Munchausen by Proxy (MBP) Maltreatment Manifesting as Child Sexual Abuse

Abstract: Munchausen by Proxy (MBP) is a recognized form of maltreatment in which caregivers deliberately feign or produce physical and/or psychological-behavioral problems in others. MBP maltreatment may manifest as physical abuse, emotional abuse, medical neglect, sexual abuse, or a combination thereof. When sexual abuse is suspected during an MBP maltreatment investigation or MBP is suspected during a sexual abuse investigation, both sexual abuse and MBP investigation activities and techniques must be combined. This article will provide an MBP overview and an introduction to the basics of appropriate MBP investigation and substantiate/unsubstantiate.

Key Words: Munchausen by Proxy, Munchausen by Proxy Syndrome, Munchausen Syndrome by Proxy, Factitious Disorder by Proxy, MBP, MSBP, MSP, maltreatment, abuse, neglect, physical abuse, emotional abuse, neglect, sexual abuse.

In the paper that follows, we will provide an overview of the disturbing and complex form of maltreatment called Munchausen by Proxy (MBP). We will explain how MBP can manifest itself through child sexual abuse, provide basics of the appropriate MBP investigation and confirmation-disconfirmation process, and offer ideas about enhancing the sexual abuse investigation through consideration of MBP. It is not possible in this piece to provide information regarding all activities and methods of the process. We strongly suggest that, if MBP maltreatment is suspected in any situation, a professional with considerable, credible expertise specific to MBP be involved. The following material is based on our knowledge and experience in the field of MBP.

MBP is sometimes called Munchausen Syndrome by Proxy, Munchausen by Proxy Syndrome, or Factitious Disorder by Proxy. All of these terms apply to a well-established variant of maltreatment (abuse and/or neglect) in which caregivers deliberately feign or produce ailments in others. The perpetrator deliberately misleads others knowing that there is no reason to believe the victim has an underlying physical and/or psychological-behavioral problem. The signs and symptoms perpetrators falsify or create are usually physical. For instance, a mother might repeatedly suffocate a child in secret, then claim to doctors and family members that these respiratory arrests were spontaneous. Less frequently, the problems are mainly psychological or behavioral. For example, a mother might falsely allege that a child is suicidal. Physical and psychological-behavioral "problems" may occur in the same case. Regardless, the victim typically then undergoes unnecessary physical or mental health examinations, tests, medications, and/or surgeries. These activities can not only be painful, frightening, and embarrassing, they may also place the child at emotional and/or physical risk in the present and the future. Individual cases of MBP may incorporate physical abuse, emotional abuse, medical neglect, and/or sexual abuse.

The perpetrator's principal motivation is usually to attract attention, sympathy, care, and concern as the parent of a child with problems. She may be motivated by other "internal" goals as well, such as the desire to control and manipulate others, including a spouse or a high-status medical professional. For example, in a troubled marriage, the perpetrator may create "problems" intended to avert the spouse's leaving home or finding a new partner. In this example, the perpetrator may intend to gain the spouse's attention, interfere with the new relationship, or obtain revenge. When MBP presents in the context of divorce or custody dispute, those very situations may be a part of the motivation or provide "triggering events" for the MBP maltreatment.

The victims are usually infants or toddlers, but older children, adults, and the elderly can be victimized as well. In this piece, we will discuss only cases that involve child victims. Also, because the vast majority (75 to 95 percent) of known perpetrators are mothers, we will be using the terms "mother" and the pronoun "she" to refer to them.

MBP perpetrators typically bring the child to health care settings such as hospitals, emergency rooms, and clinics, but conceal their own role in the problem(s). Sometimes they mobilize the sympathy and attention of others but do not actually access medical or mental health care. MBP is usually diagnosed through the accumulation of solid circumstantial evidence. Investigative techniques such as secret video surveillance (i.e., filming the mother abusing the child in the hospital room) may provide direct confirmation of MBP-like behavior but do not necessarily "prove" that the behavior constitutes MBP maltreatment. As mentioned above, direct evidence can be very important but may not usually be necessary to prove that MBP maltreatment is involved.

