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.     

Knowledge and management strategies in incest cases: A survey of physicians, psychologists and family counselors

A questionnaire was mailed to all 255 psychologists, psychiatrists, pediatricians, and family counselors listed in the 1983 telephone directory. Of the 108 private practitioners who responded, over one-half had treated a child or adult incest victim in the past year; 86% requested more training in this area. Practitioners had a high level of general knowledge about intrafamilial child sexual abuse. Nevertheless, one-third stated they would not refer to protective services a child who had first made, but then retracted, an incest allegation. While most pediatricians would recommend physical examination of a child who had retracted, only half of other professionals would do so. Women practitioners were more realistic about the high frequency of actual father-daughter incest and were more likely to report the hypothetical case of the retracted allegation.     

Childhood Maltreatment and School Problems: A Danish National Study

The association between child maltreatment (CM) and educational outcomes have been well documented. However, there is a paucity of research that explores the association between different types of maltreatment and other school problems that may affect the educational outcomes of maltreated children. This study examined the association between different types of CM and school changes, concentration problems, and special educational needs. Gender differences were also examined. Structured interviews were conducted with 2,980 participants. Significant associations emerged between CM, in particular, multiple maltreatment experiences and school problems. Males had higher concentration difficulties and special educational needs. More research attention is needed into optimal learning environments and interventions that support maltreated children more effectively.     

Child abuse and neglect and intimate partner violence victimization and perpetration: A prospective investigation

This paper describes the extent to which abused and neglected children report intimate partner violence (IPV) victimization and perpetration when followed up into middle adulthood. Using data from a prospective cohort design study, children (ages 0–11) with documented histories of physical and sexual abuse and/or neglect (n = 497) were matched with children without such histories (n = 395) and assessed in adulthood (M_age = 39.5). Prevalence, number, and variety of four types of IPV (psychological abuse, physical violence, sexual violence, and injury) were measured. Over 80% of both groups – childhood abuse and neglect (CAN) and controls – reported some form of IPV victimization during the past year (most commonly psychological abuse) and about 75% of both groups reported perpetration of IPV toward their partner. Controlling for age, sex, and race, overall CAN [adjusted odds ratio (AOR) = 1.60, 95% CI [1.03, 2.49]], physical abuse (AOR = 2.52, 95% CI [1.17, 5.40]), and neglect (AOR = 1.64, 95% CI [1.04, 2.59]) predicted increased risk for being victimized by a partner via physical injury. CAN and neglect also predicted being victimized by a greater number and variety of IPV acts. CAN and control groups did not differ in reports of perpetration of IPV, although neglect predicted greater likelihood of perpetrating physical injury to a partner, compared to controls. Abused/neglected females were more likely to report being injured by their partner, whereas maltreated males did not. This study found that child maltreatment increases risk for the most serious form of IPV involving physical injury. Increased attention should be paid to IPV (victimization and perpetration) in individuals with histories of neglect.     

Families at risk of poor parenting: A descriptive study of sixty at risk families in a model prevention program

Sixty families assessed to be at risk of poor parenting were the subject of this study. These families were participants in a model multidisciplinary program designed for the secondary prevention of poor parenting and the extremes of child abuse and neglect. The model program consists of special medical, psychological, social and developmental services to families on an inpatient, outpatient, and in-home basis. Demographic information on these 60 families was tabulated. Each family was given a monthly rating on a simple measure of family function. Ratings over lime were observed, and families were characterized in terms of a family rating vector (up. up-plateau, plateau, fluctuating, and down). Families were also described in terms of the constellation of problems brought to the therapy situation. Problem lists for each family were subjected to factor analysis. Five factor constructs which made clinical sense emerged from the analysis. Each factor could be labeled as a “family type.” These types were: (I) Abusive Family. (II) Neglectful or Antisocial Family. (III) Family with an Emotionally Unstable Parent, (IV) Family with Cultural or intellectual Limitation, and (V) Family with Child-Rearing Difficulties. Approximately 20% of these families did not fit the typology. Families were then divided into two groups—those who were relatively long-term, ongoing recipients of services, and those who left the program in the observation interval. Families were categorized according to family function rating vector and “family type.” It was noted among long-term families, measured improvement in family function was most evident in families with transient situational crisis (who did not fit the typology) and those with intellectual and cultural deficits (Type IV). Among the families who dropped from the program. 15% were no longer at risk. Sixty-three percent of the remaining families were not improving. These techniques may be useful in determining which at risk families are more successful candidates for prevention efforts.     

Behavioral and musical characteristics of the children who are exposed to child maltreatment and poverty in South Korea: A survey

A preliminary survey was conducted on primary school aged children (N = 302) between seven to twelve years of age, who attend the local Community Child Centers (CCC) in the economically deprived areas of Jeollabukdo in South Korea for the purpose of identifying the children who have been exposed to on-going child maltreatment and poverty, and their needs. Both standardized and non-standardized self-report types of surveys were carried out and completed by both the children and the teachers of the CCC. As would be expected, emotional and behavioral problems are more pronounced by the children who are exposed to child maltreatment and poverty compared to the children who were not exposed to these adversities, or who were not poor. The more severely abused children in terms of frequency and co-occurrence of different abuses appear to display more behavioral problems than less severely abused children. Teachers reported that the children who were able to play a musical instrument and had arts therapy experiences appear to have less behavioral problems, particularly delinquent and aggressive behavior in comparison to the children who did not have such ability and experiences. Through the survey, it was possible to identify the children in need of therapeutic intervention and discover clinically relevant information. Clinical implications will be discussed further.     

