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Child Abuse & Neglect
Characteristics of hospital-based Munchausen Syndrome by Proxy in Japan
夽Takeo Fujiwara
a,∗, Makiko Okuyama
a, Mari Kasahara
a, Ayako Nakamura
baDepartment of Psychosocial Medicine, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
bUmegaoka Hospital, Tokyo, Japan
a r t i c l e i n f o
Article history:
Received 17 August 2006
Received in revised form 16 May 2007 Accepted 7 June 2007
Available online 2 May 2008
Keywords:
Munchausen Syndrome by Proxy Child abuse
Japan
a b s t r a c t
Objective: This article explores characteristics of Munchausen Syndrome by Proxy (MSBP) in Japan, a country which provides an egalitarian, low cost, and easy-access health care system.
Methods: We sent a questionnaire survey to 11 leading doctors in the child abuse field in Japan, each located in different hospital-based sites. Child abuse doctors answered questions regarding the characteristics of MSBP cases for whom they had helped care.
Results: Twenty-one MSBP cases (20 families) were reported. Characteristics of the vic- tims included: no differences based on sex, 4.6 years of age on average when MSBP was confirmed, and an average of 1.9 years duration of MSBP abuse. Biological mothers were at least one of the perpetrators in 95% of cases. Among the 12 cases (57%) who remained with their families, 2 victims died. Only 5% of perpetrators had a medical background or relatives who engaged in healthcare work.
Conclusion: There are similar features of MSBP cases between Japan and other English- speaking countries, such as the UK or the US. However, perpetrators of MSBP in Japan did not have a medical background. Easier access to hospital resources in Japan may give greater opportunities for perpetrators to obtain medical knowledge from doctors or nurses.
Practice implications: The findings suggest that perpetrators of MSBP should not be assumed to possess a medical background in a country which provides universal medi- cal care such as Japan. A contributory factor of MSBP may be the high frequency of medical consultations and equal level of accessibility of medical resources for Japanese citizens.
Social welfare services that need to decide on custody for MSBP victims should recognize the relatively high risk of life-threatening danger in their family of origin. Further collab- oration between hospital staff including pediatricians, nurses, medical social workers and staff at the social welfare services is needed to protect children from MSBP.
© 2008 Elsevier Ltd. All rights reserved.
Introduction
Munchausen Syndrome by Proxy (MSBP) has been recognized worldwide since first reported byMeadow in 1977. Most cases have been reported from developed and English-speaking countries, such as Australia, Canada, New Zealand, the UK,
夽 This research is supported by Research on Children and Families, Health and Labor Sciences Research Grants from Ministry of Health, Labor, and Welfare, Japan.
∗ Corresponding author.
0145-2134/$ – see front matter © 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chiabu.2007.06.008
and the US, but a recent review reported MSBP cases from non-English-speaking countries, including Japan (Feldman &
Brown, 2002). In this review, however, there was only one MSBP case reported from Japan (Honjo, 1996) and this case was not MSBP based onRosenberg’s (1987)definition (Sheridan, 2003).
Since MSBP might be, in part, related to health care accessibility, the patterns of MSBP may vary depending on the national health care system. It is our aim to compare the characteristics of MSBP in Japan with those from developed English-speaking countries. These countries, such as the UK and the US, employ a primary physician system, whereas Japan is also a developed country, but does not utilize this type of system. All Japanese citizen are covered equally in terms of medical care, and they can approach any doctor at any clinic or hospital, including a specialized doctor at a university hospital, with no discrepancy in cost, because of the egalitarian health care system (Ikegami & Campbell, 1999). In addition, parents who have an income below a specific amount do not need to pay any costs to the hospital with regards to medical care for their children.
