Setting the record straight on child abuse

Setting the record straight on child abuse

Inaccurate reporting confuses details of psychiatric
disorders

By Brenda Bursch

I am writing in response to an article printed on the front page
of the Daily Bruin on Friday, Feb. 16, titled "Lawsuit filed
against Neuropsychiatric Institute." I am extremely concerned about
the inaccuracies that appeared in the article.

Considering the very serious subject of child abuse, clarity is
critical. I am writing to correct the record. Additionally, I
strongly urge you to consider more stringent oversight of your
procedures and staff. The very sloppy reporting, extensive
misquoting and inability to even correctly spell a major
psychiatric diagnosis when provided with written materials on the
subject is an embarrassment to the newspaper and school.

While I am unable to comment on the accuracy of the family’s
claims, I am able to comment on the accuracy of the reporting,
based on my interview with the Daily Bruin reporter. Following are
summaries of the most obvious errors in the article:

1. Dr. David Beck provided psychiatric consultation services to
pediatrics in the UCLA Medical Center. I clearly explained this to
the Daily Bruin reporter. The assessment of the child in the
article must have occurred when the child was a patient of a
pediatrician in the Center for Health Sciences, not the
Neuropsychiatric Institute.

This means that the child would have been assessed minimally by
both a pediatrician and Dr. Beck, and probably by others who also
agreed with the final diagnosis.

2. It was apparent that the reporter lacked even a simplistic
understanding of the California child abuse reporting laws or the
legal system, as she repeatedly suggested that Dr. Beck and UCLA
had it within their power to "prosecute" or to "press charges"
against a family for child abuse.

The obligation of health care providers is to report suspected
child abuse. Individuals within the legal system determine what
actions will follow the report. The language used by the reporter
was unnecessarily inflammatory, inaccurate and irresponsible.

3. The reporter’s account of how Munchausen Syndrome by Proxy is
suspected and reported was impossible to understand and inaccurate.
There are specific warning signs which should raise providers’
concerns about Munchausen Syndrome by Proxy and, if present, should
result in the inclusion of child abuse as a diagnostic possibility.
If assessment by the UCLA pediatric team reveals child abuse, it is
always reported.

4. Illness has been fabricated in healthy children and in
children with true medical problems. For a case of suspected
Munchausen Syndrome by Proxy to be investigated by the Department
of Children and Family Services, the child may or may not have a
true medical condition.

5. Also discussed with the reporter (but not reported in the
article) are other considerations of a child exhibiting symptoms
for which a sufficient medical explanation cannot be found. A
common alternative diagnosis is Somatoform Disorder, which is not
reported because it is not child abuse.

Somatoform Disorder includes the following features: the
involuntary production of symptoms suggesting a medical disorder,
the absence of medical findings which are consistent with the
clinical presentation, and the presence of psychological factors
which are thought to play a role in the onset, severity,
exacerbation or maintenance of the symptoms.

The symptoms are real (the child or parent is not faking
symptoms) in a Somatoform Disorder. When medical findings are at
odds with the child’s clinical presentation, it is possible for
both Munchausen Syndrome by Proxy and Somatoform Disorder to be
among the diagnostic considerations.

One or both of these problems may be present in the same child.
A diagnosis of Somatoform Disorder alone is not child abuse and is
not reported. If assessment by the pediatric team reveals child
abuse, it is always reported.

6. Perpetrators of Munchausen Syndrome by Proxy fabricate
illness and deny knowledge of the etiology of the illness. This, by
definition, makes every perpetrator a liar. It is possible for
perpetrators to appear to be quite normal with reasonable
explanations. It is also possible for them to appear quite
disturbed. As in other forms of child abuse, it is rare for a
perpetrator to admit to the abuse.

7. The most common criteria used to conclude Munchausen Syndrome
by Proxy are 1) the presence of a fabricated illness in a victim by
a caretaker, 2) the victim is presented by the caretaker for
medical (or psychiatric) care, usually persistently, for the
fabricated problem, 3) the perpetrator denies knowledge of the
etiology of the illness, and 4) acute symptoms and signs of illness
cease when the victim is separated from the perpetrator.

Because separation is often not possible in the hospitals, the
final diagnosis is often made after the child has been separated
from the suspected perpetrator for a period of time. Sometimes,
this separation occurs as the result of court action. Sometimes,
doctors are in a position to confirm Munchausen Syndrome by Proxy
during the assessment of the child.

8. Tourette’s syndrome (not "Teret’s") is a severe tic disorder
which typically begins in early childhood. Most commonly, the child
first experiences motor tics, and later, phonic tics. The tics tend
to occur in bouts and can present themselves in a wide range of
behaviors.

Additionally, many children diagnosed with Tourette’s have
associated behavioral or emotional problems. Many etiologic factors
have been found to be related to the disorder. Stress is one of
these many factors. Stress has been considered a risk factor for
the development of the disorder, responsible for the exacerbation
of symptoms and a consequence of having the disorder. Neuro-imaging
studies, EEG readings and lab tests are rarely useful in diagnosing
Tourette’s.

9. It is possible for a child who is a victim of Munchausen
Syndrome by Proxy to also suffer from Tourette’s Syndrome, or to
falsely appear to suffer from Tourette’s Syndrome.

While I am highly distressed by the inaccuracies in the article,
I also must defend the potentially unsuspecting reporter. If the
family presented in the article is a Munchausen Syndrome by Proxy
family, it is quite possible that the reporter is one of many
people who have been fooled by them. If this is true, it is
possible that some of the inaccuracies and inflammatory language in
the article were used by the family and simply repeated by the
reporter.

Bursch is associate director of the Pediatric
Consultation-Liaison Service in the department of psychiatry and
biobehavioral sciences.Comments to [email protected]