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Munchausen Syndrome By Proxy in the cinema. From The Sixth Sens (1999) to A Child’s Cry for Help (1994)

María Lucila Merino Marcos

Departamento de Pediatría del Hospital Universitario de Salamanca (Spain).

Correspondence: María Lucila Merino Marcos. Hospital Universitario. Paseo de S. Vicente s/n. 37007. Salamanca (Spain).

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Received 6 November 2005; accepted 10 December 2005


Summary

One form of child abuse that has been included in the script of several films is the Munchausen syndrome by proxy. The plot of A Child's Cry for Help (1994) portrays a clinical case of this syndrome, while in Chakushin ari/ One Missed Call (2003) it underlies the whole plot, and in The Sixth Sense (1999) it is part of the subplot.

Keywords: Munchausen’s Syndrome by Proxy (MBP), Child Abuse, Child Maltreatment, Paediatric Condition Falsification (PCF), Personality Disorders

Many rare illnesses form the core or are part of the screenplay of some films1. One of them is Munchausen’s Syndrome by proxy, a form of child abuse. The impact of this syndrome in the cinema is scarce. Among the films addressing it in some way are The Sixth Sense (1999) by M. Night Shyamalan, One Missed Call/ Chakushin ari (2003) by Takashi Miike and A Child's Cry for Help (1994) by Sandor Stern. Mama/M.A.M.A. (2003) by Nonny de la Peña and A Boy's Life (2003) by Rory Kennedy and Nick Doob are two documentaries whose interest also focuses on this syndrome.


Munchausen’s Syndrome by Proxy

This is a serious form of child abuse with high rates of recidivism and a high mortality. Those involved are people who take care of the abused child, usually the mother. The perpetrator gives the impression that the child is ill, pretending that he or she has symptoms, or even provoking them, so that the child must be sent to hospital and undergo diagnostic procedures and invasive therapeutic techniques. It involves both the abused and the abuser, who is characterised by not gaining any benefit, unless psychological, from the abuse meted out1,2.

It was described by the British paediatrician Roy Medow in 19773, who gave this name for its resemblance to Munchausen’s Syndrome, which involves people (generally adults) who feign or produce symptoms in order to gain admission to hospital. This syndrome was described in 1955 by Richard Asher, who named it after Baron Von Munchausen, the great narrator of invented stories4. Both of them are included within the sphere of factitious disorders2, characterised by the patient or someone close wanting to give the impression that there is an illness. Munchausen’s syndrome by proxy has attracted huge professional interest; in 2004 alone twenty-one articles appeared in PubMed.

Munchausen’s syndrome by proxy involves two players: the child that suffers the abuse and the person who inflicts it. The American Professional Society on Abuse of Children has proposed that they should be diagnosed respectively as a “paediatric condition falsification” and a “factitious disorder by proxy”1,2.

In most cases the perpetrator is the abused child’s mother. She (or he) nearly always alone or cohabits with a partner who is not really relevant in the relationship and hence contact with doctors can replace this absence of affection. Many such perpetrators have some degree of medical knowledge: they may be nurses, clinical assistants or child carers. This circumstance facilitates not only the actual carrying through the abuse, because they know how it should be done, but -worse- it allows them to continue their tragic actions in hospital, because they gain the confidence of the staff, who then allow them to take care of the child. The apparent dedication they show towards their children leads them to gain the medical staff’s recognition and that of their family, although when they are not being watched, of course, they can continue with their dark deeds. Very often they give a thoroughly detailed and complete case history of their children. Thus, they are undoubtedly psychologically or psychiatrically disturbed. Indeed, they often have personality disorders: factitious, somatoform, narcissistic, histrionic and/or borderline. Many of them suffer from Munchausen’s syndrome or have been victims of Munchausen’s syndrome by proxy in their childhood. It is hard to know why they carry out this type of voluntary, deliberate abuse. One reason that might induce them to do it is the need to use the child as a way to draw the attention of doctors and other health staff. Thus, they assume the role of a patient through another person. Contrary to other types of abuse, in this syndrome the person responsible for the abuse does not gain any profit or benefit for him or herself unless it be psychological1,2,5.

Most children that suffer abuse are less than five years old, and most of them are infants1,2, although even teenagers may be subjected to it5. In most cases, the abuse is directed at two siblings.

