Munchausen by Proxy Syndrome - Criminal Justice

Munchausen by proxy syndrome (MBP) is a form of child abuse in which a caretaker, usually the mother, exaggerates, fabricates, simulates, or induces symptoms of illness in a minor child. The caretaker presents the child for medical care while denying knowledge of symptom origin. The caretaker wants the child to be regarded as ill in order to meet his or her own self-serving psychological needs. When first identified in the literature, the falsified symptoms of illness were physical (Meadow 1977). The falsification of physical symptoms, and thus medical illness, remains the most commonly identified and physically dangerous form of MBP abuse. The feigning of psychological/psychiatric signs or symptoms has come to be commonly included in MBP definitions as well. In addition, there has been professional realization that caretakers may use other falsified signs or symptoms such as learning disabilities, developmental delays, and the falsification of child abuse allegations to meet their own self-serving psychological needs as well.

The perpetrator is often quite ingenious in the methods used to attempt to deceive medical personnel and other professionals. Most cases present with some mixture of exaggeration, false reporting, and symptom induction. Methods for feigning symptoms are incredibly diverse. These have included ostensibly rather benign actions such as lying, falsifying medical charts, and presenting one’s own blood or other specimens as the child’s. However, many cases have involved such serious and potentially lethal actions as suffocating the child, introducing foreign substances (oral, fecal, and vaginal secretions) into an intravenous line, poisoning, overdosing with laxatives, and giving medications not prescribed for the child. The medical symptoms which are thus falsified or induced are quite varied but commonly include apnea, anorexia or feeding problems, diarrhea, seizures, cyanosis, asthma, allergy, fevers, pain, bleeding, infections, and vomiting. Victims typically present with more than one symptom, which may involve multiple organ systems. This results in an often dizzying array of medical subspecialists who are evaluating and treating the child. As a result, the child-victim may experience numerous medical procedures, which are sometimes painful and invasive. Child-victims may begin life entirely healthy, while other children start life with prematurity or compromising illnesses. The perpetrator may fabricate illness where none exists; the child might really have an illness, about which the perpetrator exaggerates; or the perpetrator may be abusing the child by over- or undertreating an existing condition. Symptom induction commonly occurs even while the child is in the hospital, and has been documented to occur even after the perpetrator has been told that she is under suspicion for abusing her child.

In Dr. Roy Meadow’s original article (1977), a mother simply added her own urine or menstrual discharge to her six-year-old daughter’s specimens and presented her repeatedly for medical care due to foul smelling, bloody urine. This created such concern for the child that the following occurred:

12 hospital admissions, sevenmajor X-rayprocedures . . . , six examinations under anaesthetic, five cystoscopies, unpleasant treatment with toxic drugs and eight antibiotics, catheterizations, vaginal pessaries, and bactericidal, fungicidal, and oestrogen creams; the laboratories had cultured her urine more than 150 times and had done many other tests; sixteen consultants had been involved in her care. (p. 344)

While the child’s mother never admitted any wrongdoing, specimens collected under strict supervision showed no abnormalities, while the ones collected by the mother or left in her presence were grossly abnormal. Furthermore, analysis of the mother’s urine sample suggested that the unsupervised specimens contained some of the mother’s urine. While the mother was under psychiatric care, the child had no further urinary problems.

The other case reported by Meadow involved a toddler boy who was having sudden attacks of vomiting and drowsiness associated with hypernatremia only at home. Extensive investigations showed no problems with his endocrine and renal systems. Between attacks he was otherwise healthy and developing normally. Furthermore, during a prolonged hospital stay, the mother was excluded from visiting the boy and he had no illness until the weekend she was allowed to visit. It was believed that his illness was caused by extreme sodium administration, probably by the mother. During the time arrangements were being made to address these suspicions, the child was again admitted to the hospital and died. Meadow (1994) subsequently reported that the mother twenty years later admitted to killing her son.

