Maltreatment 213always the mother) who has induced the illness. The child is usually
brought repeatedly by the mother to hospital for investigation, yet when
she is away the symptoms and signs abate. The parents deny any knowl-
edge of the cause of the illness. Other siblings have often been subject
to fabricated illness too, and indeed one study found that 1 in 10 had
died in mysterious circumstances. Forms of fabricated illness include, in
descending order of reported frequency, respiratory arrests due to smoth-
ering, poisonings, seizures, apparent bleeding from a variety of orifices,
skin rashes and other skin conditions, fevers and high blood pressure. As
the mother spends more time on the ward it may become apparent that
she enjoys medical attention; often mothers have nursing or other health-
related training or experience. Other types of physical abuse such as non-
accidental injury and non-organic failure to thrive often co-exist.
Failure to thrive refers simply to less-than-expected weight gain. It is
a relatively common presentation in paediatric clinics. In the majority a
medical condition is found, such as heart disease, lung disease, gut disease
or hormonal problems. In a minority, however, no medical cause can
be found. This group comprise non-organic failure to thrive (NOFT). A
proportion of these will simply have undiagnosed medical conditions, but
many arise in the context of deviant parent–child interaction patterns. The
deviant interactions are especially common in this group at meal times,
with the result that most cases of NOFT end up receiving insufficient
nutrition (as do many cases of organic failure to thrive, where parent–child
interaction is, by contrast, usually normal). To demonstrate that adverse
upbringing is the cause, it is essential to document that the weight of
the child catches up when they are placed in a benign environment (for
example, a hospital ward, or with foster parents). Children with NOFT
have been shown to be at far higher risk of later neglect and abuse than
controls.
Neglect
This refers to an absence of appropriate care rather than positively inap-
propriate acts. However, the effects of neglect on children can be just as
devastating as the effects of abuse, if not more so. Most areas of care may
be involved:
1 Lack of physical care. This includes undernutrition and sometimes NOFT,
recurrent infections, unkempt dirty appearance, housing dirty and dis-
organised.
2 Lack of medical care, with failure to bring the child for immunisations,
failure to seek appropriate medical help for illnesses and accidents. This
can result in avoidable complications of medical conditions, including
defective vision from untreated squints, impaired hearing from un-
treated otitis, and occasionally death, for example, from hypothermia.
3 Lack of enforced house routines, rules and supervision.Thisleadstoan
increased rate of accidents at all ages, including domestic and road
traffic. Younger children frequently wet and soil for no organic reason.