Caretaker Cruelty: Munchausen’s and Beyond

By Bruce Gross, PhD, JD, MBA, FACFEI, DABFE, DABPS, DABFM, DAPA

Born in 1720, Karl Friedrich Hieronymus, Freiherr von Münchhausen, spent his youth as a page to Anthony Ulrich II, the Duke of Brunswick-Lüneburg (“Munchhausen,” 2008). Münchhausen moved to Russia with Ulrich, and both served in the Russian cavalry: Ulrich as a “generalissimo” and Münchhausen as a “cornet.” Together, they served in two campaigns against the Ottoman Empire with Münchhausen remaining in the military even after Ulrich was imprisoned in 1741. By 1750, Münchhausen had been promoted to the position of “rittmeister,” or captain, and shortly thereafter, retired from the cavalry and returned to his family’s manor in Bodenwerder, Germany.
The facts of Münchhausen’s personal life are scant and often contradictory. By all accounts, Münchhausen married in Latvia in 1744, with his wife dying in Bodenwerder in 1790. By some accounts, Münchhausen remarried 4 years later, to a 17-year-old girl who was supposedly pregnant with his only child. This marriage reportedly ended in a highly tumultuous divorce, and his son, Polle, is thought to have died of unknown or mysterious circumstances around the age of 12 months. By other accounts, Münchhausen died childless in 1797.

One certain fact regarding Baron von Münchhausen was the reputation he earned after his return to Bodenwerder and maintained for more than 40 years. Münchhausen was known for two, seemingly incongruous traits. First, he was a remarkably honest businessman, and secondly, he was a delightful and steadfast liar. Münchhausen typically became the center of attention at social gatherings, regaling his friends with incredible stories about his alleged feats and experiences during his travels and military service. It was Münchhausen’s ability to tell a bold-faced lie that earned him a name in the history of psychology.

Münchhausen’s History
In 1951, an article appeared in a medical journal written by Richard Asher, a London physician (Asher, 1951). In it, Asher described a syndrome in which patients presented with rather dramatic symptoms they had consciously fabricated or induced. They often underwent numerous, costly, and painful procedures that did not result in a diagnosis or alleviate symptoms, and they had extensive medical histories. Asher also noted these patients had all traveled and/or moved a great deal. In recognition of his travels and propensity for fabrication, Asher named this syndrome after Baron von Münchhausen, or “Munchausen’s Syndrome” (having anglicized the spelling).

In 1977, English pediatrician Roy Meadow published a report of a new type of child abuse, in which mothers consciously invented stories of illness in their children that they frequently substantiated by inducing physical symptoms (Meadows, 1977). Carrying the parallel with Münchhausen even further, Meadow labeled this destructive dynamic “Munchausen Syndrome by Proxy” (MSbP). He asserted that mothers suffering from MSbP were willfully hurting and sometimes even killing their children, claiming that “one sudden infant death is a tragedy, two is suspicious, and three is murder, until proved otherwise” (Meadow, 1997). This posit became known as “Meadow’s Law” and for a time, became the “rule of thumb” for British child protection agencies.

In more recent years, a focused presentation of MSbP—referred to as the contemporary-type of MSbP—has become increasingly common. Although all MSbP involves child maltreatment, in contemporary-type MSbP, the caretaker asserts the child has been subjected to physical, sexual, or emotional abuse, to neglect, or to any combination of such.

By Any Other Name
Since Asher’s coining of the term “Munchausen’s Syndrome,” there has been decades of debate over the appropriateness of the term. Some felt the label was not scientific or serious enough. Others believed the term ridiculed those patients suffering from the syndrome, not to mention the Baron himself. Over the years, “Munchausen’s Syndrome” has been renamed many times, referred to as “pathomimia,” “peregrinating problem patients,” “ipsepathogenic patients,” “nosocomotropism,” “hospital addiction,” “hospital hobo,” and “Van Gogh Syndrome,” to name a few.

