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Semrau GM, Härlin R, Di Maria C, Schwartländer B, Winter SM. [Medical Child Abuse - A Guideline to Detecting this Particular Form of Child Maltreatment]. Prax Kinderpsychol Kinderpsychiatr 2024; 73:85-109. [PMID: 38275232 DOI: 10.13109/prkk.2024.73.1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
The term Medical Child Abuse (MCA) describes a form of child abuse in which the medical system is "abused" by carrying out unnecessary medical procedures on a child. This abuse of the medical system occurs through misrepresentation, non-disclosure, fabrication, misinterpretation or active causation of symptoms by a parent. In this article, the construct ofmedical child abuse is defined and predisposing and motivational factors are examined. It also provides an overview of terms that are used synonymously or comparably in the literature and discusses the connection between MCA and Munchausen-by-proxy-syndrome.The core of the article is the presentation of an internal guideline, which was created by the interdisciplinary working group on MCA of the Clinics for Paediatric and Adolescent Medicine, the Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, the Child Protection Outpatient Clinic and the Social Services at the Charité. It also outlines possible interventions.
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Affiliation(s)
- Gina-Melissa Semrau
- Forschungssektion Traumafolgen und Kinderschutz, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Campus Virchow, Charité - Universitätsmedizin Berlin Deutschland
| | - Ruth Härlin
- Forschungssektion Traumafolgen und Kinderschutz, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Campus Virchow, Charité - Universitätsmedizin Berlin Deutschland
| | - Caroline Di Maria
- Forschungssektion Traumafolgen und Kinderschutz, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Campus Virchow, Charité - Universitätsmedizin Berlin Deutschland
| | - Birgit Schwartländer
- Forschungssektion Traumafolgen und Kinderschutz, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Campus Virchow, Charité - Universitätsmedizin Berlin Deutschland
| | - Sibylle M Winter
- Lehrstuhl für Kinderschutz und Traumafolgen, Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters Charité Universitätsmedizin Berlin, Campus Virchow Klinikum Augustenburger Platz 1 13353 Berlin Deutschland
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Vega S, Nienow SM, Huang MZ, Stover LB. Medical Child Welfare Task Force: A Multidisciplinary Approach to Identifying Medical Child Abuse. Pediatrics 2023; 151:190491. [PMID: 36655381 DOI: 10.1542/peds.2022-058926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 01/20/2023] Open
Abstract
Medical child abuse is a complex form of maltreatment with powerful and long-lasting impacts on the overall health of affected children. The complexity of this condition renders it challenging for clinicians to recognize its presence and intervene appropriately. The failure of medical systems to identify and deescalate care in this form of maltreatment can result in grievous patient harm. Although the medical literature provides limited guidance on how to address these multifaceted cases, several studies advocate for a multidisciplinary approach. Following a severe and chronic case of medical child abuse at our institution, deficits in response became clear within our hospital system. In reaction to these gaps, the Medical Child Welfare Task Force was developed to formalize education and multidisciplinary collaboration around medical child abuse. The support of institutional leadership and the involvement of multiple medical disciplines that commonly encounter these patients was vital to the implementation and long-term success of the endeavor. To facilitate case identification, education was provided to clinicians in a variety of forums. Moreover, we leveraged the electronic medical record to streamline our ability to monitor cases of medical child abuse and communicate the concerns and plan of care to other providers, both within and outside of our health system. A postimplementation survey determined that the establishment of a multidisciplinary team increased provider comfort and skill in identifying and managing cases of suspected medical child abuse.
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Affiliation(s)
- Sarah Vega
- Child Abuse Pediatrics Division.,Department of Pediatrics, University of California, San Diego, California
| | - Shalon M Nienow
- Child Abuse Pediatrics Division.,Department of Pediatrics, University of California, San Diego, California
| | - Maria Z Huang
- Pediatric Hospital Medicine Division, Rady Children's Hospital, San Diego, California.,Department of Pediatrics, University of California, San Diego, California
| | - Laurie Bernard Stover
- Pediatric Hospital Medicine Division, Rady Children's Hospital, San Diego, California.,Department of Pediatrics, University of California, San Diego, California
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3
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Challenging Case: Caregiver-Fabricated Illness Masquerading as Autism Spectrum Disorder. J Dev Behav Pediatr 2023; 44:e66-e68. [PMID: 36394955 DOI: 10.1097/dbp.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022]
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4
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Wear KR, Li S. Guideline review: RCPCH perplexing presentations, fabricated or induced illness in children guidance 2021. Arch Dis Child Educ Pract Ed 2022; 107:288-291. [PMID: 34728544 DOI: 10.1136/archdischild-2021-322406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/13/2021] [Indexed: 11/03/2022]
Affiliation(s)
| | - Simon Li
- Paediatrics, Derby Hospitals Foundation Trust, Derby, UK
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5
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Sherry DD, Gmuca S, Christian CW. Recognizing medical child abuse in children presenting with chronic pain. Br J Pain 2022; 16:433-438. [PMID: 36032349 PMCID: PMC9411756 DOI: 10.1177/20494637221075186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Medical child abuse (MCA), previously referred to as Munchausen by proxy, can present as chronic pain. We report the presentation of five children seeking treatment for chronic pain who we identified as victims of MCA. The index case had essentially not eaten for the 6 years of her life due to alleged allergies to all foods, developed severe pain, used a wheelchair for ambulation beyond a few blocks, and was alleged to have dysautonomia requiring oxygen monitoring at night. Other cases posed as arthritis that resulted in foot amputation and total body pain, fibromyalgia with alleged mutation negative Stickler syndrome who had symptoms only in her mother's presence, severe incapacitating intermittent pains along with abdominal pain that resulted in appendectomy, cholecystectomy, and pancreatectomy, and alleged disabling hypermobile Ehlers-Danlos in a non-hypermobile child for which the mother sought a power wheelchair. The unusual pattern to the pain, the presence of multiple additional, atypical symptoms and diagnoses, and a generally well appearing child are characteristic. The perpetrator is typically over-invested in the symptoms, derives tangible and intangible secondary gain from the child's alleged illnesses, and is able to present the child in such a fashion to enlist the physician to aid in perpetuating the abuse. These children are highly over-medicalized and suffer significant morbidity. Multiple barriers exist to identifying and reporting these children to Child Protective Services, which need to be recognized and overcome in order to protect these vulnerable children.
