Download MSBP, Medical Child Abuse, and Caregiver

Challenging Patients & Families –
MSBP, Medical Child Abuse, and Care
Giver Fabricated Illness in a Child:
A Practical (But Never Easy) Approach to
Navigating These Patient Encounters
Anne Beasley, MD, Advocate Children’s Hospital, Chicago, IL
Jodi Carter, MD, Phoenix Children’s Hospital, Phoenix, AZ
Kelly Kelleher, MD, Phoenix Children’s Hospital, Phoenix, AZ
Disclosures
• We have no relevant financial relationships
with the manufacturers(s) of any commercial
products(s) and/or provider of commercial
services discussed in this CME activity.
• We do not intend to discuss an
unapproved/investigative use of a commercial
product/device in this presentation.
https://www.bostonglobe.com/metro/2013/12/15/justina/vnwzbbNdiodSD7WDTh6xZI/story.html
Who Are These Patients?
• Non-specific medical diagnoses
• Examples:
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Mitochondrial Disorders
Seizures
Hypogammaglobulinemia
Behavior Component
Non-Pulmonary Cystic Fibrosis
Apnea
GI Dysmotility
• Vomiting
• Regurgitation
• Constipation
Objectives
• Review recent literature and terminology related to
challenging patient encounters, MSBP, medical child
abuse and caregiver fabricated illness in a child.
• Share patient case examples identifying elements that
have been successful and, equally as important,
unsuccessful encounters.
• Discuss a practical approach to forming a Complex Care
Committee including members of the committee and
their role.
• Discuss legal issues and concerns regarding removal of
a child with caregiver fabricated illness from a
guardian’s custody.
Agenda
• Break into small groups (15 min)
– Patient presentation/discussion
• Return to large group (20 min)
– Review literature
– Discuss Complex Care Committee concept
• Small Group (15 min)
– Develop a treatment approach for your patient
• Large Group (25 minutes)
– Common pitfalls
– How to translate to your home institution
– Available resources
Disclaimer
• Age, gender and dates have been altered in
each case
Case 1
• 12 yo female with autism, MTHFR gene mutation, lead
poisoning and mitochondrial disorder admitted for HSP and
abdominal pain
• Family has recently relocated from out of state
• After admission, pt’s parents request an immune work up
and mention that pt’s four younger siblings have functional
antibody deficiency, autism, mitochondrial disorder and
MTHFR gene mutation for which they receive multiple
services and take multiple medications.
• Patient’s neurologic and developmental exam is completely
normal. Patient is articulate, makes good eye contact and
follows directions well.
Case 2
• 7-yr-old female with constipation
• 6 hospitalizations in 3 months for constipation
Case 3
• 8 and 10 year old sisters
• Both carried tentative diagnoses of Mitochondrial
Disorder NOS due to reported severe GI dysmotility of
unknown etiology with largely normal work-ups
• Extensive genetic testing without conclusive diagnoses
in multiple states
• Both with diagnoses of GI dysmotility with subsequent
GT and then GJ tube placement
• Repeated hospitalizations for fecal impaction and Golytely clean-outs despite aggressive outpatient bowel
regimens and monthly follow-up with GI
Small Group Case Discussion
• Please break into 3 small groups
• What makes this case challenging?
• Did you have a “spidey sense” kick in?
– Would you have listened to it? Why or why not?
• What is your current approach to these
patients and families?
