What are the Criminal Implications of Munchausen Syndrome by Proxy?

Courtesy of Godoy Medical Forensics

Munchausen Syndrome by Proxy was first described in 1951 by a British physician, but it was not until 1977 that the condition was labeled “Munchausen Syndrome by Proxy” by pediatrician Roy Meadow. The syndrome was defined as “a condition in which a parent or other caretaker persistently fabricates symptoms on behalf of another, causing that person to be regarded as ill.” Dr. Meadow was the first to describe this behavior as abuse and is still considered a form of abuse by the American Professional Society on the Abuse of Children. Currently, in the United States the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM–5), the syndrome is termed Factitious Disorder Imposed on Another (FDIA).

The Victim

According to the literature, boys and girls are equally victimized in Munchausen’s Syndrome, and 77 to 90 percent of the time, the perpetrator is the child’s biological mother. In addition, 29 percent of perpetrators have symptoms of Munchausen Syndrome themselves.

What the victim might look like:

  • Failure to thrive due to nutritional neglect;
  • Child has a history of multiple hospitalizations;
  • Is usually less than age five at the time of symptom onset;
  • Has a deceased sibling or a sibling with a complicated medical history;
  • Testing completed does not match the clinical picture of the child;
  • Worsening of the symptoms reported by the caregiver, but not seen by the medical providers;
  • May also exaggerate symptoms to obtain caregivers attention;
  • Symptoms worsen upon discharge.

The Offender

What the caregiver might do to mimic illness in the child:

  • Adding chemicals to the child’s urine or stool;
  • Withhold food so the child looks like they are anorexic;
  • Make up lab results to be abnormal;
  • Give the child drugs to make the child throw up or have diarrhea and abdominal pain;
  • Infect an intravenous line (IV) by adding feces or saliva to the IV site;
  • Applying fecal matter to wounds or rubbing dirt and coffee grounds into orthopedic pin sites;
  • Injecting urine into the child;

What the offender may look like:

  • Usually is a parent and is typically the mother of the child, but can be the father;
  • May also be a health care professional;
  • Is very friendly and cooperative with the health care providers;
  • Appears quite concerned or overly concerned about the child or designated patient;
  • Is even willing to have the child undergo painful or risky procedures and/or operations in order to get the sympathy and special attention given to people who are truly ill;
  • Utilizes many different medical providers and facilities as a way to earn praise from others for their devotion to the child’s care
  • Tends to be quite “fluent” in the medical jargon and able to explain medical details easily;
  • Will not usually leave the child alone with the medical provider.

Criminal Implications

Munchausen’s Syndrome is considered a form of medical child abuse in terms of physical abuse and medical neglect. This type of abuse is considered to be premeditated. Medical providers are considered a mandatory reporting entity, but many do not recognize the syndrome or get “sucked into” the sympathy for the caregiver. “Even when fabricated illness is reported to child protective services, many children are not protected from further harm. In a 2-year surveillance study in the UK, approximately one-third of the children (46 of 119) were allowed to return home. Approximately one-quarter of the children still had signs or symptoms of abuse at follow-up. Only one-third of the children were placed in caregiving arrangements outside the control of the alleged offending parent.” (American Academy of Pediatrics, 2013)

Estimates suggest that about 1,000 of the 2.5 million cases of child abuse reported annually are related to Factitious Disorder Imposed on Another (FDIA) or Munchausen’s Syndrome by Proxy. “This disorder can lead to serious short-and long-term complications, including continued abuse, multiple hospitalizations, and the death of the victim. Research suggests that the death rate for victims of FDIA is about 10 percent.” (Cleveland Clinic, 2014).

Monsters in the Closet: Munchausen Syndrome by Proxy

Materia Medica is a brief review of current literature in medicine relevant to criminal law designed to help prepare you for your next case.

Monsters in the Closet: Munchausen Syndrome by Proxy by Laura Criddle, RN PhD, ACNS-BC, CCRN, CCNS

This article discusses Munchausen’s Syndrome by Proxy (MSBP) and states that it is underrecognized and underreported. Some points in the article to be brought forward for defense attorneys are:

  • “…there is likewise no standardized definition of the disorder.”
    • This ambiguity allows the defense attorney to question the medical diagnosis.
  • “Although the condition is often characterized as ‘rare,’ lack of a standardized definition and centralized reporting repository make it difficult to quantify the incidence of MSBP. Expert estimates range from 1 in a million children to 2.8 in 100,000 children.”
    • The only consensus is that it is a rare disease. There is little literature that defines its incidence. Rarity alone supports a defense case.
  • “…if this fabrication does not garner sufficient interest from medical providers, abusers are driven to increase the stakes.”
    • The disorder is considered an escalating disorder. It is beneficial to review past medical history of the child and determine if there were previous incidences of potentially mild symptom fabrication, such as claims of apnea or ataxia.
  • “Mothers, and other women in a guardian role, are by far the most frequently reported perpetrators (93%), but Sheridan’s large scale review found that fathers were primarily responsible approximately 7% of the time.”
    • This is relevant for both male and female defendants. Defense may postulate that the male defendant is an unlikely suspect, or that the female is not the exclusive perpetrator in this condition.