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Affiliation(s)
- David D Sherry
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sabrina Gmuca
- Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, PA, USA
- Policy Lab, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, PA, USA
| | - Cindy W Christian
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Khalil AA, Torbey J, Akoury-Dirani L, Alameddine RM. Difficult diagnosis of factitious disorder. BMJ Case Rep 2022; 15:e244699. [PMID: 35787502 PMCID: PMC9255364 DOI: 10.1136/bcr-2021-244699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/03/2022] Open
Abstract
Factitious disorder imposed on another, or medical child abuse, has been rarely reported to have primary ocular presentations. We report an unusual and difficult diagnosis of factitious disorder imposed by a mother on her infant resulting in bilateral blindness. An infant was referred with a history of recurrent periorbital cellulitis and sanguineous discharge associated with seizure-like episodes. Symptoms have been going on for more than 14 months, and child had been treated by different physicians from different specialties without a clear ophthalmic diagnosis. The right eye was previously enucleated at an outside hospital for secondary complications of similar symptoms. He was admitted for exhaustive diagnostic tests and multiple surgical treatments, and his hospital stay was complicated with multiple corneal perforations and apnoeic episodes despite optimal treatment. After suspicion of factitious disease, continuous electroencephalography and video monitoring revealed evidence of the mother inflicting physical harm to her child.
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Affiliation(s)
- Ali A Khalil
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Julien Torbey
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Leila Akoury-Dirani
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ramzi M Alameddine
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
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Munchausen syndrome by proxy (MSBP): a review regarding perpetrators of factitious disorder imposed on another (FDIA). CNS Spectr 2022; 27:16-26. [PMID: 32772954 DOI: 10.1017/s1092852920001741] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Munchausen syndrome by proxy (MSBP) is well-known to clinicians, but its usage is discouraged now in favor of other terms placing emphasis on the victim. This study aims to determine the most common characteristics of perpetrators but only in case reports labeled as MSBP, published in PubMed literature in the past 15 years. MSBP has been described as a rare form of abuse due to illness falsification, where the perpetrator usually receives the diagnosis of factitious disorder imposed on another (FDIA). We extracted data from 108 articles, including 81 case reports. Almost all perpetrators were female (91% female, 1% female and male, 7% unreported). Twenty-three cases (28%) had a perpetrator with psychiatric diagnosis: factitious disorder imposed on self (10%), depression (9%), and personality disorders (7%). In more than one-third (36%) there was familial conflict or abuse. Fourteen cases (17%) had perpetrators working in healthcare. The most common type of falsification was induction (74%); however, 15% of cases had more than one type of falsification. The most common outcomes were: separation (37%); no follow-up (22%); imprisonment (14%); death of victim (12%); treatment of the perpetrator (10%); continued living together (4%); and suicide of perpetrator (1%). Recurrence was present in more than three quarters of cases. Our results reiterate that awareness of the most common findings in MSBP allows physicians to identify them in a clinical context.
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Gupta P, Pulikkaparambil R, Jain V. Fabricated Diabetes Mellitus: A Rare Presentation of Munchausen Syndrome by Proxy. Indian J Pediatr 2022; 89:88. [PMID: 34661858 DOI: 10.1007/s12098-021-03989-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Priyanka Gupta
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Vandana Jain
- Division of Pediatric Endocrinology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Hornor G. Medical Child Abuse: Essentials for Pediatric Health Care Providers. J Pediatr Health Care 2021; 35:644-650. [PMID: 33589306 DOI: 10.1016/j.pedhc.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/24/2021] [Indexed: 11/16/2022]
Abstract
Medical child abuse (MCA) is a rare but potentially deadly variant of child maltreatment. MCA results in unnecessary health care for a child because of a caregiver's exaggeration, fabrication, or induction of physical and/or psychological symptoms of illness. These unnecessary health care interventions result in a morbidity rate of 100% in the form of complications and disabilities and a mortality rate as high as 9%. Although MCA is relatively rare, it is estimated that pediatric health care professionals, including pediatric nurse practitioners, will most likely encounter at least one MCA victim in the course of their career. This continuing education article will discuss MCA in terms of definition and features, epidemiology, perpetrators, variants in presentation, consequences, and implications for practice.
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Abebe E, Scanlon MC, Chen H, Yu D. Complexity of Documentation Needs for Children With Medical Complexity: Implications for Hospital Providers. Hosp Pediatr 2021; 10:670-678. [PMID: 32727931 DOI: 10.1542/hpeds.2020-0080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Care coordination is a core component of pediatric complex care programs (CCPs) supporting children with medical complexity (CMC) and their families. In this study, we aim to describe the purpose and characteristics of clinical care notes used within a pediatric CCP. METHODS We conducted observations of provider-family interactions during CCP clinic visits and 5 focus groups with members of the CCP. Focus groups were recorded and transcribed. Field observation notes and focus group transcripts were subjected to qualitative content analyses. RESULTS Four major themes help characterize clinical care notes: (1) Diversity of note types and functions: program staff author and use a number of unique note types shared across multiple stakeholders, including clinicians, families, and payers. (2) motivations for care note generation are different and explain how, why, and where they are created. (3) Program staff roles and configuration vary in relation to care note creation and use. (4) Sources of information for creating and updating notes are also diverse. Given the disparate information sources, integrating and maintaining up-to-date information for the child is challenging. To minimize information gaps, program staff devised unique but resource-intensive strategies, such as accompanying families during specialty clinic visits or visiting them inpatient. CONCLUSIONS CMC have complex documentation needs demonstrated by a variety of professional roles, care settings, and stakeholders involved in the generation and use of notes. Multiple opportunities exist to redesign and streamline the existing notes to support the cognitive work of clinicians providing care for CMC.