Literature Review
“The largest impediment to early
diagnosis of MSBP was omission
of factitious illness from the
differential diagnosis1”
Current Problems in Pediatric
Adolescent Healthcare
• Jackson et al.2
• Unique complexities of Medical Child Abuse
• Incorporates physical abuse, emotional abuse
and neglect
• Stresses that the threshold to report MCA is
suspicion, not diagnosis
• Multidisciplinary Team Approach
Current Problems in Pediatric
Adolescent Healthcare
• Heightened awareness
– Historian’s consistency with information
– Chronic discrepancies between presentation of
child and history given
– Expanding list of familial ailments
– Multiple nonspecific diagnoses
– Medications prescribed solely on history
Current Problems in Pediatric
Adolescent Healthcare
• Document and Obtain Outside Documentation
– Historian
– Implausible histories
– Escalating behavior
– Exaggerated symptoms in the setting of actual
pathology
– Unexplained tests with no medical findings
– Suspicious polymicrobial infections
Current Problems in Pediatric
Adolescent Healthcare
• Children can be intentional or unintentional active
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participants in MCA
Identify with the sick role
Children using adult terminology
Responding inaccurately to pain scales
Self injurious behavior to feign symptoms
Document inconsistencies with history (wheelchair
bound) vs. clinical picture (running down the hall)
Pediatrics
• Rabbone I et al3
• Highlights how induced illness can simulate true medical
conditions
• Physicians search for what they know
• Easy to lose objectivity
• Especially in the instance of medical conditions not easily
feigned
• Trust your gut
• Red flags
Child Abuse and Neglect
• Brown AN et al4
• Other Clues in the Social Media Age
– Caregiver blogs
– Go Fund Me
– Care Pages
– Facebook Pages
Child Abuse and Neglect
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Distortion Patterns
Escalation Patterns
Attention Patterns
Exposure of pediatric patients to public
viewing
• Attitude towards medical providers
• Fundraising and charity
Lancet
• Bass C et al5
• Effects of MCA on the child
– Physical Health
• Repeated investigations, treatments, admissions
• Serious harm, 6% Mortality
– Daily life and functioning
• Low school attendance
• Few normal activities
• Assuming sick role
• Social isolation
Lancet
• Psychological health
• Distorted view of health
• Confused about state of health
• May develop somatoform disorder or factitious
disorder
• Therapeutic needs of the Child
• Therapeutic needs of the family
• Therapeutic needs of the perpetrator
Lancet
• Prognosis: Better Outcomes
– Illness fabrication is acknowledged
– Willingness to work with agencies
– Capacity of the treating team to work with psychiatric plan
formulation
– Stressors at the time of abuse
– *Little evidence on reunification
– 20% of cases abuse reoccurs if the child stays with the
caregiver
Hospital Pediatrics
• Greiner et al.6 Hospital Pediatrics 2013
• Chart review screening instrument for early
identification of medical child abuse (MCA) in
hospitalized children
• Assessed children, caregiver and illness
characteristics
Hospital Pediatrics
• Children admitted for evaluation of
emesis/diarrhea, apnea, seizures
• Retrospective case/control chart review
• Screened the 1st hospitalization of cases
where MCA was confirmed
Hospital Pediatrics
• 15 item screening tool
• Score > 4 with sensitivity and specificity of 0.947 and
0.956 respectively; (p<0.5)
• Most predictive patient items: illness abatement out
of care of the primary caregiver
• Most predictive caregiver items: personal history of
child abuse, features of Munchausen syndrome,
mental illness, and caregiver requests to leave AMA
or be transferred
PCH Complex Care Team
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Motivation
– “I am intimately involved with a clinical case with concern for medical child
abuse and feel really uncomfortable making a final determination and plan
for this patient by myself.”
• Jodi Carter email to PCH Social Work Manager, 2013
Solution
– Ad hoc committee that convenes when a PCH team member has a
concern for medical child abuse
– Any PCH team member may request to present to the committee
(Physician, SW, RN, etc.)
Objectives
– Review clinical information to determine if PCH should report medical
child abuse to DCS
– Identify a comprehensive care plan to ensure a child does not receive
unnecessary and/or potentially life threatening procedures or treatments
while investigation is underway
PCH Complex Care Team
• Standing Members:
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Physicians – Hospitalist, Psychiatrist, Forensic Pediatrician
Social Work Manager
Forensic Social Worker
Risk/Legal
• Available Members
– invited after the committee has determined the need for their
involvement in a particular case
– Police
– CPS Representative
– Pediatric subspecialists
– PCP
– Other
Complex Care Team Procedure
• Any concerned staff
member may convene
the committee
• Concerned party may
request presence of any
subspecialist or other
team member
PCH Complex Care Team
• Potential outcomes
– There is sufficient evidence to make a DCS and/or
police report immediately
– More information is needed (medical records from
other hospitals, search for previous DCS reports, etc.)
• Plan made to monitor situation
• May involve a plan for the next presentation to medical
attention (office visit, admission, ER visit)
• Follow up meeting arranged
– There is not sufficient evidence to support a concern
for medical child abuse and case is dismissed
Small Group Cases
• How would you present this case to a Complex
Care Committee?