The symptoms aimed at calling the medical staff’s attention can be feigned, deriving from tampering with analysis samples (e.g., by adding blood) or, more often, they are induced. Examples of the latter often involve to obstruction of the respiratory tract or the administration of exogenous substances. These usually involve drugs (emetics, laxatives, psychoactive drugs, hypoglycaemic agents, etc.), but there may also be other elements, such as cleaning products and fluids containing microorganisms. Apart from suffocation, direct physical abuse has also been used, involving lacerations, changes to the diet, etc. The induction of infection is also frequent5,6. The abused child shows atypical symptoms that do not match known illnesses and the process is either not controlled or when it seems to be controlled unexpected relapses appear2. The clinical manifestations vary; the most frequent ones are apnoea, depression of the CNS, convulsions, vomiting, diarrhoea, fever, exanthema, clinical allergies and psychiatric symptoms1. The children may be admitted to hospital several times and be shuttled from hospital to hospital until in the end, in the best of cases, a diagnosis of abuse is given. On average, the duration of the abuse surpasses one year. Many of these children suffer physical alterations and nearly all are subjected to psychological abuse, with sequellae many years later1,6. Among the damage elicited is that derived from the health personnel’s actions, induced by the symptoms provoked by the perpetrator1.

The suspicion of abuse obliges a thorough analysis of the child’s case history and those of the child’s siblings, searching for suggestive information. Special precautions must be taken with the child’s safety and well-being and also as regards the possibility of future legal demands. Diagnosis is confirmed by forensic and toxicological analyses, video surveillance (depending on the legislation of each country) and with a “separation test” between the two people involved, at which moment the symptoms should presumably disappear. For the diagnosis and handling of the syndrome, it is essential to have multidisciplinary teams involving doctors, social workers and lawyers1. During treatment it is crucial to separate the child from the abuser and ensure future psychiatric treatment of the perpetrator. It should be borne in mind that the latter, once discovered, may commit suicide6; evidently, the necessary measures must be taken to prevent this.


The Sixth Sense

Technical details

Title: The Sixth Sense

Country: USA

Year: 1999

Director: M. Night Shyamalan

Music: James Newton Howard

Screenwriter: M. Night Shyamalan

Cast: Bruce Willis, Haley Joel Osment, Toni Collette, Olivia Williams, Mischa Barton, Donnie Wahlberg, Peter Tambakis, Jeffrey Zubernis, Bruce Norris, Glenn Fitzgerald, Greg Wood, Trevor Morgan and Angelica Torn

Color: Color

Runtime: 107 minutes

Genre: Drama, Thriller

Production Companies: Hollywood Pictures, Spyglass Entertainment and The Kennedy/Marshall Company

Synopsis: A child psychiatrist takes as a patient a child who is suffering from the same illness as a patient whom he previously failed to cure and who committed suicide after shooting him.


The Sixth Sense is a film of drama and intrigue where in a subplot, limited to a single sequence, Munchausen’s syndrome by Proxy appears. From the cinematographic point of view, this is a good film that succeeds in what it attempts to portray and has “twists” for the spectator. Bruce Willis’ acting is excellent.


The film

Malcom Crowe (Bruce Willis) is a child psychiatrist who has just received an award in acknowledgment of his professional work. The night he receives the prize, a patient Crowe had treated when the former was a child, and whom he failed to cure, enters his house. After the patient reproaches the psychiatrist for his earlier failures, he shoots Crowe and then commits suicide. Soon after, we learn that the psychiatrist treats an eight year old child, Cole Sear (Haley Joel Osment), who has the same symptoms; he sees dead people. He becomes obsessed with the child’s condition and even neglects his wife and marriage until he manages to cure the child.


Munchausen’s Syndrome by Proxy in The Sixth Sense

As mentioned before, this syndrome is simply a subplot in the film. After a young woman’s funeral [Kyra (Mischa Barton)], Cole goes to his room. There, the woman appears again and asks him to take a tape to her father. The father puts it in the video and sees how his wife adds some kind of poison to the food she is serving her daughter (figure 1). It is considered that in Munchausen’s Syndrome by Proxy mortality ranges between 9 and 10%, and reaches 33% when suffocation or poisoning are used1,2. One must assume that the abuse portrayed in the film belongs to this syndrome, although we cannot be sure of this since we are only allowed one glimpse of the mother’s behaviour.


