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Archives of Disease in Childhood, 1982, 57, 92-
Munchausen syndrome by proxy
ROY MEADOW
Department ofPaediatrics and Child Health, St James's University Hospital, Leeds
SUMMARY Information is presented^ about^ 19 children,^ under^ age^7 years,^ from^17 families,^ whose
mothers consistently gave fraudulent clinical histories and fabricated signs so causing them
needless harmful medical investigations, hospital admissions, and treatment over periods of
time ranging from a few months to 4 years. Episodes of bleeding, neurological abnormality,
rashes, fevers, and abnormal urine were commonly simulated. Often^ the^ mothers^ had had^ previous
nursing training and some^ had^ a^ history of fabricating^ symptoms^ or^ signs^ relating^ to^ themselves.
Two children died. Of the 17 survivors, 8 were taken into care and the other 9 remained at home
after arrangements had been made for their supervision. Study of these children and their families
has enabled a list of warning signs to be compiled together with recommendations for^ dealing
with suspected acts. The causes and the relationship of this form of^ behaviour^ to^ other forms of
non-accidental injury, iatrogenic injury, and parental-induced^ illness^ are^ discussed.
The label Munchausen's syndrome was devised by Richard Asher to describe patients who consistently produce false stories and who fabricate evidence so causing themselves needless medical investigations,
operations, and^ treatments.'^ It^ has^ become^ a^ well-
known condition and can sometimes affect older children.2 3 The children described have parents who, by fabrication, have caused them innumerable harmful medical procedures-a Munchausen syndrome by proxy. Since details of 2 such families were published in 19774 I have encountered 2 more families and I have been told of several similar cases by other paedia- tricians. Details on 19 children have been collected from 17 families with the^ aim^ of^ studying^ the characteristics of the syndrome and of finding features which may aid early detection and help for the families.
Methods
The children are ones for whom there was clear evidence of massive and persistent fabrication by a parent of both the history and the signs. Cases of suspected or^ mild^ fabrication^ are not^ included,^ nor are the slightly more common instances of children
who were poisoned by a parent. However if poison-
ing occurred as well as other fabricated acts^ by^ the parent the^ child is included. Three other clear cases of Munchausen syndrome
by proxy are excluded because records were not sufficiently detailed. The information on^4 children,^ each from^ a different family, was obtained from my own records and from the notes of the hospitals and referring
doctors. The other 15 children were notified to me
by other paediatricians in England. Further^ details
of the events, the^ children, and^ the^ families^ were
obtained by correspondence, a^ questionnaire, and^ a
study of^ medical^ notes^ and^ hospital^ records.^ The
considerable detail obtained is a reflection of the time
and trouble taken by the paediatricians. Some of
these children have been the^ subjects of short
reports or^ of^ correspondence^ in^ medical^ journals.`
The enquiry considered the following aspects: the
child, the 'illness' and its perpetration, the conse-
quences and outcome, and the parents. In^ most cases full^ details^ were^ available^ for each aspect;^ in^ a
few information was not sufficient for a particular
aspect and so was omitted. Thus the^ results refer^ to all 19 children and^ all^17 families^ except^ in^ instances
in which the group total is specified as being smaller
than the full number.
Results
Features of Munchausen syndrome by proxy.
The child and the illness
The 19 children, 10 boys and^9 girls, come^ from^17
families. By the time the^ deception was^ revealed^ the
Munchausen syndrome by proxy 93
ages of the children ranged from 4 months to 7 years (mean age 3 years 2 months). The children had had a plethora of^ serious symptoms and signs. Generally^ the^ features sug- gested a multisystem disorder, although in a few the features were limited to one system-for example the urinary tract. The false symptoms and signs had persisted or recurred for an average of 13 months
(range 1 j months to 4 years)^ until^ the moment of
revelation, after which they stopped. The principal signs are listed in Table 1. Most of the children had been seen by many different doctors, and had been referred from hospital to hospital for^ additional specialist^ advice. One had been examined by 28 different consultants. Although the initial reported symptoms and signs were false most of the children incurred secondary symptoms and signs as a result of investi- gations, operations, and medications. During their 'illness' many^ different^ diagnoses^ had^ been^ con-
sidered. Table 2 lists the diagnosis that was con-
Table 1 Nature and incidence offabricated signs in 19 children Fabricated sign No (^) of children Bleeding 12 Haematuria n =^7 Haematemeses n =^5 Haemoptyses n =^3 Blood in faeces n =^3 Epistaxes n^ =^1 Neurological 7 Drowsiness/coma n^ =^5 Seizures n = 3 Unsteadiness n =^2 Rashes 6 Glycosuria 5 Fevers 4 Biochemical chaos 4 Faeculent vomits 2
Table 2 Diagnosis^ that^ was^ considered^ most^ likely in (^14) children immediately before the deception was revealed. (Porphyria and dermatitis herpetiformis were earlier, or additional secondary, diagnoses) Provisional (^) diagnosis Chronic granulomatous disease Diabetes mellitus Encephalopathy Leigh's encephalopathy Grand-mal epilepsy Pituitary disorder Pulmonary haemosiderosis Renal tubular dysfunction Nephritis Polyarteritis nodosa Ulcerative colitis Food intolerance Recto-vesical fistula Osteomyelitis
- Porphyria (n =^ 4) Dermatitis (^) herpetiformis (n 4)
sidered most probable in the week before deception was revealed. Dermatitis herpetiformis and por- phyria had been considered in many as a secondary additional diagnosis.