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Affiliation(s)
- Ephrem Abebe
- Department of Pharmacy Practice, College of Pharmacy and
| | - Matthew C Scanlon
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Haozhi Chen
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana; and
| | - Denny Yu
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana; and
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Hamilton JC, Leventhal JM, Asnes AG. Origins and Early Management of Medical Child Abuse in Routine Pediatric Care. JAMA Pediatr 2021; 175:771-772. [PMID: 33999102 DOI: 10.1001/jamapediatrics.2021.0919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- James C Hamilton
- Department of Psychology, University of Alabama, Tuscaloosa.,Department of Internal Medicine, University of Alabama, Tuscaloosa
| | - John M Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Andrea G Asnes
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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12
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Brassard MR, Hart SN, Glaser D. Psychological maltreatment: An international challenge to children's safety and well being. CHILD ABUSE & NEGLECT 2020; 110:104611. [PMID: 32660756 DOI: 10.1016/j.chiabu.2020.104611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Child psychological maltreatment (PM), also known as emotional abuse and neglect, mental violence, and emotional maltreatment, is the least recognized and addressed of the four major forms of child maltreatment. OBJECTIVES This article provides an 1) the history of PM and its relationship to children's rights, 2) an overview of the current state of knowledge, 3) implications of diversity for the topic of PM, 4) an example of a topic-relevant intervention, and 5) a vision for further progress in addressing this form of child maltreatment. PARTICIPANTS AND SETTINGS NA. METHOD Literature review, intervention description of fabricated or induced illness, and expert opinion. RESULTS PM is directly implicated in seven of the articles of the Convention. PM is common, reliable definitions of PM exist and need to be applied to practice and public health surveillance, harmfulness has been empirically established but is not fully appreciated, and countries vary dramatically in terms of incidence. CONCLUSIONS PM is a human rights issue that must be addressed through child protection and promotion of child wellbeing. Adoption of reliable definitions of the different aspects of PM for Child Protective Service practice is a top policy goal. The development of empirically supported curricula on PM for training professionals and parents and culturally sensitive interventions to change social norms on the use of psychologically aggressive disciplinary practices and other forms of PM are critical research needs. Well-validated interventions to support quality parent-child relationships and support families exist and need to be widely adopted. Individual child protective measures should be confined to cases of ongoing serious PM when interventions have failed to reduce harm to the child.
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Affiliation(s)
| | - Stuart N Hart
- Indiana University Purdue University at Indianapolis, USA
| | - Danya Glaser
- Great Ormond Street Hospital for Children and University College, London, UK
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Abstract
Children with medical complexity (CMC) are a unique pediatric patient population with increased exposure and interactions with the health care system and reliance on family caregivers. These attributes place CMC at high risk of overmedicalization (OM). This article reviews the risk factors for OM in CMC and presents an algorithm that primary providers can use to recognize and address this issue. Involvement of a broad multidisciplinary team, including child advocacy when needed, is recommended. The article also focuses on challenges and additional considerations that arise when medical child abuse as the cause of OM is suspected in this population. [Pediatr Ann. 2020;49(11):e478-e485.].
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Glaser D. Fabricated or induced illness: From "Munchausen by proxy" to child and family-oriented action. CHILD ABUSE & NEGLECT 2020; 108:104649. [PMID: 32805620 DOI: 10.1016/j.chiabu.2020.104649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/22/2020] [Accepted: 07/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND In fabricated or induced illness (FII), a child is harmed due to caregiver(s) behaviour and actions, carried out to convince mainly doctors that the child's physical and/or psychological health is more impaired than in reality. Harm is caused directly by the caregivers(s) and also often inadvertently by doctors' responses. OBJECTIVES To describe: dynamics underlying FII; wider definition of FII; alerting signs for early recognition of possible FII; respective responsibilities of health, social care, education. METHODS Literature review, clinical experience, expert opinion. RESULTS AND CONCLUSIONS Caregivers are motivated by gain from having their child treated as ill, and/or by erroneous beliefs about their child's health, either way needing medical confirmation about their contentions. Their behaviour is therefore directed primarily towards doctors. Most cases of FII present unexplained discrepancies between caregiver reports/actions and independent observations of the child. More rarely, the child has actual signs of illness, induced by the caregiver, occasionally fatal. Children are harmed in all aspects of life: health, daily functioning including education, and psychologically. Harm emanates directly from the caregiver(s) but also unintentionally from medical responses. Illness induction and clear deception by the caregiver require immediate child protection. Otherwise, the initial focus is on assessing the child's current health and functioning rather than caregiver's mental health. If, beyond verified illness, there is no medical explanation for the child's reported ill-health, the family require help to function better. This requires co-ordinated, multidisciplinary rehabilitation and long-term monitoring. If caregivers refuse rehabilitation, child protection is required. Several unanswered questions remain.
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Affiliation(s)
- Danya Glaser
- Great Ormond Street Hospital for Children, London, WC1N 3JH, England.
