Munchausen Syndrome by Proxy as a Possible Factor When Abuse is Falsely Alleged
Deirdre Conway Rand*
ABSTRACT: Munchausen syndrome by proxy (MSP) is a
reportable form of child abuse in which a physical or mental disorder of
the child is either fabricated or induced by a parent or other adult
caretaker. While most often diagnosed in medical settings, a
contemporary-type MSP has emerged in which the parent fabricates or
induces the idea that the child has been abused by someone else, with
the accusing parent/caretaker then gaining recognition from helpers as
the protector of an abused child. The case illustrated in Bad Moon
Rising: A True Story, is discussed. Professionals are reminded of the
importance of thorough fact-finding and the need for a multidisciplinary
approach in diagnosing MSP.
Persons coming in contact with child abuse cases,
especially cases where sex abuse is alleged, should be aware of a
clinical syndrome called Munchausen syndrome by proxy (MSP). Munchausen
syndrome by proxy is a specialized form of child abuse in which a
physical or mental disorder of the child is either fabricated or induced
by a parent or other adult caretaker. A related psychiatric disorder,
Munchausen syndrome, refers to the individual who either fabricates or
induces a medical or psychological problem in themselves. The name
Munchausen comes from a notorious 18th century teller of tall tales,
Baron Von Munchausen. Whereas in Munchausen syndrome the person gains
positive attention from medical personnel for their own factitious
illness, in MSP the perpetrator gains attention as the concerned
caretaker of a sick child, who is the proxy.
The parent/child cases in the literature involve the
mother as perpetrator, but the possibility of father/child cases cannot
be ruled out. There is one report of an adult male perpetrator abusing
two female adults (Sigal, AItmark, & Carmel, 1986). In another
notorious case, authorities in Texas investigated a daycare operator
after they became aware of the abnormal frequency with which she was
requesting emergency medical care for the young children in her care,
reporting seizures in each case. The daycare operator was suspected of
inducing the seizures, and one child actually died.
Examples of what could be called classical MSP run
the gamut from fabricating the child's medical history, to altering
laboratory specimens, to inducing or inflicting physical findings on the
child. Jones et al. (1986) state that false reports of seizures are
particularly common, or the mother/caretaker may actually induce
seizures in the child by suffocation. Further instances are described
where rashes have been simulated by dying the skin, pricking the skin,
or rubbing the child's skin with caustics. Cases have been reported in
which the child was given poison to induce symptoms, or in which
contaminated fluid was introduced into the child's intravenous tubing.
The physical consequences of classical MSP may
include the child: 1) undergoing painful tests; 2) receiving unnecessary
treatments and surgeries; 3) being subject to frequent and/or prolonged
hospitalizations. In more extreme cases of classical MSP, the child may
actually die. Meadow (1982) estimated a mortality rate of 10%, while
Kaufman, Coury, Pickrel, and McCleery (1989) placed the figure at 22%.
With young children, the child is what might be termed a simple victim.
When an older child is involved, the child may accommodate the MSP
mother and go along with the mother's deception in a kind of folie â
In the past, MSP has been considered rare, but most
authors agree that the incidence of the syndrome has been grossly
underestimated. In fact, the incidence of MSP may actually be on the
increase, due to a contemporary variation of the syndrome that is unique
to the 1980s.
Contemporary-type MSP involves fabricating or
inducing the idea that the child has been abused by someone else, with the accusing
gaining recognition from helpers as the protector of an abused child.
Upsurge over the last decade of social concern about child abuse has
created new opportunities for the MSP parent. In addition to attention,
the adult accuser in contemporary MSP may accomplish additional agendas
such as strengthening her symbiotic bond with the child, or being
awarded custody of the child in divorce proceedings.
Libow and Schreier (1986) describe an MSP mother who
became obsessed with the idea that her daughter had, at age two, been
molested by a female relative. The mother began taking her daughter to
emergency rooms and to outpatient clinics, asserting, despite lack of
medical findings, that her child had been permanently damaged by the
alleged molestation. Eventually, by providing misleading clinical data,
mother convinced a new pediatrician to do a vaginal examination of the
child under anesthesia. She also managed to have the daughter
hospitalized for observation twice. This case is contemporary in the
aspect that the mother alleged the child was the victim of abuse, but
classical in the mother's insistence on repeated medical examinations of
the child. In other contemporary cases, the MSP parent pursues repeated
contacts with police, the courts, Child Protective Services, and mental
health workers. The child may be subjected to numerous psychological
and/or legal examinations, as well as intrusive sexual assault exams.
Contemporary variations of MSP can become very complicated because of
all the professionals and agencies that become involved and who may
actually participate, however unwittingly, in the perpetuation of MSP
(Zitelli, Seltman & Shannon, 1987).