One Missed Call/ Chakushin ari

Technical details

Title: One Missed Call

Original title: Chakushin ari

Country: Japan

Year: 2003

Director: Takashi Miike

Music: Kôji Endô

Screenwriter: Yasushi Akimoto and Minako Daira

Cast: Kou Shibankasi, Shinichi Tsutsumi, Kazue Fukiishi, Renji Ishibashi, Goro Kishitani, Anna Nagata, Atsushi Ida, Yutaka Matsushige and Mariko Tsutsui.

Color: color

Duration: 112 minutes

Genre: Horror, Thriller, Mystery

Production Companies: Kadokawa-Daiei Eiga K.K./ ABL Augusta

Synopsis: A series of violent deaths occur, all linked through friendship. In all of them, the dead person has received a missed call three days earlier in which his or her voice can be heard or the image of the person appears at the time of their death.


The film

Yumi Nakamura (Kou Shibasaki) is terrified when she learns how some of her friends from University die violently. The reason for these deaths seems to be related to a strange call received through their mobile phones. Her desperation reaches its climax when it is apparently her turn.

The drama starts on the day she meets with a group of friends. Yoko (Anna Nagata), the closest of them, receives a surprising phone call on her mobile. The ring tone announcing it is not the one she has chosen; the screen tells her it is a missed call, and, surprisingly, the caller has used her own phone, and the voice mail emits her own words, ending in a piercing scream. Moreover, the strangest thing is that the call has not yet taken place; it is dated three days later. After that time is up Yoko dies in a railroad accident. A few days later another friend dies under equally suspicious circumstances, falling down a lift shaft.

After this, she runs into Hiroshi Yamashita (Shinichi Tsutsumi), a young man whose sister also died in such macabre circumstances, in this case in a fire. The woman was working in a hospital for children. Investigating the different dates on which the people died and his sister’s diary, Hiroshi realises that a little girl whose record indicates she had died from an asthma attack had been to his sister’s hospital several times for treatment of the condition. But what is most surprising is that his sister had gone too, but in her case for different, clearly self-provoked problems, such eating drawing pins or minor burns. They start investing this and they discover a clear Munchausen syndrome by Proxy. The cause seems to be the mother and the mistreated individuals are the two little girls.


Munchausen’s Syndrome by Proxy in One Missed Call

Apart from the scant cinematographic value of this Japanese film, abuse pervades the plot, since there is no better way to inflict it than killing someone; in this case several people.

The only University activity in which some of the characters are involved is a lecture on abuse, where we hear that “abuse engenders abuse”. This can be applied perfectly to the Munchausen Syndrome by Proxy, in which many perpetrators are subjected to abuse in their childhood.

The origin of these deaths points to a mother who abuses her two daughters, one of whom dies from an asthma crisis. This reason is used in the film in order to give a fairly correct explanation of what the syndrome is, although it is not true that abuse is limited to children5.

The subsequent development tells us that we are dealing with an atypical case of the syndrome; the abuser is not the mother but the little girl who died of an asthmatic crisis. She had inflicted physical harm to her younger sister several times so that she had to be cured in hospital (figures 2 and 3). In one of these instances the mother leaves her alone and fails to give her the bronchodilator aerosol, so that she can take the sister, who has just been abused, to hospital. Under these circumstances, it is an asthma attack that causes the death.


A CHILD’S CRY FOR HELP

Technical details

Title: A Child's Cry for Help

Country: USA

Year: 1994

Director: Sandor Stern

Music: Joseph LoDuca

Screenwriter: Jan Jaffe Kahn y Sandor Stern

Cast: Veronica Hamel, Pam Dawber, Daniel Hugh Kelly, Lisa Jakub, Cynthia Martells, Daniel Benzali, James Pickens Jr., Jeff Williams, Zachary Charles, Tobey Maguire, Regina Krueger, Lois Hicks, James Gale, Connie Craig and John Ashton.

Color: Color

Length: 116 minutes

Genre: Drama

Producer: Hallmark Entertainment, Longbow Productions and Ronald J. Kahn Productions.

Synopsis: A doctor attends a little boy, the son of a “self-sacrificing widow”, who suffers from non-specific, atypical acute abdominal pains and who, after surgery, develops bouts of unexplainable bacteremia.


This is a film made for television in which Munchausen’s Syndrome by Proxy is the core argument. It was shown in Spain by the Hallmark Channel under the following titles A child cries for help and Intensive Care.


The film

Two plots coexist, the main one deals with the professional activity of Doctor Paula Spencer (Veronica Hamel) and focuses on the case a small boy who has a strange condition, while the subplot, which could well have been omitted, portrays the problems the Doctor has with her daughter. Both of them overlap, and there is eventually a happy ending for the main character.


