Munchausen Syndrome by Proxy: Integration of Classic and Contemporary Types
Deirdre Conway Rand*
ABSTRACT: The current article elaborates on the concept
that a contemporary manifestation of Munchausen syndrome by proxy (MSP)
has emerged in which a parent or other adult caretaker fabricates or
induces the idea that a child has been abused and presents the child to
professionals as a victim (Rand, 1989). The evolution of the diagnosis of
MSP is described since its introduction into the literature by Meadow in
1977. The three major roles in the MSP triangle of professional —
mother/care taker — child are discussed, with emphasis on issues that may be problematic
for the professional when sex abuse is alleged. A list of warning signs is
provided for both classic and contemporary-type MSP. Evaluation procedures
should include checking the details of the personal, social, and family
history that the mother/caretaker has given and contacting other family
members. It is important to look for the motive for the behavior and, in
the case of contemporary MSP, to uncover the context in which allegations
were made. When the disorder is treatable, case management, rather than
traditional psychotherapy, appears to be the treatment of choice.
Recently, a contemporary manifestation of Munchausen
syndrome by proxy (MSP) has emerged in which a parent or other adult
caretaker fabricates or induces the idea that a child has been abused and
then gains recognition from professionals as the protector of an abused
child (Rand, 1989). Munchausen syndrome by proxy is a specialized form of
child abuse in which a physical or mental disorder of the child is either
fabricated or induced by a parent or other adult caretaker. Fabricated and
induced symptoms in classical cases have led doctors to diagnose and treat
children as suffering from a wide variety of medical conditions, including
diabetes, epilepsy, nephritis, cystic fibrosis, recto-vesical fistula,
ulcerative colitis, etc. in classical cases, the child or
"proxy" often undergoes painful tests, unnecessary and/or
harmful treatments and surgeries, as well as frequent and/or
lengthy hospitalizations. It is estimated that the child dies in ten to
twenty-two percent of classical cases.
Evolution of Munchausen Syndrome by Proxy as a
Munchausen syndrome by proxy derives from adult
Munchausen syndrome, which was first described in the literature in 1951
by Asher. In adult Munchausen syndrome, the patient fabricates and/or
induces his own symptoms and presents himself for treatment. The
description of Munchausen syndrome by proxy was first made in 1977, after
British pediatrician Roy Meadow recognized that mothers of two children in
his practice were engaging in dissimulations that put their children in
the patient role, using the children as proxies. Subsequently, Meadow has
collected and presented a number of cases, noting from the outset that is was
often the doctors who harmed the child most through their unnecessary
tests and treatments.
Originally, Meadow observed the mother of the child as
perpetrator and the child as a simple victim, stating in 1982 that only
children up to age six were used as proxies because a child older than
that would likely reveal the deception. After two more years of study,
however, he reported in 1984 that an older child could act as a
confederate of the mother, with the two involved in a sort of folie â
deux, a pattern that might be perpetuated even after the child reached
adulthood. Thus, Meadow began to describe the complex psychological
nature of MSP.
Today, our understanding of the perpetrator role has
expanded as well. For example, MSP has been found to be practiced with
children not the perpetrator's own (Elkind, 1983; United States vs. Woods,
1973). Sigal, Carmel, AItmark, and Silfen (1988) described a male
perpetrator abusing two female adults, while Sinanan and Haughton (1986)
cited the bizarre case of a female perpetrator who manipulated nurses and
their families into the proxy role, seeing to it that they received about 100 unnecessary
injections, from which one of the nurses became very ill.
It wasn't until the 1980 edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-III) that Munchausen syndrome
was officially incorporated, classed under the generic name of factitious
disorder. In addition to production of factitious physical symptoms,
factitious psychological symptoms were recognized. Factitious psychological
symptoms have been found to include factitious post-traumatic
stress disorder, factitious psychosis, factitious depression, factitious
rape, and factitious bereavement.
According to Sinanan and Haughton "the probable
range of variations in the presentation of Munchausen syndrome is likely
to develop in parallel with the evolution of medical and social
services" (1986, p. 465). Thus, it is to be expected that the
proliferation of services available to sex abuse victims will be
accompanied by a parallel increase in factitious "adult molested as
child" presentations (factitious disorder with psychological
symptoms) as well as factitious claims by an adult that a child has been
molested (Munchausen syndrome by proxy, contemporary-type).
