Medical child abuse (MCA) occurs when a caregiver falsifies signs and symptoms resulting in a child receiving unnecessary and harmful or potentially harmful medical care. Like other conditions, MCA can be diagnosed using traditional diagnostic methods. MCA carries significant risk of morbidity and mortality. Collaboration between clinicians, and when necessary, between clinicians and Child Protective Services increases the likelihood of diagnosis and successful management.
Key points
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Consider medical child abuse (MCA) when signs, symptoms, and interventions consistently deviate from expected patterns.
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Make reasonable attempts to both objectively verify symptoms and avoid unnecessary diagnostic testing.
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Medical child abuse is a diagnosis with both medical and legal ramifications.
Introduction
History, Definitions, and a Medicolegal Critique
Dr Roy Meadow described “a sort of Munchausen Syndrome by Proxy” in 1977 to highlight a condition where caregivers, particularly mothers, deliberately falsified illness in their children. Over time, various terms were introduced to describe this form of abuse, including pediatric condition falsification, abuse by pediatric condition falsification, and caregiver-fabricated illness in a child. These terms focused on the caregiver’s motivations alongside the abuse and neglect of the child. The terminology has since shifted toward medical child abuse (MCA) to emphasize the harm inflicted on the child rather than the caregiver’s motivations. In 2009, Roesler and Jenny defined MCA as, “a child receiving unnecessary and harmful or potentially harmful medical care at the instigation of a caretaker.” This shift in definition focuses on the harm to the child as opposed to the intent of the caregiver and has generally been well received and adopted by the American Academy of Pediatrics and similar child serving organizations.
MCA is also a diagnosis about which pediatric clinicians testify across the United States, particularly in family courts. Nevertheless, there has been an unexpected critique of the process by which MCA is introduced as evidence in court. Professor Maxine Eichner’s law review article, “Bad Medicine: Parents, the State, and the Charge of Medical Child Abuse,” examines the legal and constitutional implications of the MCA diagnosis, challenging its application in both judicial and clinical contexts. She questions the scientific validity of medical child abuse as a diagnosis, claiming it is based on inadequately tested criteria, which makes it susceptible to error and subjective interpretation. Furthermore, Professor Eichner raises ethical concerns including that the MCA diagnosis can inadvertently lead to family separation and stigmatization of parents.
Background
Epidemiology
MCA is an underrecognized diagnosis affecting children in both developed and developing countries. , Most studies report similar numbers of affected male and female patients, and like other forms of child maltreatment, the youngest patients are the most vulnerable. , The incidence of MCA is often cited as 0.5 to 2 cases per 100,000 children younger than 16 years and approximately 2.8 per 100,000 children less than age 1 year. , Most children are less than age 5 years at the time of diagnosis and 1 to nearly 2 years on average may elapse from onset of symptoms to diagnosis. , , Similar to other forms of maltreatment when the diagnosis is missed, children may be reinjured or die. Mortality is estimated to be 6% to 12%. , Long-term morbidity is estimated to be 8%. Sixty-one percent of siblings present with similar or suspicious signs and symptoms to index patients, and between 8% and 25% of siblings are known to be dead. At an Italian academic hospital, the MCA prevalence was described as 0.53% among hospitalized patients. Prevalence in an outpatient asthma clinic is described to be 1%. Anecdotally, most primary care pediatricians will report seeing at least 1 case of MCA in their career, and large American academic institutions may identify 20 to 30 cases per year. There is literature on factitious illnesses by most pediatric subspecialties as all organs can be affected. Gastroenterology (for procedures), anesthesiology (for intubation and sedation), neurology, radiology (including interventional radiology), and pulmonary medicine are invariably consulted at large pediatric teaching hospitals prior to MCA entering a patient’s differential diagnosis. Despite the relative rarity of MCA, 1% of all central lines placed over approximately 20 years at a pediatric hospital were placed into patients ultimately diagnosed with MCA.
