The deceit continues: an updated literature review of Munchausen Syndrome by Proxy

A medical child abuse case with spurious bleeding; importance of collecting the evidence

BACKGROUND

Medical Child Abuse (MCA) is a severe form of child abuse. In MCA, the caregiver abuses the child by exaggerating, fabricating, simulating, or inducing symptoms, and unnecessary, potentially harmful medical care harms the child. Bleeding is one of the most common manifestations of MCA. Diagnosis of MCA is challenging, and late diagnosis may increase the severity and complications. Once suspected, it is essential to apply all relevant methods of investigation to support and confirm the diagnosis, as soon as possible, as late diagnosis increases the risks.

CASE PRESENTATION

An 18-month-old boy was referred to the Pediatric Hematology by the Department of the Emergency with multiple admissions in a 2-week period for recurrent said-to-be bleeding episodes from different sites. Previously, he had been investigated for recurrent bleeding episodes in different hospitals for 4 months. In our center, the review of medical history, examination findings, and laboratory results showed some important inconsistencies leading to suspicion of MCA and the mother as the perpetrator. Then he was hospitalized for close observation. During hospitalization, multiple episodes of said-to-be bleeding were reported by the mother, but active bleeding was never observed by any hospital staff. No bleeding foci were detected in the nose or ears, supporting the diagnosis of MCA. After the file was forwarded to the prosecutor's office, the child was taken for institutional care, and no further bleeding was observed after separation from the mother. DNA, which was obtained from a so-called nosebleed during hospitalization, was analyzed and was reported to belong to the mother, confirming the diagnosis.

CONCLUSIONS

This case report draws attention to timely diagnoses by focusing on inconsistencies in the history and clinical signs and good clinical practices for the management of MCA, with a special emphasis on collecting evidence, including DNA samples, to confirm the diagnosis and help the legal process.

Seizures, medical child abuse, and the pediatric neurologist

Previously known as Munchausen syndrome by proxy, medical child abuse is a form of child maltreatment whereby the caregiver creates an environment in which medical care harms or threatens the wellbeing of a child. Approximately 40-50 % of medical child abuse cases involve neurological symptoms, with fabricated or induced seizures accounting for a significant proportion. Identifying fictitious seizures is often difficult even for the most experienced clinicians. Therefore, having a low threshold for clinical suspicion is essential in the timely diagnosis of medical child abuse. This article provides a review of the epidemiology, diagnosis, and management of medical child abuse when it involves seizures.

Munchausen syndrome by proxy: A narrative review and update for the dentist and other healthcare professionals

Munchausen syndrome by proxy (MSbP) is a form of abuse in which a caregiver with Factitious Disorder Imposed on Another (FDIA) fabricates or induces signs or symptoms in a person under their care to satisfy a self-serving psychological need. Unnecessary clinical evaluations, procedures, and treatments that are initiated based on falsification by the abuser inadvertently add to the trauma experienced by the victim. It is a form of abuse and the impact on victims can be severe, sometimes fatal, and far-reaching such as prolonged neglect and extension to affected siblings. The long-term exposure to MSbP may predispose the victim to eventually developing factitious disorder imposed on self (FDIS). While MSbP often involves child victims, elderly, adults, and pets have also been reported as victims. MSbP can be a diagnostic challenge, and the important keys to timely identification of MSbP include the ability to detect deception by caregivers through awareness, clinical suspicion, and careful review of available health records; it also involves collecting collaborative information from other relevant healthcare providers including dentists, schoolteachers, and social workers. To date, there are limited published cases of MSbP with oral findings. This paper provides a narrative review of the current understanding of MSbP with a section on cases with oral findings. This paper aims to increase awareness about the clinical presentations and management considerations for MSbP among dentists and other healthcare professionals.

[Medical Child Abuse - A Guideline to Detecting this Particular Form of Child Maltreatment]

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.

Medical child abuse: Medical history and red flags in French adolescents

BACKGROUND

Medical child abuse (MCA; or Munchausen syndrome by proxy) is a severe form of adult and medical maltreatment of children. Currently, few data on MCA in adolescents exist.