Goodwin (1982) was one of the first to write that
Munchausen syndrome by proxy appeared to be operating in some sex abuse
cases. She described mothers who became obsessed with the idea that their
young child had been molested, taking the child for repeated pelvic exams
that the mother observed. Libow and Schreier (1986) report a case
consistent with this pattern. According to Goodwin, some of these mothers
repeated the pelvic exam again at home, perpetuating the abuse. In a case
reported by Wakefield and Underwager (1988), a divorced mother admitted
to examining the children herself for sex abuse after visits with the
father, as well as taking them for post-visit medical exams. Eventually,
she was suspected of using a tampax to dilate the youngest child's vaginal
opening and produce "physical evidence" of the alleged abuse.
Schuman (1986) has suggested that Munchausen syndrome
by proxy may be operating in some divorce-related false allegation cases.
Ferguson (1988) gives a fictionalized account of a true, post-divorce
drama that was eventually diagnosed as Munchausen syndrome by proxy.
two teenage children, living with their biological mother, began making
sex allegations against relatives and were taken by their mother to
several therapists in search of one who would confirm abuse. The
accusations became so numerous, however, that the court removed the
children from the biological mother's home, an action that mother and
children perceived as punishment. The investigation that followed
concluded that the biological mother had induced the idea of molestation through the use of
formal brainwashing techniques. The children were allowed to return home
on the condition that the family receive therapy to learn healthier ways
of relating, but instead they obtained further treatment for the original
sex allegations. Subsequently, these therapists left the agency and the
mother and children sought treatment from new therapists for new
allegations against relatives. The fact that several sets of professionals
were drawn into providing this inappropriate treatment demonstrates some
the problems that professionals have with MSP.
MSP and Its Professional Participants
Meadow (1982) observed that the doctor's tendency to
react in a stereotyped manner resulted in his doing the most harm to the
child with his tests and treatments. He attributed the doctor's reflexive
reaction to the fear of missing an organic cause for a complaint. Analogously, in the sex abuse arena, the stereotyped response of many
professionals has been, "Children don't lie" and "Believe
the child." A quick and zealous reaction to suspected abuse reports
is deemed necessary to prevent even the possibility of abuse. However,
premature commitment to the idea that abuse has occurred will make it
difficult, if not impossible, to correctly diagnose MSP.
Zitelli, Seltman and Shannon (1987) go a step further
and identify, "Physicians and legal and protective service
agencies" (p. 1099) as unwitting participants in the MSP when they
fail to recognize the MSP and treat the true disorder. It is not
surprising that professionals should find themselves in this position, for
the mother or other adult caretaker in MSP is, by definition, manipulating
and exploiting the professionals' response. Goodwin makes a similar point
in describing, "Nineteenth century cases in which fathers and
physicians collaborated to devise inspections and punishments to prevent
children from masturbating. (This) probably represents another instance of
the cooperation of the professional in the perpetration of sexual
According to Meadow (1982) and others, it is common in
classical MSP for the perpetrator to be in a medical or quasi-medical
field. In fact, the knowledge gained by being in the profession can help
the perpetrator to fabricate or induce convincing symptoms. It is only a
matter of time before it is recognized that contemporary-type MSP may
occasionally be perpetrated by some mental health professionals, social
workers, and prosecutors who induce the idea that a child has been abused
(Underwager & Wakefield, 1989).
Pathology of the MSP Perpetrator
Whether the MSP is classical or contemporary in its
manifestation, the adult perpetrator gratifies his or her own needs at the
expense of a child or other dependent/enmeshed individual. Thus, it is
not surprising that the DSM-III and the literature on Munchausen
syndrome are clear on the presence of a severe underlying personality
disorder. Folks and Freeman (1985) observe that histrionic, schizotypal,
borderline, antisocial, and masochistic personality disorders have all
been observed to coexist in cases of Munchausen syndrome. Spiro (1968)
mentions several cases in which psychosis was present. Psychotic features
were identified in several reports of contemporary-type MSP as well
(Ferguson, 1988; Goodwin, 1982; Wakefield & Underwager, 1988). Mothers with MSP have also been noted, in some cases, to fabricate or
induce symptoms in themselves, an expression of adult Munchausen syndrome.