In Japan, the process of receiving medical care for a child is as follows: when a child becomes sick, parents can approach practicing pediatricians, a children’s hospital, or pediatricians in a general hospital. Occasionally, patients may go to general practitioners. When practicing pediatricians or physicians decide that the child needs further examination or treatment, he or she is referred to other larger hospitals. For example, if a pediatrician believes that a CT scan is needed because a child is frequently vomiting after a fall, that pediatrician must contact the nearest larger hospital and ask the physicians there to examine the child and order a CT scan and hospitalization. In the case of MSBP, many victims would be referred to larger hospitals because the etiology of symptoms tend to be difficult to find (i.e., they are simulated or produced).
The Japanese medical system may essentially be providing the opportunity for more frequent visits to physician offices or hospitals for mothers to bring their children in for treatment. According to theOrganization for Economic Co-operation and Development (OECD) report (2005), doctors’ consultations per capita in Japan in 2000 was 14.4, while the same data in the UK are 5.4, in the US, 8.9, and in Canada, 6.3, partly due to the availability of doctors and the cost of consultation for individuals. Because we can estimate that children in Japan are more frequently in contact with physicians than children in other developed, English-speaking countries, we hypothesized that the unique Japanese health care system might affect the characteristics of victims and perpetrators of MSBP in Japan. Therefore, the purpose of this study was to explore the characteristics, victims, perpetrators, and patterns of MSBP in Japan.
Methods Subjects
We held the Child Abuse Working Group Meeting in the Nippon Association of Professionals and Scholars on the Abuse of Children, the Japanese version of the American Professional Society on the Abuse of the Children, in December 2004. In the meeting, 11 leading doctors in the field of child abuse in Japan, working in different hospital-based sites, reported MSBP cases (including suspected and confirmed cases) for whom they had helped care. Following the meeting, we sent a questionnaire survey to these 11 doctors who had reported MSBP cases. As detection of MSBP is not yet commonplace in Japan, we assumed that these specialized doctors are most able to detect probable MSBP cases. All 11 child abuse doctors reported back MSBP cases, from 1 to 4 cases each. They also answered questions regarding the characteristics of the MSBP cases, both suspected and confirmed, for whom they have helped care during a 10-year time period (1995–2004).
To include reports of cases from doctors, we defined MSBP based onRosenberg’s definition (1987)as “an odd form of abuse in which the mother fabricates illness in her child and repeatedly presents the child for medical care, disclaiming any knowledge about the cause of the child’s illness.”
We categorized MSBP into two groups based onMonteleone’s definition (1998):
(1) Simulated:
(a) Faked symptom by the caretaker (e.g., mother’s contamination of the child’s urine specimen with her own blood and subsequent claim that the child had been urinating blood),
(b) False or exaggerated history by the caretaker (e.g., mother’s continuous claim of seizures by the child, although no one had witnessed these symptoms), and
(2) Produced:
(a) Caretaker actually inflicted (e.g., the injection by the mother of a foreign material such as feces or a drug into the child’s intravenous line or formula, causing physiological disorders).
Surveyed characteristics
Investigated variables for victims of MSBP were: sex, age at first visit to a hospital, age at which MSBP was confirmed, duration of abuse, and existence of a developmental disorder.
Investigated variables of perpetrators were: relationship with victim, age of perpetrator, existence and diagnosis of mental disorder, existence of a medical background, such as nursing, having relatives or close friends who are engaged in health- care, resources of medical knowledge, and family structure. Psychiatric evaluation of perpetrators was performed based on the Diagnostic Statistical Manual (DSM) by psychiatric pediatricians who treated the victims of MSBP. However, because
MSBP perpetrators visit hospitals due to the alleged symptoms of victimized children, it is extremely difficult to convince perpetrators to undergo a psychiatric evaluation.
We also investigated characteristics of the incidents such as: reasons why MSBP was suspected, method of how MSBP was confirmed, location of the victim when MSBP was confirmed, classification of MSBP (simulated or produced), type of physical/psychological symptoms, existence of life-threatening danger, extent of medical treatment which the victim received (length of hospitalization, surgical operation, or other special medical treatment), number of hospitals where the perpetrator brought the victim to treat for symptoms, loss of educational opportunity and interaction with peers, presence of a medical social worker, report to the Child Guidance Center (CGC: CGC plays a significant role to protect children by making systematic inquiries and decisions from a child social worker’s viewpoint, giving necessary guidance to children’s guardians, and authorizing arrangements for the temporary custody of children by foster parents or for the entry of disadvantaged children into residential welfare facilities), involvement of the CGC, involvement of any other institutions, and disposition (i.e., treatment of victims after detection of MSBP by the CGC).
