2025 – PAGE 442 – PSYCHIATRY AND SOME SOCIAL ISSUES

NEGLECT

Neglect occurs when there has been an omission of care that results in harm, or risk of harm, to a child. Report suspicions to the authorities.

PEARL: Child neglect is said to be the most common form of child abuse. If a mother is noted to go against the usual recommendations because it’s just “easier” to continue with the neglectful behavior, then work on the psychosocial issues rather than the specific act. For example, instead of focusing on how a parent should do “X,” focus instead on how a child’s needs are not being met a particular category (such as, emotional support, cleanliness, social/peer interaction, etc.).

CAREGIVER-FABRICATED ILLNESS (AKA MUNCHAUSEN SYNDROME BY PROXY) (AKA FACTITIOUS DISORDER)

A form of child abuse where a caretaker, usually the mother, fabricates or induces symptoms in a child that result in unnecessary medical testing and procedures. The caretaker does this in order to assume the “sick” role by proxy, and for any secondary gain that comes from being in that position. The most common presentations include a child with bleeding, seizures, CNS depression, apnea, diarrhea, vomiting, fever, and rash. The caretaker will fabricate an illness by lying, poisoning, suffocating, specimen tampering, and chart falsifying. The caretaker often establishes an unusually close relationship to the hospital staff and may often be extremely pleasant, cooperative, and appreciative. The caretaker may also be very knowledgeable about medical facts, tests, and procedures. Report suspicions to the authorities. The child victim will need foster home placement in order to ensure that the patient is safe. Both the child and caretaker require psychiatric evaluation and follow-up.

HEALTH CARE PROVIDER ROLE IN CHILD ABUSE AND NEGLECT

Build rapport with the caregivers and never make an accusation on the initial meeting. Screen for parental depression, drug/alcohol abuse, domestic violence, crime, social isolation, lack of support, poverty, and food insecurity. Diagnostic assessment includes a detailed medical history and physical exam with video and photographic evidence if indicated. Health care providers are mandated to report suspected child abuse, and the authorities must be notified immediately. Support the family with a social work referral, home nursing support, close medical follow-up, environmental support, and financial services support as needed.

MISCELLANEOUS TIDBITS AND PEARLS

TONGUE TIED (AKA TONGUE TIE)

Being “tongue tied” (AKA tongue tie) means that a child is unable to get the tongue out past the incisors. This is due to a short frenulum. If it results in a problem with feeding, surgery is recommended.

PEARL: An inability to say “th” does not mean a patient is tongue tied, and it warrants no interventions. Reassure the family that it will likely resolve since the ability to make the “th” sound typically develops between the ages of four and seven.

ENURESIS AND ENCOPRESIS

Enuresis and encopresis occur when children involuntarily wet or soil themselves. Most kids have bowel/bladder “control” by 3 years of age. Parents should provide positive feedback when a child shares his/her need to urinate. This helps with faster toilet training. The term “enuresis” should not be used as a diagnosis until a child is at least 3 years of age.

• PRIMARY ENURESIS: Means a child never had a time period of continence and continues to wet his/her bed. A parental history of primary enuresis significantly increases the likelihood of it in a child. Use bed alarms for long-term use and consider using intranasal desmopressin (DDAVP) for children going to a sleepover.
• SECONDARY ENURESIS: Means a child begins bedwetting again after a dry period in which s/he was potty-trained and continent of urine.
• ENCOPRESIS: This is when a child voluntarily or involuntarily soils himself/herself after having previously been potty-trained. This can be related to stool withholding. Treat by putting the child back into diapers for a while and providing positive feedback to him/her. You may use laxatives temporarily for older children.