Archives of Disease in Childhood 1995; 72: 528-530
about the diagnosis of Munchausen syndrome by proxy
C J Morley
The purpose of this paper is to share my concerns about
the difficulties and pitfalls with the diagnosis of Munchausen syndrome by proxy in
general and in particular with regard to suffocation.
Concern about the use of the label Munchausen syndrome by
Following the suggestion that Beverley Allitt had Munchausen syndrome by proxy1 this diagnosis has become charged with emotion
and those who are now accused are tarnished with her reputation. The diagnosis of
Munchausen syndrome by proxy gives no indication about what happened to the child. As a
substitute I suggest that the exact nature of the problem should be stated: suffocation,
poisoning, putting blood in the urine, falsely reporting fits, or whatever is the problem.
Concern about the criteria for diagnosing Munchausen
syndrome by proxy
It has been suggested that the term can be used if the following criteria are
However, they are very non-specific and can be misinterpreted.
THE ILLNESS IS FABRICATED BY THE PARENT
A mother may superficially appear to the doctors to fabricate her
child's symptoms when in reality they have not listened carefully to her story. Many
mothers are just over anxious and trying to get the doctor to listen, or exaggeration may
be part of her normal language.
THE CHILD IS PRESENTED TO DOCTORS,
The frequency of mothers presenting their children for medical care is
not known and therefore we do not know what is normal or abnormal. Some mothers maintain
their children are never ill and anxious mothers request advice almost weekly. Children
who are seen frequently may genuinely be ill.
THE PERPETRATOR (INITIALLY) DENIES
CAUSING THE CHILD'S ILLNESS
The 'perpetrator' may genuinely be innocent and that is why she
persistently and vehemently denies harming her child. I am concerned that in some cases
the mothers are told they have to confess to harming their child before they can have
treatment and if they do not confess they are unlikely to have their children back. This
is blackmail and may result in a false confession from a mother desperate to get her child
back. Surely help, counseling, and treatment can be started and continue without a
THE ILLNESS CLEARS UP WHEN THE CHILD IS SEPARATED FROM
The illness clearing up when the child is separated from the 'perpetrator' needs to be
considered very carefully. Many childhood illnesses get better with time. Some conditions
such as apnoea or vomiting improve towards the end of the first year, just about the time
many of these children are taken into care. If the underlying problem is mother's anxiety
the symptoms she is worried about may not be considered abnormal by a more experienced
carer and disappear when the child is removed.
Concern is about the 'indicators that presenting
symptoms may be fabricated'
The following 'diagnostic pointers' have been recommended.3 At first glance these seem useful. However, when
they are examined carefully they are very non-specific.
Symptoms and signs that are unusual or bizarre and inconsistent with known
pathophysiology - The interpretation of these depends on the experience of the doctor.
- Inconsistent histories from different observers - The
interpretation of inconsistency depends on how the history was obtained and whether the
same questions were asked in the same way.
- Observations and investigations inconsistent with parental reports or the
condition of the child - This may simply be because of the way the parent was asked to
report. Some mothers are poor at giving a detailed account of a life threatening event.
Rarely are they told to give a scientifically accurate report to the doctors.
- Treatments which are ineffective or poorly tolerated - This is common.
- Symptoms or signs which begin only in the presence of one
parent/carer - Most concerned mothers are with their ill child all the time. It is not
surprising that they are often the first witness.
- Parents who are unusually calm for the severity of illness - Parents who appear
outwardly calm may be suffering inner turmoil.
- Parents who are unusually knowledgeable about the illness and its
repercussions - This is common in concerned parents and those with a chronically ill
child, particularly if they have been properly informed by the doctors.
- Parents who fit in contentedly with ward life and attention from staff -
This is common when the children have been in a ward several times or where the ward is
well organized and the staff caring and compassionate.
- Unusual or unexplained illness or death in previous children - It is
important not to jump to conclusions but to investigate the details of the deaths or
- Parents who have a history of unusual illness or themselves were abused as
children - This needs careful history taking, scrutiny of the notes, or confidential
discussion with the mother's doctors.
- Parents who have a history of conduct or eating disorders - These are
relatively common in the community. Most of these people do not abuse their children.
The accuracy and predictive value of these diagnostic pointers are not
known. As Munchausen syndrome by proxy is very rare these pointers are much more likely to
be associated with normal behaviour and common illnesses. Unthinking use of such
indicators without realizing their non-specific nature may lead to mothers being falsely
accused and their children taken into care.
Concern about 'exaggeration' being labelled
Munchausen syndrome by proxy is being used to describe the behaviour of
mothers who exaggerate a child's symptoms. This is a cause for concern because mothers
frequently exaggerate their child's symptoms, not through any malignant desire to mislead
the doctor but as part of common language: 'he hasn't eaten a thing all week', 'he vomits
up all the feed'. Such phrases are part of everyday life and experienced paediatricians do
not take the mother's story at face value but take a careful history to find out exactly
what has been happening. We have no idea how common it is for mothers to exaggerate their
children's symptoms. If exaggeration is included in Munchausen syndrome by proxy this will
devalue the diagnosis and more mothers will be accused.
Concern about inadequate history taking
Diagnosing Munchausen syndrome by proxy is very serious because the
outcome for the child and family may mean care orders, separation, and even criminal
prosecution. It is primarily a medical diagnosis and must be based on sound medical
practice. This means taking a very careful history, eliciting exact details about what has
happened.4 It may
mean talking to the mother for hours to get a clear understanding about all the episodes,
why she is concerned, and her own background. Unfortunately, in some cases, the senior
doctors have hardly talked to the mother. In a recent case the mother briefly saw the
consultant during the children's illnesses and he did not take time to sit down and talk
with her until he came with a social worker to say she was accused of Munchausen syndrome
by proxy. This is indefensible.
My experience is that some mothers repeatedly take their child to the
family doctor or paediatrician because they are anxious. Some are naturally anxious; some
have hypochrondia; and others are anxious because their children have previously been very
ill. The doctor realises the illnesses are trivial and repeatedly tells the mother not to
worry. If the doctor had taken the time, in the early part of the illness, to take a full
history, to explain what was happening, understand why she was so concerned, and support
the mother, he could have prevented many of the repeated presentations and the subsequent
accusation of Munchausen syndrome by proxy.
Munchausen syndrome by proxy is a term I suggest we use with
caution and preferably abandon in favour of giving an exact description of what has
happened to the child. It has become a diagnosis with emotional overtones which do not
help in the management of these difficult cases. I do not consider that a mother
exaggerating genuine symptoms or signs should be considered part of Munchausen syndrome by
proxy. I urge caution about some of the criteria for this diagnosis and concern about some
to the accuracy, sensitivity, and ethics of some techniques being used. I urge doctors to
take detailed histories and talk to the mothers in a caring way about their concerns. It
is important to protect a child who is being harmed by his mother. It is equally important
not to harm the child by falsely accusing his mother of Munchausen syndrome by proxy
thereby breaking up the family.
University of Cambridge School of Clinical Medicine
Department of Paediatrics
Addenbrookes NHS Trust
Hospital Box 116 Hills Road
Cambridge CB2 2QQ
1. The Allitt inquiry. London: HMSO, 1994.
2. Meadow SR.
Who's to blame - mothers, Munchausen or medicine? JR Coll Physicians Lond 1994;
MP, Southall DP. Munchausen syndrome by proxy. Br J Hosp Med 1992; 47: 759-62.
Party of the British Paediatric Association. Evaluation of suspected imposed upper airway
obstruction. .London: BPA, February 1994: 24 (section 6.2.5).