Munchausen Syndrome by Proxy: A Complex Type of Emotional Abuse Responsible for Some False Allegations of Child Abuse in Divorce
Deirdre Conway Rand*
ABSTRACT: Munchausen syndrome by proxy (MSP) is a complex form of child
abuse in which an adult, usually a mother, creates the appearance that
her child is ill by fabricating evidence and even by inducing symptoms
in the child. A contemporary form of this syndrome occurs when the
mother creates the appearance that the child has been abused by someone
else, generally the father in a divorce and custody or visitation
dispute. Warning signs for contemporary-type MSP are presented
along with descriptions of the dynamics involved and the factors that
are important in diagnosis and case management.
Munchausen syndrome by proxy (MSP) is a complex
type of emotional abuse that may overlap with other forms of child
abuse. The syndrome was first identified in pediatric settings where
some mothers were discovered to be creating the appearance that their
children were ill (Money & Werlwas, 1976; Meadow) 1977). These
mothers would fabricate evidence to support their claims, falsify health
records, contaminate laboratory samples and even induce symptoms in the
child. The perpetrator of MSP type abuse is almost always the child's
mother, though occasionally a father, grandparent, day care operator, or
nurse has been discovered engaging in this behavior.1
Physical abuse may be part of the clinical picture, for example, when
the mother goes so far as to induce symptoms in her child and when the
child undergoes unnecessary tests, surgeries and hospitalizations that
are painful or even dangerous. Even when physical abuse is not present,
the emotionally abusive aspect of Munchausen syndrome by proxy can be so
pervasive as to ruin the child's life, distorting as it does the child's
self-concept, sense of reality; and the way in which the child interacts
with others. The mother's overwhelming need for her child to be ill
results in the child living a life based on lies. Munchausen syndrome by
proxy is a reportable form of child abuse.
The term "Munchausen syndrome by proxy" derives from
Munchausen syndrome, a phenomenon among adult medical patients in which
the individual fabricates or induces his or her own medical symptoms,
factitiously assuming the patient role. Munchausen syndrome is named
after Baron von Munchausen who was a 17th century teller of tall tales.
When an adult fabricates or induces symptoms in a child, placing the
child in the patient or victim role, it is called Munchausen syndrome by
The complex process by which an MSP parent casts her child in the
patient role parallels another manifestation of the syndrome in which
the mother casts her child in the victim role. In this variation of
Munchausen syndrome by proxy, the parent fabricates or induces the idea
that the child has been abused by someone else, presenting the child to
professionals in the victim rather than the patient role. For purposes
of comparison, I refer to cases where the mother creates a factitious
medical condition for her child as "classical MSP" and use the
term "contemporary-type MSP" for cases where the theme of the
fabrication is the child being sexually or physically abused, with the
child cast in the victim role (Rand, 1989; 1990).
Contemporary-type MSP has arisen in tandem with the upsurge of social
consciousness about child abuse which has dramatically changed the way in
which child abuse complaints are handled. Legislation and services addressing this social problem have been proliferating
for the last 20 years. In today's climate, the accusation that a child
has been abused or molested is accepted at face value, with little, if
any, effort made to distinguish between true and false allegations.
energy of the authorities is directed towards keeping the accused away
from the child and punishing the accused whenever possible. The
there is an adult prime mover of the allegation is rarely taken into
account. Additionally, there are many professionals eager to support an
accuser on the assumption that they are helping the accuser protect the
child. This makes it relatively easy for divorced parents, who are
either unscrupulous or blinded by their own emotional needs, to enlist
the aid of the authorities in supporting a false abuse scenario.
There are a variety of ways in which the classical MSP mother creates
the appearance that her child is ill. She may fabricate the child's
medical history or actually alter medical records. She may contaminate
the child's laboratory specimen, for example add her own blood to the
child's urine. She may even induce the medical symptoms by such means as
rubbing the child's skin with a caustic to produce rash or secretly
administering poison to the child. Although physical harm to the child
may be done directly by the mother in her efforts to induce symptoms,
most of the physical harm is inflicted by doctors who, relying on the
mother's report, subject the child to painful, sometimes dangerous
tests, treatments, surgeries and hospitalizations (Meadow, 1982; 1989).
The maternal profile in Munchausen syndrome by proxy varies. Some
mothers set out consciously and deliberately to create the appearance
that their child is ill. Others come to believe, at least intermittently,
that their child's symptoms are real, a kind of quasi-delusional
thinking (Ravenscroft & Hochheiser, 1980). Caught up in their own
ideas, they manipulate reality to fit their needs and seem unaware of
their role in creating the child's illness. Some are obsessed with the
idea that their healthy child is ill and are never reassured, no matter
how many times they take the child to the doctor. The mother is so
driven by her need to
keep the child helpless and dependent that she imposes invalidism on the
child as a way of life. Regardless of variations in maternal profile,
the mother's investment in her child being ill prevents the child from
leading a normal life and progressing normally through the stages of
It was originally thought that only very young children could be
victims of Munchausen syndrome by proxy because after the age of 5 or 6
a child would be old enough to reveal what was going on. As more cases
were discovered, however, it became apparent that even young children
will go along with the mother's deception by being aware of what she is
doing but not volunteering that information to anyone.
The complex psychological nature of MSP became even more apparent
when it was observed that older children may become active participants
in creating their factitious illness, with either the child or the
mother initiating aspects of the deception with which the other then
goes along. Mother and child may develop a folie ‚ deux relationship
concerning the child's medical condition, with both believing that the
child is genuinely ill or disabled. Recurrent and/or chronic illness
becomes a way of life for these children. Some of them continue this
pattern when they become adults, exhibiting Munchausen syndrome. Some
are not so fortunate as to reach adulthood. The mortality rate for child
victims of classical MSP may be as high as 20 to 30%. This is not
surprising in light of the fact that some of these mothers make the
child appear ill by smothering or poisoning the child to induce
After being involved in hundreds of these cases, Meadow concluded
that the boundaries of MSP type abuse are wide and overlap with other
forms of abuse (Meadow, 1989). There were abusive aspects to some of
these cases that went beyond interface with the medical establishment.
For example, some of the MSP mothers with whom he came in contact would
not allow the child to attend school because of the factitious illness
just a day missed here and there but on a regular basis. In some
instances the child was forced by the mother to adhere to a diet that
was very inconvenient and nutritionally unsound. Some of the children
had to sleep in unusual and uncomfortable sleeping conditions which the mother claimed were necessary because
of the illness.
Meadow also recognized the power of persistently told false stories
alone, explaining in his commentary on Godding and Kruth (1991) that the
term Munchausen syndrome by proxy "Has also permitted child care
workers and legislators to intervene more easily ... in some serious complex cases of emotional abuse in which mothers
were not physically harming their children but were ruining their lives
with stories of false illnesses" (p.960). The power of false
stories to control a child's life is particularly relevant to the
concept of contemporary-type MSP where false abuse scenarios may ruin
not only the child's life but the life of the child's father and others.
Meadow views MSP behavior as existing on a continuum, as do beliefs
and behaviors regarding illness generally. For example, ordinary people
may embellish their medical complaints for sympathy, become overly
concerned with their health, go to the doctor excessively, or call in
sick to work when they need a day off. Munchausen syndrome by proxy
behavior is a matter of degree more pervasive, extreme, and
manipulative, causing identifiable harm to the child. Existing as it
does on a continuum, Munchausen syndrome by proxy can be mild, moderate,
severe, or fatal. Viewed on a continuum, it is much more common than was
In contemporary-type MSP, the parent creates the appearance that the
child has been abused by someone else and is invested in presenting the
child as a victim. The most common scenario is for her to create the
appearance of the child as sexually abused, though sometimes physical
abuse by another is alleged.
As in classical cases, contemporary-type MSP is generally practiced
by the mother who most often accuses the father in a divorce and custody
or visitation dispute but who also may accuse the father's new wife and
her children or the father's relatives. Occasionally, a father
practicing contemporary-type MSP may demand repeated sexual abuse exams
of the child based on allegations against the mother's boyfriend, new husband or the mother and her new parmer together.
In contemporary-type MSP, the accusing mother welcomes additional
sexual assault exams, police interviews, and therapy that focuses on
aberrant sexual experiences, just as the classical MSP mother welcomes
painful tests, unnecessary hospitalizations and surgeries for her child.
In contemporary cases the mother is determined to keep the allegations
going and to prove that the abuse occurred. She is not interested in
helping the child recover from abuse and moving on. In taking the child
from professional to professional, she seeks out those who will validate
the alleged abuse and rejects any professional opinion to the effect
that abuse did not occur. If the father wants his expert to examine the
child, however, she will likely refuse additional examinations on the
grounds of protecting the child from further trauma.