Spiro and others suggest that production of factitious
symptoms and the attention received thereby may actually help to stave off
further psychotic decompensation. If this effort is successful, the
presence of psychosis may be difficult to detect, especially if the
professional accepts the factitious symptoms at face value. This is
particularly true in contemporary-type MSP where the perpetrator's
obsession with the idea that abuse has occurred may be impossible to
disprove. Ravenscroft and Hochheiser (1980) have characterized the MSP
parent's thinking as "quasi-delusional," hypothesizing that the
parent may come to believe, at least intermittently, that the child's
problem is real and not fabricated.
Certainly, in order for the mother to maintain the
deception as the child grows older, it serves her purpose to make the
child believe that he or she is ill, disabled, or abused, as the case
might be. Meadow (1985) notes the example of a 22-year-old confined to a
wheelchair because he was brought up to believe he had spinal bifida and
couldn't walk — medical examination showed his back and legs to be normal.
This manipulation of the child's belief seems to occur in contemporary-type
MSP as well, where a non-abused child is induced, sometimes with the help
of professional participants, to believe that he or she was abused.
The DSM-III states that in factitious disorder the
production of symptoms is voluntary and conscious, but this fails to take
into account the "quasi-delusional" aspect. A mother who adds
blood to the child's urine specimen or who tells a child directly to say
that daddy did something sexual is clearly acting voluntarily, displaying
anti-social features. However, where the mother's underlying pathology is
histrionic or psychotic, the distinction between conscious and
unconscious fabrications may be blurred.
Despite the severe underlying pathology, in classical
cases, the mother is often described as making a good impression on staff
by being attentive to the child, helpful to staff and appreciative of
their efforts. In fact, Meadow (1985) stated that, as a rule, mothers
appeared normal on psychological tests, with no disorder apparent to the
psychiatrist. He adds that the psychologist and psychiatrist often write
that they do not believe the mother could be practicing the kinds of
deception that have been discovered. This suggests that interpretation of
test results may have been biased by professional disbelief or lack of
understanding of perpetrator dynamics. Rosen et al. (1983) describe a case
where the mother's MMPI fell within normal limits and her Rorschach and TAT
also showed no signs of psychosis or of psychopathic tendencies. However,
a seemingly psychodynamic interpretation of the test data resulted in a
diagnosis of narcissistic personality disorder, with the mother filling
her sense of emptiness by adopting the role of a dedicated mother to
children with rare, undiagnosed illnesses. As understanding of MSP
continues to evolve, perhaps practitioners will be better able to draw
useful information from psychological tests and interviews.
It is often difficult for professionals to reconcile
the incongruity between how caring the MSP mother may seem to be and what
she is really doing, for example scratching the child's skin to induce a
rash, overdosing the child on medications to make the child ill, or
suffocating the child to induce seizures, etc. Professionals may have
further trouble accepting the fact that, if the adult caretaker in
classical MSP can induce symptoms, then it is to be expected that this
will occur in some contemporary-type MSP cases as well, like the divorced
mother mentioned by Wakefield and Underwager and cited earlier.
The motivations for MSP appear to be varied. While
staving off of psychotic decompensation may be a factor in some cases,
Meadow (1985) recommends looking for the individual reinforcers in each
case such as increased social status, improved family relationships,
direct or indirect financial benefit, to name only a few. Sigal et al.
(1988) remark on the acting out of sadistic impulses in MSP, while another
commonly mentioned motivation is the attention the adult caretaker gains
by presenting the child in the "sick" role, or, in
contemporary-type MSP, the "victim" role. Additionally, the
adult's dependency needs may be met through the symbiotic bond with the
child that is reinforced by the production of factitious symptoms.
In divorce, a powerful motivation for developing the
idea that a child has been abused is to gain custody and to sever the
child's emotional relationship with the other parent. According to the definition of
contemporary-type MSP offered here, these cases, described as Parental
Alienation Syndrome by Gardner (1987), appear to be a sub-type of MSP.