OBJECTIVE

To describe the clinical characteristics and medical history of children and adolescents aged 10 to 18 years with suspected or confirmed MCA in the pediatric hospital setting.

METHODS

We included patients aged 10 to 18 years who were seen in five tertiary care hospitals in the Paris area and identified by physician recall such as suspected MCA between 2015 and 2021.

RESULTS

We included 29 adolescents; the mean (SD) age was 12.9 (10.8-15.0) years at suspected diagnosis. Medical wandering was common, with a mean of 23 (12.8-33.2) alleged symptoms and 33 (9.2-56.8) specialized consultations in a mean of six different hospitals. The mean number of emergency visits was 11.8 (0-25.9) and radiologic exams 24.3 (5-43.6). Overall, 62 % (18/29) of the adolescents had an underlying organic pathology. The impact of MCA on quality of life was major, with a high rate of school dropout (96 %). The mean delay to the suspected diagnosis was 5.8 (2.6-9) years, and even when recognized, it was rarely the subject of a social or judiciary report (only 42 % of adolescents). In total, 50 % of the adolescents subsequently exhibited Munchausen syndrome.

CONCLUSION

Adolescent MCA is poorly known among the medical profession. Increasing awareness, education and knowledge of risk factors could contribute to better care.

Medical Child Abuse: A Review by Subspecialty

Medical child abuse (MCA), formerly called Munchausen syndrome by proxy (MSP or MSBP), occurs when a caregiver, usually the mother, falsifies or exaggerates symptoms resulting in harm to a child through inappropriate medical care. MCA is underrecognized, underreported, and results in significant morbidity and mortality. Pediatrics subspecialists should consider MCA when unusual disease presentation [THAT] do not respond to traditional treatments. This article reviews the more common diagnoses encountered in MCA cases by specialty.

Munchausen by Proxy: Quem e Como? Uma Revisão da Literatura

A síndrome de Munchausen by proxy resulta numa forma de abuso infantil relativamente rara, que acarreta importantes consequências a curto, médio e longo prazo nas vítimas, geralmente crianças. O abusador, frequentemente a mãe da vítima, sem pretensão de ganhos secundários, exagera, fabrica, simula ou induz, de forma deliberada e persistente, sinais e sintomas na criança, levando os profissionais de saúde a acreditarem estar perante alguma patologia real, seguindo uma marcha diagnóstica infrutífera. Pouco se sabe sobre as características dos perpetradores, nomeadamente no que diz respeito à sua história pessoal, antecedentes psiquiátricos e características sociodemográficas, já que a grande maioria dos dados disponíveis na literatura incide apenas nas características das vítimas. Sendo um diagnóstico que levanta diferentes desafios, e provavelmente com prevalência subestimada, esta revisão da literatura debruça‐se sobre o perfil dos agressores, pretendendo consciencializar e auxiliar os profissionais de saúde na sua correta identificação, tão precoce quanto possível.

Suspicion of Munchausen syndrome by proxy with a child's presentation of undernutrition, scurvy, and an apparent Avoidant Restrictive Food Intake Disorder

PURPOSE

Avoidant Restrictive Food Intake Disorder (ARFID) was recently characterized in the DSM-5 classification. Potential differential diagnoses remain poorly reported in the literature. Our purpose was to present a possible Munchausen syndrome by proxy with undernutrition and scurvy, presenting as ARFID in a child.

METHODS

We describe here a case of an 8-year-old boy who presented with severe undernutrition (BMI = 11.4) and scurvy leading to joint pains. The boy had had a very selective diet since early childhood, and his condition required hospitalization and enteral refeeding. Because of his specific eating behaviour, an ARFID was initially suspected. However, observation of the mother-child relationship, analysis of the child's eating behaviour, and retrospective analysis of his personal history suggested that this was not a true ARFID, and that the selective eating behaviour had probably been induced by the mother over many years, who probably maintained a low variety diet.

CONCLUSION

Munchausen syndrome by proxy is a difficult differential diagnosis, which may also affect patients with ARFID symptoms, which may also present in the affected child as apparent ARFID.

LEVEL OF EVIDENCE

Level V, descriptive study.

Difficult diagnosis of factitious disorder

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.