* MBP is dangerous. It has been estimated that 6 to 10 percent of MBP victims die. When victims die, it is usually because:

1. The perpetrator goes too far or miscalculates. For example, she smothers the child too long or gives the child too much of a sedating drug such as Phenobarbital.
2. Through false reports or manipulation of lab results or other "objective" information, --the perpetrator gives misleading information to the doctor, and the resulting treatments (such as anesthesia and surgery) lead to complications resulting in death.

In a few cases of MBP, a mother has deliberately killed the child. In these cases, the mothers seem to covet the sympathy that comes with the dying, funeral, and other bereavement activities.

* MBP is a recognized kind of maltreatment (abuse/neglect). There are now hundreds of published reports of MBP from around the world. They prove that MBP is not simply a "theory," but that it is a specific form of maltreatment that is of international dimensions. Several books devoted to the topic have appeared in recent years. Most not only summarize the professional literature, but present important new perspectives and recommendations. Though MBP is clearly recognized as a kind of child maltreatment, the American Psychiatric Association is currently studying whether or not it constitutes a formal mental health diagnosis. MBP, under the term "Factitious Disorder by Proxy" is included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) only as a suggestion for further study.

*MBP perpetrators deliberately engage in MBP behavior. Perpetrators usually carefully plan out the ways in which they will create the appearance of having a child with "problems" and the stories they will tell to conceal their deceptions. They consciously engage in improper behavior and know right from wrong.

*MBP perpetrators deliberately feign, simulate, exaggerate, aggravate, or induce "problems" in others. There is virtually no medical or psychological malady that cannot be portrayed in MBP. Definitions follow:

Feign: The perpetrator gives false reports that the child has a problem.

Example 1: The mother of three-week-old David calls 911 to report frantically that the baby stopped breathing and turned blue, but that she resuscitated him with rescue breaths just in time. In fact, the child has been sleeping uneventfully.

Example 2: Knowing that Tamika, age 13, has not exhibited any problems, her mother calls a children's therapist for an urgent appointment. She states that she recently caught Tamika eating food out of the garbage and cutting herself with a knife, and that Tamika claims that a strange lady comes into her room at night.

Example 3 (Suspected Sexual Abuse Case Example): Even though she knows it is untrue, the mother of 6-year-old Danny makes a report to Child Protective Services (CPS) and states that, after his return from visiting his father last weekend, Danny told her that "Daddy made me touch his weenie" and that he is "afraid of Daddy."

Simulate: The perpetrator creates tangible evidence of a problem, but hides her own role.

Example 3: Kim, age 6 months, is a healthy child. Kim's mother mixes up a substance that looks like vomit and places it on and around Kim. Kim's father then comes into the room, sees it, and is told that "Kim has been throwing up again".

Example 4: Randy's mother tells his pediatrician that he has always seemed to be a sad little boy and that she feels he is very depressed. She produces a video of her 4-year-old son in which he repeatedly says he is going to kill himself. The doctor does not know that Randy is just pretending, in accordance with his mother's instructions.

Example 5 (Suspected Sexual Abuse Case Example): Karen's mother rubs her husband's sperm on 3-year-old Karen's panties, presents the panties to law enforcement, and states that she thinks Karen has been sexually abused by her stepfather. The child then undergoes pelvic and anal examinations under anesthesia.

Exaggerate: The perpetrator verbally embellishes a real problem.

Example 6: One-year-old Molly has a fever that has lasted a few days. Although she knows that the temperature has never risen above 100.5, Molly's mother repeatedly calls the pediatrician's office to say that, despite her following the doctor's instructions, Molly's temperature ranges from 103 to 105.

Example 7: Scotty, age 8, is a very active child who tends to constantly be in motion and is sometimes quite obstinate. His mother asks the pediatrician for a referral to a child psychiatrist, stating that he has daily temper tantrums that last for hours.

Example 8 (Suspected Sexual Abuse Case Example): Consuela, age 10, tells her mother that she has "itching between her legs." Consuela does have a slight rash on her inner thighs, but her mother calls the clinic saying that her daughter's "private parts are covered with a terrible oozing rash that smells."

