The deceit continues: an updated literature review of Munchausen Syndrome by Proxy

OBJECTIVE: This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP). METHOD: Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles. RESULTS: Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury. CONCLUSION: Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.     

Munchausen by proxy: a case, chart series, and literature review of older victims

The history of an older child victim of Munchausen by proxy (MBP) is described. He was referred for evaluation after repeated sinus surgeries for recurrent sinus infections believed to be related to a falsified history of an immunodeficiency. The perpetrator was the mother of this 14-year-old victim, consistent with the majority of such cases. This case prompted a review of cases of MBP in older children reported in our hospital as well as a literature search for other cases in older children. METHODS: This study was a chart review of children over 6 years of age who had been evaluated by social services at the Children's Hospital at the Cleveland Clinic and reported as cases of Munchausen by proxy to Child Protective Services between January 2001 and June 2003. Also, an OVID, Psychline, and Pubmed literature review of published cases of Munchausen by proxy were identified, and cases occurring in the older child were selected for review. RESULTS: Older children who are the victims of Munchausen by proxy may have an induced illness, but falsified reports of symptoms and medical history to coerce the child to undergo medical procedures may be more common. Collusion of the victim with the perpetrator may also become a factor as the child ages and adopts the deception. Given the complex relationship that exists between the parent and child, it is difficult to predict whether the victim either will assist the caregiver in maintaining the factitious illness or be able to recognize the falsification. CONCLUSIONS: Older children who are the victims of Munchausen by proxy may fear consequences of revealing the factitious illness. Physicians must consider the possibility of this diagnosis whenever there are discrepancies in a child's illness that makes a factitious illness a consideration.     

Malingering-by-proxy: Need for child protection and guidance for reporting

The feigning of disabling illness for compensation at the direction or pressure by others, which is called malingering by proxy (MBP), has been the subject of several spirited articles. Chafetz and Prentkowski (2011) suggested that MBP has the potential for real harm to the child. In a poster at the AACN scientific session in 2011, Chafetz and Binder (2011) pursued a case of MBP that showed the child had clearly suffered and failed to progress in the 6 years that had passed since she was first evaluated as an 11 year old. In the present article, we identify three cases that compare and contrast effects of MBP, illustrating that child abuse and/or neglect can be a serious and reportable consequence of MBP behavior. To illustrate how MBP behavior can cause child abuse, we compare MBP behavior with Munchausen Syndrome by Proxy (MSBP), another condition of volitional noncredible behavior produced in a vulnerable person at the direction or pressure by others. Guidance criteria for reporting MBP as child abuse/neglect are introduced in this article.     

Characteristics of hospital-based Munchausen Syndrome by Proxy in Japan

OBJECTIVE: This article explores characteristics of Munchausen Syndrome by Proxy (MSBP) in Japan, a country which provides an egalitarian, low cost, and easy-access health care system. METHODS: We sent a questionnaire survey to 11 leading doctors in the child abuse field in Japan, each located in different hospital-based sites. Child abuse doctors answered questions regarding the characteristics of MSBP cases for whom they had helped care. RESULTS: Twenty-one MSBP cases (20 families) were reported. Characteristics of the victims included: no differences based on sex, 4.6 years of age on average when MSBP was confirmed, and an average of 1.9 years duration of MSBP abuse. Biological mothers were at least one of the perpetrators in 95% of cases. Among the 12 cases (57%) who remained with their families, 2 victims died. Only 5% of perpetrators had a medical background or relatives who engaged in healthcare work. CONCLUSION: There are similar features of MSBP cases between Japan and other English-speaking countries, such as the UK or the US. However, perpetrators of MSBP in Japan did not have a medical background. Easier access to hospital resources in Japan may give greater opportunities for perpetrators to obtain medical knowledge from doctors or nurses. PRACTICE IMPLICATIONS: The findings suggest that perpetrators of MSBP should not be assumed to possess a medical background in a country which provides universal medical care such as Japan. A contributory factor of MSBP may be the high frequency of medical consultations and equal level of accessibility of medical resources for Japanese citizens. Social welfare services that need to decide on custody for MSBP victims should recognize the relatively high risk of life-threatening danger in their family of origin. Further collaboration between hospital staff including pediatricians, nurses, medical social workers and staff at the social welfare services is needed to protect children from MSBP.     

