Program: Munchausen by Proxy: when parents hurt their kids

Professor Brenda Bursch: You know, like many people, even today, it was mind-blowing to imagine that somebody could falsify medical illness so successfully that clinicians, physicians, would treat that child, you know, with very sometimes intrusive types of treatments and not ever suspect that they were being misled. I found that just unbelievable, but then also as a psychologist, of course, incredibly fascinating.

Sana Qadar: Back in the early 90s, Brenda Bursch was a brand new baby psychologist. At that point in time, she didn't know much about Munchausen by proxy. It had never been mentioned in her university psychology courses, and it wasn't until her internship year that she even first heard the term.

Professor Brenda Bursch: I had never heard the term before, as most people had not at that point in time.

Sana Qadar: But then, early in her clinical rotations in a pediatrics ward, Brenda was thrown into the Munchausen by proxy deep end.

Professor Brenda Bursch: I had a supervisor who had had quite a number of cases of Munchausen by proxy, and in fact, there was one that had just come into the hospital at the time that I rotated over there. And interestingly, it was his first case seven years earlier. It had resurfaced because he came to learn that the judge had ultimately sent this child back into the care of her mother.

Sana Qadar: This child was a young girl, a 10-year-old, and this was an extreme case. Because when her mother had first come to the attention of doctors seven years earlier, it was discovered that one of the lies she was telling was that her daughter would have episodes where she would stop breathing.

Professor Brenda Bursch: She had been falsifying the illness in her daughter her whole life, and the mother was a licensed respiratory therapist. So not only did she know the language to use, but she also knew what kind of symptoms to report to steer the doctors towards a particular diagnosis. And so she actually, when she was quite young, at one point, had a tracheotomy, so a hole in her throat, attached to a breathing machine 23 hours a day. The child had no medical problem. The mother was so convincing that the clinicians believed her. And so that's an example, you know, of how severe of a case it was.

Sana Qadar: This is All in the Mind. I'm Sana Qadar. Munchausen by proxy is a form of child abuse where a parent or caregiver lies about a child being sick, or intentionally makes their child sick. Rightly or wrongly, these kinds of cases seem to captivate the public imagination.

Professor Brenda Bursch: It's so hard to relate to. You can't imagine doing that yourself. You can't imagine somebody doing that to you. And so it requires a lot of thought to try to unravel that. And it's kind of a mystery.

Sana Qadar: And the question everyone wants to know is why? What would drive a mother, and it's usually mothers, to hurt their child in this way?

Dr Jon Jureidini: We think of this kind of abuse as something that happens between usually the mother and the child. But there's a third party in every case, and that's the medical system. And in every case of this kind of abuse, the medical system has got things wrong.

Professor Brenda Bursch: I mean, I think it taps a similar fascination people might have with serial killers or something like that, right? Are they evil or are they damaged? Are they both? Where do you categorize that? How do you process that?

Sana Qadar: These questions about motivation, drivers, psyche, they're the kinds we're aiming to answer not just in today's episode, but over the next few as part of our new four-part series on All in the Mind called Criminal Psychology. We'll be looking at extreme behaviors from Munchausen by proxy to arson and pyromania to theft and kleptomania.

Clip from upcoming episode: I've never been caught and I hope to let it stay that way.

Sana Qadar: Because yes, there is a natural curiosity out there about this kind of stuff. But it's also only through understanding the why and how of extreme behaviors that you can better protect people from harm and improve prevention and treatment. So today, it's episode one of Criminal Psychology on All in the Mind, the drivers and devastation of Munchausen by proxy.

Professor Brenda Bursch: My name is Dr. Brenda Bursch. I am a medical psychologist on faculty at UCLA in the departments of psychiatry and pediatrics. I've spent over 30 years working in the inpatient setting and since the beginning also have worked forensically, so have been hired by Child Protective Services to act as an expert in court cases related to Munchausen by proxy.

