Illness induction syndrome: paper I--a series of 41 children from 37 families identified at The Great Ormond Street Hospital for Children NHS Trust.

At the hospital 41 children from 37 families were identified as having had illness induced by a parent who in all but three cases was the mother. Their case records were reviewed. Four patterns of presentation occurred; failure-to-thrive through the active withholding of food; allegation of allergy and withholding of food; allegation and fabrication of medical symptoms; and active interference by poisoning or disrupting medical treatment. Four of the children died, two as a result of the illness induction. In 35% of the families a sibling had been previously subjected to some type of abuse. All the children had been presented with potentially serious symptoms, but post-identification only five were found to have serious medical problems requiring ongoing treatment. There were no specific characteristics of either the child or family associated with each type of presentation. Seventeen children had previously presented with failure-to-thrive, feeding problems or food allergies. All the mothers had suffered at least one of the following: privation, child abuse, psychiatric illness, or significant loss or bereavement, whereas only half the fathers had grown up in a deprived family situation and/or had earlier or current health difficulties. Forty percent of the parents had serious marital problems. A combined medical/psychosocial team identified the abuse and attempted to understand the family's belief system regarding the illness. The process of Illness Induction was conceptualized as being initiated by the parents perceiving the child to be ill and using this focus on illness as a way of solving major personal, marital, and/or family difficulties.

Some clinical and methodological implications of a treatment outcome study of sexually abused children.

The clinical implications of the results of a treatment outcome study are presented for 47 sexually abused children and adolescents attending a specialist psychiatric facility. The children and their nonabusing parents or caregivers were randomly assigned to contrasting treatment programs. The treatment focused on family members allocating blame for the abuse appropriately, optimizing family relationships, and dealing with causes and effects of the abuse. Clinicians rated the children and the mothers on 12 family treatment aims before and after treatment; on the same occasion additional standardized measures were used to assess behavior and mental state of the children and mental state of the mothers. On the standardized measures mothers made more significant progress than their children in the year of treatment, but there were no effects of type of treatment on the progress made by mothers or children. By contrast, clinical ratings suggested that those following the additional group work made better progress than those following the treatment without group work. The implications of these results for the clinical programs are discussed.

Sexual abuse of children in the United Kingdom.

Questionnaires were circulated to 1,599 family doctors, police surgeons, paediatricians, and child psychiatrists to determine the frequency and nature of child sexual abuse in the United Kingdom. At least three per 1,000 children are currently being recognized as sexually abused sometime during their childhood. The majority of cases reported involved actual or attempted intercourse, and 74% of the perpetrators were known to the child. Family disturbance was noted in 56% of the cases. The most common outcome (43%) was criminal prosecution of the perpetrator. Area Review Committees had no clear policy for the management of sexual abuse. Before it is possible to protect children and to develop therapeutic services for the family, it will be necessary to acknowledge that sexual abuse is part of the child abuse spectrum.

Using spoken attributions to classify abusive families.

Despite claims that beliefs held by abusive parents are important indicators of family functioning, few studies have explored the relationship between patterns of beliefs and severity of abuse. This study applies findings from marital research that demonstrate that maladaptive attributional patterns predict the level of distress experienced in adult relationships. It examines spoken attributions produced by 18 families during diagnostic therapy sessions following serious abuse of a child. Attributions were identified from transcripts and coded using a standard system. Patterns of attributions, defined on the basis of previous work, successfully predicted classification of families by therapists as Good, Uncertain, and Poor, in terms of prognosis for rehabilitation. Using this classification to test hypotheses based on attributional style, group differences were found. In families rated Good, parents were more likely to attribute more control to self than child for negative outcomes. They were also more likely to nominate themselves as causing negative events. Case accounts of families from each category are presented to illustrate how attributional analysis can contribute to an understanding of the individual nature of child abuse.

Withholding consent to lifesaving treatment: three cases.

The refusal of children or their parents to consent to treatment that professionals regard as essential always results in a dilemma. Responding to such refusals demands careful and sensitive clinical and thicolegal intervention and close cooperation among professionals, in particular doctors and social workers. Since the introduction of the Children Act 1989 the number of cases in which children have withheld consent to lifesaving treatment has risen, and it is now increasingly recognised that children have a right to have their views legally represented if a local authority or health authority seeks a court's leave to carry out treatment. Professionals have to consider which legal route, under either the Children Act or the Mental Health Act, is likely to be best for the individual child.