Aggravate: The perpetrator worsens a pre-existing medical or psychological ailment.

Example 9: Jessica, age 6, has juvenile-onset diabetes mellitus for which daily insulin injections are prescribed. Her mother deliberately gives her too little insulin in each syringe, causing her blood sugar readings to be too high.

Induce: The perpetrator deliberately causes a real problem to exist.

Example 10: Infant Sam's day care provider smothers him with a pillow until he stops breathing, then calls a neighbor for help.

Example 11: Ten-year-old Vicky's mother repeatedly mixes pills from her own supply of Valium into Vicky's food. As a result, Vicky appears confused and is often incoherent, and she is eventually admitted to a psychiatric hospital for assessment.

Example 12 (Suspected Sexual Abuse Case Example): The local CPS agency takes custody of 8-year-old Min-Li because, following a visit to her father's home, she was found to have blood on her panties and a small vaginal laceration. Later, it is revealed that no such visit ever occurred and that the mother had nicked the child's vagina with a razor blade to create the laceration.

*Cases that appear to involve only false reports or simulation should be considered as dangerous as those in which induction of illness has been suspected or confirmed.

As noted, physical abuse, emotional abuse or neglect, medical neglect, and sexual abuse may all occur in MBP cases. Most cases involve physical abuse, emotional abuse, and medical neglect, but sexual abuse should be added if involved. Unfortunately, few states currently identify MBP as a separate kind of maltreatment when reporting their maltreatment statistics. Thus, it is important to link the MBP perpetration to the kind(s) of maltreatment included in state statutes or other legal guidelines.

In juvenile or family court cases involving MBP, however, it is important to obtain a court finding of MBP per se if at all possible. Only in this way can case plans specific to MBP be legally mandated. Without a case plan appropriate to MBP maltreatment, it is unlikely that the victim will be protected in the short and long term. Case plans contain elements and activities that must be successfully completed prior to consideration of reunification. MBP maltreatment case plans must contain specific and unique elements if victims are to be protected both short and long term. Without a court finding of MBP maltreatment, it is virtually impossible to legally justify a MBP-specific case plan.

1. There is no "profile" or combination of personal characteristics that can determine whether or not someone is an MBP perpetrator. A person does not "have" or "suffer from" MBP, though they may have co-existing emotional or DSM-IV diagnosed problems such as personality disorders or depression.
2. Although mental health evaluations and psychological testing may be useful for other purposes, there is no mental health test or evaluation that can determine whether or not someone is an MBP perpetrator.
3. Most confirmed MBP perpetrators are mothers. However, foster mothers, fathers, day care providers, health care professionals, and others have perpetrated MBP maltreatment.
4. MBP perpetrators usually appear, at least on the surface, to be "normal." They may strike others as being good, even exemplary, caregivers for their "abnormal" or "problematic" children.
5. The relationship between MBP perpetrators and their victims usually appears, at least on the surface, to be appropriate, even very loving.
6. The hallmark of MBP maltreatment is deception. MBP perpetrators are usually accomplished deceivers and manipulators. They are typically extremely convincing and are able to give seemingly plausible reasons for any inconsistent or odd findings or personal behaviors.
7. MBP perpetrators are not simply overanxious or overprotective. The overanxious parent is sincerely concerned that something is wrong with her child and sticks to the truth. MBP perpetrators deliberately feign or create "problems."
8. MBP perpetrators do not necessarily have to have extensive health care knowledge or be particularly intelligent. It does not take special knowledge to engage in many kinds of MBP maltreatment.
9. MBP perpetrators usually deny that they have engaged in maltreatment, even when there is incontrovertible evidence. When they do acknowledge their behavior at all, they will typically admit only to whatever they have been caught doing, and not to the pattern of MBP maltreatment.
10. MBP perpetrators may not stop their MBP behavior when they are suspected or even caught. However, the type of MBP behavior may change or seem to subside temporarily. Even if they have no contact with the victim, they may continue to use the child as an object and gain attention by asserting that the child does or did have problems. They commonly make accusations against the child protection agency for "not providing appropriate care," send voluminous letters to government officials, solicit appearances in the media, etc.
11. MBP perpetrators do not necessarily add or change health providers frequently ("doctor shop"). If they find a provider who endorses all of their claims and provides avid attention, they may not feel any need to pursue other practitioners.
12. MBP perpetrators may have a history of feigning or producing "problems" in themselves or of over utilizing physical or mental health care resources. A history of psychiatric treatment or of problems with substance abuse is not uncommon.
13. If MBP perpetrators believe they are suspected of maltreatment, they may become even more dangerous. They may flee with the victim and/or escalate the MBP in an attempt to "prove" that the child has authentic "problems" or that genuine problems have developed and occurred naturally.
14. MBP perpetrators may seek emotional satisfaction by misleading a variety of people, whether professionals or nonprofessionals. Their precise motivations can vary from case to case and even change over time. When perpetrators seek attention and nurturance, the main source of the support is not necessarily a health care professional.
15. MBP perpetrators often have a "dramatic flair" or report having been involved in numerous exciting or unusual events. They sometimes provide spurious reports of personal heroism or victimization, or falsify their personal histories in other ways. Essentially nothing a suspected or confirmed perpetrator says should be taken at "face value." In the same way, information that could have originated with the suspected or confirmed perpetrator, or someone she gave information to, should be scrutinized. Friends, neighbors, relatives, etc. should not necessarily be considered good information verifiers, as they too may have been "taken in" by the perpetrator.
16. MBP perpetrators may have a pattern of falsely accusing others of wrongdoing.

