Child Abuse in the Medical Setting

Report
Parent Google Experts: An
Approach to Medical Child Abuse
Cortney Demetris, MD
Objectives
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Define Medical Child Abuse
(MCA)
Know why the term
Munchhausen Syndrome by
Proxy is no longer preferred
Differentiate Vulnerable
Child Syndrome from MCA
Differentiate Simulators from
Producers
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Understand the importance
of documenting objectively
in all cases of suspected
child abuse
Understand the benefits and
limitations of covert video
surveillance
Know the risk in siblings of
affected victims of MCA
What’s in a name?
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Munchausen Syndrome by Proxy (MSBP)
Factitious Disorder by Proxy (FDBP)
Pediatric Condition Falsification (PCF)
Child Abuse in the Medical Setting
Medical Child Abuse
Situation specific descriptive terms
Munchausen Syndrome by Proxy
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Initially described by Sir Roy Meadow as a case
report published in the Lancet in 1977
Defined as “parents who, by falsification, caused
their children innumerable harmful hospital
procedures – a sort of Munchausen syndrome by
proxy.”
Active debates regarding the use of this term
Remains the most commonly used and most easily
recognized term for this type of child abuse
Factitious Disorder by Proxy
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Initially described in 1994 in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV)
Used to describe the perpetrator of the child abuse
and diagnosed by a psychiatrist or psychologist
Defined as “intentional production or feigning of
physical or psychological signs or symptoms in
another person who is under the individual’s care”
Can only be used if the motivation is determined to
be related to attention received as the sick role by
proxy
Pediatric Condition Falsification
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Described in 2002 by the American Professional
Society on the Abuse of Children (APSAC)
Used to described the abused child and diagnosed
by pediatric care providers caring for the child
May be diagnosed in the abused child in the
absence of a diagnosis in the perpetrator of FDBP
APSAC describe the term MSBP in cases where the
child is diagnosed with PCF and the perpetrator is
diagnosed with FDBP
Child Abuse in the Medical Setting
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Described in 2007 by the AAP Committee on Child
Abuse and Neglect
Also called Medical Child Abuse, especially in the
recent British literature
Described as distinct from other forms of child
maltreatment because of “the involvement of the
medical treatment community in the abuse process.”
Situation Specific Descriptive Terms
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Advocated for as a way to solve the current debate
surrounding terminology
Example: 6 m/o repeatedly presents with seizures
that are witnessed only by the mother and eventually
determined to be falsified by the mother.
The child is diagnosed with:
–
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Maternal falsification of seizure disorder
Child abuse
Definitions
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Defining Medical Child Abuse
Current AAP terminology: vulnerable child
syndrome, illness exaggeration, illness
fabrication, and illness induction
Commonly used terms – simulator versus
producer
Medical Child Abuse Defined
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Illness is persistently and secretly, simulated and/or produced,
by a parent or in loco parentis; and repeatedly presented for
medical assessment and care
Results in multiple medical procedures both diagnostic and
therapeutic
Acute signs / symptoms of illness stop when the perpetrator
and the child are separated
Specifically excludes:
–
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physical abuse only
sexual abuse only
non-organic failure to thrive that is solely the result of nutritional /
emotional deprivation
Vulnerable Child Syndrome
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Initially described in 1964 by Dr. Green
Described as a physically healthy child who is viewed by his
parents as being at greater risk for behavioral, developmental,
or medical problems
Most of the children were previously critically ill or perceived by
their parents are having a “close call” medical event and most
“outgrow” the diagnosis following the pre-school years.
Parents present for medical care early and often in the course
of a minor childhood illness and often overindulge the child,
have trouble setting limits, tolerate physical abuse towards the
parent, and have difficulty with separation from the child
Levy (1980) interviewed 750 parents and found 27% of them
felt that their child was unusually vulnerable to illness. Review
of medical records revealed that there was not any medical
basis for this belief in 40% of the cases.