Ethical issues
In order not to violate ethical issues, we collected this information without any identifying data, such as name or date of birth of the perpetrator or the victim. This survey passed the Institutional Review Board of National Center for Child Health and Development.
Results
Twenty-one cases were identified: 15 confirmed cases and 6 highly suspected cases. These 21 cases were from 20 families, and 2 cases were siblings and were perpetrated by both the biological mother and father. Therefore, we found 21 victims and 21 perpetrators.
The characteristics of the victims are shown inTable 1. Males were 48% of the sample. More than half of the victims were less than 4 years old when they first visited the hospital. Mean age at which MSBP was confirmed was 4.6 years old (standard deviation (SD) = 3.5 years, range: 0.08–13 years) and mean duration of MSBP abuse was 22.8 months (SD = 16.8 months, range:
1–60 months). Five (23.8%) MSBP victims were also diagnosed with a developmental disorder. Doctors confirmed that the developmental disorders shown among MSBP victims were actual disorders. However, whether the disorder was due to child abuse (e.g., inflicted head trauma) is unknown.
The characteristics of the perpetrators are shown inTable 2. Most of the perpetrators were the biological mothers (90.5%).
The majority of the perpetrators were over 29 years old (60.0%), with 20 years old being the youngest age of a perpetrator in our sample. Six perpetrators (28.6%) were single parents. We had information on 18 of 21 regarding mental disorders, and more than half of the perpetrators (55.6%) had mental disorders such as factitious disorder, dissociative disorder or borderline personality disorder. Interestingly, none of the perpetrators had a medical background, such as nursing, and only one perpetrator had a mother who was a nurse; 11 (52.4%) perpetrators obtained their medical knowledge from doctors they visited or from doctor shopping.
Table 1
Characteristics of victims of MSBP (N = 21)
Characteristics %
Sex
Male 47.6
Age at first visit to a hospital
<1 year old 28.6
1–<4 years old 28.6
4+ years old 42.9
Age at MSBP was confirmed
<1 year old 23.8
1–<4 years old 19.0
4+ years old 52.4
Duration of MSBPa
≤3 months 15.0
4–6 months 10.0
7–12 months 10.0
1–2 years 30.0
2–5 years 35.0
Development disorder
Yes 23.8
aThere is one missing case which is excluded from denominator.
Table 2
Characteristics of perpetrators of MSBP (N = 21)
Characteristics %
Relationship with victim
Biological mother 90.5
Biological father 9.5
Agea
<20 years old 0.0
20–29 years old 40.0
30–39 years old 45.0
40+ years old 15.0
Single parent
Yes 28.6
Mental disorderb
Yes 55.6
DSM Axis I
Factitious disorder 22.2
Dissociative disorder 11.1
Eating disorder 5.6
PTSD 5.6
DSM Axis II
Borderline personality disorder 22.2
Histrionic personality disorder 5.6
No 44.4
Medical backgrounda
No 100.0
Having relatives engaged in health worksa
Yes 5.0
Mother of perpetrator was nurse 5.0
No 95.0
Resources of medical knowledge (not mutually exclusive)c
Doctors they visit 40.0
Doctor shopping 40.0
People who are familiar with disease, but not medical professionals (e.g., patients in waiting room, neighbors who have disease) 13.3
Pharmacological store 6.7
Other 6.7
aThere was one missing case which was excluded from denominator.
bThere were three missing cases which were excluded from denominator.
c There were six missing cases which were excluded from denominator.