Asher’s “Munchausen’s Syndrome” essentially led to the formal diagnostic category of “Factitious Disorders” (FD). According to the Diagnostic and Statistical Manual of Mental Illness, Fourth Edition, Text Revision (DSM-IV-TR), FD involves the intentional feigning or production of physical and/or psychological symptoms (as opposed to the unconscious process in somatoform disorders) (APA, 2000). To meet the diagnostic criteria, the purpose of FD must be to fulfill a psychological need to assume the patient role, rather than to achieve an external gain (as with malingering). Within the DSM-IV-TR classification system, “Munchausen’s Syndrome” represents the most severe and chronic form of the category of factitious disorders with predominantly physical symptoms. Despite being a subtype of FD, the term “Munchausen’s Syndrome” tends to be used interchangeably with “Factitious Disorder.”

As with “Munchausen’s Syndrome,” Meadow’s term “Munchausen Syndrome by Proxy” has also been referred to by several different names. In a slight variation, the syndrome has been called “Munchausen by Proxy” and, for a time, it was known as “Polle Syndrome” after Münchhausen’s son. In light of the speculation regarding the very existence of Polle, the term “Polle Syndrome” is no longer used. Most recently, in 2002, the American Professional Society on the Abuse of Children suggested using the term “Pediatric Condition Falsification” for the syndrome (Ayoub et al., 1998). MSbP was not mentioned in the DSM until 1994 (in the DSM-IV) when it was suggested that the problem be studied further for possible future inclusion as a diagnostic category (APA, 1994).

A Syndrome of Abuse
Although MSbP is not a diagnosis, per se, it is a recognized and reportable form of child abuse or maltreatment that is identified by the perpetrator’s behavior (Stirling, 2007; Ludwig, 2006; Berkowitz, 2004; Meadow, 1977).  Offenders often go undetected not because of the cleverness of their deception, but because the perpetrator’s behavior is so heinous, surrealistic, and incongruent with their presentation. While health-care workers are trained to be objective and observant, most would not automatically suspect that a “caring” and “normal” caretaker could be so calculatedly cruel to a child.

In an attempt to dispel doubt and disbelief about MSbP, English pediatrician David Southall literally documented the bizarre syndrome. Southall hid video cameras in the hospital rooms of 39 children whose medical presentation suggested the possibility of MSbP (Southall et al., 1997). Of those 39 mothers, 34 were recorded poisoning, smothering, or harming their child in some other way. Five of those mothers later admitted to having murdered one of their children.

Although MSbP can be varied and complex in its presentation, it is always characterized by an adult caretaker (usually a mother) deliberately exaggerating, fabricating, and/or inducing symptoms in someone under their care (typically a child). The mother creates a multidimensional scenario that might include providing a fabricated or exaggerated report of her child’s history and current “problems,” which she, in fact, inflicted. For example, she might have given her child any number or combination of poisons (including excessive amounts of salt or pepper) to create a range of physical signs and symptoms. She might have simulated or created rashes on any part of her child’s body by repeatedly pricking his or her skin, rubbing the skin with some caustic agent or material, or even by applying dye to mottle the skin’s appearance.

In other cases or at other times, a mother with MSbP might falsely report that her child is having seizures, or she may actually induce seizures by suffocation or excessive pressure on the carotid artery. She might alter laboratory specimens by, for example, returning a urine sample into which she has introduced her own blood. If her child has a legitimate immediate or chronic illness, the mother might exacerbate the symptoms or condition by feeding her child something to which he or she is allergic, for example. While hospitalized or at home, the mother may introduce a poison or contaminated fluid into her child’s intravenous line. It is important to note that it is not uncommon for a mother with MSbP to change her methods over time, as the possibilities for creating a “sick” child are limited only by her knowledge, experience, and imagination.

