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Munchausen syndrome by proxy (MSBP), first described by
Meadow in 1977, is child abuse perpetrated by an adult care-
giver through fabrication of illness in a child presenting to the
medical profession.1Rosenberg described four central features:
(i) illness in a child that is simulated (faked) and/or produced
by a parent or someone who is in loco parentis; (ii) presenta-
tion of the child for medical assessment and care, usually per-
sistently, often resulting in multiple medical procedures; (iii)
denial of knowledge by the perpetrator of the aetiology of the
child’s illness; and (iv) acute symptoms and signs in the child
that abate when the child is separated from the perpetrator.2
However, there is debate over what constitutes this form of
child abuse. There is lack of specificity using Rosenberg’s
criteria and an overlap with a range of other child abuse
syndromes – non-accidental suffocation, non-accidental poison-
ing, non-organic failure to thrive and physical or sexual abuse.3,4
Cases classically involve overt fabrication of symptoms and
signs but there is a continuum of severity from exaggeration of
existing symptoms through to physical harm to the child, e.g.
poisoning or suffocation. The Diagnostic and Statistical
Manual of Mental Disorders (DSM IV) attempts to delineate
this form of child abuse by proposing a definition that includes;
‘motivation for the perpetrators behaviour is to assume the sick
role by proxy’.5There are inherent problems in using motiva-
tion as a criterion for MSBP. It is difficult to differentiate what
constitutes an ‘appropriate’ parental response to a child’s phys-
ical condition from the ‘inappropriate’ where the caregiver is
actively procuring or exaggerating symptoms or signs so to be
seen by the medical profession for their own needs6(Fig. 1).
Despite these reservations, McClure et al. identified repeated
presentations of an infant or child with a disability or illness
fabricated by a caregiver to the medical profession for the
benefit of that caregiver as central to the delineation of MSBP
child abuse.7
Munchausen syndrome by proxy has been described as a
rare condition. In the only prospective study reported to date,
McClure et al. reported a combined annual incidence for the
United Kingdom and Republic of Ireland of MSBP, non-
accidental poisoning, and non-accidental suffocation in chil-
dren under 16 years as at least 0.5/100 000.7Excluding cases
of non-accidental poisoning and non-accidental suffocation
not presenting as MSBP, they found an annual incidence of
0.4/100 000. More recently there has been increasing
awareness and recognition of this syndrome of child abuse and
there is a possibility that it is more common than reported by
McLure et al.7The aims of this study were to: (1) report
J. Paediatr. Child Health (2001) 37, 240–243
Epidemiology of Munchausen syndrome by proxy
in New Zealand
SJ DENNY, CC GRANT and R PINNOCK
Department of General Paediatrics, Starship Children’s Hospital, Auckland, New Zealand
Objective: To determine the epidemiology of Munchausen syndrome by proxy (MSBP) in New Zealand and describe the
effects of this condition on children and their paediatricians.
Methodology: A mail-out survey was sent to all paediatricians in New Zealand in 1999. Paediatricians were asked to
identify all cases of MSBP, non-accidental poisoning or non-accidental suffocation diagnosed or suspected in children less
than 16 years of age that had been seen in the past 12 months. Those paediatricians who identified a case were then inter-
viewed by telephone to ensure that identified cases were new cases and that they were unique.
Results: Responses were obtained from 148 (95%) of 156 practising paediatricians in New Zealand. Eighteen unique
cases of MSBP were identified where the diagnosis had been made in the preceding 12 months. The incidence rate for
MSBP in children aged less than 16 years was 2.0/100 000 children. Eleven (61%) of the 18 cases were referred to child
protection agencies or the police. The mean time taken to diagnosis from initial presentation was 7 months in the cases
referred to child protection agencies and 23 months in cases not referred. The median age at diagnosis was 2.7 years. The
mother was the suspected perpetrator in all cases. Most children (72%) presented with multiple symptoms. Over half (55%)
had an underlying chronic illness. The morbidity for the child in the majority of cases was not severe, and in nine (50%)
cases it was noted that following diagnosis there was improvement or resolution of symptoms. Ten (56%) of the 18 paedia-
tricians involved with cases reported experiencing considerable stress.
