Drs. Teresa F. Parnell and Deborah O. Day didn't set out to be experts on Munchausen by proxy syndrome (MBPS). They got involved in 1989 when a local child protection agency selected Dr. Day to evaluate a woman suspected of having the disorder.

MBPS is a form of child abuse in which a caretaker fabricates and/or induces illness in a dependent person, usually a child. The induction or fabrication of illness can lead to numerous unneeded and painful medical procedures and can go on for years before detected.

The majority of mental health practitioners see, at most, one case of MSBP in their entire careers, so after Dr. Day had handled the 1989 case, she became the local "expert." By 1998, Drs. Parnell and Day had consulted on over 30 suspected cases of MSBP nationwide, and advised on 10 more cases.

In their newly published book "Munchausen by Proxy Syndrome: Misunderstood Child Abuse" they provide a comprehensive overview of MBPS, a psychotherapy model developed out of years of working with acknowledged perpetrators, and a multi-disciplinary approach to treating the disorder.

The problem is that the research about the disorder, especially research about successful treatment, is scant. This is the case because most perpetrators do not accept their diagnosis and discontinue therapy.

Their "secret thought pattern," according to Parnell and Day is that they are able to focus almost exclusively on themselves and able to dehumanize their children in order to meet their own needs for attention. When confronted, they often leave town and seek medical intervention elsewhere.

That was certainly the experience of one Tallahassee, Florida, psychologist, Dr. Larry Barlow, who was called in on a case of suspected MSBP several years ago. Barlow observed in this case something that Parnell and Day say is characteristic of many MBPS perpetrators - overall fabrication. Many MBPS patients fabricate not only about their child's illness and their own treatment of the child, but about almost every aspect of their lives.

Dr. Barlow noted that the woman he attempted to treat told grandiose stories about her family's wealth and social position before she discontinued therapy. As Parnell and Day point out, patients who fabricate about all aspects of their lives are the least likely to benefit from therapy.

Parnell and Day also found that the presence of an abusive spouse severely limited the success of therapy. They noted domestic violence to be prevalent in their clinical population of MSBP perpetrators.

The abusive spouse usually opposed treatment, often tried to undermine the process and even attempted to sabotage treatment entirely.

Successful treatment of MBPS perpetrators is difficult, but so is prosecution. Usually, a child abuse statute or some type of attempted murder charge is used to prosecute perpetrators. This involves proving that the alleged perpetrator was aware of the harm she was doing (MBPS perpetrators are almost always women).

The authors note in the book that very few courts have addressed the issue of MBPS, or admitted evidence of MBPS. The first case in which evidence of MBPS was introduced was in California where the court allowed an expert witness for the state to testify via a hypothetical question as to whether the mother willfully endangered the life of a child. But, two other state courts have barred admission of MBPS evidence.

MBPS evidence has been introduced during the sentencing phase in some cases and dependency courts have admitted evidence of MBPS to determine whether or not parent's rights should be terminated. Evidence of MBPS has also been admitted into evidence in divorce cases where custody was at issue.

Because many people, even those in the criminal justice system, have never heard of MBPS, educating law enforcement and court personnel about the disorder can be a challenge. Investigation is complicated and evidence gathering must be meticulous. Jurors must be able to understand complex medical issues. In addition, Parnell and Day characterize mother-perpetrators who actually believe their child is ill to be "some of the smoothest liars [law enforcement and prosecutors] will ever encounter."

This is an interesting book for mental health practitioners and anyone who would like to know more about this disturbing disorder.

For more information see Teresa F. Parnell and Deborah O. Day (Eds.) Munchausen by Proxy Syndrome: Misunderstood Child Abuse. Thousand Oaks: Sage Publications, 1998. There are also a number of sites on the Internet about MBPS.