[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.

Caregiver-fabricated illness in a child

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.

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.

Caregiver-fabricated illness in a child: a manifestation of child maltreatment

Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver who falsifies and/or induces a child's illness, leading to unnecessary and potentially harmful medical investigations and/or treatment. This condition can result in significant morbidity and mortality. Although caregiver-fabricated illness in a child has been widely known as Munchausen syndrome by proxy, there is ongoing discussion about alternative names, including pediatric condition falsification, factitious disorder (illness) by proxy, child abuse in the medical setting, and medical child abuse. Because it is a relatively uncommon form of maltreatment, pediatricians need to have a high index of suspicion when faced with a persistent or recurrent illness that cannot be explained and that results in multiple medical procedures or when there are discrepancies between the history, physical examination, and health of a child. This report updates the previous clinical report "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in the Medical Setting" The authors discuss the need to agree on appropriate terminology, provide an update on published reports of new manifestations of fabricated medical conditions, and discuss approaches to assessment, diagnosis, and management, including how best to protect the child from further harm.

Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting

The condition widely known as Munchausen syndrome by proxy comprises both physical abuse and medical neglect and is also a form of psychological maltreatment. Although it is a relatively rare form of child abuse, pediatricians need to have a high index of suspicion when faced with seemingly inexplicable findings or treatment failures. The fabrication of a pediatric illness is a form of child abuse and not merely a mental health disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home. In this statement, factors are identified that may help the physician recognize this insidious type of child abuse that occurs in a medical setting, and recommendations are provided for physicians regarding when to report a case to their state's child protective service agency.

Update on Munchausen syndrome by proxy

PURPOSE OF REVIEW

Munchausen syndrome by proxy (MBP) is a complicated form of child maltreatment. Difficulties remain in properly defining the condition, as well as in detection and differentiation from organic illness. This review will discuss the epidemiology and diagnosis of MBP, as well as the role of the physician in sorting out these cases.

RECENT FINDINGS

Several recent case studies, including two in which children were diagnosed with celiac disease, add to our knowledge of the protean manifestations of MBP. There is growth in our understanding of how sudden infant death syndrome (SIDS) and the symptom complex seen in acute life-threatening events (ALTEs) may in fact represent manifestations of MBP. Recent legal issues in the United Kingdom pose concern for all physicians engaged in child protection work.

SUMMARY

In spite of these challenges, the high mortality and recidivism rates associated with MBP make it imperative that pediatricians be familiar with the condition, the subtle signs and symptoms with which it may present, and methods to best protect the children in their care.

Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is difficult to diagnose unless healthcare providers are astute to its clinical features and management. A case is presented to educate nurses and advanced practice nurses, of the nursing, medical, legal, and social complexities associated with Munchausen syndrome by proxy. This article also provides a brief review of the definition of Munchausen syndrome by proxy, its epidemiology, common features of the perpetrator, implications for healthcare personnel, and the legal and international ramifications of Munchausen syndrome by proxy.

When the System Works: Rescuing a Child From Munchausen's Syndrome by Proxy

This case study presents a consultation-liaison client and family. The author illustrates how a coordinated staff effort and the nurse-patient relationship resulted in improved treatment.

[Child abuse syndrome]

The aggrievement of children is not only a present day problem. The term: child abuse has appeared in the literature in the mid XIX century. In this paper an attempt has been made to reference this phenomenon in region of Bydgoszcz. There were 2889 cases of children with bodily injuries requiring hospital treatment in the years 1992-1996. 10 cases were victims of long lasting violence in their homes. This paper also presented the basic regulations and pays attention to the requirement of greater engagement of the whole society. A restrictive system of child protection can contribute to a significant decrease in the scale of this phenomenon. Scandinavian countries can be used as an example of such an approach.

Concerns about research and prevention strategies in Munchausen Syndrome by Proxy (MSBP) abuse

There would seem to be three motives for research into Munchausen Syndrome by Proxy (MSBP) abuse; first to enhance treatment; second to enhance our understanding of the psychopathology of those who carry out the abuse; and third to find interventions to prevent its occurrence. We will argue that only the first justification is valid. The second and third should be questioned for several reasons including: MSBP abuse is the wrong kind of event to think of in terms of categorical diagnosis; rare events are inherently difficult to predict; and better research targets are available. We propose that research energy would be more productively directed towards furthering our understanding of somatization and certain problematic aspects of modern pediatric practice. We offer suggestions as to appropriate areas for research.