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Affiliation(s)
- Sasha Ban
- Senior Lecturer in Children and Young People's Nursing, Northumbria University
| | - Daryl Shaw
- Staff Nurse, Paediatric Critical Care, Royal Manchester Children's Hospital
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Iwanaga N, Yamamoto K, Takazono T, Saijo T, Imamura Y, Miyazaki T, Izumikawa K, Yamamoto Y, Yanagihara K, Yasuoka A, Mukae H. Munchausen syndrome mimicking refractory subcutaneous abscess with bacteremia, diagnosed by repetitive element sequence-based polymerase chain reaction: a case report. J Med Case Rep 2019; 13:287. [PMID: 31511062 PMCID: PMC6740024 DOI: 10.1186/s13256-019-2212-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022] Open
Abstract
Background Rapid diagnosis and appropriate treatment of Munchausen syndrome is important not only for the patient but also for health care workers because a delay in diagnosis can worsen patients’ clinical outcomes, and result in a substantial medical cost. Case presentation A young and previously healthy 24-year-old Japanese woman, a nurse, presented with complaints of refractory abscess on her left upper limb for 3 months. A physical examination on admission revealed low-grade fever and a subcutaneous abscess in her left forearm. Laboratory data suggested mild systemic inflammation and liver dysfunction, but no abnormalities of the immune system, including changes in the number of lymphocytes and neutrophils, neutrophil phagocytic capacity, and natural killer (NK) cell activity, were observed. A human immunodeficiency virus test was also negative. Multiple modalities, including positron emission tomography-computed tomography, failed to detect any cause and focus of infection except her left upper limb. Streptococcus mitis and Prevotella buccae were detected from the wound, but no microorganisms were detected in a blood culture. The cellulitis promptly resolved; however, exacerbation of the subcutaneous abscess with polymicrobial bacteremia repeatedly occurred unexpectedly. Because of this puzzling clinical course, the possibility of self-injury was finally suspected. Three syringes with needles, with a turbid liquid, were found in our patient’s bag. Enterobacter cloacae and Enterococcus faecalis were detected in the liquid, and an analysis via repetitive element sequence-based polymerase chain reaction determined that Enterococcus faecalis in the wound and syringe contents were genetically identical. She was diagnosed as having Munchausen syndrome and treated with the collaboration of a psychiatrist. She finally confessed that she had injected her own saliva and toilet water into the drip line and wound. Conclusions This case report is valuable in that it is the first case in which this syndrome was diagnosed by a genetic method. Munchausen syndrome should not be neglected as a possible cause of refractory and recurrent infection.
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Affiliation(s)
- Naoki Iwanaga
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.,Division of Respiratory Medicine, National Hospital Organization, Nagasaki Medical Center, Omura, Japan
| | - Kazuko Yamamoto
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan. .,Department of Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan. .,Division of Respiratory Medicine, National Hospital Organization, Nagasaki Medical Center, Omura, Japan.
| | - Takahiro Takazono
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomomi Saijo
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yoshifumi Imamura
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Koichi Izumikawa
- Department of Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Toyama University Hospital, Toyama, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Akira Yasuoka
- Division of Internal Medicine, Omura Municipal Hospital, Omura, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Cardona L, Asnes AG. Disclosure of caregiver-fabricated illness to a child: A team-based approach to communicating with pediatric patients. Clin Child Psychol Psychiatry 2019; 24:494-502. [PMID: 30623688 DOI: 10.1177/1359104518816122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical practice guidelines for informing children they have been subjected to caregiver-fabricated illness are highly limited in the current literature. This article addresses this issue by offering an ethically informed, psychological approach to the disclosure of this form of abuse to school-aged children and adolescents who have been significantly harmed. A multidisciplinary, staged model of communication which illustrates that truthful communication with children and their families is a necessary component of the recovery process is proposed.
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Kelley DM, Curran KA. Medical Child Abuse: An Unusual "Source" of Vaginal Bleeding. J Pediatr Adolesc Gynecol 2019; 32:334-336. [PMID: 30923026 DOI: 10.1016/j.jpag.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/12/2019] [Accepted: 03/12/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Medical child abuse (MCA) is challenging to diagnose. Although young children are often affected, adolescents can be victims through caregiver coercion. Presentation is highly variable. Diagnosis is essential because of high associated morbidity and mortality. CASE We describe the case of a 12-year-old girl who presented to multiple subspecialty clinics with reported menorrhagia. Despite reassuring clinical examinations, the family described menorrhagia that failed to respond to standard treatment. After an urgent evaluation for reported heavy bleeding revealed only scant blood, the diagnosis of MCA was made. SUMMARY AND CONCLUSION Vaginal bleeding is a rare presentation of MCA, but must be considered whenever reported symptomatology does not follow physiologic patterns, respond to standard medical treatment, or correspond to clinical evaluation. Prompt identification is important to prevent further harm.
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Affiliation(s)
- David M Kelley
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Kelly A Curran
- Section of Adolescent Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
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Sanders MJ, Bursch B. Psychological Treatment of Factitious Disorder Imposed on Another/Munchausen by Proxy Abuse. J Clin Psychol Med Settings 2019; 27:139-149. [PMID: 31089919 DOI: 10.1007/s10880-019-09630-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lopez-Rico M, Lopez-Ibor JJ, Crespo-Hervas D, Muñoz-Villa A, Jimenez-Hernandez JL. Diagnosis and Treatment of the Factitious Disorder on Another, Previously Called Munchausen Syndrome by Proxy. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s42399-019-00057-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Munchausen syndrome and Munchausen syndrome by proxy are complex diseases that are difficult to diagnose and treat. To assist in this process, an overview of diagnostic criteria with common characteristics and red flags are discussed, with case studies illustrating identification and diagnosis of these disorders. Treatment options are addressed within the context of each of these complex syndromes. The provider's knowledge of diagnostic criteria and treatment options for Munchausen syndrome and Munchausen syndrome by proxy promotes better outcomes for patients. Without an early diagnosis and intervention, the patient is at high risk for severe complications, including organ failure and mortality.
