SPECIAL ARTICLE
Munchausen by Proxy Defined
Herbert Schreier, MD
ABBREVIATIONS. MBP, Munchausen by proxy; APSAC, Ameri-can Professional Society on the Abuse of Children; PCF, pediatric condition falsification; FDP, factitious disorder by proxy; GI, gas-trointestinal; ALTE, acute life-threatening event.
R
oy Meadow first described Munchausen byproxy (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.1As the condition became more known through professional as well as popular media (some 20 television news-magazine programs), there was a loosening of defi-nitions so that even some workers in the field came to regard medical falsification of a condition in a child sufficient for the diagnosis.2Through brief ex-amples, this article will illustrate the essentials of definitional guidelines compiled by a multidisci-plinary group convened by the American Profes-sional Society on the Abuse of Children (APSAC),3 which were reviewed and modified with the input from several professional societies.4 These defini-tions 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 exagger-ation or fabricexagger-ation that pediatricians and others en-counter 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 psy-chological needs. MBP then is retained as the name applied to the disorder that contains these 2 ele-ments, a diagnosis in the child and a diagnosis in the caretaker.
The APSAC group’s definition recognized that the usual clinical presentation, motivation, and progno-sis 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 adequate-ly), 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 repeat-edly fool the doctor an/or garner attention for her-self 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,5as 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 unknow-able, it is very common both in the criminal justice system and the fields of psychology for an under-standing 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 elsewhere6,7and can only be touched on here. The primary motivation seems to be an intense need for attention from, and manipulation of, powerful professionals,4most frequently, but not exclusively a physician.8 –10It is important to understand that this phenomenon almost always involves the participa-tion of the child’s physician, who at times might be the agent of harm to her child.11In 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,12and 40 to 100 operations for nonexistent conditions are not uncommon. Other “audiences” (social workers, lawyers, therapists) may become im-portant 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 provid-ing an entrance to the excitprovid-ing ambiance of the hos-pital and directly to the pediatrician. Despite a very convincing presentation of deep caring for their chil-dren, 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
suspi-From the Department of Psychiatry, Children’s Hospital Research Institute, 747 52nd St, Oakland, CA 94609. E-mail: [email protected] Received for publication Apr 19, 2001; accepted Mar 6, 2002.
PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad-emy of Pediatrics.
cion to lead to separating her from the child. Fre-quently, 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 motiva-tion of the caretaker may be more difficult and at times requires the skills and efforts of others. How-ever, although the prognosis for caretaker’s treat-ment 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 defini-tions.
PEDIATRIC CONDITION FALSIFICATION IN FACTITIOUS DISORDER BY PROXY: MBP A 6-year-old boy was hospitalized on a major Uni-versity medical center gastroenterology unit. He had exhibited failure to thrive as an infant and was sub-jected to repeated tests including biopsies, for vari-ous gastrointestinal (GI) problems including chronic diarrhea and vomiting. The only positive finding was mild gastroesophageal reflux. During an exten-sive hospitalization that lasted 6 months, he exhib-ited findings that made no clinical sense, eg, gastros-tomy 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 dur-ing 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 psychother-apy. The mother remarried during this time to a man who participated in some of her psychotherapy ses-sions.
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 se-vere 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 hospi-tal. Furthermore, investigation revealed that the mother’s pseudo-seizures had ceased when she be-came 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 demon-strates 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 oc-currence in these cases. This author has reviewed a case in which, when a teaching hospital team sug-gested the strong likelihood of a diagnosis of FDP, an abuse expert doubted the team and the child’s pedi-atrician removed the child from the care of the hos-pital. 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 pro-tected the mother from additional investigation. Years later this child came back near death from “mitochondrial encephalopathy” when several sub-stances, 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 pub-lished case reports involving 105 different symptom presentations.6 GI, neurologic, infectious, dermato-logic, 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. Al-gorithms have been developed for the most common presentations, eg, apnea, to help distinguish it from cases of suffocation, and for pseudo-bowel obstruc-tion.13Indeed, 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.14,15In 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 ill-nesses that will distinguish real sickness from simu-lated 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/hyperac-tivity 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 presen-tation 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.10Another situation where the target seems to be someone other than a physi-cian is seen in some cases of false allegations of sexual abuse.9Generally, false accusations of sexual abuse involve secondary gain such as wresting cus-tody from an abandoning spouse. However, there have been several cases that involve typical MBP motivation and occur along with medical presenta-tions of MBP as well.8It should be noted that con-trary 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 sec-ondary 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 syn-drome,”19in 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 Schreier20and 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 distinc-tion 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 catego-rized as PCF. And neither should a parent who seems difficult because of personality problems, or clashes of temperament with the doctor, be diag-nosed with FDP. Although many MBP mothers can be quite ingratiating, some can be aggressive with medical staff who do not do their bidding. Distin-guishing MBP from situations in which parents ex-hibit contentious interpersonal styles especially those who disagree with the treatment, can also be diffi-cult.21
Culturally specific practices and beliefs can be con-fused with PCF. Although they can cause grave med-ical risks at times,22 this behavior should not be confused with MBP.23,24There 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 ep-isodes 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.27She is so convincing at present-ing a picture of serious asthmatic symptoms28 that she has been intubated unnecessarily on several oc-casions.
CONCLUSION
circum-stances, 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 impor-tant 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 clin-ical-sense of a case is not resulting from some med-ical 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 dem-onstrates 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 pro-cess. These cases may require changes in the way many of us like to think of ourselves practicing med-icine, but in the long run it will hopefully be in the best interest of our patients.
ACKNOWLEDGMENT
This work was partially supported by the Palm Fund in Child Development and Psychiatry.
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DOI: 10.1542/peds.110.5.985
2002;110;985
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Herbert Schreier
Munchausen by Proxy Defined
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