Sana Qadar: When Brenda first came across that 10-year-old girl whose mother had previously lied about her breathing issues, she was unsurprisingly shocked. But she was also confused. And really, there were a whole range of emotions over many years because Brenda ended up being that girl's therapist until she was 18. And they're still in touch.

Professor Brenda Bursch: When she was 10, she was no longer attached to a breathing machine, but she was in a wheelchair and she was on three different anti-epileptic medications because, you know, the mom had fabricated epilepsy. And she believed she was deaf, so she signed. And she had no medical problems. You know, kids who have medical problems underneath are actually at somewhat higher risk. So, have plenty of kids that maybe they have a problem at baseline, but the parent makes it worse either by exacerbating it or by withholding medication or doing things to manipulate it. In this particular case, at baseline, there was absolutely nothing wrong with this child. So, not only was she vastly over-medicalized, but her mom home-schooled her. Her mom did Girl Scouts with her. She had no outside influence outside of her immediate family and no friends.

Sana Qadar: I mean, this is abuse, isn't it?

Professor Brenda Bursch: Oh, it's extreme abuse. It's extreme abuse. I mean, because if you think about it, if you are, you know, normally when we think about child abuse, we'll think about a parent who maybe comes home drunk and hits their kid or something like that. In those situations, it's usually episodic. And the kids become very attuned to, oh, well, when, you know, dad comes home drunk, you know, I need to like stay real low-key. I need to lock myself in my room. And then when they're at school or in another place, they can feel safe. But when you are a victim of Munchausen by proxy, there's no break from it. Because the abuser not only lies to the physicians, but to everybody in the sphere of that child's life, including the child. So everybody treats them as if they're more ill or impaired than they are. And, you know, the child believes it.

Sana Qadar: One of the problems with Munchausen by proxy is there have been many cases that have been documented in the media.

Various news clips: The mother has been charged with deliberately harming her daughter... Throughout Gypsy Rose's adolescence, Dee Dee claimed falsely that her daughter suffered from leukemia.

Sana Qadar: And in the academic literature. But it's still really hard to know how rare or common these cases are, or how many might fly under the radar.

Dr Jon Jureidini: We don't really know. There were surveys done maybe 15 or 20 years ago that tried to establish the prevalence of it.

Sana Qadar: This is Dr. Jon Jureidini.

Dr Jon Jureidini: I'm a child psychiatrist and have a career-long interest in child protection issues, in particular what's been called Munchausen by proxy.

Sana Qadar: He works in Adelaide. And when it comes to prevalence, here's how he summarizes it.

Dr Jon Jureidini: I think the best way of thinking about it is that in a big pediatric center, one of the major capital city children's hospitals, it would be on average maybe one or two cases a year.

Sana Qadar: And one of the reasons it's hard to research Munchausen by proxy and get a clear sense of prevalence is because of the very nature of the perpetrators.

Professor Brenda Bursch: These are people who are master deceivers, right? So you can't send out a survey and say, do you have this? And they're actively deceiving a lot of the medical system already. So we can't ask physicians, like, how many do you have? We can say, how many do you know you've seen? But it's really not very solid research.

Sana Qadar: In a word on the name Munchausen by proxy, clinically, officially, it's called factitious disorder imposed on another. And that's what you'll find in the DSM, the Diagnostic and Statistical Manual of Mental Disorders. However, in popular culture, the original term Munchausen by proxy remains the name people are most familiar with. So you're going to hear both terms throughout this episode. And if you're wondering where that name comes from, it was coined back in 1977 by a British doctor named Roy Meadow. Yes, Meadow, not Munchausen. And he named it as an extension of Munchausen syndrome, which itself was coined back in 1951 to refer to people who lied about medical illness in themselves. The doctor who named that was Richard Asher. Again, not Munchausen. So where does Munchausen come from? Well, a German historical figure, of course.

Movie clip "The Adventures of Baron Munchausen": I'm Baron Munchausen....