• Who would you want to be present to hear
the case?
• Begin to develop a treatment approach.
Case 1 Resolution
• This patient and many of the siblings
subsequently frequently admit to the hospital
• Clinical picture consistently differs from
history
• Parents consistently request escalation in care
without justification
• All 5 children removed from the home
• All diagnoses disproved
Case 1 Resolution
Case 2 Resolution
• 7-yr-old female with constipation
• Pt hospitalized 6 times in 3 months
• Mom also reported feeding refusal and
vomiting
• Placed on NG tube feeds
• Mother requesting G-tube placement and
cecostomy tube placement
Case 2 Resolution
• Complex Care Committee met following a
hospitalization to develop a treatment plan for
the next hospitalization.
• Final hospitalization, parents were removed from
bedside by DCS.
• Patient ate all meals without difficulty. Bowel
regimen was decreased.
• Pt remains in foster care, on miralax.
• No hospitalization since the final discharge when
removed from biological parents care
Case 3 Resolution
• Younger sister hospitalized for fecal impaction and a clean-out
through her G-J tube
• Hospitalization utilized as a springboard to convene all
concerned team members to review the cases of the two
sisters and determine treatment plan
• Several days later, the older sister was brought in by mother
to the hospital for fecal impaction
• Further meetings held with Complex Care Committee and DCS
revealed multiple internet donation-based care pages and
“Go Fund Me” pages managed by the mother claiming
completely fabricated illnesses for the two sisters
Case 3 Resolution
• Overwhelming belief by all physician members of the care team including
all outpatient providers that the children should be removed for their
safety and risk of further harm by remaining under their mother’s care
• Both children were taken into DCS custody
• After removal independent review of the case and psychiatric evaluation
of the mother revealed MSBP
• Youngest sister now doing well, GJ tube removed, eating everything by
mouth with normal stooling habits, maintaining a healthy weight.
• Older sister with more psychiatric sequelae resulting from the prolonged
abuse and difficulties with deep-rooted beliefs that she possesses the
diagnoses her mother told her she had. GJ tube removed. Eating by
mouth.
How can you translate this concept at
your institution?
• Would you appreciate having a committee like
this at your institution?
• Is this feasible at your institution?
• What barriers do you predict might exist when
trying to create a committee like this?
• Can you think of cases you’ve been involved
with that might have benefitted from this type
of committee?
Available Resources
• What/Who do you have at your disposal?
– Hospital
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Social Work
Hospital Care Managers
Legal Department
Physician Champion
– Insurance Plan
• Medical Director (CMDP)
• Care Managers
– Community
• Child Protective Services
• Law enforcement
• PCP
– Other Providers
• Psychiatry
• Forensic Pediatrician
• Other subspecialty providers
Questions/Discussion
References
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Rosenberg DA. Web of deceit: a literature review of Munchausen by
proxy. Child Abuse Negl. 1987;11(4)547-563
Jackson AM, Kissoon N, Greene C. Aspects of Abuse: Recognizing and
Responding to Child Maltreatment. Curr Probl Pediatr Adolesc Health
Care. 2015(45)58-70.
Rabbone I, Galderisi A, Tinti D, Ignaccolo MG, Barbetti F, Cerutti F. Case
Report: When an Induced Illness Looks Like a Rare Disease. Pediatrics
2015;136(5)1-5.
Brown AN, Gonzalez GR, Wiester RT, Kelley MC, Feldman KW. Care taker
blogs in caregiver fabricated illness in a child: A window on the
caretakers thinking? Child Abuse Negl. 2014;(38)488-497.
Bass C, Glaser D. Early recognition and management of fabricated or
induced illness in children. Lancet 2014;383:1412-1421.
Greiner MV, Palusci VJ, Keeshin BR, Kearns SC, Sinal SH. A Preliminary
Screening Instrument for Early Detection of Medical Child Abuse.
Hospital Pediatrics. 2013(3)39-44.
Contact Information
• Dr. Anne Beasley
– [email protected]
• Dr. Jodi Carter
– [email protected]
• Dr. Kelly Kelleher
– [email protected]