Abstract

In typical cases of Munchausen by proxy maltreatment, a mother feigns or produces illness in her child. Her primary goal is to accrue emotional gratification, and no mental disorder better accounts for the behavior. We present the first published case in which the principal manufactured ailment was celiac sprue. In addition, a panoply of other ailments ranging from seizures to behavioral abnormalities was reported. The case is also very unusual in the involvement of the paternal grandmother and, to a lesser extent, the paternal grandfather as the perpetrators. Although definitive intervention to protect the child occurred only after 7 years had passed, multidisciplinary teamwork ultimately resulted in a successful outcome for the child, who is now doing well.

Munchausen by proxy (MBP) is defined as the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care. ¹ Its complexity and uniqueness is illustrated by the fact that it can manifest as physical abuse, emotional abuse, sexual abuse, physical or emotional neglect, educational neglect, or a combination of these. Regardless, the perpetrator’s principal goal in all cases is emotional satisfaction, which can stem from garnering attention and nurturance; mobilizing attention as an indefatigable, even heroic caregiver; expressing rage or jealousy that is sometimes displaced from other people onto the child; or controlling others—including high-status professionals such as physicians who become unwitting “professional participants.”^2,3 In contrast, malingering involving children (so-called “malingering by proxy”⁴) involves the pursuit of external goals such as disability payments or opioid medications. ¹ In representative cases of MBP, the perpetrator of the medical and/or psychological abuse is the mother and the victim is her child. ³

Although reports have been published in which other gastrointestinal ailments, such as pseudo-obstruction, ⁵ bleeding, ⁶ and intractable diarrhea ⁷ have been fabricated, we present what we believe to be the first reported case in which MBP was manifested through false claims of celiac disease. The case is also very unusual in that the primary perpetrator was the child’s paternal grandmother and the paternal grandfather was actively complicit at times. Only three other published cases ^8,9 involving grandmothers as perpetrators were uncovered on a search of the MEDLINE, PsycINFO, and MD Consult computer databases, and there have been no previously published reports involving a grandfather.

Key Points

* In representative cases of Munchausen by proxy (MBP) abuse, a mother deliberately deceives doctors and others into believing that her child is physically and/or emotionally ill.

* Years may pass before physicians realize that the illnesses have been fabricated or induced.

* This is the first case to report fabricated celiac disease as the main manifestation of MBP and the first to report that the perpetrators were the paternal grandparents acting jointly.

* A key component of detection is the finding that the child’s health improves during separation from the suspected perpetrator.

* A multidisciplinary, multiagency approach assists with MBP confirmation, intervention, and ongoing child protection. These cases are uncommonly prosecuted criminally.