Issues in the identification and long-term management of Munchausen by Proxy Syndrome within a clinical infant service

Munchausen by Proxy Syndrome is a version of Munchausen's Syndrome whereby a parent, usually the mother, simulates or fabricates disease in one or more of her children in order to seek medical attention. Because this disorder is usually identified in pediatric settings, current literature focuses on identification of the syndrome, with little discussion of treatment issues or management strategies other than confrontation of the parent and removal of the child from the home. With the increased availability of infant mental health services, infant clinicians are likely to be called on to evaluate and treat cases of this disorder. This paper reviews the Munchausen by Proxy literature for infant clinicians and describes the identification and long-term management of one Munchausen by Proxy case within the context of an infant home-visiting service. Pertinent issues that emerged included the difficulties inherent in documenting the mother's pathological behavior, the clinical tension between preventing flight from treatment but limiting harmful behavior, the need for a long-term collaborative relationship with a designated pediatrician, and the importance of further education of protective service workers about this syndrome.     

Maternal Role Confusion: Relations to Maternal Attachment and Mother–Child Interaction from Infancy to Adolescence

Self‐reports of role confusion with the parent in childhood are associated with a variety of adverse outcomes. However, role‐confusion has been studied primarily from the point of view of the child. The current study evaluated an instrument for assessing role confusion from maternal interviews rather than from child observations or self‐reports in adulthood. Fifty‐one mothers participating in a longitudinal study since their own child's infancy were administered the Experiences of Caregiving Interview (C. George & J. Solomon, 1996) when the child was age 20. Interviews were coded using the newly developed Parental Assessment of Role Confusion (PARC; L. Vulliez‐Coady & K. Lyons‐Ruth, 2009). Maternal PARC scores were related to observational measures of role‐confusion in interaction with the child both in infancy and late adolescence. PARC scores also were related to mothers’ hostile‐helpless states of mind on the Adult Attachment Interview (C. George, N. Kaplan, & M. Main, 1984, 1985, 1986) and to the extent of Unresolved loss, but not Unresolved Trauma. PARC scores also were related to mothers’ self‐reports of helplessness experienced in the parenting role. Discriminant validity of the PARC was demonstrated in that role confusion on the PARC was not related to hostile or disoriented forms of parent–child interaction. Implications for clinical assessment of role confusion are discussed.     

Risks and Outcomes Associated with Disorganized/Controlling Patterns of Attachment at Age Three in the NICHD Study of Early Child Care and Youth Development

Disorganized/controlling attachment in preschool has been found to be associated with maternal and child maladjustment, making it of keen interest in the study of psychopathology. Additional work is needed, however, to better understand disorganized/controlling attachment occurring as early as age three. The primary aims of this study were to evaluate risk factors and outcomes associated with disorganized/controlling behavior at age three and to evaluate the risk factors and outcomes differentiating the four subtypes of disorganized/controlling attachment. Analyses were conducted with the first two phases of the NICHD Study of Early Child Care and Youth Development, a prospective study of 1,364 children from birth. At 36 months of age, across the attachment-relevant domains of maternal well-being, mother-child interactions, and child social adaptation, the disorganized/controlling group evidenced the most maladaptive patterns in comparison to both secure and insecure-organized groups. At 54 months of age, the disorganized/controlling group displayed the highest levels of internalizing and externalizing behavior problems, as rated by mothers and teachers, and the lowest quality relationships with teachers. Significant differences found among the disorganized/controlling subtypes indicated that the behaviorally disorganized and controlling-punitive subtypes had more maladaptive patterns across variables than did the controlling-caregiving and controlling-mixed subtypes.