During assessment of medical
records, the reviewers evaluate the veracity of
the medical history obtained from the
perpetrator. A careful comparison of the
medical record to the medical history can be
illuminating. This underscores the importance
of careful charting, especially documentation
of observations by nurses. Making clear the
source of the evidence is especially helpful.
For example, "seizure for 10 minutes" is less
helpful than "mother reports seizure for 10
minutes; child appears stable at this time."
Other evidence of
fabrication of illness includes recurrent
illnesses that appear unusual or incorporate
inconsistencies in the narrative. A parent who
reports prolonged and persistent vomiting in a
child who appears well-nourished, for example,
may raise suspicions. The review may reveal a
parent seeking the advice of several healthcare
providers but not facilitating communication
between them, or the parent may even conceal
evidence of consultations.
Review of other
records may be helpful, such as school records
for attendance and performance information,
court records, and police reports for evidence
of legal issues.
If the review of
medical records raises the level of suspicion
enough to support a child abuse claim, the
diagnostic process will include a trial
separation between the child and the
perpetrator. Staff nurses play a crucial role
on the team involved in this step. From the
point of admission, the child must be
constantly monitored, and there must be careful
documentation of behaviors. At least one
observer should be in the child’s room at all
times. In addition to serving as witness and
documenter, the observer enforces visitation
guidelines, often established in court. These
guidelines require that the nurse remain
vigilant but courteous and firm. The obligation
of terminating a visit when infractions occur
can be daunting, but the nurse must be willing
and able to defend the visitation rules. They
are designed to provide a safe environment for
the child while continuing to allow gathering
of objective and accurate evidence.
Emotional support of
the victim during a trial separation is an
important part of the nursing care plan. It is
helpful to remember that the abuse may be clear
to the healthcare team, but it will be a new
and unwelcome suggestion for the child and for
the abusive parent. Generally, supportive
remarks are appropriate. Building trust and
generating an environment of support are
important nursing goals.
of patient behavior before, during, and after
family visits plays a critical role in
determining the plan of action. In general, the
more detail, the better. Details about parent
behavior, child response, increase or decrease
of physical symptoms, and emotional response
all are important. This nursing documentation
often requires adaptation of existing charting
forms to accommodate the volume of detail.
Research about MBP
reveals that most perpetrators are women,
usually mothers. Meadow found that 90 percent
of perpetrators were mothers. In 5 percent of
cases, the perpetrator was another female. One
report describes two nurses who eventually were
found to be perpetrators.8
In only 5 percent of cases, the perpetrator was
the father.2 As
our understanding of this illness increases, we
may discover variations in these findings.
evaluation of the perpetrator can be helpful in
construction of a plan of management. The goal
of the evaluation is to understand the motives.
The technical definition of MBP requires that
the perpetrator intentionally falsify
information specifically with the purpose of
gaining attention, respect, or other emotional
advantage. The term to describe the behavior of
perpetrators who fit this description is
factitious disorder. If evaluation of the
perpetrator reveals delusional behavior or
other psychosis, factitious disorder may not be
the most accurate diagnosis, and the situation
is not technically one of MBP. Perpetrators who
falsify medical information about a child
clearly for financial gain or other material
goods (for example, narcotics) probably do not
have factitious disorder, but are malingering
and will require intervention.
As the evaluation of
perpetrators becomes standard practice, we will
learn more about the motives and the effective
management of these cases. Reports to date
reveal some consistent findings. In one study
of 47 mothers, 55 percent displayed
self-destructive behaviors, 72 percent had a
history of somatoform disorders (psychological
issues expressed through physical complaint),
and 89 percent had a history of personality
disorders. Twenty-six percent revealed a
history of learning disorders.9
The etiology of MBP
remains the subject of debate and
investigation. With more conventional child
abuse, the abuser usually admits to, or an
investigation reveals, a volatile temper, a
lack of strategies for dealing with stress, or
even a lack of attachment to the abused child.
