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Munchausen Syndrome By Proxy (MSBP) is a rare behavioral disorder affecting a child’s primary caregiver that leads to child abuse from illness falsification. It is also referred to as Factitious Disorder Imposed on Another (FDIA), Medical Child Abuse, or Pediatric Condition Falsification.1-6


First reported in 1977,7 it is thought to occur when the abuser’s, usually the mother, psychological needs take precedence over the needs of the child, causing harm to the child.2 The need to be perceived as smart, caring, selfless and in control, is associated with needing care and attention.5

Epidemiology including risk factors and primary prevention

97.6% of abusers are female, 95.6% are the victim’s mother, with 75.8% being married. Mean age of the caretaker is 27.6 yrs.3 Incidence according to AAP is 0.5-2.0/100,000 children <16 years.5

In one study of 47 mothers, 72% had a history of somatic symptom disorder, 21% substance abuse, 55% self-destructive behaviors, 89% personality disorders. Death rate is thought to be 6-10%.8 There is a high rate of recurrence, up to 77% in one study.6

Risk factors

  • Female (often the victim’s mother)
  • Childhood abuse
  • History of Munchausen syndrome
  • Personality disorder
  • Lack of support/disengagement from other parent
  • Often well-educated
  • Rarely leave the bedside of child/victim
  • Develops close relationships with hospital staff


The abuser is usually a member of a healthcare related profession (45.6%), may have a history of being maltreated themselves in childhood (30%). The abuser is usually the mother, predominantly female, and may have a coexistent personality disorder (borderline, histrionic, sociopathic, or mixed).5 They have a poor intellectual and emotional relationship with their spouse.7

Children may present with genuine symptoms or conditions of the disorder which may be exacerbated by the abuser, or they may present with fabrication of disorder.  In one study, nearly one third of children had an underlying medical illness.6 The abuser is usually a member of a healthcare related profession (45.6%) and may have a history of being maltreated themselves in childhood (30%).3

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Various types of falsification may be seen. They could include providing false information or withholding it, exaggeration, simulation, neglect, induction, or coaching.5 The deceptions are usually conscious and are carefully planned out. For instance, exogenous insulin may be used to cause hypoglycemia.4

Specific secondary or associated conditions and complications

SystemPossible symptoms 9
MusculoskeletalLimping, broken bones, muscles weakness
NervousSeizures, headaches
RespiratorySleep apnea, respiratory distress, asthma, hypoxia
DigestiveNausea/Vomiting, abdominal pain, diarrhea, weight loss, disorders needing parenteral nutrition
UrinaryUrinary Tract Infections11
IntegumentaryRash, Ecchymosis, Wounds

Complications include- blindness, altered gastrointestinal function, brain damage, hearing loss, scarring, organ removal, surgical alterations of anatomy, gait abnormality (limping), and death.5

Essentials of Assessment


Mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder are at heightened risk for Medical Child Abuse (MCA).3

Piecing together inconsistencies among history, examination, and clinical presentation is key.13

Diagnosis is often not considered in early presentation of symptoms.13 It may be difficult to differentiate between fabricated and genuine illness, especially since they can coexist, and abusers may exploit the genuine illness of the child.6

 Warning Signs5,14

  • Symptoms and behaviors incongruent with observations
  • Discrepancy between abuser reports and medical records
  • Extensive medical assessments without identification of medical explanation
  • Unexplained worsening of symptoms/new symptoms in the presence of caregiver
  • Other individuals in the home have had unusual or unexplained illness or medical conditions
  • Animals in the home have had unexplained illness or medical conditions, may be similar to the child’s presentation
  • Medical conditions may improve in one child and present in another child
  • Caregiver is reluctant to provide medical records
  • Caregiver/parent reports the other parent is not involved, does not wish to be involved, and may not be contacted
  • A parent, child, or family member expresses concern about possible falsification of medical care or increased medical care involvement of the healthcare system
  • Observations of clear falsification by the caregiver: inaccuracies of previous instances, tests, exam results, or diagnoses
  • History of Direct Harm (Poisoning, Suffocation)14
    • Children’s urine may be altered with glucose acetone for apparent diabetes diagnosis7
    • Children may be poisoned with phenothiazine for presentation as a seizure disorder7
    • Actual disease may be caused by apparent disease: placement of blood in an infant mouth by parents who present with bleeding concerns that results in apneic episodes from airway obstruction7
    • Injecting oral or fecal excretions into a child mimics an immunodeficiency7
  • Overexposure to clinical interventions14
  • Limiting Appropriate School/Social & Developmental Opportunities causing development of a distorted view of a child’s own health and abilities14