Sana Qadar: Baron Munchausen was a real person who lived in the 1700s, but he was later fictionalized in a novel and then much later in a film. And his shtick was telling tall tales, exaggerated stories like fighting a 40 foot long crocodile or traveling to the moon. Clearly fantastical stuff, but the tall medical tales that parents tell in cases of Munchausen by proxy, they often get believed. And so the question remains, what motivates people to tell tall medical tales? Like the mother of that 10 year old that Brenda Burse treated early in her career.

Professor Brenda Bursch: You know, I have treated abusers in the past. And so, you know, I've gotten some insight from other abusers. I did not treat this mother. So I don't know for her, but I can say that she was very severe on that, you know, in her psychopathology. And she at one point said that she would rather never see her daughter again than ever acknowledge that she did something wrong.

Sana Qadar: Oh my goodness.

Professor Brenda Bursch: And that's something I've heard more than one time from abusers.

Sana Qadar: Why? That's incredible.

Professor Brenda Bursch: You think about somebody who has a normal attachment to their child, and they're in danger of losing that child. They would just lie to not lose that connection. They would say, fine, I'll do whatever you say. I'll take parenting classes. I just want my child back. That's what parents who have a normal attachment to their child would probably on average do. But it's interesting and really reflective of how the narrative is way more important to these individuals than the actual relationship.

Dr Jon Jureidini: So for somebody to perpetrate this kind of medical abuse on a child, then they have to be somebody who puts their own needs ahead of the needs of their children.

Sana Qadar: This is Adelaide-based child psychiatrist Jon Jureidini again.

Dr Jon Jureidini: And who gets some kind of perverse gratification either from the direct effect of harming their child in a kind of sadistic way, or more commonly, I think, some gratification from the interaction with the medical system.

Professor Brenda Bursch: Think of it almost like an addiction to sometimes it's a medical setting. Sometimes it's to being thought of as a caring parent. Sometimes it's, you know, besting the doctor. Sometimes it's creating chaos.

Dr Jon Jureidini: Feeling really good about being a special person within the medical system or pulling the wool over the eyes of people who are supposed to be very smart.

Professor Brenda Bursch: The most common thing you do see is a desire for attention and affection. So in our culture, moms are revered and thought of very positively. And if you're a mom of an ill child, then you're a saint.

Sana Qadar: Each case can be quite different though, and John does caution that there isn't a single explanation for what motivates this kind of abuse.

Dr Jon Jureidini: Because the circumstances and motivations are different from case to case.

Sana Qadar: But other common themes that pop up are that often, though not always, parents have some sort of medical background, like the mother of Brenda's patient, who was a respiratory therapist. They've also often experienced abuse themselves as children. And often, though again, not always, they've also lied about their own health.

Professor Brenda Bursch: 40% or more of these individuals also falsify illness in themselves.

Dr Jon Jureidini: There can be a link through pregnancy. So that we've seen cases where mothers have fabricated symptoms and illnesses during their pregnancy. And that's kind of a bridge into doing the same thing with their children.

Sana Qadar: What all of this leaves me wondering is whether there's also often a personality disorder at play.

Professor Brenda Bursch: Almost always. You know, and I should mention that when I'm talking about this, I'm talking about Munchausen by proxy. And again, so psychiatrically, that would mean factitious disorder imposed on another. And the most common comorbidity, which means a co-occurring diagnosis, psychiatrically, is a personality disorder.

Sana Qadar: That could be something like borderline personality disorder, which is characterized by extreme mood swings, unstable relationships, impulsiveness, and an extreme fear of abandonment. Or histrionic personality disorder, which is characterized by a pervasive pattern of extreme attention-seeking behavior, unstable emotions, and exaggerated emotional displays. But Brenda says there isn't actually much data on which personality disorders are most common in these cases. And the limited studies that exist suggest it's often a mixed personality disorder, with a combination of antisocial, borderline, histrionic, and anxious traits all rolled in. All of that can make it quite tricky to figure out what exactly is going on when there is a suspected case of Munchausen by proxy.

