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Medical Child Abuse: Essentials for Pediatric Health Care Providers

Published:February 12, 2021DOI:https://doi.org/10.1016/j.pedhc.2021.01.006

      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.

      KEY WORDS

      DEFINITIONS AND FEATURES

      Medical child abuse (MCA), formerly known as Munchausen Syndrome by Proxy, was first described by
      • Meadow R.
      Munchausen syndrome by proxy: The hinterland of child abuse.
      and was defined as a behavioral pattern in which a caregiver creates, exaggerates, or induces mental or physical illnesses in someone who is in their care, to gain the attention of medical professionals and others. MCA has been known by many names since it was first recognized by Meadow in 1977. Other descriptions of the disorder have placed the primary focus on caregiver or perpetrator motivation or action, including Munchausen Syndrome by Proxy (
      • Meadow R.
      Munchausen syndrome by proxy: The hinterland of child abuse.
      ), factitious disorder by proxy (
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ), pediatric condition falsification (
      • Ayoub C.
      • Alexander R.
      • Beck D.
      • Bursch B.
      • Feldman K.
      • Libow J.
      APSAC Taskforce on Munchausen by Proxy, Definitions Working Group
      Position paper: definitional issues in Munchausen by proxy.
      ), and caregiver-fabricated illness in a child (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ). Conversely, MCA (
      • Roesler T.
      • Jenny C.
      Medical child abuse: Beyond Munchausen syndrome by proxy.
      ) focuses on the resultant harm caused to the child. MCA is a form of child maltreatment that involves the caregiver using the pediatric health care provider and the system as the instrument of abuse (
      • Jenny C.
      Child abuse and neglect: Diagnosis, treatment, and evidence.
      ). MCA occurs when a caregiver exaggerates or fabricates symptoms that cannot be verified or purposely induce physical or psychological symptoms in a child (
      • Petska H.W.
      • Gordon J.B.
      • Jablonski D.
      • Sheets L.K.
      The intersection of medical child abuse and medical complexity.
      ). This caregiver behavior results in the child receiving unnecessary, painful, harmful, or potentially harmful medical care. MCA recognizes that regardless of caregiver motivation for their actions, their aberrant behavior results in harm to the child (
      • Petska H.W.
      • Gordon J.B.
      • Jablonski D.
      • Sheets L.K.
      The intersection of medical child abuse and medical complexity.
      ).

      INSTRUCTIONS

      To obtain continuing education credit:
      • 1.
        Read the article carefully.
      • 2.
        Read each question and determine the correct answer.
      • 3.
        Visit PedsCESM, ce.napnap.org, to complete the online Posttest and evaluation.
      • 4.
        You must receive 70% correct responses to receive the certificate.
      • 5.
        Tests will be accepted until December 31, 2022.