Illness Exaggeration
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Exaggerates actual symptoms
Exaggerates actual past medical history
Examples:
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Child has a mild cough for 1 day and parent reports
coughing “non-stop” for a month, can’t get any sleep, posttussive emesis, and respiratory distress
Child with 2 episodes of non-bloody non-bilious emesis and
parent reports 25 episodes of emesis some with blood in
them
Illness Fabrication
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Reports non-existent symptoms
Fabricates medical tests
Examples:
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Reports school is sending the child home for emesis at
school everyday for a month; school reports no emesis ever
and a near perfect attendance record
Puts eggs in a urine specimen to make it positive for protein
Puts menstrual blood in a child’s diaper to cause the
appearance of bloody stools
Puts the thermometer under hot water when the nurse steps
out of the room
Grossly under reports oral intake on a calorie count
Illness Induction
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Does something to the child to cause the
symptoms to be present
Examples:
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Smothers a baby to the point of apnea
Gives the child ipecac to induce vomiting
Give the child oral hypoglycemic medications to
cause low blood sugars
Poisons the child with rat poison to cause
excessive bleeding
Simulators versus Producers
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Simulators
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Producers
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Illness exaggeration
Illness fabrication
Illness Inducers
In Rosenberg’s literature review of MSBP (1987) he
reports
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25% simulators only
25% producers only
50% simulators and producers
Case Presentation - Benjamin
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4 m/o male with multiple complaints including
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Emesis
Seizures
Raspy breathing
Coughing
Feeding problems
Large previous w/u mostly negative
Case Presentation - Benjamin
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Patient placed on a Video EEG
ST and OT to work on a feeding plan
Home medications continued
Patient observed by hospital staff to be healthy
Mother reporting multiple significant problems; none
of which are observed when video EEG is reviewed
Mother reporting to her family members that patient
is deaf, was admitted with a bad pneumonia, has
such bad seizures he may never recover, and “I
can’t stand looking at him looking so sick”.
Work-up - Benjamin
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Extensive history
Complete medical record review
Watch video component of the video EEG
Medical Record Review
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4 different hospitals
2 pediatricians
4 pediatric subspecialty physicians
many ancillary services
totaling 32 medical visits in his 4 months of
life
Medical Record Review - Studies
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Pyloric Ultrasound on
5/5/08
Chest X-ray on 5/5/08
Basic Metabolic Panel on
5/6/08
Pyloric Ultrasound on
5/6/08
Upper GI on 5/6/08
Abdominal X-ray on 5/7/08
Complete Blood Count
with Differential on 5/21/08
Basic Metabolic Panel on
5/21/08
Blood Culture on 5/21/08
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Catheterized Urine Culture
on 5/21/08
Spinal Tap on 5/21/08
Pyloric Ultrasound on
5/21/08
Upper GI on 5/22/08
Chest X-ray on 5/31/08
Basic Metabolic Panel on
5/31/08
Pyloric Ultrasound on
5/31/08
Abdominal X-ray on 5/31/08
Skeletal Survey on 5/31/08
Medical Record Review - Studies
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Head CT scan without
contrast on 5/31/08
Auditory Brainstem Evoked
Response (hearing test) on
6/2/08
Complete Blood Count with
differential on 6/14/08
Comprehensive Metabolic
Panel on 6/14/08
Coagulation studies on
6/14/08
Catheterized Urine Analysis
on 6/14/08
Catheterized Urine culture
on 6/14/08
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Blood Culture on 6/14/08
Abdominal and Chest X-ray
on 6/14/08
Pyloric Ultrasound on
6/14/08
Stool culture on 6/14/08
Stool for ova and parasites
on 6/14/08
Head CT scan without
contrast on 6/15/08
EGD and Colonoscopy were
performed at The Surgery
Center of Carmel on 6/25/08
Basic Metabolic Panel on
6/19/08
Medical Record Review - Studies
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Blood culture on 6/19/08
Catheterized Urine Analysis
on 6/19/08
Catheterized Urine Culture
on 6/19/08
Abdomen X-Ray on 6/19/08
Chest X-ray on 6/19/08
Abdominal X-ray on 7/3/08
Stool Hemoccult three times
on 7/3/08
Gastric Emptying Scan on
7/22/08
Barium Swallow Study on
7/22/08
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EEG on 8/22/08
Brain MRI without contrast
on 8/18/08
Lactic Acid on 8/18/08
Acylcarnitines, plasma on
8/18/08
Carnitine on 8/18/08
Portable 48 hour EEG on
8/27/08
Video EEG on 8/28/08
Auditory Brainstem Evoked
Response (hearing test) on
9/5/08
Diagnosis - Benjamin
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“I have had the opportunity to complete an extensive
medical history given by Benjamin’s mother; conduct
a thorough physical examination on Benjamin;
carefully review medical records from 4 different
hospitals, 2 pediatricians and 4 pediatric
subspecialty physicians as well as ancillary services
totaling 32 medical visits; spend many hours
reviewing the video associated with Benjamin’s
Video EEG; and to review documentation by nurses,
physicians, and various ancillary staff members
during Benjamin’s current hospital stay.”
Diagnosis - Benjamin
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“After this complete review of all the above
mentioned information it is clear to me that
Benjamin is suffering from child abuse in the
form of Medical Child Abuse (formerly
called Munchausen Syndrome by Proxy).
Medical child abuse is a form of child abuse
in which the child suffers at the hands of
health care providers who have been given
an inaccurate medical history by a caregiver
leading to many unnecessary medical
interventions.”