Ferguson's (1988) Bad Moon Rising: A True Story
(reviewed in the Book Review section of this journal) details one such
case. The book covers events that occurred from 1984 to 1986 and is
presented as a divorce drama, which is how it was viewed by many of the
participants. The diagnosis of MSP was not made until 1987, when
subsequent events made the diagnosis more apparent to the court
In this case, as a divorced father and his wife, who
raised the older of father's two children, agree to let the teenage boy
try living with his biological mother. During the nightmare that ensues,
first the boy's sister, then the boy himself make allegations of sexual
abuse against relatives. The allegations become so numerous that the
authorities remove the children from the mother's home, while
simultaneously indicting the relatives for sexual abuse. The
investigation that follows shows how the mother, with her sister as
confederate, induced the children to allege abuse. The children were subjected to exorcism rituals and
brainwashing sessions. The mother obtained the children's cooperation in
presenting a fabricated history to various mental health professionals,
in an effort to convince them that abuse by relatives had actually
occurred. To gain further sympathy for herself, the mother falsely
alleged that she, too, had been abused as a child. This similarity of
symptoms in mother and child is one indicator that MSP may be operating
(Zitelli et al, 1987). Mother's fabricated history of abuse in her own
past is also not uncommon among Munchausen adults (Hyler & Spitzer,
In the case of Bad Moon Rising, there was reason to
believe that the MSP mother, and to a much lesser extent the son,
already displayed Munchausen syndrome proper prior to the allegations of
abuse. The emergence of Munchausen syndrome by proxy, when the mother
became the protector of allegedly abused children, may have been in
response to external stressors such as the boy returning to live with
her after so many years and the intense sibling rivalry that developed
between the boy and his younger sister. The distinction made by Nadelson
(1979) between episodic MSP in response to external events such as
divorce or the threat of out of home placement, and MSP as an ongoing
way of life, may be blurred. As Meadow (1984) reports,
There are several instances of children who have
taken over the false illness behavior completely and begun to act like
adults with Munchausen syndrome. Other children have grown up as chronic
invalids, remaining in the family home as adults and being told falsely
by parents that they have fits at night and still have epilepsy. Child
abuse does not cease when the child reaches adult age — childhood ends
when you lose your parents" (p. 673).
Thus, once initiated, the consequences of MSP can be
long lasting. In contemporary-type MSP, there may also be devastating
and long-term consequences for the person falsely accused of abuse by
the MSP parent/child dyad.
Although Munchausen syndrome by proxy is a reportable
form of child abuse, many professionals have never heard of it (Kaufman,
Coury, Pickrel, & McCleery, 1989). This is not so surprising when
one realizes that the first professional article on the subject was
published only twelve years ago (Meadow, 1977). While Munchausen
syndrome (factitious disorder) appears in the Diagnostic and Statistical
Manual III-R, Munchausen syndrome by proxy does not.
Munchausen syndrome by proxy, with its prominent
deceptive aspect, should remind professionals of the importance in all
cases of verifying information that is presented as fact, as well as
additional, independent fact-finding. Releases should be obtained to
talk with all persons who may have relevant
information. Professionals should be open to a multi-disciplinary
approach, which is often a prerequisite for recognizing the possibility
of MSP and for confirming the diagnosis.
Ferguson, D. (1988). Bad Moon Rising: A True Story ().
Nashville, TN: Winston-Derek, Inc.
Jones, J .G., Butler, H. L., Hamilton, B., Perdue, J.
D., Stern, H. P., & Woody, R. C. (1986). Munchausen syndrome by
Child Abuse & Neglect, 10, 33-44.
Kaufman, K. L., Coury, D., Pickrel, E., &
McCleery, J. (1989). Munchausen syndrome by proxy: A survey of
Child Abuse & Neglect, 13(1), 141-148.
Libow, J., & Schrier, H. (1986). Three forms of factitious
illness in children: When is it Munchausen syndrome by proxy. American Journal of Orthopsychiatry,
Meadow, R. (1977).
Munchausen syndrome by proxy: The hinterland of child abuse. Lancet,
Meadow, R. ((1982). Munchausen syndrome by proxy. Archives of Diseases in Childhood,
Meadow, R. (1984). Munchausen by proxy and brain damage.
Developmental Medicine and Child Neurology, 26(5), 672-674.
Nadelson, T. (1979). The Munchausen spectrum: Borderline character
features. General Hospital
Psychiatry, 2, 11-17.
Sigal, M., AItmark, D., & Carmel, I. (1986). Munchausen syndrome
by adult proxy: A perpetrator abusing two adults. The Journal of Nervous
and Mental Disease, 174(11), 69&698.
Zitelli, B., Seltman, M., & Shannon, R. (1987). Munchausen's
syndrome by proxy and its professional participants. American Journal of
Diseases of Children, 141, 1099-1102.
* Deirdre Conway Rand is a licensed psychologist
practicing with Marin Psychological Services, 650 East Blithedale, Mill
Valley, CA 94941. [Back]