MSBP, also known as Factitious Disorder by Proxy (FDP), is a form of abuse in which a caregiver fabricates or produces symptoms of an illness in a child, elder, or disabled person — it is an unusual and potentially lethal form of abuse which warrants more attention from nurses. MSBP, as it will be referred to in this module, is an established form of child abuse which carries the risk for significant harm to the child victim and siblings, with long-term physical and emotional consequences for many.^1,2,3 Approximately 10% of cases are fatal and more than 25% involve more than one child.^1,2,3 A parent, usually the mother, induces or reports physical symptoms in a child and fabricates a corresponding history that results in unnecessary medical evaluation and treatment. Common physical symptoms noted in the children are apnea, seizures, diarrhea, vomiting, bleeding, fever, and rash.⁴ Involved parents may commit many deceptions. For example, the perpetrator can make a child’s emesis, urine, or feces appear bloody by adding their own blood, or paint, dye, or cocoa. Feeding a child large amounts of salts or sugars can create electrolyte imbalance. Scraping a child’s skin with a sharp object or applying irritating solutions, such as oven cleaner or dyes, can cause rashes that can last for days, weeks, or even months. Sedatives, tranquilizers, or the injection of drugs or foreign materials can induce neurological symptoms.^3,4,5 Only the imaginations of these parents limit the variety of believable signs and symptoms. The children not only suffer from the parents’ actions, but also are subjected to an extensive array of invasive radiological, medical, and surgical procedures that are unnecessary and painful.

In some instances, clinicians’ lack of familiarity with MSBP allows this abuse to continue. Nurses who work in primary care settings, outpatient clinics, pediatric units, and emergency departments may encounter, but not recognize, its victims. Specialists in a variety of settings may unknowingly consult in cases of MSBP when presenting symptoms require expertise in surgery, neurology, pulmonary, ear/nose/throat, genetics, cardiology, infectious disease, psychiatry, hematology, ophthalmology, allergy, or endocrinology. For the protection of the victims, there is a need to educate all members of healthcare teams, child and adult protective service teams, law enforcement, and the legal community about MSBP.⁵ Because nurses can play a vital role in profiling and aiding in the diagnosis of MSBP, they must be able to identify symptoms, warning signs, and the typical characteristics of a perpetrator, as well as the psychosocial dynamics. Nurses must understand that their careful documentation of forensic evidence may be a prime factor in ultimately keeping the children safe from further harm.

A Legend Lives On

In the 1950s, Richard Asher, MD, a London physician, first coined the term Munchausen syndrome to describe patients who consistently produced false stories about themselves to receive needless medical investigations, operations, and treatments.⁶ Asher named the syndrome for Baron Von Munchausen, a distinguished German soldier and politician who was born in 1720. Von Munchausen often entertained guests with fabricated stories of incredible travels and brave military exploits. A series of German fables in the 18th century told of the Baron’s dramatically untruthful adventures. Asher used the term “Munchausen syndrome” because of these characteristics.⁶ Munchausen syndrome by proxy was first used in 1977 to describe a condition in which parents falsified illnesses or fabricated symptoms for their children.⁷

A Lost Childhood

Reported cases of MSBP vary in complexity from simply fabricating symptoms, tampering with laboratory specimens, or altering health records, to using direct methods to induce symptoms.^{3,4 5} According to the Diagnostic and Statistical Manual of Mental Distorders (DSM), 4th edition, four principal features of MSBP include —

• Intentional production or feigning of physical or psychological signs of symptoms in another person who is under the individual’s care.
• The motivation of the perpetrator’s behavior is to assume the sick role by proxy.
• External incentives for the behavior (such as economic gain) are absent.
• The behavior is not accounted for by another medical disorder.⁸

