*James C. Hamilton, PhD: 10/30/2019

Transcript

• 00:00A welcome to pediatric grand rounds. I just want to make a few announcements before our speaker is introduced. These are the 2 grand rounds that are coming up that you want to take note of a 2 very interesting. Grand rounds over the next couple of weeks, so please look. Please come back and it's just a reminder that our grand rounds is accredited for CME and we've done all the appropriate disclosures if you want see me.
• 00:30You can use the QR readers to access the survey and enter your name also remember to please silence your phones and your beepers.
• 00:41So they don't go often disturb everybody in the middle of the grand rounds. An also reminder that you just after the grand rounds will be gathering outside for coffee in the hallway right with lunch was so you're welcome to hang around for a few minutes. So, your colleagues interact with our speaker who will also be there and so we're really fortunate to be able to have a visiting speaker here from the University of Alabama and we're going to have an introduction on a very.
• 01:12Interesting topic so welcome John Leventhal, he's not the speaker he said. I'm not the speaker, which is fine. He's next in the University of Alabama, nice to see you all and it was hard to for people to stop talking 'cause this scene friends that they haven't seen for awhile so maybe we could have a whole grain rounds on that.
• 01:32So I'm John Leventhal from the child abuse programs here, sometimes called the dark program and I'm delighted today.
• 01:40To introduce a friend and colleague doctor Jim Hamilton, who say psychologist and associate professor of psychology at the University of Alabama in Tuscaloosa, an one of my other friends is very much of a friend and favorite of the University of Alabama and she says. Every time she says. University of Alabama. She says Roll Tide and any of you who know about football know the importance of that terminology, but that's not what gyms here to talk about today.
• 02:12Jim is from Stratford CT.
• 02:17He received his Masters and his PhD in psychology at Case Western.
• 02:25Uh and then uh did some post doctoral work Philadelphia and in Colorado and spent the last 25 years at the University of Alabama in Tuscaloosa. He coordinates the clinical health psychology. Doctoral program there, so this is a clinical a lot of clinical activities and his special interest is in factors that lead to excessive medical illness behavior 1 version of that we call Munchausen syndrome by proxy.
• 02:56Or medical child abuse and that's why he's here today. When we when he was on sabbatical 5 years at Yale 5 years ago at Yale. He started coming regularly to our child abuse meetings are weekly dark meeting and I learned about his interest in his expertise and then I had a chance to interact with him and talk to him a lot about this? He sees cases, not at the beginning or in the middle like we do, but he sees cases that are referred to him by lawyers because of his interest in this area.
• 03:31So he has a very different approach and thinking about it, but one that I think will be very appropriate for us today. So I'm honored that Jim you're here today. Thank you very much. He's going to talk about medical child abuse also known as Munchausen syndrome by proxy detection and Prevention, so thank you very much for commentary.
• 04:03Well, thank you very much for that introduction John I want to express my special thanks to the department for asking me here and to John, for all the help and support and mentor mentoring. He's provided over the years we've become pretty good friends since my time here so.
• 04:22So I have a couple of disclosures to make.
• 04:26One disclosure is as John said I do paid legal consulting work. So lawyers will call me to review thousands and thousands of pages of medical records that are generated by these cases and I do that for money. So I have some skin in the game. But I hope if I'm successful today. This talk will be bad for business is what I'm going to focus on is prevention. I also have another disclosure, which is that John made me put Munchausen syndrome by proxy in the title because he thought he would get you to come and.
• 04:56Look at, I've never going to doubt him again. But we're actually not going to talk about Munchausen syndrome by proxy. We're going to talk about medical child abuse. We're going to talk about the front end of these cases and leave that aside and I'll explain that more munchausen by proxy continues to be fashionable. There was a case just this week. That was adjudicated in Colorado or woman who made her child seem critically ill. The whole shebang make A wish foundation etc. The child died Unfortunately.
• 05:30And on autopsy it was apparent that the kid had nothing of what she was alleged to have had and that was it seemed to have been documented well in her medical records.
• 05:42So one of the places we get our information is from the media and these extraordinary cases. The other, we get from case studies that are reported in our literatures. These have 2 features to them. One is that they are usually sort of obscure techniques in which people physically make a child ill that are of interest to a particular subspecialty and the writers want to alert their colleagues to that mechanism of simulation or induction. The other is just the an unusual case of.
• 06:13And it you know, getting these case reports published it's it's like become a game of can you Top this?
• 06:19And Unfortunately all of these strategies lead us to focus on the most unusual of these unusual cases. and I want to focus our attention on the more typical of these unusual cases.
• 06:31So essentially you get to see the sensational media portrayals and you get to see clinically oriented case reports so there's three ways that we can learn about these cases, you get to see about 2 of them, but you don't get to see about the 3rd one. You don't have to see about forensic evaluation cases. The vast majority of cases I see go through family court and that those records of those proceedings are not public.
• 06:56So the only way you can get access to those records as to actually be involved in the legal proceeding itself, which is what I do.
• 07:04What about clinical research you might say well? We've tried to put ads in the paper for people who medically abuse their children but the Phone doesn't ring.
• 07:13And so we are quite limited. I've talked to John John has some great ideas about how we might use large databases. To understand some of these things and we're beginning to work on that now.
• 07:25So what is medical child abuse medical child abuse is subjecting a child to assessments are treatments that are unnecessary to make the child, well or to keep the child, well.