Physical examination

Important factors5,14

  • Incongruency in history, examination, and clinical presentation
  • Extensive medical assessment without identification of medical explanation
  • Unexplained worsening of symptoms/new symptoms in presence of caregiver
  • Animals or others in the home have unusual or unexplained illness
  • Reluctance on the part of the caregiver to provide medical records
  • Caregiver/parent reports another parent is not involved, does not wish to be involved, and may not be contacted
  • A parent, child, or family member expresses concern about possible falsification of medical care or increased medical care involvement of the healthcare system
  • Observations of clear falsification by the caregiver: inaccuracies of previous instances, tests, exam results, or diagnoses

Clinical functional assessment: mobility, self-care cognition/behavior/affective state

Exam focused questions should be directed to children, while watching for parental influence at time of question.

Comprehensive Neurologic and Musculoskeletal Exam (Gait Analysis), Dermatologic Exam is very important.

When a child is separated from the caregiver, symptoms improve or resolve.14

Laboratory studies

Laboratory studies are not recommended and are clinically difficult to identify the contaminants, medicines or chemicals expected to be present.14


Unnecessary imaging should be avoided as this perpetuates and delays the diagnosis. There are no imaging recommendations.

Supplemental assessment tools

Video surveillance is useful in documenting caregiver attempts at illness induction, simulation or to document absence of falsely reported symptoms. Although provider opinions are divided, covert video surveillance in hospitals can serve as an assistant assessment tool when proper protocols are put in place.15

Common characteristics of perpetrators of Munchausen syndrome by proxy16

  • Female (often the victim’s mother), especially those with depression, substance abuse, self-harm, or other mental illnesses15
  • Childhood abuse
  • History of Munchausen syndrome
  • Personality disorder
  • Lack of support/disengagement from other parent
  • Often well-educated
  • Rarely leave the bedside of child/victim
  • Develops close relationship with hospital staff

Early prediction of outcomes

Children who survive can have severe psychological damage with highly disturbed attachments with others. Emotional problems are reported in survivors, including but not limited to anorexia, trouble sustaining relationships, suicidal ideation, rage towards family members, feeling of anxiety, and depression.14


It is important to be cognizant of family dynamics while caring for the patients. The environment in which the child is part of and is being returned to should be investigated thoroughly once the diagnosis has been made. Recommendations usually focus on removing the child from the harmful environment.

Social role and social support system

The abuser may not have a social support system and may not have any confidants. They may be socially isolated or be part of the care team manipulating and helping the treatment plan.

Professional issues

Healthcare providers should be cautious while evaluating and ordering tests, particularly in children who have had repeated admissions. Awareness of the criteria for MBSP/FDIA should be part of the training to prevent delayed identification.

