Roy Meadow first described Munchausen by proxy (MBP) in 1977 in England. Since then, there have been over 400 reports in the world’s pediatric and child psychiatry literature. Although it is often described as a rare disorder, when the results of a very carefully conceived, total population study done in England are transposed to the United States, some 1200 new cases of suffocation and poisoning alone would be expected to occur each year.1 As the condition became more known through professional as well as popular media (some 20 television news-magazine programs), there was a loosening of definitions so that even some workers in the field came to regard medical falsification of a condition in a child sufficient for the diagnosis.2 Through brief examples, this article will illustrate the essentials of definitional guidelines compiled by a multidisciplinary group convened by the American Professional Society on the Abuse of Children (APSAC),3 which were reviewed and modified with the input from several professional societies.4 These definitions create a specific term to be used for the medical diagnosis in the child, to wit “pediatric condition falsification” (PCF). But this approach recognizes that there are many serious forms of illness exaggeration or fabrication that pediatricians and others encounter that involve motivations other than those found in MBP. Factitious disorder by proxy (FDP) is the diagnostic category for the caretaker who harms her child though PCF for particular self-serving psychological needs. MBP then is retained as the name applied to the disorder that contains these 2 elements, a diagnosis in the child and a diagnosis in the caretaker.
The APSAC group’s definition recognized that the usual clinical presentation, motivation, and prognosis in MBP is such that distinguishing it from other forms involving PCF is essential for the protection of the child. The mother who falsifies symptoms in her child to get help either for herself (because she might be overwhelmed) or the child (because she truly believes that the child is not being treated adequately), or the mother who does so because she has a delusional belief that the child is ill, will pose much different risks for that child than the mother whose motivation might be a compulsive need to repeatedly fool the doctor an/or garner attention for herself as an ideal parent. This is not an a priori belief; rather, it has been demonstrated that the recidivism rate of mothers suffering from FDP is exceptionally high even in the moderately serious cases,5 as is the death rate of 6%.1 These mothersa have even been known to kill their children on supervised visits.
Although others have argued that it is difficult to know another’s motivation, even that it is unknowable, it is very common both in the criminal justice system and the fields of psychology for an understanding of motivation to be based on circumstantial evidence. In the case of FDP, there have been enough cases studied intensively that show commonalities that strongly suggest motivational needs that can be seen as quite distinct from those found in other forms of PCF and from the more common forms of child abuse. These data have been elaborated on in greater detail elsewhere6,7 and can only be touched on here. The primary motivation seems to be an intense need for attention from, and manipulation of, powerful professionals,4 most frequently, but not exclusively a physician.8–10 It is important to understand that this phenomenon almost always involves the participation of the child’s physician, who at times might be the agent of harm to her child.11 In a meta-analysis of early published cases, 75% of the morbidity occurred in hospitals (1 mother suffocated and revived her 2-year-old 3 times in 1 day) and at the hands of the physician,12 and 40 to 100 operations for nonexistent conditions are not uncommon. Other “audiences” (social workers, lawyers, therapists) may become important to her after the mother has been suspected and the child removed from her care. The child is kept close at hand, and serves the mother by providing an entrance to the exciting ambiance of the hospital and directly to the pediatrician. Despite a very convincing presentation of deep caring for their children, these mothers, when observed for many hours through surreptitious videotaped surveillance, do not relate or are directly cruel to their children. Even when they leave glaring clues of their actions, it is astonishing to see how long it often takes for suspicion to lead to separating her from the child. Frequently, it is only on such separation that it becomes apparent that there is nothing medically wrong. These guidelines recognize that pediatricians will usually initially recognize and respond to the harm and abuse of their patient. Teasing out the motivation of the caretaker may be more difficult and at times requires the skills and efforts of others. However, although the prognosis for caretaker’s treatment will vary by her diagnosis, the responsibility of the pediatrician to report to protective services must be defined by the child’s harm. What follows are cases that exemplify the use of the APSAC definitions.