• 07:35OK.
• 07:37And this has to be to a degree, either because of severity or chronicity that actually causes harm to a child or a risk of harm to a child.
• 07:48In our work and hopefully after this talking your work you'll think about this as a 2 step process. The first step is simply like determining that a parent or caregiver? Whomever I'm going to say parent and mom a lot. I'm not going to talk about a lot of Epidemiology, but one thing we know is that this is between 90 and 95% moms so forgive me. If I just slip and say Mom's so the first step is to find out if the parent is engaging in some behavior.
• 08:19That's leading directly or indirectly to the over medicalization of the child. The second step is the step where Munchausen by proxy comes in the second step is understanding the motivation for that excessive illness behavior. And if you only think about Munchausen syndrome by proxy you're making a clinical error. There are other reasons that people might.
• 08:39Like over medicalized their children and those reasons should evoke our sympathy and they should've Oh car care because some of these things are modifiable psychosocial types of issues.
• 08:51So first step I hope I don't have to tell anybody hear this, but it's widely believed for example, among the lay public and among lawyer types and judge Tyson jury types that if there's evidence of a real illness.
• 09:06It can't be medical child abuse and that's nothing could be further from the truth probably 80% of the cases I see start out with a parent and a child being exposed to the medical world through a genuine illness.
• 09:21So next we need to look for indicators that the medical care is care seeking is unnecessary. We think about exaggerations of existing problems. We think about total falsifications of problems. We think about simulations of things things that cause a child to look ill. Some of those involve manipulating the child's body but sometimes it's only manipulating samples.
• 09:44And then actually inducing the illness so you know, I'm not going to talk about all the crazy cases where the mom, literally cultured like bacteria from her toilet and infected her child's wound with it and back and forth to the hospital and you're eating and I'm sorry.
• 10:03Do that.
• 10:05So the next thing you have to show is you have to show that the child has been harmed in some way the most obvious ways that child is harmed is through the mother doing something like I just described and won't say that again poisoning the child. I had a case recently where the child mom. Blues video recorded putting a hand over a trach things like that.
• 10:26But there's lots of less obvious things it's like and these are the harms that you do to your patients. You do those harms to the patients because you're balancing that against other benefits so a little X Ray isn't going to kill a kid if it means we find out they have pneumonia and we treat it properly but.
• 10:46You know, I work the case. This is a very unusual case where the victim showed up at my door step.
• 10:52So I found some records in my basement.
• 10:55This happened to me when I was a kid and I had all the records now very interesting case, but she was before she was 2 years old when her case was uncovered. She had twelve of these cold laser correction things for subglottal stenosis like that's more haircuts than most people get in 2 years.
• 11:14And maybe like if she was genuinely ill. Those would be OK and necessary and you know you gotta do what you gotta do, but she wasn't sick.
• 11:23And less obvious still all of our literature, both about you know, excessive illness behavior in adults. Munchausen syndrome factitious disorder end with kids. It's all focused on the Medical Center? What problems it causes you and diagnosis and treatment and disturbing. You know the staff operations on the floor and all that stuff, but don't stop looking for harms an risks of harms in the hospital look outside.
• 11:47Think about how all of this stuff that a kid is being subjected to changes the way they function and develop and learn in their world.
• 11:56You think about how it effects their parental attachments their family attachments by being in the Nick you in the in the pediatric ICU so much so. If you take our focus in literature and in the media on people hurting their child poisoning. The kid with salt and killing him. That way by accident. Stuff like that, what you end up focusing on is the right side of this graph. But if you think about like people who are over doing their children's medical.
• 12:27Complaints there seeking excessive care on behalf of their children. There's many more people in this Green Zone to the left the problem with the Green Zone to the left? Is it's very hard to prove that stuff. It's easy to prove the stuff on the right. We have no psychological way of diagnosing this we don't even have a good clue of where to look or where to start but by Golly. We can catch people walk into the kids room and see the mom, putting something in there Ivy.
• 12:57OK, we can catch them holding a pillow over there over their face and so then you want to be sure right. You don't want to make this accusation capriciously so we know about those cases and we're sure about those cases. And when we think about harm the harms right there, so these are the easy cases.
• 13:17So that's where we see MCA but what about the anxious mom over here.
• 13:21This is kind of a bit of an old term, but whose heart of vulnerable child syndrome.
• 13:27It's this idea that kids who have critically ill babies develop sort of a poor sense of attachment with them. They are worried that they're going to die, so they don't attach well and they're also very nervous and are bringing the kid in all the time so somebody who comes to the doctor looking like this.
• 13:45No, we don't pay attention to these cases, but I always go too long. So I infuse. The thing with take home messages. So if I died right now, you would still get something out of this.
• 13:58Roughly 45 to 50% of cases that go to litigation so these like these are pretty certain cases.
• 14:0745 to 50% of the cases that go to litigation never get out of the Green Zone.
• 14:13They never lay a hand on that kid.
• 14:16At least I can't find it.
• 14:18OK.
• 14:19Cases in the Green Zone are easier to manage.
• 14:22You know when somebody has been found, putting their hand over the kids trach. It's hard to walk that back right.
• 14:29It's not what it looks like now, it is what it looks like it's exactly what it looks like.
• 14:33And here's the big take home message for you. This is the self interest take home point.
• 14:38When the mom is caught putting Oh well say salt in a kids G tube.