The frequency with which an adult with MSbP induces symptoms in a child and/or subjects the child to unnecessary medical procedures varies. It may occur as a single event or as intermittent episodes triggered by an external stress (or stressors), such as a pending divorce. At the other extreme, MSbP may become an ongoing way of life that may transfer from one child to another.

Motivation to Harm
While Baron von Münchhausen’s motivation to fabricate adventures was apparently to entertain and impress listeners, persons with MSbP are motivated by a range of drives and desires (Rogers, 2004). Most simply, as the term implies, MSbP allows the perpetrator to assume the “sick role”—by proxy. However MSbP is clearly more than a vicarious experience of illness. The perpetrator gains some form of internal gratification, such as attention and sympathy for having a “sick” child, or admiration and respect for being a committed and emotionally strong parent/caretaker. The motivation for consciously inflicting pain on a child can range from what can best be described as an addiction to the world of health care, to the desire to be seen as a “saint” and “savior.”

MSbP behavior may be further motivated by more temporal or situational needs and desires. For example, a sick child might improve family relationships, allowing the members to rally together on behalf of the child. In a similar vein, being a “good mother” to an ill child might quash a husband’s criticism and demands. Being not just a mother but also a “caretaker” to a sick child serves to increase the child’s dependency. That very connection can also serve to create distance between the child and father, even to the point of severing the relationship. An MSbP mother may use her child’s illness—and her caretaking skills—to her advantage during a divorce where custody is disputed. In the case of contemporary-type MSbP, the accusing parent may gain recognition for “protecting” the child; in the case of divorce, where the father is the accused offender, the fabrication may be sufficient for the mother to gain sole custody.

Despite the appearance of putting her child’s needs above her own, the singular focus of an MSbP mother on her own needs allows for a unique form of cruelty, and often lethality. To date, there are no profiles of MSbP offenders and victims. There are, however, certain recognized signs and characteristics, most of which are behavioral (Rogers, 2004; Sharif, 2004; Schreier, 2002; Meadow, 1997).

The Perpetrators of MSbP
MSbP almost always involves a biological mother whose behavior is that of a good, dedicated, confident parent/caretaker. She is extremely attentive to her child and seems always to be at her child’s side. While the amount of time she spends with her “sick” child may cause an observer to wonder if she might not be neglecting any other children, that thought is usually pushed aside because she appears to be such a “good” mother.

Perpetrators of this form of child abuse often encourage health care providers to perform many tests, even to the point of pushing. They seem to welcome invasive and painful procedures that non-MSbP would only agree to with some hesitation or reluctance. Mothers with MSbP tend not to show anxiety or fear when other parents might. If they express anxiety or concern, their words may not match their affect. In fact, medical personnel may demonstrate more concern for the child than does the mother.

Many mothers with MSbP have a background in health-care or an allied field, or they may possess medical knowledge beyond that of the average mother. They may approach health-care providers as a “peer” and initiate conversations with staff members about other patients’ medical problems. These mothers may be well liked by health-care professionals (especially nursing staff) as they are extremely helpful (lightening the employee’s workload), exceptionally appreciative, and show inordinate concern for their feelings and well-being.

Aside from being “too good” and seeming “off” in some unidentifiable way, perpetrators may have no evident mental health problems. In fact, they may produce assessment results that are entirely within the normal range. At the other extreme, there may be identifiable pathology, such as a personality disorder, paranoia, or sadistic impulses. (If the abusive behavior arises from psychosis or in the presence of delusions, the behavior may not be knowing, willful, or voluntary, and as such, would not qualify as MSbP.) Any dependency needs they may have are often masked by a presentation of confident capability. Their need for attention is not always directly evident, although some might be described as “drama magnets.” Central to the syndrome, mothers with MSbP are very accomplished liars, deceivers, and manipulators who can be remarkably convincing.