Although most commonly found in the context of divorce,
contemporary-type MSP does occur in non-divorce situations as well.
Loftus and Ketcham (1991) report a case of false accusation against a
day care worker in which one of the accusing mothers used overt rewards
and punishments to make her young child report and embellish stories of
abuse. When, in response to her mother's repeated questioning, the
girl admitted that the accused abused her, mother gave her a cookie, a pat on
the head, a smile or a hug. The girl was sent to her room if she denied
that the accused had done anything, or if she preferred going out to
play to talking about abuse.
By contrast, the mother of another little girl at the day care asked
her child solicitously about the possibility of abuse by the day care
worker in question, but let the matter drop when she was reassured that
her child had not been abused. The child whose mother was obsessed with
abuse experienced considerable trauma as a result of her mother's
obsession, although the mother's actions were attributed to love.
Contemporary-type MSP may be a variant of the cases reported by
Herman-Giddens and Berson (1989) in which the children were subjected to
painful washing of their genitals, ritualistic inspections of the
genitalia, and unnecessary applications of medicines to the genitals, as
well as hospitalizations, repeated pelvic exams, and invasive medical
procedures related to the genitals. Parents who exhibit this pattern may insist that the reason
they focus so much attention on the child's genitals is that someone has
molested their child. Libow and Schreier (1986) describe one such case
where the mother sought repeated pelvic exams for her child, including
one under anesthesia, in an effort to confirm her belief that a female
relative had molested the child.
In the context of divorce, where parents allege and believe the worst
about one another, it is not surprising that both mothers and fathers
have been found to take the child for pelvic exams after every visit
with the other parent, using suspicions of abuse to justify the behavior.
Ironically, this pattern may itself represent a covert form of sexual
Elements of classical and contemporary-type MSP were found to overlap
in a study of 14 children from seven families, with the mother inventing
both physical illness and factitious abuse for the children (Meadow,
1993). The false allegations of abuse were deemed to cause more
suffering for eight of the 14 children than the factitious illnesses.
is noteworthy that for most of these children, the discovery that the
abuse allegations were false preceded the discovery of the mother
physical illnesses. Thus, it was the false allegations of abuse that
lead authorities to discover that these children were also being
subjected to classical MSP abuse. This study indicated that children who
are involved in false abuse scenarios tend to be older than child
victims of classical MSP and that indoctrination of the child with the
story of abuse was prominent in the clinical picture. Although the study
specifically excluded abuse allegations made at the time of divorce, in
four instances ex-partners or ex-husbands were included among the men
Some professionals incorrectly assume that in the context of divorce,
false allegations of child abuse have an obvious external motivation
that of gaining custody. Paradoxically, the accusing parent's
investment in the abuse scenario is sometimes so irrational that he or
she will persist in bringing the accusations to people's attention even
when threatened with toss of custody and visitation for continuing to do
so. This is particularly true when the accusing parent is delusional and
believes the accusation, or when the accusing parent thrives on the
attention received from the authorities. I have had to recommend supervised visits until the
child reaches majority for some of these parents because they either
would not or could not refrain from imposing their abuse scenario on the
child unless there was a court-appointed supervisor present. Despite
punishment for the MSP behavior, some of the contemporary MSP
perpetrators, just like the classical MSP mothers, seem unable to modify
their behavior and will reoffend when given an opportunity to do so.
In some instances, the accusing parent is motivated by both internal
and external motivations. For example, she may feel so competitive with
her former spouse that she wants to prove she is the best parent, an
agenda that goes beyond custody. In another version, her need to control
the child may be so great that she will go to any lengths to gain and
keep that control, including creating a false abuse scenario to win
custody. Parental motivation in custody disputes is often complex, as
any custody evaluator knows. Motivation notwithstanding, a false abuse
scenario may be developed and maintained through MSP type emotional
abuse in a variety of contexts, including, but not limited to, divorce.
MSP and Other Forms of Child Abuse
Munchausen syndrome by proxy can overlap with other forms of abuse,
including (but not limited to) mental cruelty, neglect, physical abuse
and abduction. In one of the most severe classical cases ever reported,
the parents induced abuse dwarfism in their child (Munchausen syndrome
by proxy) as well as subjecting him to beatings, being burned,
starvation, and being forced to live in a closet. The siblings of the
target child were forced to beat him once a week or be beaten themselves
(Money, Annecillo & Hutchinson, 1985).
As in other forms of child abuse, it is important to intervene and
break the cycle of abuse abusive parents rarely stop on their own.
Recent research involving 56 children who had been victims of fabricated
illness showed that both the proxy child and the siblings of such
children are at risk for non-accidental injury, neglect, inappropriate
medication, and failure to thrive type neglect (Bools, Neale &
The overlap with other forms of child abuse is seen in
contemporary-type MSP as well. The case described in Bad Moon Rising: A
True Story ()
(Ferguson, 1988) involved a divorced MSP mother who was neglectful
when the child was young and who tried to abduct him from his father's
custody when he was 10. Several years later she used formal brainwashing
and physical abuse to induce the boy and his sister to accuse the
father's relatives of sex abuse. The book shows how the psychological
abduction of the children succeeded where the mother's attempt at
physical abduction had failed.
In one case about which I was consulted, a 7-year-old boy was induced
by his mother to accuse his father of physical and sexual abuse during a
divorce action. As a result, the boy had no contact with his father
until, as a young teen, he announced to his mother that he intended to
tell the truth. She responded by beating him and handcuffing him to the
bed. As a result of her attack, he was psychiatrically hospitalized.
the investigation that followed, it came out that it was the mother and
her boyfriend who had previously engaged in sexually abusive behavior
with the boy. Custody was awarded to the father, at which point the
mother abandoned all interest in her son.
In the classical cases reviewed by Bools, Neale and Meadow (in
press), the child victims and their siblings did not appear to be at
unusual risk for sexual abuse. In contemporary-type MSP, there is probably
a greater risk for sexual abuse by the MSP parent or her agents since
parent is obsessed with the child as a sexual object. Repeated sexual
exams and interrogations of the child about aberrant sexual experiences
may constitute an indirect or covert form of sex abuse.
In Munchausen syndrome by proxy, as in other forms of child abuse,
the parent is driven to gratify her needs at the expense of the child's.
As such, it is to be expected that, in order to prove the father is a
molester, a small number of contemporary-type MSP mothers will actually
inflict physical findings of sexual abuse on the child. Over the last
five years, I have received communications from two different
professionals about this type of scenario. In one instance, the
professional confronted the mother, who then admitted to rubbing her
child's anus with scouring powder to create the appearance of
molestation by the father.
Divorce Puts Children at Risk
A number of authors have expressed concern about the emotional burden
on children whose needs are subverted in the service of an angry or
disturbed parent. Judith Wallerstein, foremost researcher on the effects
of divorce on children, devotes a chapter in her book, Second Chances
& Blakeslee, 1989), to what she calls the overburdened child. After
the divorce, the overburdened child's developmental needs are thwarted
by the need to take care of a chronically troubled parent who may be
intensely dependent, alcoholic, disorganized, enraged, and so on. With
only one parent in the home, there is no adult to buffer the child's
pain or to relieve the child of the caretaking burden.
There are many reasons why divorce puts children at risk:
In most crisis situations, such as an earthquake, flood, or fire,
parents instinctively reach out and grab hold of their children,
bringing them to safety first. In the crisis of divorce, however,
mothers and fathers put children on hold, attending to adult problems
first. Divorce is associated with a diminished capacity to parent in
almost all dimensions discipline, playtime, physical care, and
emotional support. Divorcing parents spend less time with their children
and are less sensitive to their children's needs. At this time they
may very well confuse their own needs with those of their children.
Divorce is also the only major family crisis in which social supports
fall away ... Friends are afraid that they will have to take sides;
neighbors think it is none of their business ... Grandparents may be
helpful but are apprehensive about getting caught in the crossfire.
They often live far away and feel their role is limited ... Divorce is a
different experience for children and adults because the children lose
something that is fundamental to their development the family
structure (Wallerstein & Blakeslee, 1989, pp.7-11).
The hazards of divorce do not necessarily pass with the crisis of
dissolution. In their 10-year follow-up, Wallerstein and Blakeslee
(1989) found the effects on both parents and children to be profound and
long-lasting. They found that one-half the women and one-third of the
men in the study were still intensely angry at the former spouse and
that anger is a prominent theme in the lives of the children as well.
and even 15 years later, one-third of the women and one-fourth of the men in their sample were unhappy with their lives in general,
feeling life is unfair, disappointing, and lonely. As for the children,
many of them were having problems in adulthood with relationships.
of betrayal and rejection were intense and pervaded their relationships
with the opposite sex. While longing for a loving, faithful marriage,
many were afraid to take the risk and make the commitment.