International perspectives on child abuse

This paper reviews an extensive sampling of the international literature on child abuse. The paper focuses on: (1) where the international research on child abuse is being conducted; (2) similarities and differences in definitions of abuse and violence; (3) the types of research methods and theoretical models used to study abuse; and (4) what we currently know about child abuse in other countries. The paper concludes with a discussion of how we can advance our understanding of child abuse by pursuing cross-cultural research. Awareness of child abuse, internationally, varies a great deal, often depending on the political, social, economic, and cultural milieu of the country. Also, despite noticeable trends within countries, the research techniques and theoretical models used to guide scientific investigations vary considerably from one country to the next. For these reasons, one must draw conclusions about the patterns, causes, and extent of child abuse around the world very tentatively. There is much variation as to the likelihood of children being abused, although western, industrialized nations report the highest rates of abuse. Explanations for the variation of child abuse from one country to the next emphasize cultural differences in attitudes towards, and values placed on children, and the cultural appropriateness of using violence as a means of social control.     

A systematic review of the state of the literature on sexually exploited boys internationally

This systematic review assessed the current state of the literature on sexually exploited boys internationally. We aimed to describe what is known about sexual exploitation of boys, identify gaps in the literature, provide implications for practice, and make recommendations for future research. Multiple database searches were conducted using a combination of controlled vocabulary and keywords to capture child and adolescent sexual exploitation. Our search identified 11,099 unique references and excluded studies that did not include male participants less than 18 years old or disaggregate results by relevant age groups and/or by sex. This review identified 42 studies from 23 countries, providing evidence that sexual exploitation of boys is an issue in both high- and low-income countries. Seventeen articles had sexual exploitation as their primary variable of interest, the majority of which sampled boys who accessed services (i.e., shelters, health care, social, and justice services). Boys’ experiences of sexual exploitation varied in terms of venue, exploiters, and compensation. Compared to their non-sexually exploited peers, sexually exploited boys more commonly reported experiences of child abuse, substance use, conduct problems, and mental health problems such as anxiety, depression, and self-harm. Despite increasing evidence that boys are sexually exploited around the world, the current literature provides limited data about the antecedents, sequelae, and the specific features of sexual exploitation experiences among boys. Further research is needed to inform, policy, social services and health care delivery specific to the needs of sexually exploited boys.     

Long-term psychological correlates of childhood sexual abuse in two samples of college men

Using a retrospective questionnaire approach, the current study explored the relationship between a history of childhood sexual abuse and later psychological and sexual adjustment. Subjects were 582 college men from two different geographic locations: 253 from a midwestern university and 329 from a southeastern university. The definition of child sexual abuse employed in this study was a broad one which included both contact and noncontact experiences. In order to be defined as abusive, however, an age discrepancy between victim and perpetrator was required. Although not so for the southeastern sample, for the midwestern sample a number of small but significant correlations emerged between a history of sexual abuse and psychological adjustment as measured by the SCL-90. In both samples, very few significant correlations emerged between a history of sexual abuse and later sexual adjustment and behavior.     

The politics of disclosing female sexual abuse: a case study of Palestinian society

INTRODUCTION: This paper argues that, by understanding the socio-cultural and political context within which disclosure or non-disclosure of sexual abuse takes place we are better able to develop an analytical framework that might shape culturally sensitive social policy towards sexual abuse and thereby reduce it. METHOD: The data for the study were extracted from records available on 38 cases of sexually abused Palestinian girls, as well as interviews conducted with victims and their parents whenever possible. In-depth interviews were conducted with 19 professionals who dealt with these 38 cases. FINDINGS: Contextual analysis of the data revealed that acknowledgment of sexual abuse took place only in situations where the abuse was extremely traumatic, publically apparent, and the victim absolved of blame. Disclosure resulted in approximately 10% of the cases in the killing of the victim. Responses involving measures such as hymen reconstruction, marriage to the rapist, and abortion were used by family and society to "nullify" sexual abuse. The intricacies bearing on the decision to disclose or not disclose sexual abuse were discussed within a socio-cultural and political frame of reference. A paradigm of analysis is provided to clarify this complex relationship.     

