Dr. James Metz and Tracey Wagner, Forensic RN from the University of Vermont’s Child Safe Program talk with Cassie Gillespie about Medical Child Abuse, formerly known as Munchausen syndrome by proxy.
Cassie Gillespie (00:03):
Hi, I’m your host, Cassie Gillespie. And you’re listening to Welcome to The Field, podcasts with targeted trainings for Child Welfare Workers, caregivers, and professionals.
Cassie Gillespie (00:14):
Today, we have the honor of welcoming back, Dr. James Metz and Forensic Nurse Tracy Wagner from UVM Medical Center’s Child Safe Program. And we’re going to get them to talk to us about medical child abuse today. And also we should let you know that because it’s COVID times we’re all recording from our own homes. I’m not in a fancy studio. So the sound might sound a little bit different. Alright, James and Tracy. Welcome back. Thanks for joining us today for those folks who aren’t familiar with your program, Tracy, would you start and just let us know a little bit about the UVM Child Safe Program in general, and then about your role there and how your team works?
Tracy Wagner (00:55):
Sure. We are a specialty program at University of Vermont Medical Center and children’s hospital where the specialty is child abuse medicine, and that looks at all types of neglect, physical abuse, sexual assault, medical child abuse, as we’ll talk about today, but we are a interdisciplinary team. We work hand in hand with our community partners, we work with DCF and schools, nurses, pediatricians’ offices, to objectively come up with the best ways to solve issues of child safety and promote children’s health and safety. And our team consists of Dr. Metz. He’ll introduce himself in a sec. And Mary-Ellen Rafuse who as some of you may know is a social worker with our program, and myself I’m a Forensic Nurse. We used to be called sexual assault nurse examiners. The profession has expanded to encompass more forms of abuse and violence.
Cassie Gillespie (01:57):
Thanks, you know, when I was a worker, we called your role SANE nurses. So it’s good to be up to speed on the new terminology. James, would you give us a little intro about your background and how you came to be with the clinic?
Dr. James Metz (02:09):
Sure. I grew up in Vermont and then left to go to Seattle to train in pediatrics and then in child abuse medicine. Most people probably don’t know that there is such a specialty as child abuse medicine, but sure enough, there is. I worked there for a few years and then came back to Vermont to work and continue to develop a child protection program or child safe clinic here at the hospital. And as Tracy said, I work with Tracy and our social worker on this project.
Cassie Gillespie (02:42):
So if there is a DCF case of sort of significant injury or, or physical abuse or medical child abuse, is it safe to assume that the DCF folks are working with you on that case?
Dr. James Metz (02:55):
Yes. Correct. And I just want to be clear. We are a separate entity from DCF. We work for the University of Vermont. We are not paid by DCF, but we do because of the nature of our work, we do work closely with them. We come up with our own opinions and we evaluate things from a medical perspective and take those concerns to DCF when they need to be. But we are a separate entity from DCF.
Cassie Gillespie (03:25):
Tracy Wagner (03:26):
I would say our role is also to synthesize the current research and evidence and be sure that we are practicing child abuse medicine to the best of our abilities, just to provide that expertise statewide.
Cassie Gillespie (03:40):
Yeah. So thanks for coming in today, to help us with a little bit of expertise in this area. You know, we said at the top that we’re going to talk about medical child abuse, what is medical child abuse, but what have you be willing to give a definition of what it is and what we may have called that historically?
Dr. James Metz (03:55):
Sure. It’s a great question. And I appreciate you spending some time talking about it today because it’s probably not the most common form of child abuse that we think of when we think about child maltreatment, but nonetheless, it is a important and concerning form of child maltreatment. So most of us probably think of it as Munchausen by proxy. That’s what it’s been termed for years and years. But more and more we’re changing that language for a lot of reasons to include the term medical child abuse or caregiver fabricated illness or a fictitious disorder. And the main reason or the main focus of this is to identify the injury or the harm to the child and not necessarily the motivation of the perpetrator. Okay. So it may be semantics a little bit, but I think it’s very important when we say medical child abuse. We’re focusing on the abuse to the child by medical means. Whereas when we say Munchausen by proxy, that is really a diagnosis of the perpetrator. And just, because I’m a pediatrician and not a psychiatrist or a psychologist, it’s harder for me to diagnose the perpetrator with some sort of psychiatric illness. And to be fair, it’s probably not the goal for me, my goal and our goal here is to diagnose the child and the harm that’s being inflicted on the child.