      OBJECTIVES

      • 1.
        Define medical child abuse.
      • 2.
        Discuss the epidemiology of medical child abuse.
      • 3.
        Describe factors that should raise practitioner concerns for possible medical child abuse.
      • 4.
        Discuss consequences of medical child abuse.
      • 5.
        Discuss practice behaviors to enhance the identification of medical child abuse.
      Posttest Questions
      Contact hours: 0.75
      Passing score: 70%
      This continuing education activity is administered by the National Association of Pediatric Nurse Practitioners (NAPNAP) as an Agency providing continuing education credit. Individuals who complete this program and earn a 70% or higher score on the Posttest will be awarded 0.75 contact hours.
      Earn FREE CE Contact Hours Online
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      • 1.
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      • 2.
        In the Course Catalog, search for the name of the CE article.
      • 3.
        If you already have an account with PedsCESM, log in using your username and password. If you are a NAPNAP member, log in with your username and password. If you are a first-time user and NAPNAP nonmember, click on “New Customer? Click Here.”
      • 4.
        Once you have successfully passed the Posttest and completed the evaluation form, you will be able to print out your certificate immediately.
      Currently, the use of the term MCA is not universal. While MCA is the recognized name for the disorder in the United States, in the United Kingdom, the disorder is known as fabricated or induced illness in children (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ). Further confounding the nomenclature of the disorder is that the fifth edition of the Diagnostic and Statistical Manuel of Mental Disorders (DSM-V) introduces another name for the disorder: factitious disorder imposed on another (FDIA;
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ).
      The DSM-V classifies FDIA as a factitious disorder of which there are three: FDIA, factitious disorder, and malingering. The DSM-V differentiates between factitious disorder and malingering by apparent motivation for the actions, falsification, or induction of symptoms of illness in oneself. Individuals with the factitious disorder appear to be motivated by no secondary gain other than to play the sick role. By contrast, malingering is motivated by secondary gains such as seeking money, drugs, or shelter. FDIA involves the simulation or production of factitious disease in another, typically their child, by a parent or caregiver (
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      ). See Box 1 for DSM-V diagnostic criteria for FDIA. FDIA is a perpetrator diagnosis and focuses on the perpetrator's motivation for their actions: making the child sick or appear to be sick so the perpetrator can vicariously assume the sick role or the sainted caregiver role with its’ perceived benefits. Conversely, MCA is a victim diagnosis focusing on the effects on the child victim regardless of perpetrator/caregiver motivation, which could be assuming the vicarious benefits of their child being ill or could involve secondary gains such as money or celebrity. MCA focuses on what (abuse) and how (medically) a child has experienced harm (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ).
      Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for factitious disorder imposed on another
      • (1)
        Falsification of physical or psychological signs or symptoms, or induction of disease or injury in another, which involves deception
      • (2)
        The individual presents the victim to others as injured, ill, or impaired
      • (3)
        The deceptive behavior is present even in the absence of external motivation or external incentives
      • (4)
        The behavior is not explained by another mental disorder
      Note.
      American Psychiatric Association
      Diagnostic and statistical manual of mental disorders.
      .

      EPIDEMIOLOGY

      The true incidence of MCA is difficult to quantify as this form of child maltreatment often goes unrecognized and unreported even when recognized (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ). MCA is not unique to English-speaking industrialized countries (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ).
      • Feldman M.D.
      • Brown R.M.
      Munchausen by proxy in an international context.
      described MCA cases found in 24 different countries involving 122 cases with perpetrators speaking nine different languages. Approximately 0.5–2.0 per 100,000 children under the age of 16 years are victims of MCA (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ;
      • Christian C.W.
      Committee on Child Abuse and Neglect, & American Academy of Pediatrics
      The evaluation of suspected child physical abuse.
      ;
      • Ehrlich S.
      • Pfeiffer E.
      • Salbach H.
      • Lenz K.
      • Lehmkuhl U.
      Factitious disorder in children and adolescents: A retrospective study.
      ;
      • McClure R.J.
      • Davis P.M.
      • Meadow S.R.
      • Sibert J.R.
      Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.
      ;
      • Rosenberg D.A.
      Web of deceit: A literature review of Munchausen syndrome by proxy.
      ). The true number of victims may be even higher for several reasons. Studies suggest that pediatric health care providers require a strong degree of certainty before reporting MCA to child protective services. Many cases of MCA go unreported when a provider is suspicious yet not certain of the MCA diagnosis (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ), differing from the recommended practice of reporting a suspicion of child maltreatment to child protective services (CPS) (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ).
      In addition, contributing to the difficulty in identifying cases of MCA is that pediatric health care providers, including pediatric nurse practitioners (PNPs), are trained to trust a child's caregiver to provide an accurate history of their child's illness. That, in fact, caregivers know their child best. This innate trust of caregiver history provides an opportunity for caregivers to insist on more invasive testing and procedures, despite health care provider reservations (
      • Crumm C.
      • Culotta P.
      • Cruz A.
      • Camp E.
      • Donaruma-Kwoh M.
      Identification of medical child abuse.
      ), thus opening the door to MCA. This trust in caregiver history often results in a failure to consider MCA in the differential diagnosis, the most common reason for missed diagnosis (
      • Squires J.E.
      • Squires Jr., R.H.
      Munchausen syndrome by proxy: Ongoing clinical challenges.
      ). Further confounding the identification of the true numbers of MCA victims is that up to 30% of victims have a true underlying medical disorder (
      • Rosenberg D.A.
      Web of deceit: A literature review of Munchausen syndrome by proxy.
      ) with a caregiver who at some point in the treatment of the medical problem begins the exaggeration, fabrication, or induction of illness symptoms.
      Girls and boys are equally victimized (
      • Sheridan M.S.
      The deceit continues: An updated literature review of Munchausen syndrome by proxy.
      ). Younger children are more vulnerable, with a median age at diagnosis between 14 months and 2.7 years (
      • Sheridan M.S.
      The deceit continues: An updated literature review of Munchausen syndrome by proxy.
      ). Although at less risk for MCA because of increased independence with age, older children also experience MCA; 25% of victims are greater than 6 years of age (
      • Denny S.J.
      • Grant C.C.
      • Pinnock R.
      Epidemiology of Munchausen syndrome by proxy in New Zealand.
      ;
      • McClure R.J.
      • Davis P.M.
      • Meadow S.R.
      • Sibert J.R.
      Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.
      ;
      • Sheridan M.S.
      The deceit continues: An updated literature review of Munchausen syndrome by proxy.
      ). If MCA has been long-standing, the child may take on the sick role themselves (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). Siblings often also suffer MCA (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ), many with similar symptoms or illnesses as the identified MCA victim.

