INTRODUCTION — The clinical features, diagnosis, and management of medical child abuse (MCA) with a focus on recognition and care of the affected child will be reviewed here.
Other forms of physical child abuse and neglect are discussed separately. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management" and "Child neglect: Evaluation and management".)
TERMINOLOGY — Medical child abuse (MCA) refers to a child receiving unnecessary and harmful or potentially harmful medical care due to a caregiver's overt actions including exaggeration of symptoms, lying about the history or simulating physical findings (fabrication), or intentionally inducing illness in their child .
By contrast, acts of omission (failure to provide basic needs for a child such as food, clothing, education, and medical care) are usually labeled as "neglect." Hence, medical neglect indicates a caretaker acting in a way that a child does not receive appropriate health care. (See "Child neglect: Evaluation and management".)
All of the following terms have been used to describe MCA [2-10]:
●Munchausen syndrome by proxy 
●Munchausen by proxy syndrome 
●Fabricated or induced illness in a child by a caretaker 
●Child abuse in the medical setting 
●Meadow syndrome 
●Polle syndrome (erroneously) 
●Caregiver fabricated illness in a child 
●Pediatric condition falsification and factitious disorder by proxy 
We prefer the term "medical child abuse" because it focuses on the potential or real harm being done to the child regardless of the perpetrator's motivation. Pediatricians are more likely to use this term while psychologists tend to use one of the other iterations that focus more attention on the perpetrator .
The American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 uses the term "factitious disorder imposed" on another, and applies it to the perpetrator rather than the abused child . In contrast with MCA, this diagnosis requires a specific motivation on the part of the perpetrator and is not specific to children but may include, for example, fabricated or induced illness in an adult or pet .
Lying or providing false information in the medical setting is also an important component of the following conditions or behaviors:
●Factitious disorder imposed on self (Munchausen syndrome) (see "Factitious disorder imposed on self (Munchausen syndrome)")
EPIDEMIOLOGY — There is limited evidence regarding the incidence or prevalence of medical child abuse (MCA) and existing evidence primarily focuses on severe cases . Based upon observational, population-based studies that have counted cases of MCA reported to child protection agencies using strict definitions, the estimated annual incidence is approximately 0.4 to 1.2 per 100,000 in children younger than 16 years of age [15,16].
However, these estimates do not account for less severe cases of MCA that are not reported to child protection authorities and thus, likely reflect a significant underestimate of how frequently MCA occurs. A more recent population based study of consecutive hospitalizations identified 4 of 751 children who met criteria for MCA (0.53 percent or 530 per 100,000) . Our experience suggests that most clinicians who care for children on a regular basis encounter the milder forms of MCA commonly during the course of their practice.
Patient features — There is no typical clinical presentation for medical child abuse (MCA). Because the history gathered from a caretaker is the starting point for medical care, symptom constellations that depend upon caregiver report (eg, gastrointestinal complaints such as vomiting or diarrhea; neurologic symptoms such as coma, ataxia, seizures, or apnea; or allergic responses) may occur more commonly . Almost every disease category has been implicated in cases of MCA (table 1) [2,18-23]. Efforts to characterize the types of illnesses exhibited by victims of MCA have resulted in several series of similar presentations including children who present with pseudo-seizures , apnea , pseudo-obstruction , polymicrobial sepsis , and asthma . Other authors organize illness presentations by subspecialty [22,23,29,30]. (See 'Spectrum of illness' below.)
However, published reports of MCA reflect some of the most complex and extreme cases and do not adequately reflect the full spectrum of illness, especially the milder forms of MCA .
General features that can occur in children with MCA include [2,10]:
●The reported history varies from what is observed (eg, descriptions of severe illness in the presence of a normal appearing child) or does not make sense.
●Histories may vary significantly by different observers and suggest that the perpetrator's history is distorted.
●The illness is often recurrent, unexplained, unusual, or prolonged and does not respond to treatment as expected. If the child has a specific diagnosis, it may be extremely rare. However, a significant portion of victims of MCA also have an underlying chronic illness or disability. (See 'Differential diagnosis' below.)
●Family history may indicate siblings who have died or who have similar illnesses.
●The patient is subjected to a large amount of health care without improvement in reported signs or symptoms including:
•Repeated office visits and examinations
•Multiple diagnostic tests
•Multiple medical interventions (medications and/or surgery)
•Management by multiple subspecialists
●Signs or symptoms only begin in the presence of the caregiver.
●In children with induced or fabricated illness, clinical improvement often occurs when they are separated from the caregiver.
Perpetrator features — Limited evidence suggests some common features among perpetrators. Systematic study of mothers or primary caretakers who medically abused their children have focused on perpetrators of severe abuse and found the following associations [31-33]:
●Over 95 percent are female, mostly mothers or primary caretakers, although cases of collusion with other caregivers, including male members of the household have been described [1,2]
●History of factitious or somatoform disorders 
●History of unfortunate childhoods (eg, deprivation and abuse)
●Past history of self-harm, alcohol or drug abuse, and criminal activity
Numerous attempts have been made to develop a "profile" of a typical perpetrator . Characteristics such as having extensive medical knowledge, exhibiting calm during otherwise stressful medical events, being a medical provider, and becoming angry at medical providers who do not agree with them, have all found their way into profile descriptions [2,34]. It is now widely accepted that such descriptions, while potentially helpful in raising one's suspicion about the possibility of MCA, have little predictive value [2,35]. The clinician should remain focused on the experience of the child rather than the personality of the perpetrator.