The action starts when Paula (figure 4), a renowned specialist in foetal cardiopathy from UCLA (University of California, Los Angeles), goes to a new hospital in Denver as Director. Hitherto unknown to the staff of the hospital, she finds herself in the ER with another woman, Monica Shaw (Pam Dawber) (figure 5), who is requesting urgent treatment for her son Eric (Zachary Charles) (figure 6). The child has abdominal pains and a fever. Passing by, the little boy she takes some time to examine him and asks a surprised member of the staff, who does not know her yet, to arrange for a doctor to attend to the boy’s abdominal pains.

After she has settled into her job, Dr. Alec Jefferson (Jeff Williams) informs her that a surgeon has seen the child and has made a diagnosis of acute appendicitis, for which he is to be operated. Doctor Spencer disagrees with the diagnosis, since although the child has a high erythrocyte sedimentation rate (ESR) and leucocytosis he does not have any pain or any rigidity in the right iliac fossa. In the end she agrees, to the operation because the surgeon convinces her that the benefit is bigger than the risk: a few sutures as opposed to a ruptured appendix.

From the case history compiled by Doctor Jefferson it seems that the mother and her son had previously been living in Arizona, specifically in Tucson and Phoenix. During the exploration Paula, becomes aware that the woman has a thoroughly updated medical record of her son’s illnesses. She tells the Doctor that he has had mumps, measles, chickenpox, scarlet fever and German measles and informs her that she has monitored her son’s illness closely, because she herself is the daughter of a doctor, at the same time extolling her father’s professional virtues. She then tells Paula that she never lost a chance to be with him

The surgery tells us that Paula was right, the laparotomy shows that the boy’s appendix was normal; only large degree of intestinal inflammation with obstructed vessels is observed.

From that moment on the mother tries to get closer to Paula. She gives her a map of Denver so that she can move around the city easily on her own (figure 7). She discloses certain personal information, such as the fact that she was widowed when Eric was three. She flatters Paula, saying that she is like her father, that she treats the patient and not the disease, and in the end she manages to get Paula to take charge of her son’s condition. However, once Eric is out of the recovery room and in a ward he begins to suffer from unexplainable bouts of bacteremia.

First, after his mother has manipulated the drip during the night he develops a fever and two types of microorganism are found in the blood culture: Candida albicans and Streptococcus viridans group. The laboratory says it is impossible that these could be of abdominal origin, since they are usually only present in the saliva. Paula is surprised when she sees the mother manipulating the i.v. perfusion pump (figure 8) just as she is about to tell her that Eric is getting better thanks to the antibiotic treatment. Her surprise deepens further when the child sharing Eric’s room develops the same symptoms and the same microorganisms are isolated from his blood culture.

This leads Doctor Spencer to suspect that the bacteremias are induced. To prevent this, anyone not related to the patients is barred from entering his room, including people with gifts, such as flowers. Eric remains alone in his room.

Despite this measure, in the middle of the night she receives a phone call telling her that Eric has had another relapse. This time a faecal microorganism -Escherichia coli- is isolated. She no longer has any doubts: the infections must be induced because the microorganisms are different.

She receives new information that instead giving her a good feeling about Monica Shaw has quite the opposite effect. The nurses admit that the mother is excellent, that she never leaves her child even for a moment; that she doesn’t even go home to change her clothes. She begins to suspect Monica and her suspicions begin to look like evidence. She orders the boy to be checked on every quarter of an hour and then goes to the library. She consults several medical treatises and contacts a psychiatrist from Boston. She then orders that the boy be put into isolation, although without the placet of Morris (Daniel Benzali), who has always shown little sympathy towards her. In the end, after pointing out some of Monica’s characteristics that suggest she might have a case the Munchausen Syndrome by Proxy on her hands, she manages to get the boy isolated. The mother is furious and reproaches Paula for her behaviour; she thought they were friends. Eventually, she very skilfully beguiles her way back into her son’s room dressed in isolation clothes.

Paula, without hospital authorisation, goes to the Social Services Department (figure 9) and manages to get a lawyer interested in the case. In the office she talks about the mother: she says that she certainly must love him but that she is trying to kill him; her behaviour is different from that of the health staff, who exacerbate their patients’ condition in order to claim the merit of saving them.

