Munchausen Syndrome by Proxy

Child Abuse and Neglect

Basil J. Zitelli MD , in Zitelli and Davis' Atlas of Pediatric Physical Diagnosis , 2018

Medical Child Abuse

Medical child abuse, known also as Munchausen syndrome by proxy, occurs when a child receives unnecessary and harmful or potentially harmful medical care caused by the caregiver's exaggerating or lying about the history, causing illness in the child or falsifying physical findings.

Many of these parents seek care from multiple providers, so it is especially important to try to access all documentation of prior care when there is concern about possible medical child abuse.

Diagnosis of medical child abuse, although difficult because the onset can often be gradual but escalating, is important because prognosis can be poor if appropriate action is not taken.

Munchausen Syndrome by Proxy

Joeli Hettler MD , in Pediatric Clinical Advisor (Second Edition), 2007

Basic Information

Definition

Munchausen syndrome by proxy (MSBP) is a form of child maltreatment in which caretakers exaggerate, feign, or induce symptoms or illness in children in search of attention and personal gratification for themselves.

Synonyms

Factitious disorder by proxy

Meadow's syndrome

Pediatric falsification syndrome

Polle's syndrome

ICD‐9‐CM Code

301.51 Munchausen syndrome by proxy (MSBP)

Epidemiology & Demographics

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Children are affected equally with respect to gender and birth order.

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Perpetrator characteristics are as follows:

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The patient's mother in 76%

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Often has training in a medical field

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May have an affective or personality disorder

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May have experienced physical or sexual abuse as a child

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Duration from onset of symptoms to diagnosis is months to years.

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Mean age at diagnosis is 20 to 22 months.

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Children 5 years of age with MSBP are likely to have developmental delay.

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55% of children have other chronic illness.

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One incidence study from Great Britain found the following:

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2.8 per 100,000 children younger than 1 year of age

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0.5 per 100,000 children younger than 16

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The mortality rate is 6% to 33%.

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25% of victims' known siblings are dead.

Clinical Presentation

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Gathering a meticulous history is crucial; poor history taking has been implicated in contributing to the misdiagnosis of MSBP.

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There is no typical history; the most common presentations include the following:

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Seizures

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Bleeding

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Central nervous system depression

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Apnea

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Vomiting or diarrhea

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Fever

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Rash

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A few generalizations can be made:

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The child's medical problems have not responded as expected to therapy.

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The child's medical course has been unusual in some way.

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Family history may elicit numerous medical problems that seem implausible.

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Others have unexplained illness while under the supervision of the caregiver.

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There may be signs of physical abuse, neglect, or failure to thrive.

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Signs and symptoms of child's illness fail to occur in the caregiver's absence.

Etiology

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Many practitioners believe that MSBP is symptomatic of a psychiatric disturbance in the perpetrator, who acts in a premeditated way, rather than out of acute frustration or rage.

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Some argue that MSBP is a product of many factors:

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A parent who has the capacity for abuse and the potential to be gratified by the medical system

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A medical system that is specialized, investigation oriented, fascinated by rare conditions, often ignorant of abusive behaviors, and accepting of reported histories

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Caregivers may do any combination of the following:

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Give a false story of illness

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Fabricate a sign of illness

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Interfere with test results

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Abused and Neglected Children

Robert M. Kliegman MD , in Nelson Textbook of Pediatrics , 2020

16.2

Medical Child Abuse (Factitious Disorder by Proxy, Munchausen Syndrome by Proxy)

Keywords

apnea

bleeding

factitious disorder by proxy

MCA

medical child abuse

Munchausen syndrome by proxy

recurrent sepsis

seizures

The termMunchausen syndrome is used to describe situations in which adults falsify their own symptoms. InMunchausen syndrome by proxy, a parent, typically a mother, simulates or causes disease in her child. Several terms have been suggested to describe this phenomenon: factitious disorder by proxy, pediatric condition falsification, and currently,medical child abuse (MCA). In some instances, such as partial suffocation, child abuse may be most appropriate.

The core dynamic of MCA is that a parent falsely presents a child for medical attention. This may occur by fabricating a history, such as reporting seizures that never occurred. A parent may directly cause a child's illness, by exposing a child to a toxin, medication, or infectious agent (e.g., injecting stool into an intravenous line). Signs or symptoms may also be manufactured, such as when a parent smothers a child, or alters laboratory samples or temperature measurements. Each of these actions may lead to unnecessary medical care, sometimes including intrusive tests and surgeries. The "problems" often recur repeatedly over several years. In addition to the physical concomitants of testing and treatment, there are potentially serious and lasting social and psychological sequelae.