Child sexual abuse: A study of prevalence in Great Britain

Of 2019 men and women (aged 15 years and over) interviewed as part of a MORI Survey of a nationally representative sample of Great Britain, 10% reported that they had been sexually abused before the age of 16 (12% of females; 8% of males). There was no increased risk associated with specific social class categories or area of residence. For all types of sexual abuse, the mean age of victims when first abused was significantly lower for females. Subjective reports of the effects of sexual abuse indicated that the majority (51%) felt harmed by the experience, while only 4% reported that it had improved the quality of their life. We estimate that there are over 4.5 million adults in Great Britain who were sexually abused as children, and that a potential 1,117,000 children will be sexually abused before they are 15 years of age. At least 143,000 of these will be abused within the family. The social and mental health implications are enormous, and the authors suggest that an effective intervention and prevention policy is urgently required.     

Child sexual abuse in Japan: A systematic review and future directions

IntroductionEstimating the national prevalence of child sexual abuse (CSA) and its association with health and developmental outcomes is the first step in developing prevention strategies. While such data are available from many countries, less is known about the epidemiology of CSA in Japan.MethodsFor this systematic review, we searched English databases: Embase, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), Ovid OLDMEDLINE(R), PsycINFO, and Japanese databases: Cinii, J-Stage, Children’s Rainbow Center Japan, Japan Child and Family Research Institute, Japanese Journal of Child Abuse and Neglect to identify articles published before July 2015 examining the lifetime prevalence of CSA in Japan using non-clinical samples. Data were extracted from published reports.ResultsWe initially identified 606 citations and after abstract review, retrieved 120 publications. Six studies that met the selection criteria and additional two relevant studies were reviewed. The range of contact CSA for females was 10.4%–60.7%, and the prevalence of this type of CSA for males was 4.1%. The range of penetrative CSA for females was 1.3%–8.3% and that for males was 0.5%–1.3%. A number of methodological issues were identified, including a lack of validated measures of CSA, and low response rates.ConclusionIn contrast to a lower prevalence of penetrative CSA, the prevalence of contact CSA among Japanese females may be comparable or higher in relation to international estimates. Future research on children's perceptions of and exposure to sexual abuse, crime and exploitation in Japan is discussed.     

Mothers in methadone treatment and their involvement with the child protection system: A replication and extension study

Objectives

Although a high level of involvement with the child protection system has been identified in families where parental substance use is a feature, not all such parents abuse or neglect their children or have contact with the child protection system. Identifying parents with substance-use histories who are able to care for their children without intervention by the child protection system, and being able to target interventions to the families who need them the most is important. This study interviewed a relatively large sample of mothers about their histories, their children and their involvement with the child protection system. We hypothesized that mothers in opioid pharmacological treatment who are involved with child protection services are different in characteristics to those mothers who are not involved.

Methods

One hundred and seventy-one women, with at least one child aged under 16 years, were interviewed at nine treatment clinics providing pharmacological treatment for opioid dependence across Sydney, Australia.

Results

Just over one-third of the women were involved with child protection services at the time of interview, mostly with children in out-of-home care. Logistic regression analyses revealed that factors which significantly increased the likelihood of the mother being involved with the child protection system were: (1) having a greater number of children, (2) being on psychiatric medication, and (3) having less than daily contact with her own parents.

Conclusions

This study replicates and extends the work of Grella, Hser, and Huang (2006) and the limited literature published to date examining the factors which contribute to some substance-using mothers becoming involved with the child protection system while others do not. The finding that mental health problems and parental supports (along with the number of children) were significantly associated with child protection system involvement in this study, indicates a need for improved interventions and the provision of treatment and support services if we are to reduce the involvement of the child protection system with these families.     

Listening to Children: A study of child and family services

This paper reports on child data generated in a pilot project of the ACCESS Study of Child and Family Services , an investigation of the degree to which child and family services meet user needs within local communities. Based on theoretical perspectives drawn from social capital theories, the pilot study was undertaken by a partnership of local early childhood services within the precinct of Queensland University of Technology, Brisbane (Australia) and included two childcare centres, two kindergartens/ preschools, one playgroup and one primary school. Seventy-six children aged 3-8 years were asked, in informal conversations with their caregivers, to comment on their experiences in the service and to consider possible advice they might give to children coming into the service. Theoretical perspectives from the sociology of childhood are used to examine children's accounts of their lived experience in early childhood services.     