Predictors of legal intervention in child maltreatment cases.

Using information extracted from child protective services and criminal court records, this research examines the extent and nature of dependency and criminal filings in 833 substantiated intrafamilial child abuse and neglect cases reported in Denver (CO), Los Angeles (CA), and Newcastle (DE) Counties in 1985-1986. Techniques of chi-square and discriminant analyses were used to identify factors associated with dependency and criminal filings. Results indicate that legal intervention is rare: Dependency filings and prosecutions occur in just 21% and 4% of the sample, respectively, although treatment plan development and out-of-home placement of the child occur in approximately 75% and 50% of the sample, respectively. Eighty percent of cases with criminal filings proceed to trial or plea bargaining, with 92% resulting in conviction. Bivariate analyses indicate cases involving abandonment, sexual abuse, frequent maltreatment, and severe maltreatment are most likely to result in an initial dependency filing, while cases involving sexual abuse, severe maltreatment, a nonparent perpetrator, an ethnic minority perpetrator, a female victim, and a victim aged 7-12 years are most likely to result in a criminal filing. The multivariate analyses show the primary predictor of both dependency and criminal filings is whether the case involved sexual abuse. This finding reflects the widespread public and professional attention child sexual abuse has received in recent years.     

The international epidemiology of child sexual abuse: A continuation of Finkelhor (1994)

ObjectiveThe purpose of this paper was to compare the prevalence rates of child sexual abuse reported by [Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18 (5), 409–417] with those found in recent publications in order to confirm the widespread prevalence of child sexual abuse.MethodsRelevant articles about prevalence of child sexual abuse were identified through searches of computerized databases and a handsearch of Child Abuse & Neglect and the Journal of Child Sexual Abuse.ResultsThirty-eight independent articles were identified, corresponding to 39 prevalence studies; these articles report the prevalence of childhood sexual abuse in 21 different countries, ranging from 0 to 53% for women and 0 to 60% for men.ConclusionsComparison of the present study with that of [Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18 (5), 409–417] shows a similarity between prevalence distributions; there appears to be a general pattern that remains more or less constant over the years, especially in women.Practice implicationsTwelve years after the first revision study about the international prevalence of child sexual abuse, there is still a need for new data about this topic. The present study shows child sexual abuse is still a widespread problem in the society. In this research, carried out on 38 independent studies, there is new data for 21 countries over the world, being especially relevant the results obtained from other countries different from those pertaining to North America or Europe. It is important to point out the high prevalence found in most of the countries, so this information could be a new warning to make society and governments aware of this problem and undertake actions to prevent sexual abuse in childhood.     

Abuse of children in foster and residential care

OBJECTIVE: There have recently been many debates in the UK about how to provide good care for children placed away from home. Professionals have realized that the level of child abuse in foster care and children's homes is high. This research examines the characteristics of physical and sexual abuse of children in foster and residential care in a city in England. The number of cases of abuse reported by pediatricians in this group was compared to the number reported by the same pediatricians for the population of Leeds as a whole. METHOD: This is a retrospective study of 158 children, fostered or in residential care who were involved in 191 episodes of alleged physical and/or sexual abuse assessed and reported by pediatricians over a 6 year period from 1990 to 1995 in Leeds, England. Details of the child including the reason for placement in care, their physical and mental health, abuse characteristics, including perpetrator and case management were studied. RESULTS (see Table 1): 158 incidents of abuse in 133 children in foster/residential care are described. In foster care, 42 children were physically abused, 76 were sexually abused, and 15 experienced both forms of abuse. In residential care, 12 children were physically abused, 6 were sexually abused, and 6 experienced both forms of abuse. In foster care 60% of sexual abuse involved girls and 60% of physical abuse involved boys. In residential care almost twice as many boys as girls were reported to be abused. Foster carers perpetrated the abuse for 41%, natural parents on contact for 23%, and children 20% of incidents. A significant proportion of abuse was severe with 1 death, 8 children with burns, 18 with genital, and 34 with anal penetration. Long-standing emotional, behavioral and learning difficulties were common. Most children (80%) had been abused prior to entry into care. Foster children were 7-8 times and children in residential care 6 times more likely to be assessed by a pediatrician for abuse than a child in the general population. CONCLUSIONS: Children in foster or residential care form an at risk group for maltreatment. Their special needs include additional measures to protect them from abuse.     

