The assessment of alleged inflicted injury in children is never a particularly easy area. This is exemplified by situations where injuries are subtle and/or hidden. In 1977, Meadow [1] introduced the term “Munchausen syndrome by proxy” to describe certain clinical scenarios where child carers, most often mothers, had allegedly either induced or fabricated disease in a child, resulting in considerable medical attention and treatment. The term derived from Munchausen syndrome, a psychological condition that forms part of the deception syndromes where an affected individual wanders from doctor to doctor, pathologically lying and simulating illness in order to gain treatment and/or hospital admission [2, 3]. In Munchausen syndrome by proxy (MSBP), the psychological benefits are thought to derive from using a substitute or proxy.

The symptoms and signs of the victim in MSBP are extremely diverse, ranging from failure to thrive due to chronic poisoning, to recurrent sepsis and lethal apneas [4]. Key features of the presentation are that a child appears ill or suffers from an illness that requires intense medical investigation and/or treatment, and that the symptoms and signs disappear once the perpetrator has been separated from the child [5].

There is no doubt that identifying this scenario has had considerable benefits in drawing medical and lay attention to the fact that certain child carers may cause or falsify illness in their children for reasons that are still not clearly understood. On occasion these actions have been clearly captured on video surveillance cameras [6]. Explanations for this type of behavior have ranged from simple attention seeking to “perversion” and behavior akin to serial killing. While a number of mothers have had previous diagnoses of Munchausen syndrome, most have not, and there is usually no evidence of psychosis or of psychiatric illness. As the psychological basis of MSBP in the perpetrator has not been clarified to any great degree, this suggests that the “syndrome” represents an extremely eclectic group characterized predominately by similar behavior on the part of the perpetrator. Given that a number of cases of multiple deaths within families have been reported in the medical literature and press, a heightened level of awareness has, however, enabled the early identification of some cases and intervention to protect the child victims [6]. Unfortunately, when a carer has been sequentially harming or even killing children, the failure of treating physicians to recognize that this has been happening has led to active participation by doctors in the process, with perpetuation of the situation [7].

Despite some successes there is no doubt that problems exist with the overuse of the term and these involve both the “legalization” of a medical situation, and conversely the “medicalization” of legal issues—a situation that is not uncommonly found in other areas of medicine that come before the court. In particular, the use of a specific name may create more certainty in police and legal circles than exists in reality; i.e. if it is truly a syndrome then legal investigators may assume that there must be clear diagnostic criteria with a defined victim and an identifiable perpetrator. The “black and white” culture of the law thrives on such oversimplification, with failure to recognize or understand that in medicine a syndrome is not a diagnosis. Also, the overenthusiastic adoption of this concept may result in children with genuine but rare illnesses, or parents who may simply be over-concerned about their child’s health and welfare, being stigmatized with this “diagnosis.” This admixture of complex and conflicting issues and lack of defining features has led many to shy away from the term and has resulted in certain courts declaring that MSBP cannot be regarded as a recognized psychiatric disorder or mental illness but is instead “merely a name for a type of behavior”[8].

Although the term “Munchausen syndrome by proxy” is an elegant construction, neatly linking fabricated illness with the involvement of a proxy, the situation is unusual in that the same diagnostic term is being applied to two quite different individuals. The question that is often asked is “who exactly is suffering from MSBP?”—the individual creating the deception (the Munchausen component), or the victim (the proxy)? The reality is that no one suffers from MSBP, as it refers to a particular set of circumstances rather than a diagnosis. If this is accepted then it can be seen why problems have arisen when the term has been used synonymously with a clinical disorder as this has led to attempts to seek defining diagnostic features. Abandoning the name MSBP in favor of “inflicted fabricated or induced illness” may, therefore, provide a more useful term for legal investigators confronted with such situations, as this describes the situation without attempting to link it to any particular type of psychiatric illness.

From a medical standpoint it may be equally useful to avoid a general term and to label the specific medical problem that is manifesting in the victim, such as recurrent apneas or septicemias, while still acknowledging that the presentation and recurrent nature are different from other forms of child abuse and of illness. Investigation of the possible existence and nature of the inflicted illness in the victim can then be undertaken without automatically linking this to the possible motives and psychological profile of the perpetrator.

Although the term MSBP has been seriously criticized, there is no doubt that in rare cases certain parents repeatedly hurt their children to gain medical attention. While it is useful to have a general term that describes a set of circumstances surrounding a presenting illness in a victim, the term should not suggest that those circumstances, in themselves, constitute a specific pathological process with clearly defined, fixed criteria.