Munchausen syndrome by proxy: A family affair

Munchausen syndrome by proxy is an unusual form of child abuse: a child presents with an illness that has been factitiously produced by a parent, typically the mother. A case of chronic illicit insulin administration to a one-year-old girl is described. Despite temporary separation of the child from the mother and long-term psychiatric intervention, factitious illnesses continued, including urine specimen contamination, laxative-induced diarrhea, suspected bladder catheterization, and suspected poisoning. Retrospective review of the medical records of the mother and two siblings demonstrated previously unrecognized evidence of factitious illnesses. The medical records contained evidence of 30 separate episodes of suspected or documented factitious illness in these four members of the same family. This unique family illustrates the significant morbidity of Munchausen syndrome by proxy and a poor response to psychiatric treatment.     

The perpetrators of medical child abuse (Munchausen Syndrome by Proxy) – A systematic review of 796 cases

IntroductionLittle is known about the perpetrators of medical child abuse (MCA) which is often described as “Munchausen’s syndrome by proxy” or “factitious disorder imposed on another”. The demographic and clinical characteristics of these abusers have yet to be described in a sufficiently large sample. We aimed to address this issue through a systematic review of case reports and series in the professional literature.MethodA systematic search for case reports and series published since 1965 was undertaken using MEDLINE, Web of Science and EMBASE. 4100 database records were screened. A supplementary search was then conducted using GoogleScholar and reference lists of eligible studies. Our search yielded a total sample of 796 perpetrators: 309 from case reports and 487 from case series. Information extracted included demographic and clinical characteristics, in addition to methods of abuse and case outcomes.ResultsNearly all abusers were female (97.6%) and the victim’s mother (95.6%). Most were married (75.8%). Mean caretaker age at the child’s presentation was 27.6 years. Perpetrators were frequently reported to be in healthcare-related professions (45.6%), to have had obstetric complications (23.5%), or to have histories of childhood maltreatment (30%). The most common psychiatric diagnoses recorded were factitious disorder imposed on self (30.9%), personality disorder (18.6%), and depression (14.2%).ConclusionsFrom the largest analysis of MCA perpetrators to date, we provide several clinical recommendations. In particular, we urge clinicians to consider mothers with a personal history of childhood maltreatment, obstetric complications, and/or factitious disorder at heightened risk for MCA. Longitudinal studies are required to establish the true prognostic value of these factors as our method may have been vulnerable to publication bias.     

Care taker blogs in caregiver fabricated illness in a child: A window on the caretaker's thinking?

Three recently diagnosed cases of caregiver-fabricated illness in a child at Seattle Children's Hospital shed light on a new manifestation of their caretakers’ attention seeking. The patients’ mothers were actively blogging about their children's reputed illnesses. Although it is not uncommon for parents of chronically ill children to blog about their child's medical course, specific themes in these blogs of parents suspected of medically abusing their children were noted. In particular, gross distortions of the information parents had received from medical providers were presented online, describing an escalation of the severity of their children's illnesses. The mothers reported contacting palliative care teams and Wish organizations, independently from their medical providers’ recommendations. They sought on-line donations for their children's health needs. We believe these blogs provide additional direct evidence of the suspected caregivers’ fabrications. Although we have not performed formal content analysis, blogs might also provide insight into the caretakers’ motivations. Protective Services and/or police investigators could consider querying the internet for blogs related to children at risk for caregiver-fabricated illness in a child. These blogs, if viewed in parallel with the children's medical records, could assist medical diagnosis and legal documentation of medical fabrication and assist in protective planning for the affected children.     

Persistence of pediatric post traumatic stress disorder after 2 years

One-hundred and fifty-six children were randomly evaluated at an inner-city juvenile/family court. These children were removed from their parent's custody subsequent to a finding of severe child maltreatment. From our original sample of 156 children, 62 met strict criteria for Post Traumatic Stress Disorder (PTSD). Fifty-two of these 62 were successfully recruited and participated in the 2 year re-examination. Each PTSD diagnosis was conferred by the Diagnostic Interview for Children and Adolescents (DICA). From our sample of 52 PTSD children re-examined after 2 years, 17 (32.7%) retained the full PTSD diagnosis, while 67.3% did not meet criteria.     

