Diagnostic Criteria for Munchausen Syndrome by Proxy
I wrote earlier that the Proxy Project submitted a book chapter called, “Patient-centered 
Medicine and Prevention of Munchausen Syndrome by Proxy” for consideration of publication in an upcoming book, “Patient Centered Medicine”. It was accepted, and should be coming out soon!
In one section of the chapter, I review the various diagnostic criteria proposed in the literature for MSbP over the years. I’m going to quickly summarize this information here for you.
Meadow’s Criteria in 1995
I’ve written extensively on Roy Meadow, the pediatrician who named MSbP. Even though Dr. Meadow first named MSbP in 1976, it wasn’t until 1995 that he proposed these diagnostic criteria:
- Illness in a child which is fabricated by a parent, or someone who is in loco parentis [acting in the role of a parent of a child],
- The child is presented for medical assessment and care, usually persistently, often resulting in multiple medical procedures,
- The perpetrator denies the aetiology of the child’s illness, and
- Acute symptoms and signs of illness cease when the child is separated from the perpetrator.
All of these criteria must be met for a positive diagnosis.
Rosenberg’s Criteria in 2003
In 2003, Rosenberg, who has a history of writing about child abuse, proposed this set of MSbP diagnostic criteria in a single-authored paper:
- Child has been repeatedly presented for medical care,
- Test/event is positive for tampering with child, or with child’s medical situation,
- Positivity of test/event is not credibly the result of test error or misinterpretation, nor of miscommunication or of specimen handling,
- No explanation for the positive test/event other than illness falsification is medically possible, and
- No findings credibly exclude illness falsification.
All of these criteria must be met for a positive diagnosis.
Current Diagnostic and Statistical Manual for Mental Disorders (DSM-V) Criteria
The DSM’s approach to MSbP diagnosis evolved over the years, but currently, they call the condition “factitious disorder imposed on another”, and list these criteria:
- Making up physical or psychological signs or symptoms or causing injury or disease in another person with the intention to deceive,
- Presenting another person to others as sick, injured or having problems functioning,
- Continuing with the deception, even without receiving any visible benefit or reward, and
- Behaviour is not better explained by another mental disorder.
Review of these Criteria
There are some problems with all these approaches. Unfortunately, all of these criteria are for identifying perpetrators, not victims. If victims are not given a diagnosis, they cannot be protected or get treatment. Hence, the clinical focus turns to the perpetrator, who is not the one in danger and may not be treatable. There is consequently a lack of information now about victims due to a lack of diagnosis. Victims also are not followed through time.
It seems illogical that there would be one diagnosis and one set of diagnostic criteria for a condition that, by definition, must involve more than one person playing different roles.
This lack of follow-up due to lack of victim diagnosis is probably a contributing factor to the high rate of dead siblings in victims that are identified. Also, it has probably been a contributing factor to the misclassification of MSbP murders as Sudden Infant Death Syndrome (SIDS) deaths.
Why “Diagnostic” Criteria?
We don’t have “diagnostic” criteria for aggravated assault. Why would we need diagnostic criteria for a crime that by definition involves at least two people? Why not have criteria the crime needs to meet to be called an MSbP crime?
What should the criteria be?
Here’s what I think they should be – read this post where I list the three strategies used by MSbP perpetrators. I think if someone is using all three strategies on their victims, we definitely have a case of MSbP on our hands.
Images from Senderos, Geralt (question marks), and Geralt (quality control emblem).
The Proxy Project 
F**** and A***, ADHD is bogus, and in the view of Sami Timimi, so is Autism Spectrum Disorder. So these things being bogus, they are not being caused by parents. They don’t even exit.
But there is what A**** called this “othering”. In other times I have compared it to being made into a leper, like in the Gospels. And then there is what I call Maternal Hatred Syndrome.
Read this, Jayne Lytel, a frightening woman who clearly finds her younger son Leo to be an embarrassment.
So as it stands today, a parent can take their child to a doctor and get them diagnosed and drugged. And if for some reason one doctor won’t do it, another will. And there are doctors who advertise this. And then there are some who will make the child more subservient without even needing drugs. What these all have in common is that they legitimate the parents.
So they used to call this Munchausen’s Syndrome By Proxy. But now they are just calling it Medical Child Abuse. Usually they mean situations where the parents are fabricating the child’s illness. But when you have doctors who market their services for treating such bogus illnesses, it gets more complicated.
What will stop this though is outside oversight, someone who is looking out for the rights of the child. Then the doctors will have to report, and the parents won’t be showing up at their door anymore.
Existing law makes it a felony to not report a suspected case of child abuse, its just that the laws have not really been enforced as written. Sure I wish this were not necessary, but it is, as finding ways to establish that the child has a defect, and using doctors to do this, is one of the hallmarks of the middle-class family.
We have to have outside oversight to protect children, otherwise it is all controlled by their parents, and by the doctors who market to them.
Nomadic
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I totally agree with ADHD being bogus. ADHD was used as an excuse to emotionally abuse me when I was a child. I went through many doctors and tests before my mother found a doctor to label me as the horrible person I was thought to be. Apparently ADHD means “rather chatty and quite anxious due to pressure at school” these days.