One of the emotional burdens to which children of divorce may be
subject is that of Parental Alienation Syndrome in which one parent
seeks to sever the child's ties with the other, sometimes using
fabricated sex abuse to help accomplish this goal (Gardner, 1987, 1992).
In a significant number of cases, Gardner has found that the child, as
well as the alienating parent, has an emotional agenda that is met by
the Parental Alienation scenario, such that the child may actively
participate in the alienation. (More discussion of the child's agenda
in divorce appears below.) Parental Alienation with fabricated sex abuse
may involve Munchausen syndrome by proxy type abuse.
The fact that divorce has become common does not make it any less
traumatic. Some people are able to make a healthy adjustment and to move
on with their lives constructively. They understand that children need
both parents. Unless the other parent is really awful, they set aside
their personal feelings enough to insure that the children have a
relationship with both parents. When contemporary-type MSP occurs in
divorce and the accusing parent is supported by the legal system, as is
often the case, the child loses not only their two-parent nuclear family
but one whole parent as well. The child is used as a tool to ruin the
father financially, destroy his reputation, and even send him to jail.
Contemporary-type Munchausen syndrome by proxy can be seen as a severely
maladaptive adjustment to a problematic life event.
Literature on Munchausen Syndrome by
There has been a steady increase in the number of MSP articles in
medical and psychological journals since Meadow first reported his
findings in 1977. Ten years later, a literature review of Munchausen
syndrome by proxy was published in
Child Abuse & Neglect (Rosenberg, 1987).
For their upcoming book on MSP as experienced in
their hospital practice, Libow and Schreier estimated that over 200
articles have been published (personal communication). Books have been
written about the true stories of classical MSP cases that ended in
children's deaths (Elkind, 1983; Wright, 1984). Recently, the FBI
featured an article on MSP in their Law Enforcement
1991). Several years ago, the TV program, A Current Affair, introduced the
public to a woman with adult Munchausen syndrome; "the blind
skier" she was called, except that she was not blind. Newspapers
report with some regularity on cases of MSP that are particularly
shocking, for example a mother caught suffocating her child in the
hospital to induce seizures.
The first references to the connection between MSP and some sexual
abuse allegations appeared in the early 1980s. Goodwin (1982) reported
mothers obsessed with the idea that their child had been abused,
although this did not appear to be the case. These mothers not only took
their children for repeated pelvic exams that the mother observed, but
the mother actually repeated the pelvic exam again at home.
One of the first reports in the literature of false sex abuse
accusations in divorce was by Kaplan and Kaplan (1981). They diagnosed
the mother/child dyad as exhibiting folie ‚ deux, a clinical phenomenon that
is associated with a number of psychiatric illnesses (Munro, 1986),
including Munchausen syndrome by proxy. Schuman (1986) reported on 7
cases of false accusation in divorce, suggesting that MSP might be
operating in some instances. Wakefield and Underwager (1988) described a
mother who had taken the children for sex abuse exams after visits with
their father, as well as examining the children's genitals herself.
stories of contemporary-type MSP in divorce have also been made into
books (Spiegel, 1986; Ferguson, 1988). In February, 1993, the
Minneapolis Star Tribune reported on a mother in a divorce action who
lost custody based on findings that she had been practicing
contemporary-type MSP with the children.
The study of false accusations of child abuse is discouraged in the
current social climate, which is unfortunate since clinical information
on the topic is much needed. Seeking to meet that need, Ackerman and Kane
(1991) published my list of warning signs for contemporary-type MSP in the supplement of their
book, How to
Examine Psychological Experts in Divorce and Other Civil Matters ()()(). This
list, printed below, was adapted and expanded from Jones, Butler,
Hamilton, Perdue, Stern & Woody (1986), who originally took it from
Warning Signs for Contemporary-Type MSP
||The accusing adult seems to know more about what allegedly
happened than does the child.
||The child answers negatively about abuse when questioned away from
the mother/accuser; the child reports to evaluator, "Mommy says I was
||The adult accuser and/or the child manipulates information by
fabrication, omission, or distortion of the truth, e.g. erroneous
statements about medical history and findings, employment, school records.
||The accuser is more interested in building a case than in helping
the child deal with abuse and moving on.
||The child continues to be presented in the victim role through
"add on" allegations, "add on" details to the original
allegation, and "newly remembered" episodes of abuse.
||The adult accuser gives a history of herself having been molested
as a child, although this view is inconsistent with the view of the
family held by the majority of its members and also when this view is
inconsistent with the family history as constructed by evaluator
interviews with different family members.
||The allegations of abuse are factually contraindicated, e.g. the
molester is alleged to have taken the child upstairs for molest when he
had a medical condition that prevented him from climbing stairs.
||The allegations of abuse are bizarre or improbable, with multiple
family members accused, including grandparents.
||The child appears well-adjusted during the period that the abuse
was supposed to have occurred.
||The child does not recover from abuse through therapy or a
previously well-adjusted child regresses during therapy, developing
nightmares, bed wetting, etc.
||The child recites allegations in a rote manner; the child is eager
to tell story of abuse; the child describes abuse in same language as
the accusing adult.
||The adult accuser has child repeatedly evaluated for abuse and is
dissatisfied with negative or equivocal results.
||The adult accuser welcomes repeated sexual assault exams and
interrogations of the child, even though these may be painful or
upsetting to the child.
There is a symbiotic, enmeshed relationship between mother and
child, e.g. the mother insists on staying in the room with the child for
the child's evaluation or therapy interview.
||The Parental Alienation Syndrome is either present or in
with the child inappropriately alienated from the accused parent while
presenting a united front with the accuser.
The Mother, Mother/Child Dyad, and the Child in MSP and Divorce
In contemporary-type MSP, the mothers have been variously described
as histrionic, obsessed, angry, fanatical, self-righteous, aggressive,
emotionally labile, manipulative, dramatic, unpredictable, and unable to
distinguish fact from fantasy. Like classical MSP mothers, they are
often observed to be anxious and overprotective. Perhaps for this
reason, some of them have also been described as wonderful mothers,
devoted to their children, just like classical MSP mothers who are often
seen by medical staff as loving and attentive to the child, until the
deception is discovered (and sometimes after that).
Out of 72 parents who falsely accused in divorce, Wakefield and
Underwager (1990) found four fathers, three of whom were described as
hypervigilant, defensive, hostile, paranoid, intimidating and
controlling, which is consistent with my clinical experience. The fourth
father presented as docile and passive, a passive-aggressive individual.
Research has recently been completed in England on 47 classical MSP
mothers (Bools, Neale & Meadow, in press). When their lifetime
psychiatric histories were studied it was found that 27 of these mothers
had engaged in acts of self-harm, 10 had a history of alcohol or drug
misuse, 34 had exhibited factitious or somatoform disorder, and 9 had
been convicted of offenses other than child abuse, for example theft or
arson. This finding suggests that more careful attention should be
given to the presence of antisocial features when MSP is suspected.
unique aspect of this study was the fact that 20 of the mothers were
interviewed 1 to 15 years after the original fabrications. Some mothers admitted to the interviewers that
they had fabricated, while others maintained complete denial of their
The aspect of the Bools et al. (in press) study that specifically
examined maternal psychopathology indicated that 18 of the 20 mothers
who were interviewed not only had personality disorders, but met the
criteria for several personality disorders. Where this was the case, the
researchers determined which personality disorder was predominant,
concluding that borderline, histrionic and dependent disorders tended to
characterize the mothers in their sample.
Wakefield and Underwager (1990) found personality disorders in
three-fourths of the 72 parents who falsely accused in the
divorce/custody context. These parents were compared to 67 divorcing
parents who did not bring false allegations of abuse, of whom only
one-fourth were diagnosed as having personality disorders. Histrionic,
borderline, paranoid, passive-aggressive, and mixed personality
disorders characterized the majority of the falsely accusing group.
Persons with personality disorders tend to have chronically
maladaptive coping styles that do not necessarily render the individual
non-functional but may result in a variety of life difficulties. Only a
few of the falsely accusing parents in Wakefield and Underwager's sample
were dysfunctional to the point of losing touch with reality although
some exhibited bizarre behaviors, or believed themselves to have rare
spiritual powers or religious connections. Of the seven accusers that
Schuman (1986) reported on, only one was diagnosed as mentally ill,
although all displayed intrapsychic and familial dynamics that were
active in generating the accusations.