      PERPETRATORS

      MCA focuses on what (abuse) and how (medically) a child has experienced harm (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ), and the motivation of the perpetrator is not relevant to this basic truth. However, it is important that pediatric health care providers possess a basic understanding of MCA perpetrators to be better able to identify victims. Although little is known about the perpetrators of MCA, research has begun to reveal some commonalities.
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      conducted a systematic search for MCA case reports and series published since 1965, yielding a total sample of 796 MCA perpetrators. Perpetrators were almost exclusively female (97.6%) and the mother of the child victim (95.6%). The majority were married (75.8%). The mean age of the abuser at the time the child was identified as a victim of MCA was 27.6 years. A health care related occupation was noted for nearly half (45.6%) of perpetrators (
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      ). If the perpetrator is not an actual health care professional, MCA perpetrators appear medically savvy and knowledgeable (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ).
      MCA perpetrators often have a history of experiencing trauma and have underlying psychiatric diagnoses. Nearly one-third (30%) of MCA perpetrators reported a personal history of child maltreatment victimization (
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      ). Somatoform and factitious disorders are not uncommon among MCA perpetrators (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ;
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ), with
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      reporting a prevalence rate of 30.9% among perpetrators. Both are mental health disorders that involve the fabrication or induction of symptoms of illness in oneself. The distinguishing factor between the two diagnoses is based on conscious choice. Somatoform disorder involves an adult who is consciously unaware of their own fabrication or induction of symptoms in themselves. Whereas with factitious disorder, the adult is consciously aware of their symptom fabrication or induction and possible gains involved. Studies reveal that mothers with somatoform and factitious disorders tend to have children with more health problems and subsequent higher rates of seeking medical care (
      • Craig T.K.
      • Cox A.D.
      • Klein K.
      Intergenerational transmission of somatization behaviour: A study of chronic somatizers and their children.
      ;
      • Marshall T.
      • Jones D.P.
      • Ramchandani P.G.
      • Stein A.
      • Bass C.
      Intergenerational transmission of health beliefs in somatoform disorders: Exploratory study.
      ), suggesting that their children are at increased risk to become medicalized and in turn MCA victims. Factitious disorders in pregnancy, including reported antepartum hemorrhage, feigned premature labor, and induced postpartum hemorrhage, have been noted in MCA perpetrators, with
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      noting that 23% of MCA perpetrators reported obstetric complications.
      • Sheridan M.S.
      The deceit continues: An updated literature review of Munchausen syndrome by proxy.
      states that in the few cases in which fathers are the primary MCA perpetrators, fathers are likely to have a factitious disorder or clinically significant somatoform disorder. Personality disorders have also been noted in MCA perpetrators (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ), with antisocial, histrionic, borderline, avoidant, and narcissistic types being most frequently identified (
      • Parnell T.
      Guidelines for identifying cases.
      ). Depression (14.2%) has also been noted (
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      ).
      Nonperpetrating fathers of MCA victims are typically described as distant, uninvolved, and somewhat emotionally and physically detached from the family (
      • Morrell B.
      • Tilley D.S.
      The role of nonperpetrating fathers in Munchausen syndrome by proxy: A review of the literature.
      ). Fathers may be completely unaware of what is happening with their child's medical care, others believe the mother's statements regarding the child and believe the child to be ill, and others might have concerns and challenge the mother without success (
      • Parnell T.
      Guidelines for identifying cases.
      ).
      • Yates G.
      • Bass C.
      The perpetrators of medical child abuse (Munchausen syndrome by proxy) - A systematic review of 796 cases.
      described the methods of abuse used by MCA perpetrators: fabrication by words was noted in 45.9% of cases; simulation or interfering with medical care in 21.7% of cases; and symptoms induction in 57.4%. Many perpetrators (54.4%) continued to fabricate symptoms even when the child was hospitalized. MCA resulted in victim death in 7.6% of cases, and all deaths involved induction of symptoms by perpetrators. A small number of perpetrators (6.9%) abused the child for their own financial gain. Social media sites provide a proliferation of outlets for sharing medical stories and fundraising, thus facilitating the use of the MCA victim's illness for fundraising efforts (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ).