It is important to document details, including names of clinicians involved in care, education provided, episodes of nonadherence to care, request for specific interventions, unexplained equipment malfunction or suspected tampering.5

 Obstacles to Treatment7

  • Tendency by physicians to focus on unnecessary test, hospitalizations, and treatment
  • Not appreciating the extent to which the child’s life may be at risk
  • Follow up care may not be attended, as child and abuser may seek hospitalization in another facility
  • Many victims have genuine medical problems or iatrogenic medical conditions that require medical attention and treatment.17

Rehabilitation Management and Treatments

Available or current treatment guidelines

Rehabilitation management of MSBP is often seen as a multidisciplinary approach involving medical and non-medical professionals such as hospital and non-hospital agencies, school system, child protection services (CPS), and non-traditional sources (social media)13

The Treatment Team should include the following: Pediatric Psychiatrist, Pediatric Physiatrist, Pediatricians, Physicians (involved in initial diagnosis), Attorneys, Child Protection Services, Mental Health Professionals7

Recommendations of the Psychiatric Community and MSBP Task Force 5

  • Gather all medical records from past and present medical professionals
  • Make contact and regularly communicate with both parents and caregivers
    • Provide caregivers with ongoing education and feedback about observations and recommendations
    • Ask all caregivers to repeat back information provided
    • Carefully document all education and other discussions with caregivers
  • Collect information from school and independent observers who are regularly involved in the child’s life
  • Review suspected abuser’s online social media activity
  • Devise evaluation and rehabilitation plans that challenge claims made by abuser or victim
    • Remember all descriptions of symptoms and disability made by family members may not be accurate in description
    • Family members cannot be relied upon to prepare children for diagnostic assessments and treatments
  • Meet with other physicians and clinical staff involved in the care of children to compare information and coordinate a shared plan
  • Alert other physicians about the poor reliability of symptoms from suspected abuser
  • Report child abuse and neglect to authorities5

At different disease stages

Multidisciplinary treatment model for each stage

  • Active involvement with Psychiatry during treatment
  • Acute: Remove offending individuals or modality if able; limit adaptive equipment. Initiate psychological assistance for abuser and victim. Begin structured objective treatment modalities on a scheduled basis: Outpatient Physical, Occupational, Speech Therapy (2-3 times per week with objective measurements documented). This may include grip strength, muscle strength testing, treadmill testing.
    • After outpatient duration, may admit to inpatient rehabilitation for recording/monitoring progress (change of environment, predictable team) Multi-disciplinary therapies as above

Coordination of care

Coordination of care between primary care providers and other specialties is key to not continue the cycle of abuse and endanger the child. Health care providers have to be cautious while confronting the abuser so as to not antagonize them.

Patient & family education

Victim and abuser education center on child therapy, abuser therapy, family therapy, and eventually re-unification of family as warranted.

Measurement of Treatment Outcomes including those that are impairment-based, activity participation-based and environmentally-based

There has been limited research done on the outcomes of treatment options, including those that are impairment, activity or environmentally-based participation. One study has shown that family reunification was possible after psychiatric intervention in certain cases with the caveat that long-term follow-up would still be needed in order to ensure the safety of the child. In this study, outcomes for children who were reunified with their caregiver compared well to untreated cases.18 Translation into Practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

FDIA red flags – the perpetrator19

  • Observations and investigation are inconsistent with the caregiver’s report on the condition of the child
  • Vague and inconsistent details about child’s medical history
  • Repeated presentations at medical settings often with new symptoms 20
  • Invasive diagnostic and surgery procedures are accepted without concern
  • The perpetrator shows medical knowledge
  • Requests are made for further interventions, procedures and second opinions.
  • Attention and approval of medical staff are sought
  • Several medical appointments are missed
  • Previous history of psychiatric disorder
  • No relationships, family, and marital problems

 FDIA red flags – the victim19

  • Atypical presentation of disorder
  • Tests and observations are normal
  • Medical problems don’t respond to treatment
  • Symptoms and signs occur only in the caregiver’s presence and disappear in his/her absence
  • Multiple hospitalizations and surgeries
  • Presence of multiple medical illness (e.g., mental disorder, microcephaly)
  • Occurrence of complications or of new pathology when the findings prove negative
  • Unexplained impairment of child’s daily life, including but not limited to decreased school attendance and social isolation20
  • Father is absent or not present in the life of the child

Cutting Edge/Emerging and Unique Concepts and Practice

According to DSM 5, the following criteria must be met in order to make the diagnosis of FDIA19

  • The Perpetrator engages in the deceptive falsification of physical or psychological signs or symptoms, or of induction of injury or disease in another;
  • The Perpetrator presents the victim to other as ill, impaired or injured;
  • The deceptive behavior is present also in absence of external incentives (e.g., in the case of malingering);
  • The behavior is not better accounted for by another mental disorder (e.g., psychotic or delusional disorder).