Organophosphate insecticide poisoning with monocrotophos-induced fabricated illness in a 7-year-old girl with refractory seizures over a 4-year period

Munchausen syndrome by proxy is a form of abuse in which an adult, usually the mother, deceives health workers by exaggerating, falsifying or directly inducing psychological or physical symptoms in the child victim for psychological gratification. In 2013, the American Academy of Pediatrics coined the term 'caregiver-fabricated illness in a child' to describe this form of child abuse. A 7-year-old girl had many encounters with health workers over a period of 4 years and presented with evolving clinical features including refractory seizures and red urine for which she was followed up as a case of acute intermittent porphyria. She was later discovered to be the victim of chronic monocrotophos organophosphate poisoning by her mother. If all medical staff who manage children are to avoid becoming inadvertent participants in medical child abuse, this case report is an important reminder that a high index of suspicion is warranted in cases which present a diagnostic dilemma and who respond unexpectedly to treatment.Abbreviations AIP: Acute intermittent porphyria; APSAC: American Professional Society on the Abuse of Children; ASM: anti-seizure medication; CFIC: caregiver-fabricated illness in a child; CT: computed tomography: DVT: deep vein thrombosis; EEG: electroencephalogram: ESR: erythrocyte sedimentation rate; HDW: high-dependency ward; ICU: intensive care unit; LFT: liver function test; MBP: Munchausen syndrome by proxy; NICU: neonatal intensive care unit; RFT: renal function test; TB: Tuberculosis; UTH-CH: University Teaching Hospitals Children's Hospital.

Medical Child Abuse: Essentials for Pediatric Health Care Providers

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.

The Application of Geometric Morphometrics to Explore Potential Impacts of Anthropocentric Selection on Animals' Ability to Communicate via the Face: The Domestic Cat as a Case Study

During their domestication via artificial selection, humans have substantially modified the morphology and thus visual appearance of non-human animals. While research highlights the negative impact of these modifications on physical functioning, little is known about their impact on behavior and signaling, either toward humans or conspecifics. Changes in the appearance of the face, such as those associated with, but not limited to, facial expressions, form an important part of non-verbal communication. In companion animals, the face is one of their most visually diverse features (due to human-driven selection), which may impact the visual clarity of expressions and other forms of signaling. Using the domestic cat as our model, we applied a new analytical technique in order to understand the impact of breed variation on relative positioning of facial landmarks, chosen specifically for their association with the production of various facial movements, and the expression of affect. We then assessed the extent to which facial appearances known to be associated with a specific underlying state (i.e., pain, assessed via a validated, facial pain score), could be reliably detected in a morphologically diverse population. Substantial baseline variation in landmarks was identified at both the cephalic (e.g., brachycephalic, dolichocephalic, mesocephalic) as well as breed levels. While differences in facial pain scores could successfully differentiate between "pain" and "no pain" in the facial appearance of domestic shorthaired cats (DSH), these differences were no longer detectable when assessed within a larger more morphologically diverse population, after corrections for multiple testing were applied. There was also considerable overlap between pain scores in the DSH "pain" population and the neutral faces of other breeds. Additionally, for several paedomorphic breeds, their neutral face shapes produced scores indicative of greater pain, compared to most other breeds, including the DSH cats actually in pain. Our findings highlight the degree to which anthropocentric selection might disrupt the communicative content of animals' faces, in this case the domestic cat. These results also suggest a potential human preference for features extending beyond the infantile, to include negatively-valenced facial forms such as pain.

Fabricated or induced illness: From "Munchausen by proxy" to child and family-oriented action

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.

A case report and literature review: Factitious disorder imposed on another and malingering by proxy

Factitious disorder imposed on another (FDIA) and malingering by proxy (MAL-BP) are two forms of underreported child maltreatment that should remain on physicians’ differential. This case of a 2-year-old boy, which spans 6 years, reveals the complexity in and difficulties with diagnosis. Key features include the patient’s mother using advanced medical jargon to report multiple disconnected concerns and visits to numerous providers. As a result, the patient underwent many investigations which often revealed normal findings. FDIA was suspected by the paediatrician, especially following corroboration with the child’s day care and past primary health care provider. This case demonstrates the possible overlap in diagnoses, which are characterized by a lack of consistent presentation and deceitful caregivers, often complicated by true underlying illness. The authors use clinical experience and limited existing literature to empower paediatricians to confidently diagnose and report FDIA and MAL-BP to limit future harm to children.

