SOCIAL CARE CONSULTANTS
Charles Pragnell Dip. S.W.  L.R.C.C							 	74 Redcar Lane,
Consultant / Director									  	 	 Redcar and Cleveland.
										      		    TS10   2JN.
									   	   Tel:   + 44    (0)1642 472417
						    	             E-Mail 113440.2404@compuserve.com.uk

MUNCHAUSEN SYNROME BY PROXY  - A MYTHICAL MALADY!.

I am an independent social care management consultant with over thirty years of experience in working directly with children and young people as a social worker and as a senior manager of social services. In the last eight years,  I have undertaken research for the National Children’s Bureau and several local authority Social Services Departments and Education Departments and for Health Authorities.  I have also made presentations at national and international conferences on child care issues (including child protection) and social policy issues, and have provided occasional lectures at Universities. I am an External Examiner to social work qualifying courses and an Expert Witness in Court Proceedings involving children.

Also in the last eight years I have undertaken in a voluntary capacity to act as an adviser  and representative for children who are looked after by local authorities and their families,  in Case Review Procedures or where they have had cause for complaint regarding the actions of local authorities and social workers in particular.

During the last two years I have been approached for advice and guidance by a number of families across the U.K. who have been given a medical label of Munchausen Syndrome By Proxy.

From enquiries and research I have conducted over the last three years into Munchausen Syndrome By Proxy, I am increasingly concerned at its use as a medical diagnosis by paediatricians and other professionals, and in particular the effects it has been having on families because of the implication of child abuse.  

There are many parallels in the use of this medical diagnosis to events in Cleveland in 1987 when anal dilatation testing was used  to suggest large numbers of children had been sexually abused.  The Butler Sloss Inquiry was deeply concerned that a medical diagnosis should be used as the sole determinant of child abuse and this is again happening in regard to Munchausen Syndrome By Proxy.  

If, like Cleveland, the numbers of cases of MSBP had been diagnosed in a similar time period and within a small geographical area, I have no doubts that a similar public outcry would have occurred long ago regarding the use of the MSBP medical diagnosis.

From the research I have conducted into the literature concerning Munchausen Syndrome By Proxy and the documentary and oral evidence of families labelled with this particular medical label,  the following are my findings and considered opinions :-

Munchausen Syndrome By Proxy

1.  A PAEDIATRIC DIAGNOSIS!.
The term Munchausen Syndrome By Proxy [MSBP] was first created in 1977 by a Dr. Roy Meadows of St. James Hospital Leeds and  was based on anecdotal evidence from an extremely small number of cases.  These cases have since been subjected to critical analysis and the conclusions which were drawn by Meadows are open to serious challenge.

_____________________________________________________________________________________
Member of  :-
	Institute of Child Care and Social Education	[U.K.]			Social Care Association					[U.K.]	
Dr. Meadows defined MSBP  as a condition used in regard to children and therefore a Paediatric Diagnosis in which it is alleged that an adult carer causes or fabricates an illness in a child with the objective of obtaining medical attention for themselves.   Meadows set out clear diagnostic criteria and guidelines for making diagnoses.   The diagnosis has therefore implications for child protection agencies as it is held that where an illness is fabricated this could lead to inappropriate medical treatment for the child, or  if an illness is caused by an adult carer, these actions could constitute `significant harm’ to the child. Other terms are also used for MSBP including Meadow’s Syndrome, Polle’s Syndrome,  and Munchausen By Proxy.

Not only were Meadow’s original  findings of questionable validity, but as far as is known, MSBP  was never subjected to any trial period under clinical and scientific conditions  by any national medical body in the United Kingdom prior to its introduction as a medical diagnosis,  nor  has there been any  trial period under clinical and scientific testing conditions to monitor and review its implementation.

In 1994,  Dr. Meadows declared with considerable concern in regard to MSBP that,   “There is a real danger of the term being overused”.  Journal of Clinical Forensic Medicine (1994) 1 121-127.

Other concerns have also been raised within the medical profession regarding the diagnosis of MSBP and principally by Dr. Colin Morley of Addensbrooke Hospital, Cambridge  [Archives Diseases in Childhood 1995; 72; 528-538].   Dr. Morley raised  numerous concerns regarding the appropriateness of the diagnostic label of MSBP and the specificity of the criteria used in the diagnosis.

