Objective. Münchausen by proxy syndrome (MBPS) is a form of child abuse in which a parent fabricates or produces illness in a child. Although the medical consequences of MBPS have been well described, there is no detailed published account of what it was like to grow up in a family where the mother systematically induced serious illness. This article describes one victim's childhood experiences.
Methods. The medical history was obtained from a review of the original medical records, notes from the primary physician, discussions with two physicians who provided treatment, and several meetings with the victim and the victim's therapist.
Results. This article chronicles the actual experiences of an MBPS victim through 8 years of medical abuse at the hands of her mother, reveals the victim's account of what happened to her, describes what her family was like, details the long-term consequences on emotional and physical development, identifies the factors that influence recovery, and details the impact on family relationships.
Conclusions. Child maltreatment and MBPS need to be part of the differential diagnosis when the clinical picture is atypical or does not appear medically plausible. The consequences of MBPS are psychological and physical and impact the entire family. Suggestions to assist heath care providers recognize, assess, and report cases of suspected MBPS are provided.
Münchausen by proxy syndrome (MBPS), first described in 1977 by Professor R. Meadow,1 is a form of child abuse in which a parent, usually the mother, systematically fabricates information about their child's health or intentionally makes the child ill.2 Some of these child victims die at the hands of their mothers. The majority suffer a degree of physical and psychological damage, either from outright harm or from painful procedures, unnecessary medications, or hospitalizations ordered from unwitting physicians.3 This form of abuse differs from other forms of child maltreatment in several ways: the perpetrator is almost always female and usually presents as a model parent, there is little or no indication of family discord, and the abusive behavior is clearly premeditated, not impulsive or in reaction to the child's behavior.
Although the medical consequences of MBPS have been well described,3 there are few articles that describe the long-term psychological impact of MBPS on its victims.5-8Only one article describes MBPS victims as adults.9 To date, there is no detailed published account of what it was like to grow up in a family where the mother systematically induced serious illness. This article chronicles the actual experiences of a MBPS victima through 8 years of medical abuse at the hand of her mother. The medical history, obtained from original medical records and notes from the primary physician (J. Scholl. Notes covering the medical course of the case between 1961 through 1964, personal communication, 1993), details the hospitalizations, procedures, and medications resulting from the mother's abusive behavior. Subsequently, the victim's account of what happened to her and depictions of what her family was like is described. The specific passages that illustrate the warning signals and significant aspects of the disorder associated with the MBPS are in italics. We conclude with suggestions to help health care providers recognize and treat children victimized by this form of child maltreatment.
THE MEDICAL HISTORY: THE DOCUMENTED TRUTH
In the summer of 1961 a 2-year-old girl was referred to an orthopedic surgeon because a trivial injury to the right ankle had not healed. Examination revealed mild swelling with no laceration or evidence of a fracture. The leg was splinted. Over the next 4 months the swelling continued and the child began to have spiking fevers. Two castings of the leg and a course of antibiotics did not totally resolve the problem. A hematologist was consulted and diagnosed mild thrombosis. A bone biopsy was done. The pathology report described evidence of reactive fibrosis and hemorrhage, cause unknown. Repeated radiographs revealed no evidence of osteomyelitis. The hospital record indicates a total of 28 hospitalizations, 24 surgeries, multiple blood transfusions, dozens of radiographs, several incision and drainage procedures, as well as skin and bone grafts. Numerous courses of different antibiotics were used. Temperatures were frequently recorded in the 103° to 105°F range. One report indicated the child was hospitalized after a febrile seizure at home. After each discharge from the hospital, the child was closely followed as an outpatient with various and continuous medications; yet she continued to have spiking fevers.
Between the ages of 2 and 4, the infection was limited to the right leg. The initial diagnosis was cellulitis. Eventually, this became chronic osteomyelitis, although the child never followed a typical course and repeated radiographs never revealed evidence of osteomyelitis. Several incision and drainage procedures were performed because of frequent temperature spiking and swelling. Response to antibiotic therapy was poor. Eventually, irrigation tubes for antibiotic treatment were inserted in the tibia.