Conclusions: The annual incidence in New Zealand of MSBP in children under 16 years is higher than that reported from
other countries. Chronic illness is often associated with this condition. The morbidity for the majority of children was not
severe and often improved with diagnosis. Paediatricians reported stress and difficulty in association with caring for children
with this syndrome of child abuse.
Key words: asphyxia; child abuse; Munchausen syndrome by proxy; poisoning.
Correspondence: Dr SJ Denny, University of Minnesota, Suite 260 McNamara Center, 200 Oak Street SE, Minnesota, MN 55455, USA.
Fax: (61 2) 626 2134; email: denn0117@umn.edu
Accepted for publication 24 October 2000.
the incidence of MSBP, non-accidental poisoning, and non-
accidental suffocation, for the population of New Zealand’s
children under the age of 16 years and (2) describe the epi-
demiology of this syndrome within this population.
METHODS
A mail-out survey to all paediatricians in New Zealand was
conducted from May to August 1999. Paediatricians were iden-
tified from the Paediatric Society of New Zealand and the New
Zealand Medical Council. The case definition for MSBP used
was where ‘an infant or a child is presented to doctors, often
repeatedly, with a disability or illness fabricated by an adult,
for the benefit of that adult’.7Paediatricians were also asked
to identify all cases of non-accidental suffocation and non-
accidental poisoning. Approval for the study was obtained from
the Auckland Ethics Committee.
Paediatricians were asked to identify all cases in children
aged less than 16 years, seen in the past 12 months, that had
been referred to child protection agencies or the police. They
were also asked to identify all cases seen in the last 12 months
where they were highly suspicious of the diagnosis of MSBP,
including non-accidental suffocation and non-accidental poison-
ing but had not made a referral. Those paediatricians who
identified a case were asked further information including
demographic information about the child, nature of abuse,
degree of abuse and outcome for the child and paediatrician.
A four-point scale was used to categorize the degree of
parental/caregiver fabrication: (i) most severe – physical harm
to the child (i.e. suffocation presenting as recurrent apnoea);
(ii) severe – active procurement of symptoms (i.e. manufac-
turing false test results); (iii) moderate severity – invention of
history (i.e. fabricating non-existent symptoms); and (iv) least
severe – exaggeration of existing symptoms only.
A 10-point scale adapted from the DSM IV global func-
tioning axis5was used to rate the resulting child morbidity
from the abuse (Table 1). Information was sought that des-
cribed the nature of abuse, the outcome for the child and the
consequences for the paediatrician.
A follow up telephone interview was completed with all
paediatricians identifying cases. This confirmed that cases
had been identified in the preceding 12 months and that they
had not been reported by another paediatrician.
RESULTS
Responses were obtained from 148 (95%) of 156 practising
paediatricians in New Zealand. Forty-seven cases were identi-
fied by 32 paediatricians. Twenty-six of these cases were
excluded as they had not been diagnosed in the past 12 months.
The remaining 21 cases included two cases of non-accidental
poisoning and four cases of non-accidental suffocation. In one
case of non-accidental poisoning, the mother freely admitted
she poisoned her child and in two cases of non-accidental
suffocation the infants presented as sudden death occurring at
home with signs of physical abuse and no previous presenta-
tion to the medical profession. The two remaining cases of
non-accidental suffocation occurred in hospital while being
investigated for recurrent apnoea. Excluding the three cases of
non-accidental injury, there were 18 cases of MSBP reported
by paediatricians throughout New Zealand for the 12-month
period from May to August 1998–99. Eighteen paediatricians
reported 18 cases with three paediatricians reporting two cases,
and two cases reported by more than one paediatrician.
The total number of children under the age of 16 years in
New Zealand, as of March 1999 based on the 1996 Census was
895 860.8Thus the incidence rate for MSBP, including non-
accidental poisoning and non-accidental suffocation presenting
as MSBP in children aged less than 16 years was 2.0/100 000.
Eleven (61%) of the 18 cases were referred to child pro-
tection agencies or the police. In the remainder, the diag-
nosis was felt to be highly suspicious but referral was not
made. Excluding cases, where referral was not made, the
incidence rate for MSBP in children aged less than 16 years
was 1.2/100 000 children. Of the 11 cases referred to child
protection agencies or the police, in seven cases the paediatri-
cian made known their suspicions to the person thought to
be perpetrating the abuse. When referral was not made, only
one paediatrician made their suspicions known. The mean time
taken to diagnosis from initial presentation was 7 months in the
cases referred to child protection agencies and 23 months in
cases not referred.