• 14:46The mom gets arrested the mom gets in trouble. The cases in the Green Zone, where the mom never lays a hand on that kid.
• 14:54You get in trouble, they say look at the records they diagnosed me with asthma, they told me to use the nebuliser I've use the nebuliser the kid had a bunch of of pneumonia as they screwed up. Then they got Mad 'cause. They didn't get it right and now they are accusing me.
• 15:14OK, like you don't wanna be there, you don't want to be there.
• 15:20So let's talk about some clinical presentations of the usual case. Anything is possible. But I do adult cases affective disorder and do these kid cases, the adult cases no tool like?
• 15:31The kid cases there almost all alike.
• 15:35They either start with respiratory problem and it's usually something like cough.
• 15:40Or they start with some kind of feeding problem, not the kid spits up all the time and sometimes it's seizures. We get people reporting seizure seizures, or easy because you can say. Yeah, it happened at home and you bring the kid in the kids fine, we didn't see it.
• 15:58So I've started to refer to these cases cases in the crossroads of chaos. This little like 4 inch strip of your neck where you know you could have gastroesophageal reflux. Maybe that's what's making you cough and or maybe you have some sort of reactive airway disease asthma thing. Maybe that's what's making you cough and it doesn't look like this. I'll send you to the other guy and then you add on the NT guy well. Maybe it's something structural and.
• 16:28I get a lot of these militias you're big on those malachias tracheomalacia laryngeal malacia and anything that can get Malay did up there.
• 16:39And then various kinds of Stenosis Pi Lorick Stenosis and Subglottal Stenosis and so forth, then you know other kids having all these infections and Fevers and they call the Allergist and they call in Infectious Diseases. They call in the developmentalists. They get OT and PT for speech therapy and feeding etc.
• 17:00They're given a raft of different kinds of medications and they were given a bunch of surgeries.
• 17:05The woman who found the records in her basement came to see me had a Nissan fundoplication at 6 months because she was having gerd that she couldn't control through these Proton Pump Inhibitors.
• 17:21Now I know what you're sitting there, thinking you're sitting there, thinking.
• 17:25I know that you know all of your cases have some of this stuff you're saying like if we're not going to pay attention and deal with this like a lot of businesses what we do. It's not that all of your cases have some of this stuff is that some of your cases have all of this stuff.
• 17:42If you have a case if you encounter a case that has all of this stuff, maybe there's something in this.
• 17:51One of the like as we're reading. These records and we say, Oh no Oh no don't do it don't do it don't do it and it's placing a port.
• 18:01Hortensius developments so placing a port like an Ivy Port Tour for total parent Terrell nutrition. Ivy infusion is popular among this crowd. They like to get Ivy infusion to treat unsubstantiated immunodeficiencies.
• 18:19Placement site infections are real those happen like this is one of the consequences if you put these these pipes in sometimes they get infected and you have to deal with that. But if the pipe is unnecessary. Then the infection is unnecessary. This is a route through surreptitious poisoning.
• 18:35Having these tubes confers a sense of medical legitimacy on these children that the next provider C and save somebody's typing this quite seriously.
• 18:44So putting in the airport when you when it's unnecessary is a really bad idea in these cases. It also extends the age at which the child can be victimized.
• 18:54As a child you know you feed a kid, too much salt. Mom will say what's up with the spaghetti sauce. It's got too much salt in it?
• 19:03But if you put salt and import kid numbers so it looks like Mom's putting Medison in port like she always does.
• 19:10And it also further segregates the child thinking now outside of the clinic. It segregates the child from normal life in some cases. Andy is from New Orleans, she knows what Lagniappe is.
• 19:22Right when the app is a little something extra these cases tend to come in and they report something that's the main thing, but they always give you little lagniappe, so little sleep problem. Little rash little food allergy. Something these people seem to have like an affinity for seeing their children's autistic.
• 19:39Or having sensory processes processing deficits.
• 19:42None of those like stigmatized psychological disorders only the fashionable ones.
• 19:48So it's your turn.
• 19:51And put these these 3 descriptions on there's a medically child abuse person up there. Anybody find out which one. It is anybody have any guesses to shut out your answers were short on time.
• 20:07Our combined there's not much stuff up there just shout, it out what's your I'll come on.
• 20:13Is it little is it too little?
• 20:18Free.
• 20:20Who's in all 3? What smarty pants? Is you are hairy GAIL?
• 20:29It's not all 3 it's 1.
• 20:33So we have in this area, something called a snapshot problem in the snapshot problem is that somebody, especially to a high level care facility like ale this person will show up and they will already be pretty sick and pretty over involved when they get here.
• 20:49And you'll diagnose the case it's usually somebody who has The Who has simulation or induction of the problem.
• 20:58And the important thing here is that?
• 21:02This threshold for accusing people of things is higher than the threshold of suspicion and higher than the point of no return.
• 21:11So after people have done physical things to their kids and represented their kids in certain ways like they have lied and there's almost no way for them to back away from that.
• 21:23So we're fascinated with these an we have this catch and kill idea that we find this out were big heroes and we save the kid would take it out of the home and all that stuff, but
• 21:34I have not yet seen a case that starts there and that does this walks across that line, they always start here.
• 21:44And here is the only place we can work on them here is the only place that we can make a difference.
• 21:52So here's some take home messages it takes.
• 21:57So.
