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Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation

Abstract

OBJECTIVES To investigate outcome, management, and prevention in Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

DESIGN Ascertainment through British Paediatric Surveillance Unit and questionnaires to responding paediatricians.

SETTING The UK and Republic of Ireland, September 1992 to August 1994.

SUBJECTS Children under 14 years diagnosed with the above.

MAIN OUTCOME MEASURES Placement and child protection measures for victims and siblings; morbidity and reabuse rates for victims; abuse of siblings; prosecution of perpetrators.

RESULTS Outcome data for 119 with median follow up of 24 months (range 12 to 44 months). No previously diagnosed factitious disease was found to have been caused by genuine disease. Forty six children were allowed home without conditions at follow up. Children who had suffered from suffocation, non-accidental poisoning, direct harm, and those under 5 years were less likely to go home.

 Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal.

CONCLUSIONS This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur.

  • None of the cases originally reported as Munchausen syndrome by proxy were found to have had genuine illness

  • Evidence from abuse in siblings suggests that in half the families with a child with suffocation there would be further abuse, some fatal

  • Evidence from abuse in siblings suggests that in 40% of the families with a child with non-accidental poisoning there would be further abuse, some fatal

  • Even in the cases of Munchausen syndrome by proxy without physical harm allowed home, 17% were reabused in a two year follow up period

  • Cases involving direct harm (including suffocation or poisoning) and younger victims were less likely to have been rehabilitated with their families

  • A quarter of all victims had ongoing morbidity as a result of their abuse

  • Follow up of victims and their families by a paediatrician is essential

  • child abuse
  • Munchausen syndrome by proxy
  • poisoning
  • suffocation
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