Child healthcare professionals are typically misled into thinking that the child really has a medical problem. Parents, sometimes working in a medical field, may be adept at constructing somewhat plausible presentations. A convincing seizure history may be offered, and a normal electroencephalogram (EEG) cannot fully rule out the possibility of a seizure disorder. Even after extensive testing fails to lead to a diagnosis or treatment proves ineffective, health professionals may think they are confronting a new or rare disease. Unwittingly, this can lead to continued testing (leaving no stone unturned) and interventions, thus perpetuating the MCA. Pediatricians generally rely on and trust parents to provide an accurate history. As with other forms of child maltreatment, an accurate diagnosis of MCA requires that the pediatrician maintain a healthy skepticism under certain circumstances.

Clinical Manifestations

The presentation of MCA may vary in nature and severity. Consideration of MCA should be triggered when the reported symptoms are repeatedly noted by only 1 parent, appropriate testing fails to confirm a diagnosis, and seemingly appropriate treatment is ineffective. At times, the child's symptoms, their course, or the response to treatment may be incompatible with any recognized disease. Preverbal children are usually involved, although older children may be convinced by parents that they have a particular problem and become dependent on the increased attention; this may lead to feigning symptoms.

Symptoms in young children are mostly associated with proximity of the offending caregiver to the child. The mother may present as a devoted or even model parent who forms close relationships with members of the healthcare team. While appearing very interested in her child's condition, she may be relatively distant emotionally. She may have a history of Munchausen syndrome, although not necessarily diagnosed as such.

Bleeding is a particularly common presentation. This may be caused by adding dyes to samples, adding blood (e.g., from the mother) to the child's sample, or giving the child an anticoagulant (e.g., warfarin).

Seizures are another common manifestation, with a history easy to fabricate, and the difficulty of excluding the problem based on testing. A parent may report that another physician diagnosed seizures, and the myth may be continued if there is no effort to confirm the basis for the "diagnosis." Alternatively, seizures may be induced by toxins, medications (e.g., insulin), water, or salts. Physicians need to be familiar with the substances available to families and the possible consequences of exposure.

Apnea is also a common presentation. The observation may be falsified or created by partial suffocation. A history of a sibling with the same problem, perhaps dying from it, should be cause for concern. Parents of children hospitalized for brief resolved unexplained events (or apparent life-threatening events) have been videotaped attempting to suffocate their child while in the hospital.

Gastrointestinal signs or symptoms are another common manifestation. Forced ingestion of medications such as ipecac may cause chronic vomiting, or laxatives may cause diarrhea.

Theskin, easily accessible, may be burned, dyed, tattooed, lacerated, or punctured to simulate acute or chronic skin conditions.Recurrent sepsis may be caused by infectious agents being administered; intravenous lines during hospitalization may provide a convenient portal. Urine and blood samples may be contaminated with foreign blood or stool.

FAMILY FUNCTION AND DYSFUNCTION

Stephen Ludwig , Anthony Rostain , in Developmental-Behavioral Pediatrics (Fourth Edition), 2009

Parental Overuse of Medical Care: Munchausen Syndrome by Proxy

Munchausen syndrome by proxy (Rosenberg, 1987) refers to a parental fabrication or induction of illness in young children so that the parent gains recognition and support from a medical institution and its health care providers. The term is an outgrowth of a psychiatric disorder described in adults who subject themselves to multiple diagnostic evaluations and surgical treatments to derive the care and comfort extended to a patient. Munchausen syndrome by proxy may be seen as opposite of medical neglect. Instead of the family's underproviding medical services, it overprovides them, sometimes by exaggerating symptoms or sometimes by falsifying symptoms and laboratory findings. It is unclear whether Munchausen syndrome by proxy represents a distinct psychiatric problem, or whether it is the extreme end of a spectrum that begins with parents' prolonging an acute minor illness (Libow and Schreier, 1986), doctor shopping, making an excess number of physician visits, or using a child's illness to postpone their own return to work. Many forms of Munchausen syndrome by proxy have been reported, including administration of insulin, false hematuria, false fevers, suffocation, and intravenous administration of feces to cause polymicrobial infections (Levin and Sheridan, 1995). Meadow (1977) has named the syndrome the "hinterland of child abuse."