At age 4 and weighing 24 pounds, the child suffered a spontaneous spiral fracture of the right femur while in the hospital. Themedical records for this hospitalization show the mother's handwriting on the nursing notes, medication sheets, and intake and output records. The child was discharged home in traction with a pin through her right heel. For the next 7 years the pin tract remained infected and drained continuously. Amputation of the right leg was considered and discussed with the parents after informal consultation with a physician from another hospital. The infection responded to the next course of antibiotics.
When the child was 5, the left limb became involved after a fall while playing. A cast for a broken left wrist was placed at the physician's office. One week later the wrist was severely swollen and required an incision and drainage procedure. There was evidence of infection butradiographs were negative for osteomyelitis. The wrist responded to antibiotic therapy over the next several months of treatment.
At age 6, the third limb was involved and the child presented with what appeared to be cellulitis of the right arm. Radiographs revealed no evidence of osteomyelitis. Two incision and drainage procedures were performed over the following 3 weeks and the severe temperature elevations dropped. Cultures again revealed bacterial infection and a course of antibiotics was initiated. At age 7, the child was brought to the emergency department with skin slough on her arm. The skin defect involved three quarters of the right arm and there were contractures of the elbow. The infection persisted for another eight months and there was significant loss of muscle mass. Two skin grafts were performed over the next few years but motion still remains restricted. At some point in time when the child was 8 years old, the left leg also became infected. The medical record indicates that the physician remained puzzled as to how the osteomyelitis traveled from the right to left leg.
When the child was 10 her medical condition dramatically improved. Three corrective surgeries were performed over the next 4 years; one to repair the right tibia, another to correct an internal foot rotation, and the third for skin grafting to the right arm. No further incidents of osteomyelitis occurred. Height and weight remained at or below the fifth percentile until midadolescence. Final adult height and weight falls in the average range.
MY STORY: THE PAINFUL TRUTH
I was raised in a small college town in the Midwest. I was the middle child, with a sister 20 months older and a brother 7 years younger. My mother was a registered nurse with a bachelor's degree. She did not work until I was a teenager. My father never completed college. He worked for a pharmaceutical company and did carpentry work on the side. We lived with my grandmother, who was a microbiologist and worked for the same company as my father, in a middle-class neighborhood.
The first page of my 400-page medical record begins when I was 2 years old; the year was 1961. My parents reported that I had fallen down a flight of stairs and twisted my right ankle. Six weeks after the incident I was still limping, my foot was swollen, and there was a large bruised area over my ankle. Our family physician made a referral to an orthopedic surgeon who was to become my primary physician for the next 8 years.
An initial diagnosis of cellulitis was made. After several weeks of not responding to antibiotics, an incision and drainage procedure and biopsy were done of the area. The results of the report read “sections of periosteum exhibit chronic inflammation with fibrosis and old hemorrhage. No evidence of specific etiologic agent.” What the physicians who were treating me didn't know was the injury to my ankle was no accident; the cause—repeated blows with a hammer by my mother.
My earliest memory of abuse is between the ages of 2 and 3. I was in the high chair with the tray pulled tightly to my chest. I could barely breathe, let alone move. My left leg was tied to the leg of the high chair with a dish towel. My hands were bound to prevent me from pulling at my mother's hair. She was very angry at me for fighting her. Her words were always the same and repeated frequently over the next several years: “I'm doing this for your own good. The doctor wants me to do this treatment to make you better.” As the blows of the hammer were hitting my foot all I could understand was the pain. I tried hard to escape her grasp. This made her even more angry. “If you don't hold still, it will take even longer.” I came to believe it was my fault she was angry. I was not a good girl. I needed to try harder to please her so she would love me.
My mother's “treatments” were scheduled three times a week, always after the midday news. Once I started school, the time changed to late afternoon. By picking me up a half hour early from school, a “treatment” could be completed before my sister walked home. During school breaks my sister was sent to a friend's house or outside to play. When neighbors asked about the cries coming from our house it was explained that I was being difficult during dressing changes.