PEDIATRIC CONDITION FALSIFICATION IN FACTITIOUS DISORDER BY PROXY: MBP
A 6-year-old boy was hospitalized on a major University medical center gastroenterology unit. He had exhibited failure to thrive as an infant and was subjected to repeated tests including biopsies, for various gastrointestinal (GI) problems including chronic diarrhea and vomiting. The only positive finding was mild gastroesophageal reflux. During an extensive hospitalization that lasted 6 months, he exhibited findings that made no clinical sense, eg, gastrostomy drainage volumes 5 to 6 times what he was being given. He also had 2 acute life-threatening events (ALTEs) during which he stopped breathing. These occurred late in the hospitalization, and during revival efforts the mother was overheard by a nurse “gleefully” describing the events. However, it was not until the second ALTE that the child was separated from her. He recovered totally except for residua from his apnea events.
He was returned wheelchair-bound to his mother after a 6-month course of court-ordered psychotherapy. The mother remarried during this time to a man who participated in some of her psychotherapy sessions.
Years later an infant child of this mother was being evaluated at several centers, including one affiliated with the first university hospital, for a puzzling severe growth retardation (the child weighed 7 pounds at 7 months old). He had been subjected to numerous tests including muscle biopsies. The geneticist at one hospital called this author, knowing of his familiarity with FDP because she had discovered that the mother had been treated for pseudo-seizures. When the author went to meet with the GI staff in the hospital where the infant was being evaluated, he recognized from the names in the history that this was the parent of the first child who had the ALTEs and GI problems. The infant was separated from the mother and gained 2 pounds in 2 days in the hospital. Furthermore, investigation revealed that the mother’s pseudo-seizures had ceased when she became pregnant with this child’s older sibling, who also exhibited FTT. That child started gaining weight when the mother became pregnant with the child that was now being starved.
Not only did the father of these 2 infants support his wife at her family court trial, the therapist who treated her in court-ordered therapy relating to the first child testified that she did not have MBP, and believed that she was being falsely accused.
There is no doubt that this mother was involved in multiple episodes of pediatric condition falsification, some of which were fabrications and some were direct harm induction. Both types were potentially lethal. In each case, the mother’s motivation seemed to be to seek involvement with the medical staff, either through herself (pseudo-seizures, pregnancy) or her children. She left glaring clues that were not recognized, even by a physician very familiar with MBP.6
The details of the 6-month hospitalization demonstrates the importance of the medical milieu for this mother. She exhibited gleeful responses to the near death of her child as well as her ability to starve at least 1 helpless infant over a similar time frame. These behaviors strongly support the dynamics as described above. The fooling of another nonmedical professional (her therapist) is not an uncommon occurrence in these cases. This author has reviewed a case in which, when a teaching hospital team suggested the strong likelihood of a diagnosis of FDP, an abuse expert doubted the team and the child’s pediatrician removed the child from the care of the hospital. A sibling of this child had died mysteriously years before and a possibility of MBP was raised, but could not be proven. The pediatrician herself initially raised the possibility of FDP in this child, but protected the mother from additional investigation. Years later this child came back near death from “mitochondrial encephalopathy” when several substances, including toxic doses of aspirin that he had been given, proved to be the cause of his state. The mother in the first case described above received minimal jail time (90 days), but did eventually lose custody of her children. She has since had another child.
There are numerous conditions (PCF) included in case presentations of MBP. In 1993, there were published case reports involving 105 different symptom presentations.6 GI, neurologic, infectious, dermatologic, and cardiopulmonary are the most common forms of fabrications. Younger children, particularly infants, are the most likely victims. However, when undiscovered, the problem can go on for years. Algorithms have been developed for the most common presentations, eg, apnea, to help distinguish it from cases of suffocation, and for pseudo-bowel obstruction.13 Indeed, it is difficult to evaluate the possibility of 2 and especially 3 sudden infant death syndrome deaths occurring in a family as some of the reports finding a “genetic” component were confounded by cases of MBP involving multiple suffocations.14,15 In a British study, one tenth of children who suffered “cot deaths” were siblings of children in the child abuse lists. From another point of view, a sibling of a child on the abuse list had a 1 in 26 chance of dying as a cot death.16 There is a great need to develop clinical algorithms for many common pediatric illnesses that will distinguish real sickness from simulated disorders (see reference 17 for example).
FDP INVOLVING PSYCHIATRIC CONDITIONS
Cases of FDP involving psychiatric conditions have been described,18 and they include multiple personality disorder, bipolar disorder, psychosis, chronic fatigue syndrome, attention-deficit/hyperactivity disorder, and various psychological symptoms associated with severe allergies. In one recent case that this author consulted on, a 9-year-old boy was placed in a special long-term psychiatric unit after multiple hospitalizations for acute psychosis. It took 8 months for him to drop a very convincing presentation of psychosis and admit that he went along with his mother’s false description of his mental state. Psychiatric FDP is likely to be more difficult to uncover, but it also seems to be much less common that medical presentations.