The following are indicators of possible MBP. More than one indicator will usually be present in order for there to be a serious suspicion of MBP maltreatment. If there is evidence for some of the warning signs, it does not mean that MBP is present, only that a thorough and appropriate investigation and substantiate/unsubstantiate process must be undertaken. There is no specific number of indicators that must be present to establish or disprove MBP.

1. The episodes of physical and/or psychological-behavioral "problems" begin when the mother is or has recently been with the child.
2. The problems abate when the child is separated from the mother.
3. The child has been to numerous caregivers without a cure or clear diagnosis.
4. The problems do not respond to appropriate treatment.
5. The mother has a diagnosis or history suggesting self-harm, feigning or inducing "problems" with regard to herself, or personal over utilization of health care.
6. The suspected problem or problem pattern is extremely rare.
7. Data from tests and procedures are consistent with feigned or produced problems. For example, particular blood studies can help indicate whether or not insulin or other drugs have been administered.
8. The mother is unusually eager to have the child undergo invasive testing and surgery.
9. The mother is strongly suspected or proved to have provided false information or fabricated a problem.

As mentioned earlier, there is virtually no problem that cannot be feigned or produced as part of the spectrum of MBP. Sexual abuse is no exception. The possibility of MBP maltreatment should be considered if it is suspected that a caregiver is telling others that she thinks the child has been sexually abused or if she is causing a child to be subjected to sexual abuse investigation activities--even though she knows that there is no reason to believe that the child has been maltreated in this way. In the setting of a custody dispute, if the mother knowingly makes false claims of sexual abuse against the father solely to strengthen her case, the goal (custody of the child) is external and an MBP confirmation would usually not apply. This kind of situation demands a thorough MBP investigation and substantiate/unsubstantiate process in order to make the determination.

Example 13: A mother takes her child from doctor to doctor for sexual abuse physical exams and from therapist to therapist for sexual abuse forensic interviews. She tells the professionals that the child is exhibiting behavior suggestive of sexual abuse, such as masturbating in public, having nightmares about a man hurting her, and experiencing a sudden drop in her school grades. When the professionals tell her that they have detected no signs of sexual abuse, the mother takes the child to others. The child herself denies any such abuse, which her mother attributes to "denial." After learning more from the child, a therapist who had received MBP education finally reports his suspicion to CPS. An MBP-specific investigation is initiated.

Example 14: A mother has a pattern of contacting Child Protective Services (CPS) with various allegations, including sexual abuse, against her ex-husband - none of which have been found to be true. The current CPS investigator, who has received MBP education, reviews past investigations and discovers several inconsistencies in information given by the child. Based on the mother's pattern of reporting and the inconsistencies, the investigator initiates an MBP-specific investigation.