An Australian research scientist with a doctorate in natural sciences, Viera Scheibner Ph.D. states in a medical paper in regard to MSBP that,

“…..it,  (MSBP) became a way for some doctors to camouflage the real observed side-effects of especially measles (M),  Measles-Mumps-Rubella (MMR), and Measles-Rubella (MR) vaccinations in the U.K.”

The term Munchausen Syndrome By Proxy first came to public attention in 1993 during the trial of Beverly Allitt, a young woman who was on trial for causing the deaths of a number of small children in a day nursery. I understand that although expert evidence was submitted to the trial that she `suffered’ from MSBP, such testimony was not accepted by the court and she was found not to have MSBP but from a serious mental disorder.   Unfortunately the incorrect association of MSBP with Beverly Allitt has remained in the public consciousness, and this has also affected the views and opinions of several health and social work professionals who have failed to properly research the subject before making assumptions regarding the applicability of the diagnostic label.

The principal irrationality of the claim that Munchausen Syndrome By Proxy as a paediatric diagnosis is that there are no medical symptoms associated with the claimed diagnosis, there is no medical condition associated with the diagnosis,  and there is no  medical treatment associated with the diagnosis.  The major purpose of the diagnosis’ is to declare that the child is not ill or any other diagnosed illness of the child has been induced by an adult.

2.   A PSYCHIATRIC DIAGNOSIS!.
 In the United States of America, Munchausen Syndrome By Proxy has been retitled  Factitious Disorder By Proxy by psychiatrists (principally Drs. Herbert Schreier and Marc Feldman) who claim it is a form of psychiatric illness but with the identical symptoms as described by Meadows.   The term `Disorder’ is often 
liberally exchanged with `Illness’ and `Disease’ (with an implication that it is infectious).  Some of the proponents of FDBP has taken matters a stage further by claiming that there is a standard `Profile’ of a person with `Munchausen’s’ and such `Profile’ now  includes trying to be a `perfect mother’. The question has to be raised therefore, which mothers would such a profile exclude!.

In October 1995, Dr. Meadows disputed  the use of the diagnosis as a psychiatric diagnosis, and in a letter to an American paediatrician states,  “……. The most important step in the diagnosis is in ensuring that the child is assessed by a paediatric specialist…… although mothers who perpetrate this form of abuse may have certain characteristics and personalities, one does not identify the abuse by examining the mother.”  And that no-one “suffers” from MSBP.

However despite Professor Meadows protestations there are known cases in the U.K. where MSBP has been variously  diagnosed and attributed by Physiotherapists, Anaesthetists, Neurologists, Psychologists, and even Veterinary Surgeons.   

Psychiatrists in the United Kingdom do not accept that adult carers in alleged MSBP cases have any form of mental disorder and the diagnosis of Munchausen Syndrome By Proxy  does not appear in the Diagnostic and Statistical Manual of Mental Disorders [DSM IV] published by the American Psychiatric Association.

3.	A GENERAL DIAGNOSIS OF SEVERAL PROFESSIONS ?.  

The confused, almost chaotic, situation regarding the diagnosis of MSBP is added to further by some social workers claiming that they can diagnosis Munchausen By Proxy as it is in their view a behaviour disorder and amenable to their interventions in a social work capacity.  This variant is termed Munchausen By Proxy, obviously omitting the Syndrome reference because it has medical diagnostic connotations (e.g. Louisa J. Lasher - Child Abuse Professional - U.S.A.) which such professionals are not qualified to make.

The concern regarding the spread of variants of MSBP is expressed in a paper by an American lawyer and a nurse (Goldman and Yorker) who have tried to introduce an umbrella term of Paediatric Condition Falsification as acceptable to the various professionals now engaged in the diagnosis of MSBP but this seems to have had little impact.

In America, some mothers have faced criminal charges following accusations of Munchausen Syndrome By Proxy / Factitious Illness By proxy but several of these cases are now being appealed and the evidence of MSBP is being ruled as inadmissible on the grounds that :-

1. 	It is not generally supported by the specialist medical profession e.g. Dr. C.J. Morley - “Munchausen Syndrome By Proxy be used with caution  and preferably abandoned in favour of giving an exact description of what has happened to the child……. diagnostic criteria are very non-specific and can be misinterpreted.”