The perpetration. In each case the mother was the source of the fraudulent history and the fabricator of false signs. Generally most harm to the child was done by doctors who were investigating or treating the false illness. In a^ few cases the^ mother herself was concerned in^ directly harmful activity^ too-for example by giving a^ poison or^ scratching^ the^ child's skin. The false histories were impressive in their medical detail and the fabricated signs were realistic. The
methods combined cunning, dexterity, and, quite
often, medical knowledge. Bleeding was generally the result of the mother adding her own blood to the child's vomit, urine, or faeces. Sometimes blood was smeared on a young
child's face or perineum. The blood was usually
obtained by the mother pricking herself but one
mother used blood from an^ open thigh wound.
Another mother stirred^ a^ vaginal tampon (during
menstruation) in^ the^ child's urine^ specimen.^ A^ few
mothers simulated blood in a specimen from the
child by adding paint, cocoa, or phenolphthalein.
Faeculent vomitus was produced by a^ resident
mother who kept in^ her cubicle^ a^ container^ of^ soft
faeces which she mixed into the^ child's vomit. Fevers were produced by rubbing thermometers
or immersing them in hot liquids.
Biochemical chaos arose from either diluting or adding chemicals-such as salt-to blood^ specimens.
While the specimen was being altered^ a^ variety of
tricks was used to^ distract^ the doctor^ who^ had taken
the blood specimen.
Rashes were fabricated in three main ways. (1) By rubbing the skin gently and repetitively with
a finger nail or sharp object to^ obtain a^ bullous
lesion 'dermatitis herpetiformis'. (2) By applying
caustic solutions to^ small^ areas^ of^ skin.^ (3) By
painting with^ a^ dye-such^ as^ phenolphthalein.
The neurological features were generally the
result of the mother giving sedatives or tranquilisers
which had been prescribed for^ herself, to^ the^ child.
They were given in doses greater than those pre-
scribed for the mother. One mother applied pressure
to the child's neck (carotid sinus pressure) to^ cause
the child to^ have^ seizures.
The consequences. All the children suffered^ needlessly,
incurring long stays in^ different^ hospitals together
with painful and^ damaging investigations and
harmful treatments. One 6-year-old boy incurred 13
Munchausen syndrome by proxy 95
their mothers' behaviour and the doctors' responses. Three aspects deserve particular consideration as (^) a better (^) understanding may lessen the chance of harm to children. (1) Ways of detecting the (^) fabricated happenings earlier-that is warning signals. (2) Prompt and effective action once the syndrome is
suspected. (3) The behavioural cause.
Warning signals. Munchausen (^) syndrome by proxy affects children under age 6 years. After that age the child would be likely to reveal the deception. The more common methods of fabrication are shown in Table 1, but the possibility of fabrication needs to be considered in (^) any young child who has: (1) per- sistent or recurrent illnesses (^) which cannot be
explained; (2) investigation results and signs which
are at variance with the general health of the child-
for example fevers or blood loss when the child
neither looks ill nor as if he is bleeding. In such
children there is a discrepancy between the clinical
findings and the history, and the symptoms and
signs do not make clinical sense; (3) worrying
symptoms and signs which cause experienced
specialist doctors to remark that they have 'never
seen a case like it before'; (4) symptoms and signs
which do not occur when the child is away from a
parent (the mother); (5) any mother who is particu-
larly attentive in prolonged visiting, or living in
hospital with her child, and who refuses to leave the
child alone in^ the hospital ward even for an hour;
(6) treatments^ that^ are^ not^ tolerated:^ sticking plaster
or local treatment causing an 'allergic rash', intra-
venous drips that keep coming out, inability to
tolerate any prescribed drug treatment because of
vomiting; (7) a^ very rare^ disorder: Munchausen
syndrome by proxy is less^ rare^ than certain^ notorious
disorders-for example porphyria (for which several
of the children had been investigated); (8) any
mother, who despite her child's fearful problems,
does not seem as worried about her child as are the
medical and^ nursing staff.^ (When I^ was^ particularly
upset and desperate because of failing to resolve the
problems of one child, her mother sat me down,
gave me a cup of tea, and told me how she admired
me for trying so hard and that I^ 'must not worry
so much'); (9) 'seizures' that do not respond to
carefully administered anticonvulsants.