      PRESENTATIONS AND CONSEQUENCES

      The possible presentations of MCA are endless; any symptom of illness can be exaggerated or fabricated, and many can be induced. See Box 2 for examples of possible presentations of MCA. Caregivers have fed infants formula laced with salt resulting in hypernatremia leading to seizures, neurological devastation, and even death. Caregivers have also chronically given infants or children laxatives leading to severe diarrhea, malabsorption syndrome, weight loss, assumed inability to tolerate oral or enteral feedings resulting in the use of parental nutrition presenting a variety of possible complications. The specific consequences of MCA are dependent on the specific exaggerations, fabrications, and inductions of their caregiver and the specific resulting medical tests or procedures. It is important to understand that one form of MCA can evolve into another—a caregiver may begin with exaggerating or fabricating symptoms and then move to inducing symptoms (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). While exaggeration and fabrication of symptoms result in negative consequences for MCA victims, those children for whom caregivers induce symptoms are most at risk for severe physical, behavioral, and emotional consequences, including a 6% mortality rate (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ).
      Possible presentations of medical child abuse
      Tabled 1
      Neurological
       Apparent life-threatening event/seizures/ataxia—gait abnormality/muscle weakness- paralysis/chronic headaches/nystagmus/blindness
      Gastrointestinal
       Diarrhea/vomiting/bleeding including hematemesis and blood in stool/anorexia/unexplained weight loss/refusal or inability to eat by mouth/disorders leading to need for parental nutrition
      Urological
       Hematuria/proteinuria/urolithiasis/urinary tract infections/nocturia
      Renal
       Hypertension/hypernatremia/hypokalemia/renal failure
      Rheumatologic
       Arthritis/arthralgia/systemic autoinflammatory disease
      Ear injuries and trauma
       Chronic otitis media/hearing loss/otorrhea/swallowing disorder
      Allergies
       Food/environmental/rash
      Dermatologic
       Erythema/vesicles/scratches/lacerations/burns/rashes
      Developmental
       Developmental delay/attention-deficit hyperactivity disorder/psychosis
      Endocrine
       Polydipsia/polyuria/diabetes/hypoglycemia/glycosuria
      Infection
       Fever/sepsis/unusual bacteria at site of infection/multiple unusual organisms at the same time of low pathogenicity
      Respiratory
       Respiratory arrest/apnea/cystic fibrosis/bleeding from respiratory tract/intractable asthma
      Note.
      • Bertulli C.
      • Cochat P.
      Munchausen syndrome by proxy and pediatric nephrology.
      ;
      • Doughty K.
      • Rood C.
      • Patel A.
      • Thackeray J.D.
      • Brink F.W.
      Neurological manifestations of medical child abuse.
      ;
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ;
      • Petska H.W.
      • Gordon J.B.
      • Jablonski D.
      • Sheets L.K.
      The intersection of medical child abuse and medical complexity.
      ;
      • Rees P.
      • Al-Hussaini A.
      • Maguire S.
      Child abuse and fabricated or induced illness in the ENT setting: A systematic review.
      ;
      • Wittkowski H.
      • Hinze C.
      • Häfner-Harms S.
      • Oji V.
      • Masjosthusmann K.
      • Monninger M
      • Foell D.
      Munchausen by proxy syndrome mimicking systemic autoinflammatory disease: Case report and review of the literature.
      .
      The consequences of MCA can be significant. All victims suffer some degree of at least short-term morbidity as the result of unnecessary medical tests and procedures (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ). Mortality is reported to range from 6% to 9%, with approximately the same numbers of victims suffering long-term disability or permanent injury (
      • McClure R.J.
      • Davis P.M.
      • Meadow S.R.
      • Sibert J.R.
      Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.
      ;
      • Rosenberg D.A.
      Web of deceit: A literature review of Munchausen syndrome by proxy.
      ;
      • Sheridan M.S.
      The deceit continues: An updated literature review of Munchausen syndrome by proxy.
      ). MCA often continues while the child is hospitalized (
      • Schreier H.
      On the importance of motivation in Munchausen by Proxy: The case of Kathy Bush.
      ), even in the intensive care unit (
      • Su E.
      • Shoykhet M.
      • Bell M.J.
      Severe hypernatremia in a hospitalized child: Munchausen by proxy.
      ). It is estimated that approximately 75% of victim morbidity has been the result of caregivers’ behaviors while the child was hospitalized (
      • Rosenberg D.A.
      Web of deceit: A literature review of Munchausen syndrome by proxy.
      ).
      The harm resulting to the child because of MCA exists on a continuum from relatively benign to potentially life-threatening. There is often a significant delay in making the diagnosis of MCA; months and even years can pass between initial child symptom presentation and MCA diagnosis resulting in ongoing victimization (
      • Flaherty E.G.
      • Macmillan H.L.
      Committee on Child Abuse and Neglect
      Caregiver-fabricated illness in a child: A manifestation of child maltreatment.
      ). MCA can result in consequences for the child affecting their physical health, developmental/life functioning, and psychological health (see Box 3), both short-term and long-term. MCA, by definition, results in harm to the child in the form of unnecessary medical care, including tests (i.e., blood draws, lumbar punctures), procedures (i.e., urinary catheterization, surgical procedures), which all result in some degree of physical pain, psychological distress, and potential complications. Child victims of MCA are essentially forced into the role of a chronically ill child by caregiver symptom exaggeration, fabrication, or induction resulting in social isolation from peers, inability to attend school, and physical limitations to activity placing the child at risk for developmental and social delay. The chronically ill child often experiences psychological distress, which can manifest in a variety of ways, including anxiety, depression, emotional and behavioral problems, and post-traumatic stress disorder (
      • Compas B.E.
      • Jaser S.S.
      • Dunn M.J.
      • Rodriguez E.M.
      Coping with chronic illness in childhood and adolescence.
      ). As victims of MCA become older, the complexity of the situation increases. Children may become complicit in the falsification of symptoms colluding with their caregiver becoming trapped in the falsification of illness (
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ).
      Potential consequences of medical child abuse
      Tabled 1
      Physical health
       Repeated unnecessary medical tests, procedures, and treatment
        Pain
        Anxiety
        Psychological distress
        Potential complications resulting in physical health consequences including death
       Hospital admissions
       Induction
        Illness/complications
        Hospitalization
        Death
      Development/life functioning
       Developmental/social delays
        Frequent hospitalizations
        Physical limitations secondary to testing/treatment/diagnosis
        Low or interrupted school attendance and education
        Few normal-school activities
       Assumption of sick role with aides
        Wheelchair
        Feeding tubes
      Psychological health
        Social isolation
        Distorted view of their health
        Anxiety regarding their health
        Collude with the illness presentation
        Develop a factitious or somatoform disorder
        Emotional and/or behavioral problems
      Note.
      • Bass C.
      • Glaser D.
      Early recognition and management of fabricated or induced illness in children.
      ;
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      .

