Munchausen Syndrome by Proxy

	Topic Overview
	Symptoms
	Exams and Tests
	Treatment Overview
	Home Treatment
	Other Places To Get Help
	Related Information
	References
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What is Munchausen syndrome by proxy?

Munchausen syndrome by proxy (MSBP) is a mental health problem in which a caregiver makes up or causes an illness or injury in a child under his or her care. The caregiver is usually a mother, and the victim is her child. Because children are the victims, MSBP is a form of child abuse.

The caregiver with MSBP may:

• Lie about the child’s symptoms.
• Change test results to make a child appear ill.
• Physically harm the child to produce symptoms.

Victims are most often small children. They may get painful medical tests they don't need. They may even become seriously ill or injured or may die because of the actions of the caregiver.

Children who are victims of MSBP can have lifelong physical and emotional problems and may have Munchausen syndrome as adults. This is a disorder in which a person causes or reports his or her own symptoms.

What causes Munchausen syndrome by proxy?

Doctors aren't sure what causes it, but it may be linked to problems during the abuser's childhood. Abusers often feel like their life is out of control. They often have poor self-esteem and can't deal with stress or anxiety.

The attention that caregivers get from having a sick child may encourage their behavior. Caregivers may get attention not only from doctors and nurses but also from others in their community. For example, neighbors may try to help the family in many ways—such as by doing chores, bringing meals, or giving money.

How does someone with Munchausen syndrome by proxy act?

A person with MSBP often:

• Has medical skills or experience.
• Seems devoted to her child.
• Looks for sympathy and attention.
• Tries too hard to become close and friendly with medical staff.
• Needs to feel powerful and in control.
• Does not see her behavior as harmful.

What are the clues that a person may have Munchausen syndrome by proxy?

Doctors or nurses may suspect a problem when:

• A child has a repeated or unusual illness, and no reason can be found.
• The child doesn't get better, even with treatments that should help. Symptoms only occur when the caregiver is with or has recently been with the child. But symptoms get better or go away when the caregiver is not there or is being closely watched.
• The other parent (usually the father) is not involved in the child’s treatment, even though the child's condition may be serious.
• A caregiver suddenly changes doctors and lies about prior testing and treatment.
• Normal test results don't reassure the caregiver. And she may be strangely calm or happy when her child’s condition is getting worse.
• The caregiver is seen (or videotaped or recorded) harming the child or causing symptoms.
• Another child in the family has had unexplained illness or death.

How is it treated?

Caregivers with Munchausen syndrome by proxy need long-term counseling. They may resist treatment or deny that there is a problem. Medicines are used only when the caregiver has another health problem, such as anxiety disorder, along with MSBP.

Even after treatment, caregivers may repeat their behavior. So doctors, counselors, and family members need to closely watch how the caregiver interacts with her children.

For victims, the first step is to protect the child by moving him or her into safe custody. Then a doctor will assess the child. Most of the time, the child’s symptoms stop after the child is away from the caregiver. Some children need counseling or other help.

What should you do if you think someone has Munchausen syndrome by proxy?

MSBP is child abuse. If you suspect that a child is a victim, do not confront the suspected caregiver. This might make the problem worse. Instead, think about these options:

• Keep a journal of the child’s symptoms and other related events.
• Talk with your doctor about your concerns.
• Report your concerns to your local child welfare agency. You can make a report without using your name (anonymous).

Frequently Asked Questions

The following warning signs may alert health professionals that a parent (typically the mother) or caregiver has Munchausen syndrome by proxy (MSBP):

• A child has a recurring or unusual illness for which no adequate explanation can be found. The parent has the child go through many different tests and evaluations. And the child continually fails to respond to or tolerate medical treatments that in most cases are effective.
• Symptoms occur or begin only when the caregiver is with or has recently been with the child. Symptoms improve or do not occur when the caregiver is absent.
• The other parent (usually the father) is noticeably absent. He is uninvolved even though a child's condition may be or appear to be serious.
• Evidence proves that the parent has given false information to health professionals or others.
• Normal test results do not reassure the parent. She is inappropriately calm or euphoric when her child's condition is most severe.
• The caregiver makes an exceptional effort to become friendly and close to medical staff. She may seek medical care for the child from a series of doctors if current relationships become strained.
• The caregiver is seen or videotaped directly harming the child or causing symptoms.

The discovery that the caregiver has been diagnosed with a similar condition, Munchausen syndrome, in which a person causes or reports symptoms in herself, is also a symptom.

Symptoms in the child who is a victim of Munchausen syndrome by proxy vary, depending on the actions of the abuser. The caregiver may report false symptoms (such as periods of not breathing during sleep, known as apnea), manipulate laboratory samples (such as by adding blood or feces to them), or physically harm the child to produce symptoms. In some cases, the caregiver smothers the child or otherwise causes him or her to stop breathing. The caregiver may also feed or inject the child with substances such as medicines or poisons to cause illness.

