Medical Child Abuse: Beyond Munchausen Syndrome by Proxy
by Thomas A. Roesler, MD and Carole Jenny, MD, MBA, FAAP, Elk Grove Village, IL, American Academy of Pediatrics, 2009, 337 pp, Hardcover, $89.95.
This book has a straightforward theme: it is time to drop Munchausen syndrome by proxy as a diagnosis, and replace it with medical child abuse. By medical child abuse, the authors mean cases “when the child receives unnecessary and harmful or potentially harmful medical care at the instigation of a caregiver.” Medical child abuse is analogous in every significant way (except one) to all other forms of child abuse and should be treated as child abuse. It is different from other forms of child abuse in that physicians and the medical system are implicated by being the instruments that deliver the abuse because of the inaccurate information. Medical child abuse differs from Munchausen syndrome by proxy in that the motivation(s) of the caregiver are irrelevant to making the diagnosis of medical child abuse, although they may be relevant to addressing the consequences (as for other forms of child abuse). In medical malpractice, doctors deliver bad care, care that does not meet the standards of treatment; in medical child abuse, doctors deliver usual and customary, appropriate, well-intentioned treatment based on information provided by the caretaker.
The authors articulately, carefully, and straightforwardly make a great case without glossing over difficulties and nuances. They know the literature intimately and use it wisely. Between the 2 of them (Roesler, a psychiatrist, directs a pediatric/child psychiatric day treatment program; Jenny, a pediatrician, directs a child protection program), they have a terrific depth of experience and an extensive set of cases from which to draw telling examples and illustrations. And they use it to overcome one of the classic limitations; namely, the tendency to only report the most interesting or extreme cases (the “availability heuristic” pp 8) rather than the whole range of clinical presentations from mild to severe. In their 115 cases (Chapter 7), the criterion for entry was that someone identified a concern for Munchausen syndrome by proxy (or medical child abuse). This is much closer to the real world and to what the experience is like for most readers. It makes the book more interesting and practical.
There was much to like about their approach. One is that they did not sensationalize—this is a very “down to earth” treatment that has real-world professionals in mind. Another is that all aspects of the problem are addressed. I particularly liked Chapter 5: Why Has It Taken So Long? (for the medical profession to recognize that Munchausen syndrome by proxy does not work). They argue that the differentiating feature of medical child abuse—that health professionals are participants in the abuse—puts physicians in a terrible position, the realization of which they call the “Oh, no!” moment. I also liked Chapter 15: Lawyers as Part of the Solution. The authors point out that the courts have actually been ahead of the medical profession in establishing that the key issue is the abuse of the child, and that the motivation of the parent is irrelevant.
But every chapter has its gems of history, observation, experience, and wisdom. Here are two more: (1) medical abuse tends to be deliberate and premeditated (as in sexual abuse), whereas other forms of physical abuse tend to be impulsive or reactive (pp 167); and (2) the severity of the medical abuse is not linearly related to the severity of the parent's level of involvement; simply exaggerating the symptoms can result in more medical abuse than fabricating or inducing symptoms (pp 321).
Any intelligent reader, professional or not, will understand every page of this book and every phase of the argument. It will be difficult to find a more compelling treatment of the topic. Although not a novel, I could not wait to get to the next topic and the next chapter. This book was a superb entrée to understanding this form of abuse and how to approach it; it would be great to have similar treatments for other forms of abuse. At the end of it, professional and lay readers—including the families whom, as the authors appropriately say, “help us treat their children”—will all benefit. Given how difficult all forms of abuse are, including this one, this book should help us join together to “first, do no harm.”
Ronald G. Barr, MA, MDCM, FRCPC
Centre for Community Child Health Research
Vancouver, BC, Canada