The escalation and maintenance of child abuse: A cybernetic model

A cybernetic model of child abuse is presented as a contribution to the theoretical literature on child abuse. The child's role in his or her own abuse is stressed; interaction between caretaker and child is emphasized. While the origins of abuse are discussed, the focus of the paper is on the maintenance and escalation of the pattern of abusive interaction. The author proposes to explain this pattern-maintenance through the application of Gregory Bateson's concept of schismogenesis, or regenerative feedback, a concept derived from cybernetics and family systems theory. Suggestions for intervention in this process are discussed in the conclusion.     

A novel splice mutation of HERG in a Chinese family with long QT syndrome

Congenital long QT syndrome (LQTS) is a genetically heterogeneous disease in which six ion-channel genes have been identified. The phenotype-genotype relationships of the HERG (human ether-a-go-go-related gene) mutations are not fully understood. The objective of this study is to identify the underlying genetic basis of a Chinese family with LQTS and to characterize the clinical manifestations properties of the mutation. Single strand conformation polymorphism (SSCP) analyses were conducted on DNA fragments amplified by polymerase chain reaction from five LQT-related genes. Aberrant conformers were analyzed by DNA sequencing. A novel splice mutation in C-terminus of HERG was identified in this Chinese LQTS family, leading to the deletion of 11-bp at the acceptor splice site of Exon9 [Exon9 IVS del (-12→-2)]. The mutation might affect, through deficient splicing, the putative cyclic nucleotide binding domain (CNBD) of the HERG K channel. This mutation resulted in a mildly affected phenotype. Only the proband had a history of syncopes, while the other three individuals with long QT interval had no symptoms. Two other mutation carriers displayed normal phenotype. No sudden death occurred in the family. The 4 affected individuals and the two silent mutation carriers were all heterozygous for the mutation. It is the first splice mutation of HERG reported in Chinese LQTS families. Clinical data suggest that the CNBD mutation may be less malignant than mutations occurring in the pore region and be partially dominant over wild-type function.     

Identifying and evaluating teachers’ knowledge in relation to child abuse and neglect: A qualitative study with Australian early childhood teachers

Child abuse and neglect are serious social problems that make extraordinary demands on teachers’ knowledge and professionalism. Yet the field of education has been slow to develop a discipline-specific knowledge base about child abuse and neglect for teachers and teacher education programmes and there is a paucity empirical research into teachers’ knowledge in relation to child abuse and neglect. This paper describes a qualitative study of eight purposively selected early childhood teachers. To identify and evaluate their child abuse and neglect knowledge, Grossman's [(1990). The making of a teacher: Teacher knowledge and teacher education. New York: Teachers College Press; (1995). Teachers’ knowledge. In L. W. Anderson (Ed.), International encyclopedia of teaching and teacher education (2nd ed., pp. 20–24). Tarrytown, NY: Pergamon] typology of teachers’ knowledge is used as an analytic framework on which to map the teachers’ interview data. Findings reveal that, in the absence of preservice and inservice education specifically about child abuse and neglect, early childhood teachers held and deployed knowledge in resourceful ways. They used, as a basis, their existing early childhood knowledge and adapted this knowledge by augmenting it with a range of personal and professional knowledge resources to fit their particular challenges and situations. This approach, however competent and innovative, also reveals shortfalls in knowledge. Implications of this research are drawn for child abuse and neglect curriculum development in initial and continuing teacher education including the case for specialist knowledge needed to establish teachers’ professional reputation for dealing capably with cases of child abuse and neglect.     

Research in the Netherlands on a theory of child abuse: A preliminary report

A three-factor theory of child abuse has been developed which includes: (1) a high level of parental aggression; (2) a low level of parental inhibition of overt aggression; and (3) the focusing of parental aggression on the child. In the theory each factor is the outcome of a subfactor “path.” A high level of parental aggression is the outcome of seven subfactors. A low level of parental inhibition of overt aggression is the outcome of three subfactors. The focusing of parental aggression on the child is the outcome of ten subfactors. The theory posits that the type of child abuse that occurs is determined by the ratio of total parental aggression to total parental inhibition of overt aggression. High numerical values of the ratio result in battering. Lower numerical values result, in descending order, in non-organic failure to thrive, physical neglect and emotional abuse. The theory and 50 hypotheses derivable from it are being tested on a sample of 150 child-abuse families and 150 control families.     

教学何以相长：一个社会学的视角

教学相长作为教学活动中所追求的应然目标,其存在的根源具有一定的必然性,以社会学视角探讨教学相长的可能性,可发现课堂、知识和冲突作为教学可以相长的场域、媒介和动力的客观性。     

Teaching by Principles:A Case Teaching Plan of ELT

Since the early 20th century, Chinese ELT teachers and researchers have been seeking the best method for ELT. Different methods have been introduced, tried out and found unsatisfactory. In teaching practice, many have come to favor that although no single ELT method can meet all teaching and learning needs, many ELT methods have valuable insights into ELT that should be drawn on. However, teachers need a set of principles to adapt their teaching procedure to the specific circumstances. This paper, through a case teaching plan, presents how to apply varies teaching methods to design teaching plan under the guide of teaching principles.