In its full-blown form, Munchausen syndrome by proxy is an extremely serious disorder that produces significant morbidity and mortality. Rosenberg (1987) reported 2 deaths in a series of 10 reported cases, along with 10 unexplained sibling deaths. Other authors described a 5% to 15% mortality. In less serious cases, morbidity takes the form of children learning the benefits of the "sick child role"; this may lead to future Munchausen behaviors or simply to hypochondriacal and dependent behaviors exhibited by many adults. Children may undergo unnecessary procedures, laboratory tests, and operations. They also may become involved in the falsification of signs, symptoms, and laboratory data. There have been few long-term studies of these children to document either the long-term manifestations or the possible cyclic nature of the problem.

As with the management of frankly abusive behavior, the clinician's first step is to suspect a medical problem that stumps all the experts. The parents involved usually are described as cooperative to excess. Usually there is a family pattern in which only one parent is an active caretaker, while the other is often absent, either physically or emotionally. Another clue may be that the parent may have a complex medical history or may have a professional background in nursing or in allied medical professions. If Munchausen syndrome by proxy is suspected, hospitalization may be required to finalize the diagnosis. It would not be difficult to convince the parent of the need for the hospitalization, because this ties in with the parent's existing needs. When the child is in the hospital, through close monitoring of the parent, through covert videotaping, or through restricting the parent's visiting pattern, a diagnosis can be confirmed. When the diagnosis is established, it must be presented to the parents and to CPS for the creation of a management plan. In some cases, separation of the child from the family may be necessary. The long-term outcome with therapy is unknown.

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Child Abuse and Neglect

Jeffrey A. Dean DDS, MSD, FFD(Hon)RCSI , in McDonald and Avery's Dentistry for the Child and Adolescent , 2022

Medical Child Abuse

Perhaps the most difficult form of child maltreatment to identify and treat is a fictitious disorder. Initially called Munchausen syndrome by proxy , and thenpediatric condition falsification, the problem is one of child abuse in the medical setting. It occurs when a perpetrator (usually the mother) fabricates or exaggerates signs and/or symptoms of illness, or induces illness or signs and/or symptoms of illnesses in the child, causing unnecessary and harmful or potentially harmful testing, procedures, and treatments to be performed on the child. This form of abuse is different from all other forms of child maltreatment in that the medical community is unwittingly a part of the abuse. Because health care providers are often dependent on the parental history of the child's illness, it takes some time for the practitioner to realize the inconsistencies and possibly fabricated or exaggerated nature of the complaints. These children oftenpresent with persistent and recurrent illnesses that cannot be explained and signs and symptoms that do not clinically make sense. The motivation of the perpetrators of this form of abuse can be multifactorial (e.g., to gain medical attention as a result of parental psychosis, or to obtain services or monetary benefit) but is not considered in the making of a diagnosis of medical child abuse. The bizarre nature of many of these cases makes them almost unbelievable even to the professionals involved, which can unfortunately lead to failure to protect the child.

The Specific Problem of Children and Old People in Drug-Facilitated Crime Cases

Pascal Kintz , in Toxicological Aspects of Drug-Facilitated Crimes, 2014

3.8 Glibenclamide and Munchausen's Syndrome by Proxy

Munchausen by proxy syndrome (MBPS) is a relatively rare form of child abuse that involves the exaggeration or fabrication of illnesses or symptoms by a parent or caregiver. Also known as "medical child abuse," MBPS was named after Baron von Munchausen, an eighteenth-century German dignitary known for making up stories about his travels and experiences in order to get attention. "By proxy" indicates that a parent or other adult, and not the child, is fabricating or exaggerating the infant's symptoms.

The adult deliberately misleads others (particularly medical professionals), and may go as far as to actually cause symptoms in the child through poisoning, medication or even suffocation. In most cases, the mother is responsible for causing the illness or symptoms. Typically, the cause is a need for attention and sympathy from doctors, nurses and other professionals. Some experts believe that it is not just attention that is gained from the child's "illness" that drives this behavior, but also the satisfaction in deceiving individuals who they consider to be more important and powerful than themselves. Because the parent or caregiver appears to be so caring and attentive, often no one suspects any wrongdoing. Diagnosis is made extremely difficult due to the ability of the parent or caregiver to manipulate doctors and induce symptoms in their child.