Nomenclature and Definition

‘‘Munchausen syndrome by proxy’’ was the name applied by Meadow in 1977 to those two cases of abuse in which the mother falsified illness in her child. (Baron von Munchausen was a popular eighteenth-century Prussian storybook figure with a gift for lies and tall tales.) Since Meadow’s original work, there has been debate about the proper name to apply to this form of abuse. Munchausen by proxy syndrome, Munchausen by proxy, Polle’s syndrome, factitious illness by proxy, and factitious disorder by proxy have all been used as alternative names. Although the American Psychiatric Association has yet to recognize MBP as a formal psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), factitious disorder by proxy has been listed and described in the appendix for proposed categories requiring further study. The DSM-IV lists the following criteria in its definition of factitious disorder by proxy:

Physical or psychological signs or symptoms in a person under another individual’s care are intentionally produced or feigned.
The motivation for the perpetrator’s behavior is to assume the sick role by proxy.
External incentives for the behavior (such as economic gain) are absent.
The behavior is not better accounted for by another mental disorder. (American Psychiatric Association, 1994)

Other terms which are sometimes used in the literature interchangeably with Munchausen by proxy are doctor shopping, help seeking, extreme illness exaggeration, enforced invalidism, and doctor addiction.

These varied terms have also been used in circumstances that are quite different than the original cases identified by Dr. Meadow, which can lead to confusion. The reason for using these terms to apply to other seemingly diverse circumstances is the perceived similarity in the motivations of the perpetrators. The internal dynamics that lead a perpetrator to falsify physical illness in her child often, though not always, involve using the child as an object to build and maintain a relationship with health care professionals, possibly in order to obtain their attention and approval. Thus, a parent may falsify sexual and physical abuse, psychiatric symptoms, behavioral difficulties, developmental delays, and learning disabilities in efforts to maintain relationships with authority figures such as police investigators, child protection workers, lawyers, mental health professionals, and school personnel. The perpetrator again uses whatever means are available to fabricate, exaggerate, simulate, or induce signs of these problems and then presents the child for abuse examinations, special educational services, psychotropic medication, and other services that the child does not truly need. Adding additional confusion is the application of these labels to situations as diverse as adults using other adults or their pets as the proxy.

In an effort to provide some unity of not only the terminology but the behavior being described, the American Professional Society on the Abuse of Children (APSAC) Task Force on Munchausen by Proxy developed a comprehensive set of definitions for the constellation of behaviors currently being defined as MBP that professionals could use to more accurately communicate (Ayoub et al. 2002). The APSAC framework identifies the broader behavior of abuse by condition falsification, in which the victim could be a child or adult. A subgroup, pediatric condition falsification, is defined as a form of child maltreatment in which an adult falsifies physical and/or psychological signs and/or symptoms in a child-victim, causing the victim to be regarded as ill or impaired by others. When the perpetrating adult is believed to have intentionally falsified history or signs or symptoms in a child to meet the adult’s own selfserving psychological needs, then the perpetrator is diagnosed with factitious disorder by proxy. Within this framework it is indicated that there are other situations that are abuse by pediatric condition falsification that do not involve the internal dynamics of factitious disorder by proxy in the perpetrator. These situations may have consequences for the victimwhich are equally as serious as factitious disorder by proxy, but the interventions required to protect the child and the treatment of the perpetrator and family are different. These other situations include falsified sexual abuse allegations to obtain custody or harm the child’s other parent, parental desire to keep a child home from school by using illness, and blatant falsification of symptoms as a cry for help from an overwhelmed parent. Other situations which may need to be differentiated from pediatric condition falsification or factitious disorder by proxy include classic child abuse or neglect, difficult or psychologically impaired parents caring for truly chronically ill children, and children being in the care of overanxious parents.

Perpetrators and Victims

Although most cases of MBP in the published literature are in the United States and the United Kingdom, cases have been reported from many other countries, and MBP is clearly not confined only to countries with complex systems of medical care. Statistics related to MBP rely upon single case studies and two larger-scale studies using metaanalysis (Rosenberg 1987; Sheridan 2003).

Biological mothers are the most common perpetrators of this form of abuse, and this research paper refers mostly to the perpetrators as mothers. However, there have been documented cases in which the perpetrator was a nonbiological mother, the father, a relative, a babysitter, or a nurse. Mother-perpetrators are a diverse group, but certain features seem to reoccur in many, but not all, of the identified cases. These features may be used to assist in raising suspicion about MBP, but only along with medical evidence that raises suspicion as well; and they should never be used in isolation or as the determining factor in identifying a case of MBP, as that must come only from the medical evidence. Each of these features may have alternate explanations or might not be present in a particular case at all.

