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Investigating Munchausen by Proxy
Arizona Department of Child Safety: Policy and Procedure Manual
Chapter 2: Section 4.6
Investigating Munchausen by Proxy
Reports alleging that the parent, guardian or custodian is suspected of causing or exaggerating a child’s illness require a prompt response and safety assessment. Primary consideration shall be given to the safety and well-being of the child.
Reports of suspected causation or exaggeration of a child’s illness; excessive or unnecessary health care utilization; symptom or condition falsification; medical abuse; or Munchausen by Proxy (MBP) may require an immediate and specific protective
action to ensure the child’s safety.
A present danger assessment of all siblings in the home with the caregiver must be completed to determine whether a protective action is needed to ensure their safety.
Once the child’s safety has been assured, to the extent practicable, a multidisciplinary team (MDT) should be consulted to assist in further investigation, assessment, and case planning and management of the case.
To determine if there is reason to suspect Pediatric Condition Falsification (PCF), consider if one or more of the following questions are true:
PCF Related Indicators
Does the child have a history of unexplained or unexpectedly difficult to treat medical, developmental or psychiatric symptoms or illnesses?
Does the child have a history of very frequent visits to doctors, clinicians or therapists of any type, hospitalizations, medical procedures or surgeries?
Is the child more disabled or less functional than one would expect for the reported diagnosis?
Have the child’s healthcare providers reported discrepancies with the history reported by the parent, guardian or custodian and clinical assessments?
Suspected Perpetrator Indicators
Does the parent, guardian or custodian:
have an intense desire to maintain close relationships with the clinical staff (physicians, clinicians or therapists of any type), or regularly engage in conflicts with staff regarding diagnostic and treatment decisions?
request or demonstrate unusual acceptance of recommendations for invasive, and/or painful procedures?
fail to express relief when presented with negative (normal) test findings? appear to have more of an interest in the medical, developmental or psychiatric conditions than in the child’s well-being?
insist on performing procedures or routine care in the hospital?
demonstrate a strong resistance to having the child discharged from medical care?
report numerous dramatic or life-threatening events?
Has the parent, guardian or custodian confessed to exaggerating or inducing illness in the child?
Has Pediatric Condition Falsification previously been suspected or confirmed? Is there (direct or circumstantial) evidence that the parent, guardian or custodian falsified illness in the child?
Parent-Child Relationship Indicators
Does the parent, guardian or custodian demonstrate excessive attention towards the child in the form of enmeshment, overprotection, restriction of activities and relationships?
Do older child victims behave similarly as the suspected parent, guardian or custodian (reporting symptoms, wanting clinical interventions, etc.)?
Do younger child victims appear to have a passive tolerance of painful procedures?
Has a child reported illness fabrication, coaching by a parent, guardian or custodian, being given unknown medications or other concerning information?
Have video surveillance tapes revealed that the parent, guardian or custodian is neglectful or abusive of the child when others are not present?
Do symptoms occur only when the suspected parent, guardian or custodian is present or within a few hours after they leave? (see the “Separation Section” of Munchausen by Proxy Fact Sheet)
Does separation of the child from the suspected parent, guardian or custodian result in a decrease of symptoms or disability in the child?
Does the child’s illness respond to standard medical treatment when away from the suspected parent, guardian or custodian?
Does another family member have a history of unexplained or unexpected difficult to treat medical, developmental or psychiatric symptoms or illnesses?
Does another family member have a history of frequent visits to the doctors, clinicians or therapists of any type, hospitalizations, medical procedures or surgeries?
Is another family member more disabled or less functional than one would expect for the reported diagnosis?
Has there been a sibling death due to sudden infant death syndrome, unclear reasons or due to symptoms similar to the suspected victim?
Is there a reported history of physical or sexual abuse in suspected parent, guardian or custodian’s family of origin?
The DCS Specialist and his/her Supervisor should begin to identify and convene the multidisciplinary team (MDT) as soon as practicable after determining that the report involves a caregiver who is suspected of placing the child in present or impeding
danger by causing or exaggerating his/her illness or symptoms.
The MDT participants may vary depending on the specific circumstances and needs of the case. Reasonable efforts should be made to include the DCS Specialist and his/her supervisor, the assigned Assistant Attorney General, a medical specialist who is
familiar with child abuse and neglect, and a mental health specialist who is familiar with factitious disorders on the MDT. Depending on the nature of the case, other team members may include law enforcement, visitation supervisors, probation officers,
clinicians treating the various family members including the child’s Primary Care Physician (PCP) and/or others.
Review the Munchausen by Proxy (MBP) and Pediatric Condition Falsification Fact Sheet for more information and guidance.
Follow the procedures for investigating child abuse and/or neglect as described in Chapter 2 including Section 3 (Interviews), Section 4 (Child Safety and Risk Assessment) and Section 5 (Substantiated Maltreatment).
An immediate protective action must be taken to protect the child where the caregiver’s suspected behavior(s) places the child at risk for invasive medical tests or interventions; potentially unneeded medications; physical or emotional abuse; harmful
neglect; and/or death.
A present danger assessment of all siblings must be completed, as it may be necessary to take a protective action to ensure their safety.
Interview family members and other persons with knowledge of the family, to obtain a detailed social history on all children, parents, guardians or custodians, and other significant family members. If possible, interview persons separately, but one right
after the other, so that there is little or no time for family members to coordinate their answers.
Consult with the Assistant Attorney General to identify a mental health specialist who is familiar with factitious disorders.
In most suspected Pediatric Condition Falsification (PCF) cases, placing the child with a relative or family friend is not a safe option.