The clinician should not use motivation of the perpetrator as a factor when determining if MCA has occurred, requires child abuse reporting and/or warrants child abuse specialty involvement. Although early writings purported to find a common motivation for perpetrators of MCA , there has been no clear demonstration that a consistent motivation exists in a majority of caregivers. Our experience and systematic reviews of case series and reports indicate that perpetrators offer many different motivations for their actions [1,2]. Though inferring motivation in others is difficult, it is not necessary to know a caretaker's motivation to determine if a child has experienced harm or to decide the harm should be stopped. (See 'Diagnosis' below and 'Indications for consultation with a multidisciplinary child abuse team' below.)
Caretakers have also been known to present their children for medical care in an attempt to get medicine that they take themselves, or to generate concern in the community that can translate into raising money for the use of the family. In these cases, the behavior is fraudulent in addition to MCA and some individuals have been prosecuted . To the extent the children experience harmful medical care, this is also MCA.
Perpetrator actions — Actions of perpetrators that result in MCA range from mild to severe:
●Exaggeration – At the mild end, parents exaggerate existing symptoms. A one-time episode of vomiting can be reported as "my child was vomiting all night and hasn't urinated today." Exaggeration of symptoms is common and can usually be perceived as an attempt by the parent to make sure that her concern is truly appreciated by medical providers.
However, persistent and convincing exaggeration can result in significant unnecessary medical care.
●Fabrication – A more serious parental action is fabrication or making up symptoms that have not occurred. Reported types of illness fabrication include :
•Intentionally altering medical records or providing a false past medical or family history
•Reporting symptoms that have not occurred (eg, seizures, apnea, or syncope)
•Failing to report significant medical information
•Simulation of symptoms (eg, addition of blood to urine or stool samples to simulate hematuria or hematochezia, warming a thermometer to simulate fever)
●Illness inducement – With exaggeration and fabrication, the caretaker does not personally harm the patient. She merely creates an environment in which medical care based on her actions can be harmful. At the extreme end of potential parental actions resulting in MCA, a caretaker can induce or cause an illness, lie about how the illness came about, and then present the child for medical care.
Examples of illness inducement include:
•The induction of seizures or apnea by suffocation, carotid sinus pressure, or poisoning with tricyclic antidepressants, hydrocarbons, or other agents .
•Simulating rashes by painting on the skin, applying caustics, or with various drugs .
•Causing hypernatremia by adding table salt to breast milk, formula, or other fluids (serum sodium can exceed 200 mEq/L), including seizures, coma, hemorrhagic encephalopathy, and death [1,39-41]. In children who are able to drink, salt poisoning is accompanied by acute weight gain because of increased thirst and stimulation of antidiuretic hormone . This is in contrast to children with hypernatremic dehydration, who typically have acute weight loss.
•Intentionally causing sepsis (bacteriological abuse) by injecting saliva, feces, or other contaminated material into skin or intravenous lines (frequently causing polymicrobial sepsis or leading to the false diagnosis of a poorly defined immunodeficiency) .
•Causing factitious psychiatric disorders, including attention deficit hyperactivity disorder (ADHD), bipolar disorder, and anorexia/polydipsia, by the parent describing, coaching, or inducing on cue the symptoms [42,43].
•Induction of hypo- and hyperglycemia, hirsutism, nephrocalcinosis, hypokalemia, and neurodevelopmental delay by caregiver administration of multiple drugs including insulin, glyburide, progesterone, and furosemide .
Almost any symptom a child could have can be claimed by a parent. Many can be fabricated and some can be induced. Although in our experience it does not happen often, there have been reported cases of parents "graduating" from exaggeration, to fabrication, to induction .
Spectrum of illness — MCA cases present on a continuum from mild to severe. MCA is characterized by the myriad forms of medical care that can be administered to a child without clear medical justification (table 1). It is typically recognized after the fact when a provider reconsiders whether the care given would have, indeed, been chosen if more accurate information had been available on which to base the treatment decisions. (See 'Diagnosis' below.)
Mild — Most primary care practices have parents who seek unnecessary care. Medical care aimed at "treating the parent" defined here as a mild form of MCA is fairly common but is strongly discouraged. An example would include excessive medical visits for a similar complaint, despite clinician reassurance that the child is well and eventually resulting in the clinician prescribing an antibiotic or ordering a diagnostic test for which there is no indication. Most mild forms of MCA do not exceed the threshold at which child protection is indicated but do warrant clinician interventions to address caregiver behavior. (See 'Mild' below.)
Mild MCA should be distinguished from parents who worry excessively about the health of their children. If inappropriate medical care is not given and if the clinician recognizes and addresses caregiver issues such as over-reading of symptoms or caregiver illness (eg, anxiety or depression), then criteria for MCA would not be applicable.
In cases where distinguishing caregiver anxiety or depression from MCA is difficult, case discussion with peers and mental health workers or consultation with a child abuse specialist is warranted so that the caregiver can receive support before symptoms escalate.
Moderate — Less common but routinely encountered, moderate forms of MCA involve significant disruption in the life of the child but would not be expected to be life-threatening :
●A parent insists on a wheelchair for her child when there is no medical indication.
●The caregiver simulates or causes rashes by painting on the skin or by applying caustics, or various drugs .
●A parent requests and is prescribed stimulant medication for her child despite a negative evaluation for ADHD.
●A mother/primary caregiver insists her child receive multiple sexual abuse evaluations during a custody battle.
●An apnea monitor is placed because a caretaker gives a history of "blue episodes" not witnessed by anyone else after a completely negative workup for causes of apnea.
●A child receives extensive diagnostic testing for blood in the urine until it is determined the mother/primary caregiver is contaminating urine samples with her own blood .
●Factitious psychiatric disorders, including ADHD, bipolar disorder, and anorexia/polydipsia, have been reported, with the parent describing, coaching, or inducing on cue the appropriate symptoms [42,43].