The mother-perpetrator often has a background in the medical field, through either education, training, or employment. Alternatively, she may have wished for a career in the medical field that never materialized or be exceedingly well versed in the technical details of her child’s medical condition. She may lie about other aspects of her life, even about things that are relatively easily confirmed or disputed, such as educational attainments, prior relationships, past heroic acts, or job history. Reviewing the mother’s educational and employment records as well as interviewing family members and friends will usually be sufficient to detect such fabrications. The perpetrator may have a history of falsifying illness in herself. The mother’s past medical records should be reviewed beginning from childhood when possible.

Although psychological evaluation of the mother-perpetrator is useful to gather background information, understand the mother’s motivations, and gather information pertinent to treatment and reunification, it is important to note that psychological testing and interviews will often indicate no psychopathology at all (Parnell 1998). There has been no evidence to suggest that MBP perpetrators are psychotic, delusional, or in any way not in touch with reality. They are quite aware of their deliberate and intentional fabrications and abusive behavior. They may have coexisting psychiatric disorders such as depression, anxiety, eating disorders, or somatoform disorders (i.e., physical symptoms not fully explained by a medical condition), but these are not the precipitating reasons for the MBP behavior.

The mother-perpetrator’s specific motivations for abusing her child in this manner may vary. There is no single motivation that is essential to this diagnosis, but rather the diagnosis depends upon the general motivation of the mother needing a sick child to serve her own psychological needs. In fact, there are many self-serving psychological needs that have motivated this type of abusive behavior in confirmed MBP cases. Some mothers are escaping stressful or abusive home environments. Some are trying to obtain the attention of absent spouses or family members. Some crave the attention and approval they receive from family and health care professionals for their extraordinary care of the sick child. Others seem to be motivated by the need to control and manipulate doctors and other health care professionals, who they perceive as being in positions of authority. There may be different motivations at different times or simultaneously. In addition, although external incentives (i.e., money) are exclusionary criteria in many diagnostic models, they may co-occur with the primary motivation.

Child-victims are most often infants and toddlers who are unable to disclose what is happening to them. Yet there are some reports of older children in the literature, and in fact these older victims are sometimes coached to participate in the deception or even falsify illness themselves (Libow 2000; Sanders 1995). Male and female children are abused in relatively equal numbers when the perpetrator is the mother. When the much less common scenario occurs and the father is the perpetrator, then male children are more often victimized. Victimization is a repeated pattern of behavior, and those cases that have been eventually detected have gone on for months or years. More than one child in the family may be victimized, and often the method of victimization is the same among siblings. Symptoms are often produced while the child-victim is in the hospital. More than half of the time, the perpetrator actually does something physically to the victim to cause the symptoms, rather than just fabricating, exaggerating, or having the victim simulate illness.

The impact on the victim of MBP is not well understood, since this form of abuse is really still in the early stages of identification and case management. What is known is that the child-victim may suffer unnecessary physical pain either from the parent’s actions or from the intrusive medical procedures ordered by the physician as a result of the deception. Over time the child may experience reduced opportunity to participate in age-appropriate social and educational activities due to repeated or protracted hospitalizations. This may result in long-term developmental disruption. Case reports and one larger-scale study (Bools, Neale, and Meadow 1993) have found conduct and emotional problems for the children, as well as problems related to school and limitations on their lifestyle by questionable or now real disabilities. In adults who had been child-victims of this type of abuse, problems include posttraumatic symptoms, feelings of inadequacy, relationship problems, and poor self-esteem (Libow 1995). In addition, there may be long-term physical damage which results, once again, from the mother’s direct actions or from the unnecessary medical procedures performed to deal with the conditions she has created. MBP abuse can be fatal (Rosenberg 1987; Sheridan 2003).

It is important for survivors, practitioners, and others with healthy concerns in these children’s lives to recognize that this form of child abuse violates the most basic sense of trust and security in the parent–child relationship—typically during the important early years of attachment.