Manipulations involving the same dynamics as MBP in the context of the school system, where school psychologists have been the major “targets,” have also been described.10 Another situation where the target seems to be someone other than a physician is seen in some cases of false allegations of sexual abuse.9 Generally, false accusations of sexual abuse involve secondary gain such as wresting custody from an abandoning spouse. However, there have been several cases that involve typical MBP motivation and occur along with medical presentations of MBP as well.8 It should be noted that contrary to Diagnostic and Statistical Manual of Mental Disorders, other motivations than those described here may co-exist in MBP, eg, monetary gain or gaining custody, but in MBP such concerns are secondary to the dynamics described above.
PEDIATRIC CONDITION FALSIFICATION (PCF), BUT NOT FDP (ie, NOT MBP)
There have been several situations in which illness fabrication (PCF) can take place and not be a part of MBP. These include the so-called “masquerade syndrome,”19 in which a caretaker, to keep a child with her, will amplify or falsify an illness or go along with a child’s doing so to keep her home from school. A mother who has a delusional belief that her child is ill will stop bringing her to the doctor when the cause of her delusion (eg, psychotic depression) is dealt with. A mother who is using a fabricated illness (eg, cranberry juice in the child’s diaper) to get help for herself will stop this behavior if she is given the help she seeks. The latter case represents the so-called “help-seeker” described by Libow and Schreier20 and is not MBP. There will be overly anxious parents who “doctor-shop” because they believe that their child is not being diagnosed or treated correctly. These parents may agree to tests, but usually will be anxious about them, want to know what they are for, and if there are risks. This is not typical of FDP mothers. “Doctor shopping” per se, then, is not MBP. It is only when the motivation involves the self-serving psychological needs described above that the term should be used as a part of MBP. This distinction is not always easy to discern.
NEITHER PCF NOR FDP
Parents who describe accidental injury to cover their own abuse of that child should not be categorized as PCF. And neither should a parent who seems difficult because of personality problems, or clashes of temperament with the doctor, be diagnosed with FDP. Although many MBP mothers can be quite ingratiating, some can be aggressive with medical staff who do not do their bidding. Distinguishing MBP from situations in which parents exhibit contentious interpersonal styles especially those who disagree with the treatment, can also be difficult.21
Culturally specific practices and beliefs can be confused with PCF. Although they can cause grave medical risks at times,22 this behavior should not be confused with MBP.23,24 There are bona fide medical conditions that can raise suspicions of being caused by a parent. For example, we have seen cases of cyclical vomiting where the parent was suspected by a doctor unfamiliar with the condition, and a child with repeated ALTEs associated with vaso-vagal episodes caused by strong emotions associated with sobbing.25
Munchausen Syndrome in Teens
Munchausen syndrome, ie, self-harming behavior, in a teenager for purposes similar to that seen in MBP is at times a continuation of a process wherein the teen was a child victim of MBP abuse, but can arise de novo, even in young teens. One teenager self-administered coma-inducing levels of insulin just after her mother had visited her in the hospital. Many of the MBP mothers describe inducing illness in themselves in their teenage years.26 This author has seen a teenager who demanded and received pain medication in our hospital for her nonexistent sickle cell disease.27 She is so convincing at presenting a picture of serious asthmatic symptoms28 that she has been intubated unnecessarily on several occasions.
MBP is unfortunately not an uncommon disorder. Its toll is taken not only on the child, or on medical care services through unnecessary expense, but in a special way on physicians and other caretakers. The role the physician plays in the process deserves longer discussion.6 The interested reader is referred to an article on the “perversions of mothering” for thoughts on the intrapsychic dynamic issues in the mothers,29 and to chapter 7 of Hurting for Love,6 which examines the interpersonal dynamics between the mother and the professionals involved. Suffice it to say, few of us dedicating our lives to helping children, and seeing ourselves not only as altruistic but also as independent and capable of solving difficult medical puzzles, when faced with a woman who seems to be deeply caring and sacrificing, and who is in our profession (many FDP mothers have nursing or other medical backgrounds), will be hard pressed not to be caught-up in trying “too hard” to find the cause of the child’s pain. In these circumstances, the potential for missing that she is standing right next to us at the bedside, is great.