In none of these examples is the child's life in danger. However, each has the potential for long-term negative consequences for the child and warrant consultation with a multidisciplinary child abuse team led by child abuse specialists and child protection involvement. (See 'Indications for consultation with a multidisciplinary child abuse team' below.)
Severe — Severe forms of MCA are potentially life threatening and while parents at this end of the spectrum are more likely to induce illness in the child, illness induction is not necessary for the medical care received to be potentially fatal [1,2,21]:
●A child given a central line and begun on total parenteral nutrition based on a parent's insistence that the child could not eat and was failing to thrive, despite having normal growth parameters.
●A child administered anticancer medication based on a false parental report of a past cancer diagnosis.
●Multiple bouts of polymicrobial sepsis resulting from a parent injecting feces into a central venous catheter.
●Surgical removal of the small bowel based on parent reports of symptoms attributed to pseudo-obstruction .
●The mother/primary caregiver produces cyanosis and altered consciousness by suffocating her child.
●A child is given parenteral insulin or oral hypoglycemics to induce severe hypoglycemic episodes.
In these examples, the patient's life is in danger primarily from the harmful medical care. The parent who injected feces or suffocated the child was guilty of assault as well. All of these examples require urgent consultation with a multidisciplinary child abuse team, prompt child protection services notification, prompt police notification if a crime has been committed (this notification may be made by child protection services), temporary removal of the child from the care of the perpetrator, and legal intervention. (See 'Moderate and severe' below.)
DIAGNOSIS — Diagnosis of medical child abuse (MCA) requires the clinician to recognize that the caregiver is exaggerating, fabricating, or inducing illness in a child. Identifying that the normal doctor/patient relationship has become pathologic is central to making the diagnosis; the clinician is now harming the patient rather than helping because of deception on the part of the caregiver.
Clinicians carry a great responsibility in this interchange. They are expected to judge the quality of information they receive before making medical decisions. Medical providers who assume the information given about the patient is accurate and do not subject it to tests for accuracy can become unwitting partners in the abuse.
For this reason, clinicians who care for children need to be vigilant for signs of MCA and appropriately consult child abuse specialists when they have clinical suspicion. (See 'Indications for consultation with a multidisciplinary child abuse team' below.)
Clinician behaviors that help to identify MCA include :
●Careful documentation of the caregiver history
●Comparison of this history with that provided by other caregivers or observers as well as documentation of caregiver history by other clinicians who have evaluated the patient
●Comparison of the caregiver history with clinical findings including:
•The patient's physical examination
•Original reports of laboratory, pathologic, and imaging studies
Caregiver behaviors that may be associated with MCA, although not diagnostic, include [1,2]:
●Insisting upon painful procedures or hospitalizations despite clinician explanation that these are not necessary
●Repeated office or emergency department visits for similar complaints that do not have objective abnormal findings
●Failure to respect professional boundaries (eg, showing up at the clinician's private home or contacting the clinician by other unsanctioned means [eg, social media or cell phone])
DIAGNOSTIC EVALUATION — The degree of diagnostic evaluation necessary to identify and manage medical child abuse (MCA) varies according to the severity of the abuse. (See 'Mild' below and 'Moderate to severe' below.)
Mild — Caregivers who repeatedly seek unnecessary care for their child or exaggerate symptoms of their child's illness are frequently encountered in pediatric practice and readily identified as "demanding," "difficult," or "needy." In most instances, further diagnostic evaluation is not necessary, and the clinician can assess and manage the caregiver's behavior without undue harm occurring in the child. (See 'Mild' below.)
For cases of mild MCA, input from other observers (eg, father, other family members, day care providers, or teachers) can frequently confirm the clinician's suspicions that the initial history is not consistent with the true situation. A review of all documentation, including emergency department and urgent care visits and any other medical encounters, can also give a sense of the scope and frequency of the caregiver's abnormal behavior. The clinician should avoid giving in to irrational demands for testing or treatment. It is the clinician's responsibility to keep the care to an appropriate level based upon objective medical findings.
Moderate to severe — Because the caregiver will usually deny any abusive actions, the diagnosis of moderate to severe MCA can be difficult. It requires an index of suspicion and a coordinated approach by all members of the medical team. Whenever possible, a multidisciplinary child protection team that includes a child abuse specialist or a pediatrician with similar expertise should be consulted and guide the diagnostic evaluation and family interventions [2,46]. Psychosocial, legal, and child protective expertise should also be sought. (See 'Indications for consultation with a multidisciplinary child abuse team' below.)
Key questions to answer when evaluating the patient are as follows :
●Are the history, signs, and symptoms of disease believable?
●Is iatrogenic harm to the child occurring?
●If there is iatrogenic harm, who is causing this harm to occur?
For moderate to severe presentations the evaluation will often take place in the hospital setting. All professionals caring for the child should be educated regarding MCA, danger signs, and the need to protect the child. The primary concern must be the health and safety of the child and his or her siblings. The interactions between patient and parent should be monitored closely by an experienced medical professional to prevent further harm to the child . Medical providers performing documentation should be clear about whether any clinical manifestations of disease were reported by the caretaker only and not directly observed. It is critical that all members of the healthcare team remain discreet about the purpose of the evaluation, results of testing, and prevent inadvertent disclosure of the suspicion of MCA to the perpetrator.
Important steps in the specialist evaluation include the following:
●Review all of the child's medical records – Obtain medical records from all clinical settings and perform a careful review. A chronologic summary helps to identify the following features that are characteristic of unnecessary and harmful medical care [1,2,35,47]:
•Management by multiple medical providers, often at multiple medical facilities
•Frequent testing, procedures, medical therapies, hospitalizations, and surgeries without clinical improvement
•Finding that the child carries multiple, unrelated diagnoses involving multiple systems
•Documentation of frequent missed appointments or leaving the hospital or emergency department against medical advice
•Discrepancy between the conditions documented in the medical records and the suspected perpetrator's direct report
Compiling a table that chronologically lists the date and site of all medical care since birth, the treating clinician, chief complaint, and summary of medical findings, treatment, and comments can help organize this evaluation and identify MCA (table 2).
