PEDIATRICS Vol. 121 No. 2 February 2008, pp. 444-445 (doi:10.1542/peds.2007-3068)
LETTER TO THE EDITOR |
Further Thoughts on "Beyond Munchausen by Proxy: Identification and Treatment of Child Abuse in a Medical Setting"
Brenda Bursch, PhDDepartments of Psychiatry and Biobehavioral Sciences and Pediatrics
David Geffen School of Medicine
University of California
Los Angeles, CA 90024
Herbert A. Schreier, MD
Department of Child Psychiatry
Children's Hospital Oakland
Oakland, CA 94609
Catherine C. Ayoub, EdD
Department of Psychiatry
Harvard Medical School
Boston, MA 02215
Judith A. Libow, PhD
Department of Psychiatry
Children's Hospital Oakland
Oakland, CA 94609
Mary J. Sanders, PhD
Department of Psychiatry and Behavioral Science
Stanford School of Medicine
Palo Alto, CA 94301
Beatrice C. Yorker, JD, RN, MS, FAAN
College of Health and Human Services
California State University
Los Angeles, CA 90032
To the Editor.—
This letter is in response to an article by Dr Stirling and the American Academy of Pediatrics Committee on Child Abuse and Neglect titled "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in a Medical Setting."1 We were pleased to see the article published to remind pediatricians of this unusual but potentially fatal form of child abuse. We are writing today with 2 comments.
First, the authors indicated that the motivation of the suspected parent is unimportant when evaluating for possible illness falsification and, later in the article, that treatment options vary depending on the motivation of the parent. We can see how this might be confusing to readers (see ref 2). We agree that abusive illness falsification must be reported to child abuse authorities regardless of motivation and recognize that motivation is important in relation to both the nature of the abuse and safety and treatment issues. Clinicians frequently assess motivation in suspected child abuse cases. For example, they attempt to discern if a child was overdosed because of a parent not understanding the new dosing recommendation, pharmacy error, intentional poisoning, or neglectful lack of supervision. As the authors pointed out, the position statement written by the APSAC Taskforce on Munchausen by Proxy3 suggested terminology to reflect these 2 components (abuse and motivation). Interested readers should refer to this statement to clarify this seemingly confusing paradox.
Second, the authors suggested that only a physician can diagnose illness falsification. Aside from the fact that anyone who witnesses a parent suffocating a child and then calls for help can and should identify that behavior as abusive, we are concerned about the vulnerable role of the pediatrician in cases of Munchausen syndrome by proxy (MBP). Unlike other forms of child abuse, the unsuspecting pediatrician is frequently a central figure in perpetuating MBP abuse through unnecessary or harmful treatment and in defending the seemingly dedicated and loving parent. Therefore, not only is it important to have others involved who may notice and call attention to this process that often goes on for exceptionally long periods of time, potentially placing the child at grave risk, but it is also important to appreciate the role of all mandated reporters. The key behavior of MBP abusers is a pattern of intentional lying to cause others to treat the child as more ill or impaired than warranted. Professionals other than the primary pediatrician may have more experience detecting MBP, more exposure to the family in a wider range of contexts, or a more objective perspective by virtue of not being the target of the caregiver's manipulations. There is no advantage in placing the abuse-detection responsibility solely on the shoulders of the person who potentially is being most aggressively misled and manipulated. Although we applaud all efforts designed to encourage physicians to take on the responsibility of considering and evaluating for child abuse, it helps no one to undermine the expertise and dedication of professionals from other disciplines who are often at the front line, attempting to protect both the child and the physician. Consulting a clinical consultation team experienced in the evaluation of suspected MBP can reduce the risk that a mental health professional, unaware of the nature and depth of this psychopathology, will be fooled by a mother's "too-good-to-have-done-this" presentation.
FOOTNOTES
Statements appearing here are those of the writers and do not represent the official position of the American Academy of Pediatrics or its Committees. Comments on any topic, including the contents of PEDIATRICS, are invited from all members of the profession; those accepted for publication will not be subject to major editorial revision but generally must be no more than 400 words in length. The editors reserve the right to publish replies and may solicit responses from authors and others.
Please see www.pediatrics.org for instructions on submitting letters.
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
(5):1026
–1030
[Abstract/Free Full Text] - Reading R. Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting. Child Care Health Dev. 2007;33 (5):650
- Ayoub CC, Alexander R, Beck D, et al. Position paper: definitional issues in Munchausen by proxy [published correction appears in Child Maltreat. 2004;9(3):337].
Child Maltreat. 2002;7
(2):105
–111
[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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