Nearly all studies have identified specific traits commonly shared by MCA perpetrators. In a systematic review of 796 cases, Yates and Bass found that 97.6% of the MCA perpetrators were female, with 95.6% being the victims’ mothers. These perpetrators often have coexisting personality disorders characterized by dramatic, erratic, or emotional behaviors such as antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder, as well as a personal history of abuse or neglect. Additionally, research indicates that a significant proportion of these perpetrating caregivers have a history of substance misuse and self-destructive behaviors. This unresolved psychological trauma can contribute to MCA as a maladaptive coping mechanism, with some caregivers potentially not fully comprehending the harm they are inflicting. In other cases, the behaviors may be more deliberate. In the age of social media, some caregivers may create online blogs or fundraisers, sharing medical information to gain attention or secondary monetary gain. Additionally, some caregivers may be driven by a need to exert control over a child’s life or medical environment, deriving a sense of power and importance that they may not achieve elsewhere in their lives. Perpetrators are almost always described as a single female caregiver, typically the biological mother, who has a background in health care. , , However, only 5% to 33% of mothers have a background in health care. , , Rarely will a male or more than 1 caregiver be reported as perpetrating MCA. , Bias and profiling may result in failure to consider the male caregiver which may leave a patient’s sibling(s), the female caregiver and possibly pets vulnerable to maltreatment and death. In some instances while a second caregiver may not be the active perpetrator of MCA, the second caregiver may be aware of and fail to protect the child(ren) or lie to protect a partner.
Screening and Inclusion on the Differential Diagnosis
MCA should be including in the differential when a child has multiple diagnoses with no sensible or mainstream unifying explanation, or unexpected responses to mainstream medical treatment, or a pattern of objective findings on physical examinations or diagnostic tests that are inconsistent with caregiver reports. Induction is the direct creation of symptoms or impairments and is a severe form of MCA. In a detailed analysis of the experiences of 451 MCA patients, 57% experienced induction; the caregiver actively produced symptoms, mostly commonly by suffocation, giving of drugs and poisoning. Induction occurred while hospitalized in nearly half (126) of patients. Therefore, patients may not be safe even when hospitalized and all pediatric clinicians need to add MCA to the differential diagnosis when appropriate. A 15-item preliminary screening tool allows for early detection by prompting further evaluation for MCA. In this study, patients with a MCA diagnosis were compared with patients with a discharge diagnosis of apnea, diarrhea/vomiting, or seizures. A score of ≥4 on a 15-item questionnaire had a sensitivity of 0.947 and a specificity of 0.956 ( P <.05) in detecting MCA. The most predictive caregiver items included a personal history of child abuse (odds ratio: 72) and features of Munchausen syndrome (odds ratio: 46). The most predictive patient items were illness abatement when not under the care of the perpetrating caregiver (odds ratio: 89), bruising or trauma to the face/neck (odds ratio: 73), and toxic drug levels on more than 1 occasion (odds ratio: 46) ( Box 1 ).
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Caregiver’s Medical History
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Multiple diagnoses, surgeries, hospitalizations without a specific diagnosis
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Child maltreatment
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Counseling/psychiatric care
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Patient’s Medical History
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Illness abates when patient is out of the care of primary caregiver
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Bruising or trauma to the face, neck
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History of cyanosis
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More than 1 episode of apnea after discharge from nursery
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Prescription, request for apnea monitor
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Chronic diarrhea with or without vomiting for more than 2 weeks
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Chronic vomiting, diarrhea without definite diagnosis
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Toxic drug levels more than once
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Erratic drug levels
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Consults with 1 or more subspecialists
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Care at more than 1 hospital in 6 months
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Leaves hospital against medical advice or insists on transfer
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MCA can present with range of signs and symptoms and illnesses can involve all organ systems. Caregivers most commonly report apnea (26.8%), anorexia/feeding problems (24.6%), diarrhea (20%), seizures (17.5%), cyanosis (11.7%), behavioral concerns (10.4%), asthma (9.5%), allergies (9.3%), and fevers (9.3%). Signs and symptoms may be caused by falsification ( Table 1 ) including exaggeration, fabrication, or induction (by poisoning and asphyxiation). Apnea is the most common reported symptom among children who die from MCA. Risk factors that should prompt consideration of abuse by suffocation are history of recurrent and poorly explained apneic episodes, age older than 6 months, oronasal bleeding, and family history of similar events. Unexplained neurologic signs and symptoms may also lead to unnecessary antiepileptics, imaging, lumbar puncture and other procedures, sometimes necessitating intubation and sedation.