●Obtain a comprehensive history and physical examination – The comprehensive history should include history from the suspected perpetrator, the child (alone) if feasible, and other members of the immediate family. These interviews should be conducted individually. The condition of the child when outside the care of the suspected perpetrator should also be documented if possible [36,48]. Any available reported witnesses to the child's illness (eg, babysitters, relatives, teachers, clinicians, and nurses who have previously treated the child) should also be interviewed [21,48].
The family's medical history should be reviewed, including neutral sources (not just the statements of the immediate family members), with attention to any unusual illnesses or deaths in the siblings or parents. Whenever possible, get consent from the suspected perpetrators to speak to their own clinicians to try to determine if they have a history of factitious disorder or other somatoform disorder (eg, conversion disorder).
Objectively noted abnormal physical findings warrant additional testing to identify or exclude other diagnoses according to the clinical findings. However, testing or procedures solely based upon history should be avoided. When testing is performed, the least invasive means to confirm or exclude medical illness should be chosen.
●Confirm the history – Directly contact all treating clinicians to determine whether the history you obtained matches the histories they received and document any discrepancies. A pattern of markedly differing histories provided to different medical providers indicates false reporting of illness. It is important to ask these clinicians how certain they are that a medical condition exists and to determine if they have any concerns for MCA.
●Identify whether symptoms depend upon the perpetrator's presence – Spontaneous improvement that occurs when the child is not in the perpetrator's care is an important finding. In many, but not all patients, hospitalization may lead to a cessation of symptoms, only to have them recur when the patient is discharged. Continued symptoms in the hospital, however, do not exclude MCA .
●Obtain additional evidence – When multidisciplinary review of history, physical examination, and additional studies indicate a high likelihood of MCA, the evaluation might require obtaining additional evidence for diagnostic and forensic purposes.
Possible sources of evidence of MCA include the following:
•Laboratory testing – When illness is induced, the clinician may need to obtain laboratory testing to confirm the diagnosis, depending upon the type of condition being reported or induced. Blood, urine, and stool samples, potentially contaminated intravenous fluids or lines, and other materials should be retained for future analysis, with care taken to establish a chain of evidence for law enforcement purposes (this includes proper sealing, labeling, and storing of specimens to ensure that specimen tampering cannot occur) [21,39,48].
Analysis of these materials can include :
-Blood group typing
-Testing of stools for phenolphthalein or other laxatives
-Analysis of blood, urine, intravenous fluid, or milk for added substances
Because false positive and negative results may occur, especially with toxicologic testing, involvement of a clinical laboratory or medical toxicology specialist may be warranted to ensure that the proper testing is ordered and correctly interpreted.
•Video surveillance – Video surveillance requires extensive preparation of staff and a process that ensures protection of the child and legal protection for the participants. Thus, it should only be performed in conjunction with a multidisciplinary child abuse team and requires involvement of hospital and other personnel not typically directly involved in clinical care (eg, security, hospital administration, legal counsel, and regional child protection services).
Video surveillance sometimes reveals deliberate harmful actions by the parent (suffocation or administration of medications or contaminants). Video surveillance in cases of suspected induction of illness in a child is controversial [2,49-54]. It is considered by some to be an invasion of privacy, unethical, and a form of entrapment . Others argue that the need to protect the child overrides these concerns [49,54,55]. Most hospitals inform patients that video surveillance is used in the hospital in material the patients' parents sign on admission. Many interpret this as having permission to use covert video.
Proponents of surveillance argue that without it, cases of fabricated or induced illness will go undetected due to the reluctance of clinicians to make the diagnosis, the tendency of patients to switch clinicians once the diagnosis is suspected, and the difficulty in proving inducement or fabrication of illness without monitoring. The use of video surveillance can either support or exclude abuse . As an example, one study reviewed the use of covert video surveillance in the evaluation of 41 cases of suspected feigned or induced illness . Suspicions were confirmed in 23 cases. Video surveillance was required to make the diagnosis in 13 cases (56 percent), was supportive of the diagnosis in five cases, and ruled out the diagnosis in four cases.
It is important to remember that videotaping in the hospital and not "catching" a caretaker abusing a child does not rule out that abuse has taken place in the past.
Initiation of covert video surveillance should be preceded by the following steps:
-Assessment of the case by a multidisciplinary team, including representatives of the medical and nursing staff, social services, hospital risk management, and security services, with the conclusion that either fabricated or induced illness is likely and surveillance is necessary to protect the child, or it is unlikely but no other explanation of the child's symptoms can be determined.
-Local child protection services should be notified that monitoring is taking place.
-All personnel involved in patient care must maintain strict confidentiality about the occurrence of the video monitoring.
-The video feed should be monitored continuously by security officers or other personnel who have been trained in the manifestations of fabricated or induced illness in a child and the monitoring of caretakers for unusual or dangerous actions.
-All healthcare workers on the floor should be aware of the monitoring. When notified by the security officer of an unusual or dangerous action on the part of the caretaker, medical providers should be ready to enter the room immediately, assess the situation, and intervene if necessary .
●Monitoring social media – Social media makes it possible for persons with similar beliefs to find each other easily. The provision of anonymity also allows people to make claims that can never be substantiated. Social media is also often public. There is a growing awareness that parents who get unneeded medical care for their children often find an audience on social media . They post pictures of their "sick" children, write blogs about their medical experiences, and complain about clinicians who do not agree with them. They also raise money for purposes having to do with claiming their child needs expensive care for a nonexistent illness. A quick survey of social media sites can be very helpful in providing information confirming suspicions of MCA.
