Child Protective Issues and Reunification

MBP abusers engage in falsification compulsively; identification of the behavior is not an effective intervention to prevent it. Additionally, treatment for the abuser is frequently ineffective. McGuire and Feldman (1989) followed six victims of illness falsification and found that all six were abused during and after the abuser's participation in psychotherapy. Additionally, five of the six children continued to be abused after referral to child protective services. One might expect that parents genuinely interested in the health and safety of their children would agree to ongoing monitoring and support. However, when confronted with evidence of illness falsification, MBP abusers commonly engage in the following behaviors: entrenched denial; hostility; attempts to remove the child from the medical setting; threats of lawsuits; and a search for individuals, personal and professional, who are willing to support and strengthen their position of denial (Kinscherff and Famularo 1991).

Generally, predictors associated with poor outcome among parents seeking reunification include parental history of severe childhood abuse, persistent denial of abusive behavior, refusal to accept help, severe personality disorder, mental disability, and alcohol and/or drug abuse. PCF abuse, including nonaccidental poisoning and illness falsification, is most often associated with poor prognosis and increased child mortality (Jones 1987).

For those who have been victims of MBP abuse, predictors associated with poor psychiatric outcome include victimization that lasted more than 2 years, delayed permanent placement, unsupervised contact with their mothers, contact with mothers who had received insufficient treatment, and contact with fathers who were unable to care for them due to dependency on mothers (Ayoub 2006). Children fare the best psychologically when they are removed from their biological homes at a young age, are placed in permanent safe alternative homes as early as possible, and have little or no contact with the mother (or individuals she significantly influenced). The exception appears to be when abusing mothers fully admit their perpetration early and are sincere, are committed in their work to change their behavior, and complete an extended course of treatment over 5-7 years (Ayoub 2006).

To determine risk, child protection authorities compare the health status and medical care contacts of the child 1) prior to separation from the suspected abuser and 2) after separation and stabilization/rehabilitation. This technique is not reliable if complete separation and stabilization have not occurred. Children who have been victims of symptom induction (e.g., poisoning or suffocation) appear to be at greatest risk for death, although iatrogenic deaths as well as significant physical and psychological morbidity also occur as a result of procedures and treatments provided to children based on exaggeration and fabrication alone. Assessing risk may be challenging when the victim has a legitimate chronic illness that has been manipulated by the parent to create excessive symptoms or disability.

The persistence of denial of MBP by the parent perpetrator in the face of a finding by the court is justification for denial of contact and for placement of the child outside the home. If denial continues, then termination of parental rights with the father as well as the mother is often recommended.

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