Detecting fabricated or induced illness in children
http://www.100md.com
《英国医生杂志》
May now necessitate controversial surveillance tools
Fabricated or induced illness, sometimes called Munchausen syndrome by proxy, occurs when a carer fabricates the impression of illness in a child, sometimes deliberately harming the child to produce signs.1 The syndrome is uncommon but is associated with mortality of around 10%.2 The increased risk of unexplained death in siblings of children identified as having fabricated illness3 shows that the syndrome may be underdetected and current methods for identifying it are underdeveloped.4 The validity of the concept of fabricated or induced illness is accepted by expert professionals but has been rejected by some medical correspondents, senior politicians, and members of the public.
The commonest methods for inducing illness seem to be poisoning, including the misuse of prescribed medication, and suffocation (which is also the cause of some cases of apparent sudden unexplained death in infancy—cot death).3 Poisoning—although not the identity of the perpetrator—may be confirmed by toxicological testing of specimens from the child but with suffocation, should the child survive, observation of the abusive act seems to be the only method of confirmation.5 Covert video surveillance of infants in paediatric units is one such form of observation. Although in principle an ethical investigation, it potentially infringes civil liberties and risks exposing a child to harm, and currently is rarely practised in the United Kingdom. Its use is governed by the Regulation of Investigatory Powers Act 2000 under the European Convention on Human Rights. The accompanying guidance identifies "public health," "public safety," and "preventing and detecting crime" among acceptable reasons for such surveillance outside the home,6 so its use in hospital may be motivated by appropriate health or safety concerns. Unhelpfully, only crime is mentioned in the guidance for its use in fabricated or induced illness.1 The threshold for using covert video surveillance7 is equivalent to an interim care order, which a court may grant if, on the balance of probabilities, grounds for a full care order—in particular, the risk of significant harm—might be met following investigations, and so has a lower standard of proof than a full care order. An interim care order requires the court to proceed to a full care hearing8 and must not alter the balance of power between the parents and the local authority.9 The imposition of a full care order (which makes local government—the local authority—responsible for a child's care, rather than the parents) requires that the risk of significant harm is proved in court10 and as significant harm to children is rare, the proof has to be of a high standard even to confirm the balance of probabilites.11 Evidence which is insufficient to secure conviction in a criminal case beyond reasonable doubt cannot be used to prove risk in care proceedings.12
The General Medical Council recently censured two of the UK's leading experts on child abuse, Professors Meadow and Southall, finding their interpretations of circumstantial evidence insufficient to reasonably support their claims of probable child abuse in cases where suffocation was suspected as the cause of death.13 14 Given this, courts considering protection of children from serious harm could become more sceptical about paediatric expert evidence before imposing full care orders, so covert video surveillance may now be needed to protect some children adequately. One expert witness in the UK has reported a recent case where a court turned down his recommendation for covert video surveillance and gave an interim care order, but then deemed the circumstantial evidence eventually obtained to be insufficient for a hearing on full care proceedings despite continuing concerns of the multiprofessional team about the child's safety (M Samuels, personal communication, 2005).
Covert video surveillance is a potentially important tool for detecting fabricated or induced illness in children, and its use may soon increase as courts demand firmer evidence of such child abuse. To implement such surveillance effectively, legally, and ethically5 7 the NHS and police will have to invest in appropriate facilities and comprehensive training.
David M Foreman, consultant
Berkshire Mental Health NHS Trust, Bracknell RG12 1LH (David_Foreman@doctors.net.uk)
Competing interests: None declared.
References
Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government. Safeguarding children in whom illness is fabricated or induced: supplementary guidance to working together to safeguard children. London: Department of Health, 2002. (No 28835.)
McClure R, Davis P, Meadow S, Sibert J. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child 1996;75: 57-61.
Sheridan M. The deceit continues: an updated literature review of Munchausen syndrome by proxy. Child Abuse Negl 2002;27: 431-51.
Rogers R. Diagnostic, explanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception. Child Abuse Negl 2004;28: 225-38.
David T. Imposed upper airway obstruction. Lancet 1994;344: 133.
Home Office. Covert surveillance code of practice pursuant to section 71 of the Regulation of Investigatory Powers Act 2000. London: Home Office, 2000.
Foreman DM, Farsides C. Ethical use of covert video techniques in detecting Munchausen syndrome by proxy. BMJ 1993;307: 611-3.
Cazelet J. Hampshire CC v S 1993;1 FLR: 567.
Waite L. Re G (Minors)(Interim Care Order) 1993;2 FLR: 845.
Humberside CC v B, 1993;1 FLR: 257.
Bainham A. Children: the modern law. Bristol: Family Law, 2000.
H and R 1996;1 FLR: 80.
GMC Professional Conduct Committee. David Patrick Southall 1491739. 2004;7-15 June and 5-6 August. www.gmc-uk.org/probdocs/decisions/pcc/2004/SOUTHALL_20040806.htm (accessed 18 Oct 2005).
GMC Professional Conduct Committee. Samuel Roy Meadow 0533803. 2005;21 June-15 July. www.gmc-uk.org/probdocs/decisions/ftp_panel/2005/meadow_20050715.htm (accessed 18 Oct 2005).
