More than a decade ago, an American Professional Society on the Abuse of Children taskforce recommended professionals separate the concepts of child maltreatment and psychopathology when discussing, evaluating, or treating Munchausen by proxy (MBP).1 Although not a formal medical or psychiatric diagnosis, MBP refers to abusive illness falsification that is due to factitious disorder imposed on another (FDIA) in the abuser. FDIA is the DSM-5 psychiatric disorder that describes individuals who persistently falsify illness in another even when there is little or nothing tangible for them to gain from the behavior. It is a compulsive behavior associated with a high degree of denial, akin to that of substance abuse behavior or an eating disorder.
Why do I need to know about MBP?
Victims of MBP may suffer from fear, pain, and loss of normal attachment, and from delayed development, growth, social functioning, and/or academic progression.2-4 They may develop physical and psychiatric problems due to being persistently regarded as ill; from deprivation; from unneeded assessments, medications, procedures, or surgeries; and/or from iatrogenic complications.
Some clinicians believe that they can avoid legal action and conflict by simply believing or avoiding parents who regularly present them with false information. It is important to note that clinicians who failed to file a mandated report for suspected illness falsification have been civilly sued for medical negligence and failure to report suspected child abuse.5 Some states, such as Texas and California, also have penal codes outlining criminal punishment for failing to report suspected child abuse.
It would be difficult to fool me
Can you tell if you are being lied to by a parent/caregiver? Research has consistently found that conscious assessments of veracity are only slightly more accurate than chance.6 Published case reports suggest that any disorder can be successfully falsified. One describes a case of factitious cystic fibrosis that included a falsified history, altered sweat tests and stool fat analyses, and sputum samples stolen from cystic fibrosis patients.7 Another describes a patient with factitious chronic intestinal pseudo-obstruction who received a small-bowel transplant.8 Falsified mental health problems have included learning disorders, attention deficit disorder, autism spectrum disorder, and bipolar disorder.9,10
Warning signs: induction not required
Many individuals confirmed to have engaged in illness falsification (typically female caregivers) have the ability to appear normal as parents/caregivers.11 Formal psychiatric interview and psychological testing may suggest that no psychopathology is present. Others may be dramatic, aggressive, manipulative, and/or obvious in their lies. Between 30% and 70% of those who falsify illness in children also falsify illness in themselves.12-14
Medical, psychiatric, and/or developmental disorders can be falsified in a variety of ways. Table 1 lists warning signs of possible illness falsification. While child victims of suffocation, poisoning, or other forms of induction are at highest risk for death, symptom exaggeration or medical noncompliance in a child with a genuine medical disorder can be sufficient to place the child in lethal danger.11
Clinicians are required to report child abuse suspicions to authorities. As with physical or sexual abuse, the determination of whether abusive illness falsification has occurred is normally based on careful data analysis—it is rare to directly observe an abusive act. In the case of a suspicious fracture, for example, a skeletal survey may be performed along with a clinical interview. Because the core feature of illness falsification is deception, assessment requires evaluation of objective data and of collateral data.10,15Table 2 lists some general assessment approaches for clinicians.
Medical record analysis can be more helpful than contacting past clinicians because clinical information recorded at the time of the health care visit is less subject to clinician recall bias and defensiveness. Chronologically summarizing each medical contact into a table reveals patterns of health care utilization and parent/caregiver behavior in a format that is easy to analyze.15 Each row describes a health care contact. Columns include date of contact, health care location, reported signs/symptoms as stated by caregiver, objective test results and observations of the health care provider, conclusions/diagnoses made along with the care plan, and other comments or observations.
Dr Bursch is Clinical Director of the Pediatric Psychiatry Consultation Liaison Service and Professor in the departments of psychiatry & biobehavioral sciences and pediatrics at the UCLA David Geffen School of Medicine in Los Angeles. She regularly serves as an expert witness on the topic of Munchausen by proxy.
1. Ayoub CC, Alexander R, Beck D, et al; APSAC Taskforce on Munchausen by proxy, Definitions Working Group. Position paper: definitional issues in Munchausen by proxy [published correction appears in Child Maltreat. 2004;9:337]. Child Maltreat. 2002;7:105-111.
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14. Sheridan MS. The deceit continues: an updated literature review of Munchausen syndrome by proxy. Child Abuse Negl. 2003;27:431-451.
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16. Feldman MD. Denial in Munchausen syndrome by proxy: the consulting psychiatrist’s dilemma. Int J Psychiatry Med. 1994;24:121-128.
17. Rogers R. Diagnostic, explanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception. Child Abuse Negl. 2004;28:225-238.
18. Jones DPH. The untreatable family. Child Abuse Negl. 1987;11:409-420.
19. Bursch B. Individual psychotherapy with child victims. Munchausen by proxy: psychiatric presentations, treatment findings, what to do when a new child is born. Presented at: American Academy of Child & Adolescent Psychiatry Annual Meeting; October 1999; Chicago.