Once incisions were made to drain the infection, my mother not only used a hammer to create the swelling, but also used a sharp instrument to probe and contaminate my wounds with potting soil and coffee grounds to prolong the infection. My medical record indicates the wound cultures always showed the same organisms: Pseudomonas aeruginosa, Proteus mirabilis, and Escherichia coli.
By the time I was 2½ years old I had several open and draining wounds on my right leg. Because my mother was a nurse I was often released early from the hospital and continued having intravenous therapy at home. My mother was allowed to provide total care for me during my hospitalizations, including giving medications and charting in the hospital records.
I turned 3 years old when my ninth hospitalization occurred, because I developed sepsis. A system was set up to continuously irrigate my leg with antibiotic solutions. I was responding well to treatment after a month long hospital stay, when my next “accident” occurred. Although still in the hospital, but in my mother's care, I suffered a spiral fracture of the right femur. The nursing note (in my mother's handwriting) states “started to walk, took a couple of steps when a crack was heard and leg hung. Doctor notified.” I was placed in traction with a pin through my right heel. This pin tract would not heal for the next 7 years.
It was during this hospitalization that I began to understand that my mother's “treatments” were different from the way the other nurses treated me. I became truly terrified of her and understood the extent of her power over me. Her love was connected to hurting me and keeping me sick. She threatened that if I told the truth no one would believe me. I would be taken away from my family forever. It was enough of a threat to keep me silent for 30 years.
There were times when my right leg was casted by the physician. This did not stop my mother from putting things down my cast and using a hammer on my exposed toes and knee. The swelling would force the physician to take the cast off. One time my mother used the hammer to smash the cast until it was soft. She then told the doctor I never listened to her and was always running, jumping, and playing on my right leg.
After a while my mother started to attack my left leg too. I was forced to use a wheelchair or to remain in bed. Meanwhile the doctors continued to puzzle over my case. Why did I not respond to antibiotics? Why was the osteomyelitis now showing up in another extremity? My mother had them running in circles.
I was 6 years old when I truly gave up hope of ever being rescued. My mother poured boiling water in the incision on my right arm, bandaged it up and waited till morning to take me to the emergency room.The staff was well acquainted with me because I was taken there one or two times a month for blood transfusions due to anemia.
This time I came into the emergency room hysterical screaming “Don't let her hurt me any more.” Everyone thought I was reacting to my arm wound and I was given a sedative.I lost three-fourths of the skin on my arm and had a large gaping deep wound for the next 2 years. What in fact was a third degree burn was documented in the medical chart as “skin loss due to severe infection.”
I was in fourth grade when I realized I would have to save myself. I was very ashamed and too frightened to ask for help. Sometimes I thought I would lose my mind having to pretend that everything was okay. All I ever heard was how wonderful my mother was and all that she was sacrificing for me (some friends and relatives still speak of her as if she is a saint). Who would ever believe me if I told the truth?
One afternoon, as my mother was preparing for one of my “treatments,” I stood up to her and said I was going to tell my teacher and doctor. I don't know why she backed down, but she did. Maybe it was because I was physically stronger and fighting her more frequently or it could have been because my brother, who was 3, was an easier target. Only my mother knows the real reason.
MY BROTHER: THE HURTING CONTINUES
When the abuse ended for me I was filled with guilt becausemy little brother became my mother's next victim and began to manifest similar symptoms. For 2 years, he had problems with “osteomyelitis” in his knee. Because I was so afraid I could not bring myself to tell anyone. I felt I had let my brother down. He was alone, frightened and unprotected, just as I had been.
