By Kathryn A. Hanon
Investigator Orlando, Florida, Police Department
This article originally appeared in the FBI Law Enforcement Bulletin, December 1991.
The range of investigations for modern day law enforcement officers is unparalleled in the history of criminology. Investigators must use innovative techniques in order to solve today's more sophisticated, bizarre criminal acts.
For example, cases of an obscure form of child abuse--Munchausen's Syndrome by Proxy (MSBP)--are being seen more and more frequently. MSBP is a form of child abuse that involves long-term physical abuse, usually by a parent.
However, in order to conduct MSBP investigations effectively, it is necessary to understand the complexity of the disorder and the unorthodox investigative procedures that may be necessary to prosecute the case successfully. This article discusses the disorder and how officers should approach the investigation of this crime.
Defining The Syndrome
Munchausen's Syndrome by Proxy is a form of child abuse in which the abuser fabricates an illness in a child. When the child is taken for medical care, the parent tells physicians that there is no apparent cause for the illness, knowing that this will most likely result in the hospitalization of the victim for tests or observation. It is during this period of hospitalization that the actual abuse usually occurs. In one known case of MSBP, a mother injected fecal material into the victim; in another case, a mother suffocated and then revived her child on several occasions during the hospitalization period.
Symptoms of MSBP are generally recognizable by the time the victim reaches 14 months of age. However, MSBP is usually not diagnosed until the child is approximately 3 years of age. The mortality rate for this type of abuse is high.
There are both mild and severe cases of MSBP. In mild cases, the parent fabricates a history of a non-existent condition in the child. For example, some parents contaminate their children's feces with blood and claim that they passed the blood.
In severe cases of MSBP, a parent actually harms the child in order to create symptoms of an illness. Suffocation or blood poisoning are typical in this form of MSBP.
Offender And Victim Characteristics
Most MSBP offenders are mothers of the victims. However, there have been cases where the offender was the father or a person outside of the family.
MSBP offenders are uncharacteristically calm in view of the victims' baffling medical symptoms, and they welcome medical tests that are painful to the children. They also maintain a high degree of involvement in the care of their children during treatment and will excessively praise the medical staff. They seem very knowledgeable of the victims' illnesses, which may indicate some medical study or training. They may also have a history of the same illnesses being exhibited by their victims.
In addition, MSBP offenders typically shelter their victims from outside activities, such as school or playing with other children, allowing only certain persons to be close to them. They may even speak for the victims when anyone approaches them. MSBP offenders are attentive to their victims, even though they are harming them. They seem to find emotional satisfaction when their child is hospitalized because the hospital staff believes that their attentiveness indicates that they are good parents.
Victims of MSBP can be of either gender. They are often immature for their age, due to their forced dependency on the abusing parent, and female victims may assume multiple roles. For example, they may take on a motherly role as they imitate their closest role model--the offender--and then regress to the role of a sick, weak, dependent child.
Characteristics Of Non-Offending Parent
MSBP victims are rarely abused by their fathers. Passive and indifferent, the father does not play a primary role in the care of the sick child. His hospital visits with the victim are limited, and although he may be suspicious of the baffling course of his child's illness, he is unable to stop the child's abuse.
The Victim's Siblings
There is a good chance that younger siblings of MSBP victims will also be abused. When offenders stop abusing their victims--either because the child gets older and more mature or because the child dies--they may look to their other children in order to continue the abuse. A study of the medical history of these children may indicate whether there is a pattern of abuse within the family.
Recognizing MSBP
Because cases of MSBP are often times first recognized in hospitals or doctor's offices, it is imperative that the medical community be aware of this type of abuse. MSBP should be suspected if illnesses in children remain unexplained after medical testing, and there is a history of multiple visits to different hospitals and physicians.
Primarily, observing an ill child during a hospital stay can support a suspicion of MSBP. In such instances, the suspected victim should be placed in an open ward, where there is less opportunity for the offender to continue the abuse. This also gives hospital personnel a chance to observe any changes in the patient's symptoms. If the symptoms cease and then recur when the victim is again readily accessible to the offender, in all likelihood, MSBP is taking place.
A Team Approach
When law enforcement officials are contacted concerning suspected cases ofMSBP, it is critical to use a multidisciplinary approach to the case. Medical staff, child protection teams, social services personnel, and hospital administrators, as well as prosecutors and law enforcement personnel, should assist in the investigation.
The early involvement of prosecutors is especially helpful in MSBP cases because there is little existing case law to which investigators can refer for guidance. Therefore, it is important to coordinate the investigation with those who will prosecute the case.