MSBP perpetrators use one of two general methods to gain the attention they seek: 1) they falsify information about their child, such as giving an inaccurate or fictitious history or by the contamination of laboratory specimens; or they induce illness in the child by administering medications or agents to cause physical symptoms.⁵ Abuse occurs when the parent seeks medical attention that subjects the child to unnecessary extensive testing and medical interventions.^2,3,5 The spectrum of illnesses reflected in cases of MSBP is startling. The syndrome may include apnea, seizures, hematuria, bleeding from the upper respiratory tract, vomiting, diarrhea, skin problems (infection, lesions, rashes, bleeding), pyogenic arthritis, vaginal and rectal bleeding, cardiorespiratory arrests, induced seizures, and nonaccidental poisoning.⁴ One highly publicized case of MSBP involved Jennifer Bush.⁹ Hillary Rodham Clinton chose Jennifer to represent her campaign for healthcare reform. Later, authorities charged that Jennifer’s mother was responsible for inducing a long list of medical problems that could not be explained otherwise. Among the consequences of the mother’s actions to Jennifer may have been more than 200 hospitalizations and 40 surgeries, including the removal of her gallbladder, appendix, and part of her intestines.⁹

An example of a serial MSBP case involved three children.¹⁰ The first child died at the age of 14 months after a premature birth, intraventricular brain hemorrhage, bronchopulmonary dysphagia, and apnea. The oldest child, a 9-year-old boy, was admitted to the hospital after 14 days of vomiting and deteriorating mental status. He died the day after admission and a cause of death was not established even after autopsy. Approximately two months later, the 8-year-old brother was admitted to the same hospital with vomiting, dehydration, and abdominal pain of one day’s duration. He died seven days later. The admission of the 8-year-old with symptoms similar to his older brother triggered a thorough investigation into possible causes of this mysterious illness. An analysis of the children’s home, including soil and water samples, revealed nothing unusual. However, toxicology analysis of the last boy’s tissues uncovered dramatically elevated arsenic levels. Subsequent analysis of tissues saved from the 9-year-old brother also revealed a high liver arsenic level of 1,239 g/g, when a normal level is less than 0.034 g/g.¹⁰

Profile of a Perpetrator

Researchers have identified a widely accepted profile of the MSBP perpetrator based on frequently observed characteristics.^1,2,3,4,5 MSBP perpetrators are found in all socioeconomic classes. Studies have found that 90% of the perpetrators are the biologic mothers, 5% are other female caregivers, and 5% are the fathers. The majority are Caucasian women who are between 20 and 30 years of age.⁵ Given that the mother is the perpetrator in the majority of cases, subsequent discussion will assume this characteristic. The few cases of fathers as perpetrators indicate that they may not fit the accepted profile associated with mothers.¹¹ The majority of the families in which MSBP occurs are dysfunctional, but tend to be intact. There may be a family history of this problem.

Several theories exist about a mother’s motivation to commit the abuse of MSBP.^2,3,4,5 She may believe that the ill child will bring a closer relationship with the spouse. More likely, though, is the idea that the mothers have had an emotionally deprived childhood with a high probability of a history of physical abuse. These women may feel insecure, uncertain, lonely, and depressed. MSBP may be a mechanism for expressing anger and fear; perpetrators are seeking emotional support, love, and nurturing in the context of disease and illness. Furthermore, the medical environment may allow the mother to escape some of the responsibilities of parenthood and the reality of unpleasant events in her life or provide her with the attention she seeks. When confronted with a sick, young child, the healthcare team will turn to the mother for a history, and in an effort to provide holistic care, she will be included in decisions and treatments. This inclusion and consultation regarding her child reinforces the mother’s need for attention and support. Thus every time the child is ill or brought in for treatment, unsuspecting nursing and medical personnel are meeting her dysfunctional psychological needs.

