Factitious Illness by Proxy
Factitious illness by proxy (Munchausen syndrome by proxy) is a form of child abuse that is particularly difficult to diagnose and treat.1 In Munchausen syndrome by proxy, a caregiver (usually the mother) pretends an infant or child is ill or causes the child to be ill.2 The caregiver’s motivation for this behavior is thought to be a psychological need to join the child in the sick role and to receive attention by proxy.
Because of the syndrome's potentially lethal outcome and the high risk of long-term physical and psychological morbidity, recognition is critical. There are two components associated with diagnosing Munchausen syndrome by proxy: identifying the victimization of the child and identifying the psychological motivation and characteristics of the perpetrator. A child subjected to victimization related to the syndrome is a victim of child abuse. The perpetrator would be diagnosed as having factitious disorder by proxy.1
The following may help primary care providers diagnose the syndrome:*
- The victim is most commonly an infant or a young child
- The perpetrator is usually the child’s mother and often has had some medical training
- The majority of symptoms involve the gastrointestinal, genitourinary, or central nervous systems
- The child’s signs and symptoms may be incongruous with the presented history or usual clinical course of defined illnesses
- History may reveal that the child has received care at a number of facilities
- The caregiver may report that commonly accepted treatments have not been effective or have been poorly tolerated
- Often a number of subspecialists are consulted, locally and nationally
- Signs and symptoms may occur only when the caregiver is present, and/or they seem not to respond to prescribed treatments
- The caregiver may report that the child is allergic to a wide variety of foods and/or drugs
- Laboratory results are often inconsistent
- The child may be discharged from the hospital against medical advice
- The caregiver may remain constantly at the child’s bedside but may not appear appropriately worried about the child’s illness
Because of the difficulty in diagnosing and addressing this syndrome, a supportive team approach taken by medical, psychiatric, nursing, and social work personnel is essential. When faced with confusing or contradictory symptoms, particularly of the gastrointestinal, the genitourinary, or the central nervous system, the primary care provider should consider consulting with a colleague on diagnosis and treatment.
If a case of Munchausen syndrome by proxy is suspected, the following interventions may be helpful:**
- Ensure the child's safety while the evaluation is being conducted. If the child is hospitalized, he should be under constant observation by health professionals. If the child is not hospitalized, or if the caregiver insists on taking the child home before the evaluation is complete, health professionals need to decide whether the child is in sufficient danger to warrant seeking legal custody through the courts or child protective services. (Be aware that the caregiver may remove the child from care if the caregiver’s suspicions are aroused.)
- Hospital attorneys should be informed of any suspected cases of Munchausen syndrome by proxy.
- Health professionals should obtain as much medical and psychosocial history as possible and should strive to form an alliance with family members.
- Child psychiatric consultation is key in assessing and supporting the child, family, and health professionals.
- Encourage all health professionals involved to communicate openly and regularly about all aspects of the child’s care to avoid the possibility of being manipulated by the caregiver.
- Once enough evidence has been obtained to make the diagnosis, all health professionals involved should discuss how to present the conclusion to the family. Follow-up with needed services (child protective service agencies, mental health services for the child and family) should be in place when the diagnosis and treatment plans are presented to the family.
- Careful documentation of all treatment and interventions is essential, as repeat offenses are common, and it is often difficult to definitively diagnose the syndrome.