It is uncommon in both classical and contemporary-type MSP for the
mother to be diagnosed as floridly psychotic, although psychotic
features may be present. Particularly when the fabrication involves sex
abuse, the allegations may be one of the early signs that the
mother/accuser is decompensating, although this may not be recognized at
the time. Some of these cases unfold over several years and the
decompensation of the accusing parent only becomes apparent with time
and subsequent events.
Diagnostic labels such as borderline, histrionic, paranoid,
narcissistic, and antisocial are used in the DSM- III-R (American Psychiatric Association, 1987) to
describe personality disorders and/or personality features. They may also be used
in combination, for example borderline with narcissistic and antisocial features.
In other instances, more probably when the contemporary-type
MSP is mild to moderate, the Axis II diagnosis may be limited to
histrionic features or narcissistic features, etc. Individuals with borderline, histrionic,
paranoid, narcissistic and antisocial features and personality disorders
are more likely than normals to distort or misinterpret events, harass
others, lie and otherwise manipulate people, including their children.
Divorcing parents with some or all of these characteristics may
instigate false allegations of abuse in their maladaptive effort to grapple with
the myriad problems of divorce. I have outlined below a series of profiles
for parents who exhibit predominantly borderline, histrionic, paranoid,
and antisocial personality styles.
Mother/accusers with borderline features or borderline personality
disorder: These parents often exhibit remarkable rage that does not seem
to abate with time. They experience extraordinary mood swings, so they
may appear normal one day and "off the wall" another. This can
pose problems for the custody evaluator since the relatively limited
time spent with each parent may preclude seeing the borderline parent at
their worst. On their "off the wall" days, these parents may
exhibit "transient periods in which bizarre behaviors, irrational
impulses, and delusional thoughts are exhibited ... they may be driven to
engage in erratic and hostile actions ... These episodes of emotional
discharge serve a useful homeostatic function since they afford
temporary relief from mounting internal pressures" (Millon, 1981,
It is not difficult to imagine how a divorcing borderline mother
might become caught up in the idea that the husband who left her has
abused the child. Professionals sometimes minimize the pathology of this
rage because it seems understandable that a woman would be angry because
her husband left her. Among the cases I have become involved in,
however, are those in which it is the borderline mother who left her
husband. This woman never seems to get over her disappointment and rage
that the marriage did not meet her expectations. In either
hostile action of trying to destroy the father with false allegations of abuse provides a release for her hostility, helps her
gain control of the situation, and binds the child more closely to her
so that at least she has someone.
Mother/accusers with histrionic features or histrionic personality
disorder: The parents want others to pay attention to them and they
achieve this through dramatic and energetic behavior. They habitually
manipulate others to get attention so that the manipulation of the child
and of professionals in MSP type abuse is just another expression of
this interpersonal style. They become easily excited, have angry
outbursts, and prefer playing their own hunches to a more rational,
reasoned approach. They are suggestible and easily influenced by social
trends (the current focus on child abuse could certainly be considered a
current social trend). The histrionic mother might notice a rash on her
daughter's thigh, become excited and angry, and play her hunch that
father molested the child. The child would be overwhelmed by the
mother's emotions and accommodate to her expectations, creating the
mutually reinforcing cycle discussed by Schuman (1987).
Mother/accusers with paranoid features or paranoid personality disorder: There are a number of
variations on the paranoid theme,
including paranoid features, personality disorder, and delusions.
Paranoids are angry and suspicious. When the accusers in this group
suspect someone has bothered their child, they badger the child until
the child gives in just to be left in peace. They are also aggressive towards
who they feel have slighted them and use their feelings of hurt and
humiliation as an excuse to harm others. Individuals in this category
are often litigious and may harass those by whom they feel persecuted.
They tend to distort objective reality and to construct a new reality in
its stead, preferably a new reality which affirms their personal stature
and significance. The accusers in this group avoid any blame for the
divorce and gain personal stature as the virtuous protector of an abused
child. Individuals with paranoid features will counterattack in response
to any perceived threat, and divorce, by its very nature, offers many of
The paranoid coping style can pervade many areas of the person's life
or it can be limited to a specific area as in paranoid delusions. An
idea need not be bizarre to be a delusion. When the accuser really believes
that the child was molested by the former spouse or his agents, she may be
exhibiting delusions of persecution "by proxy."
Delusions are fixed,
false beliefs that are confined to a single theme. Persons with
delusional paranoid disorder may appear relatively normal in their
intellectual and occupational functioning, although their marital
functioning is often disturbed because of their tendency to blame,
become angry and be suspicious.
Rogers (1992) reports on five cases in which delusional disorder
preceded the mistaken or false sexual allegations in the divorce/custody
context. For the clinician, Rogers offers some good differential
There is a range of conditions that may share some commonality with
Delusional Disorder where there may he varying degrees of loss of a
reality basis with overvalued ideas at one end of the continuum
merging into actual delusional thinking at the other. ... Disorders
that should be considered and ruled out include Affective Disorders,
especially Bipolar Disorder, Schizophrenia, Schizophreniform Disorder,
Brief Reactive Psychosis, organic delusional syndromes ... and Paranoid
Personality Disorder. ... Differential diagnosis is important because
the prognosis of the affected individual may vary; some of these
individuals have a good outlook and may recover well enough to carry
out all of their parenting functions, while others have a less
positive outcome (p.48).
Rogers' list is a helpful reminder that there are a number of
psychiatric conditions which are characterized by erroneous beliefs and
actions consistent with such beliefs. Whenever there is an adult prime
mover of abuse allegations, professionals should consider the diagnostic
alternatives for that person and the social influence that person has on
Paranoid delusions may be shared between two or more people. When, as
a result of their association with each other, two people hold the same
fixed, false belief, it is called folie ‚ deux. In contemporary-type MSP,
the accuser, the child, certain friends and relatives may actively share
the fixed but false belief that the child was molested by the father.
Mother/accusers with antisocial features or antisocial personality disorder:
Accusers who lie deliberately and who feel no compunction about telling
the child to lie may have antisocial features or full-blown antisocial personality disorder.
Antisocial features were exhibited by the mother
described above who had instructed her son to lie about his father
abusing him, then handcuffed him to the bed when he threatened to reveal
the deception. Antisocials have no regard for authority or for the rights
of others, including their children and their former spouses. They
personal power and have no compunction about enlisting the power of the
authorities to achieve their personal goals, such as getting a former
spouse jailed and being free permanently from the inconvenience of
sharing the child with the father. By the same token, parents in this
group feel justified in flouting the law and kidnapping their children
to protect them from the falsely accused former spouse. Gender bias in
diagnosis may make evaluators reluctant to diagnose antisocial features
Mother/accusers misperceived by professionals: It is often difficult for
professionals to reconcile the incongruity between how caring the MSP
mother seems to be and what she is really doing that is harmful to her child.
Based on involvement with over 200 classical cases Neale, Bools and
Meadow (1991) found that, "With MSP abuse, mother-child interaction
often appears close, although on inspection is actually over-controlled.
The child may appear materially well cared for by a loving mother.
mothers went to great lengths to foster that impression" (p.8).
There are a number of reports in the literature of classical MSP
mothers who, upon psychiatric evaluation, appeared quite normal. One can
only assume that the mothers so described must have outwitted their
examiners. The limited nature of the evaluation itself may be a factor in
some instances. The examiner is at a disadvantage unless he or she has
the opportunity to carefully compile and verify an accurate, comprehensive
history. My own experience is that even in severe cases of
contemporary-type MSP, where the MSP parent exhibits what most people would
consider significant psychopathology, there is often at least one
professional involved who is willing to offer a benign diagnosis.
The interaction between mother and child can provide important clues
in diagnosing Munchausen syndrome by proxy. Custody evaluators have a
unique opportunity to evaluate this interaction since it is customary to meet with all the parties
for this type
The mother-child relationship in MSP is often described as enmeshed,
symbiotic, mutually anxious and overprotective. The mother has no sense
of psychological boundaries between herself and her child and therefore
it is difficult for the child to develop boundaries with respect to her.
In contemporary-type MSP it is not unusual for the mother to insist on
staying in the room with the child during an evaluation. She may send
the child to individual therapy sessions with a tape recorder so that
the mother can go over the session with the child later.
The lack of boundaries between parent and child is illustrated by a
common feature of MSP in which the mother "donates" her symptoms
to the child, assigning symptoms to the child that are similar to ones
that she reports having had herself. In classical cases, the mother may
assert that both she and the child have a history of treatment for
abdominal pain. Likewise, mothers who have induced the idea that the
child was molested by the father may assert that they, too, were
molested as children, even though the mother's adult-molested-as-child
scenario is quite new and is at odds with the view held by the rest of
In divorce, these mothers assume that since they have no further use
for the father, the child does not either. The idea that the child has a
need for the father that is independent of the mother or the marital
relationship is inconceivable to these women. In classical MSP the
father is also excluded from the mother/child dyad although he is
usually in the home. Fathers in families where the mother
illness are not privy to the deception. They tend to be more passive and
in the background, with lives of their own to lead. This is similar to
how Blush and Ross (1987) described the fathers in their sample of cases
of what they term the SAID Syndrome, an acronym for sex allegations in
divorce. The picture that emerges is that the mothers are much more
dominant than the fathers in relationship to the children.