Pulling the Wool Off Our Eyes: Medical Child Abuse

Medical child abuse (MCA) continues to remain a challenging form of abuse to recognize, diagnose, and manage. The perpetrators of MCA have some common features that may heighten the suspicion that a child is the victim of MCA. Once suspected, the development of a multidisciplinary care plan that incorporates all subspecialists and health care providers involved in the child's care is essential. A structured approach to record review can clarify the concerns and discrepancies as well assist in potential future testimony. The use of overt or covert video surveillance systems are potential modalities to aid in making the diagnosis of MCA. If called to testify, it is helpful to understand the court system. Risks to the child from MCA are great and include a high level of long-term morbidity and mortality. Understanding this diagnosis and having a plan in place to address it when suspected can prevent further harm to the child. [Pediatr Ann. 2020;49(8):e354-e358.].

The other face of illness-deception: Diagnostic criteria for factitious disorder with proposed standards for clinical practice and research

Objective: This paper aims to develop diagnostic criteria for factitious disorder (FD) and a heuristic for research by creating standards for delineating criterion groups.Method: Both FD and malingering are conceptualized within a rubric of illness-deception. The history of FD research was compared to the research history on malingering. Differences in the measurement of these constructs were described. The potential utility of performance validity tests (PVTs) and symptom validity tests (SVTs) in FD is discussed in light of successful applications in malingering. Methods for obtaining evidence for FD are delineated in a table of diagnostic criteria.Results: The comparison of FD and malingering research shows that the scientific measurement of malingering evolved rapidly with the introduction of forced-choice validity testing and cogent guidelines for the formation of criterion groups. Likewise, PVTs and SVTs hold promise as methods of measuring deceptive behavior in FD. The most salient differences between FD and malingering are understood to be matter of context/setting: malingering occurs in an external incentive context, while FD occurs in a medical/psychological context. Guidelines to assess FD are developed to fill the need for known-groups research.Conclusions: Evidence for FD, a form of illness-deception, can be obtained by using validity testing, which, together with careful clinical observation, allows for the development of probabilistic diagnostic criteria. Similar to the other form of illness-deception - malingering - these criteria can be used to form known groups for research.

Medical Child Abuse Hidden in Pediatric Settings: Detection and Intervention

Medical child abuse, sometimes referred to as Munchausen Syndrome by Proxy or childhood factitious disorder, poses significant diagnostic, intervention, and ethical issues for medical and mental health practitioners alike. Psychologists working in pediatric hospitals and medical clinics should remain mindful of the health and ethical risks posed by these conditions, which are challenging to detect and treat. The surreptitious nature of the conditions and hazards they pose require an integrated medical, psychological, and child protective response. This article provides historical and clinical background on the condition along with tabular guides and recommendations to assist in detection and intervention.

Fabricated or induced illness in twins associated with insertion of trocar needles into their bodies

Fabricated and/or induced illness (previously known as Munchausen syndrome by proxy) is a form of child abuse in which the perpetrator induces, exaggerates or fabricates illness in his/her child. Two-month-old twins were referred to the paediatric surgery centre with trocar needles lodged in different organs. A radiograph undertaken in one of them because of acute respiratory distress demonstrated needles in the heart and diaphragm which were removed surgically. The second twin, referred one week after his brother, had a needle deep in his liver and it was decided not to operate owing to the possibility of haemorrhage but, sadly, he died unexpectedly and the autopsy concluded that it was owing to sudden infant death syndrome. Because of a number of admissions to different units in the same hospital, there was a delay in the eventual diagnosis. Recurrent admissions to different hospital units should raise the suspicion of fabricated and/or induced illness.

Disclosure of caregiver-fabricated illness to a child: A team-based approach to communicating with pediatric patients

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.

Medical Child Abuse: An Unusual "Source" of Vaginal Bleeding

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.

An Overview of Munchausen Syndrome and Munchausen Syndrome by Proxy

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.