Lack of attachment often is present in MBP,
especially as revealed by covert video. But in
the case of MBP, perpetrators often are eager
to convince the healthcare team that they are
essential to the child’s well-being. In public,
they may appear to treasure the relationship
with the child. One author offered a thoughtful
proposal about the combined forces of culture
and personality that may exist for
perpetrators: "Women as nurturers often
associate self-worth with caring for others,
especially children. If, in addition, they
experience powerlessness—in family structure or
in social structure, and especially if abuse is
in the background—they may become MBP
perpetrators as a strategy for safely but
pathologically reclaiming power and self-esteem
by making their role as caretaker absolutely
Meadow found emotional abuse and neglect in the
histories of 70 percent of mothers who had
suffocated their children.2
The first step in
management usually requires removing the child
from the perpetrator. In other situations of
child abuse, the extended family may provide
foster care. In cases of MBP, however, more
distance is the usual recommendation. Family
members often are deeply incorporated in the
deception and may subvert the therapeutic
The victim of MBP will
undergo therapy based on the kind of abuse
suffered. Physical and occupational therapy may
be necessary to secure a healthy physical life.
Psychotherapy will help the child process the
confusion and pain associated with the abuse.
Psychotherapy also is recommended for the
perpetrator, but this therapy may be more
difficult to secure. Perpetrators who continue
to deny the diagnosis will often refuse
treatment or deceive the therapist during
sessions. In some cases, the perpetrators
eventually do gain insight. The therapeutic
effort to help perpetrators redefine strategies
for gaining personal attention can be
In any event, the
management plan requires collaboration of a
widely multidisciplinary team. Nurses can
contribute their intimate knowledge of the
physical and mental health of the victim and
the perpetrator. They should be prepared with
thoughtful interpretations of behaviors and
clinical data. This information should be
well-defended by thorough documentation in the
Most experts remain
pessimistic about the efficacy of family
reunification in the presence of MBP.5
Well-monitored visitation by parents, however,
can play an important and therapeutic role. In
any case, current recommendations include
having a court-appointed pediatrician serve as
the primary healthcare provider for the
remainder of the victim’s childhood so that all
medical decisions are overseen by a
practitioner well-informed about MBP. It is
usually recommended that the child resume
normal school attendance as soon as possible.
The prognosis for
children with MBP can be good if they are
removed from the family soon enough and if
therapeutic intervention is aggressive. Many
children are able to regain complete physical
function after removal from the perpetrator.
Psychological health also can be achieved.
Long-term studies of survivors will shed light
on the effectiveness of current management.
Prognosis for the
perpetrator is less optimistic.5,7
To date, therapeutic interventions have not
produced uniform or predictable outcomes.
Imprisonment of perpetrators is probably not a
constructive response since they suffer from
complicated dysfunctions, not necessarily a
failure of character. We need to understand
more about the dynamics of this challenging and
disturbing syndrome before we can provide a
better outcome for the perpetrators.
Munchausen by proxy
remains a complicated, challenging form of
child abuse. Perpetrators violate the
conventions of trusting communications between
providers and clients. They defy our
expectations about loving parents. Nurses play
a critical role in the recognition and
management of this troubling form of child
abuse. An informed response will help ensure an
effective and compassionate response.
C.C., & Alexander, R. (1998). "Definitional
issues in Munchausen by proxy."
APSAC Advisor, 11(1), 7-10.
- Meadow, R.
(1977). "Munchausen syndrome by proxy: the
hinterland of child abuse."
Lancet, 2(8083), 343-5
D.P., et al. (1997). "Covert video recordings
of life-threatening child abuse: lessons for
Pediatrics, 100(5), 735-754.
I., et al. (1993). "Apnea and factitious
illness (Munchausen syndrome) by proxy."
Pediatrics, 92(6) 810-814.
- Levin, A.V.,
& Sheridan, M.S. (Eds.). (1995).
Munchausen Syndrome by Proxy: Issues in
Diagnosis and Treatment. New York:
abused girl, Broward jury decides." (1999,
Coral Springs (Fla.) Sun-Sentinel
[online]. [2000, March 1].
M.J., & Bursch, B. (2000). "Forensic
assessment of illness falsification,
Munchausen by proxy, and factitious disorder,
NOS." unpublished paper.
S., & Cox, C. (1998). "The legacy of Allitt."
Nursing Times, 94(30), 27-8.
- Bools, C.N.,
Neale, B. A., & Meadow, R., (1994).
"Munchausen syndrome by proxy: a study of
Child Abuse and Neglect, 18(9),
one continuing education hour for this course,
completing this exam.