Teachers' recognition and reporting of child abuse: a factorial survey

OBJECTIVE: The major aim of this study was to determine the effect of characteristics of the case, the teacher, and the organizational setting on recognition and reporting of child abuse. METHOD: A factorial survey design was employed in which a probability sample of teachers (N = 480) responded to vignettes in which case characteristics were systematically manipulated. RESULTS: Analysis using OLS regression showed that case characteristics alone accounted for 50.30% of the variance in recognition and 51.08% of the variance in reporting: the strongest effects were from type and seriousness of abuse, positive behavior of the victim and positive psychology of the perpetrator. The inclusion of variables describing the teachers and the school explained only a very small additional proportion of the variance in teacher's responses. CONCLUSIONS: Teachers responses to child abuse are relatively unbiased by either the extraneous characteristics of the perpetrator or victim, the responding teacher, or the school setting. The findings do not appear to support the problem of "overreporting." There is evidence for "underreporting," particularly in less serious cases involving physical and emotional abuse. Teachers are undeterred by the many problems and fears that may accompany a report of child abuse to Child Protective Services. Teachers use discretion in reporting abuse they recognize.     

Children's Literature as Prevention of Child Sexual Abuse

This article addresses the issue of child sexual abuse, providing contextual information about the problem, such as the fact that in 85–95% of cases, the offender is known to and trusted by the victim. Because children are greatly influenced by situations depicted in books (and other media), positive and negative influences of general children's literature are discussed. More importantly, the author argues that carefully selected children's literature can help to prevent child sexual abuse. Since statistics reveal that the average sexually abused victim is eight years old, this study focuses on current and suggested literature for children ages four through eight. Content and evaluative criteria are discussed, followed by a survey of thirteen children's books that deal with child sexual abuse. Finally, ideal characteristics of prevention are suggested and some literary models are proposed.     

Child abuse in the eyes of the beholder: lay perceptions of child sexual and physical abuse

OBJECTIVE: The purpose was to explore the effects of victim and perpetrator gender, type of abuse, and victim-perpetrator relationship on university students' and non-students' perceptions of different kinds of child abuse. METHOD: One hundred and ninety-nine participants (including university students and non-student adults) evaluated each of 24 vignettes (within-subjects design) describing an abusive interaction between a child and an adult. The following four variables were manipulated: the victim's gender, the perpetrator's gender, the type of abuse (physical, relatively mild sexual, or relatively severe sexual), and the perpetrator's relationship to the victim (parent or babysitter). Participants rated each vignette on a number of dimensions: degree of trauma and severity, likelihood of general occurrence and reoccurrence, victim believability, and "repressibility" of the event. RESULTS: Significant interactions emerged on each dimension. For example, sexual abuse (whether mild or severe) was rated as being more traumatic and severe if perpetrated by a parent, but relationship type did not affect perceptions of physical abuse. In addition, significant perpetrator gender by victim gender interactions indicated that homosexual abuse was perceived as more traumatic and repressible than heterosexual abuse, but as less likely to occur; and male participants tended to be more affected by the gender of the perpetrator and abuse type than female participants. CONCLUSION: The results suggest that people have stereotypes about the circumstances and consequences of child abuse. These stereotypes are often, though not always, consistent with existing empirical findings.     

The extent, nature, and validity of sexual abuse allegations in custody/visitation disputes

Using information from mail and telephone surveys and personal interviews with legal and mental health professionals who deal with child abuse cases, and empirical data from 12 domestic relations courts throughout the United States, the study concludes that only a small proportion of contested custody and visitation cases involve sexual abuse allegations. Records maintained by family court workers place the figure at less than 2%. A sample of 169 cases for which data were gathered from court counselors, family court, and CPS agency files also found that accusations were brought by mothers (67%) and fathers (28%) and third parties (11%). Fathers were accused in 51% of all cases, but allegations were also made against mothers, mothers' new partners, and extended family members. In the 129 cases for which a determination of the validity of the allegation was available, 50% were found to involve abuse, 33% were found to involve no abuse, and 17% resulted in an indeterminate ruling. Four factors were significantly associated with the perceived validity of the abuse report: age of the victim, frequency of the alleged abuse, prior abuse/neglect reports, and the amount of time elapsing between filing for divorce and the emergence of the allegation.     

