Child abuse has gained more and more attention in this country ever since the passage of the first child protection laws, which interestingly were validated by the existence of legislation against cruelty to animals. The issue has gone from being entirely a closed-door, hush-hush issue no one dared mention in public to an issue on the social and governmental agenda. It is still regarded as an aberration but the public is undoubtedly more aware of it now than at the turn of the previous century, thirty years ago, or even ten years ago. While many children still suffer in relative silence unbeknownst to many around them, more and more abusers are finding they cannot get away with what was once sadly considered a parent’s prerogative.

However, one form of child abuse has still received somewhat little notice in the public eye, short of an occasional fantastical news account or made-for-TV movie. This form of abuse goes by many names but is perhaps best known by the moniker Munchausen syndrome by proxy (MSBP). This term was first applied in 1977 and usually refers to an unusual manner of child abuse in which a parent (almost always the mother) repeatedly presents a child for medical or psychological treatment with symptoms either falsified, greatly exaggerated, or directly induced by the caregiver (Murray, 1997). MSBP is a rather rarely recognized form of child abuse, though reports of confirmed cases of the syndrome become more common year to year (Murray, 1997; Siegel & Fischer, 2001).

Although Munchausen syndrome by proxy can take the form of abuse from any caretaker toward a loved one (adult child-elderly parent, spouse-spouse), it is most commonly reported in parent-child relationships and is commonly noted in the literature simply as a form of child abuse (Ben-Chetrit & Melmed, 1998). This is an important issue that should concern all social workers, child protective workers, and other health and safety workers. MSBP is probably underdiagnosed, given both the unlikelihood that a professional would even consider diagnosing the syndrome and the wide range of difficulties that pertain to all parties involved in the event of such a revelation (Sanders, 1999; Horwath, 1999).

Considering a MSBP diagnosis is even more difficult at times for people in the social work field, as they are often educated and/or trained to operate on a strengths perspective. Parents who are perpetrating Munchausen abuse on their children often present as very attentive, loving, cooperative, closely invested in the child’s treatment, and having a familiarity with medical terminology or a medical background (Siegel & Fischer, 2001; Schreier, 1997). All of these traits would appear on the surface, to both social workers and most other professionals, as parental strengths that would aid in the child’s healing process. Since social workers in particular are often taught to focus on strengths, it is practically counterintuitive to view the same characteristics once conceptualized as strengths instead as part of the evidence supporting the diagnosis of Munchausen syndrome by proxy, even when other factors that would validate suspicions of MSBP become evident. The pereptrators of MSBP abuse rarely present as psychologically disturbed but rather as model parents (Murray, 1997).

Munchausen syndrome by proxy is usually perpetrated on younger children, and although the children may be basically very healthy, at young ages they are even more prone to confabulation when confronted with a parent’s constant worries about their health. The psychological and physical ramifications of being forced to remain bedridden or of being shuffled in and out of hospitals and clinics may ensure that a child adopts a lifelong habit of this lifestyle (Meadow, 1999). Munchausen syndrome by proxy is similar to other forms of child abuse in that victims of the crime can often become perpetrators as adults (Davis et al., 1998). The need to diagnose the condition as early as possible and intervene quickly is therefore all the more important. However, like physical abuse, sexual abuse, and emotional or psychological abuse, there has been strong societal resistance to recognize the MSBP form of child abuse (Siegel & Fischer, 2001).

Few would argue that much time was needed for society to formally recognize child abuse and that each successive form of abuse documented and operationalized took time to gain clinical and public acceptance. This continues to be a problem for the identification and diagnosis of MSBP over twenty years after it was first described (Siegel & Fischer, 2001). It persists as a difficult diagnosis to make because most clinicians refuse to accept even their own suspicions that a parent could be intentionally causing a child’s symptoms and illness (Szajnberg & Moilanen, 1996). With health professionals uneager to diagnose the condition, social workers unlikely to consider suggesting the existence of such a syndrome, and many professionals simply unknowledgeable about MSBP, the potential for actual cases of the abuse to go unrecognized is high. This should obviously be an area of great concern for professionals in any discipline who deal with children who are abused and/or ill, as well as their parents, especially when some of the risk factors to be discussed herein are present. Social workers should take part in any multidisciplinary team meeting that might be called on behalf of a child victim of Munchausen syndrome by proxy.