It is not uncommon for mothers with MSbP to fabricate a history of sexual abuse in her own past, and there may be striking similarities between her alleged abuse and that of her child. Despite having inflicted symptoms and illness in their children) for varying lengths of time (even years), very few of these mothers have prior involvement with child protection agencies. When perpetrators sense they are about to be “found out,” they generally do not stop the behavior. Rather, they may change their method or mode of maltreatment, or abruptly relocate with the child. In fact, these mothers are often the most dangerous when they believe they are about to be “caught.”
The Victims of MSbP
Demographically, the vast majority of victims of MSbP are children (equally male and female) under the age of 6 years (Schreier, 2002). Historically, they tend to have an atypical or unusual course of medical treatment, including many physicians from the same specialty. Victims of MSbP mothers generally have multi-systemic illnesses that are prolonged or rare, with symptoms that are baffling and incongruent. Oftentimes, there is no apparent “fit” between the child’s reported history and clinical presentation or findings. The child’s symptoms may be inconsistent with test results and may not respond as expected to treatment.

As mentioned above, rashes and seizures (especially those that do not respond to anticonvulsants and witnessed only by the mother) are common, specific symptoms with which victims of MSbP present. Other common signs and conditions include multiple allergies; bleeding with failure to clot; apnea (induced by suffocation); diarrhea and/or vomiting (induced by ipeacac or laxatives); blood in the stools or urine (introduced by the mother or resulting from injury to the rectum or urethra); sugar imbalance; depression of the central nervous system; infections from a range of often unusual organisms; and, in the case of contemporary-type MSbP, vaginal or rectal injuries that are inconsistent with the alleged abusive behavior. In fact, the range of fabricated and/or induced symptoms is endless and tends to shadow the advent of new medical and social services.

On the least abusive end of the spectrum, victims of MSbP may present with no symptoms, but with a factitious history supplied by the mother. At the other end of the continuum, victims may suffer recurrent life-threatening events (induced by the mother). Somewhere in the middle are those children who have a legitimate illness that is exacerbated at will by the mother (and which may become lethal).

A victim of MSbP may have symptoms that are only witnessed by his or her mother, or only occur/flare when she is present. Similarly, the symptoms may begin to improve or completely disappear when the victim and mother are separated. Hospitalized victims may show a sudden recurrence when discharge is discussed or planned, or may have a relapse very soon after returning home. Of note, the victim’s father may be completely absent during his child’s hospitalization. The victim may have one or more siblings who died of “sudden infant death syndrome” and/or relatives who have experienced unexplained illness.

The Consequences of MSbP
Victims of MSbP suffer a range of physical and emotional consequences, including a very fundamental betrayal of trust. Psychological consequences can include depression, anxiety, shame, and the development of phobias, to name just a few. Physically, victims of MSbP can suffer compromised immune systems, multiple scars, organ loss, induced chronic illness, and much more—including death.

Unfortunately, the risk of maltreatment to the child comes not only from the mother, but also from health-care professionals. Professionals can mistreat the MSbP victim severely, albeit unintentionally, by peril of failing to diagnose the syndrome in the mother. With their attention focused on the child, countless unnecessary and often painful tests (including exploratory surgery) are conducted in an effort to arrive at a diagnosis. The child is subjected to interventions, aimed at resolving symptoms, which can be damaging in themselves. In the case of the contemporary-type of MSbP, the mother may insist on a vaginal examination; if the child is very young, that can only be done under anesthesia. Older children may be subjected to repeated interviews, psychological evaluations, and legal proceedings.

If the child victim is often kept home due to “sickness” or hospitalized for frequent and prolonged periods, he or she may suffer delays in emotional, social, and/or educational development. If an older child is involved, he or she may have accommodated to the syndrome, “going along” with the mother’s behavior, and maintaining her secrecy. An older child may even take part in inducing or exacerbating symptoms (potentially developing “Munchausen’s Syndrome” or “Folie a Deux”). In an unknown number of cases, the victim is raised believing he or she is chronically ill (e.g.; told he or she is having seizures during sleep) or in some way disabled. In these situations, the child may remain with the perpetrator mother indefinitely, with the MSbP involving a mother and her adult child. As Meadow said, “Child abuse does not cease when the child reaches adult age, childhood ends when you lose your parents (Meadow, 1984).”