• 22:00Focusing on those extreme case is not a good idea, and it's important to see medical child abuse. A developmental thing and the question is how does it develop?
• 22:10And a focus on early identification and management before that point of no return.
• 22:16Can actually it's not like you're catching a case of medical child abuse early you literally preventing it?
• 22:23People don't wake up in the morning as child medical medical child abusers. They are sort of coaxed into it and they're kind of coaxed into it by y'all unwittingly of course.
• 22:36So the evidence you don't get to see in your work you see this part of the musical score. You might see 3 bars from 3 different instruments, I get to see everything.
• 22:48I get to see the whole thing from the beginning from everybody so I have this great Monday morning. Quarterback job of looking back at everything that was done things you had no idea were going to happen when you begin the case. This is an actual case. This is a 4 year old girl. We will call Zoe. It's hard to talk about these cases publicly because at any moment any of these things can go like into the media become sensational things and even though I haven't.
• 23:18Disclosed anybody's personal information now you put 2 and 2 together when you see it in the in the in the media so she was had problems like failure to thrive asthma immune deficiency. All of the things that I talked to you about in these crossroads of chaos cases.
• 23:34She was well and her first pediatrician did a good job of managing her. She did have neonatal complexity, like most of these cases have?
• 23:44But the doctor did a good job of making sure the kid was fine. It was just respiratory distress syndrome handled nicely extra 3 days in the hospital no big deal.
• 23:53But the mom was a worrisome mom and this early pediatrician wrote down. I think she has vulnerable child syndrome. I think this is an anxious mom, said it a bunch of times in the charts. It's very easy for me reading the charts to see.
• 24:09This pediatrician I think did a good job of addressing the mom in a sensitive way and the mom was having none of it and got another pediatrician and then all hell broke loose.
• 24:20The pediatricians office that she went to was kind of pediatricians office that has like 5 pediatricians in 50 PS.
• 24:29And so she didn't see the same person. You know, but once every 5 or 6 visits so even though you in your mind. You think they have a primary care provider. It might be hard for that primary care provider to put it all together, because of the way the practice is set up.
• 24:44Pick lines in place talked about how that's a bad idea. All sorts of problems with the pic lines and then lots of time goes by until suspicions are raised again. When somebody in a hospital. This was a major teaching hospital famous sort of competitor of yours.
• 25:03They put it all together and somebody got all the all the practitioners together. All the specialist together and say look what we're doing, and they diagnose the case properly.
• 25:13So, in the end. This is what's always care looked like she had 3. PCP's she had 3 allergist immunologists. I'm not going to read it all. It's a lot of stuff, she's 4 years old.
• 25:26So because of the vastness of these records catalog every medical contact and analyze it and this is an example of a way to see what's going on. This is what happens when the things start to get out of Control with that pediatrician. The first one, that pediatrician tenant puts the brakes on things they go to another person they maintain this high level. A custody fight ensues, where the mom is using the illness of the child to keep the child away from the dad and things go Sky High.
• 25:58And this is whoops.
• 26:00Well and this is where anybody raised suspicions.
• 26:04So here's a take away that isn't on here. I'm looking at the time and it's crazy.
• 26:11People think you're doing a bad thing when you raise suspicions.
• 26:15I have never had a case where things got worse for the child after people started to think suspiciously.
• 26:23Thinking suspiciously saves the kid.
• 26:26Don't feel bad don't feel guilty thinking suspiciously saves the kid.
• 26:32So this is one of those, 45 to 50% of cases there's no evidence that that kids mother ever laid a hand on it.
• 26:40She used exaggeration persuasion doctor shopping and gradually produced a picture of a child if you looked at her record. It produced even if you've got the records it produced a picture of a child, who is genuinely ill.
• 26:54And made all that care seem reasonable.
• 26:58Once the case got going, the bomb had very little to do to keep it going.
• 27:04It's just she started that sled visa northern metaphor started that sled down the Hill and then gravity took care of the rest.
• 27:13So what are the indicators for access that I look at when I'm trying to say? Yes, this is medical child abuse that you can look at 2.
• 27:21Une observe signs fever, you know mom comes in for fever, all the time and then starts to say, Well, it's mostly at night. Well, that's convenient. It's mostly at night 'cause you can't see it coughing coughing. That's not observed in office, a lot of these cases take off just from coughing so who coughs slow.
• 27:42So the mother the mother just says that he insists the kids coughing all the time I've had cases where the nurse takes a call from the mom. Now, I'm making a red car. I take school from the mom and the mom is talking and the kid is talking in the background mom. Can I do this mom? Can I do that? Mom like kids? Do when you're on the phone and the nurse smartly says. Hey, I talked to her for 15 minutes and I didn't hear that kick off once.
• 28:08And she was calling to talk about the kids unrelenting cough.
• 28:13Incompatible evidence I see this all the time to mom comes in and says the kids have tended 12 bouts of diarrhea every day for the last 2 weeks.
• 28:20That I don't know anything about Madison, but that kids should probably look like beef jerky right 2 weeks and losing all that fluid like little babies. They dehydrated quickly untold and so the pediatrician puts that down. Then puts down there, not dehydrated well appearing active and playful.
• 28:41Looks like alright, dude do something about that something doesn't fit here act on that.
• 28:48Um mom complains the kid feeds terribly and spits up after every feeding and can hardly get announced down but you look at the kids growth chart and they're doing fine? How's that happened?