| Falsification | Manifestations |
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| Producing false information | Falsehoods or altered documents about current symptoms, limitations, past medical and other history, prior results, recommendations, and treatment. |
| Withholding information | Failing to provide pertinent information including about caregiver role in illness. |
| Exaggeration | Enhancements designed to make genuine symptoms or limitations seem more frequent or severe. |
| Simulation | Altering biologic specimens or medical procedures to yield abnormal results. |
| Neglect | Withholding medication, nutrition, or treatment to exacerbate symptoms. |
| Induction | Directly creating symptoms or impairments. |
| Coaching | Manipulating patient or another caregiver to answer questions in a way that substantiates false claims of the primary abuser. |
Anorexia/feeding problems, vomiting including hematemesis, diarrhea, and constipation are common gastrointestinal (GI) complaints. Carefully supervised inpatient feeding observations may be helpful along with judicious testing. Otherwise, persistent GI complaints may result in increasing periods of nonoral feeds, medications for reflux and motility issues, Nissen fundoplication, G-tube placement, endoscopies and colonoscopies with biopsies, abdominal surgeries, and associated imaging. When MCA patients are compared with nonmaltreated patients on a G-tube placement protocol, both patient groups have gastrointestinal and neurologic complaints (reflux and oromotor dysfunction). MCA patients are older with a higher number of primary or unusual GI diagnoses, specifically eosinophilic esophagitis/gastroenteritis, oromotor dysfunction, intestinal dysmotility/pseudoobstruction, multiple food allergies/intolerances, and constipation, prompting more diagnostic testing and procedure-related complications compared with G-tube protocol patients.
MCA should also be included in the differential when there are caregiver reported drug reactions such as anaphylaxis without skin findings, multiple food sensitivities and highly restricted diets in patients without abnormal allergy testing, recurrent ear and other infections refractory to standard treatments, unexplained or recurrently hypoglycemia, and unexplained bleeding from multiple orifices.
Fever is both a complaint and an urgent clinical concern, particularly in the youngest patients or those with indwelling devices. A significant minority (17% at one children’s hospital) of patients diagnosed with MCA have central venous catheters (CVC) placed and sometimes replaced multiple times due to concern for sepsis, dislodgement, or other complications. The use of CVC in patients ultimately diagnosed with MCA has been contrasted to more well-defined uses of CVCs in patients on established treatment protocols. In MCA, clinicians have retrospectively noted that CVCs were often placed to reverse unexplained deterioration or nonresponsiveness to more conventional interventions. CVCs were placed in MCA patients for nutritional support, administration of intravenous (IV) antibiotics or IV gamma globulin, and insulin administration in a diabetic child, reportedly resistant to subcutaneous insulin. Consistent with other studies of MCA, there was a range of falsified illnesses in patients with CVCs including falsehoods about seizure activity, exaggeration of asthma severity, intentional dilution of formula, intentional contamination of urine, intentional oral intoxications, Heparin and Dilantin intoxications via CVC, intentional induction of sepsis via the CVC, and induction of blood loss and air emboli via the CVC.
Diagnosis, Diagnostic Challenges, and Medical Management
Gathering proof of MCA is arguably the most important factor in the diagnosis of MCA. After MCA is added to the differential diagnosis, it is important to involve pediatric clinicians with the expertise and time to gather and review medical records, collaborate with treating subspecialist physicians, and in many cases report to and explain medical concerns to Child Protective Services (CPS). Collaboration with pediatrics subspecialists familiar with evidence-based guidelines and mainstream medical treatments related to their specialty along with the expected range of patient and caregiver responses to specialized care plans is beneficial. Input from a pediatric geneticist is suggested if chart review reveals multiple rare or unusual diseases or diagnoses in the same patient (eg, a single patient with a presumed mitochondrial disorder, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections [PANDAS], and multiple food allergies). The focus of the record review should be whether the child is receiving unnecessary and harmful or potentially harmful care because of a pattern of caregiver falsification. There are 7 possible types of falsification that may emerge upon chart review: producing false information, withholding information, exaggeration, simulation, neglect, induction, and coaching (see Table 1 Types of Falsification). In addition to the possibility of a patient being coached, the older patient may collude with their caregiver. Nevertheless, clinicians should consider speaking in an open-ended manner with the older child about child’s perceptions of their illness. Ultimately, a comprehensive chart review and discussions with other pediatric clinicians will help make or refute the MCA diagnosis by revealing whether there is a pattern of caregiver falsification and continued caregiver insistence on additional medical care despite education, reassurance, and nondiagnostic test results ( Box 2 ).
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