There may be behaviors of concern in the mother/child interaction
that do not relate directly to the allegations. In one custody
evaluation I reviewed where MSP was suspected, the mother was asked to work with her 3-year-old daughter to create a
family drawing. Given
the child's age, the evaluator expected the mother to organize the task.
The mother had no sense of organization in her approach, did not follow
the evaluator's instructions, and the task was never carried out,
despite repeated instructions and encouragement from the evaluator.
evaluator further observed that the mother projected her feelings onto
the child and spoke to the child using concepts that were much too old
for her. This child was also unable to meet with the evaluator without
her mother present, exhibiting obvious separation anxiety.
Especially as the child grows older, mother and child in
contemporary-type MSP may share a mutual delusion or folie ‚ deux
is limited to the allegations of abuse against the father. The
their shared belief system is delusional may go unrecognized by the
authorities for several reasons: 1) mother and child seem to be in touch
with reality in other areas, 2) the authorities believe the allegations
to be true, or 3) the allegations cannot be disproven. In evaluating
cases where folie ‚ deux is suspected, consideration should be given
to the adaptive function of such a delusion, for example it allows
mother and child to identify with each other, channel aggressive drives
outside their relationship and preserve intimacy in the face of a world
they experience as lonely or hostile.
The Child in MSP
The primary focus in the classical MSP literature was originally on
the mother, although increasingly attention is being given to the child.
A study of the psychological effects of classical MSP on child victims
(P)sychological development (was) thwarted at the most basic
level-basic parental trust. ... toddlers and preschoolers were not
allowed separation and individuation and developed withdrawn)
hyperactive, and oppositional behaviors ... The older children and adolescents
developed conversion symptoms, cooperated with their
parent's deceptions, and began to fabricate their own history and
symptoms. In these cases and several others we have seen, the syndrome
is dearly multigenerational ... the child victims of Munchausen
syndrome by proxy become adult Munchausen syndrome patients (McGuire
& Feldman, 1989, p. 291).
There are multigenerational effects on the child victims of
contemporary-type MSP as well. If they come to believe the allegation,
they may live the rest of their lives rejecting their father, based on
the belief that they were molested by him. Children in this category may
tell their children about the molest so that it becomes part of the
family history. Male role models become negative. Family relationships
that were broken off because of the accusations will result in loss of
those same relatives by the next generation. Thus, when the child grows
up and has children, those children are deprived of paternal
grandparents and other relatives on the father's side. Children who
remained conscious of the fact that the abuse scenario was a lie may
carry the knowledge of the lie into adulthood and feel considerable
The tragic consequences of one case of contemporary-type MSP were
related by a psychologist, "Dr. Smith" (Smith, 1991). A
17-year-old girl came to him and revealed her anguish over going along
with the mother's program years before of accusing the father of sexual
abuse. The father was sent to prison and eventually committed suicide.
When the girl found out the consequences of how her mother had used her,
she overdosed on her mother's sleeping pills and died. In this case, the
multigenerational effect of the MSP type abuse was that there would be
no further generations.
An understanding of how children react to divorce at different ages
may shed light on how the child's needs can be exploited by the MSP
parent in this context. Young children are vulnerable by virtue of
fearing further abandonment. Having lost one parent, they are afraid
they will lose the other. The mother may reinforce the child's anxiety
that there is only one parent who can be relied on by telling the child,
"He doesn't care about you. He never cared about anyone but
himself." The fact that the father has left the home and has been
prevented from seeing the child will seem to the child to validate this.
Children in this situation are going to do everything in their power to
preserve the alliance with the remaining parent.
According to Wallerstein and Blakeslee (1989), children who are
between 5 and 8 years of age at the time of the divorce tend to
experience the divorce as a fight in which they must take sides, with or
without parental coaching. If there is parental coaching, children in this
age group may go along. If the child initiates a non-valid report of
abuse, the parent predisposed to MSP abuse has only to take advantage of
the situation and claim they are not responsible for what the child is
At ages 9 to 12, Wallerstein and Blakeslee found the children were
especially furious at the parent whom they blamed for the divorce.
was mainly children in this age group who formed "mischievous
alignments" with one parent for the purpose of humiliating or
harassing the other parent. False accusations of abuse can readily
spring from this dynamic.
Adolescents need limits setting more than any other age group but
parents caught up in their own troubles may not be able to provide the
kind of supervision and limits setting the adolescent needs. Feeling
angry and abandoned, teens of divorcing or divorced parents may act out
through accusing the parent with whom they feel they have the least to
lose. Alternatively, they may use an accusation to get the attention of
the parent in the home or to enlist sympathy from concerned school
personnel and others outside the home. They may receive more attention
for accusation of abuse than they have ever received before. Children
accustomed to years of emotional coldness and rejection by their mother
may suddenly find her hanging on their every word as long as they can
come up with more and more stories about how daddy abused them.
The issue of the child initiating deceptions was raised earlier with
respect to classical MSP. One case study describes a 10-year-old boy who
inserted a small stone up his urethra to simulate the passage of kidney
stones (Sneed & Bell, 1976). In a more contemporary-type scenario,
Goodwin, Cauthorne and Rada (1980) reported on 3 girls, ages 9 and 10,
who created the appearance of neglect by their adoptive parents. They
went so far as to change into rags on their way to school so as to
support their claims.
In addition to situational factors, each child has his or her own
personality and behavioral tendencies that influence how the child
perceives, feels, and behaves. Problems with anger, impulsivity,
dependence, or truthfulness in a child prior to the divorce are likely
to come into play as the child grapples with the divorce and its
aftermath. Not only are some parents more prone to MSP type abuse, some
children may be more predisposed to participating by virtue of their
personality and their relationship with the MSP parent. During a
presentation on MSP that I was conducting at a local hospital, a
colleague described a mother who invented medical symptoms for her two
daughters up until age 6. After that, one of the girls flatly refused to
go along with the factitious illness scenario any longer, while the
other continued to along with the mother's deceptions into adulthood.
As the above example indicates, more than one child in a family may
be subject to MSP abuse. In a recent study examining serial Munchausen
syndrome by proxy, Alexander, Smith and Stevenson (1990) maintain it is
an underestimate that multiple-child MSP is found in 25% to 33% of all
cases. Where more than one child was victimized, they found the mother's
level of psychiatric/behavioral disturbance to be high. They also
expressed concern that when the MSP abuse was not stopped with the first
child, the mother went on to abuse additional children, underscoring the
importance of breaking the abuse cycle.
In some instances, siblings may actually provide reinforcement for
each others' participation in folie ‚ deux and MSP. Likewise, sibling rivalry
may prompt a child to develop the same symptoms as a sibling who is
using the symptoms to get attention. In contemporary-type MSP one
sibling may act as a confederate of the mother and manipulate the other
sibling into maintaining the accusation (Ferguson, 1988; Gardner, 1989).
Professional Participants in MSP
The MSP triangle would not be complete without the "professional
participants," those who co-operate with the mother in her MSP
abuse of the child (Zitelli, Seltman, & Shanon, 1987). The
professionals may be well-meaning or they may be negligent, misinformed
or financially motivated, but their precise motivation is not at issue.
What is at issue is that the mother, or the mother/child dyad if the
child is older, manipulates professionals into responding as if the child
were really ill or victimized. Just as doctors cause most of the direct physical harm in classical MSP, in contemporary-type
MSP it is the sex abuse therapists, protective service workers,
detectives, etc. who do much of the reinforcing of the abuse scenario in
the child's mind. The support of sex abuse therapists, protective
service workers, judges, attorneys and detectives make it possible for
the mother to accomplish her agenda.
One of the most common scenarios in contemporary-type MSP is for the
accusing parent to take the child from therapist to therapist until one
is found who will validate abuse. As legislation and services to child
abuse victims have burgeoned, a cadre of professionals, who Gardner
(1991) called the "validators," has arisen. The validators do not see their
job as discerning which allegations ate true and which are not. Rather,
they act on the assumption that all allegations are legitimate. They
often use persistent, leading questioning, sexually explicit dolls, and
selective rewards as part of evaluation and treatment. In addition to
convincing the child that abuse occurred, validators often help the
mother mobilize the power of the authorities on behalf of her agenda.