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Affiliation(s)
- Brittany Abeln
- University of Arizona, College of Nursing, 1305 N. Martin Avenue, Tucson, AZ 85721, USA.
| | - Rene Love
- University of Arizona, College of Nursing, 1305 N. Martin Avenue, Tucson, AZ 85721, USA
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22
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Marty C, Alvey JC, Mann K, Murphy NA. Addressing Over-Medicalization in Children with Medical Complexity. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-0205-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Davis P, Murtagh U, Glaser D. 40 years of fabricated or induced illness (FII): where next for paediatricians? Paper 1: epidemiology and definition of FII. Arch Dis Child 2019; 104:110-114. [PMID: 29618482 DOI: 10.1136/archdischild-2017-314319] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 11/03/2022]
Affiliation(s)
- Paul Davis
- Community Child Health Directorate, Cardiff and Vale University Health Board, Cardiff, CF11 9XB, UK
| | - Una Murtagh
- Community Child Health Directorate, Cardiff and Vale University Health Board, Cardiff, UK
| | - Danya Glaser
- Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
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van Gemert MJC, Vlaming M, Osinga E, Bruijninckx CMA, Neumann HAM, Sauer PJJ. Pediatric Condition Falsification Misdiagnosed by Misjudged Weight Growth from the Curve of Measured Weights. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:752-756. [PMID: 29946058 PMCID: PMC6053948 DOI: 10.12659/ajcr.908770] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Male, 0–2 Final Diagnosis: Cow milk allergy Symptoms: Obstipation • airway infections Medication: — Clinical Procedure: Elementary feeding Specialty: Pediatrics
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Affiliation(s)
- Martin J C van Gemert
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, Doetinchem, Netherlands
| | - Eric Osinga
- Private Practice, Osinga Advocatuur (Law Office), Utrecht, Netherlands
| | | | | | - Pieter J J Sauer
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, Netherlands
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25
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Kapfhammer HP. Artifizielle Störungen. PSYCHOTHERAPEUT 2018. [DOI: 10.1007/s00278-018-0276-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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26
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Ferrara P, Sbordone A, Del Vescovo E, Ianniello F, Ruggiero A. Il bambino violato: aspetti moderni del maltrattamento che il pediatra deve conoscere. MALTRATTAMENTO E ABUSO ALL'INFANZIA 2018:103-117. [DOI: 10.3280/mal2018-001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
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27
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Adshead G, Guthrie E. The role of attachment in medically unexplained symptoms and long-term illness. BJPSYCH ADVANCES 2018. [DOI: 10.1192/apt.bp.114.013045] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummaryIn this article, we explore the role of attachment in the development of medically unexplained symptoms (MUS) and response to physical illness. We review the evidence that attachment insecurity is common in people with different forms of MUS and certain long-term physical conditions. We discuss a possible developmental model for understanding how MUS develop. We conclude with discussion of potential therapies and implications for services.
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28
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Yates G, Bass C. The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases. CHILD ABUSE & NEGLECT 2017; 72:45-53. [PMID: 28750264 DOI: 10.1016/j.chiabu.2017.07.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/30/2017] [Accepted: 07/14/2017] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Little is known about the perpetrators of medical child abuse (MCA) which is often described as "Munchausen's syndrome by proxy" or "factitious disorder imposed on another". The demographic and clinical characteristics of these abusers have yet to be described in a sufficiently large sample. We aimed to address this issue through a systematic review of case reports and series in the professional literature. METHOD A systematic search for case reports and series published since 1965 was undertaken using MEDLINE, Web of Science and EMBASE. 4100 database records were screened. A supplementary search was then conducted using GoogleScholar and reference lists of eligible studies. Our search yielded a total sample of 796 perpetrators: 309 from case reports and 487 from case series. Information extracted included demographic and clinical characteristics, in addition to methods of abuse and case outcomes. RESULTS Nearly all abusers were female (97.6%) and the victim's mother (95.6%). Most were married (75.8%). Mean caretaker age at the child's presentation was 27.6 years. Perpetrators were frequently reported to be in healthcare-related professions (45.6%), to have had obstetric complications (23.5%), or to have histories of childhood maltreatment (30%). The most common psychiatric diagnoses recorded were factitious disorder imposed on self (30.9%), personality disorder (18.6%), and depression (14.2%). CONCLUSIONS From the largest analysis of MCA perpetrators to date, we provide several clinical recommendations. In particular, we urge clinicians to consider mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder at heightened risk for MCA. Longitudinal studies are required to establish the true prognostic value of these factors as our method may have been vulnerable to publication bias.
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Affiliation(s)
- Gregory Yates
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London SE5 8AF, United Kingdom.
| | - Christopher Bass
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
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Abstract
Patients with factitious disorders intentionally fabricate, exaggerate or feign physical and/or psychiatric symptoms for various open and covert psychological reasons. There are many issues regarding the diagnostic state and classification of factitious disorders. Both the categorical differentiation of and clinical continuum ranging from somatoform/dissociative disorders to malingering are being controversially debated. Epidemiological studies on the frequency of factitious disorder meet basic methodological difficulties. Reported rates of prevalence and incidence in the professional literature most probably have to be considered underestimations. Illness deception and self-harm as core features of the abnormal illness behaviour in factitious disorder may refer to various highly adverse and traumatic experiences during early development in a subgroup of patients. Chronic courses of illness prevail; however, there are also episodic variants.
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Affiliation(s)
- H-P Kapfhammer
- Klinik für Psychiatrie und Psychotherapeutische Medizin, Medizinische Universität Graz, Auenbruggerplatz 31, 8036, Graz, Österreich.
