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An Evidence-Based Review Of Medical Child Abuse In The ED

April 2010


The pediatric ED setting can often become quite hectic, with clinical presentations ranging from the pedestrian-versus-motor vehicle accident to the overanxious mother worried about an infant who will not stop crying. But what does one do when a parent’s chief complaint is out of proportion to the child’s physical examination, as in the case of ALTE? Suppose a parent brings in a child and complains of multiple signs and symptoms, but the child appears healthy. Or suppose a child is brought in repeatedly for diagnosis and treatment of a chronic illness that appears unusual to the ED clinician in its presentation. In cases such as these, medical child abuse (MCA) should be considered in the differential diagnosis. By definition, MCA occurs when a child undergoes or receives unwarranted medical care at the hands of a caretaker.1

Medical child abuse has been known by many names over the years, including Münchausen syndrome by proxy (MSBP), factitious disorder by proxy (FDBP), and most recently, pediatric condition falsification (PCF).2 Münchausen syndrome by proxy is probably the most mainstream and well-known nomenclature. Historically, Baron von Münchausen, who is thought to have been a fictitious character, told stories of extravagant adventures. His name was subsequently used to describe a group of disorders (specifically Münchausen syndrome) in which patients fabricate complaints, leading to multiple hospitalizations and invasive tests and procedures.2Roy Meadow first used the term MSBP in 1977 when he described 2 cases of “parents who, by falsification, caused their children innumerable harmful hospital procedures—a sort of Münchausen syndrome by proxy.”3

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV), a diagnosis of MSBP involves 2 components: the child as the victim and the caregiver adult as the perpetrator. The child is then victimized into a sick role.4 The American Academy of Pediatrics has moved away from use of the term MSBP. There are questions regarding the term: should it be used only when the perpetrator is seeking medical care or only when trying to determine the parent’s motivation?2Moreover, who should make the diagnosis of MSBP is controversial. Should it be the pediatrician or a psychiatrist? Should the diagnosis be applied to the parent or the child?2 Finally, if the parent does not fit the DSM-IV criteria of MSBP, does that mean the child has not been abused? Recently, the American Professional Society on the Abuse of Children made an important distinction between the actual abuse caused to a child (ie, PCF) and the motivations behind the abuse (ie, FDBP). Whereas the former focuses on the impact to the child, the latter concerns the psychiatric state of the perpetrator.1

The truth is that clinicians who specialize in caring for children are ill equipped to diagnose the psychiatric state of the patient’s caregiver, whether the label involves MSBP or FDBP. Determining if and how a child has been abused should be their first concern; others can then focus on the motivation of the perpetrator.1 Thus, the term MCA, which is more inclusive and addresses the harm to the child from unwarranted medical care, is a more apt diagnosis for a pediatric patient. The term also clearly indicates that a form of child abuse has occurred.

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