Misdiagnosis Of Child Abuse Related To Delay In Diagnosing A Paediatric Brain Tumour
Author: Lynne Wrennall
Journal: Clinical Medicine Insights: Pediatrics Clinical Medicine: Pediatrics 2008:1 1-12
Publication Date: 20 May 2008
Public Health Research Group, Criminology Programme, School of Social Science, Liverpool John Moores University, Clarence Street, Liverpool, United Kingdom, L3 5UG.
Abstract
Conflicting opinion regarding the relative weight that should be allocated to the investigation of organic causes of child illness, compared to the pursuit of suspicions of child abuse, has generated considerable public debate. The discourse of Munchausen Syndrome by Proxy/Fabricated and Induced Illness is at the centre of contention. In particular, concern has arisen that children’s medical needs are being neglected when their conditions are misdiagnosed as child abuse. This paper documents a case study in which the use of Child Protection procedures was linked to the belief that the child’s illness had “no organic cause.” The case study is contextualised in a review of literature relevant to the diagnostic process. The deployment of the Child Protection perspective resulted in significant delay in the diagnosis of the child’s brain tumour. The child was ultimately found to be suffering from an optic chasm mass lesion involving the hypothalamus and the medial temporal regions, resulting in Diencephalic Syndrome. The evidence in this case is that erring on the side of suspecting Munchausen Syndrome by Proxy/Fabricated and Induced Illness, was not “erring on the side of the child.” Several lessons need to be learned from the case. The importance of ensuring that the Child Protection perspective does not displace adequate assessment of alternative explanations for the child’s condition is emphasised, as is the need for good communication in medical relationships. Strategies involving empathy, mediation, negotiation and conflict resolution may provide a more appropriate and therapeutic alternative to the use of Child Protection procedures in cases where the diagnosis is contentious. The need to re-write relevant policy, protocols and guidance is imperative.
Background
Diagnosis of child abuse in the medical context has been highly contested for some time (Hayward- Brown, 2003, 2004; Hayward-Brown et al. 2004). In the specifi c case presented here, the misdiagnosis of child abuse involving the discourse of Munchausen Syndrome by Proxy/ Fabricated and Induced Illness [MSbP/FII] displaced the medical knowledge necessary to assist a child. The Child Protection discourse of MSbP/FII that permeated the exposit case was launched in an article in The Lancet by the controversial paediatrician, Roy Meadow. Meadow (1977) presented two
case studies alleging that parents had fabricated and induced their children’s illness. Since then, the definitions of MSbP/FII have varied considerably across the literature and amongst differing professional groups. Broadly put, the discourse of MSbP/FII is constituted by allegations of child abuse centred around claims that parents and carers, usually Mothers, are harming children by causing them to suffer a fi ctional or induced illness (Wrennall, 2007:961). Proponents of the discourse argue that MSbP/FII is common, extremely dangerous and frequently fatal (Meadow, 1977; Davis et al. 1998). The discourse has been implicated in some of the major murder trials involving women and in
numerous cases in the Children and Family Courts in English speaking countries around the world (Wrennall, 2007). Subsequent critique of Meadow’s evidence as an expert witness (Royal Statistical Society, 2001; Nobles and Schiff, 2005; Streater, 2006: 7–11; Watkins, 2000) and the role of the discourse in false allegations, Miscarriages of Justice and hostile adoptions, is now well known (Wrennall, 2007; Raitt and Zeedyk, 2004).
Conclusion
The discourse of MSbP/FII has been linked to medical, forensic and legal misadventure. In the exposit case, the misdiagnosis of child abuse, delayed accurate medical diagnosis and caused serious harm to a child. It is imperative that suspicion of child abuse does not displace appropriate medical investigations.
Learning Points
• The differential diagnosis should afford due
diligence to the consideration of the views of
service users and their advocates.
• From the outset, the differential diagnosis
should allow for relevant rare medical conditions
of a serious nature.
• Claims of “no organic cause” for illness are
vulnerable to refutation and should be avoided.
• The threshold for referral to relevant medical
specialists should be lowered, especially where
pediatric neoplasm is, or should be, included in
the differential diagnosis.
• Consultants should make Primary Care Physicians
aware of the limits to their knowledge and
suggest referrals to other specialisms where
appropriate.
• A risk analysis should properly weigh the costs
of undertaking tests requested by service users
against the risk of delayed diagnosis.
• Erring on the side of diagnosing child abuse,
may not “err on the side of the child.” Judgmental
narratives can have an adverse impact on
accurate diagnostic practice.
• The potential for “Groupthink” to produce
“risky shift” judgment in the context of Child
Protection multidisciplinary teams, needs to be
considered.
• Strategies involving empathy, communication,
mediation, negotiation and confl ict resolution
should be trialed, in cases where suspicions of
child abuse have arisen,
• Policy, protocols and guidance relating to
Munchausen Syndrome by Proxy/Fabricated
and Induced Illness must be re-written to better
protect the interests of health and social care
service users.
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