If considering placement with a non-abusive parent, extended family member or other significant person as a safety monitor or placement, carefully assess the perspective caregiver’s ability and willingness to protect the child from the suspected parent,
guardian or custodian, including his or her perception of whether the suspected abuse did or could have occurred. You must also consult with a mental health specialist who is familiar with factitious disorders when assessing placement with the non-
abusive parent, a relative or significant person as a safety monitor.
The child’s placement must be one in which the parent, guardian or custodian does not have unsupervised contact with the child and does not have the ability to influence daily care or medical treatment of the child.
Gather relevant information with guidance and direction from a mental health specialist who is familiar with factitious disorders, if one is available, qualified health professional(s) and/or reporting source. Relevant information may include the
The diagnoses of and treatment being provided to the parent, guardian or custodian if he/she is being treated by a clinician.
Medical and other clinical records (from clinicians, hospitals, clinics, laboratories, emergency services, home health agencies and health insurance companies) including birth records for the suspected victim and all siblings who have been under the care
of the suspected parent, guardian or custodian. You may need to enlist the assistance of the CMDP Medical Director to obtain these records, especially from health insurance companies.
Medical facilities often keep separate records for clinic visits, emergency Department visits, hospitalizations, and home visits. Consequently, it is important to ask for all records.
In the requests for records, specifically request inclusion of nursing notes and notes from mental health professionals.
If concerning behavior was recorded via video or audiotape, the record request should also include a copy of these recordings.
If falsification during pregnancy is suspected, it may also be necessary to request prenatal outpatient and inpatient records for the mother in addition to birth records.
Record of visits to the school nurse, telephone logs, attendance records, and Individual Education Plans (IEP) reports should be requested.
Contact and Visitation
Assess the danger of the parent, guardian or custodian’s contact with the child. Ensure that visitation, including visitation in a hospital setting, is closely supervised by one or more persons who are familiar with PCF and have been instructed to
observe all physical contact between the parent, guardian or custodian and the child and to monitor all communication. Contact the Assistant Attorney General if the parent’s behavior during visitation causes a concern for the child’s safety.
Strict guidelines are needed for visitation and contact. Frequency of visitation and contact depends on the nature of the case. It is imperative that the child feel safe during visitation and contact with the suspected parent, guardian or custodian. Use
the following guidelines to develop a visitation and contact plan:
All visitations should be closely monitored in a neutral location by one or more persons familiar with the safety concerns in the case.
The parent, guardian or custodian cannot discuss the case or health-related issues, including diet, with the child.
The parent, guardian or custodian should not give the child anything that the child can consume (such as food, drinks, candy, gum, or medicine) or anything the child can put in their mouth (pacifiers, etc.).
Ointments or other topical agents cannot be applied to the child by the parent, guardian or custodian.
All conversation must be audible to the monitor.
All physical contact, activities and gifts must be developmentally and socially appropriate.
Diaper changing should not be excessive.
Clothing changes should be restricted when excessive or inappropriate. Telephone calls must be monitored.
Letters and cards must be read by the monitor prior to being shared with the child.
Audio and video recording and photographing the child are prohibited.
Case planning includes obtaining an assessment and recommendations from the mental health specialist regarding critical decisions including diagnosis, treatment, visitation guidelines and reunification.
Obtain an independent, non-treating expert to conduct the assessment for suspected Pediatric Condition Falsification and the evaluation of associated psychopathology (such as Factitious Disorder).
A Primary Care Physician (PCP) who is familiar with PCF should be assigned by the Comprehensive Medical and Dental Program (CMDP) to manage and coordinate the ongoing care of the child while in the care, custody and control of the Department. This person
may also participate in the MDT.
In order to meet the acute and ongoing needs of the child and family, ensure open and regular communication with the MDT and, to the extent practicable, consult with the team when any changes are made to the case plan, including changes to the permanency
goal, placement, visitation and service provision.
The MDT should include the assigned DCS Specialist , Supervisor, the Assistant Attorney General, the mental health specialist who is familiar with factitious disorders, clinicians treating the various family members, visitation supervisors, the safety
monitor and/or child’s caregiver.
Depending on the nature of the case, the MDT may include law enforcement, the child’s guardian ad-litem, CASA or tribal representative, if applicable.
Team members should be provided with relevant information regarding any diagnosis; treatment recommendations and progress; outcome of visitation/ contact and services provided; and progress towards achieving the permanency goal.
The team may be convened to discuss:
Unexpected increases in symptoms, visitation problems, or other acute issues. Increase in concerning symptoms and other clinical issues should also be communicated to the assigned PCP and/or other clinicians.
When any change is considered related to the placement, visitation, service provision, ongoing assessment of safety and risk, evaluation of progress in obtaining the permanency goal and change in the permanency goal.
Consider holding conference calls and/or meetings with the team monthly or less frequently depending on the needs of the case.
On an ongoing basis, obtain relevant records to monitor the ongoing physical and emotional status of the child including medical, psychological and/or school records as appropriate.
As necessary, consult with the Assistant Attorney General regarding any court action required to expedite gathering of medical records, to restrict or deny visitation, or to compel the suspected parent, guardian or custodian or other family members to
participate in assessment or treatment services.
For investigations, document outcomes of the assessment including collaboration and consultation with members of the MDT in Section II of the Child Safety and Risk Assessment.
For ongoing, document contacts including collaboration and consultation with the members of the MDT in case notes.
If the child is removed:
Complete the following windows in CHILDS when a temporary custody notice has been issued:
Document the search for relatives in the Locate Efforts case note type.