http://bmj.com/cgi/content/full/323/7308/296
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Editorials
Fabricated or induced illness in children
Munchausen by proxy comes of age
Significant harm to children such as smothering or poisoning which simulated
illness and which involved and deceived doctors has been known for
at least 40 years. It took the honesty of Roy Meadow to
describe his personal experience and his journalistic flair to label
it "Munchausen by proxy" in 1977.1 His
article drew the world's attention to fabricated or induced illness
and led to more accounts, to reviews,2 and to
research
though
research has not been helped by arguments about what is or is not
Munchausen by proxy.3
Even today one has to state clearly that some carers, including parents, do
harm children, and that they sometimes involve health professionals
in doing so. Doctors and others may not only fail to understand the
origins of a child's reported symptoms but actually deliver some of
the harm through inappropriate investigation, treatment, or surgery.4 The
Department of Health and the Royal College of Paediatrics and Child
Health are agreed that the focus must be on the welfare of the
child, and both now refer to the problem as "fabricated or
induced illness in children by carers." The department has just
published draft guidance from an interdepartmental group for
consultation.5
The college is about to issue guidance for paediatricians.
Induced physical illness does lead to death and handicap, but less acute
fabrication and illness induction (such as presenting a child with
mild arthritis as having severe disease and being wheelchair bound)
can cause significant harm to children and is more common. Neither
may be easy to detect, so rates are underestimates and the harm
(which often starts in infancy) may take some time to be identified.6
Preventive measures emerge late in the life history of a disorder, but small
studies have shown that intervention is effective in some cases and
allows some children to be safely integrated with their families.7 This may
require separation, work to help carers recognise the harm they
caused, therapy for the carer and others who allowed harm to occur,
and long term therapy and support for the child. The new guidance
indicates that doctors should be looking at the welfare of children
before serious harm has occurred. The doctor-parent relationship can
conflict with the doctor-patient (child) responsibility,
particularly in primary care. It may be difficult to reconcile the
extreme overanxiety of parents with the fact that their asthmatic
child is being grossly overtreated and is being conditioned to
believe that he or she is physically disabled.
Another interdepartmental document issued last year, A Framework for the Assessment
of Children in Need and their Families,8 can
help professionals in looking at the situation from the child's perspective.
Until recently there has been little training on this for health
professionals. In the triangular dynamics of a consultation on a
child, it is normally to the child's advantage to have a carer as an
advocate. However, this is not always so, and clinicians' prime
responsibility remains the welfare of their patientthe
child. Earlier referral to social services on the grounds of need
can make it clear that we are trying to help the family, which may
prevent harm to the child and siblings, and that this is not an
accusation of abuse. A child's doctor is not required to clarify
whether inappropriate parental care is due to mental illness,
deprivation, distorted views of science, or persisting overanxiety
before acting to promote the welfare of the child. We must also
learn what is not our responsibility and what belongs to the social
services and police, and joint working and joint training on these
latest guidelines from the Department of Health is essential.
Health authorities and trusts have responsibilities to provide adequate
resources, including advice by designated doctors organised through
named doctors. Equally, social service departments should be
expected to provide adequate social work support in every paediatric
and child health department if this excellent guidance is going to
succeed.
The draft guidance on fabricated or induced illness quotes its origin from
the Griffiths report into the research framework in North
Staffordshire NHS Trust, a report prompted by complaints against
doctors prominent in research into fabricated or induced illness in
children.9
But the guidance fails to address the unsatisfactory procedures for
investigating complaints against doctors or nurses who work with
fabricated or induced illness. Trusts have failed to carry out
competent investigations,10
and there is no protection for professionals who are attacked by
complainants.
The guidance has not acknowledged the need for comprehensive investigation
of unexpected deaths in children. Coroners' inquiries do not meet
the standards required in normal paediatric practice or child
protection investigations. It is not surprising that there are
subsequent queries on whether death might have been induced.
Munchausen by proxy has had an honourable life and valuable effects beyond
its own confines. Professionals are now more aware of the protean
forms of harm to children. The understanding of the processes
involved in a consultation,11 of the
fact that doctors and parents can misjudge a child's health or
illness whether they agree or disagree, of the need always to have
the child's welfare as the focus and when possible obtain the
child's views are all difficult but need to be part of continuing
training. The role of society in providing procedures, resources,
and support to both professionals and families is strengthened in
the new document.
The implementation of this guidance will give an enhanced responsibility to
designated and named doctors and nurses. Nevertheless, improving
care for these children mostly depends on the much greater number of
clinicians who meet children face to face. We need to have open
minds and to develop our skills to understand the complex origin of
children's symptoms and illnesses and protect those at risk of being
harmed.
Richard G Wilson
Kingston NHS Trust, Kingston KT2 7AZ (richardgwilson@yahoo.co.uk)
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1. |
Meadow R. Munchausen by proxy: the hinterland of child
abuse. Lancet 1977; ii: 343-345 |
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2. |
Rosenberg DA. Web of deceit: a literature review of
Munchausen syndrome by proxy. Child Abuse Negl 1987; 11: 547-563 |
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3. |
Fisher GC, Mitchell I. Is Munchausen syndrome by proxy
really a syndrome? Arch Dis Child 1995; 72: 530-534 |
|
4. |
Postlethwaite R. Clinical categories in fabricated or
induced illness. In: Royal College of Paediatrics and Child Health, Guidelines
on fabricated or induced illness in children. London: RCPCH (in press). |
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5. |
Department of Health, Home Office, Department for
Education and Skills. Safeguarding children in whom illness is induced or
fabricated by carers with parenting responsibilities. London: DoH, 2001www.doh.gov.uk/qualityprotects/info/publications/childprot.htm
(accessed 7 Aug 2001). |
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6. |
McClure RJ, Davis PM, Meadow SR, Sibert JR. Epidemiology
of Munchausen syndrome by proxy, non-accidental poisoning and non-accidental
suffocation. Arch Dis Child 1996; 75: 57-61 |
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7. |
Berg B, Jones DPH. Outcome of psychiatric intervention in
factitious illness by proxy (Munchausen's syndrome by proxy). Arch Dis
Child 1999; 81: 465-472 |
|
8. |
Department of Health, Department for Education and
Employment, Home Office. Assessing children in need and their families:
practice guidance. London: DoH, 2000. www.doh.gov.uk/scg/qptch.htm
(accessed 7 Aug 2001). |
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9. |
NHS Executive West Midlands Regional Office. Report of a
review of the research framework in North Staffordshire Hospital NHS Trust.
In: Leeds: NHS Executive, 2000. (Griffiths report.) www.doh.gov.uk/wmro/northstaffs.htm
(accessed 7 Aug 2001). |
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10. |
Hey E, Chalmers I. Open letter to the chief medical
officer. Learning from Bristol: the need for a lead from the chief medical
officer. BMJ 2001; 323: 280-281 |
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11. |
Eminson M, Postlethwaite R. Munchausen syndrome by
proxy abuse. London: Butterworth, 2000. |
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Other related articles in
BMJ:
PRESS
Press: Cot death confusion: explaining the unexplainable.
Trevor Jackson
BMJ 2001 323: 347.
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