Cassie Gillespie (05:29):
And I’m thoughtful about what you just said. So I realize this question might make you pause, but just for edification for our listeners, what is Munchausen by proxy? Like what does that look like? Understanding that you’re not diagnosing it still might be helpful for folks to make sure they have a mental picture of what that is.
Dr. James Metz (05:47):
Sure. Munchausen by proxy is a diagnosis of a caregiver and how that manifests itself is in over medicalization or falsification of a child’s condition. So as to perpetuate their illness.
Cassie Gillespie (06:08):
To what end?
Dr. James Metz (06:08):
Well, I think that is the big question. I think that sometimes it’s considered financial for financial reasons. Sometimes it’s a underlying psychiatric diagnosis that the parent has. We actually really don’t have a great understanding of why caregivers perpetuate or perpetrates medical child abuse. There are a lot of thoughts and theories on why they do this. But I think, again, our aim is not necessarily to discover or figure out what those motivations are. It’s more to focus on the harm that’s being done to the child.
Cassie Gillespie (06:47):
In what ways might that harm present or in what ways does medical child abuse present?
Tracy Wagner (06:52):
I can think of an example early on in my career, we had a toddler, I think she was about three who had unexplained diarrhea that was causing her to be dehydrated and have terrible skin rashes and needing to be in the hospital. And the medical team did the usual workup, tracked what she was eating, thinking about allergy testing and everything that we could think of that might cause this diarrhea, all the medical testing came back negative. And it was a really perplexing case that mom was at the bedside and dad was working a lot, so we didn’t see him too much. And everybody was very concerned about this little child and the unexplained diarrhea.
Tracy Wagner (07:48):
In the long run, what ended up happening is one of the physicians had asked the three year old, did you get anything for breakfast today? And he said that his mom gave him some chocolate and what we ended up finding out, what was it? I don’t even know if he can buy this over the counter anymore, but Ex-Lax, a laxative that used to come in chocolate bar form, and this child was being fed the chocolate bars. And the ingredients in this chocolate bar would cause a huge diaper rash. And it kind of explained the sort of coming and going of the symptoms when mom wasn’t there or when she was taking a break and going home, the diarrhea kind of slowed down or when grandma was taking care of the child, the diarrhea kind of slowed down. So it was really complicated for everybody involved to sort of figure out and distressing for everyone involved as well. And I think that again, like James said, I don’t really know why, but she was a young mom who was lonely. And I think that being in the hospital provided her some safety and comfort. And those are of course just my speculations, but, you know, we just can’t understand what’s going on.
Cassie Gillespie (09:05):
Wow, that’s really powerful. Do you have some other examples of ways that it might present? And if you don’t that’s okay. Cause I know they’re so complicated, but just to give folks a picture of what we’re talking about
Dr. James Metz (09:15):
Often in the form of diagnostic dilemmas. So that means that when a physician after extensive testing, including imaging or blood work and all these other tests still can’t find something. And by the way, pediatricians and physicians in general are always on the lookout for zebras. And when I say zebras, I mean the rare illness that we learn about in med school. And so we’re always thinking that when something is not making sense, we’re always thinking, well, maybe it’s a zebra. We should just do more testing. And that’s just the nature of our profession in some ways. And so it leads us to do more and more. And so we oftentimes in those instances are doing harm to the child, unbeknownst to the actual diagnosis. So, you know, we’ve seen children with central lines or these catheters like IVs that are in place for years for unclear reasons or a tube into their stomach called a G tube so that they can get medicines and eat for unclear reasons. We’ve seen kids like Tracy said with intractable diarrhea for unclear reasons. And we’re still as physicians, we do more and more testing because we want to get to the bottom of it.
Cassie Gillespie (10:37):
Wow. So is it an accurate assumption that in these cases, the caretakers are bringing these children in for medical care regularly and or frequently that you’re seeing these cases and these kiddos and, and having regular contact.