Child Abuse and Conditions That Mimic It

One percent to 2% of children in the United States are confirmed victims of child abuse, with many more likely affected. It can be difficult to diagnose, with often misleading medical histories, but acute care providers should be aware of its presenting warning signs and how to evaluate and document suspicious physical findings. Young children who cannot disclose are most vulnerable to forms of abuse with high morbidity and mortality, so it is important to keep it in the differential diagnosis and to be aware of and know how to rule out medical conditions that mimic abuse.

Medical Child Abuse: A Case Presenting as Anogenital Bleeding of Unknown Origin in an Older Child

BACKGROUND

Medical child abuse is a challenging diagnosis to make, particularly in older children with unusual presenting symptoms.

CASE

A 7-year-old child with complex medical history presented with anogenital bleeding of unknown origin. Extensive laboratory testing, imaging studies, and diagnostic procedures were negative for any etiology. Forensic testing confirmed the blood in her underwear was a genetic match to the patient. Trial separation from the mother was diagnostic and therapeutic in this case.

SUMMARY AND CONCLUSION

Older children who are victims of medical child abuse might present in a variety of ways, and might even collaborate with the perpetrator in falsifying symptoms. It is important to keep medical child abuse on the differential when the patient's symptoms and work-up do not match.

Factitious hypoglycemia in children and adolescents with diabetes

BACKGROUND

Factitious hypoglycemia is a condition of self-induced hypoglycemia due to surreptitious administration of insulin or oral hypoglycemic agents. In adults, it is an uncommon, but well known clinical entity observed in individuals with and without diabetes.

OBJECTIVES

To report a case of factitious hypoglycemia highlighting diagnostic pitfalls, to identify common characteristics of children and adolescents with factitious hypoglycemia, and to examine whether the information on long-term outcome exists.

METHODS

We present a case of an adolescent with type 1 diabetes who had self-induced hypoglycemia of several years' duration; and we conducted a systematic literature review on factitious hypoglycemia in pediatric patients with diabetes.

RESULTS

We identified a total of 83 articles of which 14 met the inclusion criteria (describing 39 cases). All but 1 individual had type 1 diabetes and the majority was female (63%). Average age was 13.5 ± 2.0 years with the youngest patient presenting at the age 9.5 years. Blood glucose control was poor (hemoglobin A1c: 12.1 ± 4.0%). In 35%, psychiatric disorders were mentioned as contributing factors. Only 3 reports provided follow-up beyond 6 months.

CONCLUSIONS

Factitious hypoglycemia typically occurs in adolescents with type 1 diabetes who use insulin to induce hypoglycemia. Awareness of this differential diagnosis and knowledge of potentially misleading laboratory results may facilitate earlier recognition and intervention. Little information exists on effective treatments and long-term outcome.

Fabrication and induction of illness in children: the psychopathology of abuse

Fabricating or inducing illness in children (previously called Munchhausen syndrome by proxy) is a form of child abuse in which a caregiver falsifies illness in a child by fabricating or producing symptoms and presenting the child for medical care disclaiming knowledge of the cause of the problem. The behaviour has attracted considerable interest and controversy, and some have questioned its existence. In this article, we assess the prevalence of the behaviour, describing behaviours that have been reported and identified, and discuss its psychopathology. We consider the role of psychiatric expertise in the investigation of such behaviour and in the assessment of those who carry it out, based on what is known to date about their psychopathology. We also outline an approach to management with special reference to the characteristics in the mother that may allow for reunification with the child after the abuse has been established.

Don't Judge a Book by Its Cover: Factitious Disorder Imposed on Children-Report on 2 Cases

Factitious Disorder Imposed on Another (FDIA), also known as Munchausen Syndrome by Proxy (MSbP) is a very serious form of child abuse. The perpetrator, usually the mother, invents symptoms or causes real ones in order to make her child appear sick. Usually this is due to a maladaptive disorder or to an excessive of attention-seeking on her part. We report here two new cases of FDIA. The first one is a 9-year-old boy with a history of convulsive episodes, reduced verbal production, mild psychomotor disorder and urological problems who underwent several invasive procedures and hospitalizations before a diagnosis of FDIA was made. The second is a 12 year-old girl with headache, abdominal pain, lipothymic episodes, seizures and a gait impairment, who was hospitalized in several hospitals before an FDIA was diagnosed.

