Research into Practice

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

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

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

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