Dr. James Metz (10:54):
So we, our team, the child safe program, doesn’t see it until it becomes recognized as a problem, but yes, these children are being seen at their primary care provider’s office multiple times. They’re be being seen by different specialists, the cardiologists, the gastroenterologists, the infectious disease physician and not just by the way in one location, they’re often going around the country and beyond to try to get a diagnosis.
Cassie Gillespie (11:23):
So in these cases, is it hard to tell the difference before it gets to you? So once it comes to you, I understand there’s been some concern, but when it’s first starting out, is it hard to tell the difference between a concerned parent and medical child abuse?
Tracy Wagner (11:39):
I would definitely say yes. Parents are seeking answers to questions have a heightened sense of awareness that something is wrong. And, you know, I think also typically as a pediatric medical team, our first job is to always partner with parents and believe that they’re the experts on their children. So we walk into the relationship thinking that we all have a common purpose in mind and that’s the health and the safety of the child. And occasionally when it’s not that mutual goal, that’s when things get muddy.
Dr. James Metz (12:16):
Yeah. I just want to underscore that. That is the heart of the issue is that as pediatricians, the mantra is the parents are always right. So, you know, when we’re not seeing what the parents are seeing, that’s a problem and we need to listen to them. And as Tracy said, it’s not all that common, but in certain situations, parents aren’t telling us the whole truth.
Cassie Gillespie (12:40):
And you touched on it a little bit in the beginning, but are there particular patterns that you see in perpetrators around this type of child abuse, or are there particular factors or red flags that might make this more or less likely to be happening?
Dr. James Metz (12:54):
Sure. There’s a lot of research going on about medical child abuse, and we’ve learned a lot about it over the years. There are some clear red flags for instance, an illness that only presents itself in the presence of one caregiver. So always with the mother and not when the child goes to the grandparents, that’s a red flag when the parents or caregiver are reaching out to multiple specialists that’s a concern when they fire a lot of physicians or as we sometimes call it doctor shopping that can be a concern. And again, when after a full exploration of a diagnostic workup is complete and the physician gives a reassuring news to the parent, but the parent or caregiver continues to disbelieve what the physician says and that reassuring information, that is concerning.
Tracy Wagner (13:57):
I would also add that when siblings or other family members have a history of unusual or unexplained illnesses. That can also be a red flag. We tend to think as James mentioned, the doctor shopping piece, I always want to remind folks that, you know, UVM children’s hospital has experts. All of our specialty pediatricians are experts in care and have connections nationwide and internationally. And it’s pretty rare that we can’t provide the care here. And that seems to be a common misperception that that specialized care can only occur in other States. So I just often think when, when people are going out of state for care that we’re, we’re completely competent and able to provide in Vermont. It always worries me a bit too.
Cassie Gillespie (14:53):
And so I’m so drawn to theorizing about the why, and what’s going on for the perpetrator in these cases, but does it really matter why the perpetrator is doing it?
Dr. James Metz (15:09):
Not really. I say that, but I have a lot of sympathy and compassion for the caregiver because I believe I do truly believe it’s an illness and a compulsion and a psychiatric illness that the perpetrator has. And so, you know, while it’s not my focus in order for the safe reunion of the child or the safety of the child, we need to treat the individual, the perpetrator. And we can only treat that perpetrator if we know more about the reasons that they’re doing it. Again, it is important, maybe not so much for the work that we do here at the Child Safe Clinic. But when we talk about a child being removed from the perpetrator and then brought back into the care of that perpetrator, we want to be assured that that individual has been rehabilitated or treated for their illness
Tracy Wagner (16:04):
Another component of that is sometimes we have some time constraints around this because, they can be very medically complex situations and that rise to the level of being life threatening and it’s scary. And kids deserve the quality of life and health and safety in a really timely, sensitive manner.
Cassie Gillespie (16:29):
Yeah. I’m wondering in all the cases you have seen or in the families that come through the clinic, do you see in these types of cases, perpetrators getting to the point where they have actual admissions about owning what they’ve been doing and explaining the why’s behind it?
Tracy Wagner (16:47):
In my experience, very rarely. The one case that I mentioned before we were able to provide some really intense family based support and wraparound services for this mom that was able to boost her self-esteem and help her feel safe and secure and connected. It took a really long, long time and required a bit of foster care and intensive supports.