Table 3shows characteristics of confirmation methods, classification, and symptoms of MSBP. More than half of the cases were confirmed by separating the parent and child. Produced MSBP consisted of 12 cases (57.1%), while 6 cases were considered simulated (28.6%) and 3 cases (14.3%) were deemed concurrently produced and simulated. The majority of the cases had physical symptoms (85.7%), but 23.8% had psychological symptoms.
Severity of cases, social welfare involvement, and disposition of MSBP are shown inTable 4. Two children had died, and there were 12 life-threatening cases (57.1%); 23.8% underwent unnecessary surgery and 33.3% had unnecessary special medical treatment, such as intravenous hyperalimentation. Approximately 30% of the sample were brought to five or more hospitals. Additionally, approximately 70% of victims suffered from a loss of educational opportunities or interactions with peers. Most of the cases who suffered the loss of interactions with peers were due to repeated hospitalizations which pre- vented the children from attending school. We rarely found cases in which the victims remained at home and were prohibited from attending school by their caregivers. Not all the cases were reported to the CGC. With regards to the dispositions of victims, 57.1% remained with their family after the detection of MSBP. This includes the two dead cases mentioned above;
they died after they returned home. In one victim, the CGC did not separate the child from their parent due to lack of sufficient evidence; however, on the subsequent day of discharge, the child was found dead (unspecified cause). In another case, the CGC decided to follow the child at home; however, the child died by physical abuse.
Discussion
Over a 10-year period of time, we found 21 cases of MSBP in Japan. The victims were young, most of the perpetra- tors were mothers, and the victims often experienced life-threatening danger. Perpetrators were found not to have a medical background and obtained medical knowledge mainly from visits with doctors. This study is the first to exam- ine the characteristics of MSBP within Japanese culture, which is industrialized similar to the UK or the US, but has a
Table 3
Characteristics of confirmation, classification, and symptoms of MSBP (N = 21)
Characteristics %
Confirmation
Confirmed 71.4
Highly suspected 28.6
Reasons why MSBP was suspected
Unusual course of illness 38.1
Witness of perpetration 9.5
Improvement when mother is absent 4.8
Discrepancy of symptom and explanation 9.5
Medical evidence which imply symptoms were produced by someone (e.g., injection of foreign materials) 9.5
Information from other hospital 4.8
Discrepancy of information of illness of the child from school and caretaker 14.3
Other 9.5
MSBP confirmation method
Separation 57.1
Observation of victim 19.0
Other 23.8
Location of victim when MSBP was confirmed
Hospitalized 66.7
Home 19.0
Other 14.3
Classification of MSBP (simulated or produced)
Simulated 28.6
Produced 57.1
Simulated and produced 14.3
Type of physical/mental symptoms (not mutually exclusive)
Physical symptoms 85.7
Gastrointestinal symptoms 57.1
Epilepsy/seizure 23.8
Sepsis 9.5
Diabetes inspidus 9.5
Psychological symptoms 23.8
PTSD 9.5
Behavior or conduct problems 14.3
different health care system that is egalitarian, low-cost, and easy to access. This indicates that MSBP incidence spans cultures.
MSBP victims in Japan have similar characteristics to MSBP victims reported in the literature. According to two review articles of MSBP (Rosenberg, 1987; Sheridan, 2003), sex of victims were roughly equal and victims were of a younger age. Mean duration of MSBP was also compatible; 22.8 months in our study and 21.8 months inSheridan’s review (2003). However, we found that a significant percentage (23%) of MSBP victims were also diagnosed with some form of developmental disorder, whereasSheridan (2003)’s review article showed that 5.7% had developmental delay and 10.4% had behavioral problems. A higher percentage of developmental disorders among MSBP victims in Japan might be a unique feature of the country.