2. 	The theory has not been and it is likely,  cannot be tested.  (Dr. A. Bentovim and P. Davis have both stated in British Courts that the MSBP diagnosis is merely a theory.

3. 	Reviews of MSBP research shows that the theory is unreliable and publications are marked by 
     controversy and discord.   Peer review has resulted in disagreement and 	multiple calls for abandoning
     the diagnosis.

4. 	The potential rate of error of diagnosis is unknown but MSBP diagnoses have led to many false 
accusations of child abuse.

5. 	There are no standards or controls for MSBP.

6. 	MSBP is not  generally accepted within the medical community. See Morley,  Mart, et al.

In the records of the cases I have studied, there is evidence that the children have suffered various illnesses prior to the MSBP diagnosis but these appear to have been ignored or disregarded by the paediatricians. 

In some cases, diagnoses have been made by some paediatricians solely on the basis of telephone conversations with the examining paediatricians without personally examining the children), or discussing the proposed diagnosis with the parents, or obtaining a full medical history of the child and other children in the family or examining child care methods within the family.  A practice, I would suggest, which should be seriously deplored.

The illnesses and other conditions experienced by the children appear to have their sources in :-
1. 	Congenital Disorders and Birth Injuries;				
2.  Surgical injury;	
3. 	Inappropriate medication and other medical treatments;
4. 	Allergic reactions;
5. 	Vaccine Damage;
6. 	Infections  e.g. Giardia.

It is perhaps notable that in all of these circumstances, serious questions could be raised regarding the competence of the examining paediatrician and other medical personnel and therefore whether the MSBP diagnosis is being used to mask such incidents of incompetence. In a significant number of cases the diagnosis of MSBP has been made after notice has been given by parents of their intention to bring a law suit for negligence and medical malpractice against the physicians involved or their employing health provider or where parents have threatened to report the physician to national medical bodies with disciplinary powers.

4. 	NOT A MEDICAL DIAGNOSIS
In the latter part of 1999, a letter from a Senior Adviser at the Department of Health in the U.K. states that MSBP is not a medical diagnosis but  is simply a category of non-accidental injury to children.

5. 	RESEARCH
The epidemiological research I have examined has used the diagnosis of MSBP as the starting point for the research and none appear to have examined the previous medical histories of the children nor whether the diagnostic criteria and guidelines for making the diagnosis set out by Dr. Meadows have been properly carried out.  In my view such research is thereby invalidated.

6. 	CONCERNS REGARDING THE WELFARE OF CHILDREN
The aspect of most concern as a direct result of a diagnosis of Munchausen Syndrome By Proxy, is that the parents who are so labelled avoid seeking medical treatment for themselves and their children,   although they may suffer genuine serious illnesses.  The label continues to appear in their medical records and they do not feel they will be received seriously by physicians and may even have to endure further child protection enquiries, with the strong possibility that their children may be removed from them. The names of the children remain on Child Protection Registers even if they move to other parts of the U.K.,   and in the education records of their children,  seriously affecting their relationships with their children’s teachers,  

Families are ostracised by relatives and friends and they are viewed with extreme suspicion by neighbours, especially those with children because of the common association of the label, although wrongly, with Beverly Allitt. In effect they become social isolates and outcasts, simply because of the medical diagnosis which paediatricians and others are attaching to them and their lives are thereby seriously blighted with no recourse to removing the label of MSBP once it has been attached nor of having the Child Protection entry expunged, even if the allegation is completely unfounded and the registration is cancelled.
The medical diagnosis of Munchausen Syndrome By Proxy is therefore per se’  being abusive to children and to their adult carers.

7. 	CONCLUSIONS
In conclusion, the use of the medical diagnosis of Munchausen Syndrome By Proxy does not have a validity nor authenticity for use as a suspicion of non-accidental injury of children and where such a label is attached to a child, is positively harmful toward the child and his/her family. The label should therefore be wholly disregarded in favour of normal procedures of investigation of non-accidental injury to children.

This document may be used in any forum concerned with inquiry into the use of Munchausen Syndrome By Proxy or any of its variants. The author would be prepared to respond to any further enquiry regarding the contents.

Charles Pragnell
Social Care Management Consultant