PEDIATRICS Vol. 120 No. 5 November 2007, pp. 1217-1218 (doi:10.1542/peds.2007-1917)
LETTER TO THE EDITOR |
Beyond Munchausen Syndrome by Proxy
Marc D. Feldman, MDDepartment of Psychiatry and Behavioral Medicine
University of Alabama
Tuscaloosa, AL 35487
Michael J. Light, MD
Department of Pediatrics
Miller School of Medicine
University of Miami
Miami, FL 33136
Louisa J. Lasher, MA
Monticello, GA 31064
Mary S. Sheridan, PhD, ACSW
Department of Social Work
Hawaii Pacific University
Honolulu, HI 96813
To the Editor.—
As experts in Munchausen syndrome by proxy (MSBP) maltreatment, we are writing in response to "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting."1 We commend the American Academy of Pediatrics for addressing this form of maltreatment, which is underrecognized. However, we do have several concerns about this position statement. Of these concerns, the most important is the remark that, although multidisciplinary input is important, the physician is the only professional who can actually make the diagnosis of MSBP.
We differ with this conclusion for several reasons. Most basically, MSBP is a much wider phenomenon than just "a form of child abuse taking place in a medical setting."1 Manifestations of MSBP can be seen in schools, mental health facilities, nonprofit organizations, churches, the legal system, child protection agencies, the home, and the community at large. Likewise, physical symptoms are only a part of the spectrum of MSBP, with other kinds of "problems" (eg, psychological symptoms and other behaviors) that are exaggerated, fabricated, or induced in some cases.
The methodology involved in confirming or disconfirming MSBP includes the gathering of records from many sources (not just health care), conducting specialized interviews of a variety of professionals and nonprofessionals, and performing an overall information analysis, the last conducted by, or with the assistance of, a professional who has specialized knowledge and experience in this field.2 The task of identifying the discrepancies that may be present among all these sources, and answering the medical questions that arise, often requires input and clarification from physicians, but the investigation as a whole need not be done solely by them. In fact, most physicians do not have the time required for a thorough, appropriate investigation. Although the authors stated that "child abuse is a pediatric diagnosis,"1 it is not solely a pediatric medical diagnosis. Issues of motivation and circumstance are always important in determining that a given physical condition is the result of deliberate abuse (or neglect), as opposed to accident, ignorance, or other possible causes. All states and many other nations reflect this fact by assigning maltreatment investigations to child protective agencies and, within hospitals, to multidisciplinary/multiagency child protective teams.
The statement that "psychologists, social workers, and others are not in a position to make or confirm this diagnosis" overlooks the legal requirement for these professionals, and others, to report suspicions of child maltreatment to child protective authorities. These professionals receive training in the assessment of child maltreatment, may incur legal penalties if they fail to report, and must act in accord with their professional ethics. Given the overall shortage of professionals with expertise in MSBP, it is often necessary that a counselor, social worker, or other nonphysician make the assessment and lead the multidisciplinary/multiagency team. In such circumstances, involved professionals should make every effort to work with an MSBP professional of whatever discipline and/or to obtain education from an MSBP professional in this specialized kind of maltreatment.
We believe that it can be dangerous to delay the reporting of suspicions of child maltreatment, including MSBP, as suggested by the authors' "list of possible interventions."1 Our experience has been that many situations of MSBP respond very poorly to "individual and/or family therapy," which may even be contraindicated as an early step in MSBP. Attempts by a physician to "gatekeep" or "monitor" are thwarted easily by perpetrators of MSBP who involve multiple caregivers ("doctor-shop") or even flee to another area when suspected. The extent of MSBP maltreatment perceived by the primary caregiver may be only the tip of the iceberg if, unknown to the pediatrician, other providers or agencies are also being deceived. Absent the supervision and power of the courts, it is likely that perpetrators will not tell the whole truth, genuinely cooperate with medical gatekeeping, or even remain available to the physician.
REFERENCES
- Stirling J Jr. American Academy of Pediatrics, Committee on Child Abuse and Neglect. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting.
Pediatrics. 2007;119
:1026
–1030
[Abstract/Free Full Text] - Lasher LJ, Sheridan MS. Munchausen by Proxy: Identification, Intervention, and Case Management. Binghamton, NY: Haworth Press; 2004
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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