DIFFERENTIAL DIAGNOSIS — Medical child abuse (MCA) may require differentiation from an undiagnosed medical condition and other forms of child abuse . However, both medical disease and other forms of child abuse may also be present in a child with MCA. In our sample, 74 percent of children with MCA also had a diagnosable medical condition but received medical care not justified by the severity of the underlying illness. In the rest of the group, no underlying medical illness could be detected . In a separate case series, up to 30 percent of children suffering from moderate to severe MCA have an underlying verified medical illness . Similarly, comorbid abusive conditions have also been described including failure to thrive, intentional injury, inappropriate administration of medications, and child neglect .
In most cases of mild MCA, determining that a medical condition is not present is relatively straightforward because the child appears well. In these patients, the clinician needs to maintain a stance of reassurance and not give in to parent requests for unnecessary testing or treatment solely based upon a history that differs from the normal physical examination and appropriate ancillary testing. The clinician should also investigate whether the exaggerations and frequent requests for care are amenable to simple reassurance or require more direct mental health intervention for the caregiver. (See 'Mild' below.)
However, for patients with moderate or severe MCA, the clinician needs to be careful not to be drawn into an extensive search for an illness that does not exist while ensuring that true pathology is not missed. To achieve the proper balance frequently requires a multidisciplinary approach involving a child abuse team led by a child abuse specialist, relevant medical or surgical subspecialists, and mental health professionals. Hospitalization may also be warranted. When excluding disease, noninvasive ancillary studies with low risk should be preferred and invasive testing or procedures avoided.
Complex pediatric medical conditions such as pain amplification syndromes, postural orthostatic tachycardia syndrome, mitochondrial disease, or persistent symptoms after treatment for Lyme disease present a special diagnostic challenge. These conditions can have nonspecific symptom presentations, depend on parental report of symptoms, and can be truly debilitating.
Pediatricians have become increasingly aware of overuse of medical treatments . Medical overuse can exacerbate or result from MCA [60-62]. For example, caretakers can medically neglect their child by not providing prescribed medical care. Since the child is not improving, the clinician might end up escalating care, resulting in iatrogenic medical abuse . In the complex medical conditions listed above, an MCA diagnosis must also be entertained when a parent refuses to comply or even consider following medical treatment recommendations that have been proven to be useful.
MCA differs from other forms of abuse in one important feature. The harm to the child comes from unnecessary and potentially harmful medical care. The medical care system has become the weapon with which the caretaker harms the child by the use of deception. However, regardless of the type of child maltreatment, the key intervention is to stop the abuse, involve a child abuse team whenever possible, and notify child protection when abuse is suspected. (See 'Management' below.)
INDICATIONS FOR CONSULTATION WITH A MULTIDISCIPLINARY CHILD ABUSE TEAM — Consultation with a multidisciplinary child abuse team and child abuse specialist is warranted in all situations where the clinician suspects that the caregiver's inappropriate actions are resulting in significant disruption to the child's activities (moderate medical child abuse [MCA]) or are potentially life threatening (severe MCA). Confirmation of MCA is not required prior to consultation; a suspicion of MCA is sufficient. Furthermore, given the challenges and special circumstances surrounding the diagnostic evaluation of children suffering from moderate or severe MCA, a multidisciplinary child abuse team should be involved prior to attempts at confirmation, whenever possible. (See 'Moderate' above and 'Severe' above.)
Consultation is also encouraged when the clinician is not sure whether the caregiver's behavior constitutes MCA and to support clinician's efforts to address mild MCA.
Mild — Early identification of distorted historical information, hopefully before a child is harmed, is the best way to prevent the situation from expanding to moderate or severe medical child abuse (MCA). It is the doctor's responsibility to weigh the value of the information received and challenge information that is not supported by medical observation. Discussion with peers or consultation with a child abuse specialist is encouraged to assist the clinician in identifying when mild MCA is present and to help guide intervention. (See 'Mild' above.)
The clinician should meet with all caregivers and relay the concern that the history does not match the patient's findings . It is often helpful to ask the caregiver why they are providing the inaccurate history. In many cases, the caregiver may disclose significant concern about the child's well-being, which often can be addressed by reassurance and serve to end or significantly modify their abnormal behavior or may identify stressors that are exacerbating or causing caregiver anxiety or depression. During the meeting, the clinician should explicitly state that accurate information is needed going forward to provide proper pediatric care. It is helpful to require that further evaluation be based on a complete medical evaluation by the primary care provider and not be provided over the phone. The evolving widespread use of telemedicine allows a clinician to see the child but is not a substitute for an office examination.
This conversation serves to bring into the open the discrepancy in beliefs between the perpetrator and the clinician and can have the effect of repairing the doctor/patient relationship. In addition to education and reassurance, the clinician can offer to make referrals for treatment of caregiver anxiety disorders or depression, if indicated, or activate the caretaker's social support network.
If, after the attempt to reconcile what constitutes appropriate care, the parent cannot accept the need for the limitation of medical care because the child is not ill, then the gulf between caretaker and doctor is more extreme than previously thought. In such circumstances, it is important to document the conversation and the concern regarding the caregiver's actions as well as ensuring notification of other members of the family, other providers in the practice and, when applicable, other sites where care has been frequently sought.
If the family decides to leave the practice, most clinicians receiving a new patient will want to have records sent by the previous provider. It is important for the communication between that clinician and the patient’s family to be passed along to the new treatment environment. If a parent refuses to give permission for a transfer of records, this becomes important information for the new health care provider. In the authors’ experience most parents sign requests for information routinely unless they have something serious to hide.