There are simple things that can be done that can bring this process to a quicker halt. The most important is consulting with colleagues, especially those who have treated the child before. A nonrushed, records review and case conference with as many previous treating physicians as possible is essential. This will often strongly suggest that the lack of clinical-sense of a case is not resulting from some medical problem in the child. Most of the evidence that is needed to demonstrate the mother’s hand, aside from some careful laboratory documentation, can often be garnered from a “separation test” that demonstrates that the child is free of disease outside the care of the mother. Evaluation of the mother must be by a professional thoroughly experienced with MBP.
The APSAC definitions are offered in the hope of bringing some clarity and uniformity to the difficult field of illness falsification. It seems an exaggeration to say that MBP has in some ways changed the face of pediatrics, until one has experience with the process. These cases may require changes in the way many of us like to think of ourselves practicing medicine, but in the long run it will hopefully be in the best interest of our patients.
This work was partially supported by the Palm Fund in Child Development and Psychiatry.
- Received April 19, 2001.
- Accepted March 6, 2002.
↵a Mothers will be used here because over 95% of MBP is committed by women.
- ↵McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child.1996;75 :57– 61
- ↵Rosenberg D. From lying to homicide: the spectrum of Munchausen syndrome by proxy. In Levin A, Sheridan M, eds. Munchausen Syndrome by Proxy. Issues in Diagnosis and Treatment. New York, NY: Lexington Books; 1995
- ↵Ayoub C, Alexander R, Beck D, et al. Definitional issues in Munchausen by proxy. The APSAC Advisor.1998;11 :77– 10
- ↵Ayoub C, Alexander R, Beck D, et al. Definitional issues in Munchausen by proxy. Child Maltreatment.2002;7 :105– 111
- ↵Bools CN, Neale B, Meadow SR. follow-up of victims of fabricated illness (MSBP). Arch Dis Child.1993;69 :625– 630
- ↵Schreier HA, Libow JA. Hurting for Love: Munchausen by Proxy Syndrome. New York, NY: Guilford Press; 1993
- ↵Meadow R. False allegations of abuse and Munchausen syndrome by proxy. Arch Dis Child.1993;68 :444– 447
- ↵Ayoub C, Schreier HA. Munchausen by proxy in special education. Child Maltreatment.2002;7 :149– 159
- ↵Jureidini J, Donald T. Child abuse specific to the medical system. In: Adshead E, Brooke D, eds. Munchausen’s Syndrome by Proxy. Current Issues in Assessment, Treatment and Research. London, United Kingdom: Imperial College Press; 2001
- ↵Hyman P, Bursch B, Beck D, Dilorenzo M, Zeltzer L. Discriminating Munchausen syndrome by proxy from chronic intestinal pseudo-obstruction in toddlers. Child Maltreatment.2002;7 :132– 137
- ↵Firstman R, Talan J. The Death of Innocents: A True Story of Murder, Medicine, and High-Stakes Science. New York, NY: Bantam Books; 1997
- ↵Truman TL, Ayoub C. Considering suffocatory abuse and Munchausen by proxy in the evaluation of children experiencing apparent life-threatening events and SIDS. Child Maltreatment.2002;7 :138– 148
- ↵Schreier HA. Factitious presentation of psychiatric disorder: when is it Munchausen by proxy? Child Psychol Psychiatry Rev.1997;2 :108– 115
- ↵Waller D, Eisenberg L. School refused in childhood-a psychiatric-pediatric perspective. In: Hersov L, Berg I, eds. Out of School. Chichester, United Kingdom: Wiley; 1980
- ↵Fadiman A. The Spirit Catches You and You Fall Down. New York, NY: The Noonday Press; 1997
- ↵Stephenson JBP. Specific Syncopes and Anoxic Seizure Types in Fits and Faints. Philadelphia, PA: JB Lippincott Co; 1990:59–81
- ↵Libow JA. Child and adolescent illness falsification. Pediatrics.2000;105 :336– 342
- ↵Ballas S. Factitious sickle cell acute painful episodes: a secondary type of Munchausen syndrome. Am J Hemotol.1996;53 :254– 258
- Copyright © 2002 by the American Academy of Pediatrics