The American Psychiatric Association's Diagnostic and Statistical Manual of Disorders describes Munchausen Syndrome by Proxy as the "intentional production of physical symptoms."

The term "Munchausen Syndrome by Proxy" (MSBP) was first named in a 1976 report describing four children who were so severely abused they were dwarfed. In 1977, Meadow described a somewhat less extreme form of child abuse in which mothers deliberately induced or falsely reported illnesses in their children. He also referred to this behavior as Munchausen Syndrome by Proxy.

Munchausen Syndrome by Proxy victims are usually children, and the perpetrators are almost always parents or parental substitutes. If and when victims are hospitalized, they may be subjected to multiple, and at times, dangerous diagnostic procedures that invariably produce negative or mistaken results. When the victim and the abuser are separated, however, the victim's symptoms cease. When confronted, the abuser characteristically denies any knowledge of how the child's illness occurred.

In simplicity, those having this disorder will injure or induce illness in children in order to gain attention and sympathy for themselves. They may induce breathing difficulties that mimic the symptoms of apnea and sudden infant death syndrome, poison them, or fabricate illnesses in their children. The offender then revels in the attention afforded them by relatives, doctors, and hospital personnel. The problem is, however, because the child's illness has no medical cause, doctors have difficulty making any diagnosis.

Research shows that individuals who initially engaged in Munchausen Syndrome (self-inflicted injury) may eventually practice Munchausen Syndrome by Proxy. The degree to which the offspring of Munchausen offenders become the subjects of abuse may increase proportionately with the number and increased severity of incidents of self-inflicted abuse. MSBP may occur when the perpetrator of Munchausen Syndrome crosses over the threshold of self-inflicted injury into abuse of an unsuspecting child. Often times, the offender claims that injuries to the child were inflicted by a fictitious person and in some cases, offenders injure themselves in order to substantiate the presence of this unknown perpetrator. Diligent investigation of these allegations often leads to a dead end.

Although there seems to be a multi-generational link between Munchausen Syndrome and MSBP, this connection has not been established scientifically to the level that most courts require.

In the standard offender-victim relationship, suspicion centers on the biological mother and, in fact, the vast majority of MSBP cases resolved through investigation have implicated the victim's mother as the sole offender.

You should be aware that the MSBP offender profile has widened to include other perpetrators, both within and outside the victim's family structure. Fathers, grandmothers, aunts, and baby-sitters have been identified as offenders. Regardless of the relationship to the victim, the offenders all had one thing in common. Each acted as the victim's primary care giver.

In very rare cases, medical professionals also could be included in the list of potential suspects. While it appears that only immediate family members would receive the gratification from attention, increased self-esteem, and false sense of belonging afforded by MSBP, similar motivations lead some health-care workers to cross the line of the Hippocratic Oath into the realm of child abuse. By inflicting MSBP, and then "saving" the child, these offending medical practitioners hope to excel within their fields and win acceptance by their peers. Fortunately, the frequency of cases involving health-care workers has been relatively low. The possibility does exists, though, that a medical professional's actions might indicate MSBP in certain circumstances.

The method by which investigators approach suspected MSBP offenders is the key to resolving these cases. During interviews, the investigator needs to convey to the suspect that they are keeping an open mind regarding the case. Investigators can expect sound rationalization on the part of offenders, as well as a series of open-ended allegations that cannot be substantiated.

The investigators should make every effort to segregate other family members from suspects during the interview process because relatives probably will voice support and belief in the allegations if the suspect is present. In those cases where obvious inconsistencies exist, family members might view facts differently when questioned away from the suspect.

With continued investigation, the identified MSBP offender might be linked to the deaths of other children. Often, the original medical examiners may have incorrectly identified these deaths as resulting from sudden infant death syndrome. If the deceased child or children have not been cremated, then exhuming their bodies for forensic testing might be appropriate. When advised of previously identified causes of death within a family, forensic pathologists or medical examiners might be able to uncover particular toxins or evidence pointing to homicide.

Whether the child actually knows that the offender has induced the illness depends on the child's physical age and the offender's covert skills. Certainly, the longer the abuse continues and the older a child grows, the more likely it becomes that the victim will understand the offender's actions.