The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) - A systematic review of 796 cases

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.

Apparent cyclic vaginal bleeding in a child: factitious disorder

A 20-mo-old girl was brought to our department by her mother because of breast enlargement. She was diagnosed with premature thelarche. One month later, she returned to our hospital with a complaint of vaginal bleeding. During the subsequent 6 mo, her vaginal bleeding recurred every month while her breast development disappeared. We performed laboratory tests and imaging. At the end of 6 mo, we realized that her mother’s menstrual bleeding and the patient’s blood staining were concurrent. The mother confessed applying her vaginal flow to her daughter’s underwear. Factitious disorder should be included in the differential diagnosis of unexplained vaginal bleeding in childhood.

Munchausen syndrome by proxy and pediatric nephrology

Munchausen syndrome by proxy is a persistent fabrication of illness done by a person to another. Renal and urologic forms of this syndrome are not as uncommon as can be thought; a review of all the cases of Munchausen-by-proxy syndrome reveals that 25% of the children had renal or urologic issues. This syndrome can result in a serious diagnostic dilemma for the physicians; knowing this entity can allow early recognition of falsification and limit the physical and psychological damages caused in the victim. In this study, we reviewed the pediatric nephrology cases of Munchausen syndrome by proxy, grouping them through the principal signs of presentation.

The Intersection of Medical Child Abuse and Medical Complexity

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.

Factitious disorder: a systematic review of 455 cases in the professional literature

OBJECTIVE

Patients with factitious disorder (FD) fabricate illness, injury or impairment for psychological reasons and, as a result, misapply medical resources. The demographic and clinical profile of these patients has yet to be described in a sufficiently large sample, which has prevented clinicians from adopting an evidence-based approach to FD. The present study aimed to address this issue through a systematic review of cases reported in the professional literature.

METHOD

A systematic search for case studies in the MEDLINE, Web of Science and EMBASE databases was conducted. A total of 4092 records were screened and 684 remaining papers were reviewed. A supplementary search was conducted via GoogleScholar, reference lists of eligible articles and key review papers. In total, 372 eligible studies yielded a sample of 455 cases. Information extracted included age, gender, reported occupation, comorbid psychopathology, presenting signs and symptoms, severity and factors leading to the diagnosis of FD.

RESULTS

A total of 66.2% of patients in our sample were female. Mean age at presentation was 34.2 years. A healthcare or laboratory profession was reported most frequently (N=122). A current or past diagnosis of depression was described more frequently than personality disorder in cases reporting psychiatric comorbidity (41.8% versus 16.5%) and more patients elected to self-induce illness or injury (58.7%) than simulate or falsely report it. Patients were most likely to present with endocrinological, cardiological and dermatological problems. Differences among specialties were observed on demographic factors, severity and factors leading to diagnosis of FD.

CONCLUSIONS

Based on the largest sample of patients with FD analyzed to date, our findings offer an important first step toward an evidence-based approach to the disorder. Future guidelines must be sensitive to differing methods used by specialists when diagnosing FD.

Child abuse and fabricated or induced illness in the ENT setting: a systematic review

BACKGROUND

Child maltreatment is persistently under-recognised. Given that a third of maltreated children may return with serious or fatal injuries, it is imperative that otolaryngologists who are in frequent contact with children are able to detect maltreatment at first presentation.

OBJECTIVE OF REVIEW

This review aims to identify ENT injuries, signs or symptoms that are indicative of physical abuse or fabricated or induced illness (child maltreatment).

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

An all-language search, developed in Medline Ovid and consisting of 76 key words, was conducted of published and grey literature across 10 databases from inception to July 2015, for primary observational studies involving children aged <18 years.

EVALUATION METHOD

Each relevant article underwent two independent reviews with full critical appraisal, applying strict quality standards.