[Preventive treatment of mothers and their babies in a day care setting]

Certain aspects of the communication between mother (and father) and baby are of major influence on the developmental outcome of the child. Mentally ill mothers in psychiatric day care are considerably limited in their communicative abilities, especially in themes of developmental relevance. As a consequence of their inherent ego weakness the mothers' flexible adaption to the babies' needs is impaired. Because of their own emotional neediness mothers are not sufficiently sensible and responsive to the babies' signals. Almost all of the mothers feel aggressive impulses towards their babies. Indication for day care depends to an essential part on the mothers' reflective function concerning aggression. Although there is some danger of child abuse, the joint treatment is considered to prevent early attachment disorders and/or a pathologic developmental outcome in the child. In addition, mother-baby-therapy is indicated in cases of severe regulation disorders. The specific models of our therapy are illustrated in two case examples.

Munchausen syndrome by proxy

Munchausen syndrome by proxy is the most difficult form of child abuse. It carries substantial morbidity and mortality. The diagnosis relies on appropriate suspicion and careful investigation. The psychological illness/need of the perpetrator is the main clinical feature. Early recognition and appropriate intervention prevent further abuse and criminal actions.

Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation

OBJECTIVES

To investigate outcome, management, and prevention in Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

DESIGN

Ascertainment through British Paediatric Surveillance Unit and questionnaires to responding paediatricians.

SETTING

The UK and Republic of Ireland, September 1992 to August 1994.

SUBJECTS

Children under 14 years diagnosed with the above.

MAIN OUTCOME MEASURES

Placement and child protection measures for victims and siblings; morbidity and reabuse rates for victims; abuse of siblings; prosecution of perpetrators.

RESULTS

Outcome data for 119 with median follow up of 24 months (range 12 to 44 months). No previously diagnosed factitious disease was found to have been caused by genuine disease. Forty six children were allowed home without conditions at follow up. Children who had suffered from suffocation, non-accidental poisoning, direct harm, and those under 5 years were less likely to go home. Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal.

CONCLUSIONS

This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur.

Illness induction syndrome: paper I--a series of 41 children from 37 families identified at The Great Ormond Street Hospital for Children NHS Trust

At the hospital 41 children from 37 families were identified as having had illness induced by a parent who in all but three cases was the mother. Their case records were reviewed. Four patterns of presentation occurred; failure-to-thrive through the active withholding of food; allegation of allergy and withholding of food; allegation and fabrication of medical symptoms; and active interference by poisoning or disrupting medical treatment. Four of the children died, two as a result of the illness induction. In 35% of the families a sibling had been previously subjected to some type of abuse. All the children had been presented with potentially serious symptoms, but post-identification only five were found to have serious medical problems requiring ongoing treatment. There were no specific characteristics of either the child or family associated with each type of presentation. Seventeen children had previously presented with failure-to-thrive, feeding problems or food allergies. All the mothers had suffered at least one of the following: privation, child abuse, psychiatric illness, or significant loss or bereavement, whereas only half the fathers had grown up in a deprived family situation and/or had earlier or current health difficulties. Forty percent of the parents had serious marital problems. A combined medical/psychosocial team identified the abuse and attempted to understand the family's belief system regarding the illness. The process of Illness Induction was conceptualized as being initiated by the parents perceiving the child to be ill and using this focus on illness as a way of solving major personal, marital, and/or family difficulties.

Munchausen syndrome by proxy: a study of psychopathology

Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years. Approximately one-half of the mothers in this study had either smothered or poisoned their child as part of their fabrications. Lifetime psychiatric histories are reported for 47 of the mothers. Thirty-four had a history of a Factitious or Somatoform disorder, 26 a history of self harm, and 10 of alcohol or drug misuse. Nine mothers had a forensic history independent of convictions related to child abuse. Nineteen of these mothers were interviewed from 1-15 years after the original fabrications. The most notable psychopathology was the presence of a personality disorder in 17 of the mothers, which were predominantly Histrionic and Borderline types. Most subjects, however, met the criteria for more than one category of personality disorder.

Munchausen syndrome by proxy: unusual manifestations and disturbing sequelae

Since the initial description of Munchausen Syndrome by Proxy (MSBP) (Meadow, 1977), numerous cases have been reported varying from as simple as the complaint of a nonexistent symptom to those as complicated as altered laboratory tests leading to the false diagnosis of cystic fibrosis (Orenstein & Wasserman, 1986; Rosenberg, 1987). We report three findings previously unreported: esophageal perforation, retrograde intussusception, and tooth loss. Bradycardia has been previously reported associated with suffocation (Meadow, 1984), but in our case may have been caused by carotid artery massage. We also suggest possible induction by the mother of premature rupture of fetal membrane leading to delivery of infected infants.