      IMPLICATIONS FOR PRACTICE

      MCA is a difficult disorder to recognize in clinical practice. There is no single laboratory test or radiologic study that can confirm the diagnosis. However, it takes only one engaged, observant pediatric health care provider to have suspicions regarding MCA, start asking questions, and begin the process of making the diagnosis of MCA. PNPs working in primary, specialty, or acute care settings may encounter victims of MCA. It is critical that all PNPs possess the skill and knowledge necessary to allow for the identification of and appropriate intervention for MCA. The presence of certain clinical factors should trigger the PNP to be concerned about the possibility of MCA (see Box 4). Once MCA is suspected, this concern must be explored vigorously and confirmed to save the child from further harm.
      Factors concerning medical child abuse
      Tabled 1
      A child's diagnosis does not match objective findings
      Inconsistent histories of illness given by one caregiver
      Signs and symptoms of illness that are present only in the presence of one caregiver
      A child's illness does not respond to normal treatments
      Caregiver insistence on invasive procedures
      Lack of caregiver relief or satisfaction, when told their child, improves or does not have a particular illness
      History of unusual or unexplained illness in caregiver or siblings
      Doctor shopping
      Note. Adapted from
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      .
      MCA is a complex diagnosis and requires the input of the multidisciplinary team (MDT) to confirm. Whenever available, the involvement of a child abuse specialist at a children's hospital or child advocacy center is crucial in assisting in making the MCA diagnosis. The child abuse specialist can function as the MDT leader or coordinator to organize the sharing of information from members of the MDT, including subspecialties, primary care, therapists, social workers, and teachers. If the child has received care from other health care institutions, efforts should be made to obtain information from these health care providers. This may require permission to release information signed by the caregiver. If this is not possible, the Health Insurance Portability and Accountability Act does allow health care providers to share information if they, in good faith, believe that the failure to share health information could result in harm to the child (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ).
      The American Academy of Pediatrics recommends asking the following questions to assist in making the diagnosis of MCA: are the history, signs, and symptoms of illness credible? Is the child receiving unnecessary and harmful, or potentially harmful medical treatment? If yes, who is seeking the medical care and treatment (
      • Stirling Jr., J.
      American Academy of Pediatrics Committee on Child Abuse and Neglect
      Beyond Munchausen syndrome by proxy: Identification and treatment of child abuse in a medical setting.
      )? Harm or potential harm to the child resulting from the medical care coupled with a caregiver causing the medical care to happen are the only two necessary criteria for making the MCA diagnosis. A thorough review of the child's medical records, which may involve reviewing several years of records, is necessary to solidify a diagnosis of MCA. Records review should be conducted with a focus on documenting reported symptoms and illnesses and comparing them to objective findings from testing, health care visits, and other therapies received by the child (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). Special attention should be paid to signs and symptoms reported by caregivers that are somewhat subjective and difficult for health care professionals to verify, such as apnea, feeding difficulties, pain, food allergies, or diarrhea (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ).
      Certain circumstances may necessitate a hospital admission to directly observe a child's symptoms and child-caregiver interaction (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). During hospitalization, caregivers should not administer medications and feedings or use medical devices without the supervision of nursing staff when concerns of MCA exist. The use of covert video monitoring may be necessary, in rare circumstances, to confirm the deleterious actions of the caregiver (falsification or induction of symptoms;
      • Hall D.E.
      • Eubanks L.
      • Meyyazhagan L.S.
      • Kenney R.D.
      • Johnson S.C.
      Evaluation of covert video surveillance in the diagnosis of Munchausen syndrome by proxy: Lessons from 41 cases.
      ). A detailed hospital policy coupled with thorough training of monitoring staff is important before the initiation of covert video monitoring. There are also circumstances in which the separation of the caregiver from the child is necessary to assess for the presence or absence of illness symptoms in the absence of the caregiver. Such cases often necessitate the involvement of outside agencies such as law enforcement or CPS to facilitate the separation. The required duration of the caregiver–child separation is variable but must be long enough to determine symptom persistence or relief and if the child exhibits negative effects from the discontinuation of medications, treatments, or other therapies.