Gardner's experience with severe cases of Parental Alienation Syndrome is
that the underlying pathology of the falsely accusing parent (usually the
mother but sometimes the father) is of a rigid, often paranoid type.
order for professionals to recognize the pathology, however, they need to
be able to differentiate between fabricated and genuine child abuse, best
accomplished through a thorough evaluation that follows guidelines such as
Munchausen syndrome by proxy in its extreme, classical
form may appear to be a discrete entity, and probably is relatively rare,
though most believe that it is less rare than previously thought. But MSP
can also be viewed on a continuum, which is what Nadelson (1979) does in
going from the idea of imagining illness occasionally, to diseases that
are totally imagined, and finally to disease that is totally induced or
fabricated. The DSM-III describes a continuum from single episodes or just
a few mild episodes, on the one hand, to the production of serious
symptoms as an ongoing way of life, on the other. Libow and Schreier
(1986) divide MSP into three types, with the least severe manifestation a
"Cry for Help," while much more significant pathology is present
in the "Active Inducer" and the "Doctor Addict."
Certainly the expansion of concepts relating to MSP suggests that it is
not so much rare as it is still in the process of being detected and understood.
The Mother-Child Dyad
The boundary between mother and child is often blurred
in MSP, as seen in the common occurrence of the mother
"donating" her symptoms to the child (Meadow, 1982). This may
take the form of the mother borrowing from her medical history and
asserting that the child has the same condition. Or the mother may
actually reenact her symptoms through the child, as in the case reported
by Feldman, Christopher, and Opheim (1989). In this instance, a bulimic
mother induced vomiting and failure to thrive in her infant through
illicit doses of ipecac, apparently administered to make the child conform
to her ideals of thinness. Similarly, in contemporary-type MSP cases, the
mother or other adult caretaker may give a history of herself as an abused
or molested child.
The mother-child relationship in MSP is variously
described as enmeshed, symbiotic, and mutually anxious and overprotective.
The mother relies on the child to meet her needs, and typical of the role reversal
noted in other forms of child abuse, "The children in these cases in
some way help their parents deal with their own psychological and medical
concerns" (Waller, 1983, p. 82). Ravenscroft and Hochheiser (1980)
describe a mother who was distressed over her deteriorating marriage, and
through her symbiotic bond with the child was able to express her sense of
being "sick" by making the child sick. Her own depression lifted
as a result.
Once past infancy, the child may actually participate
with the mother in the production of symptoms. A very young child may do
this by being aware of what the mother is doing but not volunteering that
information to anyone. According to Meadow (1982), not only is there more
complicity between the child and the mother as the child gets older, but
the deception may be initiated by either one, with the other helping to
This highlights the need for more investigation into
what aspects of the child's own personality (dependency needs, need for
attention, manipulativeness) can predispose him/her to involvement in
Munchausen syndrome by proxy. Similarly, the relationship between the
mother/caretaker and one child in a group of siblings may be a
predisposing factor. In some cases, only one child in the family is known
to be a victim of MSP, while in others, several siblings are involved.
With respect to siblings, this author received the following anecdotal
report after a presentation to colleagues on MSP: An adult in therapy gave
a history suggesting that she had been victim of Munchausen syndrome by
proxy until age six, at which time she refused to go along any further
with the mother's deception. The patient reported that her sister,
however, continued, over a number of years, to participate with the mother
in MSP fabrications. In a different scenario, the interaction between
siblings can promote the development and maintenance of factitious
symptoms (Ferguson, 1988; Gardner, 1989).
There are two reports in the literature of what appear
to be manifestations of Munchausen syndrome in a child, where the child is
not acting in a proxy role, but independently. Sneed and Bell (1976)
report the case of a ten-year-old-boy who inserted small stones into his
urethra to simulate passage of renal stones. Goodwin, Cauthorne, and Rada
(1980) report on three girls, ages nine and ten, each adopted, who
exhibited the "Cinderella syndrome," in which they simulated
neglect. According to Goodwin et al. underlying the false allegations of
abuse were histories that included early loss of a mother or mother
figure, abuse in a previous placement, and emotional abuse in the adoptive
home. They emphasize the importance of not dismissing the child's fabrications as merely
manipulative but rather understanding and addressing the real family
problems of which such fabrications are a symptom.