If the parent’s continued presentations for care become detrimental to the well-being of the child (eg, frequent absences from school) or lead to unnecessary health care being provided, then moderate child abuse may be occurring and consultation with a multidisciplinary child abuse team and a report to child protection services is indicated. (See 'Moderate and severe' below.)
Moderate and severe
Stop the abuse — Suspicion or confirmation of moderate or severe MCA warrants notification of child protection services and, whenever possible, consultation with a multidisciplinary child abuse team led by a child abuse specialist. Transfer to a pediatric tertiary care center may be necessary to obtain the proper resources for the child.
Once moderate to severe MCA is identified, unnecessary medical care should be stopped. It is prudent to stop the most dangerous medical care first:
●Cancel scheduled but unnecessary surgery
●Take out unnecessary vascular access (eg, peripheral or central venous catheters)
●Stop the medications that can have the worst potential side effects such as cancer or seizure medications
Once the most dangerous treatments are discontinued, other medications and treatments can be taken away at an appropriate time.
Typically, there are multiple providers involved in the care of these children. A challenging but essential step is to get agreement from all providers on the diagnosis of MCA and the new course of treatment. A multispecialty case conference should be arranged so that each provider can re-examine the care initiated and justify the care with appropriate, objective evidence or agree that current care can be discontinued. The use of videoconference platforms such as Microsoft Teams, Skype for Business, and Zoom permits recording of such proceedings in compliance with patient privacy regulations and facilitates scheduling.
Unanimous agreement on the treatment plan going forward must occur; if even one provider does not agree, the parent will gravitate to that provider and efforts to prevent harm, including appropriate response from child protection services, will be significantly compromised.
A multidisciplinary child abuse team led by a child abuse specialist is needed to facilitate the process of getting this consensus on appropriate medical care from the healthcare providers. Child abuse specialists can also provide the necessary bridge between healthcare providers and governmental child protection agencies and guide proper mandated reporting that is required in cases of MCA. (See 'Involve child protection agencies' below and "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)
Additional steps that must be taken promptly once clinician consensus on the diagnosis of MCA and ongoing management is established include [1,2]:
●Notification of child protection services – Coordination with child protection services in terms of timing of the informing session described below with their initiation of an investigation, possible removal of the child from the perpetrator's care, or legal action against the perpetrator is critical and can be facilitated by the child abuse team. Specific timing of these events varies according to the severity and type of MCA. (See 'Involve child protection agencies' below and 'Legal intervention' below.)
●Informing session – A meeting that includes representatives of the child abuse team, medical treatment team including the primary care clinician, or the clinician having the most involvement in the child's care, the perpetrator and other caregivers, and other adult sources of support for the perpetrator should occur.
The goals of this meeting are as follows:
•Summarizing the child's medical condition, the treatments that will be stopped, and the treatments that will be continued with an emphasis on the "good news" that the child is not as ill as previously thought.
•Obtaining agreement with the new treatment plan and the necessary monitoring that may be imposed on the family to ensure that the new plan is followed (including involvement of child protection services) in the form of a signed written contract.
This contract should contain a description of the new treatment in simple, clear language, and the medical providers who will implement it. One to two written pages is sufficient. Parents, medical treatment personnel, and anyone helping to enforce the contract are asked to sign. The process of writing, reading, and signing the contract is a concrete demonstration that a new relationship exists between the medical care establishment and the family.
A signed contract can be distributed to all treating personnel, to emergency departments, and to other treating facilities. This ensures that everyone involved in the child's care is aware of the new approach to care.
•Assessing the perpetrator's response to the news to determine what further action is needed:
-Perpetrators who respond positively to following the treatment plan with appropriate oversight by medical providers and child protection services can likely retain custody of the child.
-If the perpetrator does not agree with the treatment plan, will not contract to follow it, or does not adhere to the new treatment plan going forward, it will be necessary to take additional steps to protect the child from abuse, including taking temporary custody of the child and possibly, permanent removal of parental rights. (See 'Legal intervention' below.)
Measures must be in place to prevent the caregiver from fleeing with the child during or after the conference. Psychosocial support should be readily available for the child (if age appropriate), perpetrator, and other family members. (See 'Provide family support' below.)
Rarely, in cases of induced disease, an assault has occurred and police notification with arrest of the perpetrator may preempt the informing session. Nevertheless, in these circumstances, the remaining caregivers and appropriate family members should still be informed as described above.
Involve child protection agencies — Communication with child protection services is essential in cases of moderate to severe MCA, and timely reporting of child abuse is a mandated requirement in many jurisdictions. As part of this communication a child abuse report is required and should provide a clear description of what the parent did to get unnecessary care, the nature of that care, and its potential danger for the child. Whenever possible, before filing the report with the child protection agency, all other treatment providers should review and ensure its accuracy and completeness. However, there should not be undue delay in filing a child abuse report. In most jurisdictions, a verbal report is required as soon as possible after the abuse is discovered and a written report should follow within a short period of time (typically 24 hours). (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)
Making certain that the child can remain safe requires involvement of child protection services. Many times, agency personnel will have little experience with MCA. There may be a need to educate an assigned worker about why the child needs protection. Calling it "child abuse" rather than emphasizing a possible mental illness in the caretaker will make it easier for the agency personnel to proceed. The primary clinician may be called upon to explain the reasons for the report. If agency response does not appear adequate, the reporting clinicians should appeal to supervisors in the agency or the agency head to make sure the need for protection is appreciated. The clinician should avoid speculation about motivation of the perpetrator or need for her to receive a psychological evaluation.