If the abuse has been present throughout the life of the child, then the victim might believe that whatever action is being done to cause the illness is normal. Because of this misunderstanding of normal behavior and the attention that the offender lavishes, the child might not view the offender as anything less than an ideal care giver, even if the abuse is blatant.

It is normal for many investigators to refrain from interviewing the victim. Even if a victim is old enough to talk, the child probably will not be able to assist verbally in the investigation and the investigator must consider the potentially traumatic consequences should the child be told that a trusted care giver is in fact an abuser. It is wise to seek the help of professionals when dealing with this aspect of the investigation to lessen the possibility of further traumatizing the victim.

In MSBP related cases, investigators face additional concerns for the safety of the child involved. Suspected offenders might react in a number of ways when confronted. Offenders may deny the allegations and blame the child's apparent illness on an unknown cause. Often, an increase in the severity of the victim's symptoms follows as the offender attempts to prove the presence of the illness. Unfortunately, the child might not be able to withstand the escalating abuse or the increased treatments prescribed to address the symptoms.

In order to reduce the possibility of further abuse to the child, investigators must work toward a swift conclusion to the case once they have confronted the suspected offender. Careful planning and caution can be critical, especially since research indicates that from 9 to 31 percent of all MSBP victims die at the hands of their perpetrators.

Some confronted offenders might react passively and relocate with the victim and other family members. If there is no protective measure to preclude a suspect from relocating with the child, the cycle of MSBP probably will continue in a new locale.

If not arrested, offenders who believe they are under suspicion might become more cautious, but usually this is only temporarily. The child's apparent illness might subside until the offender believes it is safe to resume the abuse. Offenders also may wait until a reasonable time elapses and then re-admit the child into the hospital. In either case, it appears that as offenders continue their abuse, the danger to the child increases. The "psychological needs" of these offenders have been compared to that of drug addicts. Through cycles of abuse and nurturing, MSBP offenders seek to satisfy an ever-increasing need for attention and self-validation. However, some experts believe that, unlike most drug addicts, MSBP offenders cannot be rehabilitated.

Despite seemingly strong circumstantial evidence present in some cases of apparent MSBP abuse, investigators must make every effort to refrain from making false allegations or wrongful conclusions. Accusations based on insufficient investigation and absent forensic analysis can have disastrous consequences. In one case, a mother was falsely accused of the death of her infant son. The child died as a result of apparent ethylene glycol poisoning. When she had a second child, the doctors discovered that the infant had a rare disease that had caused the death of the first child. The mother subsequently initiated legal action against the State.

The manner in which charges of MSBP originate must be considered in the total course of an investigation. Highly disputed child custody cases often generate charges of child abuse. Sometimes, MSBP offenders accuse the other parent of abuse in order to mask their own wrongdoing and to keep custody of the child. In cases where an estranged parent involved in a custody dispute reports illnesses or accuses the other parent of child abuse, investigators should explore all potential motivations for such accusations. Falsified reports for custodial purposes could be a valid concern. Any investigator involved in a potential MSBP case needs to ensure that they are not being used as a tool for secondary gain by the accusing parent.

In cases where reports of abuse originate from a noncustodial or estranged parent, the question of accuser/inflictor role reversal should be considered as an alternate cause of the child's ailments. This type of issue often arises in contested divorce situations involving minor children and also might be linked to parental kidnaping by noncustodial parents.

When custody has been denied to an offending parent, and the victimized child has been placed with the other parent, the offender might go to great lengths to regain custody. Accusations of sexual abuse, especially if the custodial parent is the father, might be made by offenders as they attempt to disguise their responsibility for the child's abuse.

The rationalization for the actions of MSBP offenders is based on their desire to regain lost custody through outward expressions of love. It appears that the longer offenders are separated from victims, the more desperate and determined they become to regain custody.

Suspected MSBP offenders who believe that they are being watched or have been accused of MSBP abuse, might seek assistance by accessing public shelters provided for victims of domestic violence. In such cases, offenders rely on their highly developed skills of deception. Because personnel working at these shelters function for the protection and assistance of traumatized women, they might be reluctant to question an incoming client's account of victimization. Once a woman settles in an abuse shelter, investigative access might be difficult, and the support system in the shelter will reinforce her fictitious explanation of the child's injuries or illness. While in the shelter, the victim temporarily might be spared from further injury to strengthen the mother's claim that another person is the source of the abuse. Unfortunately, the child's reprieve usually ends when the offender must leave the shelter and once again is alone with the victim.

