By Dawn Doran Wilsey1

Munchausen Syndrome is defined as “a condition characterized by habitual presentation for hospital treatment of an apparent acute illness, the patient giving a plausible and dramatic history, all of which is false.”2 The DSM-IV-TR uses the term “factitious disorder” to define the “physical or psychological symptoms that are intentionally produced or feigned in order to assume the sick role.”3 The ultimate goal on the part of the patient is to seek attention.

In 1977, an English pediatrician named Roy Meadow recognized the same pattern of behavior in which parents, usually mothers, would repeatedly present their children at hospitals complaining that their children were suffering from various illnesses. After running numerous tests and observing these patients over time, doctors discovered that the illnesses were non-existent or created by the parents.4 The offenders were using their children to achieve the desired result of attention for themselves. Thus, the term Munchausen Syndrome by Proxy was coined. It is defined as “occurring when a parent or guardian falsifies a child’s medical history or alters a child’s laboratory test or actually causes an illness or injury in a child in order to gain medical attention for the child which may result in innumerable harmful hospital procedures.”5 Since 1977, there have been over 300 articles published concerning the recognition, diagnosis, and treatment of this syndrome.6 Additionally, the consensus of the medical community is that Munchausen Syndrome by Proxy (also known as Factitious Disorder by Proxy) is more common than originally believed, and the rate of occurrence is increasing.7

The Munchausen Syndrome by Proxy (MSBP) case is extremely challenging to try and presents several hurdles for the prosecutor to overcome. Some of the obstacles are as follows:

The initial challenge is identifying the crime. Diagnosis is difficult because there is no set pattern of signs. Additionally, the initial diagnosis is often consistent with other accepted diagnoses, and the offender is usually able to convincingly cover the signs of abuse. For example, a mother who smothers her child repeatedly can present the sleep monitor read-outs recording these episodes, leading doctors to make an initial diagnosis of sleep apnea. Ultimately the MSBP diagnosis is made after observing persistent and contradictory patterns over time, and is the result of the collaboration of the signs and symptoms that have occurred over many weeks or years.

Some of the warning signals of MSBP are: (1) Illness which is unexplained, prolonged, and so extraordinary that it often prompts experienced medical personnel to remark that they “have never seen anything like it before.” (2) Symptoms and signs that are inappropriate or incongruous, or are present only when the mother is present. (3) Treatments that are ineffective or poorly tolerated. (4) Children who are alleged to be allergic to a great variety of foods and drugs. (5) Mothers who are not as worried by the child’s illness as the nurses and doctors, mothers who are constantly with their ill child in the hospital (not even leaving for brief outings), and those who are happily at ease on the children’s ward and form unusually close relationships with the medical staff. (6) Families in which sudden unexplained infant deaths have occurred, and families containing many members alleged to have different serious medical disorders.8

The offender is often extremely difficult to identify because the outward appearance of a concerned parent of a very sick child, and one who is actually causing the sickness, may be very similar in the beginning. At first, the offender appears to medical personnel to simply be overly protective of her child and indeed, an extremely close bond between mother and child is usually present. (While there have been documented cases of offending fathers, babysitters and other caretakers, the vast majority of offenders are mothers.)9 The offender is usually well-versed and thoroughly informed about all possible illnesses the child might be experiencing and is extremely complimentary of all medical personnel efforts. Often, the offender even has some type of knowledge or background in health care. Thus, medical staff are reluctant to suspect the actual cause of the child’s illnesses. It is not until the offender seems unconcerned about the lack of improvement in her child’s health or the lack of a definitive diagnosis that a doctor may become suspicious. Many mothers even appear anxious for the doctor to prescribe uncomfortable prescriptions and tests and perform continually invasive and painful procedures on the child. Often, the primary physician is still extraordinarily reluctant to consider MSBP and may continue with surgeries, drug prescriptions and the like to resolve the problem.10

The next hurdle in trying a MSBP case is gathering evidence as quickly as possible. It is only when a review of a victim’s medical records reveals a pattern of behavior such as doctor shopping and invasive but inconclusive surgeries, tests and treatments, that most doctors exclude other diagnoses in favor of MSBP. Consequently, once MSBP is suspected, the child probably has suffered extensively and over a length of time. It is important to swiftly initiate a multi-disciplinary team response to the case that includes the prosecutor, law enforcement, and child protective services, as well as the treating physician, a physician experienced in MSBP, and a member of the hospital’s legal staff. A social worker or psychiatrist should also be present to assist with the non-offending family members once the offender is confronted.11