We found that MSBP perpetrators in Japan were mostly biological mothers (90.5%), and tended to have additional concur- rent mental disorders (55.6%), which is consistent with previous review articles (Rosenberg, 1987; Sheridan, 2003). However, we found that the perpetrators were not likely to have a medical background, which is not consistent with previous studies (Rosenberg, 1987; Sheridan, 2003). Our finding that a lower percentage of perpetrators was engaged in healthcare work might be reflecting a lower employment rate among females in Japan when compared to the UK or the US; however, the female employment rate among Japan, the UK, and the US is comparable (63.9% in Japan, 73.8% in UK, and 72.3% in US, in 2002) (Organization For Economic Co-operation and Development, 2006). The characteristic of MSBP perpetrators as lack- ing a medical background might be related to the distinct health care system in Japan. Japan has an egalitarian health care system and citizens are able to access any hospital or clinic they choose (Ikegami & Campbell, 1999). In the UK, they also provide equal health care to citizens, but the main difference from Japan is the presence of a primary physician system.
In this system, doctor shopping is not so easily done, as they cannot visit hospitals directly without referral from a general practitioner. Therefore, not only is egalitarian health care a factor, but also universal “access” of health care, might be affecting the characteristics of perpetrators of MSBP in Japan.
Symptoms of MSBP found in this study were also similar to previous studies: gastrointestinal symptoms were the majority.
Percentage of dead cases due to MSBP in our study was 9.5%, which is comparable to previous review articles (Rosenberg, 1987;Sheridan, 2003). The relatively high risk of life-threatening danger of MSBP should be considered among those who are involved in the care of MSBP victims.
Table 4
Characteristics of medical severity, social welfare involvement, and disposition of MSBP (N = 21)
Characteristics %
Existence of life-threatening danger
Died 9.5
Yes 23.8
Possible 33.3
No 33.3
Medical treatment Hospitalizationa
Yes 85.0
≤3 months 45.0
4–6 months 15.0
7–12 months 20.0
>1 year 5.0
No 15.0
Surgical operation
Yes 23.8
Number of hospitals
1 hospital 19.0
2–4 hospitals 52.4
≥5 hospitals 28.6
Loss of opportunity due to MSBP
Loss of educational opportunity 71.4
Loss of interaction with peers 66.7
Social welfare
Presence of a medical social worker 38.1
Report to the CGCb 85.7
Involvement of the CGCb 90.5
Involvement of other institution 66.7
Disposition
Separation 42.9
Remained with family 38.1
Remained with family→ Died 9.5
Remained with family→ Separation 9.5
aThere is one missing case which is excluded from denominator.
bCGC refers to Child Guidance Center.
A limitation of our study is the data collection method. This study did not report on all the cases of MSBP in Japan, so we cannot calculate the incidence of MSBP. In addition, we might have observed different characteristics of MSBP if we were able to include all MSBP cases in Japan. As the collected cases were confirmed or highly suspected cases by leading doctors in the field of child abuse in Japan, the characteristics of MSBP cases in this article could be considered as probable features of MSBP in Japan.
In order to prevent further MSBP deaths, functions of the CGC should be reconsidered. In Japan, the CGC plays a similar role to child protective services available in the UK or US; the CGC can make decisions regarding custody for an abused child. We must encourage the CGC to be cautious when deciding the circumstances of MSBP victims in order to decrease the number of dead cases.
In conclusion, similar characteristics of MSBP were found among cases in Japan in comparison to other English-speaking countries such as the UK and the US. Perpetrators of MSBP in Japan did not possess a medical background and universal access to hospitals may provide greater opportunities for perpetrators to ascertain medical knowledge from doctors or nurses when they visit. The relatively high risk of life-threatening danger of MSBP in their family of origin should be considered by social welfare services that need to decide on custody for MSBP victims.
Acknowledgment
We appreciate Mr. Kazuhiko Abe, Dr. Yuko Inagaki, Dr. Nario Inoue, Dr. Satoru Oishi, Dr. Miyako Shirakawa, Dr. Osamu Soma, Dr. Toshiro Sugiyama, Mr. Satoru Nishizawa, Dr. Takahiro Hoshino, and Dr. Shinya Miyamoto for their cooperation of this study. We thank Dr. Ronald G. Barr and Miss Haley Tsui, who assisted with the proof-reading of the manuscript.
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