Professor Brenda Bursch: You know, there are some times when I do get referrals, either clinically or forensically, where people are, they might call it Munchausen by proxy or a suspected Munchausen by proxy. But then when you start looking at it, it's something that might lead to over-medicalization, maybe even abusive. But it's not due to that. So it could be due to somebody trying to get opiates for themselves or get custody of their child or money in some way. So external rewards. And that would be called malingering. That's just malingering. It's not a psychiatric disorder.

Sana Qadar: But if you are dealing with a case of Munchausen by proxy, so a parent with factitious disorder imposed on another, one thing those parents aren't is delusional.

Professor Brenda Bursch: These people might not appreciate always, there's this cognitive slippage that causes them to not always appreciate the harm. But they know they are putting poison in a soda that they can't tell anybody that's what's causing their child to vomit. So you can have a delusion and over-medicalize your child and that can be abusive. And we need to intervene there too. But that is something different than Munchausen by proxy. So part of what, you know, my job was to do is to try to sort all that out. At the pediatrician level, they don't need to sort any of that out. If there's a child who they discover is being over-medicalized and it's abusive and that that child needs to be protected, they have this requirement to report that. And then it's later when we're trying to figure out potential risks, you know, in the future, treatment approaches. Then it becomes really important to understand what is the thing that was driving it.

Sana Qadar: This is All in the Mind. You're listening to our new four-part series called Criminal Psychology. Today, it's episode one on Munchausen by proxy. Now, the vast majority of these kinds of cases involve mothers. It's not entirely clear why, but Jon has some guesses.

Dr Jon Jureidini: The mother has born the child. So maybe that means they've got more of a, you know, in a damaged person, that might mean that they treat the child like a possession, but that's all speculative.

Sana Qadar: And while there are cases involving fathers,

Professor Brenda Bursch: I've come across fathers, I've come across foster parents. That is just so much more rare. There was one father, I think one father who was a physician.

Sana Qadar: A doctor. Wow.

Sana Qadar: And so, is what motivates fathers quite different to what motivates mothers? Or not so much?

Professor Brenda Bursch: Good question. Don't know the answer to that. I haven't treated a father, so I can't say. I do know, in addition to primary abusers who are male, there are a lot of dads who get pulled into the dynamic and participate either passively or actively under threat. So, for example, the 10-year-old girl I talked about in the beginning, her father was threatened that if he didn't go along with the program, the mom said that she would kill our daughter.

Sana Qadar: Oh, gosh.

Professor Brenda Bursch: You know, there'd be threat of abandonment, threat of harm, threat of some sort of custody retaliation. So there can be coercion. And then in other situations, there can also be dads who are just like not really tracking, not really aware of what's going on, or not knowing how to label it and not wanting to anger their spouse. So kind of just keeping low profile about it.

Sana Qadar: Given how insidious and pervasive and debilitating, not to mention fatal, this kind of abuse can be, how do you treat a parent who's done this to their child? Can they be reformed?

Professor Brenda Bursch: Well, I mean, being generous, my law enforcement colleagues don't like it when I'm generous because they are very wanting to protect the victims, which I appreciate. But, you know, because I've treated the perpetrators, I have empathy for them, too. At least the ones I know and that I've treated, I feel like they themselves are in some kind of hell themselves. They, you know, they have gotten there for a reason. Some of it might be biology. Some of it might be environment that they grew up in. But they're trying to survive. This is how they figured out how to do it. And they're trapped in it. Now, trust me, there are some perpetrators that I have assessed through CPS who I firmly believe, like, they just need to be locked up for a long, long time until they cannot have children anymore. Because their behavior is so heinous and so repetitive and so impossible to alter that the only recourse is to protect people from them.

Sana Qadar: But for those who are on the less severe end of the spectrum, who have a chance of changing their behaviour,

Professor Brenda Bursch: You know, the psychologist in me, I try to find an angle. I try to find an in. And I try to find a way to, you know, connect with them without being misled by them, without being pulled into their narrative.

Sana Qadar: And for there to be any chance of reform, both Brenda and Jon say there is one big hurdle these parents need to pass first off.