The immediate assessment of risk to the child is imperative. Civil remedies such as removal of the child from the family or temporary restraining orders may be necessary. If immediate intervention is not warranted or can be delayed, the first step is to consider the use of Closed Video Surveillance (CVS). Although the use of CVS has been debated in the medical community,12 it may be necessary to make a definitive and timely diagnosis in many cases of MSBP.13 The prosecutor needs to be thoroughly informed of the requirements and limitations of camera monitoring and surveillance in their jurisdiction. When making an application for the court order, be prepared to argue that the level of expectation for privacy is reduced in a hospital room.14 Also, if your state’s wiretap laws allow for audio, it is important to include such a request. There are recorded cases of mothers coaching their children to have symptoms or lying about other symptoms to people in the room or on the phone.15 Additionally, the judge should be made aware that CVS can also be used as a means of exonerating a parent who is suspected of MSBP, thereby not interrupting treatment of a child who actually is ill.

If the risk is too immediate, CVS is unavailable, or the abuse occurred in the home, the collection of circumstantial evidence becomes even more important. Review all medical records of the child, and look for any unusual substances that routinely appear in the child’s blood or urine tests. Interview all nursing staff that made rounds to the hospital or were present during doctor visits. Subpoena and review medical records of both the child and the offender from all hospitals in the surrounding area. Find out if the family has lived anywhere else in the past five years and subpoena potential records from all those hospitals as well. The records of the offender can contain valuable information. Sometimes, the mother will exhibit Munchausen Syndrome years before moving on to Munchausen Syndrome by Proxy, using her child as the agent. There is also some indication that MSBP is a pattern that runs from generation to generation. Accordingly, check to see if there are any suspicious records or deaths of the offender’s siblings or parents. The offender may have even been a victim of MSBP.

Secure warrants for the offender’s home, office, and belongings, including her purse or other personal items with her in the hospital. Look for syringes, syrup of ipecac (used to induce vomiting), droppers, salt or other similar items. Speak to the doctor first about which items might likely have been used to produce that child’s particular symptoms. Assess whether the non-offending family members are supportive of the investigative effort and then interview them for information. The father tends to be withdrawn emotionally from the family and rarely present during the hospitalizations and procedures, but may provide a wealth of information once confronted with the idea that his child was intentionally abused by his spouse. The relationship may also provide a clue as to the mother’s overwhelming need for attention.

Once the evidence has been assembled and the arrest has been made, preparing for trial is the next challenge. It will be necessary to educate the judge and jurors, as well as defense counsel, on MSBP. Often, the key issue in trial is distinguishing the medical, versus the psychological, diagnosis of MSBP. The medical diagnosis of the child is that of a victim of MSBP, a form of child abuse. This must be identified and presented separately from the psychological aspects of MSBP that are attributed to the perpetrator’s actions, which is where the defense will likely focus.

MSBP as the medical diagnosis of the child is a very complex diagnosis and can require expert testimony. Courts have found that the underlying considerations in reaching a finding of MSBP are not within the knowledge of average jurors.16 One Court held that “testimony about MSBP is beyond the range of ordinary training or intelligence and is therefore a subject matter requiring expert testimony.”17 Courts are recognizing that MSBP is a form of child abuse,18 and is therefore a medical diagnosis requiring expert testimony.19 In the matter of Adoption of Keefe, the Court summed up the issue: “[l]ike Battered Child Syndrome, a diagnosis of MSBP is dependent on inferences, not a matter of common knowledge, but within the area of expertise of physicians whose familiarity with numerous instances of genuine illnesses qualifies them to express with reasonable probability that a particular illness or group of illnesses is not genuine but is instead the result of induction or fabrication of symptoms.”20 The presence of and recognition of this medical phenomenon across multiple cultures and within different medical communities also contributes to its “general acceptance” as a recognized medical diagnosis within the relevant scientific community.21