Munchausen Syndrome by Proxy Warning Signs
The first list below gives classical MSP symptoms in
bold face type (Jones et al., 1986), with contemporary-type extrapolations
of these symptoms in italics. This is followed by additional warning signs
of contemporary-type MSP.
1. Persistent or recurrent illnesses for which a cause
cannot be found; child continues to be presented in victim role through
"add on" and newly "remembered" allegations or
"add on" details.
2. Discrepancies between history and clinical findings;
history given of abuse that should produce physical findings, e.g.
repeated anal intercourse, yet medical exam negative; history includes
episodes of abuse that are factually contradicted e.g. in underground
tunnels that can't be found by police.
3. Symptoms and signs that do not occur when a child is
away from the mother; child answers negatively about abuse away from
4. Unusual symptoms, signs or hospital course that do
not make clinical sense; abuse allegations that are bizarre or improbable;
child appeared well-adjusted during the period that abuse was supposed to
5. A differential diagnosis consisting of disorders less
common than Munchausen syndrome by proxy; e.g. allegations of multiple
family members involved in incest, including grandparents.
6. Persistent failure of a child to tolerate or respond
to medical therapy without clear cause; child does not recover from abuse
7. A parent less concerned than the physician, some
times comforting the medical staff; child recites allegations in a rote
manner or eager to tell story.
8. Repeated hospitalizations and vigorous medical
evaluations of mother or child without definitive diagnoses;
mother/accuser has child repeatedly evaluated for abuse and is dissatisfied
with negative or equivocal results.
9. A parent who is constantly at the child's bedside,
excessively praises the staff, becomes overly attached to the staff, or
becomes highly involved in the care of other patients; symbiotic, enmeshed
relationship between mother and child, e.g. mother insists on staying in
room for child's therapy interview.
10. A parent who welcomes medical tests of her child,
even when painful; mother/accuser seems to welcome repeated sexual assault exams and
interrogations of child.
11. Frequent comparisons of the child's medical
problems to those of the parents; mother/accuser gives a history of having
been molested as child.
Additional warning signs of contemporary-type MSP may
1. The accusing adult seems to know more about what allegedly happened than does the child.
2. Either mother/accuser or child distorts the truth,
manipulates information by omission, or fabrications of any kind, e.g.
school, employment, medical, history.
3. The accuser is more interested in building a case
than in helping child deal with abuse and moving on.
4. There is a united front between mother and child,
especially when the child is inappropriately alienated from the other
parent, who is the accused.
5. The accuser gives a history of herself having been
molested as a child which is inconsistent with view of the family held by
the majority of its members and with the family history as constructed by
interviews with different family members.
Evaluation Procedures for Munchausen Syndrome by Proxy
Meadow (1985) offers guidelines for the evaluation of
classical MSP that include:
1. Studying the history to decide which events are
likely fabricated and which ones are real.
2. Looking at the temporal relationship between illness
events and the presence of the mother.
3. Checking the details of the personal, social, and
family history that the mother has given.
4. Making contact with other family members.
5. Looking for the motive for the behavior.
With respect to contemporary-type MSP, the evaluator
must make as accurate a determination as possible as to whether or not a
child has been abused. A good resource is the Guidelines for the Clinical
Evaluation of Child and Adolescent Sexual Abuse position statement of the
American Academy of Child and Adolescent Psychiatry (1988). The broader
context in which the allegation was made must be determined and
investigated. The evaluator should insist on access to all persons and
records that will enable the checking of the history given by the mother
or other adult accuser. In some instances, the person accused of abusing
the child is a relative stranger and though it may be desirable to evaluate that individual, it may
not be possible. When abuse allegations occur in a divorce context,
however, Gardner (1987) feels that a single evaluator should evaluate
everyone, including the accused:
On a number of occasions I have been asked to see a
child in order to ascertain whether or not he or she has been sexually
abused. Frequently I am told that I will not be permitted to interview the
alleged perpetrator. I will, however, be permitted to interview the
accuser. I have never accepted such an invitation. ... I cannot emphasize
strongly enough that examiners who involve themselves in these cases
should insist upon being given the freedom to see all concerned parties:
the allegedly abused child, the adult accuser, and the alleged
perpetrator. In addition, it is crucial that the examiner have the
opportunity to interview these parties individually and in any combination
that is warranted. To do otherwise is to conduct what can only be
described as a seriously compromised, if not completely inadequate,
evaluation (p. 107).