Dr Jon Jureidini: The first step is to have the parent acknowledge at least some level of responsibility for what's happened. We don't expect parents to immediately take full responsibility for what they've done or acknowledge what they've done. But the starting point for therapy has to be at least some level of acknowledgement.

Professor Brenda Bursch: And one of the challenges is that you often are starting at a place where they're like, I was just following the doctor's instructions. I, you know, I didn't make the diagnosis. I didn't give the medical treatment. So a lot of deflection of responsibility. And to move from there to a place where you can accept some responsibility is a long ways to move.

Sana Qadar: But if they can manage that move.

Dr Jon Jureidini: Then it's a process of ongoing confrontation. It's a process of helping the parent come to terms with a more detailed analysis of what they've done. At the same time as recognising harms that have been done to them over the years, difficult circumstances that they might be in that are contributing to the behaviour. And what we're always looking for is does this person have or can they develop parenting capacity, which is being able to recognise the child's needs and give absolute priority to those needs over their own. And by definition, in this kind of abuse, there's been a failure to give priority to the child's needs.

Professor Brenda Bursch: And along that way, even among people who admit it, sometimes they'll just admit a small part of it and not really get as comprehensive as they need to be to be, you know, a safe parent moving forward. So when you look at the big picture, the goals are to help them acknowledge what they've done and kind of understand what drove them to do it so that they can better identify earlier. Some of the warning signs like stress and things like that that might make them relapse, help them have better coping skills themselves, have an identity outside that of being the parent of an ill or disabled child. So there's a variety of steps that are taken both to improve the psychological functioning of the abuser and also to put safety rails around them because the rate of relapse is rather high.

Sana Qadar: Yeah, I was going to ask with the people you've worked with, who've perpetrated this kind of abuse, what percentage would you say land in that best case scenario of reformed behaviour and all the rest?

Professor Brenda Bursch: I think there's a spectrum of severity. And then the therapists that they end up with have a spectrum of experience, knowledge or skill in helping them. And so partly depends on where they fall on that spectrum and what kind of treatment they get. And for example, I had one mom that I treated who was poisoning her child. And she used to poison herself. And then when she stopped getting attention for that, she started poisoning her child. And she knew what she was doing was wrong. But in her mind, she thought it was safe because her daughter wasn't truly ill and she had control over it. So even though her daughter was violently throwing up in front of her, her attachment to her child was disrupted in a way that she did not have empathy for that. She did not connect to the suffering. In her situation, I saw her for many years as well. And she did get to a point where she suddenly, it clicked for her. She saw what she was doing, which was devastating when she was able to connect with that and see that, my gosh, her daughter could have died easily. You know, that was like a revelatory to her when she finally was able to make that connection and devastated her. She was like psychiatrically a mess for quite a while during that part of her treatment. She got to a place where, you know, I would think of her as good enough, but she still, it's just like, you know, it's kind of like when they say, once an alcoholic, you're kind of always an alcoholic. She still would get jobs like working in the front office of a pediatrician's office. Or she would like ask her friends if she could just go to their kids' pediatric appointments with them. And she wouldn't report symptoms or anything. She just liked being in the setting. She just liked being there. So I think, I thought of her as a dry drunk. She's an example of someone who made a lot of progress, but, you know, she still had the disorder. She just wasn't acting on it.

Sana Qadar: It is incredible to think that people can get away with these lies about their children at all, let alone for years, as is sometimes the case.

Professor Brenda Bursch: There have been kids who've received intestinal transplants based on false reports alone.

Sana Qadar: How is that possible? How can doctors, nurses, so many people be misled?

Dr Jon Jureidini: We think of this kind of abuse as something that happens between the mother and, or usually the mother and the child. But there's a third party in every case, and that's the medical system. And in every case of this kind of abuse, the medical system has got things wrong. And often that's understandable because we've been presented with inaccurate information. But most cases that I've seen could have been prevented or at least attenuated by good medical practice. So if we think about some of the problems of modern medicine, over-investigation, lack of careful history-taking, lack of building relationships, then many of those problems contribute to the possibility of perpetrating this kind of abuse in the medical system.