Repair iatrogenic harm — Much of the physical damage caused by MCA can be reversed by stopping the unnecessary care. In our experience, when medication is stopped, side effects go away. When wheelchairs are removed, children begin walking again. Rarely, some interventions may require operative reversal such as removal of gastric tubes .
The psychological effects of having been medicalized, sometimes for many years, are often more difficult to ameliorate. The few studies done on long-term psychological effects indicate children can experience increased incidence of anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms . This impact is similar to the emotional effects of other types of child maltreatment. Both individual psychotherapy for the child and parent/caregiver as well as family therapy have a place in responding to the psychological sequelae. Communicating with school-age children and adolescents who experience MCA about the nature of their abuse requires age appropriate, honest discussions of what happened and why the abuse occurred .
Provide family support — Most child protection efforts strive to keep children with their families if this can be done safely. For victims of MCA, this means that the child cannot continue to be exposed to unnecessary medical care and the iatrogenic harms associated with it; the perpetrator must change her beliefs and behaviors regarding medical issues in her children.
Psychological evaluation of the perpetrator and psychiatric therapy is a key factor in determining the safety of the child [10,66]. The motivation that caused the parent to expose her child to harm is now critically important. Such evaluation can be mandated by child protective services or in the contract signed by the perpetrator.
Sometimes the evaluation and treatment is straightforward:
●If she is ignorant or misinformed, the deficit can be rectified by education.
●If she acted in an effort to calm her own anxiety, a referral for treatment for an anxiety disorder is indicated.
●If she is a chronic exaggerator and recognizes this tendency in herself, this knowledge can be included in the ongoing treatment plan by informing the entire treatment team to take everything said by the mother/primary caregiver "with a grain of salt."
However, in many instances of moderate or severe MCA, getting cooperation from the perpetrator is challenging:
●They often have constructed a faulty and elaborate belief system to justify their actions .
●They believe they are doing the right thing for their child by getting more and more medical care.
●They think their child has a serious underlying medical condition such as a mitochondrial disorder or an immune deficiency when there is no good medical evidence to support the diagnosis.
These belief systems can be extensive and persistent. Mothers or primary caretakers who have adopted these beliefs can convince other family members and find validation from the internet where they can communicate with other primary caregivers who think similarly.
In these situations, although it may be helpful to understand why the caregiver has constructed her belief system, more importantly, for her child to remain in her care, the belief system must undergo change . As part of this change, it is essential that the caregiver understand and agree that her behavior exposed her child to danger. In many cases, this agreement is in direct conflict with the belief system she spent years assembling and justifying. Abandoning the belief system and substituting one that relies on verifiable medical evidence can be difficult to do. In our experience, the perpetrator usually requires psychiatric treatment although, in some cases, the realization that she might lose custody of her child is enough to foster the change.
Helpful psychiatric approaches for the perpetrator include :
●Mobilization of extended family members to reinforce the message that harm occurred and change in behavior is needed
●Family therapy to magnify positive beliefs and challenge destructive ones within the existing network of intimate family relationships
●Individual psychological treatments to modify beliefs using evidence-based approaches (eg, motivational interviewing, cognitive behavioral therapy, and dialectical behavioral therapy)
Specialized pediatric/child psychiatric family-based day hospital treatment programs can treat both underlying medical conditions and the distorted beliefs of the family . (See "Overview of psychotherapies", section on 'Psychotherapies'.)
The starting point for any therapy of perpetrators of MCA must be the understanding that the mother/primary caregiver's actions and beliefs exposed the child to significant danger. The therapist must have this in mind at the outset of therapy and continually as therapy progresses. The perpetrator must agree that treatment will result, in due time, in a major modification in her belief system regarding the need for medical care for her child. It is important that the psychotherapist communicates with the medical team that made the diagnosis so that they know the truth about the child's underlying medical conditions and the problems with the mother/primary caregiver's response to those conditions. A therapist who joins with the mother/primary caregiver and supports her belief systems is unlikely to be helpful in protecting the child.
Legal intervention — Child abuse is a crime. Statutes defining what constitutes child abuse and the potential penalties differ dramatically from jurisdiction to jurisdiction. What is a felony in one locale might be a misdemeanor in another. In some regions, police involvement is routine. In other settings, police investigation is initiated by child protection services.
Criminal prosecutions and convictions for MCA are rare  but are occurring more frequently . It is much more likely that a person's act will be considered criminal if induction of a life-threatening event such as suffocation or contamination of a central line is witnessed, either in person or on videotape. It is much more common for the legal action in extreme cases to consist of termination of parental or custodian rights when the parent is deemed unable to complete treatment successfully or the parent's actions were particularly damaging.
Forensic interview of the caregiver — Occasionally, child protective services or the court will require a forensic psychiatric interview of the caregiver. The interviewer might be asked to determine if the caregiver meets DSM V criteria for "factitious disorder imposed on another" (FDIA). This assessment entails determining if the caregiver has an internal motivation to deceive and the behavior is intentional. Having a psychiatric diagnosis might be offered as a mitigating factor in deciding guilt or innocence in a criminal trial. However, in clinical practice, a DSM V FDIA diagnosis has little effect on the child's management.
Risk management — When making a report of medical child abuse to Child Protective Services in a hospital setting, it is appropriate to notify risk management given the potential for legal action by parents who may allege a false report or misdiagnosis. Based on the author's experience, conditions commonly associated with these situations include mitochondrial disease, postural orthostatic tachycardia syndrome, pain amplification syndrome, Ehlers-Danlos syndrome, and persistent symptoms of Lyme disease. The threat of legal action should not dissuade the medical team from making a report when medical child abuse is suspected "with reasonable suspicion" because the child's safety must be a priority. In addition, in most jurisdictions, general protections are in place for medical providers who report a reasonable suspicion of abuse. Guidance for what constitutes "reasonable suspicion" is discussed in greater detail separately. (See "Child abuse: Social and medicolegal issues", section on 'Reasonable suspicion or cause to believe'.)
