Whether fictional or fact-based, Munchausen syndrome by proxy grips the public. Media depictions in The Sixth Sense and Sharp Objects and real-life news coverage of Gypsy Rose Blanchard’s December 2023 release from jail are hard to look away from. The most well-known cases—real or dramatized—are often the starkest ones, but Munchausen by proxy comes in subtler, harder-to-detect forms too.

“The media are fascinated, but they tend to depict the most extreme cases,” says Dr. Marc D. Feldman, distinguished life fellow of the American Psychiatric Association and author of Dying to Be Ill: True Stories of Medical Deception.

So how do more health care providers develop the skills to recognize this form of medical child abuse and report it to the appropriate authorities? 

What Is Munchausen by proxy?

Munchausen by proxy “is a form of abuse in which a caregiver feigns, exaggerates, or induces illness in another person. Typically, the caregiver is the mother, and the victim is her child,” Feldman says.

While this deception may result in tangible benefits—like disability funds or opioid medications the caregiver then abuses—the perpetrator’s primary motivation is typically attention, says Mary Sanders, a clinical psychology professor at Stanford University School of Medicine.

You may hear this type of abuse referred to by many names. While it was once primarily called Munchausen syndrome by proxy, many experts now leave out the word “syndrome” because it implied there was a neat-and-tidy checklist for diagnosing a perpetrator. There are some commonalities among the caregivers who inflict this type of abuse, but not everyone matches the same criteria, Sanders says.

Increasingly, the phenomenon is called Munchausen by proxy (MBP) abuse to emphasize the negative effects on the victim or a type of medical child abuse, Feldman says.

Medical child abuse doesn’t specify why a caregiver is overmedicalizing a child, Sanders explains. But if the caregiver is being intentionally deceptive about an illness in a child, they are also said to have factitious disorder imposed on another (FDIA), according to changes made in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a glossary of mental health diagnoses. Whatever the behavior is called, it’s pernicious—and often hard to spot.

“In the past, making a diagnosis of Munchausen by proxy was challenging because understanding the motivations of the caregiver was part of the definition,” says child abuse pediatrician Dr. Amy Gavril, a past member of the American Academy of Pediatrics (AAP) Council on Child Abuse and Neglect and an associate professor at West Virginia University School of Medicine. “The motivation of an adult is an incredibly challenging thing to figure out, and, as a pediatrician, when it’s not your patient, it makes it even harder.”

Experts believe this form of abuse is largely underreported because it’s so difficult to recognize. The official incidence is about 0.5 to 2.0 cases in every 100,000 children under the age of 16, according to a 2013 Pediatrics report, but things might be much more serious than that.

“My sense is it’s vastly underrecognized by doctors because many haven’t even heard the term Munchausen abuse or medical child abuse, or they don’t really know what it is,” Feldman says. “You can’t diagnose something you don’t understand or have never heard of.”

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Deception is central to Munchausen by proxy

It makes sense that MBP abuse is hard to recognize, considering the perpetrator has set out to fool everyone. “If the parent is really trying to be deceptive, they’re going to get away with it for a while,” Sanders says.

To skate by for as long as possible, caregivers frequently change medical practices before a health care provider has time to grow suspicious, Feldman says. But even qualified experts can have difficulty spotting MBP abuse. “The foundation of it is fabrication, and it’s very difficult to identify when a caregiver is not telling you the truth because we’re trained to listen to and take very seriously what a child’s caregiver has to say,” Gavril says. 

Sometimes, seemingly harmless instances of deception may be an early tipoff. “I had a mother who said her child was born premature at 4 pounds, 3 ounces. But when I get the birth records, it says 8 pounds, so that’s clear falsification,” Sanders says.

A host of red flags

MBP abuse remains confusing to health care providers, legal professionals, and the public, per a 2020 review article in Annals of Pediatrics & Child Health authored by Brenda Bursch, a professor of clinical psychiatry and biobehavioral sciences and pediatrics at the David Geffen School of Medicine at UCLA. But this isn’t the fault of any physician or specialty; it’s a problem with the medical education and child welfare systems. “Most clinicians lack the training and guidance needed to professionally, ethically, and skillfully protect victims of MBP,” she wrote.