The evaluator must be clear about his or her role. For
example, the therapist turned evaluator and vice versa will blur
objectivity. By the same token, a professional who takes or makes a report
of suspected abuse should not confuse that function with the role of
evaluator. The evaluator should be familiar with MSP and with other
processes by which false accusations of child abuse come about, as well as
with established guidelines for making determinations about the occurrence
of abuse. Obviously, an evaluation of the type required is often costly in
terms of time and money, but short-cuts may result in harm to the child and innocent adults.
In criminal cases, where an adult is charged with child
sexual abuse, there is often heavy reliance on statements made by the
child, with information about the mother/child dyad, context of the
allegation, and other historical material not permitted into evidence.
argument is that an allegedly molested child should be treated like an
adult rape victim. An understanding of Munchausen syndrome by proxy should
make it apparent that such an approach is ill advised.
Case Management is the Treatment of Choice
It is beyond the scope of this paper to provide a
comprehensive review of treatment of Munchausen syndrome by proxy. The
titles of two major papers on the subject are informative, however,
referring as they do to "obstacles to treatment" and
"management of Munchausen syndrome by proxy" (Meadow, 1985;
Waller, 1983;). There seems to be agreement that once the diagnosis of MSP
has been proven, the next step is to protect the child from the perpetrator's influence
and to set limits on the perpetrator's behavior. This may involve making
the child a dependent of the court, placing the child with someone else,
and/or designation by the court of a case manager to minimize the
perpetrator's manipulations. Wailer strongly recommends that the person
who successfully diagnosed the MSP remain actively involved in the case.
Meadow discusses confronting the mother in mother/child cases, with
pointers on how to do so therapeutically.
The approach taken in contemporary-type MSP will depend
on the relationship between the parties, e.g. if the perpetrator is the
child's mother and the alleged abuser is the child's father, or if the
perpetrator is someone other than the mother and the alleged abuser is a
relative stranger. If it is a divorce situation and the MSP is severe, it
may be appropriate to place the child with the accused (usually the
father), according to guidelines set forth by Gardner (1989). These would
be cases where the father has been a good parent who has been
significantly involved with the children. In order to make this work,
judicial support, supervision and enforcement is needed, with specific limitations
on the mother's contact with the children.
At the most severe level, when sex abuse has been
alleged, Gardner is of the opinion that a therapist who does not believe
the mother's delusions will be seen by her as an ally of the former
husband and thus no therapeutic alliance can be formed. He further makes
the point that ordering people into treatment is not likely to be
productive. In severe cases, therapy for the children while they are still
living in the mother's home is often not possible, either.
Traditional individual psychotherapy has, by and large,
been found to be ineffective in the treatment of MSP, although Meadow
(1985) believes that a child psychiatrist may be a source of discussion
and moral support to the pediatrician. In theory, at least, enlightened
therapy of less severe cases may be helpful if the mother is motivated, if
she exhibits minimal anti-social tendencies, and the therapy is part of a
holistic, well-supervised case plan monitored by the court or Child
Protective Services. If it is a divorce situation and therapy is
indicated, there should probably be only one therapist, minimizing the MSP
perpetrator's opportunities for manipulation. The problem with
"monitoring and supervision" is that the court system and
caseworkers are often overloaded as it is, plus there may be frequent
changes in personnel. Thus, a program that depends on monitoring and
supervision should only be attempted when these tasks can be
conscientiously carried out.
Discussion of "treatment" tends to put the
focus on the perpetrator, while the concept of case management provides
caregivers with an alternative to being a professional participant in the
syndrome. When all is said and done, however, these families remain, as
Meadow so simply and eloquently states, "exceedingly difficult and
stressful to manage."
(Author's Note: I continue to be interested in learning more about
other people's cases and invite people to contact me.)
American Academy of Child and Adolescent Psychiatry
for the clinical evaluation of child and adolescent sexual abuse.
American Psychiatric Association
(1980). Diagnostic and Statistical Manual of Mental Disorders (3rd
Ed.). Washington, DC:
American Psychiatric Association.