Finally, in jurisdictions where healthcare providers are mandated reporters, there is a legal duty to report suspected abuse to Child Protection Agencies. (See "Child abuse: Social and medicolegal issues", section on 'Mandatory reporting'.)
PROGNOSIS — Most mild forms of medical child abuse (MCA) are dealt with by the primary care provider. In these cases, the family can usually be preserved and harm to the child avoided.
Appropriate management of moderate or severe MCA usually results in the cessation of unnecessary medical care and preservation of the family. In the authors' series of 87 moderate to severe cases, temporary separation of the perpetrating parent from the family happened in 29 cases . Parental rights were terminated in only five cases and the rest of the parents eventually were reintegrated into the family. One other study reported on reunification in 14 severe presentations .
Better family outcomes are associated with the following factors :
●An identifiable stressor is present at the time of the abuse
●The perpetrator admits to the false reporting and/or induction of illness
●The perpetrator works cooperatively with child protection, pediatric, and psychiatric services
●Long-term multidisciplinary child protection, social work, medical, and psychiatric follow-up is in place for the child and perpetrator
However, severe MCA, when not recognized or allowed to continue can have dire consequences for the child, including death. In particular, geographic mobility can hinder efforts to prevent reoccurrence. A family can move across country and resume MCA with a new cast of medical providers. This potential problem underscores the need to involve child protection services and to engage family members, other than the perpetrator, to monitor for and prevent the perpetrator from fleeing with the child.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Medical child abuse (Munchausen by proxy)".)
SUMMARY AND RECOMMENDATIONS
●Terminology – Medical child abuse (MCA) refers to a child receiving unnecessary and harmful or potentially harmful medical care due to a caregiver's overt actions including exaggeration of symptoms, lying about the history, fabricating clinical findings, or intentionally inducing illness in their child. MCA is a type of child abuse. (See 'Terminology' above.)
●Clinical manifestations – There is no typical clinical presentation for victims of MCA. They may also have true medical illness or suffer other forms of child abuse. Because the history gathered from a caretaker is the starting point for medical care, symptom constellations that depend upon caregiver report (eg, gastrointestinal complaints such as vomiting or diarrhea; neurologic symptoms such as coma, ataxia, seizures, or apnea; or allergic responses) may occur more commonly. Examples of reported cases of fabricated and induced illness are shown in the table (table 1). (See 'Patient features' above.)
The vast majority of perpetrators of MCA are female. They frequently have a personal history of factitious or somatoform disorder, deprivation or abuse during childhood, self-harm, and alcohol or drug abuse. Characteristics such as having extensive medical knowledge, exhibiting calm during otherwise stressful medical events, being a medical provider, and becoming angry at medical providers who do not agree with them are not predictive of MCA but may help raise suspicion. (See 'Perpetrator features' above.)
●Spectrum of illness – MCA presents along a spectrum of illness:
•Mild – The caregiver repeatedly seeks and often demands unnecessary medical care. They may either exaggerate or lie about symptoms. History from other observers typically differs and suggests no serious illness. The physical examination is either normal or reflects minor illness that requires no intervention. The child is not harmed as long as the clinician does not give into the irrational requests for treatment. (See 'Perpetrator actions' above and 'Mild' above.)
•Moderate – The caregiver's deception has resulted in the child receiving medical care that significantly disrupts their life although it is not life-threatening. (See 'Perpetrator actions' above and 'Moderate' above.)
•Severe – The caregiver's fabrication or induction of illness has resulted in the child receiving medical treatment that is potentially life-threatening. (See 'Perpetrator actions' above and 'Severe' above.)
●Diagnosis – Diagnosis of MCA requires the clinician to recognize that the caregiver might be exaggerating, fabricating, or inducing illness in a child. Identifying that the normal doctor/patient relationship has become pathologic is central to making the diagnosis; the clinician is now harming the patient rather than helping because of deception on the part of the caregiver. (See 'Diagnosis' above.)
●Differential diagnosis – MCA may require differentiation from an undiagnosed medical condition and other forms of child abuse. However, both medical disease and other forms of child abuse may also be present in a child with MCA. In most cases of mild MCA, determining that a medical condition is not present is relatively straightforward because the child appears well. For patients with moderate or severe MCA, the clinician needs to be careful not to be drawn into an extensive search for an illness that does not exist while ensuring that true pathology is not missed. (See 'Differential diagnosis' above.)
●Indications for specialty consultation – Consultation with a multidisciplinary child abuse team and child abuse specialist is warranted in all situations where the clinician suspects moderate or severe MCA. Confirmation of MCA is not required prior to consultation; a suspicion of MCA is sufficient. Consultation is also encouraged when the clinician is not sure whether the caregiver's behavior constitutes MCA and to support clinician's efforts to address mild MCA. (See 'Indications for consultation with a multidisciplinary child abuse team' above.)
●Management – Management depends upon the severity of illness:
•Mild MCA – Mild MCA typically requires no diagnostic evaluation to exclude medical illness and, in many instances, can be managed by the primary care provider. (See 'Mild' above.)
•Moderate or severe MCA – By contrast, moderate or severe MCA requires a coordinated approach to diagnostic evaluation, notification of child protection services, and comprehensive family interventions. Whenever possible, a child abuse specialist should guide this multidisciplinary evaluation and treatment. In hospital settings, notification of risk management is also indicated. (See 'Moderate to severe' above and 'Moderate and severe' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Erin Endom, MD, who contributed to earlier versions of this topic review.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