The action enters a judiciary phase. The Social services Department forbids the mother to visit her son. She sues the hospital, whose administrators are afraid of the consequences. Since Monica shows certain atypical aspects as regards the Munchausen Syndrome by Proxy, such as that she only has one child and that the symptoms have started only a short time previously, attempts are made to investigate her life in Tucson and Phoenix, where she said they had lived before, but there is no trail of either her or her child in those cities. The idea that she is a compulsive liar begins to take shape. Eric is getting better, with the exception of a tantrum he throws on learning from a nurse that his mother cannot visit him any more. The staff of the hospital are clearly against Doctor Spencer.

In the preliminary hearing, the judge, basing herself on the fact that the child has got better since his mother has not been not with him, agrees with the Social Services and approves full separation of Mrs Shaw from her child (figure 10).

One night, dressed as a nurse, Eric’s mother enters his room while the security guard is reading at the door and paying little attention to what is going on, but when she leaves the room she is only seen by a six-year old girl who is walking around the corridors. Mrs Shaw tells her not to say a word of it (figure 11).

The next day disaster strikes the hospital; the child has relapsed and has fever and convulsions. Doctor Spencer now thinks that she has made a mistake -i.e., that Monica really is a good mother- and accordingly hands in a letter of resignation.

An unexpected occurrence rekindles our interest. Paula Spencer’s daughter Amanda (Lisa Jakub), who is doing social work at the hospital, is talking with the little girl who was strolling the corridors and learns that Mrs Shaw has visited her son in the night. Hearing of this, Paula goes to see Eric and tries to garner from him any detail that might help her for the court hearing. Unfortunately, she fails to obtain any relevant information. At that moment Dr. Alec Jefferson, the doctor who saw Eric at the beginning of the film, enters. Seeing the child’s drawings on the wall of his room, he comments that Eric must be an artist. Almost all the drawings have a medical motif, but his attention drawn is to one specific picture, depicting the Space Needle of the Seattle Centre (figure 12). Once again a clue has emerged and Paula soon informs the Social Services Department.

The hearing starts, and when questioned by the lawyer from the Social Services Department Monica mentions that her father was a fantastic doctor and that she had learned a lot from him, such as how to control a drip, but that her only real contact with him when she was ill. Her lies come out once again when she denies having living in Tucson and Phoenix. All seems lost, but at that moment the social assistant enters and hands the lawyer a note. With all the emerging evidence Monica breaks down. We learn that she and Eric had previously lived in Seattle and that Eric had been in hospital 26 times from 1989 to 1994 for unexplained abdominal pains; the definitive diagnosis was that they were due to the ingestion of laxatives. In Seattle, the doctors had suggested that Monica should visit a psychiatrist, but she abandoned the sessions one month before going to the hospital in Denver. It turns out that Mrs Shaw is not a widow: she is divorced and she was abandoned by her husband. Twelve years previously, her first son, whom she had as an unmarried mother, died at the age of nine months due to an intestinal rupture brought about by abusive use of laxatives.

Eric is getting better and is to live with his maternal grand-mother, but we are left wondering what psychological damage he has been subjected to and what the consequences will be.

Eric’s story also puts an end to the difficult relationship Doctor Spencer has had with her daughter.

When she arrived in the city Amanda did not get on well with her mother. Through her behaviour we learn of her grief for her father, deceased three years previously, the fact that her mother did not pay much attention to her, and above all the scant affection she had received from her mother. Paula does in fact worry about her daughter but she does not show it. These circumstances are reflected in the way she dresses (punk style), in the arguments she has with her companions, which earn her the threat of expulsion from the centre, and in the mutual reproachful behaviour between herself and her mother, especially when their house employee robs their house and takes all the jewels that her father had given them as presents. Psychologists have been of no use in changing this behaviour. Amanda tries to get closer to her mother; she wants to help her at home and becomes a helper at the hospital, although her mother does not realise this. All ends well when, at the end of the film, following the advice of a colleague who had recommended more affection between mother and daughter, her mother kisses her.


The Munchausen Syndrome by Proxy in A Child's Cry for Help

The film recounts, almost exclusively, a clinical case of Munchausen’s Syndrome by Proxy. The credits inform us that it is based on current clinical cases. The narration is structured around the chief character, Doctor Paula Spencer, who in the end will establish the diagnosis; the mother who is responsible for the abuse, Monica Shaw, and Eric, the son who suffers the consequences of the abuse. The main argument develops as Paula reaches a definitive diagnosis of the cause of the child’s illness and of his strange evolution. The film gathers many aspects of Munchausen’s Syndrome by Proxy.