Toward instituting a chaperone policy in outpatient pediatric clinics

ObjectivesWe sought to evaluate child, parent and medical provider preferences for chaperones for outpatient encounters and to evaluate the acceptability and frequency of utilization following institution of a chaperone policy. Secondarily, we sought to understand what medical history and examinations teens consider “sensitive.”DesignWe conducted an observational study 1 month before and 1 month after institution of outpatient clinic chaperone policy. Post clinic questionnaires were used for patients ≥12 years old, parents, and clinicians. A research assistant observed chaperone use.SettingAdolescent Medicine, Urology, and Rehabilitation Clinics at a regional, tertiary-care pediatric hospital, in a major metropolitan area were studied.ParticipantsConvenience sample: 117 clinic patients during control period and 119 after policy implementation.Main outcome measuresPreferences for and satisfaction with chaperone use were documented.ResultsAlthough non-parent chaperones were usually declined (99.6%), offers were appreciated. Non-parent chaperone use increased modestly (5.3–18.1%).Most patients preferred not to have non-parent chaperones. This preference was greater among older patients (88%), than early teens (52%). After experiencing sensitive examinations, more young adolescent patients (89%) wished their parent had been present than older patients (38%). Patients’ opinions about what constitutes “sensitive” questions and examinations and chaperone preferences varied widely. Providers often did not recognize issues patients and parents considered sensitive questioning (21% agreement), but recognized sensitive physical examinations better (74% agreement). Providers felt chaperones had been a detriment to examination and exams would have gone better without one only 1% of the time.ConclusionsAlthough usually declined, offers of chaperones were appreciated and use of non-parent chaperones increased modestly. Offering chaperones for sensitive examinations may remind providers about appropriate, respectful patient encounters. Implications for children's hospitals’ patient safety and satisfaction, and institutional staff protection and costs are significant.Practice implicationsQuestions and examinations which patients consider sensitive vary widely. Asking patients for their preferences for examination chaperones may reassure them about the appropriateness of examinations, remind staff to conduct respectful examinations and protect providers from accusations of impropriety. Since most chaperone offers are declined, the cost of asking is likely to be minimal.     

Association between mothers’ problematic Internet use and maternal recognition of child abuse

BackgroundThere are few studies about mothers’ problematic Internet use (PIU). Mothers’ PIU may lead to inadequate parenting and child abuse.ObjectiveThis cross-sectional study aimed to clarify the association between mothers’ PIU and their recognition of child abuse.Participants and settingWe analyzed data collected of health examinations of children aged 4 months, 1.5 years, and 3 years which were carried out in Matsue City, Shimane Prefecture, Japan between April 2016 and March 2017. The number of the subjects were 1685, 1729, 1674, respectively.MethodsWe used logistic regression analysis to clarify the association between mothers’ PIU (Young’s Diagnostic Questionnaire for Internet Addiction score: ≥5) and their recognition of child abuse (selecting < True of me > for < I sometimes think that I am abusing my child > on a questionnaire survey), which was adjusted for covariates such as maternal age, number of children, daytime caretaker, social support, postpartum depression, and current smoking status of the parents.ResultsBased on the multivariate logistic regression analysis, the mothers’ PIU was significantly correlated with their recognition of child abuse for children aged 4 months, 1.5 years, or 3 years [odds ratio (OR): 13.30, 95% confidence interval (CI): 1.26–139.98, OR: 7.02, 95% CI: 1.28–38.55, and OR: 28.06, 2.48–317.93, respectively].ConclusionThis study revealed the possibility that mothers with PIU recognize child abuse more than mothers without PIU. However, further studies should be conducted to increase reliability and validity.     

Growing up with parental alcohol abuse: exposure to childhood abuse, neglect, and household dysfunction

OBJECTIVE: This study is a detailed examination of the association between parental alcohol abuse (mother only, father only, or both parents) and multiple forms of childhood abuse, neglect, and other household dysfunction, known as adverse childhood experiences (ACEs). METHOD: A questionnaire about ACEs including child abuse, neglect, household dysfunction, and exposure to parental alcohol abuse was completed by 8629 adult HMO members to retrospectively assess the relationship of growing up with parental alcohol abuse to 10 ACEs and multiple ACEs (ACE score). RESULTS: Compared to persons who grew up with no parental alcohol abuse, the adjusted odds ratio for each category of ACE was approximately 2 to 13 times higher if either the mother, father, or both parents abused alcohol (p < 0.05). For example, the likelihood of having a battered mother was increased 13-fold for men who grew up with both parents who abused alcohol (OR, 12.7; 95% CI: 8.4-19.1). For almost every ACE, those who grew up with both an alcohol-abusing mother and father had the highest likelihood of ACEs. The mean number of ACEs for persons with no parental alcohol abuse, father only, mother only, or both parents was 1.4, 2.6, 3.2, and 3.8, respectively (p < .001). CONCLUSION: Although the retrospective reporting of these experiences cannot establish a causal association with certainty, exposure to parental alcohol abuse is highly associated with experiencing adverse childhood experiences. Improved coordination of adult and pediatric health care along with related social and substance abuse services may lead to earlier recognition, treatment, and prevention of both adult alcohol abuse and adverse childhood experiences, reducing the negative sequelae of ACEs in adolescents and adults.     