RESULTS

Of the 2448 studies identified and screened, 371 underwent full review, resulting in 38 included studies that detailed 122 maltreated children. Pharyngeal perforations (n = 20) were the most frequent abusive ENT injury, predominantly affecting neonates and infants, presenting with dysphagia, drooling, haemoptysis and surgical emphysema. At least 52% of children with abusive pharyngeal injuries had additional co-existent injuries. The majority of ear injuries were inflicted to the external ear (n = 11) and included auricular deformity, abrasions, petechiae, lacerations and burns. Fabricated or induced illness cases presented most commonly with recurrent, unexplained otorrhoea or ENT lesions that failed to heal despite appropriate therapy.

CONCLUSIONS

All clinicians should be familiar with the signs of child maltreatment. Pharyngeal injuries, or injuries to the external ear, presenting in young children without an explicit history of witnessed injury should prompt a child protection referral for full evaluation. Likewise, children who present with recurrent, or apparently intractable symptoms and signs despite appropriate treatment, should raise the possibility of fabricated or induced illness, and discussion with a child protection specialist is advised. Early recognition of possible child maltreatment and instigation of appropriate safeguarding measures are essential to prevent repetition and escalation of injury. This is of paramount importance to otolaryngologists, who have the potential to identify these children in their practice.

Neurological Manifestations of Medical Child Abuse

BACKGROUND

Medical child abuse occurs when a child receives unnecessary and harmful, or potentially harmful, medical care at the instigation of a caretaker through exaggeration, falsification, or induction of symptoms of illness in a child. Neurological manifestations are common with this type of maltreatment.

OBJECTIVES

We sought to review common reported neurological manifestations that may alert the clinician to consider medical child abuse. In addition, the possible sequelae of this form of child maltreatment is discussed, as well as practice recommendations for establishing the diagnosis and stopping the abuse once it is identified.

METHODS

A review of the medical literature was conducted regarding the reported neurological presentations of this entity.

RESULTS

Neurological manifestations of medical child abuse include false reports of apparent life-threatening events and seizures and reports of induction of symptoms from poisoning. Failure to correlate objective findings with subjective complaints may lead to unnecessary and potentially harmful testing or treatment. This form of child maltreatment puts a child at significant risk of long-term morbidity and mortality.

CONCLUSIONS

A wide variety of neurological manifestations have been reported in cases of medical child abuse. It is important for the practicing neurologist to include medical child abuse on the differential diagnosis.

Case Report: When an Induced Illness Looks Like a Rare Disease

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.

Safeguarding the welfare of children: what is the nurse's role?

Everyone who works with children, including teachers, GPs, other medical professionals and the police, has a responsibility to keep children safe and protect them from harm. Simply put, safeguarding children is everyone's responsibility. Children should be protected from maltreatment and any impairment that may affect their health and development. In addition, we all have to ensure that children grow up with safe and effective care. At particular risk, and therefore in particular need of safeguarding, are children who are disabled; who have educational or other specific additional needs; and who bear signs of child abuse, substance abuse, or domestic violence. Under the Children Act 1989, local authorities are required to provide services for children in need for the purposes of safeguarding and promoting their welfare. Nurses are well-placed to identify children and young people who may be at risk, and to act to safeguard them. Nurses and other health professionals should be familiar with local referral arrangements, usually to children's social care.

Malingering-by-proxy: need for child protection and guidance for reporting

The feigning of disabling illness for compensation at the direction or pressure by others, which is called malingering by proxy (MBP), has been the subject of several spirited articles. Chafetz and Prentkowski (2011) suggested that MBP has the potential for real harm to the child. In a poster at the AACN scientific session in 2011, Chafetz and Binder (2011) pursued a case of MBP that showed the child had clearly suffered and failed to progress in the 6 years that had passed since she was first evaluated as an 11 year old. In the present article, we identify three cases that compare and contrast effects of MBP, illustrating that child abuse and/or neglect can be a serious and reportable consequence of MBP behavior. To illustrate how MBP behavior can cause child abuse, we compare MBP behavior with Munchausen Syndrome by Proxy (MSBP), another condition of volitional noncredible behavior produced in a vulnerable person at the direction or pressure by others. Guidance criteria for reporting MBP as child abuse/neglect are introduced in this article.