Often, the perpetrator is familiar with the medical profession and knowledgeable about how to induce illness or impairment in the child. Medical personnel often overlook the possibility of MBPS because it goes against the belief that parents and caregivers would never deliberately hurt their child. Most victims of MBPS are pre-schoolers (although there have been cases in children up to 16 years old), and there are equal numbers of boys and girls. Often, hospitalization is required. And because these children may be deemed a "medical mystery," hospital stays tend to be longer than usual. Whatever the cause, the child's symptoms decrease or completely disappear when the perpetrator is not present. According to experts, common conditions and symptoms that are created or fabricated by parents or caregivers with MBPS can include: failure to thrive, allergies, asthma, vomiting, diarrhea, seizures and infections. The long-term prognosis for these children depends on the degree of damage created by the illness or impairment and the amount of time it takes to recognize and diagnose MBPS. Some extreme cases have been reported in which children developed destructive skeletal changes, limps, mental retardation, brain damage and blindness from symptoms caused by the parent or caregiver. If the child lives long enough to comprehend what is happening, the psychological damage can be significant. The child may come to feel that he or she will only be loved when ill and may, therefore, help the parent try to deceive doctors, using self-abuse to avoid being abandoned. Therefore, some victims of MBPS are at risk of repeating the cycle of abuse.

If MBPS is suspected, healthcare providers are required by law to report their concerns. However, after a parent or caregiver is charged, the child's symptoms may increase as the person who is accused attempts to prove the presence of the illness. If the parent or caregiver repeatedly denies the charges, the child would likely be removed from the home and legal action would be taken on the child's behalf. In some cases, the parent or caregiver may deny the charges and move to another location, only to continue the behaviour. Even if the child is returned to the perpetrator's custody while protective services are involved, the child may continue to be a victim of abuse while the perpetrator avoids treatment and interventions. 19

A 13-year-old girl was admitted to the emergency unit for coma and seizures after a stay with her mother. Blood glucose was 0.38   g/l. Blood screening for general unknowns revealed the presence of glibenclamide at 28   ng/ml. Glibenclamide is a potent, second-generation oral sulfonylurea antidiabetic agent widely used to lower glucose levels in patients with type II non-insulin-dependent diabetes mellitus. It acts mainly by stimulating endogenous insulin release from beta cells of the pancreas. The administration of glibenclamide by a parent (generally the mother) to a child has already been described. 20 Among the causes for recurrent hypoglycemic episodes in seemingly healthy patients, discriminating between sulfonylurea-induced hypoglycemia and insulinoma is of utmost importance because of medico-legal implications. Several unnecessary laparotomies and partial pancreatectomies due of erroneous diagnosis of insulinoma involving patients with surreptitious sulfonylurea exposure (inadvertent or factitious) have been reported. Therefore, toxicological analyses can be helpful. In the case of late sampling, blood or urine has little interest, and hair 21 must be considered as the best opportunity to document exposure. The mother did not challenge the use of glibenclamide.

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Pediatric Consultation

Brian P. Kurtz M.D. , ... Annah N. Abrams M.D. , in Massachusetts General Hospital Handbook of General Hospital Psychiatry (Sixth Edition), 2010

Factitious Disorder by Proxy

Factitious disorder by proxy, previously known as Münchausen syndrome by proxy, was first described as a pair of case reports in 1977. 83 It is a form of child maltreatment in which a parent, usually a mother, 84 consciously distorts her description of her child's symptoms or does things to the child to fabricate a picture of medical illness and then seeks hospitalizations and medical interventions for the child. The parent might report periods of apnea or seizures at home that have not occurred or might cause life-threatening illness by injecting the child with medication, blood, or feces to ensure that a medical work-up continues.

Some of the persons with this syndrome have had medical training in a health-related profession, such as nursing, 84, 85 and they use their medical knowledge to create "illness" in their child. The mother is usually at the infant's or young child's bedside. She tries to establish friendships with the nursing staff and is content as long as continued hospitalization and medical procedures are being scheduled and performed. She may become angry and agitated if she receives a report that her child is well and should be discharged home. Often she appears earnest and less anxious when serious diagnoses of the child are being entertained. If discharged, she may return within hours or days to the emergency department with an escalation of symptoms. The psychological understanding of this syndrome is that the mother needs the child to be sick to maintain her role as a "nurturant" mother in the protected, supported environment of the pediatric ward. She may gain a "curious sense of purpose and safety in the midst of the disasters which [she herself has] created." 84 She perceives the nurses to be her friends and the male physicians as caretaking men in her life. She lacks the empathy to be troubled by the pain and suffering she is inflicting on her child.

Factitious disorder by proxy is a difficult diagnosis to make without observing the mother doing something to the child. It may be suspected when a child's medical condition does not follow the expected course and the symptoms are persistently inconsistent. The symptoms may be observed only by the mother or might occur in conjunction with the mother's presence and may be consistent with an intentional action. Undertaking the investigation of this diagnosis, and seeking concrete evidence of risk to the child at the hands of a parent might require input from hospital legal counsel and administration.