• 28:58OK, so incompatible evidence. These are the things that should start to make you ask questions don't ask the question is this. A medical child abuser. Ask why is there an incompatibility between what the mom is saying and what you're seeing in the office and understand the psychology of that and try to help like maybe she doesn't know the difference between spitting up and projectile vomiting.
• 29:21You know so.
• 29:24In these cases there's always a bias to more and worse. The mom seems to be more reassured when you say things are bad then they're good?
• 29:32OK.
• 29:33They want more care than less care my kid was was.
• 29:38Had a congenital heart defect when he was born and they one doctor said it was OK and then I came to you. Abby and they said. Now he's really got this thing and they said he's going to have to have an operation. My first thought was like like only grow out of it. I can't we not do this? Do we have to do it right away is only 3 months old and they could not do this? But my first my gut reaction is apparent was to protect my children from that.
• 30:01These patients aren't showing that they're very hard to reassure they don't want to know nothing about growing out of stuff.
• 30:09I've had cases there. Lagniappe was the chiropractic thing and the doctor measures. There, I'm supposed to get behind the sink. Imagine my feet so the doctor says the feeder towed in by 1 degree and the kids going to grow out of it and then later on in the note the doctor says we discussed surgery in bracing inside.
• 30:29Why did you discuss that what's the answer? Why did he discuss that?
• 30:35Mom brought it up mom wanted them.
• 30:39Negative test results, fever reported, but never measured in the clinic on normal chest. X Ray in kid whose symptoms are being described like breath sounds etc. That ought to have something a bunch of times coming in with various things and never being positive for flu or RSV or strep or any of that stuff failure of reliable treatments to work I can give him the Tylenol but it's not reducing the the fever, he gets to the ER he gets Tylenol in his fever goes down.
• 31:07Inconsistencies like that this is the This is the biggest one. This is the one I'm really concerned that we talk about this idea of inappropriate influence.
• 31:16We have this idea that patients and patients. Parents should be involved in medical decision making and that's terrific but there's a place for them. There's a thing that they are expert at their expert at their lives and what they want for their kids and what effects quality of Life OK your expert at all the doctore stuff.
• 31:33And there's a place where these patients try to get involved in what's your purview. They try to influence you to do this kind or that kind of doctor E stuff.
• 31:43And you should pay attention to they do things like give inaccurate history. They'll say that doctor so and so diagnosed my child with asthma.
• 31:52Well, you were begging with doctor so and so to say that your kid had asthma, but instead doctor so and so met you halfway and said he had a reactive airway disease.
• 32:01Like it's just us here is that legit.
• 32:04Is there such a thing?
• 32:06Like it's a real thing.
• 32:07OK, so sometimes it seems like what they're told when the Doctor isn't willing to go with asthma.
• 32:13Misrepresenting the work of other providers, saying tests were done, or not done when the opposite is true controlling access to previous records. If you ask somebody. Can I get doctor so and so's record, so we make sure we do this right and they're a coil that's a bad sign.
• 32:29So we lived in California and they burned in a fire. We lived in New Orleans and they were involved in hurricane could trigger laughing. I get this like it's in the records.
• 32:40They asked to be in control of Medecins or procedures appearance shouldn't be in control of.
• 32:47If a doctor says we have 2 options. With this IG infusion. Stuff like you could do it at home or we could bring them in like I'm bring 'em in I'm not messing with all that stuff makes me uneasy most parents would might be really inconvenient. Some parents would have to do it at home, but they consistently want to be involved in more things that they should.
• 33:09An requesting port access is one of those inappropriate influences.
• 33:13You know in a lot of the cases I end up evaluating their hell bent on getting that pork.
• 33:18They asked for it in the Doctor of resist but eventually acquiesce.
• 33:24Here's this, I've always I've seen this happen in cases I've never seen a person basically narrate themselves doing this. This is from my actual case family gave us a clue that Nebulization's help better than MDIS, so at some level. I think MDI. Madison is not getting to the lungs. However, we diligently work with them at the last visit to problem shoot. They specifically describe the moms technique with the spray thing in the spacer as excellent.
• 33:54Yet it appears that the Medison isn't getting into the lungs because they're still coughing.
• 34:02Well, no they could just be lying about coffee.
• 34:06But consequently we change surf to a nebuliser I almost never do this, if you ever write down. I almost never do this.
• 34:15Maybe you shouldn't do it. There's a reason OK and this is the business about letting these cases suddenly move. You off your game move you out of your Lane change your adherence to standard practices.
• 34:29OK.
• 34:30So later it was suspected that she was putting adulterated substances in the Nebuliser as a nice way of delivering pneumonia to the child and when you look at all of the?
• 34:42Yeah, the pulmonary peoples, we never thought of that.
• 34:45Right.
• 34:47Yeah, I never thought of it easier if you learn something every day when you do these cases OK. But the description of her pneumonia is talked about all of these different kinds of you call it flora rights different kinds of bugs.
• 35:01Share this very diverse array of bugs and it's because.
• 35:05Acquiescing.
• 35:08To the request for the Nebuliser gave that mom are out. It's like a port they gave her a route to abuse.
• 35:15When John came John what was what was your thing you named after yourself when you came to talk at Alabama Leventhal is triangle.
• 35:24So you doctore people do this alot, we never do this in psychology, and I said no. I'm going to do this. This is my thing.
• 35:31So how many people think they're good doctor.
• 35:35Jesus.