Evaluating for MSbP
Because of the physical nature of the symptoms, MSbP is most often diagnosed in medical settings. However because of the nature of underlying motivations for MSbP behavior, it often presents and can be exposed during the course of custody and/or child abuse investigations and evaluations. For example, in the context of custody evaluations the possibility of MSbP should be considered when the child has been alienated from the father for no apparent reason. With MSbP, the mother may seem to encourage/support the father-child relationship and the father may be a completely adequate caretaker, but the distance exists and persists nonetheless.

If allegations of sexual abuse arise in the context of a contested divorce, most jurisdictions allow for all parties (mother; child; accused father) to be evaluated by the same person. Having access to all parties and all records increases the likelihood that MSbP, if present, will be discovered. The adversarial nature of the legal system does not allow for a family evaluation or for the review of all available records for each party. As such, it is much more difficult to assess for the presence of MSbP in the context of criminal proceedings related to child sexual abuse. Regardless the veracity of the allegations, it is a tremendous disservice to the child not to rule out the possibility of MSbP being at work.

Despite the inability to access all parties during an evaluation in a criminal context, indicators of MSbP may still be evident. One such possible indicator is the addition of new allegations or the remembering of new details when the case becomes “stuck” or about to be dropped. This becomes increasingly significant when the mother of the alleged victim seems to be overly focused on “building a case” against the accused, the child is unwilling to be interviewed alone, and/or the mother demands to be present during the child’s interview/exam. As suggested above, MSbP might be suspected if the mother of the alleged victim accepts multiple interviews and examinations of the child without some hesitation.

Other possible indicators of MSbP might be found in the allegations themselves, such as inconsistencies between the described event(s) and physical findings. Similarly, in cases of MSbP, the mother (and/or child) may present allegations of acts that are bizarre, improbable, or factually inconsistent. The child may discuss the allegations with interviewers in a rote manner, as if reciting; on the other hand, the child may be over-eager to discuss the abuse. The mother with MSbP may seem to know more about what happened to the child than does the child him/herself. The mother may compare the child’s alleged abuse to that she allegedly suffered as a child. Most importantly, the child may deny the abuse, but only when the mother is not present.

When evaluating an alleged victim of child abuse, to facilitate ruling out MSbP, the evaluator should review all of the child’s medical and educational records. Details of the child’s history as provided by the mother should be collaborated by other sources. The alleged victim’s siblings can be an important source of information, not just when investigating allegations of sexual abuse, but also to assess for possible MSBP in the mother. Perhaps most telling of all is the mother who just seems too good to be true.

The Professional Aftermath
Roy Meadow was knighted for his efforts in preventing child abuse and provided expert testimony in several high-profile MSbP cases in England during the 1990s. Several of these cases were appealed in the early 2000s, resulting in Sir Meadow temporarily losing his license to practice medicine. In 2004, David Southall was temporarily banned from working with abused children after he apparently falsely accused a man of murdering his children. Although these disciplinary actions may well have been justified, clinical experience suggests that persons with MSbP can be very litigious.

Close to two years ago in California, the mother of a chronically ill child raised the suspicion of a custody evaluator. When the mother became aware her behavior was under question, the child suffered a sudden, severe worsening of her medical condition. Within days of being hospitalized, the child died of “unknown causes” shortly after a visit by the mother. Although there was no definitive evidence of the mother’s guilt, there was very convincing circumstantial evidence provided by a witness. No criminal charges were filed against the mother who lost custody of her other child. Despite being “exposed,” the mother went on to sue all of the parties she claimed were responsible for her child’s death. Immunity laws prevented her from suing the evaluator despite repeated attempts. The insurance company of another party chose to settle (for close to half a million dollars) rather than fight the case in court. Having moved out of state, she is reported to have recently given birth to another child.

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