This topic is of particular interest to the author beyond his role as a social worker because of his belief that a close relative of his may currently be perpetrating MSBP abuse on her husband, who is recovering poorly from a successful liver transplant. There also exists evidence she may have done so in the past with one of her sons. Additionally, one family in treatment at the author’s field placement has been subjected to allegations of Munchausen syndrome by proxy.

The literature on MSBP is very helpful in a number of areas but also quite lacking or contradictory in others. The following brief literature review aims to describe the current state of knowledge regarding the etiology of Munchausen syndrome by proxy, warning signs, possible treatments for perpetrators, issues in MSBP detection, confirmation, and intervention, and what areas of knowledge appear to be most in need of expansion.

The etiology of MSBP abuse is an interesting arena of discussion. Meadow (1998) notes that although the perpetrator predictably denies inventing or causing the symptoms or diseases, a common criterion of the abusive caretaker of this type is "a need to assume the sick role by proxy" or generally practice some form of attention-seeking behavior (p. 210). Although perpetrating parents often present as model caretakers, their belief or perception that their children have physical problems preventing normal life borders on a state of delusion (Meadow 1999).

Munchausen is often referred to as a "subtle" form of child abuse (Szajnberg & Moilanen, 1996). Actions taken include everything along a continuum of lying about symptoms to deliberately poisoning or suffocating a child (Szajnberg & Moilanen, 1996; Siegel & Fischer, 2001). Perpetrators of MSBP usually prey on vulnerable infants or toddlers (children under age 5 are likely at greatest risk for this type of abuse), though older children and even adolescents can be brought into collusion with the perpetrator’s misguided actions (Murray, 1997). Siegel and Fischer (2001) delineate the following possible motivations/etiology for an MSBP abuser: a need to be the center of attention, a "profound lack of empathy" due to past experience with rejection and/or abuse, or even maladaptive coping strategies somehow connecting love to sickness (p. 23). Perpetrators are well aware of the social unacceptability of the behavior and will go to great lengths to cover their tracks through an elaborate web of alibis and false reports.

Still another researcher (Schreier, 2000) notes that the primary dynamic at work in some parents who perpetrate abuse via Munchausen syndrome by proxy is the perpetrator’s insecurity in separating from the child. Schreier goes on to assert that the attention-seeking explanation offered by many researchers is too simplistic a theory, with the motivation appearing more often to be a "perverse need" to be in a conflictual, extreme relationship with a doctor or a powerful public figure in general.

Sanders (1999) is one of the few writers who notes the likelihood that the perpetrator may have some specific psychological disorders, ranging from a history of Munchausen syndrome and somatoform illness to borderline or histrionic personality disorder. Sanders also reinforces other researchers’ assertions that the perpetrator is very likely to be someone with knowledge of the medical field (Murray, 1997). The current opinions regarding etiology seem to be a drastic improvement over the state of affairs just four years ago, when one researcher noted that virtually nothing was known about the psychodynamics of the MSBP perpetrator except that perhaps their actions were a "distorted means of obtaining medical attention for themselves" (Murray, 1997).

The literature suffers from no shortage of writers describing the warning signs for Munchausen syndrome by proxy abuse. Practically every article this author researched had some mention of the red flags that noted possible MSBP victimization. The most commonly noted warning sign was an unusual clinical picture, one that does not seem medically plausible or which finds a medical professional saying, "I’ve never seen anything like this before" (Bryk & Siegel, 1997; Murray, 1997). Such thoughts or cognitive dissonance should lead to a consideration of at least a differential diagnosis of MSBP.

Cases of Munchausen syndrome by proxy are not more common in one socioeconomic level than another, according to Murray (1997), although one researcher notes a "prototypical" perpetrator might be an ordinary middle-class mother with some medical background (Siegel & Fischer, 2001). The perpetrators often have a history of fabricated illnesses or hypochondriacal behavior themselves. Persistent symptoms with no evident cause, conflicting symptoms and/or laboratory reports, symptoms which abate in the absence of the parent, and too-frequent parental suggestion of painful or unpleasant medical tests for a child are further warning signs (Murray, 1997). Often such obsessive pursuit of tests, care, or special class placements will continue even after those demands are met (Schreier, 2000).