• 35:39Help me back to do a little self esteem work. I guess you know, everybody outside their things that people are full of themselves, which light album.
• 35:55So you I know you're sitting there, thinking, yeah, I'm going to say it because but I'm a good doctor.
• 36:01How many of you think you're a good person?
• 36:05Little more than that good OK, so we looked at what a good doctor is not a good person. How many of you had patients who you're sure didn't think you were a good doctor.
• 36:16OK, how many of you have X friends who are who are sure that you don't. You don't think that they don't you think they don't think you're a good person OK.
• 36:27Here's the thing this is Hamilton sign.
• 36:30You have people who don't think you're a good doctor and you have people who don't think you're a good person. But if you look back. How many patients have made you think that you have to choose in their care between being a good doctor in being a good person.
• 36:48Is that resonating now? Please be honest with me 'cause this will hurt myself esteem? How many people have experienced this?
• 36:55OK.
• 36:58If you find yourself having decide between being a good person and a good doctor in a case the child may be at risk for medical child abuse.
• 37:06So what you're feeling is their attempt to get you to think things and do things and endorse things an legitimize things that you don't want to do.
• 37:15This amounts to a sign that the caregiver has needs that are not aligned with the child's needs.
• 37:22OK, that what you think is best for the child.
• 37:26Like you know they're not agreeing with and they're making you feel bad for it. They're trying to coerce you by making you like please them or that make them be happy with you.
• 37:38So none of the indicators. I've talked about are sufficient conditions to like set the building on fire and pull the alarm. But they accumulate so an almost all of them are modifiable or manageable through a person centered care approach to these parents.
• 37:56Thinking about why the excess why the inappropriate influence. Why do they want this so badly. I'm not going to talk about motivations. But when people talk about munchausen syndrome by proxy what the experts understand that as is confirmed medical child views with the underlying reason be a particular kind of set of psychological processes. The need for love. The need for attention. If anybody knows what borderline personality disorder is either from school or you're married one.
• 38:26These are people who have emotional instability and emotional ability, OK and they represent that those represent core vulnerabilities for medical child abuse of a certain kind. It has everything to do at the end of a case where I get involved with whether the child can ever be reunited with their mother and cases that are legitimately Munchausen by proxy the probability is extraordinarily small.
• 38:50But.
• 38:51There are other cases, and I want you to think about the domestically abused mom. The drunk husband is coming home, and the mom shows up at the emergency room and says her kid had a seizure and is worried about it can you please admit them for observation?
• 39:07Is that an unsympathetic person?
• 39:10No, but she's engaging in medical child abuse.
• 39:14She's lying she's trying to get this kid admitted she's over Medicalizing. The child so from the small sphere of understanding medical risks and benefits.
• 39:23She is medically child abusing that kid but from the larger view of her life, she might be saving his life.
• 39:31OK, so you know this again don't have that catch and kill mentality.
• 39:36And it's easier to avoid that catching cold mentality by seeing these cases earlier on in the Green Zone.
• 39:42There are distractions that you should avoid caregiver demeanor if their communication style. You know, we talked about people liking you and not liking. You and all that stuff? How many patients have you just disliked anybody have a patient just disliked raw flat out didn't like that mom.
• 40:02Yeah.
• 40:04You keep your own counsel, you do.
• 40:07So one of the great things I learned when I was here, observing John and Andy in the team's outstanding work as they constantly reminded themselves that just because they're difficult families doesn't mean their abusers just because this looks like the perfect mom or the perfect family doesn't mean they're not abusers don't get yourself distracted with the stuff that you should be asking social worker. Lori Cardona Swell Lenska. Here, doctor card once once got to help you with.
• 40:34Like every other form of child abuse, you have to understand how that child abuse is affected keep your focus on what the parent is doing not like whether they're likable or not likable.
• 40:47Here's one of my favorite things, the clinical correlation game.
• 40:53So you have a kid, the mom, says there's breath sounds and coughing ETC. And you send the kid to get a chest X Ray and chest exercise.
• 41:04No.
• 41:05Could be something infiltrates you talk about that seems so?
• 41:10Nasty to be infiltrated.
• 41:12Like a little bit rates in this field, that field and then it says see clinical correlation.
• 41:19Well, you know what the clinical correlation is.
• 41:21The Mom says she's coughing boom. But if you think that through a little bit. You haven't learned anything in that whole process you've got to really iffy things and when you add 2. If you things together, you still have a very iffy thing.
• 41:35And because a lot of these kids get a lot of care I've seen I've seen stuff like this happen.
• 41:42So there are pediatricians in the morning and they get a chest X Ray at the pediatricians and they start talking about all these infiltrates.
• 41:50They go to the doctor in the afternoon out of place like this. The Big Hospital in town and they get the pH probe and they have to make sure it's sitting in the right place and they also you're looking at the lung fields at the same time, and they say lawnfield delightful.
• 42:07Well moments before.
• 42:09When the person was referred because they were coughing some neutral traits there.
• 42:142 hours later, 3 hours later. There's nothing there and that happens more than I want to tell you.
• 42:22Alright so let's talk about some basic preventive practices.
• 42:26Medical child abuse exists in a climate of uncoordinated care an ambiguous information.
• 42:32So most of the basic preventive things that you can do basic prevention primary care infringing means for everybody is doing better with writing and reading medical notes.
• 42:44How many older folks we have on here?