Medical staff, including physicians and nurses who have attended the victim, may suspect abuse before law enforcement's involvement in the case, and therefore, may be able to contribute valuable information to the investigation. However, for security reasons, investigators should limit the number of staff who are aware of the investigation. Investigators should gain the cooperation of some primary care personnel during the investigation, and after theinvestigation is completed, officials should strongly consider seeking psychological treatment for both the victim and the offender.
Many States require that investigators inform social services of any child abuse investigations they conduct. Those in social services can help investigators follow particular guidelines and meet set time constraints for resolving this type of case. It may also be necessary to have social services waive certain requirements because MSBP investigations are sometimes lengthy due to the confidentiality aspect.
Child protection teams work directly with the medical staff and serve as excellent liaison between law enforcement and medical personnel. Because interagency agreement is important in these investigations, it is a good idea to hold regular meetings to discuss how the case is being managed. Cooperation between all of the involved agencies is imperative in cases such as these. Although all team members should approach cases from their respective jurisdictions, the common goal should be to ensure the safety of the victims. If the abuse is not stopped, the family will relocate, and the abuse will continue. As the cycle of abuse continues, the victim is subjected to further risk of permanent injury, painful medical tests, or even death.
Evidence
In order to stop the cycle of abuse, investigators must obtain sufficient admissible evidence to convict the abuser. A particularly effective way to obtain proof in MSBP cases is to use concealed cameras to videotape evidence. For example, ceiling cameras can record a wide range of movement, and they can be easily hidden in hospital rooms.
However, placement of video cameras in hospital rooms will likely require a court order.1 In making application for such an order, investigators should stress the necessity of videotape evidence so that judges will better understand exactly what is needed in MSBP cases.
Frequently, obtaining a court order for videotaping is considerably less complicated when the request omits sound because judges do not have to considerwire tap laws.2 However, sound is not a critical element in videotapes of MSBP cases that involve suffocation, poisoning, or fabrication through simulation.
If investigators suspect that a child is being poisoned, they should collect relevant evidence, such as tubing, I.V.s, and needles. Other possible evidence might include towels that offenders use to suffocate their victims or medicine bottles that suspected abusers bring into the hospital.
Investigators should also check bio-hazard containers and garbage cans for evidence. In addition, they should check receptacles used to store urine or stool if foreign matter is present in these items.
And finally, in hospitals, investigators should be aware of any missing syringes or other medical equipment. Because MSBP offenders sometimes use items of opportunity, they obtain instruments from hospitals to abuse their victims.
Arrest Of Offenders
When there is sufficient proof in an MSBP case, investigators should arrest the offender quickly. This will preclude relocation, further injury to the child, or self-inflicted injury by the offender.
However, arresting an abuser in front of the victim causes unnecessary trauma to the child, who may view the offender as an ideal caretaker. At this juncture in the case, investigators may find it helpful to elicit the help of medical personnel who can reasonably explain the situation to the child.
Interviewing The Offender
Some investigators are affected by the fact that certain offenders are suspected of child abuse. However, in order to interview the offender successfully, it is important to always maintain a neutral position.
During the interview, many offenders will continue to deny their guilt, even when confronted with videotapes that prove intentional abuse. In some cases, they may not even recognize that they have a problem until the magnitude of the offense is brought to their attention. However, a subtle suggestion to offenders that their continued denial of guilt could lead to the untimely death of their child may be a useful interview technique.
Although MSBP offenders intentionally abuse their children, they may truly love them. That love may eventually extend beyond the fear of punishment and the shame they feel to provide an excellent avenue of dialogue between the offender and the interviewer. This dialogue is especially important in cases of unidentified poisonings, where the ability of medical personnel or investigators to determine the source of the poison directly affects the future health of the child.
When interviewing MSBP offenders, investigators should understand that the offenders need to have a feeling of self-worth. It is important for investigators to discuss the offenders' families and personal histories in an effort to build a rapport with them. It is also important for investigators to be aware that it is likely that the offenders were also abused as children.
Conclusion
Although Munchausen's Syndrome by Proxy is a problem already recognized by the mental health community, it is a problem that must also be recognized by the law enforcement community, which must remain alert to any existing cases. Sadly, previous unexplained deaths of children may actually have been preventable homicides if recognized early as cases of MSBP.
The education of both law enforcement personnel and those in the medical community, coupled with a commitment by law enforcement to prosecute cases of MSBP, may be the only hope for halting this type of abuse of children.The lives of innocent children may depend on the swift recognition and immediate prosecution of those suffering from this bizarre form of abuse.
Footnotes
Officers should consult their legal advisors to determine appropriate applicable statutes. For a more in-depth discussion of video surveillance,see Robert A. Fiatal, "Lights, Camera, Action: Video Surveillance and the Fourth Amendment," FBI Law Enforcement Bulletin, January and February 1989.
Ibid.