Success with suspected or confirmed MBP cases means completing an objective and thorough investigation and substantiate/unsubstantiate process. If MBP is confirmed, appropriate intervention, case planning, and case management are required in the short and long terms. Based upon our experience and that of colleagues, we believe the following ingredients are crucial:

*Basic MBP maltreatment education is the foundation of work with suspected or confirmed MBP cases. It is counterproductive, even dangerous, for professionals to discuss, make decisions, or formulate strategy without current and accurate education regarding MBP basics, investigation and substantiate/unsubstantiate, case planning, and case management. Reading a few articles or having been involved in a case or two does not suffice.

*A thorough and appropriate MBP maltreatment investigation and substantiate/unsubstantiate process should be performed by, or with the assistance of, a professional who has extensive and credible MBP knowledge and experience.

*A multiagency-multidisciplinary team (MMT) composed of professionals such as Child Protective Services (CPS), law enforcement, physicians, mental health professionals, nurses, social workers, school staff, and others who are, have been, or will be involved with the family and case. The precise membership of the MMT should be dictated by the unique facts of the case. An MMT should be convened even if there is a permanent hospital, county, or state team that regularly reviews all apparent child maltreatment cases. CPS, as the agency mandated for protecting children, should be involved from earliest suspicion.

*An MBP expert consultant to provide initial and ongoing education, review information, provide comments and recommendations, guide or conduct the investigation, provide on-site technical assistance, offer a final opinion and recommendations, work with the assigned attorney(s) in preparing the court case, and other related activities.

*An MBP expert witness (usually the same individual as the MBP expert consultant) to educate the court, relate education to the case at hand, provide an opinion and recommendations, and be available for rebuttal. MBP expert testimony may also be necessary in various kinds of motions hearings.

*An attorney who is properly educated about MBP, is willing to work as a team player with the MBP expert, and is fully prepared for court and related activities. It is our experience that, no matter how strong the evidence for MBP, the hearing or trial is likely to be lost unless the attorney and expert work closely together throughout the process.

When MBP maltreatment and child sexual abuse are suspected in the same case, investigative activities and methods must be combined. Many professionals, including those highly regarded in their own areas of expertise may know little about MBP maltreatment, and they may have incorrect education and misconceptions about it. Whenever MBP is suspected, whether alone or in conjunction with suspicion of another kind of maltreatment, an appropriate MBP investigation and substantiate/unsubstantiate process should be initiated.

There are four activities that overlap and interweave throughout the MBP maltreatment investigation and substantiate/unsubstantiate process:

* Information gathering
* Information evaluation
* Information organization
* The MBP maltreatment substantiate/unsubstantiate decision

Each of these activities will be briefly discussed. However, it is preferred that involved professionals receive more detailed training and assistance directly from a credible MBP professional. If investigative activities have already been accomplished relative to a different kind of maltreatment, it should not be assumed that information gathering, information evaluation, or information organization has been appropriately completed with regard to an MBP investigation. Instead, it is very likely that additional information will need to be gathered, evaluated, and organized from the "MBP perspective." Even if/when MBP is formally confirmed, these four activities must continue throughout the court process and beyond.

The kinds and variety of information that should be obtained in an investigation of suspected MBP differs from investigations involving other kinds of maltreatment. Other kinds of abuse/neglect investigations usually focus on information directly related to the suspected victim. MBP investigations require that a variety of information be gathered regarding suspected victim(s), other children presently or formerly in the home (even if deceased or now adult), suspected perpetrator(s), and sometimes others, depending on the case situation.

The MBP Suspicion Report

The first step of any maltreatment investigation is the suspicion report. Agencies should ensure that individuals accepting maltreatment reports have received accurate MBP maltreatment training, that they can identify MBP suspicion indicators even if the label MBP is not used by the reporter, and that their training includes the kinds of questions they should ask during the reporting conversation. Any suspicion report pointing to possible MBP should be placed in the highest risk category and immediately acted upon. The report should be presented promptly to the supervisor with "MBP Suspicion" emphasized. The individual assigning the case for investigation should ensure that the investigator understands initial investigative steps. As mentioned earlier, it is extremely important (until the suspected and potential victims are safe) to refrain from any activities that might result in the suspected perpetrator's learning that she is under suspicion.