Reliability of video taped interviews with children suspected of being sexually abused.

OBJECTIVE: To determine the reliability of judgments about the likelihood of child sexual abuse based only on video recorded interviews. DESIGN: Blinded rating of likelihood of abuse by seven professional groups and comparison with consensus rating. SETTING: Child and adolescent psychiatry centre. SUBJECTS: Four people from each of seven professional disciplines: specialist psychiatrists, general psychiatrists, experimental psychologists, trainee social workers, trainee clinical psychologists, lawyers, and police. MAIN OUTCOME MEASURE: Rating of 12 recorded interviews. RESULTS: Agreement between the consensus panel and professional groups was 83% (151/183) for high likelihood cases (seven cases) and 89% (118/132) for low likelihood cases (five). Specialist psychiatrists and the police were better able to identify high likelihood cases than were other groups with less experience of interviewing sexually abused children (91% (48/53) v 79% (102/129); p = 0.05). CONCLUSIONS: Raters could accurately distinguish children with low likelihood of abuse on interview evidence alone, but those with more experience of dealing with sexual abuse were better at identifying high likelihood cases.

Risk factors for development of sexually abusive behaviour in sexually victimised adolescent boys: cross sectional study.

OBJECTIVE: To identify factors that may increase the risk of a sexually victimised adolescent boy developing sexually abusive behaviour. DESIGN: Sexually victimised boys who had sexually abused other children were compared with sexually victimised boys who had not done so. SETTING: Social services departments in south east England were invited to refer sexually abused and sexually abusing boys to a London postgraduate teaching hospital. SUBJECTS: 25 adolescent boys aged between 11 years and 15 years and 11 months. MAIN OUTCOME MEASURES: Adjusted odds ratios estimated from unconditional logistic regression. RESULTS: Unadjusted odds rations for witnessing (8.1) as well as experiencing (18.0) intrafamilial violence and discontinuity of care (7.2) discriminated boys who had sexually abused from others who were solely victims of sexual abuse. Only the adjusted odds ratios for witnessing intrafamilial violence (39.7) discriminated the two groups. CONCLUSIONS: The risk of adolescent boys who have been victims of sexual abuse engaging in sexually abusive behaviour towards other children is increased by life circumstances which may be unrelated directly to the original abusive experience, in particular exposure to a climate of intrafamilial violence. Our findings have implications for the management of boys found to have been sexually abused and raise important questions about the possibility of secondary prevention of subsequent abusive behaviour in those at greatest risk.

Shame and other anxieties associated with breast-feeding: a systems theory and psychodynamic approach.

It is easy to be over-simplistic about breast-feeding--what determines the choice of the breast; what causes rejection of breast-feeding as a feeding method; what determines success and what its failure? In fact, a bewildering range of factors, physical, psychological and sociological play a part. How can these be related to each other and ordered in general and for the individual? A general systems theory approach, in which the elements are envisaged as interacting dynamically, seems to offer a possible satisfactory explanatory model. Moving from social systems to the individual's intrapsychic system helps to understand the complexity of emotions aroused about the breast and breast-feeding. Shame and anxieties are seen to arise from the confluence of life history and current events. Intervention is necessary at many levels--societal, family and individual--if breast-feeding is to be re-established as the feeding method of first choice.

The sexual abuse of male children and adolescents: a review of current research.

