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Induced illness in children

For many who were in paediatric clinical practice in 1977, Roy Meadow’s description of what he called Munchausen syndrome by proxy, sub-titled the hinterland of child abuse, was shocking. Mothers sometimes harmed their children deliberately. Furthermore, many of us realised that difficult cases we had been managing, for example children with recurrent ‘fits’ we had never witnessed, were almost certainly unrecognised examples of the condition. We doctors were perversely harming the children we thought we were helping, by being fooled into unnecessary investigations and treatment. The mothers seemed to be playing some macabre game, with their children as victims and the doctors as manipulated agents. It was a potentially lethal game which sometimes killed the child. David Southall and colleagues subsequently used covert videotape surveillance to show the scarcely credible ways in which some mothers induced illness in their children. Meadow and Southall’s publications elicited fierce opposition from public lobby groups, which denied the condition’s existence despite the evidence, elicited opposition from the media and, disturbingly, from their peers. The UK General Medical Council (GMC) was anything but supportive of Meadow and Southall, whose behaviour did not always help their own cause but who were genuinely trying to protect children. The GMC’s controversial rulings blighted the careers of both these men and set back the management of child abuse in the UK and elsewhere. The condition, which has undergone many name changes, including Meadow syndrome, factitious disorder and medical child abuse, is arguably the most confronting condition a paediatrician ever has to manage. This is particularly true when the mother is the perpetrator, as she is in three-quarters of reported cases. Bass and Glaser describe parental behaviours as being on a continuum from extreme parental neglect (failure to seek appropriate medical care), through exaggeration of symptoms to the dangerous extreme of fabricated or induced illness. There is an important distinction however between fabrication, which may just be an extreme form of exaggeration associated with maternal anxiety, and the rare but potentially lethal condition of illness induction. Many highly intelligent, deeply caring paediatricians are paralysed by cases involving induced illness. We may fail completely to suspect it or, if we do suspect it, we may fail to act appropriately, although the danger of harm is high. For all our child protection training, we often do not notify our suspicions to child protection authorities although we know notification is mandatory. Why do we not notify? The reasons may be conscious but they are more likely to be unconscious (i.e. massive denial). When professionals in the latter category do not report their suspicions, they are not deliberately ignoring or condoning the abuse, but ‘turning a blind eye’ to what is happening to the child. Kozlowska suggests paediatricians may be afraid for legal reasons or may lack time. Many paediatricians say they did not notify a possible case because they did not have enough proof. However, paediatricians should know that the Children’s Court will act to protect children on a lesser level of proof than is needed for a prosecution in the Criminal Court. The main consideration should be the level of danger of harm, not the level of evidence. For example, a hospitalised child has unexplained fevers with shock-like episodes, and blood cultures grow unexpected organisms, such as mouth or bowel organisms. If other circumstances make child abuse likely, this should mandate notification to child protection authorities, because we know people sometimes inject saliva or faecal suspensions into lines, and septic shock can kill. Yet doctors often fail to notify such cases. A review of fabricated or induced illness in children reported the mortality was 6% of 451 cases. In the last 25 years, at least three children died at the hands of their mother in our tertiary children’s hospital, as good doctors failed to act on their suspicions. Freud would probably say that doctors fail to act because their unconscious will not let them countenance that a mother could do such harm to her own child. Doctors trust mothers to tell them the truth and to do the best for their own children. Mothers who abuse their child in an apparently calculated manner betray the trust inherent in the parent–doctor relationship, in addition to their ultimate betrayal of the biologically vital mother–child relationship. As paediatricians, our primary duty is to protect the child. If we suspect that someone is inducing or fabricating illness, we need to confront our own demons and notify authorities. Not only do we need to stop children dying, but a third of maltreated children will go on to harm their own child. One could accentuate the positive and say more optimistically that two-thirds do not go on to harm their own children. Even if someone else loves the maltreated child, however, maternal love is natural, and behaviour that bespeaks the opposite is unnatural. Growing up with the knowledge your mother tried to harm you is not ideal for future mental health. All survivors of maternal maltreatment clearly need therapy, and their siblings, who may themselves have been victims, are also likely to need attention and support. Anyone who harms their child in such a calculating way clearly has major psychopathology, which we should try to understand and even treat. There is no unique diagnosis for perpetrators, but they need psychiatric assessment. Finally, medical and nursing staff need formal or informal debriefing following these most confronting of cases.