The presence of any of these is especially sus-
picious if^ the^ mother has had^ previous medical^ or
nurse training, or a history of similar illness herself.
Action. Although as^ doctors^ we^ must^ continue^ to
behave as if the mother's story of her child is accurate, we must remember that sometimes the
story is false. We need to have a^ small degree of
suspicion always.
If fabrication is suspected: (1) The child must be separated from the mother to find out if the symp- toms and signs occur in her absence. If necessary a place of safety order should be considered, and it is likely to be helpful to make contact with the social services department early. Arrangements must be made for an (^) experienced nurse to collect and (^) guard all specimens destined for laboratory (^) investigation. (2) Check all the details of the history relating to the child, the family, the mother and her life. The general practitioner, health visitor, persons in other hospitals, and (^) the mother's past employers will be useful sources of information. It is common for the fabrication to extend beyond the child's illness and for details of the mother's schooling, employment, and life to be false also. Check if the mother has fabricated symptoms relating to herself and if she
suffers, or has suffered, from the symptoms and signs
she has donated to the child. (3) Check the story for a temporal relationship between symptoms, signs, and the parents' presence. (4) Keep specimens for detailed investigation. Collect them on admission and whenever the child is 'ill' or the (^) symptoms recur. For (^) toxicological assay large volumes may be (^) needed-for example at least 50 ml urine collected in a container without added preservative, and 10 ml blood in a heparinised tube.
Complete samples of vomit should be saved. A
useful toxicological screening programme has been
outlined by Rogers et^ al. in^ relation to deliberate
poisoning of^ children.
(5) Check and check again the reliability of the signs. Check that the rash does not wash offwithwater
or spirit, that the blood really is blood and that it is
the child's. A local haematology or blood trans-
fusion laboratory may be able to differentiate blood
of the child from that of the mother but the police regional forensic laboratory will be accustomed to this sort of work and has more sophisticated
techniques.
(6) Enrol psychiatric help (I regret putting this as
a low priority; but in relation to the cases in this
paper psychiatric help seems to have been of limited
value).
Once the suspicion is confirmed the plan of action
is similar to that for a child with non-accidental injury. It^ has^ to^ be^ decided^ if the^ child should be
removed from the family, or can remain there under
supervision. Of the children reported, 9 of the 17
surviving children^ continued^ to^ live at home and
have progressed satisfactorily. In some cases the
child would not have been allowed to stay at home
had the^ forensic evidence been^ sufficient to make certain of a court care-order for removal of the child.
Eight of the children were taken into care, and all
96 Meadow
except 2 of the remaining families were confronted with their deception. But the extent of the con- frontation varied. In some instances the doctor told the mother that her deception had been uncovered, and that if further deception occurred the police might be called in. In^ other cases the doctor told the parent that since the child was coming to (^) harm in his present environment the social services had been requested to keep a check on the child and to advise whether the child would be healthier and safer elsewhere. In several cases the management was complicated by the fact that the deception was un- covered in^ a^ regional centre to which the child had been referred from a (^) peripheral unit. The continuing management and supervision was (^) sometimes entirely based on the peripheral unit. After confrontation the troubles ceased. One of the 2 children who died had gone back to a mother who was not^ confronted^ directly. In^ that case those who referred the child^ doubted^ our^ findings and conclusions, and though I thought that the (^) mother suspected that we knew of her deception there was no direct confrontation. The mother and child returned to their home town where further investi- gations were undertaken. When the child died (probably poisoned) the (^) mother wrote a letter
thanking me^ 'for^ understanding' and^ then^ took an
overdose. My sense of failure led me to favour direct confrontation, and in 2 subsequent instances I have told the^ mother that^ I^ knew and understood
what she^ is^ doing. Neither^ mother has admitted it
nor has she specifically denied it. Her response has
been (^) 'Why on earth would I do that ?'. (^) However, the troubles have stopped and the children have made miraculous recoveries. With one of these families the
social services and the^ police were involved and the
mother greets me^ in^ a^ very superficial and evasive
way when^ the child is^ brought for^ regular checks.
