münchausen syndrome was which had been mentioned in certain writings, but, at no time, did he make the link with his story and that of his wife. He does not even protest the possibility of this hypothesis raised by some. When I ask him if, at one time or another, he doubted the actions of his wife, he answers without waiting that he never doubted her. He retains his full confidence in her. The episode has not damaged his love for her and he does not express any resentment towards the person responsible for the burns, even if they were involuntary.
This man has sleep disorders, because he is very anxious about the legal consequences to come. He does not use tobacco, no alcohol or any narcotics. His speech is clear, without pathological construction. He describes his temperament having certain reactive impulsivity, but without any pathological character. Moreover, no biographical element exists to detect impulsivity tracts. His emotional control is very good during the interview, the mood remains stable throughout the exchanges. He easily stares at his interlocutor, I detect no nervous reaction, no pathological distrust, no interpretive speech, no delusional ideas. His Speech is always in tune with reality. No psychotic element is observed during the interview. The mood remains constant. Apart from since his son's hospitalization, he had never experienced a depressive turn. We can highlight a certain psychoaffective immaturity, but this does not hinder his relational or social capacities. The father remains very close to his wife and his speech does not raise any questioning either of the couple or of one of the two parents with regard to the traumatic history of Paulin.
The interviews with each of the two parents confirm the absence of a disturbing psychopathological profile in either the mother or the father (which will be confirmed by the psychiatric expertise of the mother ordered in parallel by the judge). The parental couple is strained towards a single goal, the return of Paulin to the house. I regret to see that very little questioning around the accidents of the baby's life to date. There is no evidence to confirm that the violence was intentional, but there is nothing to verify that parental abilities are now able to provide Paulin with a safe environment at home. A last telephone conversation with the psychologist from the rehabilitation center was an opportunity to take stock: the parents are always very present, extremely compliant, they always take care of Paulin under the presence of a member of the hospital. They always accept the obligation to have a nurse with them and Paulin. In fact, they are perceived by the team as quite passive and very little expressive, even smooth. Paulin benefits rehabilitation in physiotherapy, occupational therapy, and an ongoing psychomotor assessment. He still requires significant care for burns. The exit of the center of rehabilitation is not up to date.
This situation illustrates the difficulty to consider the Münchausen syndrome by proxy with the main interested parties: the absence of speech on the part of the parents is disarming, a father who is oblivious, passive, a mother who offers no justification for his questioning and, above all, do not use any energy to shout his innocence.
We had the feeling of witnessing a tacit agreement between the two parents, based on the father's submission to his wife and the trust, or at least the apparent trust that he granted her. As if the survival of this couple exceeded, in the the father psyche, the desire for the child to return home. The mechanisms at work are powerful and devastating and can put a strain on clinicians faced with this type of dramatic situation. Justice has decided: if maternal guilt could not be demonstrated, the parental ability to ensure the safety of the child was, in fact, also denied. The decree of the judgments recalled that the child was injured on several occasions, which testifies to the failure of the capacity of a couple to protect their child. So, logically, Paulin did not return to his home after the judicial investigation.
Problem of diagnosing Münchausen syndrome by proxy is pointed out in all the literature devoted to this subject. Thus, diagnostic vigilance and interdisciplinary collaboration are essential for the diagnosis and prevention of complications (Bouchalta and al., 2022)
Indeed, even though the parental abuse (mainly maternal) observed can be encountered from birth, the diagnosis is rarely made before 30 months (Binet, 2001). It is a serious, potentially very dangerous psychological illness, the objective of which is always to draw attention to the perpetrator through the victim (Hoisey and al., 2017). There is no typical parental psychological profile in this syndrome. The recurrence of cases shows that it is most often mother who is concerned. The future of these children has been the subject of few publications, the most recent in French dates from 2016 (Binet, Tarquinio, 2016) and reports numerous disorders in adults who have suffered Münchausen syndrome by proxy during the childhood, including particularly complex post-traumatic disorders, with symptomatic expression in particular centered around dissociative disorders (traumatic amnesia).
MSBP : Munchausen syndrome by proxy
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