Could Your Patient Be a Victim of Munchausen by Proxy?

The term “Munchausen syndrome” was coined in 1951 by Richard Asher, who named it after Hieronymus Carl Friedrich Freiherr von Münchhausen (also known as Baron von Munchausen), an eighteenth-century storyteller who retired from the military and became known for his fantastical “tall tales.” Asher published case reports of patients who went from hospital to hospital, feigning symptoms and embellishing their medical history.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) uses the term “factitious disorder imposed on self (FDIS),” which includes falsification of signs/symptoms or induction of injury or disease in the absence of obvious external rewards. The behavior cannot be better explained by another mental disorder (eg, psychosis).

The term “Munchausen syndrome by proxy” (MSBP) was popularized in 1977 by Sir Samuel Roy Meadow, who expanded on Asher’s work to include individuals (typically caregivers) who falsified illness or injury in others. The DSM-5 uses the term “factitious disorder imposed on another” (FDIA). Diagnostic criteria for FDIA apply to the perpetrator of the abuse, not the victim (Table 1).

An American Academy of Pediatrics Point-of-Care Reference Statement, authored by Dhvani Shanghvi, uses the term “medical child abuse” (MCA) instead of MSBP or FDIA. Marc Feldman, MD, clinical professor of psychiatry and adjunct professor of psychology, The University of Alabama, Tuscaloosa, Alabama, told Medscape Medical News that he prefers the term “MCA” because it emphasizes that the child has indeed undergone abuse and also focuses on the child victim rather than the adult perpetrator.

The reported incidence of MCA is approximately 0.5-2.0 cases per 100,000 children and teens

MCA Is a Spectrum

“Pediatricians need to understand that MCA encompasses a whole spectrum of presentations,” Amy Gavril, MD, associate professor, West Virginia University School of Medicine, Morgantown, West Virginia, and chief of the Division of Child Safety and Advocacy, told Medscape Medical News. “As a society, we’re most familiar with dramatic cases, like the highly publicized case of Gypsy Rose Blanchard, whose mother both feigned and induced illness in her child.” Fortunately, extreme cases like these are “relatively uncommon.”

More common are caregivers who exaggerate a child’s symptoms and complaints or fabricate for the purposes of driving the medical system to do more and more procedures or evaluations, she said.

Gavril clarified that MCA is not caused by a caregiver’s anxiety about the child’s potential illness or concern that subtle symptoms may be dismissed by medical providers. “A caregiver may exaggerate a child’s symptoms every now and then to try to get what they perceive as the best care for their child,” she said. “But if you see a pattern of exaggerated symptoms over a long period of time — that’s more consistent with MCA, and you should start being concerned.”

Characteristics of Perpetrators

“Perpetrators are typically master deceivers and manipulators,” said Feldman, author of multiple books on MCA, including Playing Sick: Untangling the Web of Factitious Disorder and others. “In fact, they can be so convincing and their stories so heartrending that professionals ignore their own discomforts and concerns.”

Typically, perpetrators are female caregivers, usually mothers, he said. While many have some type of medical background (eg, as a nurse), some may claim to have medical training but were actually employed in a nonmedical capacity in a healthcare setting (eg, a clerk). Many have psychiatric conditions, including depression and personality disorders, especially borderline personality disorder (Table 2).

Red Flags

Pediatricians tend to have a high level of trust, relying on adult caregivers for information about a child’s signs and symptoms. “Pediatricians, like all doctors, are taught to listen carefully to what patients and families tell them,” Feldman said. He emphasized that he doesn’t want his work in the field of MCA “to lead to loss of [parental] advocacy and trust.” But pediatricians do need to know that MCA exists and how to recognize it and intervene.

There are many ways in which caregivers might deceive (or attempt to deceive) pediatricians and other healthcare providers (Table 3).

The presence of an unusual disease is not, in and of itself, a red flag. “If a child has a track record of good health and suddenly presents with mysterious symptoms, that’s different from a child with a lifelong series of mysterious symptoms or one, two, or more unusual or treatment-resistant diseases,” Gavril noted. It’s also a red flag if the caregiver won’t allow a new pediatrician access to previous providers or records from other facilities or claims they’re inaccessible.

If You Suspect MCA

Gavril described an 18-month-old patient whose mother said she had constipation. The child had been seen by multiple gastrointestinal (GI) specialists and had been on multiple medication regimens. According to the mother, nothing had worked. The child had undergone numerous hospitalizations in which enemas were used to clean out impacted stool in the colon. The mother also reported the child was unable to ingest food by mouth.

“When I was consulted, it was because one of the physicians noticed that on prior hospitalizations, x-rays showed no stool in the colon and there were no objective findings of constipation on an exam or large amounts of stool removed by the enemas,” Gavril recounted. The child was on some “strange concoction containing Pedialyte.” According to the mother, this had been prescribed by a GI specialist. “But we observed the child during her hospitalization eating age-appropriate foods.” The child was losing weight. It turns out that no GI specialist had actually prescribed this regimen.

Gavril found out from the mother that the older brother had experienced the same symptoms until just after the patient was born, and he “was suddenly miraculously cured of his GI issues.”

This was a case in which the mother wasn’t necessarily inducing the symptoms, but she was exaggerating, fabricating signs and symptoms in the child to promote multiple hospitalizations, procedures, and lab tests, and the child wasn’t getting sufficient nutrition, Gavril said.

The next step was to “clearly document our observations over time,” Gavril reported. “We brought together the hospital GI specialists and other medical providers who had been seeing her, and we had a meeting to discuss whether it could be MCA and how to move forward. When we were all on the same page that we had reasonable concern for MCA, we reported it to Child Protective Services.”

Gavril “highly encourages pediatricians to reach out to other medical professionals taking care of the child to get a group consensus. If the hospital has a child protection team, that could also be an important resource.”

Shanghvi recommends “early involvement” of an MCA multidisciplinary team, which should include all the patient’s medical professionals and subspecialists, nurses, a child abuse specialist, a social worker, a psychologist, and legal/risk management professionals.

Ultimately, however, every medical provider is a mandated reporter of child abuse, both experts emphasized. Merely documenting the concern in the child’s chart is insufficient.

“Don’t rely on others who say they’re going to report it to Child Protective Services,” Feldman warned. He shared the story of a pediatrician who told him, “I don’t need to report this myself. One of the other providers is doing so.” This is a mistake, according to Feldman. Every provider who encounters child abuse is a mandated reporter, and medical abuse is no exception.

“You don’t need to have absolute proof that the child is being abused, only to meet the threshold of reasonable concern,” Gavril emphasized, adding, “thorough documentation is key.”

Shanghvi’s statement warns that, because many states don’t list MCA as a specific form of child maltreatment, Child Protective Services response may be “inconsistent” and advises physicians making a report to use medical language “distilled into lay terms that best embody the physician’s meaning” and “focus on how the child has been affected.”

Once a formal report has been made, Child Protective Services and law enforcement need to be involved “to determine safe disposition and to conduct further investigation.”

Pediatricians are at the front line of detecting MCA. Being alert to red flags, taking appropriate action, documenting concerns and steps taken, and collaborating with other professionals are the best ways to intervene in these complex cases.

Further medical deception resources can be found at:

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape Medical News and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).