Attorneys and custody evaluators can be professional participants in
contemporary-type MSP as illustrated in the following case. The custody
evaluation complete, the evaluator found it highly unlikely that the
father had molested his young daughter. However, to help the child
become more independent of her mother, the evaluator recommended that
the child continue in the therapy the mother had previously enrolled her
in, even though the therapist had refused to speak to him and there was
every indication that the therapist was a validator. Some time later,
attorneys for the mother and father were in court without the parties
when the mother's attorney told the judge that the girl had been
recommended for therapy by the evaluator because she had been sexually
abused by her father. The report given by the mother's attorney of the
evaluator's opinion became part of the court record.
In an interesting variation on the theme of professional
participants, Meadow (1990) describes an MSP mother who agreed with
workers from five different agencies that her MSP abuse of two of her
children was really a cry for help because she claimed to have been
molested as a child. The alleged molest occurred when she was 10, sitting on her uncle's knee.
The MSP abuse
of her children resulted in the death of one and brain damage to
Perception, Social Influence, and Memory
Divorce engenders extraordinary emotions in children and adults
alike. As such, events are subject to misinterpretations and distortions
of all kinds. This is true even in an amicable divorce, witness the
following scene. The parents were discussing their divorce and in a
friendly spirit one of them commented that things were going to work
out, meaning that the practical steps of the divorce were going
smoothly. The child overheard and, perception colored by his needs,
thought that "things working out" meant that his parents were
getting back together.
Misinterpretation is not always so benign, especially when the
divorce is acrimonious. Wallerstein and Blakeslee (1989) describe, with
grave concern, how a teenage boy in their sample had "rewritten
history." They knew for a fact that it was the father who had
insisted on the divorce while the mother, especially concerned that her
children not have a broken home, had tried hard to keep the family
together. Years later, the boy was convinced that it was his mother who
had asked for the divorce. He invented a number of other "facts"
about his mother to support his new view of reality, for example that
she was gay and hated men. The boy may have been responding to paternal
influence, he may have created the story to shore up his identification
with his father, Wallerstein and Blakeslee do not say.
Subtle social influence can be as effective as an obvious
brainwashing campaign. Schuman (1987) describes a mutually reinforcing
cycle between parent and child whereby the child accommodates to
parental expectations and perceptions. The parent experiences this as
reinforcement of his or her point of view. The child responds to the
parent's increased confidence by accommodating further. The result is
that mother and child may come to hold "true beliefs" which are
not valid but which are not "lies" either.
In MSP social influence comes not only from the mother/accuser but
from the professional participants whom she mobilizes. The professional participants can be viewed as a
group cultivated by the mother to help her manipulate rewards and
punishments so as to promote new learning in the child and to control
the child's activities. This constellation is one of the conditions
necessary for brainwashing, a form of social influence that relies on a
group with a charismatic leader. Other conditions for brainwashing
include naivetť of the subject (in this case a child), physical and
psychological dependency of the subject on the influencer (in this case
a parent) who is looked up to as an authority figure, reinforcement of
the dependency by the influencer, and discouraging of outside
attachments and influences that would compete with the influence over
the subject. These conditions are met in many polarized divorced
One of the tragic aspects of contemporary-type MSP is that the
child's memory of events may actually be altered, so that loving
interactions with the father are obliterated and replaced by negative
ones. New information, in the form of leading questions or hearing
others talk about the alleged abuse, may become incorporated into the
child's memory so that the memory is altered, distorted, or contaminated
(Loftus & Ketcham, 1991). Adult memory can be altered in the same
way. Schuman (1986) observes that multiple evaluations and sex abuse
therapy for non-abused children result in the child displaying increased
accommodation of both memory and affect.
MSP and the DSM-III-R
Munchausen syndrome by proxy belongs to the class of factitious disorders, which were first included in the Diagnostic and Statistical
Manual in 1980. The DSM-III-R (American Psychiatric Association, 1987)
describes various forms of adult factitious disorder but does not yet
specifically list Munchausen syndrome by proxy or the more generic factitious
disorder by proxy. Factitious disorder by proxy is expected
to be included in the DSM-IV (Widiger & Trull, 1991).
According to the DSM-III-R, factitious disorders are "(C)haracterized
by physical or psychological symptoms that are intentionally produced or
feigned. ... the judgment that the symptom is intentionally produced is based, in part, on the person's ability to
simulate illness in such a way that he or she is not likely to be
When discovered, individuals exhibiting factitious disorder have been
found to produce a variety of physical and psychological symptoms,
including factitious psychosis, factitious depression, factitious bereavement, and
factitious rape. Since the only limit on the type of
symptoms created is what professionals will accept and respond to, it is
be expected that there will be some cases of factitious sex abuse, and some of
these will be "by proxy." Variations of the syndrome will emerge
continuously: "By their very nature, fictitious illnesses must be
adaptive to changing circumstances, or they would be too obvious. ...
probable range of variations in the presentation of Munchausen Syndrome
is likely to develop in parallel with the evolution of medical and
social services" (Sinanan & Haughton, 1986, p. 465).
Until the DSM-IV comes out, factitious disorder not otherwise specified
can be used on Axis I to identify Munchausen syndrome by proxy or the
more generic factitious disorder by proxy. There can be more than one
diagnosis on Axis I, so that if another diagnosis also applies, for
example bipolar disorder, it can be listed here as well. The underlying
personality disorder, if there is one, would be listed on Axis II.
the accuser's thought process with respect to the alleged sex abuse can
be characterized as "persistent, non-bizarre delusions," a
diagnosis of delusional (paranoid) disorder may be listed on Axis I.
When the clinical picture can be characterized as folie ‚ deux, a
diagnosis of induced psychotic disorder (shared paranoid disorder in
DSM-III) may be appropriate, although the conceptualization in the
DSM-III-R is not very satisfactory.
Evaluating for Contemporary-Type MSP
A major obstacle to the early diagnosis of contemporary-type MSP is
the assumption by many professionals who come in contact with the case
that the allegations of MSP parent are true. In an effort to deal with
this problem, the American Academy of Child and Adolescent Psychiatry
came out with a position paper in 1988 in which they recommend always
considering the possibility of false accusations, "particularly if allegations are coming from the parent rather than
the child, if parents are engaged in a dispute over custody or
visitation, and/or if the child is a preschooler" (Schetky et al.,
1988, p. 655-656).
It is not enough to make a determination as to whether the
allegations are true or false. In addition to assessing the validity of
the abuse allegations, it is important to assess what factors in the
accusing parent, the child, and the parent/child relationship have
contributed to the development of a false accusation. The evaluator must
not only identify whether the child is subject to a complex form of
emotional abuse by the accusing parent, but must be able to articulate
how this is harmful to the child. All this requires considerable time
and expertise, since the evaluator is trying to sort out if the child
was molested by the accused, if the accuser is the one abusing the
child, and depending on the answer to these questions, which parent
should have custody of the child and how visitation should be
In classical cases, the realization tends to come slowly that the
child's medical condition is not bona fide but is an artifact created by
the mother (Meadow, 1985). The same holds true in many contemporary-type
MSP cases as well. Psychological evaluations tend, by their very nature,
to be one shot deals. If the evaluator was on the right track but did
not quite get to the MSP type abuse the first time, it may be
appropriate after more time has passed to seek a court order for the
evaluator to reexamine the parties.
A single evaluator is recommended to assess the mother, father and
children, as opposed to having one evaluator for the mother, another for
the children and so on. There is another type of evaluator, preferably
someone with expertise in MSP who reviews all the documentation in the
case, including the report of the primary evaluator, and renders an
opinion as to the likelihood that MSP type abuse is operating. This type
of evaluator integrates all the material on the case and does a
Meadow (1985) offers guidelines for evaluation of classical MSP which
are equally valuable for contemporary-type cases:
||Study the history to decide which events are likely
fabricated and which ones are real.
||Look for the temporal relationship between illness events and the
presence of the mother.
||Check the details of the personal, social and family history that
the mother has given often she will have lied about them.
||Make contact with other family members.
||Look for the motive for the behavior.
In searching for the motive for the behavior, it is helpful to
investigate how both the parents and children are adjusting to the
divorce, although the allegations often form a smoke screen that makes
this material difficult to explore. Which parent left the other?
not always the case that the MSP mother is taking revenge on a husband
who has left her. Sometimes it is the mother who left, and she wants the
father completely out of her life, without the bother of shared custody.
Who does the child blame for the divorce? This is particularly pertinent
with older children who may be participants in the MSP, initiating
allegations or going along with them because of their own unresolved
feelings. How are parents and children dealing with the feelings of
loss, loneliness, guilt and anger engendered by the divorce? Do the
allegations serve a defensive function, staving off feelings of failure,
disappointment, and loss?