Sana Qadar: Jon says it would be helpful if more medical professionals adopted a position of what he calls respectful scepticism.

Dr Jon Jureidini: I think it's important that when doctors encounter things that don't quite make sense, to have in their mind the possibility that they may not be being presented with accurate information, whether deliberately or unwittingly, and to not feel shy about pursuing that line of inquiry.

Professor Brenda Bursch: One thing I would say is that somebody brings it up as a possibility related to one of your beloved patients. Don't just shut that down right away. Recognize that anybody, including me, can be completely misled. I mean, the number of times I've done my clinical interview before, I looked at the data and thought, oh, they're lovely. Surely they didn't do this. And then I see the data and I'm like, oh, wow, holy cow. So just respect a colleague who brings it up, recognize that it's very difficult to bring up, and try to keep an open mind and try to be very scientific about it. Sure, we have rare cases. We have extreme cases of genuine medical problems. But does this just not make sense? Have you seen them lie? Have you seen them be deceptive about other things? Is there more than one child in the family with similar symptoms that are not thought to be genetic? Like, how would that be possible? So really think about statistics. How likely is this? And I think that's where you start.

Sana Qadar: Now, I want to end this episode where we started, which is with Brenda's first case of Munchausen by proxy involving that 10-year-old girl. She is now in her 40s, and Brenda and her are still in touch. And so I wanted to ask what her life was like now.

Professor Brenda Bursch: Watching her, I'll start at the beginning, you know, watching her when she was 10, going from someone who was her whole life chronically ill and believing it, to becoming fairly normative 12-year-old, 14-year-old, 16-year-old was kind of miraculous. And it was interesting because she, in addition to making all this physical progress, you know, walking again, realizing she's not deaf, everything she hears is what everybody else hears. She doesn't need to sign. Going to school for the first time, learning all the rules associated with being in school, and growing up in Southern California and never having had a suntan before, and becoming just joyful about how bizarre it is to have a suntan, and, you know, just huge joy associated with all of these discoveries for her. Confusion in the beginning because none of it made sense, and anger that she was taken away from her family who she depended on so much.

Sana Qadar: Luckily for this girl, she ended up in a really positive foster care environment, and that just made all the difference. Because it gave her the chance to develop secure attachments.

Professor Brenda Bursch: She, you know, she's been able to go on and have relationships, be employed, and have her own daughter who's healthy. It's kind of a miracle.

Sana Qadar: Does she still have a relationship with her mother?

Professor Brenda Bursch: She has some empathy for her mother because she sees how very ill her mother has been. But, no, no, there's no trust. It's not like she was going to be having her mother babysit for her kid or anything like that. There's no way that was going to happen.

Sana Qadar: So while this woman's story is a pretty positive ending for what was such an extreme case of Munchausen by proxy, Brenda says that's not the usual outcome.

Professor Brenda Bursch: From what we can tell, kids, particularly if they are not in really sustained, integrated therapy with a good support system, many of them, when they turn 18, they want to go back. And so if that parent, in the meantime, has also not gotten good treatment, then they can just fall right back into pretty disturbing, dysfunctional patterns, including abuse.

Sana Qadar: That is all in the mind for this week. Next week, episode two of our new series, Criminal Psychology, we'll dive into arson, and specifically, pyromania.

Clip from upcoming episode: Thinking from Freud was that people would be aroused by fire because they would have repressed sexual urges and would want to extinguish the fire to release those repressed sexual urges.

Sana Qadar: We'll find out if Freud was onto something or not, and how often pyromania is involved in cases of arson. For this episode, I want to say thank you to medical psychologist Dr. Brenda Bursch, child psychiatrist Dr. Jon Jureidini, and I also want to say thank you to Detective Mike Weber in the US, who we spoke to as part of the research for this episode. He's the co-author of a book called The Mother Next Door, Medicine, Deception, and Munchausen by Proxy. Thanks also to producer Rose Kerr, senior producer James Bullen, and sound engineer John Jacobs. I'm Sana Qadar. Thank you for listening. I'll catch you next time.