The second step in an MBP investigation is to convene a case-specific multi-agency/multidisciplinary team (MMT) composed of professionals presently or formerly involved with the family as well as those who will be involved in the investigation itself. The purposes of the initial MMT meeting (which should optimally occur within hours of the MBP suspicion report) are:

* To share and clarify presently known information

* To formulate strategy and come to consensus regarding recommendations, decisions, and future case activities

* To clarify the roles, procedures, and expectations for the facilities, agencies, and organizations involved

There is no substitute for case-involved professionals meeting together, to listen to each other, ask questions, compare information, identify inconsistencies, and plan strategy. They should decide what additional information should be gathered and which potential information sources should be accessed. Sometimes it is necessary for one or more professionals to be involved by telephone. It can also be very beneficial to be creative and ask the question, "If someone were feigning or inducing "problems" in this case, how might they accomplish it?" This question should be asked of specialists in the particular "problem" area, not just the child's immediate health care professional, who might be unaware that the "problem" could be feigned or created.

Obviously, it is not always possible for a full MMT to convene immediately when MBP suspicion emerges and a child appears to be in present danger. Some decisions may need to be made immediately in order to protect the child(ren). However, CPS and other immediately available case - involved professionals should be a part of immediate decision-making - via telephone conference call if necessary. The MMT should then convene within several hours to begin the investigative process. Even if there appears to be direct evidence (through covert video surveillance, for example) of MBP-like behavior unless a thorough investigation and substantiate/unsubstantiate process have been completed, the MBP-like behavior should at most be labeled as a "provisional" and a thorough investigation completed.

Written Records

It is crucial to the MBP investigation that all possible records be obtained regarding suspected perpetrator(s), suspected victim(s), other children presently or formerly in the home, and sometimes others, - depending on the case.

* Information often overlaps between various individuals' records. For example, information about a child may be found in the mother's records; information about one sibling may be discovered in another sibling's records.

* Information in one record may be inconsistent with another.

* Suspicion or confirmation of other perpetrators and victims within the nuclear or extended family may be discovered.

* Patterns suggesting the possibility of people with Factitious Disorder/Munchausen Syndrome may be identified.

* Clues to further information are likely to be found.

Records that should be gathered may vary depending on the individual case, but all possible records should be gathered regarding the above mentioned individuals. For example, records relating to physical health (including dental), mental health, education (including preschools), employment, CPS and other state/county child welfare organizations and branches, court/legal, 911 and subsequent emergency responders, applications and other paperwork regarding applied for and/or received benefits, etc. Detailed physical and mental health "insurance runs" should be obtained. Records should be requested even if there is only a hint or gut feeling that an involved individual may have received services. Many records may not be available without a release of information or court order. Obtaining them may have to wait until such time as it is safe for the involved attorney to prepare a motion asking the judge for an appropriate order. It is likely that the records hearing will need expert testimony as to why, in this kind of case, such records are needed in order to determine whether MBP maltreatment is or is not involved. Think "outside the box" when considering what records might be "out there".

Requests for written records must be detailed Incomplete records are often sent. Providers may keep different sections of a record, such as social services, mental health, or "the special file" in different places. They may assume you do not need initial and subsequent "face sheets". They may select what to send on what they consider to be a "need-to-know basis". Professionals who prepare records requests must ensure that they add detailed request information to their standard request forms, releases of information, etc. A paragraph that may be added to a standard form is as follows:

This request includes all information related to physical health, mental health, dental health, education, employment, social, and other information related to the above individuals and their nuclear and extended families. Information should include, but not be excluded to: primary records, consults, nursing, social services, initial and subsequent history, face sheets, meeting notes -- anything related to the above individual.

Information Through Specialized Interviews

It is imperative that interviewers involved in an MBP maltreatment investigation are well skilled in general investigative techniques as well as having a basic understanding of MBP maltreatment so that interviews are conducted from a perspective of possible MBP involvement.