• 42:48Who hates electronic medical records anybody.
• 42:52Oh, OK, you don't have to be able to do that. A lot electronic medical records have been the bane of my work. I had a case come close to when I started doing all this. The first two years of the case were regular old records written by real people.
• 43:07And the next 2 were electronic medical records. It was clear as day from the first two years that something Fishy was going on. If I only had the second, two I'd never find it.
• 43:18Working on a case right now for the state of Alabama and the records if I were to pilum up or this high. There's 3 kids involved and if I were to take those records and say, I'm just going to take the meaningful written narative stuff from doctors.
• 43:34It's going to be this big.
• 43:36It's awful it's horrendous.
• 43:38So.
• 43:39But you gotta gotta attack anyway.
• 43:43This is that case.
• 43:47This is A is the patient every a means a medical contact.
• 43:52And this is the kids first year of life.
• 43:58So I know those are hospitalization summer. Those are Phone calls, but it's almost half the days of the year. The mother was doing something that was focused on that child's illness.
• 44:11The child has a real illness, but if I were ambitious enough to make different colors. I took out all the red marks that had to do legitimately with their real illness and the rest is the crossroads of chaos. Stuff coughing infections bruises rashes crap like that, it would still be 1/3 of the days.
• 44:33OK.
• 44:34You're one nobody has said anything year to nobody has said anything. The kids 13 years old. And nobody said. Anything I'm looking at this kid because I was hired to look at his sister.
• 44:52And his sister has more medical records the second. The sisters born this kids medical Contacts go off the chart. And now he's a 13 year old who can't cope with his life and has functional abdominal pain.
• 45:09More basic preventive practices ask caregivers about all their current providers. You tend to focus on your specialty. What's been done. GI wise or what's been done pulmonary wise to really get the lay of the land. You have to go up to 30,000 feet and find everything they're doing, including allied professionals like psychologists and OT and PT and chiropractors and stuff like that.
• 45:31Note as I said, not refusals for your request for past records inquire about change of provider.
• 45:38OK don't forget about Doc in A box a lot of people who are rebuffed by their pediatrician. Go to the dock and box and get what they want.
• 45:46But remember this.
• 45:48You create these cases, you don't discover them so when you ask these questions early on.
• 45:55There's very little threat and maybe the person is just an anxious mom who needs a little bit of redirection. You'd be surprised if you ask these questions early on that mom will tell you.
• 46:05Will tell you all the things you can say he seems like a lot now? What can we do to improve your lives.
• 46:11If you ask him way down the road. They're going to deny it. You're going to deny you access to the records etc.
• 46:17This drives me nuts.
• 46:20Clearly source.
• 46:21The signs and symptoms that you report the results. The diagnosis, etc. I see a lot of medical records that don't tell me who brought the childhood.
• 46:33That week.
• 46:35So I worked on a case last year, an unusual case that involved both the father and the mother.
• 46:41Sometimes the father would bring the kid in sometimes the mother would bring the kid in and they asked me is this mother doing this and the answer is I can't tell because the physician either didn't tell me who was who was brought the kid in or told me that both were there, but didn't tell me who was like sitting out in the waiting room. And who was actually providing the information. So it's very little effort to make sure to say exactly who is giving you the information.
• 47:07I've had sometimes it says persons in with their parents plural. I know this is a single mom. There is no other parent.
• 47:15OK.
• 47:17Who witnessed the signs symptoms etc? The onset during and after 'cause you know? The dad might say yeah it was terrible.
• 47:26When I got in I saw I saw my wife holding the child and at that point you know the child was in a stupor.
• 47:32So he had missed the shaking around Park.
• 47:36And things like that.
• 47:38Inaccurate attributions, so doctor, so and so thinks that this child has asthma is that true or did mom report that doctor so and so, said that.
• 47:48And it makes a world of difference.
• 47:53Please don't list as an official diagnosis, something that you aren't sure as official.
• 47:58That you don't have the report from the previous features so now when I talk to John about this. He says like you know, we have got to trust our patients. There's just a zillion of them.
• 48:08And if we if we distrust everybody. We can't get the medical records on everybody paralyze the whole process. That's true and I'm glad he said that but you know, I'm talking about as you work, a little way into the case and you start having these feelings. You start seeing these reports of fun observed or inconsistent things that's when you need to turn up the heat.
• 48:32Look for bread crumbs were all afraid of accusing people of being medical child abusers because we have a sort of their medical child user or not mentality, but people will leave bread crumbs the older folks will know that you know, one patient will come in with seizures and you'll say the kids having seizures and the next patient will come in you'll say they're having seizures.
• 48:53The quote seizures that basically says I smell of Fish and that's how I read it. That's how other practitioners should read it. You don't see much of that anymore. I see things like discussed IG replacement with the mom and things like this is premature at this point that tells you that the mom was pushing for it. You got to pay attention to those signs. We had a very long conversation is a good one.
• 49:18Leave bread crumbs but leave high quality bread crumbs. I know we're all afraid of being sued. But you can do a lot better than you're doing so for example.
• 49:27You're never going to get sued for saying that you are puzzled about something doctor are judge. I don't think he was puzzled at all.