Gaps in the Evidence-Based Knowledge

Diagnosis rests on accurate history and being vigilant about the possibility of the diagnosis. There is limited data on outcomes and factors leading up to the condition. While it is expected that survivors of the abuse will have psychological and emotional problems, ongoing research is needed to identify and create treatment plans and guidelines in the care of this population and to determine the efficacy of these treatment options.


  1. Diagnostic and Statistical Manual of Mental Disorders (DSM 5). American Psychiatric Press. May 2013.
  2. Tozzo P, Picozzi M, Caenazzo L. Munchausen Syndrome by Proxy: balancing ethical and clinical challenges for healthcare professionals Ethical consideration in factitious disorders. Clin Ter. 2018 May-Jun;169(3):e129-e134. doi: 10.7417/T.2018.2067. PMID: 29938745.
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  5. Author: APSAC Task Force Title: Munchausen by Proxy: Clinical and Case Management Guidance Publication Date: 2017 Publisher: The American Professional Society on the Abuse of Children (APSAC) Retrieved from: https://www.apsac.org/guidelines
  6. Abdurrachid N, and Gama Marques J (2022). Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA). CNS Spectrums 27(1), 16–26. https://doi.org/10.1017/S1092852920001741
  7. Waller, David A. Case Report: Obstacles to the Treatment of Munchausen by Proxy Syndrome. Journal of the American Academy of Child Psychiatry, 22, 1:80-85, 1983.
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  11. Bertulli C, Cochat P. Munchausen syndrome by proxy and pediatric nephrology. Nephrol Ther. 2017 Nov;13(6):482-484. doi: 10.1016/j.nephro.2016.12.006. Epub 2017 Jun 9. PMID: 28606407.
  12. Boyd AS, Ritchie C, Likhari S. Munchausen syndrome and Munchausen syndrome by proxy in dermatology. J Am Acad Dermatol. 2014 Aug;71(2):376-81. doi: 10.1016/j.jaad.2013.12.028. Epub 2014 Mar 6. PMID: 24613506.
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  15. ZARANKIEWICZ, Natalia, ZIELIŃSKA, Martyna, KOSZ, Katarzyna, KUCHNICKA, Aleksandra, SIEDLECKI, Wojciech, KSIĄŻEK, Katarzyna and MOJSYM-KORYBSKA, Sylwia. The art of cheating medical staff- Munchausen Syndrome by Proxy. Journal of Education, Health and Sport. Online. 2 August 2019. Vol. 9, no. 7, pp. 766-774. [Accessed 18 March 2024].
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  19. Faedda N, Baglioni V, Natalucci G, Ardizzone I, Camuffo M, Cerutti R and Guidetti V (2018) Don’t Judge a Book by Its Cover: Factitious Disorder Imposed on Children-Report on 2 Cases. Front. Pediatr. 6:110
  20. Danya Glaser, Fabricated or induced illness: From “Munchausen by proxy” to child and family-oriented action, Child Abuse & Neglect, Volume 108, 2020, 104649, ISSN 0145-2134, https://doi.org/10.1016/j.chiabu.2020.104649.   

Original Version of the Topic

Cristina Marie Sanders, DO, MS, Rajashree Srinivasan, MD. Munchausen Syndrome By Proxy. 6/8/2021

Author Disclosures

Cristina Marie Sanders, DO, MS
Nothing to Disclose

Rajashree Srinivasan, MBBS
Nothing to Disclose

Varshini Suresh, BS, MBA
Nothing to Disclose

Kristin Bristow, MD
Nothing to Disclose