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Brian Morgan looks at a revised view of Munchausen syndrome by proxy from the professor who first coined the term.

The author of a definition of Munchausen syndrome by proxy (MSbP), which for 25 years has underlain diagnostic procedures in the UK (but not in the USA), has provided his first major personal revision.

In 1977 Professor Sir Roy Meadow described two cases of repetitive salt poisoning of children, one of whom died. He derived the term MSbP from the adult form of self-abuse involving unnecessary repeated hospital admissions - Munchausen's syndrome. Paediatric victims of MSbP suffer from unnecessary medical interventions, where carers give false accounts of illness in children or impose illness on them. According to accounts, many hundreds of cases have been diagnosed worldwide.

Meadow has delivered two new warnings: one, that the term MSbP has been overused; but also that an important class of potential abusers must now be recognised. Diagnostic practice in the two countries where most practitioners in MSbP are based has diverged significantly. Meadow defined a form of abuse, diagnosed in the child by following a set procedure - broadly the UK practice. In the USA, however, workers regard the carer as suffering from a form of mental illness. Diagnostic attention is directed at the carer, most often the mother.

Now, Meadow has moved closer to the US model by adding a further criterion to his original ones, namely that the perpetrator is "considered to be acting out of a need to assume the sick role by proxy or as another form of attention seeking behaviour". In other words this requires the examination of the parent or carer in addition to the child-victim at the time of the investigation, rather than, as he explains was his previous recommendation, at a second stage and only after the abuse had been confirmed.

Meadow has also revised his original statement that adults with Munchausen's syndrome were not prone to impose illness on their relatives. He now says "there must be concern about the potential dangerousness of parents with abnormal illness behaviour", although the extent has yet to be established.

Meadow clearly expects his additional definition to lead to restraint in labelling. He says: "rather too many examples of child abuse have been categorised as MSbP". Where he and others who challenge the overuse of the term will part company is his failure to address issues of wholly false allegations of MSbP.

The US expert and author, forensic psychologist Eric Mart, has reviewed Meadow's paper, and while agreeing that the term has been overused, questions the data used to link adult Munchausen's with the potential for MSbP abuse. He says: "Meadow points out that there are many references in the literature to abnormal illness behaviour in the parents of children who are the victims of MSbP. This may be true, although there has been a lack of replication of the few studies that suggest this, and since the application of the diagnosis of MSbP is so questionable (different definitions and standards across professionals) any conclusions that follow from the diagnosis of MSbP are themselves questionable."

Meadow has been criticised recently over his expert opinion in trials, where, partly as a result of his testimony, mothers were convicted of manslaughter in cases where their babies had previously been said to be victims of cot death. Despite this he maintains a pre-eminent reputation in child protection, and his new thoughts on MSbP will command attention. How they will influence future UK guidance documents will depend very largely on how health and child protection specialists respond to what appears to be conflicting advice.

R Meadow, "Different interpretations of Munchausen syndrome by proxy", Child Abuse & Neglect, vol 26, 2002

Brian Morgan is a social and health care writer