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I agree that attention problems are misdiagnosed. In adults, anxiety causes attention problems, so you have to cure those first to see if the adult actually still has attention problems. With kids, I think we do not know what “healthy attention” is. I’m sure there are kids with actual attention problems – we just don’t have any clue who they actually are.
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Well Monika, I think you’ve pointed out the problem, that these diagnostic criterion focus on the perpetrator. But to solve the problem you need to go just a bit further.
There really are two issues, and they must not be mixed up.
1. Protecting the child victim and doing everything possible to insure their future health and wellbeing.
2. Gaining evidence for criminal prosecution against a perpetrator.
And then getting mixed up in this and only causing problems is this DSM and the idea of Mental Illness.
But where you are clearly right is that the current situation is mixed up, but the real test is the separation test. This is how you protect the child. But in most cases this will not give you the kind of evidence needed to prosecute a perpetrator. In many cases you will not even get enough information to ever know what was really going on. But this is not important, as protecting the child is the paramount objective.
Back when Meadow named this as a mental illness, that was the only way he or anyone else could understand it. No one could imagine that a parent would deliberately inflict such harm, unless mentally ill. Hence you have this focus on the perpetrator, and it really causes confusion.
I think today we know better, that it is more often just using the child to give the parent importance, or some sort of a conflict with the child, or some problem the parent has with the child growing up.
In a middle-class society, people have children in order to enhance their social standing. And so weird relationships develop, and sometimes parents resort to driving the kid to the doctor. So long as they can keep hiring private doctors, they usually will get away with it. But lately, when they go to large hospitals which serve the general public, and where busy doctors cannot be bossed around, they get into trouble.
So the way I have looked at it is, there is Medical Munchausens, there is Developmental Disabilities and Neurological Difference Munchausens, there is Brain Chemical Imbalance and Psychiatric Munchausens, and then there is good old fashioned Delinquency and Salvation Status Munchausens. It is just any situation where the parent is invoking some kind of outside authority to make it like there is something wrong with the child. And every bit of it is child abuse.
And we are talking here only about situations driven by the parent. But then it gets more complicated as there are doctors who market themselves as a Fix My Kid Service, and who treat hoax ailments, like mental illnesses, ADHD, and Autism Spectrum Disorder. And then there are people who run Fix My Kid Camps and Salvation and Recovery Programs. Though not really medical, they still work in a similar way, invoking outside authority, to say that there is something wrong with the child.
And then there are parents who abuse their children and invoke these outside sorts of justifications, but without other people being involved. The father I helped put into our state prison was sexually molesting his daughters, and he was invoking all sorts of justifications, and he had the full backing of the members of his Pentecostal church. These outside people were never directly involved. But they did all seem to have scapegoat children of their own. And I made much of this in my communications to the court.
But if you want to restrict it to medical, then I say that the best way is the Medical Child Abuse model.
The current leaders, in Providence Rhode Island:
And then you aren’t worried about diagnosing any perpetrators. We don’t say that Jessie James suffered from Bank Robbing Disorder, we just say that he robbed banks.
So you protect the child victim, and then getting evidence to prosecute perpetrators is taken only if available. And remember that child protection can go into effect on the basis of “Clear And Convincing Evidence”, and that being decided by a judge. Whereas for a criminal conviction the standard is set much higher, “Proof Beyond A Reasonable Doubt”, and defendants are entitled to a jury trial, and these sorts of things can go on for years.
In protecting children, Child Protection Pediatricians are looking for diagnoses which can be manipulated. And there are some types of illnesses which are this way. And there are also doctors who want to give these flimsy diagnoses, and often there never is any real truth to come out.
But I say, if the parents care, they will cooperate and admit that they don’t necessarily know what is going on, and that the protection of the child is what is most important. And psychological family conflicts can be fatal.
CPS is legally obligated to make every reasonable effort to keep families together, and most of the time when children are removed it is only temporary. Usually it only gets really ugly when the parents insist on acting like the child is their property.
And also, medical and legal authorities must maintain confidentiality, so they rarely ever get to tell their side of the story. Whereas Child Protection laws are some of the most politically charged that we have ever had. And reactionary political and religious forces have been attacking them for decades now, because they don’t accept the premises, and there are no restrictions on what they can say.
Nomadic
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Hi Nomadic,
I hope you are well. You make some great points. One thing that we found in the literature is that MSbP parents manipulate CPS – like they file fact Child Protection accusations against teachers and other adults for their child victims.
HIPAA allows for disclosure of health information as part of abuse investigations. The problem is getting the investigations going, and the next problem is getting ALL the health information. If the healthcare system protects itself, it doesn’t turn over all its information. You have a strong belief there is nothing fishy about the Pelletier case, and if that’s so, why is all the information we need to diagnose MSbP missing? After all, Dr. Newton has this info, and she’s the one filing CPS. Again, provider-type behavior.
If we ever get universal healthcare, this will all change. Look at the UK – they are world leaders in addressing MSbP. We’ll have to wait and see!
-Monika
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