1.0 introduction during the past few years there has been an increase attention regarding mental health mental disorders and social life. more studies have focused on understanding relationships and especially the mother-child relationship how it works and the benefits of it. but when individuals start to take advantage of such relationships concerns will appear. this research will discuss some aspects of the mental disorder munchausen syndrome by proxy. the disorder that causes many conflicts due to its nature. to better understand the disorder the other type of it should be explained. munchausen syndrome ms is a disorder that initially was used in 1950s to diagnose a patient with self-induced illnesses to get the care and attention that was given to sick people. it was named after baron von munchausen a guy that used to tell unreal stories about his life. walk and davies 2010 majority of ms individuals are males between 30-50 years old glazier 2009 munchausen syndrome by proxy msbp was firstly recognized in 1977 and was mentioned in the dsm-iv under the term of factitious disorders by proxy. this disorder is characterized by someone triggering illnesses for another person in their care. usually the perpetrator is a caregiver and the victim is a child or an elderly in their care it is considered as a form of child abuse glazier 2009 msbp was introduced by roy meadow a british pediatric nephrologist. when he was faced by two cases of children. one of them was diagnosed with hematuria after looking at the tests of the child they found out that the childs urine sample was mixed with the mothers blood and the second child passed away because of salt poisoning. from these cases meadow distinguished between two types of caregivers: the one that causes the illness salt poisoning and the one that fabricates the symptoms contamination of the urine sample squires and squires 2013 the abusers will mostly be familiar with the medical treatment either by the experience they get from being a patient or by being healthcare provider or by searching on the internet criddle 2010 majority of individuals with msbp are females mostly mothers of no specific age they either suffered from childhood emotional neglect or abuse had been involved in self-harm being alcoholic or abused drugs or having mental disorder of some type glazier 2009 msbp is more common that one might expect but knowing exactly the prevalence of this disorder is still unknown squires and jr 2010 1.1 research gap. lack of information and articles on msbp accurate treatment and prevention in arab world. 1.2 aim of the research. to discuss the importance of munchausen syndrome by proxy. to cover the gaps regarding its diagnosis motivations treatment its impacts on proxy and support it with example on the impacts on the proxy. 1.3 methodology of the research. in this research the data are collected from google scholars and google.com. all is in form of secondary data such as academic articles and journals. the information is gathered through reading understanding and analyzing those articles then the information relevant to the topic is written. 2.0 discussion 2.1. symptoms and diagnosis. in the case of msbp where the perpetrator is falsifying the sickness of the child mostly the symptoms will be observed on the child. symptoms might include the following: fabricating an illness manipulating the sample provided to physician for examination e.g. adding blood to the sample inducing an illness e.g. obstructing the respiratory tract forcing the child to drink liquids containing some chemicals or microorganisms the abused child will have symptoms that does not match any disease and in some cases when physician thinks that they controlled the disease a sudden and unexpected relapse might happen sense 2006 fabricating and claiming the existence of sexual abuse flaherty and macmillan 2013 diagnosing this disorder is uneasy for physicians due to the nature of the disorder its almost impossible to accurately detect or it takes a lot of time and resources cömert et al. 2018 according to meadow and rosenberg msbp can be diagnosed through the following: the disease must be made up by a parent or someone who is responsible for the child. symptoms brought to the physician are usually vague and can take more than one for identification usually the parent will not be satisfied and will not accept the causes of the disease. the disease indicators and severe symptoms disappears once the parent is away from the child cömert et al. 2018 pediatricians needs to be aware and suspicious when they see a child with recurrence of illness an illness with unexplainable symptoms that leads to several procedures or when there is inconsistency between the physical examination history and the childs health flaherty and macmillan 2013 2.2. causes and motivations. the causes of msbp still not known or understood there is no single reason or multiple reason that was found common in all patients of msbp but there are some factors that may contribute: steel 2009 personality problems such as sociopathic histrionic narcissistic personality bipolar disorder or being involved in sadomasochist behaviors. early childhood experiences like being abused physically sexually or being neglected. motives of msbp individuals vary among abusers it can include: gaining sympathy and respect of others being the only mother that take care of a sick child. showing off their knowledge and that they can easily manipulate physicians or experts. escape other responsibilities in life education employment by taking care of an ill child. have social life by being part of hospital family. financial aid. community support criddle 2010 2.3. treatment. in the process of treating a person with msbp the safety of the child should be first prioritized the most