Cassie Gillespie (17:11):
And so the family based approach there was really the pivotal factor, would you say? I’m making an assumption I should ask.
Tracy Wagner (17:17):
Cassie Gillespie (17:19):
Are there resources out there for people who want to learn more about this type of child abuse?
Dr. James Metz (17:24):
Yes. For sure. There’s lots of good journal articles. There’s a good book on medical child abuse by Carol Jenny and Tom Rustler. And there’s lots of information in the lay press. There’s even some Netflix shows on this some recent big cases of medical child abuse that have come to light. And I would just the listeners that you may only be hearing one side of the story because the medical field, we are limited in what we can provide information on based on HIPAA and a lot of privacy issues. So when you hear parents talking about their child being removed and how all the things that they have done for their child, it’s very difficult for the medical field to respond to those claims or respond in any way because we are again bound by HIPAA. So, you know, they’re compelling, they’re interesting stories but they’re often one sided and I would just caution you about that.
Cassie Gillespie (18:29):
Okay. That’s a good caveat.
Tracy Wagner (18:31):
There’s an older book by Louisa Lasher and Mary Sheridan, who I believe are social workers. It’s called Munchausen by proxy, but they are experts. There’s some really good, simple teaching in there. And that helps you wrap your mind around it. One of the classics.
Cassie Gillespie (18:51):
So for the workers out there, the DCF folks or other professionals, if they suspect that they might be dealing with a medical child abuse case, what should they do? What are their next steps?
Dr. James Metz (19:02):
Great question again, it starts with awareness. And so I think that this is, the podcast is a great way to get people aware of it. As with any sort of child maltreatment. It’s a team effort and realizing that is truly important. So reaching out to colleagues, reaching out to experts such as the Child Safe Program and sharing your concerns and saying, Hey is this something that makes sense? Is this something I should be concerned about? And sometimes it’s easy to figure out, and sometimes it’s not, but the recognition that, you know, why is this child getting so much care? Why is the child going to Indiana for their care and not doing it here? There may be a very reasonable and explainable explanation for it, but if there’s not, and if there are more questions raised than answers, then I think it’s important to recognize that and to bring it to the attention of your supervisor bring it to the attention of our program. And don’t just let it slip by.
Cassie Gillespie (20:03):
Intentionally, for the Family Services folks that might be a re-report. I’m just going to plant that seed for you to discuss with your team. As we’re wrapping up do either of you have any last thoughts that you want people to take away? It sounds like, consult, check in with people. What else is most important for people to know about this topic?
Dr. James Metz (20:23):
I would say that it’s complicated. It’s not clear cut. And again, we really want to focus on the harm that’s being done to the child. And when you think about harm, I would just encourage you to think broadly and not just about the medical aspects of it, but the social aspects of it too. Are children being removed from school unnecessarily, are they being confined to a wheelchair unnecessarily? Are they being exposed to radiation unnecessarily? So really it takes a lot of thought to consider all the different ways that a child is being harmed by medical child abuse. And when we think about it broadly, we really can think about how we can provide safety to that child. And it might not be clear upfront what the motivations are. And I would just encourage us not to get hung up on the motivations and really kind of focus our attention on the abuse, a harm that is being done to the child, the impact to the child,
Tracy Wagner (21:26):
The hallmark of, of medical child that use is deception. That’s a real challenge for all of us working with families to be in that place and be present and be objective and thoughtful. So the more we can support each other in this work, is really important in having some good supervision and taking time for ourselves and sharing our own health and wellness is also really important.
Cassie Gillespie (21:55):
Thank you so much for taking time out to chat with us today. We really appreciate it.
Dr. James Metz (21:58):
Tracy Wagner (21:59):
Cassie Gillespie (22:00):
Thanks for listening. If you have any ideas about topics that you want us to cover or episodes that you’re interested in hearing, shoot us a message. You can reach me by email at Cassie.Gillespie@uvm.edu, or you can leave us a comment on the web page where you downloaded this podcast. Welcome to The Field is produced by the Vermont Child Welfare Training Partnership and the State of Vermont. And a special thank you to Brickdrop for composing and recording our music. See you next time!