Diagnosis

A significant obstacle to the diagnosis of MBP has been the failure of medical professionals to consider the possibility. Although physicians are trained to consider the reliability of a historian, they are not trained to consider the possibility that everything they hear from a parent may be a complete and elaborate fabrication. With the attention that has now been given to this form of child abuse, identification of cases is on the rise. However, suspicion will often hover around a case before an abuse report is made or other actions are taken to truly investigate the possibility of abuse. The diagnosis of MBP has been fraught with controversy (Allison and Roberts 1998; McGill 2002). Underpinning this controversy are three main issues. First, the perpetrators are primarily mothers and usually biological mothers. In our society it seems impossible that a mother could perpetrate such heinous abuse on her own child. Furthermore, most, although not all, of the mother-perpetrators present in a very positive manner to medical professionals, exhibiting behavior that is viewed as attentive, caring, and nurturing. In light of this, accusing such a mother of this bizarre form of medical child abuse is typically met with resistance and disbelief by other medical professionals and the perpetrator’s family. In fact, these accusations are sometimes turned around to accuse the abuse reporter and/or the physician of formulating these accusations for their own gain (i.e., to cover up medical mistakes, to avoid acknowledging uncertainty regarding the child’s problems). Not unexpectedly for any deceptive and ultimately criminal behavior, the perpetrator does not readily admit her MBP abuse of the child.

The second issue is the drama which often surrounds these cases. Even in the face of irrefutable evidence, the mother-perpetrator often maintains her denial and due to her otherwise stellar parenting and persuasive demeanor, family, friends, attorneys, and mental health professionals are drawn in to her deception and become zealous advocates. Some of these mothers seem to enjoy the excitement of the spotlight and seek attention from the media, politicians, and other high-profile public figures. These cases have also caught the attention of the popular media, being depicted in made-for-TV movies and TV series, novels, true crime books, and various news shows and documentaries. In addition, a few very sensational cases involving multiple child deaths have been labeled MBP cases and received extensive media coverage.

The third issue driving this controversy has been the process of identifying and confirming MBP cases. In early efforts to raise awareness of the possibility of MBP in seemingly caring families, features of the mother-perpetrator and the family system were identified as factors to consider in identification. However, even though it was cautioned that the indicators most salient for identification of cases were those involving the medical condition of the child (Parnell 1998), there was an overreliance on the behavior/personality features of the perpetrator and the family system. While these latter features are vitally important in the long-term management of the case, the initial diagnosis or identification must rely upon the current medical condition of the child, the child’s past medical record, and medical evidence of induction, simulation, fabrication, or exaggeration. If the medical evidence is not thoroughly and meticulously compiled, the likelihood of inaccurate identification of a case increases.

MBP concerns must be taken seriously due to the significant short- and long-term impact on the child-victim, including the possibility of death. At the same time, professionals must always consider and rule out other possible explanations for the concerns raised in a given case. In order to accurately include or exclude this diagnosis, suspected cases require an immediate and well-organized multidisciplinary investigation with a systematic approach to diagnostic clarification that relies primarily on the medical evidence.

The multidisciplinary team will consist of members of the child’s medical team, a physician consultant, child protection team coordinator or child protective services worker, law enforcement officer, psychologist or psychiatrist, prosecutor, and, if hospitalized, nurses and the hospital social worker. The first goal of the team should be child safety, but each professional will have his or her own agenda. Legal, medical, mental health, and family issues are all represented. The medical information immediately available will be reviewed and a determination made regarding whether the case warrants further investigation and also whether the child requires immediate intervention to ensure safety. If the case requires further investigation and/or immediate intervention, the team will develop a plan for both of those issues. For instance, having the child hospitalized for monitoring or requesting court involvement to remove a child from the parent’s custody could be pursued. Medical documents not readily available or prior medical professionals who need to be contacted will be identified. The team will decide the immediate steps required to intervene on the child’s behalf.