Asher, R. (1951). Munchausen's syndrome. Lancet,
(1983). The Death Shift ()(). New York, NY:
Feldman, K., Christopher,
D., & Opheim, K. (1989). Munchausen syndrome/bulimia by proxy: Ipecac as a toxin in child abuse.
Child Abuse & Neglect, 13, 257-261.
Ferguson, D. (1988). Bad Moon Rising: A True Story (). Nashville, TN:
Folks, D. & Freeman, A. (1986). Munchausen's syndrome and other
factitious illness. Psychiatric Clinics of North America, 8(2), 263-278.
Gardner, R. A. (1987). The Parental Alienation Syndrome and the Differentiation
Between Fabricated and Genuine Child Sexual Abuse
NJ: Creative Therapeutics.
Gardner, R. A. (1989). Family Evaluation in Child Custody
Mediation, Arbitration, and Litigation
. Cresskill, NJ:
Goodwin, J. (1982). Sexual Abuse: Incest Victims and Their Families
Boston, MA: John Wright - PSG Inc.
Goodwin, J., Cauthorne, C. G., & Rada, R. T. (1980). Cinderella
syndrome: Children who simulate neglect. American Journal of Psychiatry,
Jones, J. G., Butler, H. L., Hamilton, B., Perdue, J. D., Stem, H. P.,
& Woody, R. C. (1986). Munchausen syndrome by proxy.
Child Abuse & Neglect, 10, 3340.
Libow, J., & Schreier, H. (1986). Three forms of factitious
illness in children: When is it Munchausen syndrome by proxy? American Journal of Orthopsychiatry,
Meadow, R. (1977). Munchausen syndrome by proxy: The hinterland of child
abuse. Lancet, 2, 342-345.
Meadow, R. (1982). Munchausen syndrome by proxy. Archives of Disease in Childhood,
Meadow, R. (1984). Munchausen by proxy and brain damage.
Developmental Medicine and Child Neurology, 26(5), 672-674.
Meadow, R. (1985). Management of Munchausen syndrome by proxy. Archives of Disease in Childhood,
Nadelson, T. (1979). The Munchausen spectrum: Borderline character
features. General Hospital
Psychiatry, 2, 11-17.
Rand, D.C. (1989). Munchausen syndrome by proxy as a possible factor
when abuse is falsely alleged. Issues in Child Abuse Accusations, 1(4),
Ravenscroft, K, Jr. & Hochheiser, J. (1980). Factitious hematuria
in a six-year-old girl: A case example of Munchausen syndrome by proxy.
Presented at the Annual Meeting of the American Academy of Child Psychiatry, Chicago.
Rosen, C., Frost, J., Bricker, T., Tarnow, J. Gillette, P., &
Dunlavy, S. (1983). Two siblings with recurrent cardiorespiratory arrest:
Munchausen syndrome by proxy or child abuse? Pediatrics,
Schuman, D. C. (1986). False accusations of physical and sexual abuse. Bulletin of the
American Academy of Psychiatry and the Law,
Sigal, M., Carmel, I., AItmark, D., & Silfen, P. (1988). Munchausen
syndrome by proxy: A psychodynamic analysis. Medicine and Law, 7,
Sinanan, K., & Haughton H. (1986). Evolution of variants of the
Munchausen Syndrome. British Journal of Psychiatry,
Sneed, R. C., & Bell, R. F. (1976). The Dauphin of Munchausen: Factitious passage of renal stones in a child.
Pediatrics, 58(1), 127-130.
Spiro, H. R. (1968). Chronic factitious illness. General Psychiatry,
Underwager, R., & Wakefield, H. (1989). The Real World of Child
Interrogations (). Springfield, IL:
Charles C. Thomas.
United States vs. Martha Woods (1973). United States Court of Appeals,
Fourth Circuit, No. 72-2217.
Wakefield, H., & Underwager, R. (1988). Accusations of Child Sexual
Abuse ()(). Springfield, IL:
Charles C. Thomas.
Waller, D. A. (1983). Obstacles to the treatment of Munchausen by proxy
syndrome. Journal of the American Academy of Child Psychiatry, 22(1),
Zitelli, B., Seltman, M., & Shannon, R. (1987). Munchausen's
syndrome by proxy and its professional participants. American Journal of
Diseases of Children, 141, 1099-1102.