The first is the presence of acute abdominal pains with atypical symptoms in a child admitted to the ER at a hospital (figure 13). The case is so atypical that behind what looks like a medical urgency there is simply “intestinal inflammation with an increase in vascularisation”. But this is not all; after the operation the boy first gets better but then develops unexplained episodes of bacteremia (figure 14), the cause being two microorganisms. These are rare in immune competent patients and are presumably of oral origin. As if this were not enough, when the child gets better thanks to the antibiotics he develops yet another unexplainable episode of bacteremia, in this case due to a germ that in the film is attributed a faecal origin. Regarding the boy’s last bout of bacteremia, the one that arises after the security guard’s laxness, neither the agent nor the origin is mentioned. Nevertheless, at this point the spectators have found what they were looking for in the plot.

As usually happens in reality, the origin of the abuse is the child’s mother. Monica portrays a theatrical personality; she is smart, self-confident, pleasant and convincing, and very charming. She smiles readily and seeks out the staff’s friendship at the hospital. In general, she achieves her goal, since the nurses believe that she is an excellent, long-suffering mother: a veritable slave to her child (figure 15). Thus, when Doctor Spencer manages to separate her from her son, the nurses turn against her and begin to create problems. One of them tells Eric that his mother cannot visit him, causing Eric to throw a tantrum. The only staff member of the hospital in contact with the child who does not completely fall into the trap is Paula. A series of aspects about Monica begins to coalesce, and imperceptibly but progressively this leads her to distrust the mother: her saccharine kindness, the fact that she knows how to manage her child’s drip (figure 8); that she remembers all his illnesses; that she is prepared to sleep on his bed (figure 16), and that she refuses to leave him for a single moment. However, before the mistrust is fully consummated, Monica ticks her more than once; she manages to get Eric transferred so that it will be Paula, and not another doctor, who will be in charge of him. And of course, she skilfully wangles a situation in which even after Eric has been isolated she is the only one with the right to visit him in his room. In the end, Monica is surprised that she has not managed to gain the Doctor’s trust and turns nasty. The self-confidence that she shows at the beginning of the hearing breaks down when the truth comes out.

The abuse meted out to Eric is chronic, palindromic, and of different types. The first one to appear, which passes unnoticed by the spectators since they identify it as a natural illness, is reflected in the abdominal problem. With this, Monica achieves what she has set out to do: on one hand to have the child admitted to hospital and undergo surgery, and on the other to be permanently in contact with the health staff. When Medow described the syndrome, one of the symptoms of abuse he gave was indeed abdominal problems3. In the film we are not told how Monica produces the symptoms of pain and fever with which she manages to get her son admitted, although presumably, as is discovered later, she must have done so by giving him some kind of laxative. Fever is an invented sign. She is successful in her next activities because she is always at the hospital with her child and has gained the trust of the nurses. She achieves her aims by inoculating saliva into one of the child’s veins, and later on faecal material. In order be able to continue her evil deeds without interruption, she has no qualms about injecting her saliva into the veins of Eric’s room mate, so that with his bacteremia he will be transferred elsewhere and Eric will be alone.

Underlying her capacity to do harm is her medical knowledge. She is the daughter of a physician and at the hearing she confesses that she knows how to manage a drip. In the film we see how she does this, and we are given a glimpse of how she inoculates her son with saliva. Monica is a compulsive liar; she deliberately hides certain aspects of her personal life. When a doctor compiles the clinical history of her son she tells him that she had lived in Tucson and Phoenix, which she retracted at the hearing, where it is discovered, thanks to Eric’s drawings, that, they in fact they were from Seattle. At the beginning she says she is a widow, but in fact she is divorced and was abandoned by her husband. Eric is not the first child she has abused: twelve years earlier she had had a child as a single parent who at nine months died of an intestinal perforation due to an overdose of laxatives. The use of this type of drug is very common in the abuse reflected in the syndrome.

Monica does not gain any benefit from her conduct, except perhaps for her own psychological ends, since she has been able to inveigle her way into permanent contact with the medical staff of the hospital. However, as spectators we do get some insight into the reasons underlying her condition as an abuser, “factitious disorders by proxy”. As a child she was deeply impressed her father who, owing to his work schedule, could not be with her very often. We learn that in order to be with him she used to pretend to be ill; indeed she had the Munchausen Syndrome.

