Munchausen by Proxy (MBP),
a.k.a. Factitious Disorder by Proxy, Munchausen by Proxy Syndrome, and Munchausen Syndrome by Proxy

The following is the text from an "invited editorial" that appeared in the April, 2003, issue of
"CHILD ABUSE AND NEGLECT: The International Journal."

MBP Maltreatment: An International Educational Challenge
By Louisa J. Lasher, M.A.

Munchausen by Proxy (MBP) is a label for a pattern of behavior that constitutes a specific and unique kind of maltreatment. Children or adults may be victims, and MBP maltreatment almost always manifests as a combination of physical abuse, emotional abuse, and neglect. It can also manifest as sexual abuse. It is clear that this pattern of behavior was perpetrated in past generations, but MBP was identified as a kind of maltreatment only about twenty-five years ago. Thus, the MBP field is comparatively new and, as is true in other areas of maltreatment, new perspectives continue to emerge. I chaired the first known meeting of national MBP experts in 1995 in Atlanta, Georgia, and I was privileged to participate in the first international meeting of experts in 1998 in Stockholm, Sweden. Since I first became involved with MBP many years ago, I have been officially involved in over 400 suspected or confirmed cases of MBP and informally involved with hundreds of others. I have provided MBP education, case consultation, technical assistance, and expert witness services throughout the United States and internationally. Based on my personal experiences alone, I have no doubt that serious mistakes are frequently being made throughout the processes of reporting and receiving reports regarding suspicion of MBP maltreatment, investigation and confirmation- disconfirmation, court preparation and presentation, case planning, and case management - resulting in genuine MBP cases not being identified, others incorrectly confirmed, and confirmed MBP cases being managed inappropriately. These mistakes are frequently disastrous to the involved children and families.

MBP is no longer considered rare by most leading MBP professionals but, rather, under-identified due to lack of public awareness and professional expertise. A wide range of professionals across the multiagency-multidisciplinary community have the potential of being in a position to suspect and report suspicions of MBP and to become involved in suspected or confirmed cases. Non professionals, including family members, may voice suspicions to the local child protection agency, to their attorney, or to others. If victims are to be identified and protected, there must be general public and professional awareness that MBP maltreatment exists and when to suspect it. Working appropriately with suspected or confirmed cases, regardless of role or discipline, requires specialized knowledge and skills. Most professionals, including many who are highly regarded within their own fields and specialties, know little about MBP, have misconceptions about it, and lack the knowledge and experience to undertake case involvement.

In order for MBP to be confirmed correctly, there must be:

1. Proof, through direct and/or circumstantial evidence (usually strong circumstantial evidence) that the suspected perpetrator has deliberately exaggerated and/or fabricated and/or induced a physical and/or psychological-behavioral-mental health problem in another. (Exaggerate: The perpetrator deliberately embellishes a genuine problem; Fabricate: The perpetrator deliberately makes up a problem story - or makes it look as if a problem exists; Induce: The perpetrator deliberately causes a problem to exist). Until the MBP confirmation-disconfirmation process is completed, I call this behavior (deliberate "problem" exaggeration, fabrication, induction - or a combination) "MBP- like behavior".

2. Rationale that the "MBP-like behavior" is consistent with MBP maltreatment, rather than something else. Deliberate exaggeration, fabrication, or induction of "problems" may or may not qualify as MBP perpetration. In order to make the determination, specialized knowledge and skills are necessary in completing a thorough confirmation- disconfirmation process.

If MBP is confirmed, it is extremely important (particularly in child protection or divorce-custody cases) to apply the MBP label and to obtain an MBP finding of fact in court. Otherwise, it is likely to be very difficult to justify the unique kind of case plan and case management necessary to provide the victim with short and long term protection and to provide the perpetrator and family with a fair, measurable chance of safe reunification.

Among other activities, the confirmation-disconfirmation process requires the gathering of written information not usually necessary in other kinds of maltreatment cases, the ability to conduct specialized interviews, the skill to identify "falsehoods masquerading as truth" - regarding the suspected victim(s) as well as throughout the life of the suspected perpetrator(s), and the ability to identify and organize relevant information. As mentioned earlier, the process also requires the knowledge and experience necessary to determine whether MBP maltreatment is or is not involved.

When I think back about MBP cases with which I have been involved, I often think of the teenager who had lived her life as a dying child because of deliberate falsification activities by her mother from the time she was an infant; the seven year old child with a colostomy bag whose grandmother prayed with him and their minister to accept imminent death due to nonexistent celiac disease she had fabricated; and the two little ones whose graves I visited after a young woman induced severe breathing problems with regard to her own child, as well as children for whom she babysat. These are not rare examples, and all could have been avoided had involved professionals had and acted upon basic education regarding MBP.

Correct, skills-based education is the foundation of working appropriately with suspected and confirmed cases. Throughout the world, efforts must be made to convince those who have decision-making power that MBP maltreatment is real, that it is not rare, that it should be included in legal statutes as a separate kind of abuse/neglect, that polices and procedures relevant to MBP must be revised, and that comprehensive professional training must be offered. I challenge the readers of this editorial to become part of this effort.

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