Frequently, the mother has more than a basic medical knowledge that comes from previous experience as a healthcare worker. The mother often seems to be an ideal parent; she may be very concerned, devoted, attentive, loving, and sometimes overprotective or obsessed with the child’s illness.^1,3,4,5 These mothers provide continuous care, refusing to separate even for a short period of time, and they cooperate fully with medical and nursing staff, often forming close relationships with hospital staff. These parents can appear unusually calm in the face of serious difficulties in their child’s medical course. MSBP perpetrators may have complex medical histories themselves, including psychiatric problems, eating disorders, weight problems, or both.⁵ They may have a diagnosis of Munchausen syndrome themselves, a history of attempted suicide, and ongoing marital problems. Mothers who engage in serial MSBP may demonstrate more overt psychopathology than those involving only one child; they appear to be intensely loyal toward the child.^3,5 The identification of the perpetrator’s pattern of behavior is critical because, without treatment, some mothers will continue and perhaps intensify their deceptions.

When the mother is the perpetrator, the father is generally emotionally and/or physically isolated from her and the child; however, the family may be intact.⁵ The father is often unsupportive, professing to have no knowledge of the mother’s actions. He may rarely visit the child in the hospital and blame work responsibilities for this absence.

Perpetrators of MSBP often repeat illnesses in the same or similar forms with other children, unless effective intervention occurs. It is not uncommon for this child victim to have siblings with similar or unexplained illness or death. The perpetrators use the excuse that the symptoms “run in the family.” Thus, if the syndrome goes undetected in one child, the abuse is committed against the siblings as well. Between 25% and 33% of MSBP cases suggest the involvement of more than one child.^2,5 This may still under represent cases that go undiagnosed.

The Child Victims

Cases of MSBP usually start in infancy or at least by the age of 2; however; the syndrome may take months or years to be diagnosed.^3,4 The average length of time to the diagnosis of MSBP generally exceeds six months, and for many child victims, this diagnosis comes after a sibling has died of causes from MSBP. The victims are generally children less than six years of age because older children are out of the home attending school and are more likely to reveal the truth about their so-called symptoms. If MSBP continues as the child ages, the victim may accommodate to the parent’s deceptions.

Many adverse effects appear in children victimized by MSBP; 8% experience some form of long-term medical problems.^2,5,12 Parental trust, which is the most primitive psychological development, is impaired. The child may react to the abuse with developmentally appropriate behavior problems, including feeding disorders in infants and withdrawal, hyperactivity, temper tantrums, and aggressiveness in preschoolers.³ If the deception continues, older children and adolescents may exhibit hysterical disorders or may begin to participate in the hoax. They may feign sleep, lethargy, or pain when taken to the physician or nurse practitioner, or may even begin to fabricate their own symptoms and history. The strong bond between these mothers and their children creates an obstacle to diagnosing and treating the syndrome and the abnormal closeness invites further deception. MSBP may become multigenerational — child victims become adults with Munchausen syndrome.

The child victim of MSBP may suffer physical consequences from the actions of the mother and from the treatment received in response to those actions — thus healthcare professionals involved in cases of undiagnosed MSBP unknowingly contribute to the child victim’s immediate morbidity and physical deterioration.^2,6,12 Child victims can experience serious morbidity, including life-threatening respiratory arrests and bradycardia, kidney and liver dysfunction, colitis, and hearing loss.^3,13 Many children (70% in one study) demonstrate significant developmental delays in many areas of performance and learning that become more pronounced as they get older.^3,13 Complete psychological studies are not available, but evidence suggests that children also show immaturity, difficulty with family relationships, depression, conversion symptoms (conforming to the mother’s delusional beliefs), and attention-deficit disorder.^4,6,13,14

In the case of Megan, her GERD was related to the Ipecac syrup that her mother was placing into her bottles, and then into her tube feedings. Because of the Ipecac syrup and the related vomiting and other gastrointestinal disturbances, Megan became a poor eater who was slow to gain weight. After her tracheostomy, she developed frequent respiratory complications as a direct result of her mother blocking her tracheotomy airway with her thumb, a piece of gauze, a raisin, or a pillow.

Classifying MSBP

Classifying MSBP is a difficult and sometimes lengthy process that involves the efforts of many people. Nurses play a vital role in the observation and confirmation of the profile of MSBP. The first step in identifying any case of child abuse is being aware and educated about it. Also, establishing a multidisciplinary team that can meet regularly to conduct ongoing case conferences is useful. These meetings should focus on fact-finding, gathering data, and building a case to establish the diagnosis. If team members feel that they are getting close to confirming a case of child abuse and/or MSBP, they may want to notify the hospital attorney, risk manager, or administrator. Law enforcement personnel may be included at this stage.

