Munchausen by proxy child abuse and neglect

The American Professional Society on the Abuse of Children (APSAC) practice guidelines define Munchausen by proxy (MBP) as, “abuse by pediatric condition falsification, caregiver-fabricated illness in a child, or medical child abuse that occurs due to a specific form of psychopathology in the abuser called factitious disorder imposed on another” (APSAC task force, 2018). Any medical condition can be induced, simulated, misrepresented or exaggerated. Behavioral, educational and psychiatric problems can also be falsified. Therapists and school personnel, who often see youth more frequently than they are seen by pediatricians, may be in the best position to play a role in early identification of MBP. Psychologists may also provide therapy to victims or abusers and their other family members, or encounter this form of abuse and neglect during forensic activities. 

Victims can be harmed by the abuser in numerous ways, including direct harm (such as by poisoning, suffocation or more traditional forms of child abuse and neglect); overexposure to clinical interventions; limiting appropriate school, social and developmental opportunities; and causing the development of a distorted view of their health and abilities. Victims can also become ill or physically and mentally harmed by diagnostic and treatment efforts. Children who survive can have severe psychological damage and highly disturbed attachments with others.

Psychologists are encouraged to be aware of the warning signs of MBP and recommended steps when MBP is suspected. Warning signs appear in Section 1.

Section 1. Warning Signs

• Reported symptoms or behaviors are not congruent with observations. For example, the abuser says the child cannot eat, and yet the child is observed eating without the adverse symptoms reported by the abuser.
• Discrepancies exist between the abuser’s reports of the child’s medical history and the medical record.
• Extensive medical assessments do not identify a medical explanation for the child’s reported problems.
• Unexplained worsening of symptoms or new symptoms correlate with abuser’s visitation or shortly thereafter.
• Laboratory findings do not make medical sense, are clinically impossible or implausible, or identify chemicals, medications or contaminants that should not be present. An example is a serum sodium level that is not clinically possible.
• Symptoms resolve or improve when the child is separated and well protected from the influence and control of the abuser.
• Other individuals in the home or the caregiver have or have had unusual or unexplained illnesses or conditions.
• Animals in the home have unusual or unexplained illnesses or conditions — possibly similar to the child’s presentation (e.g., seizure disorder).
• Conditions or illnesses significantly improve or disappear in one child and then appear in another child, such as when another child is born and the new child begins to have similar or other unexplained symptoms.
• Caregiver is reluctant to provide medical records, claims that past records are not available, or refuses to allow medical providers to discuss care with previous medical providers.
• The abuser reports that the other parent is not involved, does not want to be involved and is not reachable.
• A parent, child or other family member expresses concern about possible falsification or high healthcare utilization.
• Observations of clear falsification by the caregiver. This may take the form of false recounting of past medical recommendations, test or exam results, conditions or diagnoses. This can also include observation of induction, such as poisoning or suffocation.

Printed with copyright permission from APSAC.

Health professionals, including mental health experts, are no better than the general public in determining if someone is lying. Section 2 summarizes evaluation and treatment recommendations for clinicians caring for a suspected victim.

Section 2. Evaluation and Treatment Recommendations

• Gather all medical records from past and present treating professionals (see procedure in the MBP guidelines, APSAC Task force, 2018).
• Make contact and regularly communicate with both parents (all caregivers). 

○  Provide all caregivers with ongoing education and feedback about observations and recommendations.

○  Ask all caregivers to repeat back the information provided to them.

○  Carefully document all education and other discussions with the caregivers.

• Collect collateral data from school personnel and other independent observers who have regular access to the child.
• Review suspected abuser’s online social media activity.
• Carefully devise evaluation and rehabilitation plans that systematically and objectively challenge claims made by the suspected abuser or victim.

○  All descriptions of symptoms and disability made by family members must be considered possibly inaccurate. For example, in suspected victims, g-tubes and other nonoral feeding interventions should not be placed based solely on verbal reports of symptoms. Objective inpatient observations by clinicians of feeding attempts provide important data for clinical decision-making.

○ Family members cannot be relied upon to properly prepare the child for diagnostic assessments or treatments. For example, 

i.  Consider performing a toxicology screen prior to manometry testing to ensure no gut-altering substances have been ingested. 

ii.  Consider having a sitter in the room for a pH probe test to ensure that the child is provided only the prescribed oral intake and to ensure the probe position is not changed. 

• Meet with the other clinicians involved in the care of the child to compare data and coordinate plans.
• Alert other clinicians (verbally and in the chart) about the poor reliability of symptom reports or behavior of the suspected abuser, the importance of relying upon objective data, to proceed conservatively and the need to document well.
• Minimize school accommodations, prescriptions, and invasive testing and treatments.
• While devising evaluation and rehabilitation plans, consult with an expert if possible.

Report reasonable suspicion of child abuse and neglect to the proper authorities.

Printed with copyright permission from APSAC.

The MBP guidelines provide education on terminology, warning signs and identification, assessment of abuse and psychopathology, reporting requirements, case management, treatment and reunification. Companion articles in the winter 2018 issue of “The APSAC Advisor,” review ways that pediatric conditions may be simulated or induced, how MBP can present in school and mental health settings, guidance for child protective services and legal professionals, and how electronic and Internet advances have impacted cases of MBP.

References

APSAC Task Force (2018). APSAC Practice Guidelines: Munchausen by proxy: Clinical and Case Management Guidance. The APSAC Advisor. March; 30(1): 8-31.

APSAC Task Force (2018). Special Issue: Munchausen by proxy. APSAC Advisor. March; 30(1).

Members of the APSAC Task Force: Abuse by Pediatric Condition Falsification

• Randell Alexander, MD, PhD, University of Florida, College of Medicine — Jacksonville
• Catherine Ayoub, RN, EdD, Harvard Medical School, Boston Children’s Hospital, Massachusetts General Hospital
• Brenda Bursch, PhD, departments of psychiatry & biobehavioral sciences, and pediatrics, David Geffen School of Medicine at UCLA.
• Kenneth Feldman, MD, Seattle Children’s Hospital
• Marc Feldman, MD, University of Alabama
• Danya Glaser, MD, Great Ormond Street Hospital for Children, London, United Kingdom
• James Hamilton, PhD, University of Alabama
• Carole A. Jenny, MD, pediatrics, University of Washington, Seattle
• Michael Kelly, MD, department of psychiatry, Stanford Medical School
• Bethany Mohr, MD, Michigan Medicine, University of Michigan, Ann Arbor
• Thomas A. Roesler, MD, Seattle Children’s Hospital
• Mary Sanders, PhD, Stanford Medical School
• Herbert Schreier, MD, department of psychiatry, UCSF–Benioff Children’s Hospital Oakland
• Suzanne M. Schunk, LCSW, ACSW Southwest Human Development, Phoenix
• John Stirling, MD, FAAP, Child Abuse Pediatrics, San Diego
• Claudia Wang, MD, department of pediatrics, David Geffen School of Medicine at University of California, Los Angeles
• Michael Weber, BS, Tarrant County Texas District Attorney Investigator
• Beatrice Yorker, RN, MS, JD, California State University, Los Angeles