Parents who perpetrate MSBP abuse often exaggerate their past as well, so it may be wise to check the validity of some parents’ stories regarding both their medical and historical past if MSBP is suspected (Meadow, 1998). Finally, Sanders (1999) notes that the syndrome should be considered as a possibility when a child’s symptoms are extremely persistent or when laboratory results are at a consistent variance from the parent’s story (e.g. a child appears of normal weight and hydration despite reports by a parent that the child is continually vomiting at home).

Treatment for Munchausen syndrome by proxy is as controversial as treatment of child molesters in some professional circles. Davis et al. (1998) noted that children who were younger than five years of age at the time of the abuse, who endured suffocation or poisoning, or who had siblings who suffered mysterious deaths were less likely to have parents who would benefit from perpetrator treatment. Unfortunately, a majority of Munchausen cases could fit at least one of these criteria. So is treatment out of the question for these individuals?

Horwath (1999) noted the difficulties in working with a diagnosis such as MSBP

because most helping or healing relationships are based on a partnership with the family or individual, and family-centered care may not be in a child’s best interest in cases of Munchausen by proxy. One prominent professional says any work with the perpetrator after the investigative phase of an MSBP case is doomed to failure, adding that any agency would need to work deliberately without a child’s parents in order to do the least possible harm to the child (Southall, qtd. in Horwath, 1999).

That being said, some attempts have been made to treat perpetrators of Munchausen by proxy abuse. What rationale is there for treating these individuals when so many other professionals are dead-set against it? Psychological treatment for this type of abusers would enable parents to care for their children again, if it can be shown to be safe. It provides for in-depth professional supervision of a child’s care plan. Social work ethics dictate a child has the right to be brought up within his/her own family whenever it is safe to do so. Successful treatment could improve the safety and quality of life for a victim’s siblings and any children not yet a part of the family. Additionally, out-of-home care would bring with it its own unique set of challenges (Berg & Jones, 1999).

The Berg & Jones study (1999) was very successful in its efforts to treat families that had experienced MSBP, and did so in an inpatient family residential setting. However, the small number of subjects (n=13) leaves the generalizability of these results in question, even with a success rate of ninety-two percent. In addition to the small number of participants, there was no control group. Furthermore, the authors of the article seem to admit to "creaming" in the selection of their subjects-- "potential referrers were aware of the unit’s policy of only accepting those cases where some degree of acknowledgment of abuse had occurred," a reality that no doubt had a positive impact on the intervention’s success (p. 466). This author, therefore, calls the reliability of the study’s results into question.

Szajnberg and Moilanen (1996) suggest a novel approach to the problem of diagnosing and treating perpetrators of MSBP-- the use of two interviewers during assessment and treatment phases, to assess the dichotomy in the parent’s presentations to each professional. This would provide for an interesting assessment of the individual’s ability to play one professional against another, as often occurs when different specialists working with a suspected MSBP family tend to alternately sense the presence of an abusive situation or adamantly deny that any such horrible thing could take place within "this" family.

Conflict among professionals is just one of the many salient issues related to a potential MSBP case (Horwath 1999). The need for inter-agency cooperation and interdisciplinary cooperation in these instances is perhaps more important than in almost any other psychological diagnosis. The perpetrator’s manipulative abilities will be in full force if he/she senses an alliance is potentially forming among professionals in contact with the family. It may be crucial to bring in individuals who have had no contact with the case to review the information from a more impartial standpoint, since reactions to suspicions of such a diagnosis can often be inflammatory and produce great fissures among professionals who need to be working together in a family’s best interest. Complicating the process, hospital doctors and general practitioners are notoriously difficult to engage in the child protection process, as they are often untrusting of social workers or the police in cases such as MSBP-type abuse (Horwath, 1999).

One can understand the hosptials’ reluctance to diagnose MSBP without rock-solid evidence given the litigious nature of Americans today. The hospital may have to endure civil suits for malpractice if parents wish to make a case of being falsely accused, or could find themselves accused of alienation of affection if an MSBP diagnosis leads to removal of a child (Sanders, 1999). It is easier to take on if the professionals form a multidisciplinary team (MDT), as suggested by some authors (Sanders, 1999; Horwath, 1999), and easier still if an MDT can find an ally within the perpetrator’s family. However, this may at times involve fracturing the family unit in turning one parent against the other, and many parents may be reluctant to do so even for the safety of their children. There are also obvious ethical concerns in using one parent as a mole of sorts, even though the nonperpetrating parent’s assistance is often needed to confirm the MSBP diagnosis through separate parent interviews regarding a child’s symptoms or illnesses (Horwath, 1999).

