Munchausen by Proxy

Two pediatricians have drafted new guidelines they say doctors should follow if they suspect a caregiver has fabricated or induced an illness in a child.

Dr. Emalee G. Flaherty of the Northwestern University Feinberg School of Medicine in Chicago and Dr. Harriet L. MacMillan of the Michael G. DeGroote School of Medicine at McMaster University in Canada released their recommendations today in the journal Pediatrics.

They stressed that doctors need to make a thorough review of a child's medical records, meticulously document everything a caregiver tells them, and reach out to and confer with other medical professionals, as well as child protective services and social workers when necessary.

Previously called Munchausen syndrome by proxy, Flaherty and MacMillan believe this disorder is more accurately classified as pediatric condition falsification, factitious disorder by proxy, child abuse in the medical setting, or medical child abuse.

“When clinicians see children [they should] ask themselves, is this history that's presented by the parent, does it really make sense, does it fit together?” MacMillan told Healthline. “Couple that with a situation where a child seems at risk of or is undergoing unnecessary or harmful procedures or medical care, clinicians really need to be thinking about what's happening here or what's really going on.”

The report was commissioned by the Committee on Child Abuse and Neglect of the American Academy of Pediatrics.

Unexplained Physical and Mental Symptoms

Caregivers who abuse children in this way often have kids who show symptoms of conditions like sleep apnea, malnutrition or anorexia, attention deficit disorder, bleeding, or seizures.

“It's not just physical symptoms; it's also emotional symptoms,” MacMillan said. “Sometimes a parent reports that a child is repeatedly trying to hurt themselves and take their life when, in fact, there's no indication that that is happening.”

The possibility of caregiver-fabricated or caregiver-induced illness presents a tremendous dilemma for doctors. Most physicians will not report the incident to authorities unless they are almost completely convinced it is true, MacMillan said.

While this syndrome is very rare, it is probably more common than doctors believe, she added.

“It's hard for clinicians to entertain the idea that a person is purposely doing this,” MacMillan said. “They're trained to trust the histories that are provided to them.”

Usually, the only way to know for certain whether a child is a victim of this kind of abuse is to remove them from the caregiver, which is a serious step to take, MacMillan said.

“When people hear that, understandably they're like, 'Wow, that's potentially very intrusive,'” MacMillan said. Still, she said placing a child with a relative or in foster care, where they can continue their daily activities, is better than putting them in the hospital for observation.

In some instances, physicians may even need to consider covert video surveillance of a hospitalized child to monitor the caregiver's actions. This is controversial, however, and many facilities are reluctant to do it, MacMillan said.

What to Watch For

The report suggests doctors look for these things if they suspect a child is been a victim of induced or fabricated illness:

  • The diagnosis does not match the objective findings.
  • The signs or symptoms are bizarre.
  • The caregiver or suspected offender does not express relief or pleasure when told that a child is improving or does not have an illness.
  • Inconsistent histories of symptoms are provided by different observers.
  • The caregiver insists on invasive or painful procedures and hospitalizations.
  • The caregiver’s behavior does not match expressed distress or the report of symptoms.
  • The child's sibling has had an unusual illness or death.
  • The caregiver publicly solicits sympathy, donations, or benefits because of the child’s illness.

What makes a caregiver abuse a child in this way? Usually, they want an intense relationship with the child's physician, perhaps to get positive feedback about how much they care for their child, MacMillan said, though there are no defined psychological problems that are common in all offenders.

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