Normally, a victim of a MSBP offender is resolved in one of the three ways. The child dies, the offender is arrested or the victim's advancing age causes the offender to move on to a younger child within the family.

In cases where a child has either died from abuse or matured to the point that the care giver believes it is too dangerous to continue the abuse, the offender might attempt to find another suitable victim. The offender commonly substitutes a younger sibling for the initial victim. In rare cases, both children might share the abuse simultaneously, but it is more likely that the offender will concentrate on one victim at a time. Because offenders revel emotionally in the attention derived from MSBP, it is reasonable to assume that only one child would be necessary to gain such attention.

Unfortunately, MSBP has become a popular means to "justify" cases when seeking to establish a link between this syndrome and maternal homicide. Not all women who kill their children are afflicted with Munchausen Syndrome or MSBP, just as not all women who kill their children are insane. With MSBP, offenders crave the attention from events surrounding their child's illness or death. Investigators should certainly consider the possibility of MSBP if they believe there to be some secondary gain, in the form of attention or notoriety, afforded the offender at the expense of the victim. If investigators find no warning signs associated with MSBP cases or no secondary gain in the form of attention, then they should consider the possibility of homicide without the association of the MSBP factor.

Some possible signs of a MSBP offender:

• Most often biological mothers of the victims, but potential offenders are not limited to this group; fathers and persons outside the family have also been identified.

• Are often upper class, well-educated persons.

• Remain uncharacteristically calm in view of the victim's perplexing medical symptoms.

• Praise medical staffs excessively. Most offenders crave the attention gleaned from hospital staffs, doctors, and family members.

• Mothers who have an unusually close relationship with the hospital's medical staff.

• Appear to be very knowledgeable about the victim's illness. Some offenders might receive gratification as they fool the doctors. They derive enjoyment from knowing what is wrong with the child while medical experts remain baffled.

• Have some medical education, either formal or through self-initiated study or experience.

• Repeated hospitalizations and extensive medical tests that fail to produce a diagnosis.

• Symptoms that do not make medical sense.

• Unexplained and prolonged illness that puzzles experienced doctors who may state that they have "never seen anything like it before."

• A parent who welcomes medical testing of the child, even if painful.

• Attempts to convince the staff that the child is still ill, when advised that the child will be released from the hospital.

• Mothers who do not seem worried about their child's illness, but are constantly at the child's side while in the hospital.

• A care giver who adamantly refuses to accept the suggestion that the diagnosis is non-medical.

• Persistent failure of the victim to respond to therapy.

• Signs and symptoms that dissipate when the victim is removed from the suspected offender's presence.

• A family history of sudden infant death syndrome.

• Mothers with previous medical or health-care experience who have a history of the same type of illness as their child.

• A model family that normally would be above suspicion.

• A care giver with a previous history of Munchausen Syndrome.

• Typically shelter victim from outside activities, such as school or play with other children.

• Allows only selected persons close to their children.

• Maintains a high degree of attentiveness to the victim.

• Offenders become more aggressive as time passes.

• Alexander, R., W. Smith, R. Stevenson, "Serial Munchausen's Syndrome by Proxy," Pediatrics, vol. 86, 1990, 581-585.

• Meadow, R., "Management of Munchausen Syndrome by Proxy," Archives of Disease in Childhood, 1985, 385-393.

• Schreier, H. and J. Libow, "Hurting for Love: Munchausen by Proxy Syndrome" Guilford, Connecticut: Guilford Press, 1993, 103.

• Hanon, K., "Child Abuse: Munchausen's Syndrome by Proxy," FBI Law Enforcement Bulletin, December 1991, 8-11.

• Rosenberg, D. A., "Web of Deceit: A Literature Review of Munchausen Syndrome by Proxy," Child Abuse and Neglect, November 1987, 547-565; R. Meadow, "Fictitious Epilepsy," Lancet, vol.25, 1984, 8; supra note 1.

• Kinschereff, R. and R. Famularo, "Extreme Munchausen Syndrome by Proxy: The Case for Termination of Parental Rights," Juvenile and Family Court Journal, vol.5, 41-49.