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30
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Wittkowski H, Hinze C, Häfner-Harms S, Oji V, Masjosthusmann K, Monninger M, Grenzebach U, Foell D. Munchausen by proxy syndrome mimicking systemic autoinflammatory disease: case report and review of the literature. Pediatr Rheumatol Online J 2017; 15:19. [PMID: 28381287 PMCID: PMC5382472 DOI: 10.1186/s12969-017-0152-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/27/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Systemic autoinflammatory diseases (SAIDs) represent a growing number of monogenic, polygenic or multifactorial disorders that are often difficult to diagnose. CASE PRESENTATION Here we report a patient who was initially erroneously diagnosed and treated for SAID. Symptoms consisted of recurrent fever, erythematous and/or blistering skin lesions, angioedema, susceptibility to bleeding, external ear infections and reversible anisocoria in the absence of laboratory evidence of systemic inflammation. After two and a half years of extensive diagnostic work-up and multiple empirical therapies, a final diagnosis of Munchausen by proxy syndrome (MBPS) was established. CONCLUSIONS The diagnosis of SAID needs to be carefully reassessed if measurable systemic inflammation is missing, and MBPS should be included in the differential diagnosis.
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Affiliation(s)
- Helmut Wittkowski
- Department of Paediatric Rheumatology and Immunology, University Children's Hospital Muenster, Albert-Schweitzer-Campus 1, Bld. W30, D-48149, Muenster, Germany.
| | - Claas Hinze
- grid.16149.3bDepartment of Paediatric Rheumatology and Immunology, University Children’s Hospital Muenster, Albert-Schweitzer-Campus 1, Bld. W30, D-48149 Muenster, Germany
| | - Sigrid Häfner-Harms
- grid.16149.3bDepartment of General Pediatrics, University Children’s Hospital Muenster, Muenster, Germany
| | - Vinzenz Oji
- grid.16149.3bDepartment of Dermatology, University Hospital Muenster, Muenster, Germany
| | - Katja Masjosthusmann
- grid.16149.3bDepartment of General Pediatrics, University Children’s Hospital Muenster, Muenster, Germany
| | - Martina Monninger
- grid.16149.3bDepartment of General Pediatrics, University Children’s Hospital Muenster, Muenster, Germany
| | - Ulrike Grenzebach
- grid.16149.3bDepartment of Ophthalmology, University Hospital Muenster, Muenster, Germany
| | - Dirk Foell
- grid.16149.3bDepartment of Paediatric Rheumatology and Immunology, University Children’s Hospital Muenster, Albert-Schweitzer-Campus 1, Bld. W30, D-48149 Muenster, Germany
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31
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Moreno-Ariño M, Bayer A. Munchausen syndrome by proxy-illness fabricated by another in older people. Age Ageing 2017; 46:166-167. [PMID: 27856413 DOI: 10.1093/ageing/afw217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/03/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
- Marc Moreno-Ariño
- Fundacio Hospital Asil de Granollers, Servicio de Geriatría, Granollers, Catalunya, Spain
| | - Antony Bayer
- Department of Geriatric Medicine, Cardiff University School of Medicine, University Hospital Llandough, Penarth CF64 2XX, UK
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32
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Petska HW, Gordon JB, Jablonski D, Sheets LK. The Intersection of Medical Child Abuse and Medical Complexity. Pediatr Clin North Am 2017; 64:253-264. [PMID: 27894448 DOI: 10.1016/j.pcl.2016.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Children with medical complexity and victims of medical child abuse may have similar clinical presentations. Atypical or unexplained signs and symptoms due to rare diseases may lead providers to suspect medical child abuse when not present. Conversely, medical child abuse may be the cause of or coexist with medical complexity. Careful consideration of whether or not medical child abuse is present is essential when assessing a child with medical complexity since either diagnosis has significant consequences for children and families.
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Affiliation(s)
- Hillary W Petska
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - John B Gordon
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Lynn K Sheets
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
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33
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Braham MY, Jedidi M, Chkirbene Y, Hmila I, ElKhal MC, Souguir MK, Ben Dhiab M. Caregiver-Fabricated Illness in a Child: A Case Report of Three Siblings. JOURNAL OF FORENSIC NURSING 2017; 13:39-42. [PMID: 28212199 DOI: 10.1097/jfn.0000000000000141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver inducing a child's illness, leading to unnecessary and potentially harmful medical procedures and treatments. This condition can result in significant morbidity and mortality. We present the case of three siblings in Tunisia who were poisoned with chloralose by their own mother. The symptoms that the children presented with led to misdiagnoses, which resulted in the death of two of the children. Characteristics of the clinical presentation are articulated, followed by a discussion of the legal measures that apply to the offender and the role of physicians, nurses, and medicolegal experts involved in such a complex medical situation.