With the other family outside agencies were not
needed and the family doctor now supervises the
family. The children are^ growing up healthily. The
mother has told false^ stories^ to^ the^ neighbours about
the cause of her daughter's long illness and the
nature of the cure in^ Leeds. She^ wrote recently 'I
will forever thank^ God^ and^ you'. Nevertheless the
fact that confrontation has produced apparent cure
in some cases does not ensure that it will always
achieve that, nor does confrontation necessarily
resolve what must be an extremely disturbed and
complex mother-child relationship.
The behavioural cause. The result for the children
was non-accidental injury, yet these children and
families differ in several ways from the more
common cases^ of non-accidental^ injury in^ our
region. The parents are older and there is not the usual preponderance of social classes IV and V families living in poor homes. The cases are more similar to deliberate poisoning of a child by a parent, and in^ some of the cases reported in this paper poisoning was one of the several actions taken by the mother. The possible reasons for parents poisoning their children have been well discussed.9 10 It would be naive to seek a single cause for the harmful behaviour of these mothers. For some the child's illness brought about a closer relationship with the husband; for others it seemed to provide welcome distraction^ from personal and home difficulties. Several of the mothers thrived on the children's wards. They seemed to love it, bustling round helping other mothers, helping the nurses, and forming close relationships with the junior medical staff. (^) They made the (^) medical staff feel that the paediatric service was really good! For the 3 mothers who themselves had marked Munchausen's syndrome the abnormal behaviour at first spilt over and then engulfed the child. For some it seemed to be a bizarre game in which they matched themselves (^) against the best specialists and the best hospitals they could find. As one problem was resolved another would be created. The common nursing and medical background was privileged in- formation for the game they created. They knew the rules, and also (^) the stereotyped responses of doctors. Most of the ex-nurses had failed their course; it could
be suggested that some were determined to defeat
the system that had defeated them. The prepon- derance of nurses and the way in which some of the
mothers thrived while resident on a^ good paediatric
ward lends support to the adage that the desires to
nurse and be nursed are closely linked. It is relevant
that adults who indulge in self-mutilation and
deliberate disability often have been nurses.1"
Therefore, it^ seems that^ nurses^ and former^ nurses
are at risk for damaging themselves and their child-
ren with the result that either they or their children
incur needless hospital admissions and investigations.
Most of the mothers seemed^ caring and^ loving
with their children. They did not appear cruel,
negligent, or uncaring. It was not possible to obtain
details of early experiences and^ family life^ for^ each
mother, but for^ those^ for^ whom^ such information
was available there seemed no excess of deprivation
or institutional life. Moreover, those mothers who
were referred^ to a^ psychiatrist tended^ to^ emerge
without a diagnostic label; this is presumably a
reflection of the difficulty of defining normal and
abnormal personality for^ we would all agree that the
mother's behaviour had been abnormal.
It was the doctors who injured the children the
98 Meadow
(^6) Clayton P T, Counahan R, Chantler C. Letter: Mun- chausen syndrome by^ proxy. Lancet^ 1978;^ i: 102-3. (^7) Verity C M, Winckworth C, Burman D, Stevens D, White R J. Polle syndrome: children of Munchausen. Br Med J 1979; ii: 422-3. (^8) Lee D A. Munchausen syndrome by proxy in twins. Arch Dis Child 1979; 54: 646-7. (^9) Rogers D, Tripp J, Bentovim A, Robinson A, Berry D, Goulding R. Non-accidental poisoning: an extended syndrome of child abuse. Br^ Med J 1976; i: 793-6. (^10) Watson J B G, Davies J M, Hunter J L P. Non-accidental poisoning in^ childhood. Arch Dis^ Child^ 1979;^ 54:^ 143-4. Hawkings J R, Jones K S, Sim M, Tibbetts R W. Deliber- ate disability. Br Med J 1956; i: 361-7. 12 Waller D, Eisenberg L. School refusal in childhood-a psychiatric-paediatric perspective. In: Hersov L, Berg 1, eds. Out of school. Chichester: Wiley, 1980: 209-29.
(^18) Fleisher D, Ament M E. Diarrhea, red diapers, and child abuse. Clin Pediatr (Phila)^ 1977;^ 17:^ 820-4. (^14) Kohl S, Pickering L K, Dupree E. Child abuse present- ing as immunodeficiency disease. J Pediatr 1978; 93: 466-8. (^15) Kurlandsky L, Lukoff J Y, Zinkham W H, Brody J P, Kessler R W. Munchausen syndrome by proxy: definition of factitious bleeding in an infant by 51Cr labeling of erythrocytes. Pediatrics 1979; 63: 228-31.
Correspondence to Professor S R Meadow, Depart- ment of Paediatrics and Child Health,^ St^ James's University Hospital, Leeds LS9^ 7TF.
Received 2 February 1981