The majority of affected children were young, with 12
(66%) under the age of 5 years. The median age at diagnosis
241Munchausen syndrome by proxy
Fig. 1 Spectrum of parental behaviour in Munchausen syndrome by
proxy (MSBP). *Adapted from Eminson and Postlethwaite.6
Table 1 Munchausen syndrome by proxy – child morbidity/outcome
scale*
1 Superior functioning in a wide range of activities.
2 Absent or minimal effect, socially and physically minimal
involvement. No impairment in school functioning.
3 Slight impairment in social or school functioning.
4 Generally functioning pretty well, some difficulty in school or
home life (i.e. frequent doctor visits).
5 Moderate impairment with moderate difficulty at school or home
life.
6 Serious difficulties at school and home (i.e. unable to attend
school regularly).
7 Major impairment in every area of school and home life
(i.e. unable to attend a regular school at all).
8 Inability to function in almost all areas (i.e. immobile and unable
to attend to self care without help).
9 Gross impairment with inability to communicate and physically
incapacitated.
10 The outcome was fatal with death of the child.
*Adapted from Diagnostic and Statistical Manual of Mental
Disorders, 4th edn.5
was 2.7 years. Ten cases (55%) were male and 10 (55%) had an
underlying chronic illness. The mother was the suspected
perpetrator in all cases. Often (73%) children presented with
multiple symptoms (Table 2) with seizures being the most
common (Table 3). The degree of parental fabrication was most
often (56%) of moderate severity with invention of history. A
higher proportion of cases where the degree of parental fabrica-
tion was more severe involved symptoms of apnoea or seizures
(Table 3) and were referred more often to child protection
agencies or the police (Table 4). The median morbidity score
on the 10-point scale for the children was 4 (interquartile range
3–6) (i.e. some difficulty in school or home life and frequent
doctor visits). In three cases, the child was removed from the
family. In nine cases (50%), it was noted in the comments
section that following diagnosis there was improvement or
resolution of symptoms.
Ten (56%) of the 18 paediatricians involved with cases
reported stress or difficulty with this condition. Court appear-
ances and lack of support were identified as being particularly
traumatic. In one case, a paediatrician had to deal with death
threats from the family.
DISCUSSION
This survey found an incidence rate for MSBP, including non-
accidental poisoning and non-accidental suffocation presenting
as MSBP in children aged less than 16 years as 2.0/100 000.
Excluding cases in this study that had not been referred to
child protection agencies or the police, the incidence was
1.2/100 000. This rate is three times higher than the only
previous reported rate by McClure et al. from the United
Kingdom of 0.4/100 000.7The criteria in the study by McClure
et al.7included all cases for which a child protection confer-
ence had been convened because of suspicion of MSBP, non-
accidental poisoning or non-accidental suffocation, which is
similar to New Zealand’s referral system to child protection
agencies.
There are several possibilities for the higher rate in this
study. Firstly, this was a retrospective survey and there may
have been recall bias with cases from previous years being
recollected. We believe the follow-up telephone interviews
allowed us to correct for this bias and enabled exclusion of
all the cases that had not been first diagnosed in the preceding
12 months. It was also apparent during the follow-up inter-
views that the uniqueness of this condition allowed most paedi-
atricians to have clear recall of the dates when these cases were
first diagnosed.
Secondly, the possibility of counting cases twice remains.
Some paediatricians were unaware that other paediatricians had
been involved. This is partly the nature of this form of child
abuse. It is common for the abusing caregiver to see multiple
doctors. Also, as this study confirms, it is common for multiple
symptoms to be presented and the caregiver may then refer
themselves for subspecialty opinions. This was again accounted
for in the follow-up telephone interviews where we were able
to cross reference cases from each region and ensure they were
not being reported twice.