MBP investigation interviewers must receive specialized knowledge and education. Interviews that have already been conducted from a non-MBP suspicion perspective must be repeated. Anyone who might have knowledge of the family and situation should be interviewed, including professionals, friends, neighbors, relatives, ex-spouses or boyfriends, etc. Although some information sought is likely to be similar to other maltreatment investigations, obtaining additional information is also important. Interviewing strategy and techniques also differ.

Suspected MBP perpetrators and others often declare that someone else can verify that they "saw the problem". This may or may not be true. Interviewing those who supposedly saw the "problem" means attempting to determine whether or not the observer actually saw and heard what happened at the "original moment" when the child supposedly changed from "normal" to having symptoms. Without specialized knowledge and skills, interviewers are likely to conclude from the interview that the problem was indeed verified.

The "Separation Test"

One of the most useful information activities in determining whether or not MBP maltreatment is involved is to separate the suspected victim or victims from the care, control, and direct or indirect influence of the suspected perpetrator and anyone she might influence -- including such individuals as the spouse/partner, father, friends, relatives, and professionals who appear to believe her. Ideally this should be accomplished as quickly as possible in the investigation; however, judges are usually reluctant to remove a child from the home without information that the child is or is likely to be in immediate danger, particularly if the request is not well thought out and lacks MBP education. An MMT recommendation may be more powerful than that of one individual or agency. Besides protecting the suspected or confirmed victim, the purpose of placement in an MBP case is to discover what happens. Do the "problems" described by the suspected perpetrator and those who may have been influenced by her occur? If the child really did have "problems", do they continue -- or do they resolve or begin to resolve? Depending on whether the "problems" are physical and/or psychological-behavioral, an appropriate health care professional should be involved in planning and monitoring the "separation test".

In order to protect the child(ren), to keep the case as taint-free as possible, and to conduct an appropriate "separation test", suspected or confirmed victims should be placed in a foster home or inpatient facility (if necessary). Foster parents are potentially important witnesses. They are likely to spend more time with the child(ren) than anyone else. If a foster home is utilized, the following guidelines should be adhered to:

* It is vital that foster parents personally receive basic MBP education, detailed case information, and instructions for monitoring, logging, and other activities prior to or within hours of placement.

* Foster home location and names of foster parents should not be disclosed.

* There should be no contact between foster parents and suspected/confirmed perpetrator, spouse, relatives, friends, etc.

* There should be very frequent contact between the assigned CPS professional and the foster parents.

If the child(ren) is to remain or be placed in an inpatient facility , the following guidelines should be followed:

* Assigned staff should personally receive basic MBP education, detailed case information, and instructions for monitoring, logging, and other activities.

* The child(ren) should be placed in a different room under a different name.

* Only specifically identified professionals should have contact with or access to information about the child(ren). A code system should be in place so that identified professionals can telephone for information.

If visitation must take place, the following guidelines must be followed:

*The visitation supervisor must personally receive basic MBP education and detailed case information.

*The visitation supervisor must remain in the visitation room or area at all times; it is not sufficient to "supervise" through a one-way mirror.

*The visitation supervisor should watch and hear everything that occurs; she should not read a book, answer the telephone, go to the restroom, etc. during the visitation.

* No whispers or note passing.

* No discussion regarding the case or health care issues.

* All conversation should be audible

* No eating or drinking by anyone unless absolutely necessary for child.

*If child must eat or drink, visitation supervisor must provide and administer, well away from others involved in the visitation.

*All visitors must sign the visitation guidelines list each time they visit.

If telephone contact must take place between the victim(s) and anyone but specifically identified professionals, the conversation must be monitored at each end by a foster parent or professional who has received basic MBP education, detailed case information, and specific information and instructions regarding monitoring and logging the conversation.

INFORMATION EVALUATION

As information is reviewed it must be evaluated in terms of usefulness to the MBP maltreatment investigation. Questions that should be asked and answered include the following:

* Is the information credible?

* Is the information relevant to confirming/disconfirming MBP or identifying other maltreatment?