As with other forms of abuse, determining whether MBP occurred will usually be based upon circumstantial rather than direct evidence. It is rare that the abusive act of the perpetrator is directly observed, although it does occur, as will be discussed below. However, more commonly, the diagnosis will be made based upon a thorough review of the child’s medical history and current condition by a qualified medical expert. In essence, the goal is to review every piece of paper about the child-victim that can be obtained (i.e., inpatient and outpatient medical records, day care records, school records). The expert has a responsibility to review the information personally and not depend on someone else. The consequences of inaccurately diagnosing MBP or of inaccurately dismissing the diagnosis are too grave. The review of medical records will offer an opportunity to determinate the accuracy of the medical history provided by the mother, confirm whether the mother has fabricated diagnoses or lab findings, and expose lack of continuity of medical care of the child. In addition, review of the records will highlight any inconsistencies between medical findings and reported symptoms, expose diagnoses that do not match medical findings, and confirm that all measures have been taken to exclude possible medical explanations for the child’s condition. An attempt should be made to obtain and review the mother-perpetrator’s medical records as well as the medical records for the mother’s other children, as evidence of illness falsification may be obtained.

When necessary the history provided by the mother should be verified by personal contact with prior health care providers. The expert must be careful to trace every supposed diagnosis of the child back to the original health care provider. Often medical records simply repeat information stated by the parent and/or the history as reported in prior records. Information regarding the mother’s interaction patterns with the child-victim and others is often noted by nurses and social workers in the records as well. The records may also provide evidence of the temporal relationship between the child-victim’s symptoms and the presence of the mother. The expert should talk to anyone who has ever seen the child’s reported symptoms from their beginning. Review of the medical records may reveal additional procedures which are needed to either rule out other medical causes for the child’s condition or detect methods of symptom induction. This may include toxicology screens, monitor recordings of heart rate and respiratory patterns, hematology screens, microbiology studies, or other tests of blood, urine, and vomit samples. It is imperative that such actions be taken in a timely manner and that samples be treated in accordance with the handling of specimens as forensic evidence.

Thorough review of the medical records and history should be sufficient to confirm or dispute a diagnosis of MBP in most cases. However, there are times when more information may be needed because the medical expert is unsure of the diagnosis or there is insufficient evidence to ensure protection of the child-victim. Directed monitoring of the child’s environment may be necessary while additional evidence is gathered. This can be accomplished safely only in the hospital. Directed monitoring means controlling aspects of the child’s environment, not simply watching the family to see what happens. For instance, the child could be monitored closely at all times with special focus on documenting times when any visitors, including the mother, are present. At those times, there should always be medical personnel present in the room. In addition, no access to the child’s records should be allowed, no food or drink should be brought in to the child except by nurses, and the parent should not participate in any medical care given to the child.

Another possibility is to separate the mother from the child by restricting her access to the child entirely. This could occur in a hospital setting after the multidisciplinary team has recommended such action and a court order has been obtained. However, such separation could also occur without hospital admission if a court order were obtained for an emergency shelter care placement. The shelter/ foster home should be a medical shelter/foster home. The foster parent will need to document very carefully all aspects of the child’s condition and functioning, especially specific to alleged medical conditions (e.g., food intake, allergies, symptoms, medications). Separation of mother and child sometimes provides very clear evidence as the child’s condition improves markedly. However, this may not occur in cases where there is also a bona fide medical condition, the symptoms occur only infrequently, the perpetrator’s abuse has now caused a true medical condition, or an older child is colluding in the falsification of illness.

In some cases, the best approach to diagnostic certainty is for the child to be monitored by video surveillance while in the hospital. The video surveillance is not disclosed to the parent and often not disclosed to all of the medical staff. Video surveillance is a controversial issue in which the child’s right to safety is weighed against the parent’s privacy. Video surveillance should never be undertaken without a multidisciplinary team of professionals first determining whether this is the appropriate action and then developing a detailed plan. Moreover, a court order for the surveillance should be obtained. However, when a child’s safety can be protected as a result of the surveillance, the child’s right to be free from future abuse and possible death must be paramount. Furthermore, visual evidence of the abusive behavior by the mother may be the only way to convince others, including a judge, that abuse is occurring and to protect the child during the often-lengthy child protective services process. Video surveillance has documented specific perpetrator acts such as choking or smothering a child, injecting substances into an intravenous line, and falsifying specimens. Clearly, this is a potentially dangerous approach to confirming abuse suspicions and should be done only in accordance with carefully defined protocols (Parnell 1998).