As regards the abused person, in this case it is an eight-year old child who is quite fond his mother. His admittance to hospital at the start of the film first occurs in Denver, but between 1989 and 1994 he had been admitted to hospital sixteen times in Seattle for abdominal pains as a result of the administration of laxatives. Thanks to this detail, the film tells us that his mother must have pressured him not to say anything about his previous stays in hospital; again, a characteristic aspect of this syndrome5. It would be impossible for an eight-year old child to forget the sixteen time he was admitted, as he tells Doctor Spencer when asked, and not the Space Needle of the Seattle Centre.

How does Doctor Spencer succeed in establishing a diagnosis of the Munchausen Syndrome by proxy? Undoubtedly, through a good capacity for observation, which in turn leads her to ask herself many questions. She is confronted with a child with acute abdominal pains with atypical symptoms, who –just when they seem to have been brought under control- then develops further complications; i.e., unexplained episodes of bacteremia. And to top it all, his room mate also develops bacteremia (figure 17). This leads her to suspect that the complications must be induced, although she does not suspect that Eric’s mother is to blame. The suspicion that the symptoms have been deliberately induced is confirmed when the child has a further episode of bacteremia, but this time of a different aetiology.

The mother’s behaviour itself leads Paula to the suspicion that there is something wrong. She searches the archives of the library of the hospital, and the findings of a psychiatrist from Boston confirm the anomaly: what she was looking for is Munchausen’s Syndrome by Proxy. She confirms the diagnosis with the “test of separation”, and the film skilfully underlines the importance of doing this properly, preventing the guilty party from having any contact at all with the patient. The child then has a relapse because his mother manages to enter the ward while the security agent at his door is distracted during the night. Thus, good investigative practices should be able to resolve doubts and account for atypical observations. As stressed in the film, Monica had had another child who she also abused.

In this narrative segment of the plot, we learn of the need in such cases of a multidisciplinary team that includes psychiatrists and staff from the Social Services Departments to deal with these abusers. The latter implies the need to communicate such cases, like any other case of child abuse, to the authorities. Moreover, the film stresses prudence and the need for a careful diagnosis, in particular as regards the possible legal proceedings and the possible harm that may be incurred if supposed abusers are not actually abusers at all. In this case, the poorly resolved separation test almost set Eric’s mother free to do as she pleased.

The abuse ends with the separation of the child from his mother, but we are left to wonder who will take care of him and what the future physical and/or psychological consequences deriving from his mistreatment and the person who inflicted it will be. These aspects are addressed effectively in the film. Many abusers with “factitious disorder by proxy” have been subjected to the Munchausen Syndrome by Proxy or Munchausen Syndrome in their childhood, like the secondary character in the film.


Conclusions

A Child's Cry for Help is an excellent film. Like other films made for television7,8 it is a faithful testimony to a particular health issue. From the educational point of view as regards the Munchausen Syndrome by Proxy, it is undoubtedly better than The Sixth Sense and One Missed Call.


References

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  4. Asher R. Munchausens Syndromee. Lancet; 1951; 1:339-341
  5. Awadallah N, Vaughan A, Franco K, Munir F, Sharaby N, Goldfarb J. Munchausen by proxy: a case, chart series, and literature review of older victims. Child Abuse Negl. 2005; 29:931-941.
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Acknowledgements

The Editors would like to thank the translation team of the Languages Service of the University of Salamanca for their collaboration in the English version of this Journal.

Translated by: Estefanía Tovornik Pérez

Figure 1: Kyra’s mother poisons her daughter’s food

Figure 2: A girl after abuse caused….

Figure 3: ... by her asthmatic sister with a sharp object

Figure 4: Doctor Spencer

Figure 5: Monica, the Erics' mother, the perpetrator of the abuse

Figure 6: Eric, the abused child

Figure 7: The abuser inveigles her way into Dr. Spencer’s trust by giving her a map of Denver

Figure 8: Monica manipulating her son’s intravenous perfusion pump

Figure 9: Paula, at the Social Services Department

Figure 10: The hearing begins

Figure 11: Evading the separation test

Figure 12: The clue: the Seattle Center Space Needle

Figure 13: A strange case of abdominal pains

Figure 14: First episode of bacteremia

Figure 15: Helping a nurse

Figure 16: Strange behaviour in a hospital

Figure 17: The bacteremia of Eric’s room mate