Nurses aid in the profiling of MSBP by participating in several actions and considering several questions.

• Take a thorough history to search for clues. Does the history fit the physical findings? Do the symptoms make sense? Does the clinical picture agree with the mother’s (caregiver’s) account of the illness?^1,2,4,12
• Does the medical history agree with the clinical presentation? Be concerned with children who are allegedly unresponsive to usual treatment.^1,12
• When taking a history, ask questions to determine if the suspected perpetrator was present each time symptoms occurred, and gather a detailed health history of the mother and family, as well as the child. For example, does the child have or had siblings with a similar medical history and illness; has a sibling died?^2,4,12,15
• Look at the frequency of hospitalizations, testing, and treatments. Has the child been repeatedly hospitalized? Is there history of extensive diagnostic testing with unusual physical and/or lab findings?^2,4,12
• Listen to and watch the child. Children give histories with both words and behaviors. What is the child saying? How is the child acting when the parent is present versus when the parent is out of the room?
• Describe the child’s affect. Is he or she warm and open or quiet and withdrawn? Is there persistent failure of the child victim to respond to medical therapy?
• Separate the mother from the child to determine whether the symptoms continue or abate in her absence. Are the signs and symptoms diminished or absent when the mother is no longer present or participating in the child’s care? Does the child get better when the mother is gone?
• Document the child’s symptoms in relation to the mother’s participation. For example, clarify in the notes what the mother or child offers as history, and what healthcare providers actually observe.^4,6,12 For example, a nurse can collect the urine specimen from the child, eliminating the mother’s opportunity to contaminate the specimen. If the child is old enough to provide a history, does it match what the mother is saying? The nurse may need to substantiate claims about care for the child given by other providers or hospitals and obtain past records.^1,4 Suspected MSBP should prompt calls to the child’s primary care provider, local clinics, and hospitals. Verify details given by the mother (caregiver) with others who have cared for the child.¹
• Find out if there is a pet in the home. If so, call the animal’s veterinarian. MSBP is well known to most veterinarians — a pet owner can fabricate signs and symptoms in an animal.¹⁴ There may be a link to what is happening with the child.

Steps in obtaining a thorough history and physical assessment lay the groundwork for determining the extent of the deception and the length of time involved. After the history, the focus turns to gathering information. Two methods can provide indisputable evidence — close observation, such as catching the perpetrator in the act, and video camera surveillance. While close observation is the most obvious method, the child remains at risk during this often lengthy process. In addition, a staff person must be in or near the child’s room 24 hours a day, and the mother is unlikely to attempt anything if she knows that she is being watched.

While covert video surveillance eliminates some of the problems of close observation, legal, ethical, and financial problems complicate this method. Detailed documentation of assessments and observations is necessary for use in courts and aids in removing the child from the abusive situation, but use of video surveillance must be handled properly.^2,5,13 Covert video surveillance is controversial, with some saying its use is unethical and an invasion of privacy, but one research study found that when MSBP is a strong diagnostic consideration, the beneficial, even life-saving aspects of the video usage outweighed concerns about privacy.¹⁶ Recommendations from the study include only using covert video surveillance after a multidisciplinary team has agreed on the procedure, understanding that video requires a commitment of time from physicians, nurses, social workers, and security officers.¹⁶ Involvement of law enforcement personnel is recommended. The video becomes part of the child’s medical record and may be able to be viewed in court.

By whatever method, scrupulous and legible documentation may provide evidence in court if MSBP is diagnosed and the perpetrator is caught. Documentation must be objective, accurate, detailed, and legible. The detailed history should include a specific review of symptoms and review of systems via a thorough physical assessment.⁵ Attention should be given to the appropriateness of parental behavior and the child’s ability to interact independently. Care must also be taken with collecting and handling laboratory specimens, as MSBP mothers are clever in their deceptions.