A toxic triangle of destructive leadership at Bristol Royal Infirmary: A study of organizational Munchausen syndrome by proxy

Although leadership literature increasingly recognizes that leadership is a complex, co-creational process among leaders, followers, and context, destructive leadership scholarship has only recently embraced this paradigm. This article contributes to the toxic triangle debate by linking destructive leadership theory and disaster research in a case study of Bristol Royal Infirmary, a UK hospital that experienced a crisis in its pediatric cardiology unit resulting in the death of dozens of babies undergoing surgery. Thus, the article expands the literature on organizational failure by offering an assessment of how seemingly good, well-intentioned professionals can nonetheless create destructive leadership dynamics and proposes a new, more nuanced theoretical framework called organizational Munchausen syndrome by proxy as a way to analyze what went wrong.

Early recognition and management of fabricated or induced illness in children

Fabricated or induced illness (previously known as Munchausen syndrome by proxy) takes place when a caregiver elicits health care on the child's behalf in an unjustified way. Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders specifies deception as a perpetrator characteristic, a far wider range is encountered clinically and is included in this Review. We describe the features of fabricated or induced illness, its effect on the child, and the psychosocial characteristics of caregivers and their possible motives. Present evidence suggests that somatoform and factitious disorders are over-represented in caregivers, with possible intergenerational transmission of abnormal illness behaviour from the caregiver to the child. Paediatricians' early recognition of perplexing presentations preceding fabricated or induced illness and their management might obviate the development of this disorder. In cases of fully developed fabricated or induced illness, as well as protection, the child will need help to return to healthy functioning and understand the fabricated or induced illness experience. Management of the perpetrator is largely dependent on their capacity to acknowledge the abusive behaviour and collaborate with helping agencies. If separation is necessary, reunification of mother and child is rare, but can be achieved in selected cases. More collaborative research is needed in this specialty, especially regarding close study of the characteristics of women with somatoform and factitious disorders who involve their children in abnormal illness behaviour. We recommend that general hospitals establish proactive networks including multidisciplinary cooperation between designated staff from both paediatric and adult mental health services.

Care taker blogs in caregiver fabricated illness in a child: a window on the caretaker's thinking?

Three recently diagnosed cases of caregiver-fabricated illness in a child at Seattle Children's Hospital shed light on a new manifestation of their caretakers' attention seeking. The patients' mothers were actively blogging about their children's reputed illnesses. Although it is not uncommon for parents of chronically ill children to blog about their child's medical course, specific themes in these blogs of parents suspected of medically abusing their children were noted. In particular, gross distortions of the information parents had received from medical providers were presented online, describing an escalation of the severity of their children's illnesses. The mothers reported contacting palliative care teams and Wish organizations, independently from their medical providers' recommendations. They sought on-line donations for their children's health needs. We believe these blogs provide additional direct evidence of the suspected caregivers' fabrications. Although we have not performed formal content analysis, blogs might also provide insight into the caretakers' motivations. Protective Services and/or police investigators could consider querying the internet for blogs related to children at risk for caregiver-fabricated illness in a child. These blogs, if viewed in parallel with the children's medical records, could assist medical diagnosis and legal documentation of medical fabrication and assist in protective planning for the affected children.

Factitious disorders and Munchausen syndrome: the tip of the iceberg

This population-based study evaluates the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy in a clinical setting. All children referred to the Pediatric Unit of the Department of Pediatrics of the Catholic University Medical School (Agostino Gemelli Hospital) in Rome were recruited between November 2007 and March 2010. An experienced interdisciplinary team of medical professionals analyzed all suspected cases. A total of 751 patients were hospitalized. Factitious disorders were diagnosed in 14/751 patients, resulting in a prevalence of 1.8%. Three of 14 (21.4%) patients fulfilled the criteria for Münchausen syndrome. Münchausen syndrome by proxy was identified in four of 751 patients, resulting in a prevalence of 0.53%. The perpetrator was the mother in three of four of these cases. The epidemiological data obtained in this population-based study indicate that the prevalence of factitious disorders, Münchausen syndrome, and Münchausen syndrome by proxy is higher than previously observed. Moreover, early detection was possible thanks to the awareness of an expert interdisciplinary team. We suggest that physicians must consider the possibility of these diagnoses whenever there are discrepancies in a child's illness presentation.