A final hurdle is preparing for the defense. The most likely defense will concentrate on the psychological aspects of MSBP as it relates to the defendant. The prosecutor can often expect an insanity defense as well. To date, no court has refused to recognize the medical diagnosis of MSBP as it relates to the victim. However, even the DSM-IV-TR has not officially included the psychological term of Factitious Disorder by Proxy as a recognized mental disorder. It is listed as a category in need of further study. Furthermore, there is no psychological test that detects adults with MSBP. Even experts agree that, while there are warning signals, there is no classic profile for a perpetrator and the best way to diagnose the syndrome is to separate the child from the suspected adult.22

If successful in excluding any psychological testimony, additional defenses a prosecutor may encounter include evidence that the child did indeed have a sickness, that other adults had access to the child, that the medical community is placing the blame on the offender for their failure to correctly diagnose and cure this child, or simply that other factors could explain the child’s illnesses. Poor investigation and reasonable doubt can also be the cornerstone of the defense case. Subpoenaing all medical records of the entire family, and gathering any other circumstantial evidence, can often combat these defenses.

Trying a MSBP case is challenging. Keep in mind that it is hard for most people initially to imagine the ultimate betrayal of a parent abusing a child simply to fulfill their own need for attention. It is the accumulation of evidence in these cases that will convince your judge or jury that the crime has been committed. Preparing for these types of cases takes a lot of work on the front end, but it will be worth the effort to be able to present a convincing pattern of MSBP and break the cycle of abuse.

1 Senior Attorney, APRI’s National Center for Prosecution of Child Abuse.
2 Thomas D. Lyon, Elizabeth E. Gilles, & Larry Cory Medical Evidence of Physical Abuse in Infants and Young Children, 28 Pacific Law Journal 93-167, at 110-111 (1996).
3 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, DC, 2000.
4 Meadow, R. Munchausen Syndrome by Proxy: The Hinterland of Child Abuse, (Lancet, 1977).
5 Zumwalt & Hirsch, Pathology of Fatal Child Abuse and Neglect, Child Abuse and Neglect, 276, 4th ed. (R. Helfer & R. Kempe, eds. 1987).
6 Ayoub, C. C. and Alexander, R. A. Definitional Issues in Munchausen by Proxy, 11 (1) APSAC Advisor 7 (1998).
7 McGuire, T. And Feldman, K. Psychologic Morbidity of Children Subjected to Munchausen Syndrome by Proxy, 83 Pediatrics 289, 292 (1989).
8 Meadow, R Management of Munchausen Syndrome by Proxy, Archives of Disease in Childhood, 385-393 (1985).
9 See Sigal, et al. Munchausen by Proxy Syndrome: The Triad of Abuse, Self-Abuse, and Deception, Comprehensive Psychiatry, Vol. 30, No. 6 (1989).
10 See Schreier, H. and Libow, J. Hurting For Love, (Guilford, 1993).
11 Wilkinson, R. and Parnell, T. The Criminal Prosecutor’s Perspective, Munchausen by Proxy Syndrome: Misunderstood Child Abuse (ed. Parnell & Day, 1998).
12 Rosenberg, D. Munchausen Syndrome by Proxy, Child Abuse: Medical Diagnosis and Management (ed. Robert M. Reece, MD 1994).
13 Hall, et al. Evaluation of Covert Video Surveillance in the Diagnosis of Munchausen Syndrome by Proxy: Lessons from 41 Cases, 105 Pediatrics 1305 (2000).
14 Some hospitals may have already obtained evidence from CVS before involving law enforcement. For an excellent discussion on preserving the evidence for trial, see Yorker, B.C. Covert Surveillance of Munchausen Syndrome by Proxy: The Exigent Circumstances Exception, 325 Health Matrix Vol. 5 (1995).
15 Id.
16 Montana v. Hocevar, 2000 MT 157 (2000), quoting Goldman, L.H. and Yorker, B.C. Mommie Dearest? Prosecuting Cases of Munchausen Syndrome by Proxy, 13 WTR Crim. Just. 2629 (1999).
17 Id.
18 Yorker, B. Legal Issues in Factitious Disorders by Proxy, p. 140, The Spectrum of Factitious Disorders.
19 See generally In the interest of B.B. 500 NW 9 (1993); Place v. Place 129 N.H. 252 (1987); In Re S.R. 157 Vt. 417 (1991).
20 Adoption of Keefe, 49 Mass.App.Ct. 818 (2000).
21 See Rosenberg, D. Muncahusen Syndrome by Proxy, in Child Abuse: Medical Diagnosis and Management 266, (ed. Robert Reece 1994).
22 Id.