Munchausen Syndrome by Proxy

What is Munchausen syndrome by proxy?

Munchausen syndrome by proxy (MSBP) is a mental health disorder in which a person falsely reports or causes symptoms in another person who is under his or her care. The caregiver almost always is a mother, and the victim, her child. Because children are the victims, Munchausen syndrome by proxy is considered a form of child abuse.

The caregiver with MSBP may:

• Falsely claim a child has experienced serious symptoms, such as seizures.
• Contaminate test results to make a child appear ill.
• Physically harm the child to produce symptoms.

Victims of MSBP, typically small children, often undergo needless and painful medical tests. They may become seriously ill or injured or may die as a result of the actions of the offending caregiver. Many children affected by MSBP develop emotional problems that can last all through life.

In Munchausen syndrome by proxy, a mother may abuse more than one of her children at different times. Children subjected to MSBP are usually younger than 6 years old but may be older. Older children may become convinced that they have an illness. They may passively or actively participate with the caregiver in deceiving health professionals.

This condition is related to Munchausen syndrome, a similar disorder in which a person causes or reports symptoms in himself or herself. Children who are victims of MSBP may later develop Munchausen syndrome as adults.

What causes Munchausen syndrome by proxy?

Medical professionals don't entirely understand what causes a caregiver to create or falsify an illness in a child. A caregiver receives attention from having a sick child. And sometimes a caregiver seeks this type of attention after having had an illness as a child or adult. Also, it appears that MSBP may be related to the abuser's childhood experience. Usually, the abuser grew up feeling unloved and unwanted. She often has poor self-esteem, is unable to manage stress or anxiety, and feels a lack of control over her life.

Also, parents may be motivated by the social rewards they feel they achieve. They may get attention from not only doctors and nurses, but others in their community. Sometimes the parents who deceive others about the health of their child are rewarded with money. People may help out in small or big ways—such as by doing chores, bringing meals, or donating money or services.

How does the caregiver typically act?

A person with Munchausen syndrome by proxy is often intelligent and may have medical training or experience. She usually appears devoted to her child. The respect, sympathy, and attention she gains from health professionals and others who are concerned about the child, including her spouse, make her feel important and in control of events. Her actions serve to maintain this sense of power and control. The caregiver gets emotional fulfillment from the close relationships she develops with the health professionals involved in her child's care. But underneath this satisfaction may be a lot of hostility, which is shown through the ongoing deception.

A person who has MSBP does not seem to perceive her behavior as harmful. She may lack empathy—the capacity to understand what another person is feeling. Although she may appear doting (showing extreme fondness or love), she may actually be emotionally removed from her child.

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

Health professionals may suspect Munchausen symptom by proxy when:

• A child has a recurring or unusual illness for which no adequate explanation can be found. The parent makes the child have many different tests and evaluations, and the child continually fails to respond to or tolerate medical treatments that should improve symptoms.
• 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 or in a setting that is closely monitored. For example, symptoms usually improve when the child is in the hospital. But a caregiver sometimes can still cause her child to develop symptoms or make it appear that way.
• The other parent (usually the father) is noticeably absent. He is uninvolved even though a child's condition may be or appears to be serious.
• Evidence proves that the parent has given false information to health professionals or has contaminated lab samples. Often a caregiver abruptly switches doctors and provides misleading information about prior testing and treatment.
• 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.
• A caregiver is seen or videotaped directly harming the child or causing symptoms.

Also, it may be discovered that the caregiver has a history of Munchausen syndrome. There is more cause for suspicion of MSBP if another child in the family has had unexplained illness or death.

How is Munchausen syndrome by proxy diagnosed?

Diagnosing MSBP is very difficult. If it is suspected, all health professionals involved in the child's care carefully observe, document, and chart all symptoms, laboratory test results, treatments, and the caregiver's behavior. This careful documentation helps ensure that the diagnosis of MSBP is widely supported and that the child does not need any further testing or treatment.

If MSBP or another form of child abuse is diagnosed by health professionals, then local children's protective services, police, and other authorities are notified. Usually, further investigation is not needed, and legal authorities and medical personnel develop a plan to confront the caregiver and ensure the child's safety.

How is Munchausen syndrome by proxy treated?

Protection of the child is the highest priority in all treatment phases. A hospitalized child may be protected by medical staff, children's protective services workers, and possibly police. If the child is currently not hospitalized, he or she is placed in safe custody away from the caregiver. Other children in the family may also be removed from parental custody. It is expected that symptoms will stop after the child is placed away from the caregiver. An individual physician is assigned as the child's primary doctor.

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. Medications are used as treatment only if another diagnosed 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. MSBP behavior has a high recurrence rate, and close monitoring and continuous counseling are usually needed.

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.

Less commonly, the offending caregiver will report symptoms of a behavioral problem or mental (psychiatric) condition such as attention deficit hyperactivity disorder (ADHD) rather than a physical illness.¹

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:²

• 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 examinations, 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 health professionals 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.

The child will be placed in a safe situation, away from the offending caregiver. 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. Whether the child returns to the caregiver's custody depends on the severity of the case and on the caregiver's response to treatment. Some children who are reunited with the offending caregiver become victims of MSBP again.

Treatment for the caregiver includes a complete physical and psychological examination followed by counseling. The counselor attempts 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.

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

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

• Child Abuse and Neglect

Citations

1. Schreier HA (2000). Factitious disorder by proxy in which the presenting problem is behavioral or psychiatric. Journal of the American Academy of Child and Adolescent Psychiatry, 39(5): 668–670.

2. 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

• Forsyth B (2002). Munchausen syndrome by proxy. In M Lewis, ed., Child and Adolescent Psychiatry, 3rd ed., ch. 102, pp. 1223–1230. Philadelphia: Lippincott Williams and Wilkins.

• Hall DE, et al. (2000). Evaluation of covert video surveillance in the diagnosis of Munchausen syndrome by proxy: Lessons from 41 cases. Pediatrics, 105: 1305–1312.

• Metz, WP (2003). Muchausen syndrome by proxy section of Developmental-behavioral pediatrics. In CD Rudolph, AM Rudolph, eds., Rudolph's Pediatrics, 21st ed., ch. 5, pp. 506–508. New York: McGraw-Hill.

• 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.