Even without intensive training, however, it’s possible to become more alert to the red flags, the most common of which is inconsistency. “You’re looking for this mismatch between what you’re being told is going on with the child and what you’re objectively seeing,” Gavril says. “It’s those ongoing inconsistencies rather than a particular symptom” that raise suspicions, she adds, because the caregiver might claim any number of medical issues afflict the child.

Munchausen by proxy perpetrators are often very involved in the child’s medical care. They might be active in advocacy organizations for the rare condition they say the child has, or they might try to act like they are friends with you as the child’s doctor, Sanders says.

Another telltale sign is if symptoms ease when the child is separated from the abusive caregiver. “I often hear from fathers who say, ‘My former wife is presenting the child as autistic, but when he’s with me on vacation, he’s perfectly fine,’ or ‘His dietary limitations are severe and imposed by his mother. When he’s with me, he eats whatever he wants.’ That kind of information is invaluable,” Feldman says.

A 2007 Pediatrics article from the AAP’s Council on Child Abuse and Neglect suggests clinicians ask themselves the following three questions to help determine if a child may be a victim of MBP abuse:

• Are the history, signs, and symptoms of disease credible?
• Is the child receiving unnecessary and harmful or potentially harmful medical care?
• If so, who is instigating the evaluations and treatment?

Any suspicion is enough to report

Physicians are mandated to report suspicions of child abuse. But that doesn’t mean doctors have to be sure of what they’re seeing. “You don’t have to know for certain that this abuse is going on. If you have a reasonable suspicion, it’s not a choice; you are a mandated reporter,” Sanders says.

Still, it’s not uncommon, Feldman says, for him to “come across cases where 20 pediatricians were consulted in a very obvious case, and no one documented any suspicions of abuse.”

That’s a problem because “the longer it goes undiagnosed, the more likely it is that permanent or severe harm is going to occur to the child,” Gavril says.

Pediatricians and mental health care providers may be most likely to notice something out of the ordinary. But every practitioner should at least be aware of the possibility of MBP abuse because victims often toggle among many different specialists, such as gastroenterologists, pediatric neurologists, and infectious disease physicians, Gavril says. These experts likely have even less training in recognizing medical child abuse than pediatricians.

Too often, health care workers are “a little frightened of documenting their concern because they’re lawsuit-averse, and they fear it’s going to be provocative if the caregiver finds out,” Feldman says. For example, in the high-profile Munchausen case of Olivia Gant, who died at age 7 in 2017, many care providers had suspicions, but none voiced concerns because “they were afraid of the bossy, domineering mom and what she might do if they made a report to child protective services,” he says. Gant’s mother is now serving 16 years in prison.

“Most doctors say ‘I didn’t report because I couldn’t prove it.’ That’s the job of child protective services or the police. We have to recognize our professional duties to the patient, and that patient is the child,” Feldman says.

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Systematic issues prohibit further advancements

Child protection services don’t currently have a specific code or label for MBP abuse, so it typically gets lumped into medical neglect, Feldman says. This makes it hard to track prevalence, Bursch says.

But if advances can be made in that coding system, it could open the door for better training and education. “If we are successful in advocating for a specific category for child/adult protective services to use to correctly label and track MBP, then mandatory training will be required to educate caseworkers about proper investigation approaches and management of suspected cases,” Bursch says. “This support would help clinicians who have a duty to report suspected abuse even when they do not feel certain it has occurred.”

A more universal approach to electronic medical records could help, too. “We all should advocate for electronic health records to be standardized such that we can easily look at records from other facilities,” Feldman says, making it easier to recognize patterns of deception.

As Sanders emphasizes, it’s essential for doctors to trust their intuition when a situation feels off. “If something is just not making sense, look further,” she says. “And not in the sense of doing more invasive investigations, but recognizing that you may not be getting accurate information.”