Need advice - is this abuse?

pumpkin · Oct 27, 2004

Hey all, I'm hoping you can help me out. Right now I feel absolutely sick about this. My cousin had a baby girl a little over a year ago. My cousin has been diagnosed with major depression and she goes on and off her meds. She's fine when she's on, but right now she's off. She's constantly taking the baby to doctors and having tests done because she thinks there's something wrong with her. This baby has gone through more invasive tests than a lot of my patients. Lisa limits the time my aunt can spend with the baby because she gets jealous when Emily gets excited to see other people. She refuses to feed her food with "empty calories", including milk and cheese. As a result, Emily is very small and developmentally delayed. Now, I am hearing this all secondhand as told to my mom from my aunt. This morning my mom forwarded me this letter from my aunt:

"Emily had another one of the episodes (on Friday)which she gets every few

months. She woke up vomiting, very weak, almost in a trance. They called

ahead and then took her to Boston Children's Hospital where they have been

seeing a couple of doctors for her. I guess she does have a metabolic

disorder which is why she isn't growing. The treatment for it is a special

diet. She gets really sick and weak when her blood sugar levels go too low

(like after sleeping all night). And lactic acid builds up in her body.

They took a lot of blood and tested it and tested her sugar levels which

were very low. They gave her a glucose IV and by late in the day she was

much better. Over two weeks ago they had given Lisa a special diet for her

to help her grow and Lisa still hasn't given it to her. It's very upsetting

to me and I can barely think about it. Lisa gets mad at me if I even say

anything about Emily's diet at all. They have to do more testing to find

out exactly what metabolic disorder Emily has. But I guess that's why she

doesn't have good balance a lot of the time too and why she walked late.

They think it is genetic. Now that Emily has been diagnosed with this,

Lisa will be even more strict about not letting us see her. She has already

told me that she doesn't want her exposed to any germs and she doesn't want us going over there if Emily is tired or anything. They are going back tothe doctor in Boston in two weeks to discuss all the results of the blood

work they did on Friday."

As a nurse, I know I am compelled to report any instances of abuse. But I'm not sure what this truly is. I haven't seen any of this first hand, and I have strongly encouraged my mother to tell my aunt to call Emily's pediatrician and tell him all of this. Maybe nothing is wrong, but maybe Lisa is doing something to Emily. For all I know, my aunt is exaggerating. My aunt doesn't know that my mom has been telling me all of this, and my mom doesn't want me to do anything because she doesn't want to start a family war.

Any advice?

kids · Oct 27, 2004

What you describe is more a case of medical neglect (for not starting the special diet) since it sounds like the child may actually have a metabolic disorder.

Have you considered the possibility that the problem is the Aunt and not the cousin? To be very honest, in years of working with medically fragile children I encountered many families where a grandparent had issues with the medical care and decision making by the childs parents. Often the grandparent had no real clue about the childs illness or needs because the childs parent limited the contact & information given due to the level of dysfunction and to avoid conflict.

As it appears the information you are getting is second or third hand it probably does not fall with your states mandatory reporting guidlines as you have no direct knowledge of abuse or neglect. You will need to let your conscience be your guide in this.

kids · Oct 27, 2004

What you describe is more a case of medical neglect (for not starting the special diet) since it sounds like the child may actually have a metabolic disorder.

Have you considered the possibility that the problem is the Aunt and not the cousin? To be very honest, in years of working with medically fragile children I encountered many families where a grandparent had issues with the medical care and decision making by the childs parents. Often the grandparent had no real clue about the childs illness or needs because the childs parent limited the contact & information given due to the level of dysfunction and to avoid conflict.

As it appears the information you are getting is second or third hand it probably does not fall with your states mandatory reporting guidlines as you have no direct knowledge of abuse or neglect. You will need to let your conscience be your guide in this.

elkpark · Oct 27, 2004

It is not required that mandated reporters have "direct knowledge" of abuse or neglect -- just that you have reasonable cause to suspect abuse or neglect. It is the job of the state's Child Protective Services personnel to make a determination about whether abuse or neglect is occurring, not the reporter.

Also, you certainly don't have to be a "mandated reporter" to report a situation that you are concerned about. As a long-time child psych CS, I would say, based on the information that you've reported (assuming for the moment that it is true/accurate), what you're describing is at least neglect and possibly abuse.

Of course, it is your choice whether to report or not. But which would feel worse -- to report and possibly create some family conflict (remember that your report is confidential), or find out later that something awful ended up happening to this little girl and you had done nothing to prevent it?

elkpark · Oct 27, 2004

It is not required that mandated reporters have "direct knowledge" of abuse or neglect -- just that you have reasonable cause to suspect abuse or neglect. It is the job of the state's Child Protective Services personnel to make a determination about whether abuse or neglect is occurring, not the reporter.

Also, you certainly don't have to be a "mandated reporter" to report a situation that you are concerned about. As a long-time child psych CS, I would say, based on the information that you've reported (assuming for the moment that it is true/accurate), what you're describing is at least neglect and possibly abuse.

Of course, it is your choice whether to report or not. But which would feel worse -- to report and possibly create some family conflict (remember that your report is confidential), or find out later that something awful ended up happening to this little girl and you had done nothing to prevent it?

Jolie, BSN · Oct 29, 2004

I know that HIPPA makes this suggestion difficult, if not impossible, but it may be worth a try. Since there is already an established relationship with a pediatric specialty hospital, would it be possible to get their social services department involved? That may be more effective than reporting to an over-worked, under-staffed state agency that will probably not be inclined to get involved without obvious signs of abuse.

Good luck.

Pediatric Critical Care Columnist · Oct 29, 2004

This sounds somewhat like Munnchausen's Syndrome by Proxy, where a caregiver continually seeks medical attention for a child or dependent adult with nonspecific complaints (often vomiting, diarrhea, failure to thrive, unresponsive episodes and such), insists on invasive testing, and actually may be harming the person in order to "prove" there's something wrong with them. Often times the symptoms are not reproducible once medical attention has been obtained. Children have had major surgeries that have turned up no sign of the suspected diagnosis, there've been cases of feeding tubes and trachs being placed in perfectly normal children, and many other incidents. A quick Google search will help make it all real to you. If you suspect that is a possibility, then social services needs to assess the situation. As the previous poster suggested, the social work department of the children's hospital would be the place to start. I would believe that your cousin's child is in danger, whether you aunt is exaggerating or not.

Gompers, BSN, RN · Oct 29, 2004

This sounds somewhat like Munnchausen's Syndrome by Proxy, where a caregiver continually seeks medical attention for a child or dependent adult with nonspecific complaints (often vomiting, diarrhea, failure to thrive, unresponsive episodes and such), insists on invasive testing, and actually may be harming the person in order to "prove" there's something wrong with them.

That's the first thought that went through my head and I'm very afraid for this child. I know this is your family, but this really needs to be reported to children and family services or at the very least the hospital social work department. You can make an anonymous call. Do it.

BBFRN, BSN, PhD · Oct 29, 2004

I thought Munchausen's by Proxy, too. I would definitely report it, even if it's not.