Doctors Need Better Skills to Identify Munchausen Syndrome by Proxy

Whether depicted in fiction like The Sixth Sense and Sharp Objects or real cases covered by the media such as Gypsy Rose Blanchard’s December 2023 release from jail, Munchausen syndrome by proxy captures public attention. The most notorious cases shown in media or real life tend to be the starkest ones, but MBP also presents itself in more subtle, harder-to-detect forms.

“The media are fascinated by the most extreme portrayals,” says Dr. Marc D. Feldman, distinguished life fellow of the American Psychiatric Association and author of Dying to Be Ill: True Stories of Medical Deception.

So how can more healthcare providers develop the abilities to recognize this form of medical child abuse and report it to the proper authorities?

What is Munchausen by proxy?

MBP “is a form of abuse where a caregiver falsely claims, exaggerates, or induces illness in another person. Usually, the caregiver is the mother and the victim is her child,” Feldman explains.

While this deception may result in real benefits—like disability funds or opioid medications the caregiver then misuses—the perpetrator’s primary motivation is generally attention, according to Mary Sanders, a clinical psychology professor at Stanford University School of Medicine.

You may hear this type of abuse called by several names. While it was once mainly referred to as Munchausen syndrome by proxy, many experts now omit the word “syndrome” because it implied there was a clear-cut checklist for diagnosing the perpetrator. There are some commonalities among caregivers inflicting this abuse, but not all match the same criteria, Sanders says.

Increasingly, the phenomenon is termed Munchausen by proxy (MBP) abuse to emphasize the negative effects on the victim or a type of medical child abuse, according to Brenda Bursch, a professor of clinical psychiatry and biobehavioral sciences and pediatrics at the David Geffen School of Medicine at UCLA.

Medical child abuse doesn’t specify why a caregiver is overmedicalizing a child, Sanders explains. But if the caregiver is intentionally misleading about an illness in a child, they are also said to have factitious disorder imposed on another (FDIA), per changes made in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a glossary of mental health diagnoses. Whatever it’s called, the behavior is harmful—and often difficult to detect.

“In the past, diagnosing Munchausen by proxy was challenging because understanding the caregiver’s motivations was part of the definition,” says child abuse pediatrician Dr. Amy Gavril, a past member of the American Academy of Pediatrics (AAP) Council on Child Abuse and Neglect and an associate professor at West Virginia University School of Medicine. “The motivation of an adult is an incredibly difficult thing to figure out, and as a pediatrician, when it’s not your patient, it makes it even harder.”

Experts believe this form of abuse is widely underreported because it’s so difficult to recognize. The official incidence is about 0.5 to 2.0 cases in every 100,000 children under age 16, according to a 2013 Pediatrics report, but the problem may be much more severe than that.

“My sense is it’s vastly underrecognized by doctors because many haven’t even heard the term MBP abuse or medical child abuse, or they don’t really understand what it is,” Feldman says. “You can’t diagnose something you don’t comprehend or have never heard of.”

Deception is central to Munchausen by proxy

It makes sense that MBP abuse is hard to recognize, considering the perpetrator aims to fool everyone. “If the parent is really trying to be deceptive, they’re going to get away with it for a while,” Sanders says.

To prolong the ruse, caregivers often change medical providers before one grows suspicious, Feldman notes. But even qualified experts can struggle to identify MBP abuse. “The foundation of it is fabrication, and it’s very difficult to pinpoint when a caregiver isn’t being truthful because we’re trained to seriously consider what a child’s caregiver relates,” Gavril says.

Sometimes, seemingly minor instances of deception may be an early warning sign. “I had a mother who said her child was born premature at 4 pounds, 3 ounces. But when I obtain the birth records, it says 8 pounds, so that’s clear falsification,” Sanders says.

A host of red flags

MBP abuse remains perplexing to healthcare providers, legal professionals, and the public, per a 2020 review article in Annals of Pediatrics & Child Health authored by Bursch. But this isn’t the fault of any physician or specialty; it’s an issue with medical education and child welfare systems. “Most clinicians lack the preparation and guidance needed to professionally, ethically, and skillfully safeguard victims of MBP,” she wrote.

Even without extensive training, however, it’s possible to become more alert to the red flags, the most common of which is inconsistency. “You’re looking for this mismatch between what you’re being told is happening with the child and what you’re objectively observing,” Gavril says. “It’s those ongoing inconsistencies rather than a particular symptom” that raise suspicions, she adds, because the caregiver might claim any number of medical issues affect the child.

Munchausen by proxy perpetrators are often very involved in the child’s medical care. They might be active in advocacy organizations for the rare condition they say the child has, or they might try to act like they are friends with you as the child’s doctor, Sanders says.

Another telltale sign is if symptoms ease when the child is separated from the abusive caregiver. “I often hear from fathers who say, ‘My former wife is presenting the child as autistic, but when he’s with me on vacation, he’s perfectly fine,’ or ‘His dietary limitations are severe and imposed by his mother. When he’s with me, he eats whatever he wants.’ That kind of information is invaluable,” Feldman says.

A 2007 Pediatrics article from the AAP’s Council on Child Abuse and Neglect suggests clinicians ask themselves the following three questions to help determine if a child may be a victim of MBP abuse:

Are the history, signs, and symptoms of disease credible?

Is the child receiving unnecessary and harmful or potentially harmful medical care?

If so, who is instigating the evaluations and treatment?

Any suspicion is enough to report

Physicians are . But that doesn’t mean doctors have to be certain of what they’re seeing. “You don’t need to know for sure that this abuse is occurring. If you have a reasonable suspicion, it’s not a choice; you are a mandated reporter,” Sanders says.

Still, it’s not uncommon, Feldman says, for him to “come across cases where 20 pediatricians were consulted in a very obvious case, and no one documented any suspicions of abuse.”

That’s a problem because “the longer it goes undiagnosed, the more likely it is that permanent or severe harm will occur to the child,” Gavril says.

Pediatricians and mental healthcare providers may be most likely to notice something amiss. But every practitioner should at least be aware of the possibility of MBP abuse because victims often see many different specialists, such as gastroenterologists, pediatric neurologists, and infectious disease physicians, Gavril says. These experts likely have even less training in recognizing medical child abuse than pediatricians.

Too often, healthcare workers are “a little frightened of documenting their concern because they’re lawsuit-averse, and they fear it will be provocative in some way,” Feldman says.