Fabricated or induced illness, sometimes called Munchausen syndrome by proxy, occurs when a carer fabricates the impression of illness in a child, sometimes deliberately harming the child to produce signs.1 The syndrome is uncommon but is associated with mortality of around 10%.2 The increased risk of unexplained death in siblings of children identified as having fabricated illness3 shows that the syndrome may be underdetected and current methods for identifying it are underdeveloped.4 The validity of the concept of fabricated or induced illness is accepted by expert professionals but has been rejected by some medical correspondents, senior politicians, and members of the public.
The commonest methods for inducing illness seem to be poisoning, including the misuse of prescribed medication, and suffocation (which is also the cause of some cases of apparent sudden unexplained death in infancy—cot death).3 Poisoning—although not the identity of the perpetrator—may be confirmed by toxicological testing of specimens from the child but with suffocation, should the child survive, observation of the abusive act seems to be the only method of confirmation.5 Covert video surveillance of infants in paediatric units is one such form of observation. Although in principle an ethical investigation, it potentially infringes civil liberties and risks exposing a child to harm, and currently is rarely practised in the United Kingdom. Its use is governed by the Regulation of Investigatory Powers Act 2000 under the European Convention on Human Rights. The accompanying guidance identifies "public health," "public safety," and "preventing and detecting crime" among acceptable reasons for such surveillance outside the home,6 so its use in hospital may be motivated by appropriate health or safety concerns. Unhelpfully, only crime is mentioned in the guidance for its use in fabricated or induced illness.1 The threshold for using covert video surveillance7 is equivalent to an interim care order, which a court may grant if, on the balance of probabilities, grounds for a full care order—in particular, the risk of significant harm—might be met following investigations, and so has a lower standard of proof than a full care order. An interim care order requires the court to proceed to a full care hearing8 and must not alter the balance of power between the parents and the local authority.9 The imposition of a full care order (which makes local government—the local authority—responsible for a child's care, rather than the parents) requires that the risk of significant harm is proved in court10 and as significant harm to children is rare, the proof has to be of a high standard even to confirm the balance of probabilites.11 Evidence which is insufficient to secure conviction in a criminal case beyond reasonable doubt cannot be used to prove risk in care proceedings.12
The General Medical Council recently censured two of the UK's leading experts on child abuse, Professors Meadow and Southall, finding their interpretations of circumstantial evidence insufficient to reasonably support their claims of probable child abuse in cases where suffocation was suspected as the cause of death.13 14 Given this, courts considering protection of children from serious harm could become more sceptical about paediatric expert evidence before imposing full care orders, so covert video surveillance may now be needed to protect some children adequately. One expert witness in the UK has reported a recent case where a court turned down his recommendation for covert video surveillance and gave an interim care order, but then deemed the circumstantial evidence eventually obtained to be insufficient for a hearing on full care proceedings despite continuing concerns of the multiprofessional team about the child's safety (M Samuels, personal communication, 2005).
Covert video surveillance is a potentially important tool for detecting fabricated or induced illness in children, and its use may soon increase as courts demand firmer evidence of such child abuse. To implement such surveillance effectively, legally, and ethically5 7 the NHS and police will have to invest in appropriate facilities and comprehensive training.
David M Foreman, consultant
Berkshire Mental Health NHS Trust, Bracknell RG12 1LH (David_Foreman@doctors.net.uk)
Competing interests: None declared.
References
Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government. Safeguarding children in whom illness is fabricated or induced: supplementary guidance to working together to safeguard children. London: Department of Health, 2002. (No 28835.)
McClure R, Davis P, Meadow S, Sibert J. Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child 1996;75: 57-61.
Sheridan M. The deceit continues: an updated literature review of Munchausen syndrome by proxy. Child Abuse Negl 2002;27: 431-51.
Rogers R. Diagnostic, explanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception. Child Abuse Negl 2004;28: 225-38.
David T. Imposed upper airway obstruction. Lancet 1994;344: 133.
Home Office. Covert surveillance code of practice pursuant to section 71 of the Regulation of Investigatory Powers Act 2000. London: Home Office, 2000.
Foreman DM, Farsides C. Ethical use of covert video techniques in detecting Munchausen syndrome by proxy. BMJ 1993;307: 611-3.
Cazelet J. Hampshire CC v S 1993;1 FLR: 567.
Waite L. Re G (Minors)(Interim Care Order) 1993;2 FLR: 845.
Humberside CC v B, 1993;1 FLR: 257.
Bainham A. Children: the modern law. Bristol: Family Law, 2000.
H and R 1996;1 FLR: 80.
GMC Professional Conduct Committee. David Patrick Southall 1491739. 2004;7-15 June and 5-6 August. www.gmc-uk.org/probdocs/decisions/pcc/2004/SOUTHALL_20040806.htm (accessed 18 Oct 2005).
GMC Professional Conduct Committee. Samuel Roy Meadow 0533803. 2005;21 June-15 July. www.gmc-uk.org/probdocs/decisions/ftp_panel/2005/meadow_20050715.htm (accessed 18 Oct 2005).