Case Presentation - Joshua
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15 m/o male with ALTE
Healthy until first presentation of ALTE at 12
m/o
Large previous w/u mostly negative
Mother of child not asking for procedures or
testing; does not appear medically
sophisticated; not “typical” of perpetrators of
this form of child abuse
Case Presentation - Joshua
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Admitted
Neurology, Pulmonology, and CPT consulted
Plan to place on Video EEG
Prior to CPT consultation patient with
episode of desats to the 50’s on monitor
Video EEG urgently arranged
Medical Record Review – Joshua
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Presented on 6/25 with first ALTE at 12 m/o
Presented on 7/29 with second ALTE and
large w/u negative for etiology at that time
Presented on 8/28 with the third ALTE and
much of the first w/u is repeated and still
negative; diagnosis is breath holding spells
Presented on 9/27 with the forth ALTE
Medical Record Review - Joshua
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Echo: nml
EKG: sinus tach
Swallow Eval: nml
EEG x 3: nml
Video EEG x 2: nml
MRI Brain: 8mm cyst;
white matter volume
loss
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Sleep Study x 2: nml
CBC x 4: nml
BMP x 2: low bicarb (19&20)
CMP x 2: low bicarb on 1
CXR x 3: nml aside from
RML atelectasis on 2
Cardiology consult
Neurology consult
Video EEG - Joshua
Diagnosis - Joshua
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During my review of the Video EEG I saw
D*** choke Joshua on at least 9 occasions
and there were two other occasions that
seem most consistent with relatively brief
choking episodes. It is my medical opinion
that Joshua is in serious and immediate
danger of death in the care of D*** and that
he is clearly the victim of child abuse.
Epidemiology - Victims
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Incidence of MSBP, non-accidental suffocation, and
non-accidental poisoning in the UK were reported as
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2.8/100,000 in infants less than 1 y/o
0.4/100,000 in children less than 16 y/o
Most victims are less than 5 y/o, in one study the
mean age at diagnosis was 15-22 months old.
Children of both genders are victims equally as
frequently.
Epidemiology - Perpetrators
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Perpetrator is usually the mother, reported in 9499% of the cases
Men reported the primary perpetrator in 5-7% of
cases
One study reported that 80% of the perpetrators
worked in healthcare facilities or daycare facilities
Studies looking at perpetrators have found many
different types of psychiatric diagnosis including
personality disorders, primary factitious disorder,
depression, and rarely psychosis; no pattern has
emerged
Epidemiology - Siblings
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Siblings are at increased risk
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In one study, of the families in which the index case
had at least one sibling; 40% had a history of abuse in
a sibling and 18% had a history of sibling death
In one meta-analysis (Sheridan, 2003) of 451 MSBP
victims, of 210 known siblings; 61% had symptoms
similar to that of the victim and 25% were dead
Birth order differences in victimization are not
present
Clinical Presentations
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Any are possible in Medical Child Abuse
Most common clinical presentation is apnea
Also reported commonly are seizures, bleeding,
vomiting, diarrhea, altered mental status, fever, and
rash
Often the symptoms or the course of the disease do
not make sense from a scientific medical perspective
Children with an underlying medical diagnosis can
be victims if the caregiver demands excessive and
unnecessary medical care
Evaluation – What do to
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Obtain and review the medical record for evidence of a
diagnosis, including, but certainly not limited to Medical
Child Abuse
Remember that there will be cases in which a full review
of the medical record reveals an unusual diagnosis or
does not support child abuse as a diagnosis
The importance of documenting objectively the
observance of unusual symptoms in a child that are
perceived and reported by a caregiver cannot be
overemphasized.