* Is the information relevant or potentially relevant to other case activities or decisions?

* Is the information potentially useable as direct or circumstantial court evidence?

It is essential that no information be accepted at "face value". Particularly if a genuine MBP case is being investigated, it is extremely likely there will be "falsehoods disguised as truth" in both written records and interview information. For example, suppose it is suspected that a mother has been causing seizures in her child. Several records from various sources include the statement, "Family has a history of seizure disorder". An investigator who has not received MBP education might believe this statement and begin to think, "since seizures run in the family, the child probably has naturally occurring seizures". Yet, what does "family has a history of seizure disorder" really indicate? All it means is that somewhere, sometime someone gave that information and it was written down without being confirmed via an absolutely reliable source. It may have been checked off in the history portion of the inpatient or outpatient face sheet. It may have been given verbally to someone who wrote it down as if it were truth. Remember that deception is the hallmark of MBP, not only with regard to the victim or victims - but usually throughout the fabric of the perpetrator's life. It is crucial that every piece of information be carefully scrutinized and the question asked: "Where did this information most likely originate?" Did it likely originate with the suspected perpetrator or someone she told (a professional, spouse/partner, relative, friend, child, etc.) Family members, relatives, and friends should not be considered reliable sources of information. They may have been duped by the perpetrator-- or may even deliberately provide false information.

INFORMATION ORGANIZATION

An MBP investigation usually produces massive amounts of information. Information must be organized in such a way that data and patterns relevant to confirming or disconfirming MBP can be identified.

One way is to manually, or through a software "sort" program, place relevant information (including potential witnesses) into various categories. Information placed into categories must be exactly as in the information source and coded for easy access back to where it was found. Information may fit into more than one category. Categories may later be sub-divided. Depending on the case, categories might include the following subcategories. Other categories are also likely.

* Each suspected perpetrator or perpetrators
* Each suspected victim or victims
* Each present or former spouse/partner/or other significant relationship
* Each other person presently or formerly living in the home
* Suspicion or confirmation of feigning (definition earlier in article)
* Suspicion or confirmation of simulating (definition earlier in article)
* Suspicion or confirmation of exaggerating (definition earlier in article)
*Suspicion or confirmation of aggravating (definition earlier in article)
*Suspicion or confirmation of inducing (definition earlier in article)
*Suspicion or confirmation of physical abuse
*Suspicion or confirmation of emotional abuse or neglect
*Suspicion or confirmation of general neglect
*Suspicion or confirmation of physical or mental health neglect
*Suspicion or confirmation of sexual abuse
*Behavior by suspected perpetrator that suggests the possibility of Factitious Disorder/Munchausen Syndrome
*Information inconsistencies
*Information that suggests rationale that any confirmed MBP-like behavior constitutes MBP
maltreatment rather than something else.
*Clues to further information, important things to follow up on, etc.

THE MBP SUBSTANTIATE/UNSUBSTANTIATE DECISION

As discussed earlier, the decision as to whether or not MBP maltreatment is involved rests on the answers to two questions:

1. Is there direct and/or circumstantial evidence that MBP-like behavior has occurred (feign, simulate, exaggerate, aggravate, induce)?
2. Is there rationale that the MBP-like behavior constitutes MBP maltreatment rather than something else (deliberate attempts to kill the victim, overanxious-overprotective mother, deliberate torture due to hatred of the child, etc.)?

It is strongly recommended that the substantiate/unsubstantiate opinion be made by or with the assistance of a credible MBP professional who has been involved in the process, who has reviewed all information, and who can testify as an MBP expert in court.

The purpose of this article has been to introduce the reader to the process of determining whether or not MBP maltreatment is involved in a case situation. Further information and guidance will be necessary prior to and during the course of investigative activities and decision-making. Further education and assistance will also be needed regarding post confirmation activities and decision making unique to MBP cases including:

* The initial confrontation interview with the perpetrator
* Court preparation and presentation
* Initial and ongoing victim risk assessment
* Designing and justifying the case plan
* Therapist selection and role
* Continuing use of the MMT
* Other short and long term case management