Less money,more problems: How changes in disposable income affect child maltreatment

A number of research studies have documented an association between child maltreatment and family income. Yet, little is known about the specific types of economic shocks that affect child maltreatment rates. The paucity of information is troubling given that more than six million children are reported for maltreatment annually in the U.S. alone. This study examines whether an exogenous shock to families’ disposable income, a change in the price of gasoline, predicts changes in child maltreatment. The findings of a fixed-effects regression show that increases in state-level gas prices are associated with increases in state-level child maltreatment referral rates, even after controlling for demographic and other economic variables. The results are robust to the manner of estimation; random-effects and mixed-effects regressions produce similar estimates. The findings suggest that fluctuations in the price of gas may have important consequences for children.     

Type and severity of child abuse and college students'' lifetime suicidality

Objective: The present study compared reported histories and severity of child sexual abuse, child physical abuse, and both, in college men and women.Method: Four hundred and eighty-six consenting undergraduates completed measures of suicidality, sexual abuse (SA), and physical abuse (PA). Based on their responses, they were categorized into 12 mutually exclusive groups: no PA/no SA (n = 234), moderate PA/no SA (n = 78), severe PA/no SA (n = 34), no PA/mild SA (n = 21), moderate PA/mild SA (n = 12), severe PA/mild SA (n = 5), no PA/moderate SA (n = 20), moderate PA/moderate SA (n = 15), and severe PA/moderate SA (n = 10).Results: Participants who reported both severe sexual and severe physical abuse reported more lifetime suicidality than participants who reported either mild sexual and/or physical abuse. Those who reported sexual abuse involving invasive sexual acts such as rape, and physical abuse involving behaviors that resulted in physical injury to the child, were more suicidal than those who reported less severe abuse. In addition, although combined sexual and physical abuse correlated with increased suicidality, unexpectedly, there was no interaction. Finally, women students endorsed more reasons for living than men and about the same level of suicidal ideas and global suicidality, despite a greater likelihood of having been abused.Conclusions: The absence of an interaction between sexual and physical abuse suggests that this increased suicidality is additive rather than multiplicative. An implication is that college counseling personnel need to be aware of the suicidal risk of women and men students reporting either sexual or physical abuse.     

Is the Brief Child Abuse Potential Inventory (BCAPI) a valid measure of child abuse potential among mothers and fathers of young children in Germany?

BackgroundIn order to prevent child abuse, instruments measuring child abuse potential (CAP) need to be appropriate, reliable and valid.ObjectiveThis study aimed to confirm the 6-factor structure of the Brief Child Abuse Potential Inventory (BCAPI) in a German sample of mothers and fathers, and to examine longitudinal predictors of CAP.Participants and settingTwo waves of data were collected from 197 mothers and 191 fathers of children aged 10–21 months for the “Kinder in Deutschland – KiD 0–3” in-depth study. Families were stratified based on prior self-report data for screening purposes.Methods138 fathers and 147 mothers were included in the analysis (invalid: 25% mothers, 30% fathers). First, validity of reporting was examined. Second, confirmatory factor analysis (CFA) was employed to assess factor structure. Third, internal reliability and criterion validity were examined. Finally, multivariate poisson regressions investigated longitudinal predictors of CAP in mothers.ResultsA previously established six-factor structure was confirmed for mothers but not fathers. CFA failed for fathers due to large numbers of variables with zero variance. For mothers, internal consistency and criterion validity were good. BCAPI score at follow-up was associated with baseline BCAPI score (β = 00.08), stress (β = 0.06), education (β=-0.19) and alcohol use (β = .58).ConclusionsFindings confirm the six-factor structure of the BCAPI among German mothers. The clinical use of the BCAPI in fathers is not recommended as it might produce data that are hard to interpret. Further research with fathers is needed to establish if this is due to limitations with this dataset or with the questionnaire.