Siegel and Fischer (2001) also note a number of barriers to proper confirmation and intervention of MSBP. The unwillingness of physicians to diagnose the syndrome unless absolutely certain leads to sometimes yearlong assessment periods, during which the child undoubtedly sustains considerable physical and/or psychological harm. The lack of inter-agency and interdisciplinary collaboration also makes it easier for MSBP perpetrators to continue their abuse, as "the burden of gathering clear and convincing evidence rests on the collaboration of the health care, protective-services, and legal systems" (p. 40). The different levels of awareness of the disorder and different levels of reluctance to diagnose it make cooperation among disciplines even more difficult.

There are many topics in need of further investigation in this area of research. The overwhelming body of research focuses on maternal abuse toward children. Only one article found by this author (Meadow, 1998) dealt with male perpetrators of MSBP. In addition, only one article (Ben-Chetrit & Melmed, 1998) dealt with abuse toward an elderly relative, and none dealt with spousal MSBP abuse. Only a few articles touched upon the role of the nonperpetrating parent in the dynamic of the MSBP family and what, if any, role he/she has in effective abuser treatment.

Multidisciplinary teams were conceptualized and protocol for these teams was provided in the literature (Siegel & Fischer, 2001; Sanders, 1999). However, this author could find no studies on the effectiveness of MDTs. Finally, given the relatively short time that MSBP has been recognized as a true diagnosis, little research has been done on the long-term effects of MSBP abuse. These all seem to be areas warranting further consideration in the empirical literature.

Munchausen syndrome by proxy is a potentially deadly form of child abuse that is often so subtle as to go unnoticed. More professionals in many fields ranging from hospital physicians to front-line child protection workers need a better understanding of the warning signs of MSBP so that families embroiled in this type of abuse might be better assisted by workers in various disciplines. Munchausen syndrome by proxy may be the most poorly addressed and undiagnosed form of child abuse present in America today. Until social workers and other professionals take it upon themselves to spread education about the syndrome and its very real presence in our society, it will continue to go unnoticed or misread far too often, and children will continue to suffer and die from its survival.

References

Ben-Chetrit, E. & Melmed, R. N. (1998). Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient. Journal of Internal Medicine, 244, 175-8.

Berg, B. & Jones, D. P. H. (1999). Outcome of psychiatric intervention in factitious illness by proxy (Munchausen’s syndrome by proxy). Archives of Disease in Childhood, 81, 465-472.

Bryk, M., & Siegel, P. T. (1997). My mother caused my illness: the story of a survivor of Munchausen by proxy syndrome. Pediatrics, 100(1), 1-7.

Davis, P. et al.. (1998). Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Archives of Disease in Childhood, 78, 217-221.

Horwath, J. (1999). Inter-agency practice in suspected cases of Munchausen Syndrome by Proxy (Fictitious Illness by Proxy): dilemmas for professionals. Child and Family Social Work, 4, 109-118.

Meadow, R. (1999). Mothering to death. Archives of Disease in Childhood, 80, 359-62.

Murray, J. B. (1997). Munchausen syndrome/Munchausen syndrome by proxy. Journal of Psychology, 131(3), 343-52.

Sanders, M. J. (1999). Hospital protocol for the evaluation of Munchausen by Proxy.  Clinical Child Psychology and Psychiatry, 4(3), 379-91.

Schreier, H. A. (2000). Factitious disorder by proxy in which the presenting problem is behavioral or psychiatric. Journal of the American Academy of Child andAdolescent Psychiatry, 39(5), 668-70.

Siegel, P. T. & Fischer, H. (2001). Munchausen by proxy syndrome: barriers to detection, confirmation, and intervention. Children’s Services: Social Policy, Research and Practice, 4(1), 31-50.

Szajnberg, N. M. & Moilanen, I. (1996). Munchausen-by-proxy syndrome: countertransference as a diagnostic tool. Bulletin of the Menninger Clinic, 60(2), 229-238.