It is crucial to protect the child's safety if this diagnosis is suspected. The reporters of this syndrome have described mortality rates and significant morbidity. 86, 87 The hospital legal department and child protective services should be notified of this diagnosis to protect the best interest of the child. If the parent thinks that she is being suspected of having hurt her child she might become angry and leave against medical advice (sometimes going straight to another hospital under the same or an assumed name). Perpetrators of factitious disorder by proxy are difficult to treat due to their psychological difficulties, persistent denial, and capacity for deception; recidivism is common. 88

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Children: Physical Abuse

B. Marc , A. Barthès , in Encyclopedia of Forensic and Legal Medicine (Second Edition), 2016

Munchausen syndrome by proxy

Munchausen syndrome by proxy (MSBP) is a covert form of child abuse. The perpetrator is unaware of this particular form of child abuse. The abuser is generally the mother, who fabricates, exaggerates, and/or induces physical, psychological, behavioral and/or mental health problems in the child ( Meadow, 1998) (Figure 18). The perpetrators are willing to fulfill their need for positive attention by hurting their own child, thereby assuming the sick role by proxy. Symptoms usually disappear in the absence of the mother. Signs and symptoms and physical and laboratory findings are highly unusual, discrepant with the patient's presentation or history. Although not uncommon, MSBP is difficult to detect and confirm. Diagnosis of the syndrome is extremely important, since mortality from MSBP is not negligible. It is said to be fatal in 6% to 33% of cases; one manifestation of MBSP, for example, is asphyxiation of an infant under soft bedcovers, which can initially be mistakenly diagnosed as sudden infant death syndrome (SIDS) (Barber and Davis, 2002). Physicians need to be cautious and suspicious for the diagnosis. As more cases with different presentations are shared in the professional literature, awareness will increase, harmful unnecessary medical investigations will eventually decrease, and further abuse and fatality will be prevented.

Figure 18. Hair tightened around a child's toe to generate local inflammation.

Munchausen syndrome by proxy is a disorder with four distinguishing characteristics:

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A child is taken to the doctor with disease manifestations that have been fabricated or deliberately induced by a person caring for the child, usually the mother.

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The child is taken repeatedly to different doctors, with excessive diagnostic testing and therapeutic interventions as the result.

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The person caring for the child denies knowledge of the true causes of the child's disease manifestations.

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The medically inexplicable symptoms and signs resolve when the child is separated from the responsible individual (Barber and Davis, 2002).

Symptoms can be induced, for example, by the administration of foreign substances (deliberate intoxication; for forensic certainty, a toxicological analysis should be performed), or else existing disease manifestations can be exaggerated, or both. The responsible mother often appears to be intensely worried. In the literature, three different clinical constellations are described, with partial overlap between them:

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The active generation of injuries and administration of substances ('active inducers');

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Presentation of the child to many different doctors, sometimes with variation in the alleged symptoms ('doctor addicts');

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Mothers whose primary motive in seeking medical attention is to receive attention, care, and help for themselves in their current situation, rather than for the child ('help seekers').

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Psychobehavioral Disorders

Thomas H. Chun MD , in Pediatric Emergency Medicine, 2008

Munchausen Syndrome by Proxy

"Munchausen syndrome by proxy" is the historical term for a subtype of factitious disorder. In this condition, the physical or psychological symptoms are intentionally produced in or attributed to another person; for example, a parent (most often the mother) deliberately causes or reports ill symptoms in his or her child. As with all factitious disorders, there is no external reward or gain for this behavior other than assuming the "sick role." Patients may present in many ways. Some will appear healthy with no findings on physical examination. Conversely, some patients will be gravely ill and some may even die as victims of Munchausen-by-proxy.

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The relationship between crime and psychiatry

Lindsay D.G. Thomson , Louise Robinson , in Companion to Psychiatric Studies (Eighth Edition), 2010

Factitious illness by proxy

This term (also known as Münchausen syndrome by proxy) correctly describes a situation rather than a psychiatric disorder (Bools 1996). The behaviour is the fabrication of symptoms in, or the injury of, a child by its carer (usually the mother), who then presents the child to a doctor or other agency for treatment. Bools describes a wide range of injurious behaviours. The condition may be a factor in child abuse and has been implicated in acts of serial killings by healthcare workers. Underlying psychiatric conditions include personality disorders (particularly antisocial and borderline types), somatisation, affective and eating disorders and substance misuse.

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