Collateral contacts with family members can provide insight into some
of these issues. They can also help clarify which items are fact and
which are distortions or fabrications and provide a clearer picture of
the family history and dynamics. Family dynamics may shed considerable
light on the diagnosis along with evaluation of the mother and children
(Griffith, 1988). In addition to providing a more objective view of
events, contact with family and friends sometimes reveals a folie ‚ deux
relationship between the accuser and another adult who is supporting her
in the allegation.
Collateral contacts with school personnel, child protective service
workers and other professionals are also important. Information should
be obtained from all previous and current investigators/treaters/examiners, whether or not the information they have is directly relevant
to the current evaluation. How have each of the parents used these
services? Did the parents use these services in good faith, manipulatively,
evasively and so on? It should be spelled out in the beginning that
the evaluator has the permission of both parents to talk to whomever the
evaluator deems appropriate. Failure to establish this ground rule
enables the MSP parent to control the information available to the
evaluator by withholding consent.
Obtaining a history of the allegations is essential. Careful
attention should be paid to the following: the context in which the
allegations were made; the manner in which the allegations have evolved,
including sequence and timing of the allegations; any and all social
influences that may be affecting the child, including interviews by
investigators and professionals; social influence between professionals;
and the motivations, both practical and intrapsychic, of the adult(s)
invested in the allegation. What I usually do is develop a working
timeline of the allegations based on my review of all the documents in
Evaluators who focus narrowly on what the child says are unlikely to
be successful in helping to bring these cases under control. There is
social pressure on mental health professionals to "believe the
child." Bending to this pressure undermines the evaluator's
effectiveness. Another handicap for the evaluator is the difficulty in
knowing for sure that sex abuse did not occur. The problem of evaluator
confidence is compounded if the accused father, though not a child
molester, exhibits psychological difficulties of his own. The greater
the evaluator's confidence in the fact that sex abuse did not occur, the
more likely he or she is to take a strong stand with respect to the
Typically, some professionals involved will believe that abuse
occurred while others will believe it did not. The evaluator must decide
where the preponderance of evidence lies. The evaluator should be
cautious about accepting at face value someone else's determination that
abuse occurred. To the extent possible, the evaluator should investigate
specifically how the conclusion was reached.
Any videotapes of the child being interviewed about the alleged abuse
are of particular importance. A therapist in one case told me that she
had seen a video of the young child being interviewed by a police
investigator and the child was very believable. I looked at the video myself and noted that the interview had been
addition, there was persistent use of leading questions, pressure and
rewards to shape the child's disclosures. I asked the therapist to view
the tape again in light of my observations. She agreed, and after
watching it a second time called me back to say not only that she saw
what I was talking about, but she had significant concerns about some of
the professional participants in the case. Until I became involved in
the case, she had been afraid to verbalize her concerns about the role
of other professionals in shaping the allegations.
Interviews that rely on leading questions, pressure and rewards, as
well as repeated interviews of the child, often teach the child what the
allegation is supposed to be. Since the evaluator also interviews the
child about the allegations, the evaluation itself can become a vehicle
for perpetuation of the MSP abuse. Sometimes, new
"disclosures" by the children will occur during the
evaluation, which the evaluator must report, muddying the waters
The allegations need to be laid to rest one way or the other,
otherwise the MSP mother will continue her manipulations that put the
child in the middle. If warning signs for MSP are present, they may
actually aid in the determination of whether or not the mother's
accusations are valid. It is often not enough for the evaluator to
determine that the allegations are not true. He or she should be
prepared to explain how the allegations came to be if they are not
valid. The evaluator may need to take an active role in educating the
court and the various professionals involved about emotional abuse and
how it is harmful to the child.
Unlike most diagnostic labels that apply to only one person, MSP
involves a triangle of mother, child, and the professional participants.
Sometimes the mother's attorney will attempt to debunk the diagnosis by
bringing in an expert who will testify that this is not really Munchausen
syndrome by proxy. The appropriate response to this is that, no matter
what one calls it, the situation is emotionally abusive to the child.
Part of stopping the MSP abuse is articulating to others how this
type of emotional abuse is harmful to the child. The inappropriateness
of using the child to ruin the other parent's life deserves comment.
Involving the child in manipulation and dishonesty is a clear detriment to the child's moral development.
In contemporary-type MSP the child's psychic energy is tied up in
carrying out the accusing parent's agenda rather than allowing the child
to love freely, invest energy in mastering normal developmental tasks,
and master the psychological adjustments of divorce. The importance for
children of experiencing the love and care of both parents needs to be
Child victims of contemporary-type MSP abuse are exposed to repeated
talk of sex, deviant sexuality, and sexual contact with once loved
relatives. The child may be exposed to this material many times a day.
One mother used to wake her young daughter in the middle of the night to
talk to her further about the alleged abuse. The mother/accuser may
enlist her boyfriend or another adult in these talks so that it is two
adults against one child. These contacts are clearly emotionally
abusive. They may constitute a kind of mental sex abuse as well.
child who is subjected to hours of talk about sex organs and sex acts
may become over-stimulated and engage in aggressive, hyperactive or
sexualized behavior which may be misinterpreted by some of the
professional participants as behavior consistent with the alleged sexual
Contemporary-type MSP almost always entails the child losing not only
the relationship with the father, but with relatives the paternal
grandparents, aunts, uncles, and cousins. In addition to the love and
support that children often receive from extended family, these people
may act as important role models.
Child Abuse Reporting
Munchausen syndrome by proxy is a reportable form of child abuse, yet
child protective service workers, mental health professionals and others
may never have heard of it (Kaufman, Coury, Pickrel, & McCleery;
1989). If they have, they have often been oriented to a very narrow
definition of MSP that defines it in terms of production of factitious
physical symptoms to get the attention of medical personnel. They may
not have been exposed to the concept of contemporary-type MSP abuse or
may not accept the fact that it is involved in some false accusations of
sex abuse. Thus, a suspected child abuse report on the MSP mother in
contemporary-type cases may further complicate the picture.
While the reporting of emotional abuse is at the discretion of the
mandated reporter, if the MSP includes physical or sexual abuse by the
MSP parent then a suspected child abuse must be filed. If reporting is
optional, the reporter should give careful consideration as to the
possible consequences of making the report. There may be some merit to
having the suspected MSP on record with the local protective service
agency. If the mother's maltreatment of the children escalates and the
protective service agency receives another report, they may be more
likely to take the report seriously if the family is already known to
The disadvantage of making an optional report is that it invites
protective service involvement, and child protective service workers are
often among the professional participants who the mother/accuser
mobilizes to her cause. There is always the risk that an inexperienced
or overzealous social worker will align herself with the mother/accuser.
Instead of protecting the child from the mother's emotional abuse, the
power of the system may be used to support and continue it. I know of a
number of cases where this has occurred, even after the MSP diagnosis
was made by a protective service's psychologist/evaluator. Social
workers and therapists may ignore the evaluator's findings, convinced
that mother and children are being given short shrift. The MSP mother is
skilled at drawing in professional participants and continues to try and
do so even after her abuse has been reported.
Management of Munchausen Syndrome by Proxy
Once the diagnosis is made, the goal is to protect the child from the
mother/accuser's influence and to set limits on her behavior, as in any
other form of child abuse. The key to protection of the child is case
management rather than therapy for the mother. Prior to diagnosis of the
MSP, the mother and her pathology have controlled the child and the
family system. Case management preempts the mother's control. with the
backing of the court, the situation is structured so that the mother must
comply or face sanctions and the child can experience normal growth and development protected from the
mother's subversive influence. The problem with therapy in these cases is
that it becomes another vehicle for the mother's agenda. In their
outcome study on the management of over 200 classical MSP cases, Neale
et al. (in press) summarized their findings:
While many mothers superficially appeared cooperative, they tried a
variety of ways to manipulate situations to their advantage. In the
best managed cases, with the best outcome for the children, access for
the mother was strictly controlled and supervised, particularly when
the children were old enough to collude with her. Often the management
was hampered by differing perceptions among professionals, particularly concerning the nature of the abuse itself; and the psychological
condition of the mother. Wide differences of opinion sometimes
occurred because of the mothers' ability to deceive and to present as
perfectly normal women ... Overall the mother's propensity to
manipulate and deceive was best kept in check where
professional/client interaction was carefully controlled; where
presenting information was verified; where adult psychiatrists
declined the role of advocate in child care proceedings; where the
child was well represented; and where professional communication was
optimized through frequent case conferences and well established
procedures for feeding back information between meetings (pp.15-18.)