I was suspicious that my mother was hurting my brother from the beginning. One day I caught her in the act. It was a warm sunny day, all of us were in the backyard playing in a wading pool. My mother called for my brother to come inside. He began to cry and refused to go. My mother picked him up and carried him inside. My heart was racing and there was a knot in my stomach. I heard a dull thud and knew she was using the hammer on my brother. I turned to my sister who was very quiet. “Did you hear that?” My sister slowly shook her head no. The noise continued. I had to do something. I raced inside and saw my mother sitting on top of my brother's chest just like she used to do to me. The hammer was poised in her hand. I immediately screamed at her to stop. She yelled at me to get back outside. I begged her to stop hurting him. The hammer whizzed past my head hitting the wall behind me. I was so scared I did as I was told. I went back outside and sat with my sister in the wading pool and sobbed.
My brother has admitted to me that mother abused him but has not discussed it with anyone else in the family. He has spent many years a lost soul, wandering from job to job, starting and never completing college classes. He was a binge drinker and abused drugs for a while. A few years ago he embraced religion and is currently studying to be a minister.
MY SISTER: SCARED OF THE TRUTH
As far as I know my sister was never abused. She staunchly supports my mother and adamantly denies any knowledge of what my mother did to me and my brother. Although she was often at school or sent to friends or neighbors when my mother was abusing me, there were many times she was just outside the door and must have heard my screams. But she never wanted to know what was going on. She was probably scared too. Today she is a very angry adult who does not seem happy or content with her life. In the past her anger overwhelmed me and made me feel guilty because I felt I was somehow responsible. Now I realize that her anger is not my problem. Perhaps someday she will open her eyes and confront what really happened. Maybe then she will be free to find happiness.
MY FATHER: HE WOULD NOT HEAR THE TRUTH
As a child, I loved the Disney stories. Tales of good versus evil and of happy endings gave me hope for the future. I desperately wanted my father to be my knight in shining armor. He was supposed to rescue me but he never did.
In the beginning, I thought my father was unaware of what my mother did to me, otherwise he would have stopped her. However,I learned differently when I told him what my mother was doing and he didn't believe me.
Sunday was family day and the only day my father was at home. After church we often took drives into the country. One Sunday, while waiting in the car for my mother, I started to tell my father about how mother used a hammer on my leg. My sister in the back seat began to scream, “She's lying, mommy would never do that.” Tears were streaming down her face, her hands clamped tightly over her ears. My father immediately confronted my mother who became teary-eyed and denied everything. My father turned to me and gave me a severe lecture about not lying and told me to never mention the subject again. I learned several lessons that day; the conditions of my father's love, the ease with which my mother could manipulate situations to her advantage, and how easily she could deceive others into believing her. To this day my father denies any knowledge of my mother's abusive behavior and does not believe me.
MY MOTHER: THE TERRIBLE TRUTH
My mother uses illness as a way to gain attention and approval. Her bizarre behavior has significantly damaged several lives, including her own. For the last 15 years she has had “problems” with thrombosis and cellulitis leading to severe infection in her right leg. Despite the use of antibiotics, the infections come and go and she has relied on several prescription analgesics for pain. In the early 1980s,one physician told my father he felt my mother's leg wounds were self-inflicted. Mom, of course, denied it. Dad believed her and found her another physician.
In the fall of 1989, my mother was arrested for falsifying prescriptions. She was addicted to pain killers and had been calling different pharmacies with bogus controlled substance numbers to get more medication. One pharmacist became suspicious and called the police. An attorney friend of the family convinced the judge my mother would enter a drug rehabilitation program and the charges were dropped. I was recently told my mother's “condition” had deteriorated further and she may become confined to a wheelchair. Her physicians were considering amputation. I talked with her physician and told him I suspected she is causing her own illness.
My mother is an incredible liar and a powerfully deceptive actress. It is amazing what she has gotten away with over the years. Although I have forgiven her for abusing me, I continue to be angry for the way she continues to abuse herself and for how she manipulates family and friends. Although I could never have a trusting relationship with her, I still yearn to know a mother's love. To date, unfortunately, she denies ever abusing me, my brother or herself. Also, many family members, friends and neighbors continue to view her the model mother. She has the love and support of my family of origin and much that she predicted has come true; my father, sister and brother are lost to me and my children. But she has not won. I am stronger than ever and have successfully built a new life based on truth and love.
