Medical Child Abuse - Pediatric Medical Experts

By Santa J. Bartholomew M.D. FAAP, FCCM

See Corresponding Case Study: Medical Child Abuse

Medical Child Abuse (MCA) also known as Factitious Disorder Imposed on Another (FDIA) is “child maltreatment caused by a parent or caregiver who falsifies illnesses or induces a child’s illness leading to unnecessary and potentially harmful medical investigation and treatment.”. Over the years, this disease has been labeled by many names, including Munchausen Syndrome by Proxy.

Munchausen Syndrome is a condition in which a patient falsifies their own medical conditions; “by proxy” is when a person falsifies their child’s medical condition. Munchausen Syndrome was named after a German cavalry officer, Baron von Munchausen (1720-1797), who traveled widely and was known for his dramatic stories, which were all fabrications. The title “medical child abuse” was first used in 1995 and is currently accepted term for this disease but regardless of the name, MCA and FDIA have proven to be a form of child maltreatment beset with perplexing diagnostic and legal challenges.

Munchausen Syndrome is a condition in which a patient falsifies their own medical conditions; “by proxy” is when a person falsifies their child’s medical condition.

MCA can occur via a variety of ways when a parent is interacting with a health system:

Fabrication: This is when a parent continually brings their child to medical providers reporting symptoms that are completely made up
1. Such as that the child is suffering from intermittent stiffening of their body followed by shaking.
2. A parent or caregiver will bring urine into the pediatrician that contains blood that s/he has tainted with their blood.
3. In infants’ non-medical failure to thrive would fit in this category. The infant is simply not fed at home, in the hospital is submitted to a series of tests and simply feeding the child causes easy weight gain.

Each of these issues would then be followed by extensive and often times painful examinations and diagnostic work.

Induction: the caregiver’s action results in symptoms or signs in the child which are real but are inflicted by the caregiver’s actions (i.e., suffocation of the child or administration of a medication to induce illness).

It is essential to realize in these circumstanced that the caregiver’s actions result in the healthcare system being used as the perpetrator of the abuse. Persons who commit these crimes do so intentionally. Often, such offenders mistakenly are believed have a mental illness, thus limiting their responsibility. However, evidence suggests that they complete understand their actions.

Medical Child Abuse is most often seen in women though not exclusively who purposefully harm their child or describe symptoms in their child that do not exist to have medical attention lavished on them and their child. A person who inflicts MCA uses the illness and hospitalizations of the child to gain adoration from others for their devotion to their child’s care. They also use the ill child to develop a relationship or (as they see it) a friendship with the healthcare providers.

The current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) applies the mental diagnosis “factitious disorder imposed on another” to individuals guilty of these acts. It describes the caregiver, not the victim. DSM-5 explains that such people practice deception—indicating knowledge of right and wrong—and refers to them as perpetrators. It links the condition to illegal behavior and compares impulse disorders and pedophilia, among other problems. For these reasons when a parent is identified as committing MCA, it is essential that the criminal system becomes involved and helps prove beyond a reasonable doubt that these offenders understand the difference between right and wrong. A psychological examination will reveal caregivers as psychologically normal with the most common finding, if any, is a behavioral or personality disorder.

The exact cause why a person who commits MCA is not well understood; however, experts believe biological and psychological factors may play a role in developing this pattern of illegal behavior. Some theories indicate that a personal history of child abuse or neglect or the early loss of a parent might be a factor. Other evidence suggests that significant stressors, such as marital problems, can trigger an initial episode and the attention lavished becomes a secondary gain for the perpetrator to repeat these actions. Research confirms that persons commit this abuse for attention. There may be other reasons a parent would seek unnecessary medical treatment for a child than solely for attention, but the belief is that a person who inflicts MCA has a primary need for their child to be seen as ill or injured. There may be a financial element that serves as a secondary motive. Academics and experts have also suggested that offenders gain excitement from deceiving personnel in medical professions, charity organizations, and media outlets.

By providing false medical histories, perpetrators can hide their crimes, sometimes for years. When making diagnoses, doctors typically rely on the information given by a parent or other guardian. They cannot constantly stay with the victim to observe symptoms. Medical professionals rarly expect caregivers to mislead them into obtaining unnecessary treatment for their children simply for attention.

Specific characteristics are common in a person inflicting MCA, including:

Being a parent, usually a mother.
Being a healthcare professional or having some medical expertise.
Being affable and accommodating with staff.
Appearing quite concerned even overly concerned.

Insistent on not leaving the bedside of the child.
Symptoms that go away when the patient is hospitalized (and out of the care of parent) but return after discharge (when back in their care)

Possible warning signs may include:

The child has many hospitalizations with strange sets of symptoms.
The child’s symptoms are reported but not witnessed by anyone but parent.
The condition and symptoms do not match the results of tests.
Blood in lab samples may be different from the child’s blood.
The child has signs of unexpected substances in the blood, stool, or urine.
A possible history of a child’s death in the family surrounded by unusual circumstances.

Diagnosing MCA is very difficult. Healthcare providers must rule out any actual pathology causing the symptoms using a variety of tests before considering a diagnosis of MCA in the adult caregiver. The dishonesty of the perpetrator is often carefully hidden from hospital staff making it very difficult to detect. Medical professionals who care for children typically believe that all parents want the best for their children despite personal challenges and obstacles making suspicion of parental harm a difficult conclusion.

If a cause for symptoms is not found, a careful review of the patient’s medical history must follow. The family and the caregiver’s medical history should also be reviewed. The most vital portion of the work-up is the review of the medical records. This is a time-consuming but critical task often overlooked, and the diagnosis of MCA can be overlooked. When reviewing the facts, healthcare providers must involve Child Protective Services and the criminal justice system.

By recognizing this as a form of child abuse that is taking place in a medical setting by not only parents but the medical team, there is a clear role for the involvement of child protective services. The state is mandated to keep abused children safe regardless of whether the abuse occurs in the home or the hospital. When considering treatment for child abuse in a medical setting, the same standards used in other types of abuse should be applied: Ensure that the child is safe and that treatment for the child and offending parent is initiated.

The American Academy of Pediatrics and the Committee on Child Abuse suggest various interventions for pediatric providers, from least to most restrictive. Some options require action by outside agencies (child protective services, private counselors, law enforcement, etc.).

Seek individual and family therapy while using a primary provider as a “gatekeeper” to use the healthcare system.
Monitor medical system usage by involving people or institutions outside the medical community. For example: having the parent authorize the school to call the physician if the child is absent or not allowing excused absences without a provider’s approval.
Admit the child to an inpatient or hospital program where their health can be monitored. This admission is an essential resource for monitoring the child for physiologic issues.
Involve child protective services to obtain custody to control the overuse of medical care.
Place the child in another home permanently.
Prosecute the offending parent and incarcerate them, thus eliminating physical harm to the child.

References:

American Academy of Family Physicians. (2021) Munchausen Syndrome by Proxy. (https://familydoctor.org/condition/munchausen-syndrome-proxy/) Accessed 1/4/2023.

Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: American Psychiatric Association, 2013): 325-27.

The Cleveland Clinic (n.d.). Factitious Disorder Imposed on Another. Myclevelandclinic.org. Retrieved January 4, 2023, from https://my.clevelandclinic.org/health/diseases/9834-factitious-disorder-imposed-on-another-fdia

Stirling, J and the Committee on Child Abuse (2007) Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting, Pediatrics 119 (5): 1026–1030.

Weber, M (2018). Investigating Medical Child Abuse, The FBI Law Enforcement Bulletin.