effective way is to remove the child immediately from the house and a safe environment should be provided. then evaluate the parent to see if the parent recognizes his illness or not auxemery 2014 since treating individuals with msbp is uneasy because it requires honesty the only available treatment would be through psychotherapy in the form of cognitive-behavioral therapy walk and davies 2010 2.4. impacts on proxy. victims of msbp usually are infants and children under 5 years they seek the approval acceptance attention and love from their mothers by acting as being sick in front of the physicians. some reported that victims of msbp grew up to be patients of munchhausen syndrome or to abuse their own children criddle 2010 the effects of falsified illness on victims might include the impacts on: daily life and functioning: it would increase the child absenteeism from school due to continuous illnesses david s. bell 2015 having difficulty in coping with colleagues due to physical and psychological factors glazier 2009 lead to social isolation david s. bell 2015 .0 physical health: the physicians will prescribe medicine according to the mothers described symptoms the side effects of this medicine will appear in case of healthy child. also children has frequent hospitalization going through unnecessary procedures some of those procedure are very painful bass and glaser 2014 the induced illnesses were linked with other serious problems and diseases and even caused death in some of the severe cases. bass and glaser 2014 depending on each medicine and on chemicals and other factors the child was taking and being exposed to will cause permanent physical damages and disorders such as: brain damage severe learning disabilities and developmental delay glazier 2009 psychological health: victims will suffer from psychological disorders the severity of the disorder depends on the age of the child and the duration of abuse the child might suffer from post-traumatic stress disorder emotional problems conduct disorders specific phobias fear of blood hospitals nightmares social development delay depression concentration difficulty decrease in self-worth and suicidal thoughts glazier 2009 2.5. example of msbp and its impacts from previous case study. a recent study was conducted on a syrian 20-months-old baby boy living in lebanon refugee camp with his mother while his father being imprisoned in syria. the mother was continuously taking the baby to the hospital for eye bleeding. she was trying to get the staffs trust and sympathy by telling them stories about the husbands supposed incarceration and the circumstances that they faced in syria or still living in the refugee camp. but after doing the proper testing and giving all possible treatment the childs health kept deteriorating. during 6 months of repeated visitation to the ophthalmology clinic. staff and doctors started suspecting child abuse situation the child was eventually removed from the mothers care after he lost his vision in both eyes. the mother was taken into custody and the child was placed in orphanage shibbani hamzeh and sharara-chami 2017 3.0 recommendations pediatricians or healthcare providers usually are not familiar with msbp distinguishing between concerned parents and parents seeking attention is the physicians job to discover. but since there is no criteria or certain diagnosis for this disorder it is harder to determine whether they should report their concerns or not. also because of the loving and caring nature of the parents physicians tend to believe the childs history afforded to them by the parents. and the way the parents persuade the physicians by giving detailed medical history makes it tougher to detect any lies squires and jr 2010 for the previous reasons msbp is a challenge for pediatricians and other healthcare providers to diagnose and find the accurate percentages of prevalence cömert et al. 2018 the following recommendations should be taking into consideration for the new researches to look for and for to increase awareness about the importance of this disorder. to make more studies about the prevention of the disorder. to make accurate diagnostic criteria for physician to follow. to find the effective treatment for patients of msbp. 4.0 conclusion to conclude munchausen syndrome by proxy is a form of child abuse. compared to other forms of child abuse msbp can be considered as a rare disorder its very dangerous illness and very little research has been done on this topic. the physicians should be aware be and be able to differentiate between a concerned mother and a mother with msbp. msbp patients fabricate or induce symptoms that does not fit into any disease the proxy child in most of the cases go through a lot of painful procedures and unnecessary tests that affect the childs health. various impacts will be on both the patient and the proxy it can be devastating. if the childs health is getting better while the mother is not there or the symptoms worsen if shes present then those are indicators for physician to suspect child abuse and msbp case. through the research it has been found out that msbp patients suffered from different personality disorders and being traumatized and exposed to different types of childhood abuse. furthermore their children suffered from physical illnesses as well as psychological disorders on short and long term. msbp patients mainly seek attention by being the caring and devoted mother that takes care of a sick child. treating this disorder is still not definite and the childs safety should be prioritized. the research was done in a limited time so there was no enough time to find more articles that cover the topic. specifying the topic made it harder to find references.
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