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34
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35
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Barros AJS, Rosa RG, Telles LEDB, Taborda JGV. Attempted Serial Neonaticides: Case Report and a Brief Review of the Literature. J Forensic Sci 2016; 61:280-3. [DOI: 10.1111/1556-4029.12873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/29/2014] [Accepted: 12/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Alcina Juliana Soares Barros
- Instituto Psiquiátrico Forense Maurício Cardoso; Avenida Diário de Notícias n 200, Room 909, PO Box 90810080 Porto Alegre Brazil
- Universidade Federal do Rio Grande do Sul; Rua São Manoel, 963- Rio Branco, Porto Alegre - RS, 90620-110 Brazil
| | - Regis Goulart Rosa
- Instituto Psiquiátrico Forense Maurício Cardoso; Avenida Diário de Notícias n 200, Room 909, PO Box 90810080 Porto Alegre Brazil
- Universidade Federal do Rio Grande do Sul; Rua São Manoel, 963- Rio Branco, Porto Alegre - RS, 90620-110 Brazil
| | - Lisieux Elaine de Borba Telles
- Instituto Psiquiátrico Forense Maurício Cardoso; Avenida Diário de Notícias n 200, Room 909, PO Box 90810080 Porto Alegre Brazil
- Universidade Federal do Rio Grande do Sul; Rua São Manoel, 963- Rio Branco, Porto Alegre - RS, 90620-110 Brazil
| | - José Geraldo Vernet Taborda
- Instituto Psiquiátrico Forense Maurício Cardoso; Avenida Diário de Notícias n 200, Room 909, PO Box 90810080 Porto Alegre Brazil
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36
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Rabago J, Marra K, Allmendinger N, Shur N. The clinical geneticist and the evaluation of failure to thrive versus failure to feed. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2015; 169:337-48. [DOI: 10.1002/ajmg.c.31465] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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37
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Piram M, Koné-Paut I. [Recurrent fevers in childhood]. Presse Med 2015; 44:1266-75. [PMID: 26549686 DOI: 10.1016/j.lpm.2015.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 07/07/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022] Open
Abstract
Recurrent fevers are defined as multiple stereotypical febrile episodes separated by spontaneous symptom-free intervals and occurring for months and years. Hereditary recurrent fevers are rare prototype Mendelian diseases due to inherited mutations in genes encoding partners of the innate immunity. Recurrent episodes of fever plus acute features of inflammation starting during childhood with family history are the main clues for suspecting HRF. Their common associated complication is AA amyloidosis. The diagnosis is made on clinical grounds but the genetic diagnosis may contribute in most cases of monogenic hereditary recurrent fevers. Recurrent fevers must be distinguished from intermittent fevers, mostly infectious, characterized by variation in associated symptoms from episode-to-episode and without periodicity.
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Affiliation(s)
- Maryam Piram
- AP-HP, université Paris Sud, CHU de Bicêtre, centre de référence des maladies auto-inflammatoires de l'enfant (CeRéMAI)(1), service de rhumatologie pédiatrique, 78, rue du Général-Leclerc, 94270 le Kremlin-Bicêtre, France.
| | - Isabelle Koné-Paut
- AP-HP, université Paris Sud, CHU de Bicêtre, centre de référence des maladies auto-inflammatoires de l'enfant (CeRéMAI)(1), service de rhumatologie pédiatrique, 78, rue du Général-Leclerc, 94270 le Kremlin-Bicêtre, France
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Rabbone I, Galderisi A, Tinti D, Ignaccolo MG, Barbetti F, Cerutti F. Case Report: When an Induced Illness Looks Like a Rare Disease. Pediatrics 2015; 136:e1361-5. [PMID: 26438710 DOI: 10.1542/peds.2014-4165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 11/24/2022] Open
Abstract
The recognition of fabricated illness (FI) in a child represents a diagnostic challenge. The suspicion of FI often arises from the discrepancy between laboratory tests and clinical history. For instance, (unnecessary) insulin injections by caregivers has been widely described as a common cause of factitious hypoglycemia that may be inferred from discrepancies between plasma insulin and c-peptide. However, contemporary administration of insulin with an insulin secretagogue (glyburide), and of additional drugs, can make the diagnostic pathway problematic. We report the case of a child 4 years and 11 months old, admitted for alternance of hypo- and hyperglycemia associated with hirsutism, hypokalemia, nephrocalcinosis, and neurodevelopmental delay. All these features were compatible with Rabson-Mendenhall syndrome, a rare disorder of severe insulin resistance linked to mutations of insulin receptor. At admission, plasma insulin levels were high during hypoglycemic episodes, but c-peptide was repeatedly in the normal range. The genetic analysis of insulin receptor was negative. The story of previous hospital admissions, inconsistency between insulin and c-peptide values, and association between hypoglycemic episodes in the child with the presence of the mother, raised the suspicion of FI. This hypothesis was confirmed by a video recording that revealed the administration by the mother of multiple drugs (insulin, glyburide, progesterone, and furosemide) that mimicked most of the features of Rabson-Mendenhall syndrome, including hirsutism and hypoglycemia with coincident, inappropriately normal c-peptide values due to the administration of the insulin secretagogue. Our case indicates that inconsistency among consecutive diagnostic tests should be regarded as a clue of FI.
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Affiliation(s)
- Ivana Rabbone
- Department of Pediatrics, University of Turin, Turin, Italy;
| | - Alfonso Galderisi
- Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Davide Tinti
- Department of Pediatrics, University of Turin, Turin, Italy
| | | | - Fabrizio Barbetti
- Department of Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy; and Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Franco Cerutti
- Department of Pediatrics, University of Turin, Turin, Italy
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39
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Affiliation(s)
- David Isaacs
- Children's Hospital at Westmead, Sydney, New South Wales, Australia
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40
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Shur N, Carey JC. Genetic differentials of child abuse: Is your case rare or real? AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2015; 169:281-8. [PMID: 26513547 DOI: 10.1002/ajmg.c.31464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The clinical geneticist can be called upon to play a role in the medical evaluation of children with clinical findings concerning for child abuse. This Introduction describes a case of suspected child abuse in an 8-month-old baby referred to clinical genetics to exclude osteogenesis imperfecta. The experience from this case raised medical and ethical considerations and prompted consideration of the role of the clinical geneticist in distinguishing rare mimics of child abuse from real cases. From this single case, and a discussion regarding similar cases, arose the idea of this issue in Seminars in Medical Genetics, Genetic Differentials of Child Abuse: Is Your Case Rare or Real? In thinking about child abuse from a clinical genetics perspective, we categorize clinical presentations into fractures, skin lesions, hemorrhage, growth disturbances, and concern for caregiver-fabricated illness (previously known as Munchausen syndrome by proxy). In this Introduction, we also discuss recent questions regarding Ehlers-Danlos syndrome and infantile fractures and concerns about caregiver-fabricated illness in the context of mitochondrial or other rare diseases. The goal is that this issue on child abuse and genetics will serve as a resource to help distinguish the rare causes from the real cases of child abuse, and those critical distinctions and correct diagnoses may be life-saving for some infants and children.
