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Recognizing medical child abuse in children presenting with chronic pain
David D Sherry1,2, Sabrina Gmuca1,2,3,4, Cindy W Christian2,5
1Department of Pediatrics, Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Insights
Medical child abuse (MCA) can manifest as chronic pain in children. Recognizing atypical symptoms and over-involvement by caregivers is crucial for identifying and protecting these vulnerable victims.
Area of Science:
- Pediatrics
- Child Abuse
- Medical Psychology
Background:
- Medical child abuse (MCA), formerly Munchausen by proxy, is a form of abuse where a caregiver fabricates or induces illness in a child.
- MCA can present insidiously, with chronic pain being a common, yet often overlooked, symptom.
- Children subjected to MCA are frequently over-medicalized, leading to significant physical and psychological morbidity.
Purpose of the Study:
- To describe the clinical presentations of five children identified as victims of MCA, focusing on chronic pain as the primary symptom.
- To highlight characteristic patterns of pain, atypical symptoms, and caregiver behaviors associated with MCA.
- To underscore the challenges in diagnosing and reporting MCA and the need to overcome these barriers.
Main Methods:
- Case series reporting on five children presenting with chronic pain who were subsequently diagnosed with MCA.
- Analysis of clinical data, including presenting symptoms, medical history, diagnostic workups, and caregiver interactions.
- Review of characteristic features distinguishing MCA from genuine medical conditions.
Main Results:
- The five cases exhibited unusual pain patterns, multiple atypical symptoms (e.g., alleged allergies, dysautonomia, fibromyalgia, Ehlers-Danlos), and significant medical interventions (e.g., amputation, multiple surgeries).
- Caregivers demonstrated excessive investment in the child's symptoms, seeking secondary gains and manipulating medical professionals.
- Children were often well-appearing despite severe alleged illnesses, complicating diagnosis.
Conclusions:
- Chronic pain in children can be a manifestation of medical child abuse, characterized by atypical symptom clusters and caregiver manipulation.
- Identifying MCA requires heightened physician awareness of subtle indicators and a willingness to question presented narratives.
- Overcoming diagnostic and reporting barriers is essential to protect children from the severe morbidity associated with MCA.
Abstract:
Medical child abuse (MCA), previously referred to as Munchausen by proxy, can present as chronic pain. We report the presentation of five children seeking treatment for chronic pain who we identified as victims of MCA. The index case had essentially not eaten for the 6 years of her life due to alleged allergies to all foods, developed severe pain, used a wheelchair for ambulation beyond a few blocks, and was alleged to have dysautonomia requiring oxygen monitoring at night. Other cases posed as arthritis that resulted in foot amputation and total body pain, fibromyalgia with alleged mutation negative Stickler syndrome who had symptoms only in her mother's presence, severe incapacitating intermittent pains along with abdominal pain that resulted in appendectomy, cholecystectomy, and pancreatectomy, and alleged disabling hypermobile Ehlers-Danlos in a non-hypermobile child for which the mother sought a power wheelchair. The unusual pattern to the pain, the presence of multiple additional, atypical symptoms and diagnoses, and a generally well appearing child are characteristic. The perpetrator is typically over-invested in the symptoms, derives tangible and intangible secondary gain from the child's alleged illnesses, and is able to present the child in such a fashion to enlist the physician to aid in perpetuating the abuse. These children are highly over-medicalized and suffer significant morbidity. Multiple barriers exist to identifying and reporting these children to Child Protective Services, which need to be recognized and overcome in order to protect these vulnerable children.
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