Why transitional public relations methodologies are needed for the reform of higher education in the countries of central and eastern Europe

This essay reflects upon the themes that emerged from the “Public Relations—An Instrument for the Transformation and Development of Higher Education in Central and Eastern Europe” seminar, for which the articles appearing in this issue of Higher Education in Europe were originally prepared. The transitional public relations approach, which was developed and introduced to the world public relations literature by the author, is used to analyze the impact of this type of public relations on the reform of higher education in the former communist countries of Europe. The main conclusion is that, in view of the common communist heritage of the countries of Central and Eastern Europe, the application of public relations strategies and instruments in higher education accelerates and facilitates reform of this key area of the economy and also causes it to become more effective. The above statement is particularly valid for private universities.     

Patterns of child abuse and neglect associated with chronological age of children living in a midwestern county.

OBJECTIVE: The main objective of the study was to investigate the relationship between age of the very young victim and the type of abuse perpetrated against that victim. A secondary objective was to examine gender and racial differences in child abuse and neglect in children between the ages of birth and 7 years. METHOD: Archived data for all cases of substantiated abuse of children for the years of 1990-1996 inclusive were retrieved from a data bank at a county children services department (N = 876). Chi-square analyses were used to determine age, gender, and racial differences in child abuse and neglect in children 0 to 7 years of age. RESULTS: Neglect was the most common form of primary substantiated abuse recorded for this population of children under the age of 7 years, although the incidence of neglect decreased as chronological age of the child increased. Sexual abuse increased in occurrence as the children got older. Girls were more likely to be victims of sexual abuse than boys. No significant age differences were observed for physical abuse or for emotional abuse, and no racial differences were detected for any of the four types of abuse examined. CONCLUSIONS: Although the findings of this study are in agreement with those of previously published reports, there is some question as to whether archived data are an accurate reflection of actual patterns of maltreatment occurring in very young children or whether they represent the types of abuse that are subjectively identified and reported by authorities.     

Child sexual abuse: very young perpetrators

Three cases of child sexual abuse by child perpetrators are presented showing that sexual abuse of a child by a child may result in the victim becoming a perpetrator, thereby contributing to a potential reservoir of adolescent and adult perpetrators. Sexual play between children requires increased attention from caretakers to determine whether it is abusive, imitated from prior experience, and potentially transmissible to other children. Parents need to be informed, possibly through schools, that incidents of sexual interaction between children should be reported. To punish children for such behavior may protect the perpetrator and silence the victim(s).     

Alleged sexual abuse at a day care center: impact on parents

OBJECTIVE: This report describes the cascade of stressful events and secondary life changes experienced by parents in a case of alleged sexual abuse at a day care program. The study evaluated parents' Posttraumatic Stress Disorder (PTSD) symptoms and general psychological responses to the stressful events 4 years after the alleged abuse, and explored predictive factors of parental distress. METHODS: A total of 39 parents were interviewed about stressful events, life changes, and social support. Current distress reactions, psychological wellbeing, and locus of control were assessed with a battery of standardized measures. RESULTS: Hearing about the sexual abuse, testifying in court, hearing the verdict, and being exposed in media reports were all rated by the parents as distressing events. The majority of the parents experienced secondary life changes after the alleged sexual abuse. Four years after the alleged sexual abuse, one-third of the parents reported a high level of PTSD Intrusive symptoms and one-fourth reported a high level of PTSD Avoidance symptoms. There was a significant positive correlation between a measure of psychological wellbeing and PTSD. Secondary life changes and locus of control significantly predicted PTSD. CONCLUSION: This study demonstrates that the alleged sexual abuse of children in day care and the resulting events in the legal system and the media constitute significant and chronic stressors in the lives of the children's parents. These findings underscore the need to expand the focus of trauma-related sequelae from the child victim to their parents and family.