Case Management and Treatment

If suspicions of MBP were not quickly dismissed and the previously described investigation occurred, it is likely that the court will already be involved via the child protective services division. If the MBP diagnosis is then confirmed, the child will need to be removed from the care of the family and placed in an entirely neutral environment, usually a medical foster home, so that the child’s condition may be carefully monitored and scrupulously recorded. Initial placement with extended-family members is not recommended. Although often cooperative with child protective services, extended-family members usually support the mother-perpetrator in her denial and will need additional information before being in a position to properly protect the child-victim. Contact between the mother and the child should not be permitted until the mother is fully engaged in psychotherapy.

Psychological evaluation is often useful during this time to gather more information about the mother-perpetrator and her relationship with the child-victim. The evaluation may establish the issues that led to the MBP abuse or, in the alternative, those issues that led to an erroneous suspicion of MBP. The psychologist can gather all of the pertinent psychosocial information, including medical, psychological, family, childrearing, and educational background. This will be accomplished through interviewing the mother and other family members, reviewing pertinent records of the mother, and conducting psychological testing. The evaluation will also identify any other individual or family issues that need to be addressed when considering reunification of the perpetrator and child. The psychologist will develop a plan for treatment of the perpetrator, including her prognosis and the estimated length of treatment. The evaluator may also address placement of the child and potential for reunification with the mother.

Psychological evaluation of the child may be beneficial to establish his/her emotional, social, and general developmental condition. Especially if the child-victim is preschool age or older, the evaluation should be done quickly to ascertain what the child’s understanding is about what is happening, to determine the child’s capacity to participate in play therapy, and to identify treatment issues. Of most importance, however, is to interview the child, even if full evaluation is not conducted. Older children can and sometimes do disclose the specific abusive behavior of the parent that led to the MBP allegations.

A swift resolution of the abuse investigation is very important as in all cases of suspected abuse. If the child has been abused, that needs to be clearly identified through proper investigation, a case plan should be developed, and a determination made regarding the possibility of reunification. If the child has not been abused, then reunification should occur quickly but with a plan to address any other problems which may have led to the suspicion in the first place. Unfortunately, it is not uncommon for an abuse report to be made and the child to be removed, but a thorough medical, psychological, and child protection investigation is not conducted and the case plan is merely a routine document of parenting classes and evaluation with an inexperienced psychologist. Professionals are often uncertain how to proceed, and the case lingers for a lengthy period of time. In such cases, sometimes the court has returned the child to the parents’ care due to this passage of time and the inadequacy of the child protection response. Needless to say, this is not beneficial for the child or family.

Treatment of child abuse perpetrators represents many challenges, not the least of which is attempting treatment of an individual who denies wrongdoing. MBP perpetrator treatment is most effective with individuals who are able to admit to the specific acts of abuse toward their children and willingly participate in treatment and have few additional psychological problems. Treatment of perpetrators has been successful with intensive individual therapy (Parnell and Day 1998), a family systems approach (Sanders 1996), and an intensive inpatient program working with the individual and the family (Berg and Jones 1999). However, this success has been limited to a relatively small number of cases. Yet, reunification of the child-victim and motherper-petrator should not be attempted without successful treatment of the mother. Some indicators of successful perpetrator treatment are continued acknowledgment of the abuse of the child, recognition of the emotional and physical impact of the abuse on the child, ability to put the child’s needs first, resolution of internal or family issues which may have influenced the decision to engage in abuse of the child, and demonstration of alternative coping skills. In addition, in order to ensure child safety, long-term case management of the family must occur, which includes careful coordination of ongoing medical care of the child, monitoring by a child protective services worker, communication with the child’s school, and family therapy.

Conclusion

MBP is a form of child abuse that may have both short-term and long-term physical and psychological consequences for the victim. While the mother-perpetrator’s actions may be driven by complex psychological processes, the focus of these cases must remain the definition of the problem as one of a dangerous type of child maltreatment.

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