One of the first steps in managing these cases is for the court to
order that the mother/accuser not be allowed to initiate any more
evaluations or therapy sessions for the child without the permission
of the court or permission of someone designated by the court. I have
consulted on cases in which the child's therapist resisted the
validator role and was concerned about what the mother was doing.
effective case management strategy in these cases has been to
structure the situation so that the mother takes her concerns about
abuse to the therapist who will then determine whether a protective
services or emergency room contact is warranted.
Once the allegations of the mother or the mother/child dyad are
determined to be invalid and the MSP diagnosis is made, consideration
must be given to where the child should live. In classical cases of
MSP, removing the child from the mother's custody is often the first
step in protecting the child from physical harm. This is often
necessary in contemporary-type cases as well, even though it may be harder to gain the court's
support for this option since psychological rather than physical harm is
generally the main issue. Unfortunately, if the child is allowed to
continue living with the mother, she will continue to sabotage the
father/child relationship, reinforcing the abuse scenario at every opportunity.
The need for some sort of separation from the mother/accuser, whether
temporary or permanent, is particularly important once the child is old
enough to initiate verbalizations about abuse in accordance with the
scenario that the mother supports. If the accused father has been a good
father and was previously involved with the children, it may be
appropriate to make him the custodial parent. If he is fit but never had
a relationship with the children, then a transitional get-acquainted
period with the assistance of a family therapist may be helpful. Placement with relatives who are not aligned with the mother may also be
In severe cases of contemporary-type MSP involving older children,
psychiatric hospitalization can be helpful in separating the children
from the mother's influence and reorienting them to a loving
relationship with the father. This option is particularly appropriate if
the children are threatening suicide or homicide if they have to have
contact with the father. In order for hospitalization to be successful,
the mother must not be allowed to see or telephone the children while
they are there and hospital staff must work cooperatively with the
professional who diagnosed MSP. In addition to giving the children an
opportunity to regain their sanity, hospitalization allows them to
become reacquainted with the father in a safe setting so that they will
eventually feel comfortable going home in his custody.
After custody, the issue of visitation should be addressed. Like
classical MSP mothers, the mother in contemporary cases often continues
her emotional abuse of the child even during brief visitation contacts.
An unsupervised visit gives her the opportunity to grill the child about
whether the father has engaged in inappropriate touching, interpret the
child's normal misbehavior as a result of father's abuse, or take the
child to a sex abuse exam or call child protective services with another
complaint against the father. A court order restraining her from talking to the child about abuse is
unlikely to be effective unless her visitation contacts with the child
are supervised. If she is able to conform to such restraints during
supervised visits, then unsupervised ones may become appropriate. The
burden should be on her to prove that she can behave appropriately with
Limiting the mother/accuser's contact is especially important at
first while the children are making an adjustment to living with the
father. Negative input from mother will cripple or even defeat this
process. Phone calls from the mother/accuser may be prohibited for
awhile since they are difficult to supervise.
Therapy for the mother should be at her discretion. Sometimes the
court holds off on case management and is persuaded to give her a
chance, ordering the mother into individual therapy or accepting her
"plea bargain" to enter therapy as an alternative to loss of
custody and visitation. Some of these mothers benefit from the support
of individual therapy, but it is not at all realistic to expect that
therapy will modify their MSP behavior since they are manipulative,
untruthful, and lack insight into themselves and their interaction with
the child and others. They reject reassurances that the child has not
been abused by the other parent. They resist efforts to make them more
aware of what the false abuse scenario is doing to the child. They
refuse to believe that it is they who are harming the child. It comes
down to the fact that there are strong intrapsychic motivations for MSP
behavior which are not subject to change through reason or persuasion.
The literature on MSP is replete with observations that the mothers do
not improve with therapy, at least where the MSP behavior is concerned.
If the mother is already in therapy, the court would be wise to
instruct the evaluator to notify the mother's therapist of the diagnosis
and to provide the therapist with information about Munchausen syndrome
by proxy. The purpose of this contact is to help the therapist maintain
the appropriate neutrality and not become a professional participant.
Informed psychotherapy for the children may be indicated if it is
integrated into a larger case management plan. Psychotherapy for the
children is not a substitute for case management any more than is psychotherapy for the mother.
Therapy for the child after the MSP
abuse is diagnosed should be carefully supervised with the goals of
treatment clearly spelled out. The child's therapist should be free to
communicate with others involved in the case. If the mother holds the
privilege then she can continue to control the flow of information by
withholding her consent for communication. If the child is already in
sex abuse therapy, a decision will have to be made about terminating
that therapy, and if so, how this should be done. It may be appropriate
for the evaluator who diagnosed the MSP to make this recommendation.
Management of these cases is most effective when the person who
officially diagnosed the MSP remains involved in the case. Continued
involvement of the person who made the diagnosis will help to insure the
necessary cooperation among family members, professionals, various
agencies and the courts. This is a more active role than most evaluators
are accustomed to, but is absolutely essential given the turnover within
agencies and the courts, each new person representing an opportunity for
the MSP mother to enlist a professional participant.
Even when custody is given to the father, ongoing case management and
monitoring may be needed. This can be done by a competent psychologist
or psychiatrist, with an understanding of MSP type abuse, whose
decisions are backed by the court.
Special Master Program
In Mann County, California, an innovative program has been instituted
called the Special Master Program.2
The Special Master Program was
developed to meet the needs of divorcing and post-divorce families where
the parents, for a variety of reasons, have been unable to cooperate or
mediate with respect to custody, visitation and other decisions about
the children. The Special Master provides a type of informed, ongoing,
binding arbitration that focuses on the child's best interests. When
parents stipulate to a Special Master, the agreement includes their giving consent for the
Special Master to access all documents and records related to the case,
as well as consent to speak with anyone who may have pertinent
information. The Special Master evaluates and then makes orders with
respect to issues raised by either parent. The Special Master's
decisions have the weight of a court order. A potential pitfall of
appointing a Special Master is that his or her services may also become
a vehicle for the mother's agenda.
Generally speaking, the Special Master is appointed by stipulation of
the parties. The MSP mother may resist this coopting of her control.
However, when the program is backed by the court, the court has various
means of "motivating" parents to stipulate to a Special
Master. The parties stipulate as to how long the Special Master will be
in place, which can be, for example, one year, five years or
indefinitely. Only if both parents agree can the Special Master
arrangement be terminated before the stipulated time. The court serves
as a back-up in the event a parent wishes to appeal a Special Master
ruling, or to enforce a Special Master with which the other parent
refuses to comply.
When contemporary-type MSP is at issue, the Special Master can
function as the case manager. The Special Master is authorized to meet
with the father, mother, children, and any other relevant professionals
for the purpose of determining the propriety of visitation between the
mother and children, as well as the conditions under which it might take
place. It would be the function of the Special Master to attempt to
educate the mother regarding the harm caused to the children by her
conduct and to encourage modification of her behavior. The Special
Master should be empowered to structure supervised visits for the mother
and children. Such visitations are usually supervised by a psychologist
or a qualified paraprofessional.
Because the Special Master is an integral part of the evaluation,
management and treatment of the case, the Special Master can take
immediate action to protect the best interests of the children. If
modification of contacts between the mother and the children ate needed,
whether expanded or reduced, the Special Master can accomplish this
promptly. There is no need to initiate protective court remedies to
protect the children which are not only expensive but may not address the specific problems in time to
adequately protect all family members.
The unique role of the Special Master allows for very creative
problem solving in difficult family situations. The court rarely has the
time or the interest in evaluating and ruling on points such as how
visitation transitions should be handled, or who in addition to the
mother may be present for visits. For example, it might come to the
Special Master's attention that the mother becomes agitated and starts
yelling every time she picks up the child for a visit. The Special Master
might fine tune the situation so that the children are exchanged in
neutral setting, such as a therapist's office or even the fire
department. Another example is that of the mother who has a friend or
relative who has been agitating on behalf of the abuse allegations.
maximize her influence, the mother may arrange for this person to be
involved with the child as much as possible. The Special Master can
evaluate the pros and cons of other people's participation and determine
what level of involvement is appropriate.
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|1 Since the
creator of factitious illness for the child is almost always the
child's mother, the perpetrator of MSP abuse will generally he
referred to as the mother. [Back]
2 For information about the
Special Master Program contact Sami M.
Mason, American Mediation Services, 700 Larkspur Landing Circle, Ste. 260,
Larkspur, CA 94939, (415) 461-8900. [Back]
* Deirdre Conway Rand is
a psychologist at Marin Psychological Services, 650 East
Blithedale, Ste. M, Mill Valley, GA 94941, (415) 485-5991.
Dr. Rand welcomes communication from individuals who believe
they may be dealing with MSP. [Back]