Thirdly, a wider continuum of cases may have been reported
in this series. Most reports emphasise the serious nature of this
form of child abuse.9–11 However in this study, the outcome for
the majority of cases was not severe, with only some difficulty
in school or home life. Also the degree of parental/caregiver
fabrication in the majority of cases was around the invention of
history, a less severe degree of fabrication than manufacturing
sign or symptoms. This may also reflect increasing recognition
of this abuse syndrome by paediatricians with more mild cases
being diagnosed. There has been increased reporting both in
the medical literature and the lay press, including a number of
cases that have been sensationalized in the media. All this has
led to increased awareness of the condition by paediatricians
242 SJ Denny et al.
Table 2 Frequency of multiple presenting symptoms in Munchausen
syndrome by proxy
No. symptoms n(%)
One 5 (28)
Two 7 (39)
Three 3 (17)
Four or more 1 (5)
Non-specific signs or symptoms 2 (11)
Table 3 Presenting symptoms in Munchausen syndrome by proxy
Symptoms and signs n
Physical harm or active procurement of symptoms:
Seizures 4
Apnoea/suffocation 4
Poisoning by anticonvulsant 1
Invention of history not caused by underlying illness:
Seizures 4
Respiratory distress 1
Reflux 1
Repeated presentations – non-specific 1
Allergy 1
Weight loss 1
Fabricated past medical illness 1
Failure to thrive 1
Exaggeration of existing symptoms with an underlying illness:
Seizures 2
Headache 2
Apnoea 1
Asthma 1
Respiratory distress 1
Reflux 1
Repeated presentations – non-specific 1
Haemoptysis 1
Table 4 Munchausen syndrome by proxy – severity of fabrication
and referral to statutory agencies
No. referred
to child protection
Total no. agencies/police
Degree of fabrication (%) (%)
Most severe – physical harm to the child 4 (22) 3 (75)
Severe – active procurement of symptoms 1 (5) 1 (100)
Moderate severity – invention of history 10 (56) 6 (60)
Least severe – exaggeration of 3 (17) 1 (33)
existing symptoms
243Munchausen syndrome by proxy
and the public. Kaufman et al., in a study in 1989, found only
50% of professionals working in the area of child abuse had
heard of MSBP.12 It seems likely this figure would now be
higher.
This study confirms previous reviews on the typical
presentations and features of this form of child abuse.2The
median age at diagnosis was 2.7 years, the mother was the
perpetrator in all cases and there were often multiple symp-
toms with seizures being the most common. Disability has
been noted previously to be more prevalent in abused children
than in the general population.7In this study chronic illness
was prevalent in children with MSBP. This suggests the
single biggest risk factor may be exposure to the medical
profession, especially during crucial periods such as the
caring of a newborn or infant where an isolated parent can be
susceptible to the attention and care bestowed upon them and
their child. Of note was the improved outcome following
diagnosis. This emphasises the importance of trying to clearly
establish the presence or absence of this condition when it is
suspected. It is in the best interests of the child to make the
diagnosis.
The high degree of stress and difficulty reported by paedia-
tricians dealing with this form of child abuse must be acknowl-
edged. There are obvious difficulties for physicians in making
the diagnosis of MSBP child abuse, not the least being the
degree to which the physician themselves may be contributing
to the abuse of the child. Most sources suggest a mutlidiscpli-
nary approach to the diagnosis and management of suspected
cases. However, there are difficulties in this approach, particu-
larly for paediatricians in remote and/or isolated settings. Also,
involving physicians not familiar with MSBP may in some
instances worsen the management, as these caregivers are notor-
ious at ‘splitting’ teams and generating diagnostic and manage-
ment uncertainty. Often the responsibility for making this
diagnosis lies primarily with the paediatrician. This exposes
paediatricians to the risk of abuse, stress, and suspicion from
the family, community and colleagues. This exposure can be
minimized by following published guidelines13–15 which
involves thorough assessment, obtaining relevant background
information from a multitude of sources, documenting pre-
cisely the interactions between caregiver and child/staff and
family, and separation of the suspected perpetrator from the
abused child.
ACKNOWLEDGEMENTS
We are grateful for the support of paediatricians from through-
out New Zealand and the staff of the General Paediatric Depart-
ment at the Starship Children’s Hospital, Auckland, New
Zealand. This study was funded in part by the Starship Founda-
tion and the ASB Bank.
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