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Munchausen syndrome by proxy (MSbP or MbP) is a behaviour pattern in which a caregiver fabricates, exaggerates, or induces mental or physical health problems in those who are in their care. With deception at its core, this behaviour is an elusive, potentially lethal, and frequently misunderstood form of child abuse or medical neglect that has been difficult to define, detect, and confirm. MSbP has also spawned much heated controversy within the legal and social services communities. In a handful of high-profile cases, mothers who have had multiple children die from sudden infant death syndrome have been declared to have MSbP. Based on MSbP testimony of an expert witness, they were tried for murder, convicted, and imprisoned for several years. In some cases, that testimony was later impeached, resulting in exoneration of those defendants.〔 ==Signs and symptoms== In Munchausen syndrome by proxy, an adult caregiver makes a child appear mentally or physically ill or impaired by either fabricating symptoms or actually causing harm to the child, in order to gain the attention of medical providers and others. In order to perpetuate the medical relationship, the caregiver systematically misrepresents symptoms, fabricates signs, manipulates laboratory tests, or even purposely harms the child (e.g. by poisoning, suffocation, infection, physical injury).〔 Studies have shown a mortality rate of between 6% and 10% of MSbP victims, making it perhaps the most lethal form of abuse. A review found the average age of the person affected at diagnosis was 4 years; slightly over half of were aged 24 months or younger, and 75% were under six years old. The average duration from onset of symptoms to diagnosis was 22 months. Six percent were dead, mostly from apnea (a common result of smothering) or starvation and 7% suffered long-term or permanent injury. About half of them had siblings; 25% of the known siblings were dead, and 61% of siblings had symptoms similar to the victim or that were otherwise suspicious. The mother was the perpetrator in 76.5% of the cases, the father in 6.7%.〔 In the above study, most presented with about three medical problems in some combination out of 103 different reported symptoms. The most frequently reported problems are apnea (26.8% of cases), anorexia / feeding problems (24.6% of cases), diarrhea (20%), seizures (17.5%), cyanosis (blue skin) (11.7%), behavior (10.4%), asthma (9.5%), allergy (9.3%), and fevers (8.6%).〔 Other symptoms include failure to thrive, vomiting, bleeding, rash and infections.〔 Many of these symptoms are easy to fake because they are subjective. For example, reports that "my baby had a fever last night" are impossible to prove or disprove. The number and variety of presented symptoms contributes to the difficulty in reaching a proper MSbP diagnosis. The primary distinguishing feature that differentiates MSbP from "typical" physical child abuse is the degree of premeditation involved. Whereas most physical abuse entails lashing out at a child in response to some behavior (e.g. crying, bedwetting, spilling food), assaults on the MSbP victim tend to be unprovoked and planned.〔 Also unique to this form of abuse is the role that health care providers play by actively, albeit unintentionally, enabling the abuse. By reacting to the concerns and demands of perpetrators, medical professionals are manipulated into a partnership of child maltreatment.〔 Challenging cases that defy simple medical explanations may prompt health care providers to pursue unusual or rare diagnoses, thus allocating even more time to the child and the abuser. Even without prompting, medical professionals may be easily seduced into prescribing diagnostic tests and therapies that are at best uncomfortable and costly, and at worst potentially injurious to the child.〔 If the health practitioner instead resists ordering further tests, drugs, procedures, surgeries, or specialists, the MSbP abuser makes the medical system appear negligent for refusing to help a poor sick child and their selfless parent.〔 Like those with Munchausen syndrome, MSbP perpetrators are known to switch medical providers frequently, until they find one that is willing to meet their level of need; this practice is known as "doctor shopping" or "hospital hopping". The perpetrator will continue the abuse because maintaining the child in the role of the patient satisfies the abuser's needs. The cure for the victim is to separate the child completely from the abuser. When parental visits are allowed, sometimes there is a disastrous outcome for the child. Even when the child is removed, the perpetrator may turn their attention to another child: a sibling or other child in the family.〔http://www.aacn.org/WD/CETests/Media/C106.pdf〕 More recently a psychiatric form of MSbP has been postulated - Psychiatric Munchausens Syndrome By Proxy - which involves the presentation of a psychiatric disorder in the child. Munchausen by Proxy can also have many long-term emotional effects on a child. Depending on their experience of medical interventions, a percentage of child victims may learn that they are most likely to receive the positive maternal attention they crave when they are playing the sick role in front of health care providers. Several case reports describe Münchausen syndrome patients suspected of themselves having been MSbP victims. Seeking personal gratification through illness can thus become a lifelong and multi-generational disorder in some cases.〔 In stark contrast, other reports suggest survivors of MSbP develop avoidance of medical treatment with post traumatic responses to it. This variation possibly reflects broad statistics on survivors of child abuse in general, where around 30% go on to also become abusers〔http://www.ncbi.nlm.nih.gov/pubmed/11731348〕 even though a significant percentage do not. The adult care provider who is abusing the child often seems comfortable and not upset over the child's hospitalization. While the child is hospitalized, medical professionals need to monitor the caregiver's visits in order to prevent any attempt to worsen the condition of the child. In addition, in many jurisdictions, medical professionals have a duty to report such abuse to legal authorities.〔Elder W, Coletsos IC, Bursztajn HJ. ''Factitious Disorder/Munchhausen Syndrome''. The 5-Minute Clinical Consult. 18th Edition. 2010. Editor: Domino F.J. Wolters Kluwer/Lippencott. Philadelphia.〕 Warning signs of the disorder include:〔 * A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling, and unexplained. Caused and/or portrayed/brought on by caretaker; particularly mother. * Physical or laboratory findings that are highly unusual, discrepant with patient's presentation or history, or physically or clinically impossible. * A parent who appears to be medically knowledgeable, fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and expresses interest in the details of other patients' problems. * A highly attentive parent who is reluctant to leave their child's side and who themselves seem to require constant attention. * A parent who appears to be unusually calm in the face of serious difficulties in their child's medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, second opinions, and transfers to other more sophisticated facilities. * The suspected parent may work in the health care field themselves or profess interest in a health-related job. * The signs and symptoms of a child's illness do not occur in the parent's absence (hospitalization and careful monitoring may be necessary to establish this causal relationship). * A family history of similar or unexplained illness or death in a sibling. * A parent with symptoms similar to their child's own medical problems or an illness history that itself is puzzling and unusual. * A suspected emotionally distant relationship between parents; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with a serious illness. * A parent who reports dramatic, negative events, such as house fires, burglaries, or car accidents, that affect them and their family while their child is undergoing treatment. * A parent who seems to have an insatiable need for adulation or who makes self-serving efforts for public acknowledgment of their abilities. * A patient who inexplicably deteriorates whenever discharge is planned. Caution is required in the diagnosis of MSbP/FII/FDP. Many of the items above are also indications of a child with organic, but undiagnosed illness. An ethical diagnosis of MSbP must include an evaluation of the child, an evaluation of the parents, and an evaluation of the family dynamics. Diagnoses based only on a review of the child's medical chart can be rejected in court. 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「Munchausen syndrome by proxy」の詳細全文を読む スポンサード リンク
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