Forensic Issues of Nursing Care and Treatment

Every nurse needs to be aware of the forensic issues involved in MSBP. RNs are legally mandated in every state to report any child who may be the victim or suspected victim of abuse to their city/state department of child protective services. As in any case of child abuse, the goal of treatment for MSBP is to stop the abuse and protect the child. Identifying abusive situations as early as possible is critical. Ensuring the safety of the child and all siblings is the first step. If the child’s life is thought to be in immediate danger, protective custody may need to be initiated and steps taken to permanently remove the child from the home. Placement of the child into a hospital or foster care environment in which the abuser is not present can be the first step in protection. The team treating the child should be together when confronting the mother, and child protection services may also need to be present.⁴

Management of the Family

The confrontation itself may be the most risky part of the diagnosis and treatment process.

• Before the parent is confronted, calls should be made to the local child protective service agency and/or the police.^1,5
• Include the spouse or other family members at the confrontation, which will enable an assessment of spousal/family complicity and an assessment of level of support for the perpetrator.⁵
• Be clear and direct with the spouse and family about what is suspected. The goal here is to inform those involved that MSBP has been discovered and that the victim will be protected while providing help for the perpetrator.⁵
• The mother usually denies the abuse, even after being presented with the evidence. She may try to take the child out of the hospital, or worse, out of the state. If this happens, the child is often lost to follow-up. Possible evasion or escape is why an open case in child protection services is so important. This may provide the only opportunity to ensure that medical information can be shared with the next care provider.^3,4
• Social services and child protection agency personnel should handle the custody of the child for the short term and any removal of siblings from the home.⁵

Although ongoing medical and psychological treatment may be necessary, the hospitalized child should not be treated as a victim of abuse but as a child with the usual age-appropriate physical needs, developmental tasks, and play requirements.^2,4,15 The nurse’s role is to act as advocate and provider of care. Interdisciplinary team management of the child includes psychiatric referral (inpatient and outpatient), as well as possible physical, occupational, play, and speech therapy. Consistent care and therapy programs may help the child victim to regain a sense of safety, trust, and self-esteem.

Refer the family to an advanced practice psychiatric nurse or other psychiatric provider for psychological support. Counseling should include other children in the home (after detailed physical and psychological assessments), the mother, the father, and extended family. Support and treatment of the family as a unit, supplemented with individual therapy, is the challenge for a positive outcome. Because of underlying psychological problems, denial, and the ability to manipulate the system, treating the offending mothers successfully is difficult.^2,5 However, attempts must be made because they have the potential to continue this type of abuse with other children.

Support for nurses

Identifying, assessing, and interacting with the victims of child abuse can be extremely disturbing for nurses. Just the suggestion of the MSBP diagnosis is both controversial and emotional, it can create dilemmas in terms of personal values and beliefs and professional practice. Nursing and other healthcare personnel have difficulty believing that the people we rely on and trust for giving accurate histories and proper care of children actually cause their illness.^4,5 Helping staff cope with their feelings of being “duped” by the mother is as important as diagnosing the victims. Recognizing the signs and symptoms of MSBP via frequent educational updates at conferences and staff meetings, learning modules, and current research literature can aid nurses in identifying children and families. Maintaining open communication channels throughout nursing, medical, social service, and outpatient teams will assist in tracking cases. In addition, providing support for the nursing staff that has had to make the diagnosis of MSBP can preserve their professional integrity and personal well-being.

Nurses play a vital role in the observation and confirmation of the profile of an MSBP case. While still considered to be a rare condition, cases of MSBP are suspected with greater frequency. Its clinical manifestations in children are varied and disturbing with well-documented, long-term physical and psychological effects. Careful documentation is an important forensic aspect of these cases, as nurses will be called to testify in court regarding their observations. Nurses in many areas are in the position to break the cycle by assessment and facilitation of profiling and early identification. These interventions may be the critical link in the survival of these children.