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Somatoform disorders due to emotional child abuse have medico-legal implications

06 Jul 2022

  • Forensic medical practitioners should be aware and initiate appropriate medico-legal interventions 
BY Ruwan Laknath Jayakody Since somatoform disorders due to emotional child abuse have several medico-legal implications, forensic medical practitioners should be aware of somatoform disorders in children caused by emotional abuse and they should suspect, diagnose, and initiate appropriate medico-legal interventions in the best interest of the child. These observations and recommendations were made by K.M.T.B. Gunathilake (attached to an Office of a Judicial Medical Officer), M. Vidanapathirana (attached to the Sri Jayewardenepura University’s Medical Sciences Faculty’s Forensic Medicine Department), and T. Gadmbanathan (attached to the Batticaloa Teaching Hospital’s Psychiatry Department) in a concept paper on the “Emotional abuse of children leading to somatoform disorder: A form of child abuse”, which was published in Medico-Legal Journal of Sri Lanka 10 (1) in June, 2022. Somatoform disorders, per O. Oyama, C. Paltoo, and J. Greengold’s “Somatoform disorders”, are characterised by persistent physical symptoms without a demonstrable organic pathology or physiological explanation along with clinical indications that the symptoms are linked to psychological factors or conflicts. Furthermore, a somatoform disorder due to emotional child abuse has medico-legal implications. There are several forms of somatoform disorders. According to Oyama et al., it includes somatisation disorder (involving multi-system physical symptoms), undifferentiated somatoform disorder (fewer symptoms than somatisation disorder), and conversion disorder (voluntary motor or sensory function symptoms). Conversion somatoform disorders appear in children following emotional abuse. As noted by Oyama et al., the challenge in working with somatoform disorders in primary care settings is to simultaneously exclude medical causes for physical symptoms while considering a psychological diagnosis. Per Oyama et al., three required clinical criteria common to each of the somatoform disorders are that the physical symptoms (a) cannot be fully explained by a general medical condition, another mental disorder, or the effects of a substance, (b) are not the result of the factitious disorder or malingering, and (c) cause significant impairment in social, occupational, or other functioning.  Further, according to the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders. Fourth edition revision (DSM-IV)”, epidemiological data suggest familial aggregation as a cause of some of the disorders. In Sri Lanka, children, especially schoolchildren, are produced before forensic medical practitioners by their parents for medico-legal examination and reporting following assaults or physical punishments by people or school teachers due to their misbehaviours. The Grade Five Scholarship Examination has become a competition among parents to obtain a good school for their children, for which they pressurise their children.  This exerts psychological pressure on children, causing traumatic experiences in their minds. This is a form of child abuse due to Munchausen syndrome by proxy (MSBP) and the use of children to fulfill their gratifications, causing a severe degree of emotional abuse to children and resulting in somatoform disorders, and then the children may, in turn, become victims of punishments or assaults due to their misbehaviours.  Somatoform disorders among children and adolescents may, A. Konichezky and D. Gothelf’s “Somatoform disorders in children and adolescents” observes, cause impairment in educational and social functioning and generate a great deal of psychosocial distress. Due to the somatoform disorder, children tend to misbehave, especially at school, and teachers or people will get irritated and the child will be punished or assaulted. When such children are produced before forensic medical practitioners, a somatoform disorder due to emotional abuse should be considered. These behaviours may not be explained by physical examinations, do not respond to treatments, and cannot be diagnosed by investigations but can be diagnosed by psychological examination. Per the DSM-IV’s “Criteria for somatoform disorders”, the diagnostic criteria for somatoform disorders were established for adults, and the same criteria, in general, are applied to children. Diagnosing somatoform disorders in children and adolescents is often more difficult because the expression of emotional distress in the form of physical complaints is developmentally appropriate in younger children.  However, according to G.K. Fritz, S. Fritsch, and O. Hagino’s “Somatoform disorders in children and adolescents: A review of the past 10 years”, when physical symptoms are persistent and a child’s functioning deteriorates, the consideration of a somatoform disorder is indicated. Putative familial risk factors for the development of somatoform disorders among children and adolescents were identified in I.E. Schulte and F. Petermann’s “Familial risk factors for the development of somatoform symptoms and disorders in children and adolescents: A systematic review” as the somatisation of parents, the psychopathology of close family members, a dysfunctional family climate, a traumatic experience in childhood, and insecure attachment. There are many theories explaining the formation of this disorder. According to K. Kozlowska’s “The developmental origins of conversion disorders”, both “freezing” and the “appeasement defence” are seen typically in young infants and toddlers, in the face of a threat. Hypothetically, in the context of a significant threat, behavioural and somatosensory components of emotional responses are activated automatically, manifesting as medically unexplained symptoms (pain, motor, or sensory). Kozlowska further adds that “appeasement defensive” behaviours are disarming strategies of rapid alternation, of signals and contradictory signals that can normally be seen in children as young as toddlers in the presence of a perceived threat within the social or family system. The diagnosis of somatoform disorders is complex due to the fact that they may appear as medical conditions. Hence, most somatoform patients, as noted by Konichezky et al., do not seek psychiatric assistance. Although somatoform disorders are among the most common mental disorders presented in the general medical setting, as pointed out in K. Kroenke’s “Efficacy of treatment for somatoform disorders: A review of randomised controlled trials”, specific treatments have not been well synthesised. Per C. Burton’s “Beyond somatisation: A review of the understanding and treatment of medically unexplained physical symptoms”, cognitive behaviour therapy has been found to be an effective treatment for somatoform disorders.  G.R. Smith Junior, R.A. Monson, and D.C. Ray’s “Psychiatric consultation in somatisation disorder: A randomised controlled study” explains that mental health professionals can be helpful in making the initial diagnosis of a somatoform disorder and treatment. “Since it is a form of child abuse, the forensic practitioner must use a multi-disciplinary approach including organising a case conference. This would help in the diagnosis of the condition, counselling of the parents who may be suffering from MSBP, and educating the perpetrators, such as teachers, to realise the impact of the problem and advise them to handle the problem empathetically,” Gunathilake et al. elaborated. The delivery of this diagnosis to parents may be the most important step, Oyama et al. emphasise. For the prevention of further emotional abuse of children, Police or healthcare workers can request “Protection Orders” under the Prevention of Domestic Violence Act, No. 34 of 2005 (PDVA). According to the Act, “domestic violence” includes physical abuse as well as emotional abuse, committed by a perpetrator with some relationship to the victim, within the home or outside. Further, “emotional abuse” means a pattern of cruel, inhuman, degrading, or humiliating conduct directed towards the victim.  


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