THE YEARS AFTER THE ABUSE: THE UNSPOKEN TRUTH
The first year after my mother stopped abusing me I was filled with constant fear and anxiety that she would resume her “treatments.” As time passed I became more confident and outspoken at home and my teen years were filled with constant power struggles with my mother. I often had the upper hand because I had a secret she did not want revealed. Her way of dealing with our relationship was to try and keep me dependent, to demean me, and destroy my self-esteem. My illness was rarely discussed by the family and the message I received was “be grateful you survived and remember you owe it all to us.” I was told I would never amount to anything and no matter what I did, I could never please my parents. I graduated in the top 5% of my high school class but my parents felt I would fail in college. I earned an academic scholarship but was told not to speak of it because it might offend my sister. I first left my family at age 18 when I decided to attend college 3 hours away from home. I had no car so visits home were infrequent. This distance allowed me to grow as an individual and to begin to learn about myself apart from my family's influence. Once I graduated from college, I continued to live away from home and because I had limited interactions with my family I continued to grow stronger emotionally.
I met my husband when I was 25 and already working as a nurse. He knew nothing of my abusive history until one weekend while visiting my family I impulsively confronted my mother after she showed me a large bruise on her thigh. I recognized the bruise as similar to those she gave me with a hammer and accused her of self-inflicting the bruise. She became hysterical, started to cry, and went to my father for support. My father continued to defend her even after I was able to show him the hammer she kept hidden in a bedroom drawer. We left my parents with nothing resolved. My parents never mentioned the incident again. During our drive home, my husband asked about my childhood but I told him I was not able to talk about it. He said “One day you will have to deal with your past and I will support you when ever the time is right for you.” It was not until the birth of my first child that I was strong enough to challenge the demons from my past.
MY RECOVERY: THE TRUTH STILL HURTS
Each time I review my medical records, I go through a period of mourning for a childhood lost. In the name of sickness and at the hands of medicine, I am disfigured with permanent physical scars. Because of distorted motherly love, I continue to battle deep emotional wounds. It is likely that my experiences with illness, pain, and hospitals were influential in my decision to choose nursing as a career as I have always felt a deep sense of wanting to help others. However, my mother also played a part; she used to tell me that “if nursing was good enough for her, it was good enough for her daughter.” I guess I was still trying to please her and earn her love by “being good” and “doing what she asked.” I am glad to report, however, that my nursing career has proved very rewarding and I have enjoyed personal satisfaction in working with and helping patients.
I am also fortunate to have a healthy, loving marriage and two wonderful daughters. I was 30 years old and a mother for the first time when I realized I needed to seek professional help to deal with my mother's abuse. It happened one day while I was holding my infant daughter in my arms and became overwhelmed by the feelings of love and protection I felt for her. It was the first time I admitted to myself how abhorrent my mother's behavior was. My impetus to enter therapy was a strong desire to be healthy in my relationship with my own daughter. I didn't want my emotional scars to be passed on to her. I was also lucky enough to have a husband who loves me and is very supportive.
Therapy was not easy. Although I always had memories of what my mother did to me, I had never talked to anyone about it. To speak out loud and relive these memories brought to the surface feelings I had spent thirty years trying to stifle. Along with individual therapy I also attended group therapy with other female survivors of childhood abuse. There, I learned I was not alone in my pain. Therapy was a safe place to vent feelings and learn how to set boundaries. The final piece of the puzzle was learning that the abuse I suffered had a name. I had always felt that my experiences were different from others in the group and I finally understood why; the medical abuse I experienced was a deliberate, premeditated act; the physical abuse that other group members experienced was more impulsive and reactive. My recovery progressed rapidly from then on.
I currently have no contact with my family and have built a life separate from them. To have any relationship with them I would have to deny everything that happened to me. Although it is painful to lose these relationships, I feel strong in knowing I can never go back to playing the role of victim ever again. Every day when I look in the mirror, I am hauntingly reminded of my abuser. The physical resemblance and the massive scars are constant reminders of what I have survived. By telling my story I hope children who are victims of this terrible abuse will be better understood and will have a better chance of survival. Health professionals need to take responsibility in recognizing this sadistic illness. Departments of social service and the judicial system need to look at their policy of keeping families intact. Every child deserves to be loved unconditionally by someone who can be trusted. In my case, the woman who gave birth to me does not deserve to be called “mother” and should not have been allowed to raise children.