      MCA is child abuse and to that end a diagnosis of MCA necessitates a report of suspected child maltreatment to CPS and law enforcement. The goal of intervention following the diagnosis of MCA is to ensure the child is safe and allow treatment of MCA in the least restrictive setting as possible (
      • Stirling Jr., J.
      American Academy of Pediatrics Committee on Child Abuse and Neglect
      Beyond Munchausen syndrome by proxy: Identification and treatment of child abuse in a medical setting.
      ). Although the input of the MDT health care team is important in decision making regarding the child's safety plan, ultimately, it is the burden of CPS to determine a safe placement for the child. There are times that it is most appropriate that the MDT health care team advocate that MCA treatment occurs in the home, such as when an over-anxious caregiver exaggerates symptoms of illness in her child resulting in unnecessary health care for her child. If the caregiver accepts and follows the plan of care, it is in the best interests of the child to remain in the home; however, close monitoring of compliance is imperative. Should the caregiver persist in symptom exaggeration and seeking of unnecessary health care, CPS needs to be informed of this caregiver behavior. Under other circumstances separating the child from the abusing caregiver appears necessary to ensure the safety of the child, such as a mother who has repeatedly induced apnea in her child by suffocation, and it is appropriate for the MDT health care team to advocate for the removal of the child or offending caregiver from the home.
      Once the diagnosis of MCA has been confirmed, there should be a meeting between the health care MDT and the child's family, including the suspected perpetrator, to inform of the report to CPS and law enforcement. A frank discussion of the child's current medical condition with a dismissal of previous claims of medical concerns along with sharing the MDT's concerns regarding the caregivers’ distorted perception of the child's health is crucial (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). A clear plan forward to normalize the child's health status must be agreed on by the caregiver (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). The care plan typically involves caregiver agreement that one health care provider, typically the primary care provider, will act as the gatekeeper for the child's ongoing health care. CPS should also be informed of caregiver disappointment when presented with positive information regarding their child's health status or refusal to cooperate with the care plan. Collaboration between the health care MDT and CPS is crucial to ensuring the safety of the child.
      It is important to recognize the potential psychological consequences to the child which can result from MCA, especially if MCA has been long-term and the child is older. Victims of MCA can exhibit anxiety, depression, and post-traumatic stress disorder (
      • Jenny C.
      • Metz J.B.
      Medical child abuse and medical neglect.
      ). The child may need assistance with changing their view of self from “sick to healthy.” In addition, there is often deep enmeshment between the child and the offending caregiver, and separation can be emotionally triggering for the child. Linkage with appropriate mental health services for the child is vital. The offending caregiver also needs appropriate mental health treatment to be able to admit to the abuse and recognize specifically how their behaviors harmed the child, demonstrate an appropriate emotional reaction to their actions, and develop strategies to identify, understand, and manage their own motivations to abuse the child to avoid doing so in the future (
      • Schreier H.
      Munchausen by proxy.
      ). Achievement of these mental health goals for the offending caregiver often requires long-term treatment, and the ability to demonstrate these skills in caring for their child must be closely monitored for a significant period.
      MCA is a significant pediatric health care problem with serious consequences for victims. PNPs can play a pivotal role in the prevention and identification of MCA. Although the diagnosis of MCA is often difficult to determine, requiring the input of multiple members of the MDT, it takes only one engaged, astute PNP to identify and raise the concern. PNPs must change their practice behaviors to allow for early recognition of factors concerning MCA. PNPs can be a force in educating other members of the MDT about MCA. All pediatric health care MDT members need to be aware of MCA red flags. Prevention of MCA is achieved by fundamentally sound health care practice and decision making by all members of the MDT.

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      Biography

      Gail Hornor, Pediatric Nurse Practitioner, Center for Family Safety and Healing, Nationwide Children's Hospital, Columbus, OH.