Care conference involving several care providers across
disciplines can be very helpful in making a diagnosis and
creating / securing cooperation with a treatment plan
Evaluation - What not to do
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The motivation of the perpetrator / caregiver should
not be considered in making the diagnosis of child
abuse in the child victim
Know that characteristics of the abuser, such as
those list below, are not sensitive or specific
indicators of MSBP and should not be relied upon to
make the diagnosis
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being female
working in the medical setting
having a disengaged spouse
Evaluation – Covert Video Surveillance
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Pros
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Evidence of a diagnosis
Child is protected from
perpetrator
Perpetrator can get
psychological treatment
for their disorder
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Cons
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4th amendment right to
privacy
Violation of trust in a
physician / parent
relationship
Need to monitor the
video continuously by
staff with a plan to
intervene for the safety
of the child, if needed
United Kingdom Experience
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39 cases suspected of MSBP as the cause of ALTE
seen 1986-1994 at 2 locations already equipped with
CVS
Compared (“controlled”) to 46 children seen in the
same time frame with ALTE requiring CPR and were
later determined to have ALTE caused by a
underlying physiological malfunction
CVS revealed abuse in 85% of the suspected cases
and included suffocation (30 cases), deliberate
fracture (1 case), and poisoning (2 cases)
MSBP versus “Controls”
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First ALTE at median
age of 3.6 months CGA
3 (8%) born
prematurely
Bleeding from nose
and/or mouth seen in
11 cases (29%)
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First ALTE at median
age of 0.3 months CGA
27 (59%) born
prematurely
Bleeding from the nose
and/or mouth seen in 0
cases
Children’s Health Care of Atlanta’s
Experience
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Established a CVS program in pediatrics for the sole purpose of
evaluation of MSBP
Reported on 41 cases seen in 1993-1997
Made a “certain” diagnosis of MSBP in 23 of the cases
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2 were inducers only
11 were inducers and fabricators
10 were fabricators only
CVS was found to be
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required to make the diagnosis of MSBP in 56% of the cases
supportive of the diagnosis of MSBP in 22% of the cases
supportive of non-child abuse diagnosis in 10% of the cases
Management Goals
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Make sure the child is safe
Make sure the child’s future safety is also
assured
Allow treatment to occur in the least
restrictive environment
Management
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Having a multidisciplinary case conference
involving DCS in many cases, is invaluable in
achieving a consensus and developing a
treatment plan for on-going medical care that
assures the safety of the child
Should also consider siblings safety
Outcomes
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By definition 100% of the victims have some shortterm morbidity as a result of their abuse, from the
unnecessary medical testing / treatments.
Long-term morbidity is reported as 8% in one study.
Mortality rates are reported between 6-10% in
general MSBP cases; however were as high as 33%
in a series looking at suffocation and poisoning
cases only.
Summary
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Always include Medical Child Abuse on the
differential of unusual medical presentations
Remember that Medical Child Abuse is not a
diagnosis of exclusion and can be worked-up
along side other plausible diagnoses on the
differential
Forget about your preconceived notions
regarding “google experts” and focus on the
nature of the presenting symptoms.
Questions?
References
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Reece RM and Ludwig S. Child Abuse: Medical Diagnosis and Management 2nd
Edition. 2001 by Lippincot Williams and Wilkins.
Stirling J and the Committee on Child Abuse and Neglect. Beyond Munchausen
Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical
Setting. Pediatrics 2007; 119:102-1030.
Hettler J. CME Review Article: Munchausen Syndrome by Proxy. Pediatric
Emergency Care 2002; 18(5):371-374.
Galvin HK, Newton AW, Vandeven AM. Update on Munchausen Syndrome by
Proxy. Current Opinion in Pediatrics 2005; 17:252-257.
Morrison CA. Cameras in Hospital Rooms: The Fourth Amendment to the
Constitution and Munchausen Syndrome by Proxy. Critical Care Nursing
Quarterly 1999; 22(1):65-68.
Donald T and Jureidini J. Munchausen Syndrome by Proxy: Child Abuse in the
Medical System. Archives of Pediatrics and Adolescent Medicine 1996;
150(7):753-758.
Mart, EG. Factitious Disorder by Proxy: A Call for the Abandonment of an
Outmoded Diagnosis. The Journal of Psychiatry and Law 2004; 32:297-314
Southall DP and Plunkett, MCB. Covert Video Recordings of Life Threatening
Child Abuse: Lessons for Child Protection. Pediatrics 1997; 100(5):265-82,
References continued
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Craft AW and Hall DBM. Munchhausen Syndrome by Proxy and Sudden Infant
Death. British Medical Journal 2004; 328:1309-1312
Parrish M and Perman J. Munchausen Syndrome by Proxy: Some Practice
Implications for Social Workers. Child and Adolescent Social Work Journal
2004; 21(2):137-154.
Meadow R. What is, and What is not, ‘Munchausen Syndrome by Proxy’?
Archives of Disease in Childhood 1995; 72:534-538.
Fisher GC and Mitchell I. Is Munchausen Syndrome by Proxy really a
Syndrome? Archives of Disease in Childhood 1995; 72:530-534.
Green, M. Vulnerable Child Syndrome and Its Variants. Pediatrics in Review
1986; 8:75-80.
Hall DE, Eubanks L, Swarnalatha M, Kenney RD, Johnson SC. Evaluation of
Covert Video Surveillance in the Diagnosis of Munchausen Syndrome by
Proxy: Lessons From 41 Cases. Pediatrics 2000; 105(6):1305-1312.
Pearson SR and Boyce WT. Consultation with the Specialist: The Vulnerable
Child Syndrome. Pediatrics in Review. 2004;25:345-349.

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