Inevitably, in a wide ranging review, there will be some important omissions. The main difficulties in assessing the available information have been the lack, in so many studies, of analysis along gender lines, the lack of control groups, and, in many instances, too small sample size. Despite these limitations there has, over the past decade, been an upsurge of interest in and awareness of the significance of the sexual abuse of boys. It permits us to identify a number of important trends and to draw certain conclusions. Firstly, the scale of the sexual abuse of boys is much greater than was believed 10 years ago. There is no reason to think this is simply an artifact of definition, or information gathering, or indeed of an increased willingness to recognize abusive behaviour between children, even though these will all have an effect. Whilst the trend is clear, the actual prevalence rate is difficult to determine, with a reported range of between 3% and 31%. A current 'best guess' suggests contact abuse in the range of 2-5% in the male population. As each study controls for its own definition of abuse, the narrowing in the ratio of boys to girls abused can be accepted as quite reliable, and additional evidence of a delayed recognition effect. Retrospective community evidence shows 1 boy is abused for every 2-4 girls abused. In contrast, the highest clinical ratios are for 1 boy to every 4 girls. Those who work with runaways, male child prostitutes, or child and adolescent psychiatric inpatient units appear particularly likely to encounter abused boys. Secondly, a variety of explanations have been advanced to explain the apparent under-reporting or under-detection of the sexual abuse of boys. Prominent among them have been the boy's fears of disbelief and of being labelled homosexual. Police patterns of reporting extra-familial abuse may mask its extent from protection or health agencies, which is important because extra-familial abuse does appear to be more common in boys, especially older boys, than girls. Although there has been some diminution of the cultural denial that girls can be abused, a parallel decrease of denial regarding boys has lagged behind. This is particularly true of father-son and of the much less common mother-son abuse. It is plausible that certain 'alertors' are more relevant for boys. The recent development of aggressive behaviour, homophobic anxiety, co-abuse of a sibling and abusing behaviour in particular deserve consideration.(ABSTRACT TRUNCATED AT 400 WORDS)

Therapeutic approach to sexual abuse.

An account is given of the development of a treatment project for sexually abused children and their families. We review incidence data which indicate that sexual abuse of children is likely to be a far more frequent problem than has been recognised and cause an appreciable degree of psychological damage. Professional responses to this are confused and treatment facilities limited. Sexual abuse is seen as an expression of severe relationship problems in the family and therapeutic provision is made, therefore, not only for the abused child but for other members of the family (including both parents). The method adopted is to offer group therapy to the child, mother, and father and regular family meetings with professionals in the community, concerned with care and protection of children. Clinical data on the first 56 children treated are discussed and our approach to treatment is evaluated.

Child sexual abuse--children and families referred to a treatment project and the effects of intervention.

The characteristics of a series of 274 families who were referred to a sexual abuse treatment programme were analysed. Information was obtained on 411 abused children and 362 non-abused children. Different forms of sexual abuse were noted, with 77% of girls and 23% of boys affected. Boys tended to be abused at a younger age, more severely, and for longer periods than girls. There was a predominance of lower social class groups among the parents, and a wide variety of family structures, with reasonable stability over time. Ninety six per cent of perpetrators were men, and biological and step-parents predominated. Contributing factors in both the family history and the current perpetrators and their wives included sexual abuse, violence, chaotic families, marital problems, sexual difficulties, alcoholism, and subnormality. Follow up of 120 families, 180 victims, and 226 siblings showed that prosecution occurred in 60% of cases, with a high percentage of perpetrators being imprisoned. Treatment was offered to 87% of families, but because the treatment programme was in the early stages of development a variable number of children and parents were offered family treatment or treatment in groups for parents and children separately. There was an improvement in the victim's circumstances in 61% of cases, and a noticeable reduction in "sexualised" and general emotional difficulties among victims, but there was reabuse rate of 16%. Protection of children was achieved through changes of family attitude and changes in family structure including divorce and separation: 14% of victims were rehabilitated to both parents, 33% to mothers only, and 26% to new families or other residences. Consensus in the family that abuse had occurred was seen as an important factor in determining which children could be rehabilitated with both their parents, with their mothers only, or with new families; which families could be offered or accepted treatment; and whether positive changes in the family occurred.

Papers and originals.

Six cases of persistent non-accidental poisoning of children by their parents are reported. Certain features may draw attention to the diagnosis, particularly bizarre symptoms and signs with no apparent pathological explanation, and toxicological analysis should be carried out to obtain rapid confirmation of the diagnosis. The underlying disorder may include marital conflict, overinvolvement between parent and child, or drug abuse in the parents. A suggested plan of action for managing this problem is outlined.

Self hypnotherapeutic treatment of habitual reflex vomiting.

A 9 year old boy with intractable postprandial reflex vomiting was taught a self hypnotherapy technique incorporating relaxation exercises, mental imagery, and suggestions of symptom relief. The sequence was recorded on a personal stereo cassette tape. Vomiting was completely eliminated within four weeks. At 12 month review vomiting had not recurred.