• 49:35They can't say you weren't puzzled all you're saying that you were puzzled. I'm puzzled at the fever is hard to control at home. Yet here in the D. We can knock it down in a few in 15 minutes with Tylenol. It's unclear to me why this reliable treatment is not working for this child. Mom is persistent, suggesting treatments that are not consistent with best practices discussed at length things like that. You cannot get in trouble for doing that in our graduate program. We occasionally have to dismiss somebody and because we're nice people. We sometimes find ourselves at the end of 4 years.
• 50:06Saying all right, you know this is really bad. We have to dismiss this person and where is the documentation that anything was going on if we had documented better year in and year out this would be easier to support and so forth document your puzzlement and your concerns in a way that is unassailable. They can't tell you, you're not concerned that can tell you, you're not puzzled.
• 50:27I got up here in a minute avoid departure from standard of care this last thing is it's not relaxing.
• 50:35A lot of times like 40 or 50% of legit medical child abusers. Munchausen syndrome by proxy patients have medical training. An y'all seem to have a tendency to give more latitude believe them or give them more responsibility for medications and for procedures. Then you would regular person try to adhere to standards of care and not do that. This is on the slides. The slides are all available to you, but this is actually a an empirical study looking at predictors.
• 51:06I've highlighted the ones that are important for you early on in cases.
• 51:11I should have highlighted prescription for an apnea monitor so people. This is another example. People who want to monitor the kids at me at home well stay in the hospital till the kids ready.
• 51:22You know, or take the kids home 'cause. He's ready, but taking the app new monitoring home leads to trouble.
• 51:29So early intervention early intervention allows you to do education early intervention allows you to use a model or a framework like stress and coping you have a difficult child here. Maybe we should get psych down here to talk your social work to help you Cope and find out what the cause of their excessive illness behavior is and help them to walk it back in a face saving way.
• 51:50Ann.
• 51:51Think about ways to intensify observations like a home nurse or using a cell Phone video to get pictures of the coughing or the spit up or whatever. I think you know, there are costs involved. I know I'm just a psychology professor. But I see a lot of cases where I wish somebody would have done an empirical hospitalization early on.
• 52:11The definitive sort of way of proving medical child abuse is separate the child from the parent.
• 52:17And that's usually done at the end after all, the damage is done like why don't we do that earlier on? Get the kid in the hospital and observe them carefully and don't give the mom, a chance to do anything.
• 52:27To see anything that you don't see or do anything that you don't know about.
• 52:33When we talked about this.
• 52:37So conclusions this is rare the best way to avoid the dilemma of complex and confusing cases, not to let it become chronic complex and confusing.
• 52:45Medical abuse often occurs at the hands of well, meaning clinicians. Yourselves cases develop in a context of unattributed reports and verified signs and symptoms etc.
• 52:54An suspicions are not recorded bread crumbs are not left.
• 52:59So engaging best practices with every patient don't let inappropriate influence move you off your game be knowledgeable attentive and responsive. Those early signs involved dark sooner rather than later. Sometimes we think it's keep going like we're going or call call Child Protective Services. It's not like that at all. The dark people will help you navigate those decisions and help with the psychosocial interventions that this parent might need don't chase the family off.
• 53:26Now somewhere in Boston, there's another group of pediatricians and they're chasing somebody off. They're going to pass on 95 and nothing will be achieved OK don't chase them off do the good work here as we're talking bout. Lagniappe if you want more lagniappe. You could take a picture of this and there's the Apsac Apsac. Let us have a whole issue on medical child abuse. So there's an issue dedicated to all the issues of terminology diagnosis procedures, etc. You could get that there.
• 53:57And the grinder paper, The Yates and bass paper and these slides. I have like, I was trying desperately to make this fit, which I only barely did so there's the long version and then there's the short version and this is the really short version.
• 54:10And I guess that's all I've said, and done.
• 54:20Questions yeah in the back.
• 54:23Hi.
• 54:26OK.
• 54:28I don't know.
• 54:40And.
• 54:45Then people.
• 54:51There are a ton of system related things.
• 54:55That that sort of push you guys into doing what you do and I understand that, like the medical record system and that's another one, you should speak to your administrators and tell them this is the pressure. I'm feeling in the mistakes. I'm afraid I'm making because of it and see if they can't make a change.
• 55:15OK.
• 55:19At what point should that be saying like I don't think this is an appropriate voices.
• 55:29Very choices.
• 55:31Sure.
• 55:33Um.
• 55:37I guess this might be evasive but I think if you're a little bit like more aware of some of the things we talked about you won't have to draw the line. You'll have a conversation and you'll have it early.
• 55:50Annual express your concerns. I actually I was very close to suggesting this on the slides and I'm going to suggest it now because I'm done and I'm disinhibited.
• 56:02If it gets bad enough.
• 56:04I wonder if it's not a good idea to say something like you know, there's a lot of stuff in the news about this whole munchausen by proxy thing.
• 56:14And I am worried that you're going to be falsely accused of that.
• 56:18And we know a little bit about how those bad how those you know unfortunate cases of false accusations develop and it's a bunch of people like doing the best they can and mistakes are made so like I don't. I certainly don't want that to happen to you? How can we guard against that?
• 56:33And it's through careful documentation. If someone leaves your hospital after you give him a talk like that.
• 56:40Drop a dime.
• 56:44Is that OK? Yeah.
• 56:47Yeah, no one in here is over used to pay Phone except you will call call dart 1st.
• 56:56Always call dark 1st.
• 56:58Is that right is that bad?
• 57:01I want to add 1 overload, you anybody else. Surely I've said something to offend or discrete.