Sometimes the caregiver will report symptoms of a behavioral problem or mental health condition such as attention deficit hyperactivity disorder (ADHD) rather than a physical illness.

Sometimes MSBP starts with a child receiving medical attention for a true illness. In order to continue receiving attention from medical personnel, the caregiver may exaggerate, prolong, or produce additional symptoms.

Munchausen syndrome by proxy (MSBP) is diagnosed if the following criteria are met:¹

• Evidence proves that the caregiver is intentionally causing or reporting symptoms in another person under his or her care (a proxy).
• The caregiver seems to be motivated by involvement with the illness of the person under his or her care.
• No outside incentives or motivations (such as payment for false medical claims) account for the caregiver causing or reporting illness in the other person.
• The caregiver is not suffering from any other mental illness.

Doctors who suspect MSBP in a caregiver usually avoid putting the child through unnecessary tests. The child may be admitted to a hospital where he or she is carefully examined and observed. Health professionals also observe first-hand or video-record the caregiver's behavior as they try to discover whether she is producing the symptoms in her child.

A review of past medical records may provide useful information or show inconsistencies about past exams, tests, treatments, and even hospital stays that can help determine whether a child's illness is real. But if the offending caregiver has provided false information, medical records can be misleading. Medical records may show that the caregiver has frequently consulted new doctors—the caregiver may change doctors to avoid confrontation with evidence of induced or fabricated illness in the child. In rare cases, a doctor gives in to the parent's demands for a diagnosis and treatment to calm a demanding or threatening parent.

If MSBP is confirmed or highly suspected, health professionals are required by law to file a report with the local health department or child welfare agency.

Child protective services, law enforcement, and doctors are all involved with treatment for Munchausen syndrome by proxy (MSBP). Treatment is very complex and involves the child, the caregiver, and possibly other family members. When a caregiver is known to have MSBP, his or her doctor will need to tell other family members how the illness affects everyone involved. Family members may be asked to support the caregiver and child as much as they can.

The child will be placed in a safe situation, away from the offending caregiver. And doctors will monitor the child for symptoms and will provide counseling. Young children who are victims of MSBP may respond well to play therapy.

A diagnosis of MSBP may be confirmed if the child's symptoms improve or disappear after the child has been separated from the caregiver. A hospital stay may be needed or continued if the child's current symptoms are serious. The child may later be placed in foster care.

Treatment for the caregiver includes a complete physical and psychological exam followed by counseling. The counselor tries to help the caregiver understand how she has harmed her child. Also, strategies are offered to help the caregiver manage anxiety, stress, self-esteem problems, and problems with feeling in control of her life. Whether the child returns to the caregiver's custody depends on the severity of the case and on the caregiver's response to treatment.

Treatment for the caregiver usually is coordinated through the legal system. Long-term psychotherapy is used to help the caregiver acknowledge and express her need for support, respect, and connection. Dealing with these emotional needs more directly may help prevent her from projecting them onto her child. Therapy also focuses on helping her to develop empathy, so she understands the effect her behavior has had on her child. Medicines are used as treatment only if another condition, such as anxiety disorder, exists along with MSBP.

Caregivers with MSBP very often resist treatment. Typically, they experience extreme denial about the problem and diagnosis. Also, these caregivers often try to manipulate health professionals involved in their treatment.

Munchausen syndrome by proxy (MSBP) is a form of child abuse. Adults who suffer from this disorder need to be diagnosed and treated by a doctor as soon as possible.

MSBP behavior has a high recurrence rate, and close monitoring and continuous counseling are usually needed. Some children who are reunited with the offending caregiver become victims of MSBP again.

MSBP affects an entire family, not just a mother and child. Support from family and friends can help the mother and child during and after treatment.

If you suspect a child is a victim of Munchausen syndrome by proxy, do not confront the suspected caregiver. This may cause the person to leave the area or hurt the child more to convince others that a reported illness really exists. Consider the following options:

• Keep a diary of the child's symptoms and significant life events, if possible.
• Talk to a health professional about your concerns.
• Report your suspicions to the local health department or child welfare agency. You can make anonymous reports.
• Report your concerns to local police authorities.

Organizations

Related Information

• Child Abuse and Neglect

Citations

1. American Psychiatric Association (2000). Factitious disorder by proxy. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 781–783. Washington, DC: American Psychiatric Association.

Other Works Consulted

• Johnson CF (2007). Munchausen syndrome by proxy (MSBP) section of Abuse and neglect of children. In RM Kliegman et al., eds., Nelson Textbook of Pediatrics, 18th ed., pp. 182–184. Philadelphia: Saunders Elsevier.

• McDermott BE (2008). Factitious disorder by proxy section of Factitious disorder and malingering. In RE Hales et al., eds., The American Psychiatric Publishing Textbook of Psychiatry, 5th ed., pp. 649–652. Washington, DC: American Psychiatric Publishing.

• Wang D, et al. (2005). Factitious disorders. In BJ Sadock et al., eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 1, pp. 1829–1843. Philadelphia: Lippincott Williams and Wilkins.