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41
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Basch MC, Chow ET, Logan DE, Schechter NL, Simons LE. Perspectives on the clinical significance of functional pain syndromes in children. J Pain Res 2015; 8:675-86. [PMID: 26504406 PMCID: PMC4605245 DOI: 10.2147/jpr.s55586] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Functional pain syndromes (FPS) characterize a subset of individuals who experience pain and related symptoms and disability without clear structural or disease etiology. In the pediatric population, FPS hold high clinical importance due to significant prevalence rates and potential to persist into adulthood. Although extensive research has been executed to disambiguate FPS, the syndromes that fall within its spectrum remain conceptually complex and sometimes ill-defined. This paper provides an overview of available research on the classification and multifaceted etiology of FPS in youth and their effects on interpersonal, psychological, and familial function. Vital aspects of a successful multidisciplinary approach to treating this population are described; however, it is evident that future research requires more longitudinal studies.
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Affiliation(s)
- Molly C Basch
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston University, Boston, MA, USA
- Boston Children’s Hospital, Center for Pain and the Brain, PAIN Research Group, Boston University, Boston, MA, USA
| | - Erika T Chow
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston University, Boston, MA, USA
- Boston University School of Medicine, Boston University, Boston, MA, USA
| | - Deirdre E Logan
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston University, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Neil L Schechter
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Laura E Simons
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston University, Boston, MA, USA
- Boston Children’s Hospital, Center for Pain and the Brain, PAIN Research Group, Boston University, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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42
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Nimmo SB. Illness deception. Occup Med (Lond) 2015; 65:514-6. [DOI: 10.1093/occmed/kqv118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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43
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Fabricated or induced illness in the oral cavity in children. A systematic review and personal experience. Cent Eur J Immunol 2015; 40:109-14. [PMID: 26155192 PMCID: PMC4472548 DOI: 10.5114/ceji.2015.50842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 12/05/2014] [Indexed: 11/17/2022] Open
Abstract
Introduction Münchausen syndrome by proxy (MSBP) describes a pattern in which a caregiver induces a disease in a child. The symptoms may manifest in the oral cavity. Material and methods PubMed was researched for articles between 1990-2014, presenting manifestations of MSPB, following PRISMA 2009 guidelines, and an in-house case of MSBP with oral manifestations was presented. Review Among 66 articles presenting MSBP symptoms, four included descriptions of oral lesions in five children. They included: tooth loss, ulcerations and ulcers on oral mucosa, scars due to old, healed lesions, bleeding, black tongue, polysialia, and discolouration and swelling in the lips. Münchausen syndrome by proxy with participation of the mother was diagnosed in four cases. Case A 13-year-old girl was hospitalised because of a non-healing ulcer of the septum, loose and lost mandibular teeth, skin lesions, and suspected immunodeficiency. She had been hospitalised numerous times at other facilities. Consultations and diagnostic tests did not confirm an organic disease. The patient and her mother agreed to undergo all examinations, and some symptoms ‘went away’ during the examinations. The behaviour of the patient and her mother during hospital stays, ambulatory care, and the psychiatric observations all pointed towards MPSB. They refused further treatment at the present facility. Conclusions A dentist should take into account the potential ‘fabrication’ of symptoms in a child by the latter or by a caregiver. Consultations with a paediatrician or psychiatrist enable a diagnosis and treatment.
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Abstract
Factitious disorders are conditions which are unknown to many physicians but have a prevalence of 1-5 % in outpatient departments and hospitals. In order to avoid prolonged and complicated (false) treatment in surgery this article gives a review of the definition, epidemiology and pathogenesis of factitious disorders as well as clinical symptoms and therapy options. A focus is placed on the identification of patients, treatment strategies and the prevention of malpractice. Additionally, clinical features of the disorder are illustrated with the description of some characteristic cases.
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Affiliation(s)
- F Werdin
- Abteilung für Plastische Chirurgie und Handchirurgie, Chirurgische Klinik, Diakonieklinikum Stuttgart, 70176, Stuttgart, Deutschland.
| | - A Amr
- Abteilung für Handchirurgie, Mikrochirurgie und rekonstruktive Brustchirurgie, Marienhospital Stuttgart, Stuttgart, Deutschland
| | - A Eckhardt-Henn
- Klinik für Psychosomatische Medizin und Psychotherapie, Klinikum Stuttgart, Stuttgart, Deutschland
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Abstract
In October 2004, a case of caregiver-fabricated illness in a child was identified in a children's hospital in the Midwest. This case report begins with a discussion and explanation of the various nomenclatures that have been used by the healthcare community such as Munchausen syndrome by proxy, factitious disorder by proxy, medical child abuse, and caregiver-fabricated illness in a child. A discussion of case facts is then presented, which includes key concepts that nurses should know regarding a diagnosis of caregiver-fabricated illness in a child and the interventions that should be taken.
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Affiliation(s)
- Cathy Koetting
- Case Report Editor: Dr. Brian McKenna, Australian Catholic University, . Author Affiliation: School of Nursing, Saint Louis University
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When the lie is the truth: grounded theory analysis of an online support group for factitious disorder. Psychiatry Res 2014; 220:1176-7. [PMID: 25169893 DOI: 10.1016/j.psychres.2014.07.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/25/2014] [Indexed: 11/22/2022]
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Affiliation(s)
- Kasia Kozlowska
- Psychological Medicine, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia; Disciplines of Psychiatry and of Paediatrics and Child Health, University of Sydney Medical School, Sydney, NSW, Australia.
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Abstract
Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.
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Affiliation(s)
- Christopher Bass
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford, UK.
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