When the abuse reported here was perpetrated, neither factitious illness nor MBPS had yet been described in the medical literature. Thus, physicians could not have been expected to consider MBPS. However, the medical record and physician notes did frequently indicate a sense of puzzlement and bewilderment by the unusual clinical course of the illness. Although medical etiologies need to be ruled out in circumstances such as these, it is also important to consider environmental and psychosocial factors when the clinical presentation does not seem medically plausible. Both child maltreatment and MBPS need to be part of the differential diagnosis when the clinical picture is atypical. You can't diagnose it unless you think of it. Once considered, “look with new eyes” at the entire case and the medical record. All medical symptoms and diagnoses the mother reports should be substantiated by lab or test results. Records from all involved physicians and hospitals should be obtained and reviewed. Also, it is important to remember the child may be more vulnerable to abuse while in the hospital, so either find a reason to restrict visitation or have a sitter in the room. The interviewer also needs to determine if other children in the family are vulnerable to medical abuse. Infants and preschool children should be considered at highest risk. Another family member (father, grandparent) needs to be interviewed separately and asked about the child's symptoms without revealing the information given by the mother. Nonmedical information provided by the mother should also be checked because fabrication can occur in multiple areas. Inquiry regarding the mother health is also important because she may have a history of fabricating or inducing symptoms in herself. Remember, however, not to alert the mother of your suspicions throughout the course of the assessment. Finally, we recommend that health care providers consult the Child Protection Team when MBPS is suspected. These teams are typically staffed with pediatricians, pediatric psychologists, and social workers familiar with hospital policy and procedures regarding child maltreatment as well as with the special circumstances involved in assessing, diagnosing, and reporting MBPS. These multidisciplinary teams can provide concrete suggestions for confirming MBPS, help initiate the necessary legal action after the diagnosis has been established, formulate a treatment/intervention plan for the mother, outline a monitoring system to protect the child in the future, and establish criteria for reunification.
The details presented in this case underscore the need to develop sensitive means of identifying and treating children who are victims of MBPS and serve as powerful reminders to directly talk with, and listen to, young patients. This child victim knew from a very early age that her mother's “treatments” were different. Yet, her mother's threats and her father's rejection and denial proved too overwhelming to allow her to directly ask for help. Had one health care provider talked with her privately and won her trust, perhaps she would have been able to talk about the things her mother was doing. When there is suspicion of foul play or MBPS, referral to a mental health professional familiar with child maltreatment could help provide the supportive environment and trusting relationship that children need to begin revealing the truth. In the case presented, a childhood was lost, sibling relationships were irreparably damaged, and an entire family was torn apart by the failure of many systems to respond to this tragedy.
We thank Drs Howard Fischer and Alan Gruskin (Children's Hospital of Michigan), and Judith Libow and Herbert Schreier (Children's Hospital of Oakland) for reviewing the manuscript and for their helpful suggestions. We are also grateful to Dr James Scholl for kindly providing a copy of his original personal notes used in a 1964 case presentation.
- Received July 19, 1996.
- Accepted November 18, 1996.
Reprint requests to (P.T.S.) Department of Child Psychiatry and Psychology, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201.
a The first author is one of the subjects described in Dr Libow's 1995 article.
- MBPS =
- Münchausen by proxy syndrome
- ↵Schreier HA, Libow JA. Hurting for Love: Münchausen by Proxy Syndrome. New York, NY: Guilford Press; 1993
- Levin AV, Sheridan MS. Münchausen Syndrome by Proxy. Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995
- McGuire TL,
- Feldman K
- Bools CN,
- Neale BA,
- Meadow SR
- Libow JA
- Copyright © 1997 American Academy of Pediatrics