Further Thoughts on “Beyond Munchausen by Proxy: Identification and Treatment of Child Abuse in a Medical Setting”: In Reply

Abstract

In Reply.—Bursch et al are all esteemed colleagues who have made significant contributions to our understanding of child abuse in the medical setting. The purpose of our clinical report and its target audience are reflected in the heading: “Guidance to the clinician in rendering pediatric care.” The report had 2 goals: (1) to remind pediatricians that medical signs and symptoms can be fabricated or inaccurately reported and (2) to encourage pediatricians to accept responsibility for making the diagnosis of child abuse that takes place in a medical setting.The statement clearly explained that consideration of motivation is important in the overall response to these cases but not in its diagnosis. Although it is true that the motivation of the caretaker is often questioned, it remains most important that whenever a caretaker's actions harm a child, steps must be taken to protect the child regardless of whether the harm was intended. The pediatrician often lacks enough reliable information to determine the motives behind an injury. The Committee on Child Abuse and Neglect continues to work to remind pediatricians that child abuse in the medical setting is a potentially dangerous condition that, like many others, often cannot be evaluated fully in the office. Thus, we recommend that the medical provider “work with a hospital- or community-based child protection team,” and we discussed (under “Treatment”) the involvement of child protective services, foster care, law enforcement, and other professionals.Determining whether the medical care given was harmful or potentially harmful is, ultimately, a medical decision and requires the judgment of a medical professional. This leads to our recommendation that “a pediatrician with experience and expertise in child abuse consult on the case.”Child abuse pediatricians work collaboratively with professionals from other disciplines and will continue to do so. We are concerned that intervention may focus on the caregiver's pathology, rather than the harm occurring to the child, and emphasize that if a child is being medically abused, the abuse must first be stopped. Whether the caretaker is treatable will vary from case to case.